Action Plan

Charter: Set up a Planning Committee and establish parameters
Establish the planning committee’s Mission Statement and Terms of Reference. Appoint a project manager and determine the scope, responsibility and authority of this role.

Nominate and appoint committee members. Ensure that all key functional areas are represented.
Establish a meeting schedule and allocate nominated roles (Chair, Minute taker)
Develop the project work plan with identified key milestones, financial resources and reporting deadlines

Conduct a risk assessment of the hazards to which your organisation is exposed:

• Identify all potential emergencies
• Identify other hazards which might not constitute an emergency (natural and human made) but which might affect you
• Make a list of the existing resources and capabilities available to your organisation to respond to these risks, emergencies and hazards.

Identify those ‘things you do’ that are critical to your operation – critical processes

• Ensure staff members involved in critical business processes are included in the identification and exploration of these processes
• Prioritise how time sensitive each critical process is – how long before you feel the impact of losing the of the function/process (see Table 9‘Business Impact Analysis Summary’ below)
• Map the inter-relationship of critical business processes where they exist
• Identify where a single point of failure which might be significant to operations exists

Conduct a business impact analysis and a business impact resource analysis

• Identify and map the potential impact of each and every risk identified on your critical processes
• Identify actions that can be put in place to mitigate any or all of the risks identified (and identify the responsible staff member if appropriate)

Document a recovery strategy for critical processes

• Utilise existing resources and capabilities, where available in recovery planning
• Identify and make provision for external resources and capabilities where necessary
• Establish your recovery time objectives, that is the maximum acceptable elapsed time to recover minimum service for each critical process
• Recovery point objectives (the point in time by which recovery of a fully effective critical process must be achieved).

Use this assessment and analysis to document your continuity strategy and plan.

The business continuity strategy and supporting plans should adopt a standard format that conforms across the aged care organisation and should be modular in design (plans interconnecting and supporting each other). This facilitates the ability to issue the sections on a need to know basis to the appropriate responsible people.

Develop a business continuity strategy with supporting plan(s) which document, test and reflect up to date processes and procedures in the following key areas:

• Organisation/Service Area Continuity Plan (this may be divided into further sections if a larger business management structure exists)
• Emergency Management Plan (Including evacuation procedures)
• Disaster Recovery Plan (DRP)
• Business Resumption Plan (BRP)

Strategic
Establish an emergency management team to develop the emergency management plan and co-ordinate full or partial implementation of it when necessary.

Define the role and responsibility of the team – for example ‘to manage and co-ordinate action in anticipation of, during and after an emergency to ensure that effects on clients and the organisation are minimised. Document the chain of command in place during emergencies and evacuations (provide an organisational chart).

Map the triggers and critical decision points (flow chart) for the team. When outlining roles, consider:

• Authority
• Delegation
• Documentation/reporting
• Confidentiality and Security of data

Operational
Allocate and document roles during an emergency and evacuation, including an Emergency Coordinator/Chief Warden.

• Identify the steps to be taken in response to an emergency

Allocate and document other key roles of designated staff during emergency and evacuation, such as the zone/section Wardens.

• Clarify their limits of control and geographical area of responsibility
• Outline the chain of command and reporting mechanism with Emergency Coordinator/Chief Warden

Clearly identify and document the roles and responsibilities of all other levels of staff in an emergency.
Ensure that a Communication Plan is invoked during emergency.

• Liaise with local aged care providers to determine an appropriate representative / liaison person for the Local Emergency Management Committee (LEMC)
• Nominated representative make contact with the LEMC - contact Local Council for relevant LEMC Chairperson
• Identify the Chair of, or the Local Emergency Management Committee, for the local aged care representative to establish a link and relationship.
• Clarify with the Local Emergency Management Committee the role and extent of Department of Community Development (DCD) involvement in emergency evacuation to welfare centres.
  • Assess the suitability of support for your resident / client group for dispatch to DCD welfare centre.
  • Document and plan for the support systems needed to meet resident/client needs during short-term
    evacuation to DCD welfare centre

Identify and incorporate key stakeholders in the Emergency Management Plan, and clarify their roles and responsibilities. Key stakeholders should include:

• Hazard management agency
• Emergency response agencies - FESA, Fire Brigade, Police
• Local & state public health agencies including hospitals

Identify and maintain an up to date contact list of:

• Hazard Management Agencies
• Emergency service providers such as transportation, emergency power, fuel, water, police, fire department.

Establish and document mechanisms for timely contact and communication (email/phone/SMS) during an emergency.
Implement a system to ensure that information is always available and current (these tasks may be written into job descriptions and duty statements, be reflected as a portfolio responsibility, may be tested on an ongoing basis through monitoring systems such as audits and reported against as a routine agenda item for the Occupational Health and Safety Committee).

