CONTINUITY OF OPERATIONS PLAN GUIDANCE FOR
INDIAN HEALTH CENTERS
DRAFT JUNE 2010
GLOBAL VISION CONSORTIUM FOR NAAEP
CALVIN FREEMAN BRIAN TISDALE
This guide is based on general guidance from the Department of Homeland Security (DHS) Headquarters Continuity of Operations (COOP) Guidance Document, and the sample Concept of Operations (COOP) template developed by the Federal Emergency Management Agency (FEMA). It is adapted for use by community health centers.
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READ ME FIRST
Welcome to the East Valley Indian Health Center and its Continuity of Operations Plan and program.
We have developed a model Continuity of Operations Plan for the simulated East Valley Indian Health Center to illustrate key elements in the development of Continuity of Operations Plans (COOP) for Indian Health Programs. This plan shows what a Continuity of Operations Plan could look like for a moderate sized health center experiencing an emergency that requires reduction of services at its primary site or relocation of services to an alternate location. The model plan does not address many of the COOP issues created by an influenza outbreak, such as social distancing and other protective measures. These steps are usually covered in a pandemic annex to the Health Center Emergency Operations Plan. While not providing a “fill-in-the-blank” template, it does illustrate how some of the key planning, preparedness, response and recovery issues are often addressed.
As with all planning templates, the model text and examples will not cover all circumstances. While terminology (e.g., Emergency Evacuation Team or Emergency Response Team or Emergency Relocation Team), organizational structures and governance vary somewhat among community clinics and health centers, this model plan is designed to present COOP planning elements that are likely to be common across health centers regardless of size, location and governance.
This document also includes two annexes. Annex A is an example of a “Restoration Plan” for an essential function. This restoration plan provides a summary of all the elements required for continuing to perform this function at the original clinic site or at an alternate location.
Annex B consists of Worksheets that are useful for organizing and recording the results of the planning effort. These forms can be kept available for rapid access and for routine updating and as information changes.
Three final points:
1. First, COOP planning begins with a robust safety and emergency management program. Ensuring the safety of patients, visitors and staff is the first priority of emergency management.
2. Second, the planning process is essential and must involve key elements of the organization to create a plan that is accurate, understood across the organization and capable of implementation. Likewise, the finished plan must be updated at least annually.
3. Third, undertaking a COOP planning process has benefits beyond emergency preparedness. It requires a strategic review and understanding of the functions that are core to the mission of the health center. It also helps to identify their day-to-day strengths and vulnerabilities, as well as vulnerabilities in emergencies.
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MODEL CONTINUITY OF OPERATIONS PLAN
FOR
INDIAN HEALTH CENTERS
FOR OFFICIAL USE ONLYInsert agency text for this restrictive marking.
All personnel are reminded that information contained in this document is FOR OFFICIAL USE ONLY. It is to be used only to contact organization personnel in response to an emergency situation.
Unauthorized use of this information may constitute an invasion of privacy.
MODEL PLAN TABLE OF CONTENTS
Executive Summary 1
I. Introduction 2
II. Purpose 2
III. Glossary and Acronyms 3
IV. Concept of Operations 8
A. Applicability 8
B. Scope 8
V. Planning Assumptions 8
VI. Coop Elements 9
A. Plans and Procedures 9
1. Risk Analysis 10
2. Vulnerability Assessment 10
3. Response Phases 10
4. Resource Requirements 11
5. Functional Dependencies 11
6. Line of Authority 11
7. Response Roles 12
8. EVIHC Emergency Management Coordinator (EMC) 12
9. Emergency Response Team (ERT) 12
10. Essential Function Personnel 13
11. Decision Process 13
a. Activation during normal working hours: 13
b. Activation outside of normal working hours: 14
12. Alert, Notification, and Implementation Process 14
13. Essential Function Systems & Equipment 15
14. Vendors & Other Agency Functions 15
B. Essential Functions 15
C. Delegations of authority 15
D. Orders of Succession 15
E. Alternate Operating Facility(ies) 16
F. Interoperable Communications 17
G. Vital Records and Databases 17
H. Human Capital 18
1. Protection of Personnel 18
2. Human Resource Requirements 18
3. Human Resource Policies 18
4. Role of EVIHC Staff 18
I. Test, Training and Exercises 19
J. Devolution of Direction and Control 19
K. Reconstitution 19
VII. COOP Maintenance 20
VIII. Authorities and References 20
IX. ANNEXES 21
Annex A: Sample Restoration Plan 22
Annex B: Worksheets 23
COOP PLAN APPROVALS
By their signatures below, the following senior level officials certify that they approve this Continuity of Operations Plan and fully understand the continuity of business operation procedures that are to be followed in the event of an emergency that impacts the facilities and employees for which they are responsible.
