Building Hospital Resiliency: Utilizing a Holistic  Approach to Respond and Recover from a                  Disruption    ...
Yale New Haven Health System          Westerly                                                                YSM         ...
Objectives• History of BCP/COOP• Terminology• Standards and Compliance• BCP Challenges & Pitfalls              Objectives•...
Overview• Event• History of BCP/COOP• Terminology•Standards and Compliance                        4
BCP/COOP Event              modified U.S. DoD graphic                             Incident Occurs                         ...
Overview• BCP/COOP should be an organization or department-wide initiative utilizing a holistic approach to prepare theorg...
Business Continuity Plan vs. Continuity ofOperation Plan• The terms Business Continuity Plan (BCP) and Continuity ofOperat...
BCP/COOP Standards & RegulationsThe goal of any standard is to follow a clearly structured good    practice guide to how t...
BCP/COOP Pitfalls & Challenges Pitfall # 1 – Not having a plan(s) •   Huge risk to the core business, operational and clin...
BCP/COOP Pitfalls & Challenges Pitfall # 5 – Not identifying essential functions •   Not everything is mission essential •...
BCP/COOP Pitfalls & Challenges • One of the challenges that prevents organizations from taking full advantage of a holisti...
BCP/COOP Pitfalls & Challenges • No organization is an island and one of the larger challenges to holistic BCP/COOP is how...
Phased Approach1-3 Months   6-9 Months   9-12 Months   12 Months   Ongoing                               13
Phase 1 - Project Initiation                C-Suite                Buy-In                          14
Phase 1 – Project InitiationEstablish Governance and Obtain Buy-In•Meet with Senior Leadership   • Obtain commitment from ...
Phase 1 – Project InitiationBCP/COOP Steering Committee Provide hospital or healthcare system-wide business continuity  p...
Phase 1 – Project Initiation BCP Project Support Team  The BCP/COOP Project will be coordinated by the  BCP/COOP Project T...
Phase 2 - Business Impact Analysis                    BIA                       18
Phase 2 - Business Impact AnalysisConduct a Business Impact Analysis•Determine your Vulnerability / Hazards  • Review Haza...
Phase 2 - Business Impact AnalysisDetermine your Business Impact         Defined by Disaster RecoveryInstitute Internation...
Phase 2 - Business Impact AnalysisDetermine your Business Impact•Gather data via a survey or questionnaire    • Can be dis...
Phase 2 - Business Impact Analysis  Determine your Business Impact  •Analyze / Review Data     • Identify the main areas o...
Phase 2 - Business Impact AnalysisIdentify Time-Sensitive Business Operation Processes andApplication Systems• Establish a...
Phase 2 - Business Impact Analysis Hazard Vulnerability Analysis Kaiser Permanente Model - http://www.nachc.com/EM-Plannin...
Step 2 – Business Impact Analysis  Example of a Business Impact Analysis survey that was completed by functional  managers...
Step 2 – Business Impact Analysis  Examples of Departmental Responses to a Disruption                                 86% ...
Phase 3 – Plan Design and Development                        27
Phase 3 – Plan Design and Development Based Upon HVA and BIA    • Plan for the most probable and highest impact      event...
Phase 3 – Plan Design and DevelopmentThe Concept of Operations describes the procedures for                   Phase 1  BCP...
Phase 3 – Plan Design and Development Identifies How Communications with Employees and Organizations are Carried Out   • D...
Phase 3 – Plan Design and DevelopmentOutlines Order of Succession / Delegation of Authority   • Orders of Succession      ...
Phase 3 – Plan Design and DevelopmentDefine How Essential Functions Will Be CarriedOut / Concept of Operations   • First e...
Phase 3 – Plan Design and Development Alternate Work Locations / Telework Arrangements    • Do you have an alternate locat...
Phase 3 – Plan Design and Development Integration with EOP / EMP •Is your plan NIMS / ICS Compliant •Can it be integrated ...