Identify and maintain an up to date contact list for:

Establish and document mechanisms for timely contact (email/phone/SMS) during an emergency.
Implement a system to ensure that information is always available and current (these tasks may be written into job descriptions and duty statements, be reflected as a portfolio responsibility, may be tested on an ongoing basis through monitoring systems such as audits, and reported against as a routine agenda item for the Occupational Health and Safety Committee).

Develop links and relationships with identified “other” aged care organisations/services in your local area (community Care, residential aged care, retirement villages and/or alternative accommodation services). For those organisations/services that have limited aged care resources within their locality, consideration may need to be given to accessing commercial accommodation services, local hospitals services and community halls that can be used by people with disabilities.

Establish and map the capacity and the level of support that could be provided by “other” aged care organisation or accommodation services within local area in case of evacuation (short and long term capabilities).

Develop a Memorandum of Understanding (MOU) with local aged care facilities or accommodation services. This MOU should detail the formal understandings regarding support and evacuation (should evacuation be necessary).

Establish mechanisms for review and confirmation of existing MOU terms and conditions on at least an annual basis to ensure currency.

Implement a system for reviewing and updating information on an a regular basis.

Determine what disasters/incident/emergencies are notifyable events - to State Health Department or Environmental Agencies or departments, and ensure compliance requirements are known and met.

Identify key stakeholder groups for inclusion in emergency communication plan

Determine the limited number of authorised spokespersons during emergency (these may only be internal personnel or it could be external public relations consultants).

Determine the mechanism, modes and frequency for communication with key stakeholders. Establish a framework for reinforcing key messages in all communications (script or text). Clearly identify and publicise the roles and responsibilities of staff in relation to communication (limitations regarding privacy and confidentiality relating to over the phone information dispensement to resident/client next of kin). Ensure that key components of the communication plan are reflected in relevant organisational policy (e.g. media, staff confidentiality). Develop and store template of key communications documents ( e.g. database of key stakeholders). Identify and utilise various communication modes as appropriate.

• Allocate one area to be a command post during an emergency so that all emergency personnel and communications can be directed to that area.
• Ensure that face-to-face communication avenues do not impinge on the effectiveness of the command post function.
  

Establish processes for tracking the communication status (and essential details) of residents / clients and employees.
Compile a Crisis and Emergency Information Kit, and distribute it to key personnel who are designated to provide key functions of the emergency communication plan.

• The Crisis and Emergency Kit should include: phone listings and addresses of essential personnel (internal and external); government and community emergency resources and utilities; local maps; disaster plans for each building; media response plan and Business Continuity Plan.
• The kits should accompany key personnel at home and at locations away from the organisation so that pertinent information is readily available.
• Develop identification cards for ‘critical’ personnel. The cards should request authorities to permit their movement in the event of an emergency and allow access to their facilities should access be limited.

Implement a system of data updating/renewal, to ensure that information is always current. Share information about the organization’s emergency preparedness and response plan with key external stakeholders such as:

• emergency management agencies
• Department of Health and Ageing, and the Aged Care Standards and Accreditation Agency
• resident/clients
• residents/clients' representatives
• contractors (and where appropriate)

A process for recording what communication has been undertaken (date, time and who), throughout a disaster/emergency situation, is paramount, in ensuring essential components of the communication plan have been initiated, assisting with crisis management and providing a time-lined analysis of the plans effectiveness.

Residents/Clients
Identify the transport needs of residents/clients in case of evacuation (specialised and other). Document these details in resident/client mobility evacuation list.

• Identify the number of staff required to assist residents/clients in safe transport/evacuation within ‘resident/client mobility evacuation list’.
• Identify and map transport options available to the organisation.
• Organisational vehicles - Ensure policies and procedures to address the use of organisational vehicles, petrol, and security are in place (review of car licenses, insurance of all key personnel will have to be maintained in the human resource management system and routinely audited).
• External vehicles – identify aged care providers who maintain transport vehicles (ie. buses) that might be available for use in emergency evacuation.
  • Develop formal understandings regarding access to external agency transport where appropriate (this could be included in the Memorandum of Understanding or other formal document/agreement).
• Publicly available transport options within the local community (taxis, St John’s Ambulance, commercial bus lines, schools, local government).

Maintenance of Service
Identify critical resources that need to be transported with evacuees and source appropriate transport options to deliver these resources (could include organisation or staff vehicles).