Approved: ______Date ______
[Name/Executive Director]
Approved: ______Date ______
[Name/Title]
Approved: ______Date ______
[Name/EVIHC Clinic Manager]
Approved: ______Date ______
[Name/EVIHC Clinic Coordinator]
NOTE: Other approvals may include: chairperson of the board of directors, tribal chairperson, health center safety manager, etc.
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Executive Summary
The purpose of the East Valley Indian Health Center (EVIHC) Continuity of Operations (COOP) Plan is to ensure the continuity of essential functions of the EVIHC during emergencies created by a variety of hazard threats and when normal, standard operations become overwhelmed. This plan applies specifically to EVIHC and the programs which operate within EVIHC. It is consistent with the COOP/COG Plan, its Emergency Operations Plan and related specific hazard contingency plans, and of the EVIHC’s Tribal Organization and the emergency plans and related ordinances of East Valley County. This plan coordinates with and is supported by the EVIHC’s Emergency Evacuation Plan; Disaster Response Plan; Pandemic Influenza Response Plan; Injury and Illness Protection Plan, including infection control measures and safety procedures; and the Information Technology Operational Recovery Plan of EVIHC and its Tribal Organization.
While the EVIHC COOP Plan is an all hazards plan, it incorporates the findings of the Hazard Vulnerability Assessment performed by EVIHC. It addresses emergencies, regardless of hazard, that occur during normal work hours or off-hours that disrupt the performance of designated essential functions. The plan is based on a worst case scenario in which the EVIHC facility is not usable, most personnel are not available, and outside assistance is not immediately available. It reflects an expectation that essential functions can be restored to an acceptable level within 24-72 hours and EVIHC can maintain operations for 30 days with external support even if the EVIHC facility is unusable.
EVIHC has identified the following essential functions:
· (Priority A) Medical care for victims in the immediate aftermath of a disaster that occurs during EVIHC’s normal business hours.
· (Priority B) Vaccine and antiviral distribution during a pandemic influenza outbreak.
· (Priority B) Ongoing essential medical services for East Valley County following a disaster.
This plan describes:
1. How EVIHC will implement its COOP plan and address critical COOP elements including activation and relocation, alternate facility operations, and reconstitution.
2. The executive decision process that takes into account the nature and extent of the emergency to determine the best course of action for response and recovery.
3. Measures to ensure the succession of organization leadership, pre-delegation of emergency authority and active command and control.
4. The operational details to implement the plan and to meet the logistic requirements for plan execution (See Annex A – Essential Function Restoration Plan).
I. Introduction
COOP Planning
Continuity of Operations (COOP) Planning is an effort within organizations to ensure the continued performance of minimum essential functions during a wide range of potential emergencies. Essentially, it is the capability of maintaining the business of the organization under all eventualities through the development of plans, comprehensive procedures, and provisions for alternative facilities, personnel, resources, interoperable communications, and vital records/databases. It also includes ensuring the succession of organization leadership, pre-delegation of emergency authority and active command and control.
The EVIHC COOP Plan is designed to meet the requirements set by the EVIHC’s Tribal Organization for COOP and other emergency response planning by its health centers and programs and facilities.
Plan Design
The EVIHC COOP Plan is comprised of a number of component parts that meet the needs of the various users of the plan and their roles in the overall COOP program. The Plan addresses high level, overview information about how an organization is supposed to respond to disruptions and, in Annex A, the operational detail necessary to support the response to these disruptions. Given the sensitivity of some of the information in this Plan, the distribution of the Plan and its associated documents is limited.