Phase 3 – Plan Design and Development  Other Considerations  •     Design a consistent departmental/work unit BCP/COOP for...
Phase 3 – Plan Design and DevelopmentOther Considerations •   Expand usage of the “Hospital     Incident Command System”  ...
Phase 4 - Plan Implementation                       37
Phase 4 – Plan ImplementationDistribution•Distribute plan to all personnel and outside agencies whohave a role in the BCP/...
Phase 4 – Plan ImplementationDeliver Training•Deliver Various Types of Training Programs asappropriate    • Computer-based...
Phase 5 – Test, Exercise, and Maintenance                         40
Phase 5 – Test, Exercise, and Maintenance Test and Evaluate The Plan and Tools •Hold a tabletop or functional exercise to ...
Phase 5 – Test, Exercise, and Maintenance Define Plan Maintenance Scheme and Schedule • Define ownership of plan data • Pr...
Phase 5 – Test, Exercise, and Maintenance Establish Status Reporting Procedures • Establish reporting procedures      • Co...
Any Questions?                 44
Contact Information      James L. Paturas, LP, CEM, CBCP, CHS-V, FACCP               Director, Emergency Preparedness     ...
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JC EM Conference 2013 -Paturas

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  • 03/12/13 Jeffery Schlegelmilch Day I: Best Practices II: Exercises: Utilizing HSEEP Tools and Concepts for Training Scenarios
  • The Yale New Haven Center for Emergency Preparedness and Disaster Response (YNH-CEPDR) provides education and training programs for healthcare emergency preparedness. Our Mission: To reduce loss of life, injury and illness by developing and delivering services within Connecticut, across the nation and around the world that advance healthcare planning, preparedness, response and recovery from emergency events and disasters through collaborative partnerships and coordinated programs.
  • The Yale New Haven Center for Emergency Preparedness and Disaster Response (YNH-CEPDR) provides education and training programs for healthcare emergency preparedness. Our Mission: To reduce loss of life, injury and illness by developing and delivering services within Connecticut, across the nation and around the world that advance healthcare planning, preparedness, response and recovery from emergency events and disasters through collaborative partnerships and coordinated programs.
  • The Yale New Haven Center for Emergency Preparedness and Disaster Response (YNH-CEPDR) provides education and training programs for healthcare emergency preparedness. Our Mission: To reduce loss of life, injury and illness by developing and delivering services within Connecticut, across the nation and around the world that advance healthcare planning, preparedness, response and recovery from emergency events and disasters through collaborative partnerships and coordinated programs.
  • JC EM Conference 2013 -Paturas

    1. 1. Building Hospital Resiliency: Utilizing a Holistic Approach to Respond and Recover from a Disruption Emergency Preparedness Conference: 2013 “Is Recovery Ever Really Over? The Joint Commission Las Vegas, NV May 1-2, 2013 1
    2. 2. Yale New Haven Health System Westerly YSM YSM Yale Medical Group Bridgeport Bridgeport Greenwich Greenwich Yale-New Haven Yale-New Haven Northeast Medical Group (NEMG) Largest, most integrated healthcare system in Connecticut with $2.6 billion in revenue 18,435 employees and 5,675 physicians 93,923 patient discharges and 1,397,632 outpatient encounters 2,130 licensed beds 6 hospitals (including a Level 1 Burn Center and a Level 1 Trauma Center), a children’s hospital, a psychiatric hospital, a comprehensive cancer hospital, a physician practice organization and ancillary primary, urgent and emergent care facilities Other clinical affiliations include the YNHHS Heart Institute, Pediatric Network, Telestroke Network and Cancer Network with other area hospitals 501c3 nonprofit organization 2
    3. 3. Objectives• History of BCP/COOP• Terminology• Standards and Compliance• BCP Challenges & Pitfalls Objectives• Tips to develop a HVA and BIA•Identify your essential functions•Identify the components of a BCP/COOP•Learn how to test and evaluate yourBCP/COOP•Discuss review and maintenance ofBCP/COOP 3
    4. 4. Overview• Event• History of BCP/COOP• Terminology•Standards and Compliance 4