• Ensure that these resources are transported in non resident/client transport vehicles (clothing, linen, personal belongings, medications and essential supplies).
• Develop inventory and check list for all stores/equipment to be taken off site.
• Develop standard package of materials to accompany resident/client and reflect this in a checklist for staff (i.e. full set clothing x 1, footwear x 1, medications x 3 days, continence aids x 3 days.

Resident/Client
Establish and implement a resident/client record system that captures all essential care requirements such as:

• Photo identification
• Name and contact details of relative / representative
• Name and contact details of GP and Pharmacy
• Principal diagnosis (diabetes, epilepsy, etc)
• Communication capabilities (sensory deficit, non English speaking, non-verbal, etc)
• Mobility limitations (link into the Resident/Client mobility evacuation list – see above section)

Ensure this information is centrally located and/or easily accessible during emergencies.
Implement a system to update resident/client identification records on an ongoing basis (consider linking with information and evacuation mobility list back up systems).

Develop resident/client identification mechanism for use in evacuation (name tags, badges etc).
Develop a resident/client coding system (that is linked with resident tagging and naming systems) to identify residents with specialised needs, such as 1:1 monitoring/supervision of residents from secure dementia areas, swallowing difficulties etc.

Staff and Visitors
Ensure there are systems in place for documenting visitors or contractors on-site, which are reflected in the emergency evacuation procedures.

Identify the key steps in the Emergency Plan ensuring that an All Hazard Approach is taken.
10Develop and/or update hazard identification:

• Ensure the facility/organisation has conducted a hazard identification according to known and anticipated (regional and seasonal) environmental, climactic and human-instigated hazards, these include:
  • Environmental (for example, toxic gas leakage, pandemic infections
  • Natural disasters (for example, cyclones, floods, tsunami, earthquake, etc)
  • Essential service failure (for example, water, gas, electricity, sewerage etc)
  • Human -made (for example, terrorism, war, bomb threats etc)
  • Building and structural failures
• Identify and document the identified hazards (and/or classifications), the range of potential incidents
  (combined incidences which have accumulative hazard consequences), within the evacuation procedure
  manual/system.
• Identify and document the circumstances that could precipitate an off - site evacuation.
• Identify and plot pathways of triggers for evacuation (including preparatory steps), to guide staff in the
  decision-making process.

Create a central emergency evacuation resource box that is mobile, readily portable, and ergonomically appropriate (e.g. suit case on wheels). It should be light enough to carry if the ground is uneven / obstructed and the wheels are unusable, and it should also be solid enough to allow use as a temporary desk to spread out documents on, and lean on to write upon.
The box should include weather - proofed resources, such as:

• Resident/client identification cards with photo identification (laser printed to prevent the water smudging/degradation of the data / photo’s).
• Map/s of the site/facility/service
• Velcro dots (1 per resident) Colour = priority or 1:1 care
• Re-sealable plastic bags for medications, medication charts (or profile) and care plans/transfer letters (1 per resident)
• Sticky labels for plastic bags
• Clip board and water resistant pens
• Blank staff identification badges
• Blank emergency volunteer staff member badges
• Current resident handover sheet
• Copies of evacuation procedures
• Temporary and portable lighting appliances (torches and long life batteries)
• Other items that may need to be considered are fluorescent partition tape to secure areas
  and fluorescent jackets/vests for staff.
• First aid kit

Ensure that systems are developed for the routine checking and stocking of this box (eg. stock / inventory checking and rotation system, and monitoring by occupational health and safety/environmental audit)

Ensure that the responsibility for accessing this box is reflected in “staff roles and responsibilities” and captured on the emergency evacuation checklist.

Consult with suitably qualified staff to review the facilities/sites existing assembly areas, to confirm their suitability in
a variety of scenarios, factoring in climatic variations. Assembly areas should:

• Be clearly marked and identifiable within the external environment (signed or ground marked with fluorescent
  painted stripes - with ‘no parking’ signage clearly alerting obstruction).
• Include multiple points of assembly (a minimum of two assembly areas).
• Be located in areas that will not be affected by prevailing winds, to ensure that those assembled will not be
  affected by smoke, toxic gases.
• Be located at a sufficient distance from major structures/buildings, to ensure that evacuees will not be
  affected by fire, debris, broken glass etc.
• Be located in areas that do not hinder the arrival of emergency services (main access road) or their use
  of essential emergency equipment, such as fire hydrants.
• Be clearly outlined and defined (with colour coding and corresponding symbols) on site/facility evacuation
  plans and site plans.
• Not be located where residents/clients will reasonably be put at further risk (e.g. risk of wandering onto a busy
  road, hard to search areas, or at risk of injury due to the terrain).

