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									Continuity of Operations Planning
for Public Health and Health Care

  Cathy Hockert, CEM, MPH, CBCP
State Business Continuity Coordinator
          State of Minnesota
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Continuity of Operations vs
  Service Continuation?
  COOP vs. Service Continuation
• Impact is usually local.
• Physical structure and
 technology are affected.
• Event is short in duration
 and triggers the COOP
 Recovery Phase.
• No notice of the event.
• Mainly affects buildings,
 equipment and technology.
• One-time event.
    COOP vs. Service Continuation
Service Continuation
 • May be local or global event
 • Physical structures and
   technology are initially not
 • Some notice, although it
   may be short.
 • Mainly affects staffing levels.
 Specific to Pandemic:
 • Impact will be global
 • May last 6-8 weeks
 • Could have multiple waves
Why have a COOP?
                 Purpose of COOP
• Ensuring continued performance of essential functions.

• Reducing loss of life and minimizing damage.

• Ensuring succession of key leaders.

• Reducing or mitigating disruptions to operations.

• Protecting essential assets.

• Achieving a timely recovery and reconstitution.

• Maintaining a test, training, and exercise program for viability.
      5 Steps to COOP Planning
Risk/Vulnerability Assessment
Disaster Readiness Assessment
  – (Identification of essential functions & resources required)

Plan Development
Plan Implementation, Maintenance &
Who should be involved in COOP
  Who should be involved in COOP
• It’s a team effort!
• Personnel at every level of the organization,
       COOP Coordinator/Point-of-Contact (POC)
       COOP Planning Team
       Senior Management
       Management and staff
       Key Personnel with ―Institutional Knowledge‖
    COOP Planning Considerations
COOP plans must:

•   Be capable of implementation anytime, with and without warning, during duty and
    non-duty hours.

•   Provide full operational capability for essential functions not later than 12 hours
    after activation.

•   Be capable of sustaining operations for up to 30 days. Agencies must develop
    operating procedures and acquire resources necessary to sustain operations for up to
    30 days.

•   Include regularly scheduled TT&E. Agencies must train members of their
    emergency staff and practice COOP procedures to ensure their skills stay current.
    Equipment and communications must be tested periodically to ensure that they are
     How do we start planning?
• What are you vulnerable to?
  – Hazards
  – Risks
• If that happened, what would be the impact to
  your agency/organization?
What Elements Should be in a COOP
 • Essential Functions    •   Public Information
 • Delegation of          •   Vital Records
   Authority              •   Human Capital
 • Order of Succession    •   Security
 • Alternate Facilities   •   Logistics
 • Interoperable          •   Training and
   Communications             Exercising
Hazard Vulnerability Assessment

• Probability of an event occurring and the impact the event
  would have on departmental and system wide operations

                                         Clara Barton Hospital Hoisington, Ks
 Hazard Vulnerability Analysis

• Allows individual health agencies to
  identify and rank various risk and
  mitigating factors

• Coordinate with local law enforcement and
  emergency management
What are your Essential/Mission
 Critical Functions/Services?
                   Essential Functions
Identification and prioritization of essential functions necessary for
   agency continuity of operations.

Essential functions include services that are:

1. Life Safety/Loss of Life

2. Public health

3. Food and Shelter

4. 24/7 Direct Care and Critical Ancillary Providers

5. Economic impact

6. Symbolic value
Essential Functions agency specific

• Define the agency mission and goals
  – What does your agency/organization do that is

• Identify the functions that are needed to
  accomplish the mission
  – Stack and rank priority/essential functions
Essential Function Prioritization

• Essential Function Prioritization ranking

  – Critical- function cannot be delayed
  – Important- function can be delayed but should
    be resumed as soon as possible
  – Non-essential- function can be delayed until
    normal business operations resume
                       Essential Functions
                         agency specific

•Identify the tasks to accomplish essential functions
     •Job Action Sheets
     •Standard Operating Procedures

•Identify the resources needed to support those tasks
     •Staffing requirements for each essential function are identified
     •Who is needed to ensure these essential functions continue?

•Resource requirements for each essential function are identified
     •What ―things‖ do the people need to do the essential functions?