    5. 5. BCP/COOP Event modified U.S. DoD graphic Incident Occurs Return to Normal Operations Recovery Time Objective Normal Operations Capability Recovery Minimum Acceptable Level of Capability Emergency Response Restoration Contingency Planning Risk Mitigation and Crisis Management Proactive HCC Time Proactive HCC Activities Activities Prevention and Preparedness Prevention and Preparedness Reactive HCC Activities Response, Recovery & Restoration 5Used by courtesy of The Virtual Corporation 5
    6. 6. Overview• BCP/COOP should be an organization or department-wide initiative utilizing a holistic approach to prepare theorganization to recover after an interruption of itsessential functions and business operations.• Taking an holistic approach to organizational resiliencewill allow hospitals and health systems and thecommunities they serve to fully embed businesscontinuity and continuity of operations into their fabric.• The process involves assessing, developing, testing,and maintaining a system-wide businesscontinuity/continuity of operations plan which addressesany type of disaster covering key technical, operating,business and clinical functions.• In general, the process undertaken will occur inmultiple steps over the course of approximately 18-36months. 6
    7. 7. Business Continuity Plan vs. Continuity ofOperation Plan• The terms Business Continuity Plan (BCP) and Continuity ofOperations Plan (COOP) are used interchangeably• According to the Business Continuity Institute, a BusinessContinuity Plan (BCP) is a document containing the recoverytimeline methodology, test-validated documentation, procedures, BCPand action instructions developed specifically for use in restoringorganization operations in the event of a declared disaster.• Continuity of Operations Plan (COOP) – Organized processesthat facilitate system restoration for emergencies, disasters,mobilization, and for maintaining a state of readiness to providethe necessary level of information processing and businessfunctions commensurate with the mission requirements andpriorities.• In either case, the ultimate goal of developing a BCP/COOP isto provide procedures and capabilities for sustaining essentialorganizational business and clinical operations and strategicfunctions while recovering from a significant disruption 7 7
    8. 8. BCP/COOP Standards & RegulationsThe goal of any standard is to follow a clearly structured good practice guide to how to develop a Continuity Management System (CMS) and to be able to audit and monitor the COOP practices of organizations • National Security Presidential Directive 51/Homeland Security Presidential Directive 20, National Continuity Policy, May 9, 2007. • Public Law 109–417, the Pandemic and All-Hazards Preparedness Act (PAHPA) was passed that included SEC. 2802. • BS 25999, the British Standard for Business Continuity Management established by the British Standards Institution., is becoming widely accepted around the globe as the de facto international standard • Its nearest competitor is the US National Fire Protection Association’s NFPA 1600 standard Standards on Disaster/Emergency Management and Business Continuity Programs • Joint Commission Hospital Accreditation Program (HAP) 2010, EM.02.01.01 8
    9. 9. BCP/COOP Pitfalls & Challenges Pitfall # 1 – Not having a plan(s) • Huge risk to the core business, operational and clinical functions of the organization • Potential loss immeasurable and the risk of legal liabilities Pitfall # 2 – Not maintaining plans • Require routine maintenance/updating • Must be dynamic and evolve as threats change Pitfall # 3 – Not exercising or testing plans • Contingencies are not part of normal operating procedures • Exercises must cover several types of contingencies Pitfall # 4 – Not raising awareness of plans • Contingencies affect everyone in the organization • Changes or updates to plans require acquainting staff with new procedures 9 9
    10. 10. BCP/COOP Pitfalls & Challenges Pitfall # 5 – Not identifying essential functions • Not everything is mission essential • Need to identify and prioritize critical assets Pitfall # 6 – Not identifying key roles and responsibilities • Chain of Command/Span of Control are essential • Must reflect current staff and their contact information Pitfall # 7 – Not coordinating plans with partners • Many interdependencies exist in a crisis/disaster • Establishes boundaries, roles and responsibilities 10 10
