CONTINUITY OF OPERATIONS WORKSHOP

Montana Department of Public Health and Human Services

Summer InstituteJuly 17-21, 2017

Billings, MT

INTRODUCTIONS

• Name

• Position

• Organization

• Experience with emergencies or disasters in healthcare

• Experience with continuity of operations planning

• What do you hope to get out of the Continuity of Operations (COOP) Workshop?

CONTINUITY OF OPERATIONS WORKSHOP

EXPECTATIONS AND OUTCOMES

• Module I: Introduction to COOP – What is a COOP? What are the elements of a successful COOP program and plan?

• Module II: Developing a draft COOP plan – Essential elements of a viable COOP plan

• Hazard Vulnerability Analysis

• Mission Essential Functions

• COOP Worksheets

• COOP Plan Template

• Module III: Evaluating the draft COOP – How do I know it works?

• Scenario based tabletop exercises

WORKSHOP OPPORTUNITIES

• Use workshop time wisely

• Establish and strengthen professional relationships

• Actively participate in discussions

• Gather and study available resources

MODULE 1

Introduction to Continuity of Operations

MODULE I: AGENDA

• Background

• EOP vs COOP

• Building a Successful COOP Program

• COOP Process

• Elements of a Viable COOP Plan

• COOP Plan Activation

• Now What?

BACKGROUND

Why do we need a COOP?

LEGAL BASIS FOR CONTINUITY OF OPERATIONS

• Federal Continuity Directive 1 (FCD 1)

• Continuity Guidance for Non-Federal Organizations

• Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers – September 2016

• Regulatory and Accrediting Conditions of Participation

• Healthcare Preparedness Program Conditions of Participation

OKLAHOMA CITY BOMBING APRIL 19, 1995

SEPTEMBER 11, 2001

HURRICANE KATRINAAUGUST 23, 2005

PANDEMIC INFLUENZAAPRIL 15, 2009

SANITARY SEWER OUTAGEOCTOBER 2010

JOPLIN TORNADO MAY 22, 2011

HURRICANE SANDYOCTOBER 29, 2012

LINCOLN EARTHQUAKEJULY 8, 2017 - ?

WITHOUT A CONTINUITY PLAN

• Businesses may lose the ability to maintain essential services during/after a disaster

• Businesses may be forced to close or struggle to stay open during/after a disaster

• Paid staff, volunteers or services may be underutilizedor not show up for work if they are untrained and don’t know the back up plan or their role(s) in that plan

• Staff may not know where to get back-up resources, which venders to contact, or know the alternate locations if the facility is no longer usable

CONTINUITY OF OPERATIONS PLAN

What is it?

• All-hazards plan used when an event incapacitates the normal functioning of the organization for more than a limited amount of time

• Framework for recovery and reconstitution of mission essentialfunction(s)

• Prioritized recovery objectives with critical support elements

What is it NOT?

• It is NOT an emergency operations/response plan

• It will NOT address every scenario

• It is NOT as step-by-step action plan

• It is NOT something one person / department can write themselves

EOP VS. COOP

We already have an EOP – isn’t that enough?

EOP VS. COOP

COOP

• COOP allows an agency to resume normal essential operations during an emergency situation with as little disruption as possible

• Addresses immediate aftermath, short-term, and long-term (up to 30 days), with focus on continuing essential business functions

EOP

• EOP establishes the framework for response to emergencies and disasters

• Addresses only immediate aftermath of an incident

EOP VS. COOP

Emergency Operations Planning:

• guides response to an emergency, disaster situation or a mass casualty incident

Continuity planning:

• augments existing EOPs

• strengthens an organization’s capacity to scale their response

• is a proactive process that identifies and prioritizes the critical (essential) functions and applications

• measures of the impact threats to those functions

KNOWLEDGE CHECK

• Which characteristics best describe a COOP?

A. Guides resumption of essential services with as little disruption as possible

B. Addresses immediate aftermath of a disaster/event

C. Measures the impact of a threat on a function

BUILDING A SUCCESSFUL COOP PROGRAM

WHAT IS A COOP?

• Continuity of Operations (COOP) is a Federal initiative, required by Presidential directive, to ensure that agencies are able to continue performance of essential functions under a broad range of circumstances.

Ensure the continuous performance of an agency’s essential functions/operations during an emergency

Protect essential facilities, equipment, records, and other

assets

Reduceor mitigate

disruptions to operations

Achieve a timely and orderly recovery from an emergency

and resume full service to customers

WHAT IS THE GOAL OF

COOP?

FOUR PILLARS TO SUCCESSFUL COOP

• Leadership - support continuity planning and ensure continuity of essential functions

• Staff - sufficiently trained and cross-trained to perform their duties in a continuity environment

• Facilities - adequate, separate locations to ensure execution of essential functions

• Communication systems -interoperable, robust, and reliable

FOUR PILLARS

Leadership

• How will organization manage risk?