•Critical data and data systems for each essential function are identified
      •What is needed from an IT standpoint to keep essential functions going?
      •Documented work-around procedures that explain how to continue providing care
      without computers, telephones, or vital medical machines
Public Health Essential Functions
 •   Communicable Disease Containment
 •   Immunization
 •   Women, Infants, and Children (WIC)
 •   Family Planning
 •   Maternal and Child Health (MCH)
 •   Vital Statistics
 •   Bioterrorism and Public Health Response
 •   Human Resources
 •   Fiscal Management
 •   Public Information Officer (PIO)
 •   Public Education
 •   Home Health/Hospice/In-Home Care Program
 •   Information System Support
 •   Environmental Health
  Hospital Essential Functions
• Patient Care including triage and treatment for inpatient and
  outpatient recipients
• Patient movement to care centers with appropriate levels of
  care for patients
• Postmortem care and disposition with appropriate
  community partners
• Patient tracking including medical screenings
• Long term care of elderly and other fragile populations
• Lab capabilities consistent with facility need
• Medical billing for procedures performed
• Patient decontamination and stabilization
• Facility and personnel security for patients and employees
• Meeting standards of care as required by State regulation or
  accrediting organization
         Order of Succession vs
         Delegation of Authority

• Order of Succession-list of individuals who would
  sequentially assume responsibility if the primary staff
  person is no longer able to carry out their functions

• Delegation of Authority-positions in which the primary
  staff person has the authority to complete a particular
            Order of Succession

• Order of succession should be established for the
  highest positions of authority.
     i.e. Public Health Director, Hospital Administrator, Director
     of EMS
• Line of succession should be established for the other
  leadership positions.
     i.e. Infection Control Nurse, ER Head, Safety Officer
• Limitations on delegate authority should be listed
   – What can and can’t they do? (Helps limit confusion)
        Order of Succession
• Rosters of trained/qualified personnel with
  the authority to perform essential functions
  and activities are maintained
• Rules and procedures for implementing order
  of succession should be established
    initiating conditions
    notification methods
    terminating conditions
Order of succession for essential
• Three deep
• Should include
   – Name and title
   – Point of contact information for 24/7
• Same successor may be named for different positions but
  avoid listing the same person as the first successor to several
  key positions
      Delegation of Authority
• Delegation of Authority for each essential
  function should include:
       Name and title of delegate
       Position title and/or source of authority being delegated
       Point of contact information (phone, cell, pager, email…)
       Limitations (if any) or exceptions to the authority being
       Date or event that triggers delegation (Activation of COOP plan)
       Date of termination or revocation (i.e. 30 day)
       Name, title and signature of the official empowered to delegate
       the authority specified
Delegation of Authority to sign
     for Schedule Drugs

        I, Howard Rodenberg, being authorized to sign the current application for registration
        under the Controlled Substances Act or the Controlled Substances Import and Export Act,
        by these presents, do make, constitute, and appoint Michael McNulty and/or Barry
        Autrey, acting jointly or severally, as my true and lawful attorney in fact to act for and in
        my name only in such manner as I could act as a registrant under the Controlled
        Substances Act or the Controlled Substances Import and Export Act, with respect to
        receiving and transferring the Strategic National Stockpile. In this connection, my
        attorney in fact is specifically authorized to execute applications for books of official
        order forms and to sign such order forms in requisition for Scheduled II and IV controlled
        substances, in accordance with Section 308 of the Controlled Substances Act (21 U.S.C.
        828) and part 1305 of Title 21 of the Code of Federal Regulations.

        I hereby ratify and confirm all that said attorney shall lawfully do or cause to be done by
        virtue hereof until notice of revocation in writing.

        Dated this _____ day of _______________, 2006.

        Howard Rodenberg, M.D.
        Director of Health and Registrant pursuant to
        the Controlled Substances Act or
        the Controlled Substances Import and Export Act

        State of Kansas               )
        County of Shawnee             )

               This instrument was acknowledged before me on the ______ day of
        _____________, 2006 by Howard Rodenberg, M.D., of the Kansas Department of Health
        and Environment, in his capacity as Director of Health and Registrant pursuant to the
        Controlled Substances Act or the Controlled Substances Import and Export Act.