    11. 11. BCP/COOP Pitfalls & Challenges • One of the challenges that prevents organizations from taking full advantage of a holistic approach is the presence of organizational silos • Most organizations, especially larger ones, are actually a conglomeration of many different divisions, departments, business units and operations. • These are often structured as silos and in some cases are self contained, self managing entities which have minimal interaction and communication with other parts of the organization. • Despite this apparent autonomy they normally have strong dependencies on services provided by other parts of the organization, such as IT, purchasing, finance, human resources and payroll to name a few. • Lack of transparency, uncooperative managers, unwillingness to buy into the BCP/COOP process and organizational politics are common aspects of silos. 11 11
    12. 12. BCP/COOP Pitfalls & Challenges • No organization is an island and one of the larger challenges to holistic BCP/COOP is how to ensure that critical suppliers are not a single point of failure and are not at risk of downtime. • This is especially true when an organization is outsourcing critical business infrastructure, such as IT services, to third parties. • As part of the holistic BCP/COOP process suppliers should be mapped and critical suppliers should be identified. • Once identified it is important to determine: • What contracts have been agreed with these companies • What BCP/COOP arrangements do suppliers have in place • Are there alternative suppliers readily available 12 12
    13. 13. Phased Approach1-3 Months 6-9 Months 9-12 Months 12 Months Ongoing 13
    14. 14. Phase 1 - Project Initiation C-Suite Buy-In 14
    15. 15. Phase 1 – Project InitiationEstablish Governance and Obtain Buy-In•Meet with Senior Leadership • Obtain commitment from leaders • Present the goals and objectives•Establish Planning Team / Steering Committee • Develop Team Guidance / Governance • Scope / Assumptions / Mission Statement•Establish Project Timeline • Outline project milestones and goals • Finalize overall project schedule • Identify project team 15
    16. 16. Phase 1 – Project InitiationBCP/COOP Steering Committee Provide hospital or healthcare system-wide business continuity planning project oversight to support the planning, response, resumption, recovery and restoration of operations The following is a list of individuals from the your healthcare organization that should comprise key decision makers representing clinical, administrative, business, technology and support services – Senior Executive – Administration – Operations – Legal/Compliance – Information Systems & Technology – Human Resources – Facilites – Financial Services – Medical Affairs – Risk Management – Patient Care Services – Emergency Management 16
    17. 17. Phase 1 – Project Initiation BCP Project Support Team The BCP/COOP Project will be coordinated by the BCP/COOP Project Team. These members serve as the BCP/COOP project liaisons and provide day-to-day support and integration of all BCP/COOP activities. The following are the BCP/COOP Project Team members.  Project Manager  Project Lead  Point of Contact (POC)  Project Database Administrator  IS&T Disaster Recovery  BCP/COOP Training and Planning Specialist  Emergency Management Specialist  Clinical Liaison  Financial Liaison  Risk Management  BCP/COOP Consultants (prn)) 17
    18. 18. Phase 2 - Business Impact Analysis BIA 18
    19. 19. Phase 2 - Business Impact AnalysisConduct a Business Impact Analysis•Determine your Vulnerability / Hazards • Review Hazard Vulnerability Analysis (HVA) • Review Risk Assessments (RA) • Review Past History of Storms Human Resources Surge Capacity • Discuss with Emergency Management Officials and other emergency response organizations in the community 19
    20. 20. Phase 2 - Business Impact AnalysisDetermine your Business Impact Defined by Disaster RecoveryInstitute International (DRII) as: “Identifying the impactsresulting from business interruptionsthat can affect the organization andtechniques that can be used to quantifyand qualify such impacts.” PROVIDES THE BASIS FOR YOUR BCP/COOP 20