• How will financial, human and material resources be allocated?

• How will you train your staff?

• How will you test your plan?

• How will you improve it?

Staff

• Is your COOP team interdisciplinary?

• Do you know what your plan is?

• Is your COOP reasonable and actionable?

• Is it inline with your business functions and organizational mission?

FOUR PILLARS

Facilities

• Can the work be completed in alternate facilities?

• Are these facilities equipped for these functions?

• Can they be accessed by those who must be there?

• What does staff need at the alternate location?

Communications

• Are they redundant?

• Are they clear?

• What message are you delivering?

• Who is the audience?

• What information do you need to communicate?

KNOWLEDGE CHECK

• Which are the four pillars of a successful COOP?

A. Financial Investment, Leadership, Communications, Staff

B. Leadership, Communications, Exercises, Training

C. Facilities, Exercises, Financial Investment, Training

D. Staff, Communications, Leadership, Facilities

COOP PROCESS

PLANNING CYCLE

4 step process:

1. Planning: select a team, identify essential functions and potential hazards

2. Training: test to confirm whether the process is needed, train staff, exercising the plan to verify that the plan works as intended

3. Evaluating outcomes with after action reports, lessons learned

4. Developing Corrective Action Plans to improve the plan

COOP PROCESS

• Identify essential functions

• Analyze and prioritize potential hazards

• Design and build the plan

• Test, train, and exercise the functions identified

• Distribute and maintain the plan

Module IIModule III

DETERMINE ESSENTIAL INFORMATION

• What?

• Who?

• How?

• Where?

• When?

• Who’s in charge?

• Return to normal?

• Essential Functions (Mission-Critical)

• Essential Positions; Functional Roles & Responsibilities; Incident Command

• Vital Records & Critical Applications; Communications Resources; Logistics Support & Resource Requirements

• Alternate Care Facility; Recovery Location

• Function Priority; COOP Phases; Recovery Time Objective (RTO)

• Lines (Orders) of Succession; Delegations of Authority

• Reconstitution; Devolution

HAZARD VULNERABILITY ANALYSIS

• Conducted to identify threats and risks that pose a hazard to the operations of the hospital, including the information technology infrastructure

• Understanding potential events allows the hospital to plan and mitigate or eliminate the impacts of these events

HAZARD VULNERABILITY ANALYSIS

DESIGN AND BUILD THE PLAN

• Appoint a Continuity Program Manager

• Select a multi-disciplinary planning team

• Determine essential functions

• Apply risk management principles to assess potential hazards

• Identify resources required for continuity planning

• Establish objectives and milestones

• Determine procedures for information gathering and decision-making

ELEMENTS OF A COOP PLAN

PURPOSE OF A CONTINUITY PLAN

• Provide for continuation of essential functions

• Enable a rapid response to any emergency situation

• Continuity plan contains:

• WHAT will occur in a continuity situation

• HOW and HOW QUICKLY continuity actions must occur

• WHERE continuity operations will occur

• WHO will participate in continuity operations

PHASES OF A CONTINUITY PLAN

• Phase I: Readiness and Preparedness

• Phase II: Activation and Relocation (0 -12 hours)

• Phase III: Continuity Operations (12 hours – 30 days or until resumption of normal operations)

• Phase IV: Reconstitution (recovery, mitigation and termination)

WHAT ARE THE ELEMENTS OF A VIABLE COOP PLAN?

1. Essential Functions

2. Orders of Succession

3. Delegation of Authority

4. Continuity (Alternate) Facilities

5. Continuity (Interoperable) Communications

6. Essential Records Management (Vital Records, Databases & Systems)

7. Human Resources (Contingency Staff and Responsibilities)

8. Tests, Training and Exercises

9. Devolution of Control and Direction

10. Reconstitution

ESSENTIAL FUNCTIONS

Essential functions are those functions that enable an organization to:• Provide vital services• Exercise civil authority• Maintain the safety of the general public• Sustain the industrial or economic base during an

emergency

There are 3 types of essential functions:• National Essential Functions (NEF)• Primary Mission Essential Functions (PMEF)• Mission Essential Functions (MEF)

MISSION ESSENTIAL FUNCTIONS

Mission Essential Functions (MEF) are those functions that enable an organization to:

• Provide vital services

• Exercise civil authority

• Maintain the safety of the general public

• Sustain the industrial or economic base during an emergency

MEF IDENTIFICATION

• Limited set of an organization’s functions and activities that cannot be deferred

• Functions include those performed at all locations, not just at headquarters

• Organizations have to focus their efforts and limited resources on those functions that cannot be deferred

MORE MEFS ARE BETTER, RIGHT?