                                                              Notary Public

                               My appointment expires:        ____________________________
                              Alternate Facilities
• Alternate facilities may be needed in the event that the health
  care facility is damaged, destroyed or overwhelmed
• In hospital terms: Alternate Care Site (ACS)
           Site for hospital administration
           Site for hospital patient care functions
• Define ACS
           Location for the delivery of medical care that occurs outside the acute
           hospital setting for patients who, under normal circumstances, would be
           treated as inpatients.
           Site may provide delivery of chronic care, the distribution of vaccines or
           medical countermeasures, or the quarantine, cohorting, or sequestration
           of potentially infected patients in the context of an easily transmissible
           infections disease
• In Health Department terms this could be an MDS/ POD or
  alternate office location to continue office operations.
 Mass Medical Care with Scarce Resources: A Community Planning Guide, Health Systems Research Inc.
           Alternate Facilities
• Consider:
       level and scope of care to be delivered
       foot print or size needed
       staffing requirements
       equipment and supplies
       ICS structure needed to integrate this facility with other health
       facilities in the event
       EMS and other transportation issues
       rules/policies for operation
• Mobile Morgues, NDMS, Field Hospitals
             Alternate Facilities
• Plan should identify:
      Logistical considerations         Provisions to sustain
      (utility services, food, water,   operations for a period of up
      etc.)                             to 30 days
      Pre-positioning of resources
      Hot site- pre-wired               24/7 Operations
      Cold site- needs installation     Considerations for the health
      Provisions for establishing       and safety of relocated
      interoperable                     employees
      communications with all           Physical security and access
      identified essential internal
      and external organizations,       controls
      critical customers and the        Co-location and duel use
                                        Formal agreements (MOU,
            Alternate Facilities
• Lessons Learned from
                                    Supplies (medical,
  Katrina:                          pharmaceutical, food, water)
     Consider pre-planning and      Credentialing
     relationship building among
                                    Patient tracking and
     Use of ICS
     Public health (shower,
     toilets, amenities, hygiene)
                                    Patient screening
                                    Pediatrics, geriatrics and
     Transportation (EMS, self
                                    psychiatric patients
                                    Accessibility to the public
                                    Special populations
             Alternate Facilities
• Challenges:
     lack of regional/state planning with clear delineation of
     responsibility and authority
     requirement that multiple entities work together who
     normally don’t
     lack of inducements to write a plan train and exercise
     licensing issues intra and interstate
     Standards of care- whole different presentation
   Interoperable Communications
• Hardware/software that talks to each other and people that can
  communicate with each other in the same language (no codes)

• Systems that need to work together include radios, phones, faxes, email,
  notification systems, IT systems, software, secure data systems

• People that need to work together include Hospital, Clinic, Health
  Department, EMS, Fire, Law Enforcement, Emergency Management,
  Tribal Governments, Social Services…

• Procedures and plans need to be written to specify how communication
  will work during COOP activation

• Maintain the capability to communicate with internal and external clients,
  critical customers and the public.
     Information Technology
• Information Technology (IT) needs should be a
  component of each essential function
• Consider during planning:
       The essential function’s dependence on IT
       Managing the IT infrastructure during COOP
       Help desk tasks to support IT needs for identified
       essential functions
       Ability to provide remote access to programs
    Information Systems Support
•   Each essential service area must define their unique or critical information system

•   Each essential service area must define their equipment needs and availability of this
             Where is it stored
             How do we move it
             Where do we get it if we do not have it
             IT contingency plans

•   Designate responsible individuals/departments within the organization for moving and
    reestablishing IT

•    If relocation to an alternate facility is necessary, these services could be allocated to
    support organizations
             Public Information
Your most important tool will be Public Information!

• Have trained back up PIO and spokes persons
• Plan for working out of a different location (i.e. JIC) Have a
• Maintain contact lists for media
• Develop alternate methods of dissemination
• Develop templates during pre-planning to avoid creating
  during an emergency
      Message maps
      Press releases
      Information sheets
      How to find alternate sites
      Navigation of alternate sites (Signs)
               Vital Records
• Vital Records Include:
    Emergency operating plans
    Policy and Procedural records
    Legal documents
    Financial records
    Personnel files
    Patient records
    Property management (inventory)
                 Vital Records
• Provisions for classified or sensitive data
• Procedures for data backup and restoration
• Identify location and accessibility to vital records
• How often are your vital records on computer backed-
• Do you have back-up records for all of the paper based
  records at your facility?
• Where are your back-up files kept? On site or off?
“With Planning and Preparation we ensure our safety today and
         preserve the future for younger generations”
            Human Resources- HR
•   Plan for a reduction in work force
     – People impacted will want to leave
     – People afraid of personal safety will want to leave
•   Identify emergency policies for:
        Leave with pay
        Leave without pay
        Flexible leave options
        Vacation time
        Sick time
•   Identify plans for employees to work from home
•   Potential health and safety issues
         Liability assessment by general counsel
•   Union issues (overtime issues,disaster support, etc)
•   Training on contingency planning
•   Employee Assistance Program (EAP) for mental health and health insurance provisions
Human Resources-Employee
• Essential Staff functioning during a COOP activation may
  have different support needs

• Plans should include consideration for staff:
      Food and Lodging
      Child care
      Elder care
      Pet care