    21. 21. Phase 2 - Business Impact AnalysisDetermine your Business Impact•Gather data via a survey or questionnaire • Can be distributed to all employees or select management group who can provide an overview for the entire organization • Asks targeted questions about what is critical to the organization • Determines impact if the service was not available for a few days • Determines any relationships between other departments or organizations•Follow Up with specific questions • For anything that is not clear, conduct a follow up interview or observe this service to see how it effects the business • Aim to truly define what are essential functions • Could be conducted in a group setting 21
    22. 22. Phase 2 - Business Impact Analysis Determine your Business Impact •Analyze / Review Data • Identify the main areas of the organization • Assess the impact of disruptions • Loss of staff • Loss of equipment • Perception by the public • Regulatory requirements • Financial • Environmental • Relationships (Public and Partners) • Determine minimum needed resources and staff to carry out • Can this service be carried out remotely? • Determine once interrupted how long will it take to restore services 22
    23. 23. Phase 2 - Business Impact AnalysisIdentify Time-Sensitive Business Operation Processes andApplication Systems• Establish a method of grouping clinical, business andoperational processes and technology application systems inline with their importance to the overall function of theorganization like business time-sensitivity ratings.• Time-sensitivity ratings are usually expressed in terms of theminimum and maximum time that the organization canwithstand an interruption of a particular clinical and/or businessoperation or technology application system.• Record each clinical business and operational processes,functions or technology application systems along with its time-sensitivity rating.• A comprehensive BCP/COOP will document a single ormultiple strategy and tasks for every level of business time-sensitivity. 23
    24. 24. Phase 2 - Business Impact Analysis Hazard Vulnerability Analysis Kaiser Permanente Model - http://www.nachc.com/EM-Planning.cfm • Mainly used for healthcare facilities, but can be adapted for public health use 24
    25. 25. Step 2 – Business Impact Analysis Example of a Business Impact Analysis survey that was completed by functional managers of departments/work units and ideally use a computer-based data collection tool The chart below identifies actual data of survey responses conducted at a healthcare system based on their title and positions 7% 2% 2% 3% 5% Directors Managers Vice Presidents 10% Coordinators Assistants CIOs Other 71% 25 25
    26. 26. Step 2 – Business Impact Analysis Examples of Departmental Responses to a Disruption 86% 90% 84% 77% 80% 70% 70% Percentage of 60% 57% Survey 50% 48%Percentage of Responses 40%SurveyResponses 30% 20% 10% 0% Patient Car e Adver se Patient Regulator y Pati ent Conf idence Compli ance Liabil ity Cash Fl ow Outcome Type of Impacts Type of Impacts 26 26
    27. 27. Phase 3 – Plan Design and Development 27
    28. 28. Phase 3 – Plan Design and Development Based Upon HVA and BIA • Plan for the most probable and highest impact events • May want to include hazard specific annexes • i.e. how workforce will be protected from Pandemic Flu Defines Roles and Responsibilities • Who is responsible for what during a BCP/COOP activation • May not be the traditional department / personnel Identifies Triggers for Activation / Devolution • Who is responsible for activating the BCP/COOP • What is the trigger for activation (storm warning, absenteeism rate, etc.) • Is this a facility specific emergency or disaster? • When should you return to normal operations? 28
    29. 29. Phase 3 – Plan Design and DevelopmentThe Concept of Operations describes the procedures for Phase 1 BCP/COOP plan implementation. EmergencyBCP/COOP plan implementation takes place in four phases: Phase 2 • Phase I: Readiness and Preparedness • Phase II: Activation and Relocation (0–12 hours) Phase 3 • Phase III: BCP/COOP Operations (12 hours–30 days or until Phase 4 resumption of normal operations) • Phase IV: Reconstitution (recovery, mitigation, and termination) 29