The EVIHC COOP Plan addresses events that disrupt or threaten to disrupt health center operations that are vital and time-critical to patients, clients and the community. Existing Tribal Organization and EVIHC contingency and emergency plans are not replaced by but are incorporated or referenced in the EVIHC COOP Plan.
II. Purpose
The purpose of this plan is to ensure the continuity of essential functions of the EVIHC during emergencies created by a variety of hazard threats and when normal, standard operations become overwhelmed.
This Plan identifies recovery strategies only for essential functions that are mission and time critical. An Essential Function (Worksheets 1 EVIHC Functions & 2 EVIHC Essential Functions) is defined as a function that enables EVIHC to:
1. Provide vital or “essential” services;
2. Maintain the health and safety of patients, visitors, staff and the community it serves; or
3. Maintain its financial and legal foundation.
Essential functions are prioritized and classified according to the maximum tolerable duration between the occurrence of a disruption and when the resumption of the function under emergency conditions, i.e. the maximum amount of time the function can be down.
A: Emergency response functions (0-2 hours)
B: High impact on public safety and health, or on critical operations (up to 72 hours)
C: Moderate impact on public safety, health or critical operations (1-3 weeks)
III. Glossary and acronyms
A. GLOSSARY
Activation - When a COOP plan has been implemented whether in whole or in part.
Agencies - Federal and state Executive Branch departments, agencies, and independent organizations.
Agency Head - The highest-ranking official of the primary occupant agency or a successor or designee selected by the official.
Alternate facility - A location, other than the normal facility, used to carry out essential functions in a COOP situation.
Automated Data Processing (ADP) equipment - Equipment that performs data processing largely by automatic means.
Collateral damage - Injury to personnel or damage to facilities that are not the primary target of attack.
Consumable office supplies - General supplies that are consumed in office use.
Continuity of Government (COG) - A coordinated effort within each branch of the Federal Government to ensure the capability to fulfill minimum essential responsibilities in a catastrophic emergency to ensure the capacity to maintain an enduring constitutional government.
Continuity of Operations (COOP) - The activities of individual departments and agencies and their sub-components to ensure that their essential functions are performed. This includes plans and procedures that delineate essential functions; specify succession to office and the emergency delegation of authority; provide for the safekeeping of vital records and databases; identify alternate operating facilities; provide for interoperable communications; and validate the capability through tests, training, and exercises.
COOP Event - Any event that causes an agency or organization to relocate operations to an alternate site or adopt non-standard procedures to assure continuance of its essential functions.
Critical Infrastructure Protection (CIP) - Risk management actions intended to prevent a threat from attempting to, or succeeding at, destroying or incapacitating critical infrastructures. Critical infrastructures are those systems and assets so vital to the Nation that their incapacity or destruction would have a debilitating impact on national security, national economic security, and/or national public health or safety.
Delegation of authority - Specifies who is authorized to act on behalf of the organization head and other key officials for specific purposes.
Devolution - The capability to transfer statutory authority and responsibility for essential functions from an agency's or organization’s primary operating staff and facilities to other employees, facilities, or organizations, and to sustain that operational capability for an extended period.
Drive-Away Kit (Go-Kit): A kit prepared by, and for, an individual who expects to deploy to an alternate location during an emergency. It contains items needed to minimally satisfy personal and professional needs during deployment.
Emergency Coordinator - This is the key senior staff appointed within an organizational element who serves as the coordinator for all emergency response and COOP related matters.
Emergency Operating Records - Records that support the execution of an organization’s essential functions.
ERT Member - Emergency Response Team member. A person assigned responsibility to report to an alternate site, as required, to perform agency essential functions or other COOP related operations.
Essential functions - Functions that enable the organization to provide vital services, maintain the safety and well being of the clients, staff and community, and sustain its economic base in an emergency.
Essential resources - resources that support the organization’s ability to provide vital services, maintain the safety and well being of the clients, staff and community, and sustain its economic base in an emergency.
Executive Agent - A term used to indicate a delegation of authority by a superior to a subordinate to act on behalf of the superior. An executive agent may be limited to providing only administration and support or coordinating common functions, or it may be delegated authority, direction, and control over specified resources for specified purposes.
Interagency Agreements - A written agreement entered into between agencies that require specific goods or services to be furnished or tasks to be accomplished by one agency in support of the other.