• Consider developing a Family Preparedness Program

• Encourage personal go-kits
  Safety and Security Concerns

• Emergency Planning Committee
     • County Emergency Response Plan (Emergency
       Support Function 8).
     • Hospital EOPs
• Ensure all necessary security and access
  controls are provided
• Ensure that local law enforcement authorities
  are notified concerning the status of the
•   Food and water
•   Fuel
•   Lodging
•   Medical
•   Transportation
•   Health, Safety, Personal
          Command and Control
• All response agencies are required to use Incident Command
  System (ICS) and follow National Incident Management System
  (NIMS) requirements (Hospitals use HICS)
• Command staff provides overall coordination of the response and
  is the central communications point
• Operations Section responsible for clinical duties including triage
  and treatment and directs all patient care resources
• Logistics Section responsible for providing facilities, services
  (food, billeting, communications) and materials
• Planning Section determines and provides for the achievement of
  each medical objective and manages human resources
• Finance/Administrative Section responsible for maintaining
  accounting records, issuing purchase orders, and stressing facility
  wide documentation
        Command and Control
• Form an Operations Team (OT) for your COOP
     Responsible for relocation activities
     Ensure all necessary and pre-planned communications
     systems are established and functioning properly
       Serve as the first shift operations at the alternate site
• Provide cross training to personnel
• Utilize Job Action Sheets (JAS) and Just in Time
  (JIT) training
• Employ call-down roster
     Advise staff where to report
     What to bring
     Training and Exercising
• Plans include annual individual and team training of
  agency COOP/COG emergency personnel.
• Plans include annual agency testing and exercising
  of COOP/COG plans and procedures.
• Plans include quarterly testing of emergency alert
  and notification procedures.
• Plans include refresher orientation for
  COOP/COG staff.
• Plans include inter-agency exercising of
  COOP/COG plans where applicable and feasible.
COOP Activation and
        Implementation Phases

• Phase I- Activation and Relocation
   – 0-12 Hours
       • Notify facilities, organizational elements and personnel of
         impending COOP activation
       • Activate plans to transfer to alternate facility, when necessary.
       • Instruct Ops team to ready facility/alternate facility.
       • Assemble documents/equipment required for essential functions
         at facility/alternate facility.
       • Secure facilities.
       • Continue essential functions at regular facility, if available, until
         alternate facility is ready if needed
• Phase II- Alternate Facility/Work Site Operations
   – 12 Hours to Termination of Emergency
       • Provide guidance to preparedness team personnel and information to the
       • Identify and brief replacements for missing or rotating personnel
       • Commence full execution of operations supporting essential functions.
• Phase III- Reconstitution
   – Termination of Emergency
      • Inform all personnel that the threat no longer exists.
      • Supervise return to normal operating facility or normal business practices
        at original facility.
      • Conduct an after action review of COOP plan execution and
      • Develop a Corrective Action Plan
 Exercising the Brain--People Respond
       the Way They are Trained

• Time Magazine, April 25, 2005
• ―How to Get Out Alive—
• From hurricanes to 9/11: What the science of
  evacuation reveals about how humans behave in
  the worst of times‖
People Respond the Way They are Trained

―Whether they’re in shipwrecks, hurricanes,
plane crashes or burning buildings, people in
peril experience remarkably similar stages.
And the first one—even in the face of clear
and urgent danger—is almost always a period
of intense disbelief.‖
   People Respond the Way They are

―People who made it out of the World Trade
  Center waited an average of 6 minutes before
  heading downstairs.‖ (Some waited as long as 30
 People Respond the Way They are

Problem—lack of data. ―Our brains require 8-10
seconds to handle each new piece of
information. The more stress, the slower the
process. Bombarded with new information, our
brains shift into low gear when we need to move
    People Respond the Way They are
People caught up in disasters fall into 3 categories:
   – 10-15% remain calm and act quickly and efficiently
   – 15% completely freak out (weeping, screaming,
     hindering the evacuation)
   – The rest of the crowd are stunned, bewildered, and
     do very little
   – Reactions are not predictable based on a person’s
     every day personality
    People Respond the Way They are
Why do a few react calmly and quickly when most freeze?

  Many who make it out of disasters alive do something
  most others don’t—They go onto a plane, or into a
  theater, or their workplace and they study the exits—
  they imagine the scenario ahead of time, enabling
  themselves to work on automatic when the time comes
  to act, instead of wasting precious moments processing
  information. They exercise mentally.
    People Respond the Way They are
• Many of those people had been through
  disasters before, sometimes several.
• This shows people can be trained to respond
  properly in a disaster, and that is the best reason
  to exercise.
    People Respond the Way They are
• ―Even in the World Trade Center, which had
  complicated escape routes and had been
  attacked once before, preparation levels were
  abysmal, we now know. Fewer than half the
  survivors had ever entered the stairwells before.‖
   People Respond the Way They are
• Only 45% of 445 Trade Center workers
  interviewed before 9/11 knew the buildings had
  three stairwells. Only half had known the doors
  to the roof would be locked.

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