    30. 30. Phase 3 – Plan Design and Development Identifies How Communications with Employees and Organizations are Carried Out • Do you have a 24/7 contact list for ALL personnel and how to notify employees? • Emergency notification system • Department cell phone numbers, office numbers, e-mail • Home number, personal cell phone, home email • Are they capable of receiving texts? • Agency 24/7 contacts • Social media uses (websites, Twitter™, Facebook™) • Mass notifications systems • Two-Way Radios 30
    31. 31. Phase 3 – Plan Design and DevelopmentOutlines Order of Succession / Delegation of Authority • Orders of Succession • In the event a person cannot carry out their duties, outlines who is responsible for that duty • Should have a backup and a backup’s backup • May not be the organization’s traditional organization chart • Should be outlined by position and duty (i.e. different person will have different responsibilities for a natural hazard vs. a pandemic flu) • Ensure 24/7 contact information for all parties • Performance of unusual or additional duties by staff or reassignment • Delegation of Authority • Delegations of authority are formal documents specifying the activities that may be performed and the legal authority of those authorized to act on behalf of the agency head or officials • Delegations of authority ensure rapid response to any emergency situation requiring BCP/COOP implementation • Identify the authority being delegates, to whom it is being delegated, limits of the authority, when authority would terminate 31
    32. 32. Phase 3 – Plan Design and DevelopmentDefine How Essential Functions Will Be CarriedOut / Concept of Operations • First essential functions are defined • What functions must your organization carry out • Then essential functions are prioritized • Defines who is responsible for these functions • Agency / Department / Person • Are they aware of their 24/7 responsibility • Are there any duties that can be suspended during a BCP/COOP? • Permitting Processes • Inspections 32
    33. 33. Phase 3 – Plan Design and Development Alternate Work Locations / Telework Arrangements • Do you have an alternate location should your office become unusable? • Is it equipped or do you need to bring supplies with you? • Can employees telework in the event of an emergency? • Do they have the right equipment to telework? • Who is essential vs. non-essential personnel • Are there other agreements for use of the facility by other departments? • Has a HVA or RA been completed for that building? • Does your employees need training to use this facility or its equipment? 33
    34. 34. Phase 3 – Plan Design and Development Integration with EOP / EMP •Is your plan NIMS / ICS Compliant •Can it be integrated with your organization’s Emergency Operations Plan (EOP) and / or Emergency Management Plan (EMP) •Are there any duplicative roles for your personnel or unrealistic roles or responsibilities •Do your personnel understand their roles in all plans? 34
    35. 35. Phase 3 – Plan Design and Development Other Considerations • Design a consistent departmental/work unit BCP/COOP format and structure used across all delivery networks that is integrated with the existing emergency management processes:  Overview  Strategy Support Materials – Recovery Plan Overview – How All BCP/COOP Plans Fit Together – Plan Distribution & Storage – Department Planning Assumptions – General Plan Scope – Directions to Recovery Location  Recovery Team Task Lists  Forms – Recovery Team Roles & Assignments – Activity Log – Delegation of Authority – Move and Relocation Forms – Department Response Team Procedures – Plan Testing and Maintenance procedures – Loss of Bldg Access  Reference Materials – Loss of Key Personnel – Recovery Time Objectives (all depts) – Loss of IT Applications – Business Impacts (all depts) – etc. – Dept Business Impact Analysis Findings – Resumption of normal operations – Business continuity policies  Call Lists – Physical and security assessments – Department Call List – Vital records and off-site storage program – Vendor Call List – Department and corporate succession – Personnel Notification Procedure plans  Recovery Resources – Budget considerations for capital and – Internal / external personnel operating expenses – Environmental Resources  Links to Emergency Response Procedures – Fixed and Portable Medical Equipment – Damage impact assessment procedures – Critical Supplies – Command center activation procedures 35