Evacuation map and plan display

• Ensure site evacuation plans and maps are positioned in prominent and pertinent areas throughout
  the building and site, for example:
  • Foyers and main entrances/exits
  • Reception areas
  • Resident/client collection areas (main rooms)
  • Each separate wing/house/section
  • All key staff areas eg staff room, back of door in staff toilets
  • In dead end areas (closed corridors)
  • Central communication notice boards
  • External weather protected notice or site directional map boards
• Consideration should be given to the limitations of residents/clients who may use these maps and plans to assist them to
  evacuation, and it therefore should be displayed in a sufficiently large point size and legible font
• As the evacuation maps may be utilised when normal lighting might not be available, buildings and essential equipment should be drawn/outlined in large symbol, text, and width
• Ensure a system is developed to routinely monitor the accuracy of these maps.
• Regularly check to make sure that paths can be used by people who may be disabled.
• Educate stakeholders in the use and locations of site evacuation plans, which should:
  • Be reflected in orientation/induction documentation
  • Be reflected in staff training and meetings

As part of the strategic business plan, the organisation/facility should have determined the potential impact of an emergency on the organisations financial situation and have developed risk reduction strategies for a range of emergency/Business Continuity issues, relating to:

• Service Area Continuity Plan
• Emergency Management Plan (organisational roles and support systems)
• Disaster Recovery Plan (DRP)
• Business Resumption Plan (BRP)

Ensure these are accessible and designated key staff members who have the authority/scope to initiate their action.
While the facility deals with the immediacy of the emergency and evacuation plan, the organisation/service needs to have developed continuity plans that assist in the delivery of business service and collection of income. Consider:

• Review scope and terms of insurance policy.
• Establish if the insurance covers loss of personal property, loss of revenue, general liability, debris removal and
  any other expenses related to disaster recovery.
• Consider the impact of long term empty residential beds post emergency and evacuation.
• Accessing credit/finance for essential services and resources
• Maintenance of payroll systems
• Facilitating resident/client access to money for the short term
• Projected financial implications of emergency or disruption to service, when impact will be felt and at
  what point a lack of available cash for the organisation becomes an issue.
• Income collection systems – how are these to be maintained if key information is lost, or not able
  to be obtained (for example
• Resident Classification Assessments are not able to be conducted or have been delayed, resulting in a forfeit
  of established categories)
• Establish the essential tasks to be activated in the case of an emergency and evacuation
• Designate and document in job descriptions the corporate coordinator for the continuity plan
• Identify the staff team members who will take over some of the tasks associated with business continuity
• Establish documentation records and tracking of actions and plans, to assist in time management
  of the continuity plan.

Analysis of needs (remember this was done broadly at committee level):

• Identify the supporting services and suppliers that are required to sustain your organisation’s services,
  and those that may be needed only in emergency situations.
• Formalise any contractual arrangement necessary with existing or new services and suppliers to ensure
  services are continued during emergencies or disruptions to service
• Determine the potential impact of an emergency on these services and suppliers and then develop a contact
  database for existing and alternative providers (to include their contact details (business and after hours), and
  the order in which they should be accessed. This database should include:
  • Contractors (plumbing, electrical, security, waste management, etc)
  • Suppliers (gas, water, electricity, fuel etc)
• Identify core staff numbers (minimum numbers of staffing and the skills mix) that are required to undertake essential services during an emergency situation, and ensure human resource management systems are reflective of this.
• Consideration should be given to documenting the names, capabilities and contact details of volunteers used
  by the organisation, as they may be very useful if normal staff are stretched or fully used.
• Establish alternative supports for community residents/clients if the organisation is unable to provide essential services (transfer delivery of services to another service supplier, for example a catering contractor for Meals on Wheels clients).
• Following these deliberations, develop an Operations Contingency Plan detailing mechanisms for
  continued provision of services

The Development of an Operations Contingency Plan

• Document pathways for essential operations in the event of an emergency and evacuation
• Ensure key responsibilities are designated for each part of the plan, and a central chain of command is established.