• If an organization identifies too many functions as essential, limited resources and/or staff availability during the emergency may not be sufficient to enable performance of all identified essential functions

• If an organization fails to identify functions as essential and does not include them in emergency and continuity plans, these functions may not be performed during an emergency

ORDERS OF SUCCESSION

Succession to office is critical in the event that the agency’s leadership is unavailable, debilitated, or incapable of performing their legally authorized duties, roles and responsibilities

DELEGATIONS OF AUTHORITY

Delegations of authority are formal documents specifying the activities that may be performed by those who are authorized to act on behalf of the agency head or key officials. Delegations of authority:

• Document legal authority

• Ensure continued operations of agencies and their essential functions

• Ensure the rapid response to any emergency situation requiring continuity plan implementation

CONTINUITY (ALTERNATE) FACILITIES

FCD 1 and CGC 1 assume that, if continuity activation is required, an agency’s primary operating facility is unavailable and that essential functions will require relocating. The alternate facility should:

• Be far enough away from the primary facility that it will not be impacted by the continuity event

• Have another continuity or devolution site in case the continuity facility is also inoperable

CONTINUITY (INTEROPERABLE) COMMUNICATIONS

Continuity of communications provides the capability to perform essential functions, in conjunction with other agencies, until the normal operations can be resumed. Continuity communications must be:

• Redundant

• Available within 12 hours or sooner, depending on the mission and requirements of the organization

• Sustainable for up to 30 days or until normal operations can be resumed

ESSENTIAL RECORDS MANAGEMENT

Essential records are categorized as:

• Emergency operating records that are required for agency essential functions during and after a continuity event

• Rights and interest records that are critical to carrying out an agency’s essential legal and financial functions

• Reimbursement from insurance carriers, FEMA requires documentation of costs directly related to the disaster

HUMAN RESOURCES

Human resources is the sum of talent, energy, knowledge, enthusiasm and creativity that people invest in their work. Concerns for human resources in a continuity situation include:

• Communicating with all employees

• Providing guidance to all employees

• Determining the best way to use continuity personnel

“One up, one down”

TESTING, TRAINING AND EXERCISE

A testing, training and exercise program provides the framework for promoting consistency and uniformity of mission-readiness activities. An effective program:

• Provides training and cross-training in areas appropriate to mission readiness

• Provides the opportunity to practice skills/knowledge needed for continuity operations

• Builds team unity, increases staff confidence

DEVOLUTION

Devolution is the capability to transfer statutory authority and responsibility for mission essential functions from an agency’s primary operating staff and facilities to other agency employees and facilities, and to sustain that operational capability for an extended period.

Devolution may be:

• Long-term: An overall plan for ensuring an organization’s continuity capability

• Short-term: A planned, temporary transfer of essential functions to a continuity site until the alternate facility is operational

RECONSTITUTION

The reconstitution process involves three broad tasks:

• Transitioning from continuity status back to normal operations

• Coordinating and planning options for reconstitution, regardless of the level of disruption

• Outlining the procedures necessary to effect a smooth transition from a relocation site to a new or restored facility

TEST, TRAIN AND EXERCISE THE PLAN

When the COOP is “complete”:

• Tests: confirm whether or not procedures, processes, and systems function as intended

• Training: ensures all personnel know what to do, how to do it and when it should be done

• Exercises: provide practice and verification of whether the plan works as intended

DISTRIBUTE, UPDATE AND MAINTAIN THE PLAN

• Distribute the plan to all key stakeholders

• Review and update annually

• Maintain the plan by keeping it current and accurate

• Have a plan for improving the plan

COOP PLAN ACTIVATION

When do we activate our COOP?

COOPs are all-hazards and are to be used during an event that incapacitates the normal functioning of the departments for more than a

limited amount of time.

Lessons Learned &After-Action Reporting

Activation and Relocation

Alternate Operating Facility Operations

Reconstitution

WHEN TO ACTIVATE A COOP

WHEN TO ACTIVATE A COOP

Internal or External Disruption(s)

• Loss of Technology. Patient record-keeping systems are inaccessible; what services cannot be stopped and what services may be postponed due to lack of software availability?

• Loss of Staff. A pandemic outbreak causes 40% of ANOTHER hospital/department staff to miss work; functions must be evaluated to determine how your facility might assist

• Loss of Facility. YOUR hospital/healthcare facility is inaccessible because the roof collapsed; what essential functions must continue to be performed at alternate facilities in order to keep your BUSINESS operational?

KNOWLEDGE CHECK

• In which situation might a COOP be activated?

A. When a staff member does not show up for work as previously scheduled

B. When a snow storm downs a tree, closing a wing of a hospital

C. When a heatwave causes a rolling blackout

SO I AM SOLD! NOW WHAT?

Even if I understand the importance and am ready to begin, what do I need to do to write a successful COOP?

Todd Cannan, MS, Emergency Management

Chief Projects OfficerOffice: 844-201-4302 ext 101

Cell: 406-581-0853toddcannan@summitet.com

Leanne Vreeland, CHPCPSenior Planner

Office: 406-251-9485Cell: 406-546-9305

leannevreeland@summitet.com