    36. 36. Phase 3 – Plan Design and DevelopmentOther Considerations • Expand usage of the “Hospital Incident Command System” (HICS) to define responsibilities, clear reporting channels, and a common nomenclature to help unify hospital recovery and restoration activities with other emergency responders • Add the position of Business Continuity Branch Director to each HICS Incident Management Team structure • Reports through the Operations Section Chief • Update all HICS Job Action Sheets (JAS) addressing “Recovery Role” for ICS personnel 36 36
    37. 37. Phase 4 - Plan Implementation 37
    38. 38. Phase 4 – Plan ImplementationDistribution•Distribute plan to all personnel and outside agencies whohave a role in the BCP/COOP • Ensure that Emergency Management, Public Health & Jurisdictional Authorities have a copy • Maintain a record of distribution for updates and changes • Ensure Control ProceduresDevelop Training•Being to develop awareness training and exercises with thefollowing goals in mind • Ensure that all participants are aware of their roles and responsibilities • Ensure all know how the office will function during a BCP/COOP (Telework, Essential Personnel, etc.) • Hold a full scale exercise so all can see how plan is activated and difference for normal working conditions and a BCP/COOP situation 38
    39. 39. Phase 4 – Plan ImplementationDeliver Training•Deliver Various Types of Training Programs asappropriate • Computer-based • Classroom • Test-based • Instructional guides and templates•Develop Awareness Programs • Management • Team members • New employee orientation and current employee refresher program•Identify Other Opportunities for Education • Professional business continuity planning conferences and seminars • User groups and associations • Publications and related Internet sites 39
    40. 40. Phase 5 – Test, Exercise, and Maintenance 40
    41. 41. Phase 5 – Test, Exercise, and Maintenance Test and Evaluate The Plan and Tools •Hold a tabletop or functional exercise to test the components of the plan • May hold multiple drills such as a communications call down drill off hours • Will reveal any deficiencies or gaps in the plan as well as strengths • Based on an actual scenario determined by the organizations response to real events, their HVA, RA or BIA •Conduct an After Action Conference / Develop After Action Report (AAR) • Hold a hot wash after the drill or exercise • Develop an AAR / Improvement Plan • Update BCP/COOP based upon AAR 41
    42. 42. Phase 5 – Test, Exercise, and Maintenance Define Plan Maintenance Scheme and Schedule • Define ownership of plan data • Prepare maintenance schedules and review procedures • Select tools • Monitor activities • Establish update process • Audit and control • Ensure that scheduled plan maintenance addresses all documented recommendations Formulate Change Control Procedures • Analyze business changes with business continuity planning implications • Set guidelines for feedback of changes to planning function • Develop change control procedures to monitor changes • Create proper version control—develop plan reissue, distribution, and circulation procedures • Identify plan distribution list for circulation 42
    43. 43. Phase 5 – Test, Exercise, and Maintenance Establish Status Reporting Procedures • Establish reporting procedures • Content • Frequency • Recipients Audit Objectives • Recommend and agree upon objectives for BCP/COOP related audits. • Audit the BCP/COOP plan’s Structure, Contents, and Action Sections • Determine if a section in the BCP addresses recovery considerations • Evaluate the adequacy of emergency provisions and procedures • Recommend improved positions if weaknesses exist •Audit the BCP’s Documentation Control Procedures • Determine whether the BCP/COOP is available to key personnel • Review update procedures •Demonstrate that update procedures are effective • Examine the provision of secure backup copies of the BCP/COOP for emergency use • List those individuals with copies of the BCP/COOP • Ensure that BCP/COOP copies are current 43
    44. 44. Any Questions? 44
    45. 45. Contact Information James L. Paturas, LP, CEM, CBCP, CHS-V, FACCP Director, Emergency Preparedness (O) 203.688.3496 (C) 203.650.7248 James.paturas@ynhh.org 1 Church Street, 5th Floor  New Haven, CT 06510 www.yalenewhavenhealth.org/emergency 45

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