• Develop and implement information technology (IT) security and electronic data storage systems, ensuring that the retrieval of information in the event of a disaster is assured. These should include:
  • Daily information technology storage back-up systems, either on a disc or remotely on a server (these should be documented in job descriptions and duty lists for those services that have systems that are manually initiated, or routinely reported and recorded for those systems that can be programmed to self initiate).
  • If this information is stored on a disc or CD, ensure it is securely stored in a fireproof area and accessible to key staff in the event of an emergency.
  • If information is stored on a disc or CD, ensure the service has access to a functioning laptop and portable printer (which are also stored in a fireproof area), to facilitate retrieval of this information.
  • Ensure that remote stored information technology data is accessible in the event of an emergency (ensure key personnel know who to contact to access this, or what sites/locations to go to facilitate this).
  • Maintenance of computer server systems, to ensure reliability and data storage capabilities.
  • Ensure anti-viral software and maintenance systems are operational, to protect the corruption of data.
  • Ensure IT data accessing security systems are robust, and are reactive to personnel changes.
  • Limit IT data access to relevant roles with associated key areas/pathways.
• An information technology disaster recovery procedures should include:
  • Who is responsible for initiating the retrieval, and who coordinates the resources associated with this.
  • Location and contact details of the external source/s of IT backups.
  • Accessing of computer equipment and resources to facilitate the use of the data, which has been backed up.
  • Process for remote back up of new information stored within the IT system, in the course of the emergency.
  • Security measure and storage requirements for transportable IT systems.

• If not already in place, develop and implement staff training records and tracking systems, and ensure designated staff are responsible for relevant data collection, and the maintenance of this system. This role should be reflected in relevant job description and expectations of education participation should be captured in the performance appraisal system.
• Undertake a staff skills review and document capabilities/skills that are not routinely reflected in their current job description, to establish key tasks they could assist with, or be developed in, that could be used in emergency situation, such as:
  • Bus and truck or bobcat license holder
  • SES or Army reserves volunteer
  • Senior First Aid certificate holder
  • Bi-lingual or non-verbal language skills
  • Certificate IV who could be used as a trainer/facilitator
  • Working at height training
  • Limited electrical license holder
  • Emergency management and response experience
  • Occupational Health and Safety officer (past or present)
• Ensure that if these extra skills are to be utilised in an evacuation situation, the relevant staff are supported to maintain their skills through training and maintain tracking systems of the same.
• Identify and establish the training requirements to effectively maintain and enact the Evacuation Plan, ensuring it is reflective of all relevant stakeholders and the roles they play in the evacuation (key personnel, staff, residents/clients and their representatives, visitors, contractors and external service support services). These should include:
  • Induction procedures (staff handbook and associated literature, competency testing, induction checklist validation)
  • Orientation (integrate into buddy system and key performance attainment in probationary processes)
  • Annual staff training modules linked in with current fire and emergency management training
  • Informal education refresher opportunities
  • Resident/client and representative case conferencing refresher opportunities
  • Staff and resident/client meeting informal education refresher opportunities
• Develop an exercise and drill program
• Ensure the required and routine education of staff is monitored within the organisation’s own internal auditing systems.

• Develop a monitoring and review process (audit tools or measures) for the Evacuation Plan, ensuring that it is reflected in existing audit schedules and key performance indicator systems. The tools used to monitor and evaluate the Evacuation Plan should be reactive to industry issues and legislation changes, and require a review of the Plan(s) at least annually.
• The Evacuation Plan testing should include annual desktop walk through of plans, annual testing of each component of the plan, and an annual full scenario based testing of the plan. Parts of these tests could take the form of:
  • Maintenance checks to make sure that equipment is working and still suitable for use
  • Process checks (including making sure that external resources are still usable or available)
  • Equipment and documentation checklist
  • Competency questionnaires for stakeholders
  • Activation of parts of the Evacuation Plan
  • Mock scenario drills. Document the results on an evaluation form and then analyse the results
  • Full activation of the Evacuation Plan, involving all stakeholders
• Identify who is to be responsible for routine monitoring and review of the plan, and ensure that it is reflected in relevant job descriptions or duty statements.
• Ensure adequate training of key personnel who are responsible for this task.
• Invite key external contractors to participate in drills.
• Identify deficiencies captured through the monitoring and review process, and ensure that action plans are developed and implemented. These should be captured and reflected in existing continuous improvement quality management systems.
• Ensure that the standard review processes (reporting on currency and robustness of the Evacuation Plan) are reported to relevant organisational committees and key personnel.

Remember, this risk management review should be updated at least annually, and be formally accepted and signed-off by the business and senior management team, as part of the ongoing strategic plan.

• Assign a staff member to be responsible for collection and dissemination of current and ongoing information relating to emergency management, in order to keep the Emergency Response Team / Planning Committee appraised of contemporary practice in the area of emergency preparedness.
• Ensure that these key responsibilities are reflected in job descriptions and evaluated through routine staff performance appraisal systems.
• Incorporate these areas into staff key performance indicator systems
• Ensure Evacuation Plan process changes resulting from contemporary practice changes, are communicated to key personnel (via training sessions etc).

10 All Hazard Approach - simply means one plan fits all hazards including evacuation, that is, you do the same thing for evacuation, irrespective of the cause

9 Table - Business Impact Analysis Summary