disruption and disaster management – response and recovery

Disruption and Disaster Management – Response

and Recovery

Document ID CHQ-PROC-62434 Version no. 2.0 Approval date 21/09/2021

Executive sponsor Executive Director Corporate Services/Chief Finance

Officer

Effective date 21/09/2021

Author/custodian Emergency Management Coordinator Review date 31/03/2022

Supersedes 1.0

Applicable to This procedure applies to all staff including contractors, consultants, students and

volunteers.

Authorisation Executive Director Corporate Services/Chief Finance Officer

Purpose

Response and recovery are core components of Children’s Health Queensland (CHQ) Disruption Management

Framework.

Response activities are situation and impact (actual or potential) specific and include initial assessment of the

disruption or emergency, incident classification, activating a code response where appropriate, and specific

actions around command, control, co-ordination and collaboration regarding the response.

Recovery activities are implemented concurrently to the incident response with a focus on returning to Business

as Usual (BAU) as soon as possible. “Lessons Learned” from incidents provide opportunities to improve plans,

procedures, processes and structures leading to organisational improvements and enhanced organisational

resilience.

This procedure defines these activities and the associated role specific requirements.

Scope

This procedure applies to disruptive, emergency and disaster incidents.

This procedure also applies to all staff (permanent, temporary, full-time, part-time and casual), organisation

and individuals acting as agents of CHQ and other partners in care such as individual contractors (including

visiting medical officers), consultants, students and volunteers.

This procedure operates in the context of CHQ Managing organisational disruption policy (CHQ-POL-62427).

All emergency incident responses defined in this procedure, operate in the context of the Australian

Government, Queensland State Government and Queensland Department of Health Disaster Management

arrangements and plans.

https://www.childrens.health.qld.gov.au/wp-content/uploads/PDF/covid-19-extranet/governance-docs/pol-62427.pdf

CHQ-PROC-62434 Disruption and Disaster Management – Response and Recovery

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Procedure

Disruption categories

Disruptive incident

A disruptive incident is an occurrence which, threatens to, or directly impacts, CHQ’s ability to operate as

Business as Usual (BAU), but does not constitute an emergency incident. Disruptive incidents may include:

localised incidents, where an impact to a local area is managed effectively through localised management

strategies; or be as broad as strategic incidents such as fraud, extortion, industrial or civil unrest.

Emergency incident

An emergency incident is an event, actual or imminent, which endangers or threatens to endanger life, property

or the environment, and which requires a significant and coordinated response1.

Internal emergency incident

Internal emergencies only involve areas within the perimeter of CHQ facilities and may relate to fire, security

or infrastructure incidents. Although staff may carry out some basic initial response to these emergencies, it is

imperative that the relevant Disruption Response Team (DRT) (or its equivalent in Community facilities) is

activated in all cases. The CHQ Health Incident Controller (HIC) and the CHQ Incident Management Team

(IMT) will be activated as appropriate. CHQ personnel are to utilise this procedure, and other specific plans

and sub-plans as relevant, to assist them in their response.

These emergencies will usually also involve, as appropriate to the incident(s), the relevant external combatant

agencies such as Queensland Fire and Emergency Service (QFES), Queensland Police Service (QPS), etc.

External emergency incident

External emergencies are managed as part of an overall state-wide plan in conjunction with the Department of

Health and other external agencies. The CHQ response to external emergencies is detailed in the External

Emergency (Code Brown) Disruption Management Plan (DisMaP) and relevant sub plans. The response will

require the activation of the CHQ Disruption Response Team, HIC and Incident Management Team.

Colour codes for emergencies

CHQ utilises colour codes as outlined in the Australian Standard (AS) 4083 – 2010, Planning for Emergencies

– Healthcare Facilities, to inform staff of emergency situations without raising unnecessary alarm in patients

and/or visitors. The colour codes are as follows:

1 Emergency Incident: Source – Australian Standard 4083:2010 Planning for emergencies – healthcare facilities


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Code Definition

Code Red Fire / Smoke

Code Yellow

Infrastructure and other internal emergencies including: Hazardous Materials incidents; or, external events, such as severe weather events or acts of terrorism, which impact directly upon infrastructure or business continuity.

Code Orange Evacuation

Code Purple Bomb Threat

Code Black Personal Threat

Code Brown External emergencies including mass casualty events, severe weather events, acts of terrorism or Chemical, Biological, Radiological (CBR) incidents, which impact on lives.

Code Blue / MET Cardiac Arrest or Other Medical Emergencies

Disaster

A disaster is a serious disruption in a community including loss of human life, injury or illness, and/or

widespread service loss or damage to the property and environment. This disruption may be caused by an

event (either natural or caused by human acts or omissions) and requires a significant coordinated response

by the State or other entities to support recovery2.

Command and control arrangements

The command and control arrangements at CHQ utilises the principles of the Australasian Inter- Service

Incident Management System (AIIMS) and Health Major Incident Medical Management Support (HMIMMS).

These are also utilised by the Queensland Department of Health (DoH), other Queensland Health (QH)

Hospital and Health Services, and other state agencies including Queensland Fire and Emergency Service

(QFES), Queensland Police Service (QPS) and Queensland Ambulance Service (QAS).

The Chief Warden and when activated, the HIC will take charge of all CHQ resources, directly involved, to

combat and resolve the emergency. Any emergency response at CHQ is to be coordinated in consultation with

the organisation’s governance and line management structures. For incidents requiring significant response

e.g. external emergencies, additional support positions, informed by the Hospital Major Incident Medical

Management and Support system are also utilised.

The CHQ command and control arrangements are detailed further in Response – activation and

implementation.

Internal disruption: No statutory combat response required

In the event of a disruption requiring only an internal response, the Chief Warden or the HIC, is responsible for

the management and/ or resolution of the incident.

Internal disruption: Statutory combat response required

In the event of an internal disruption which requires a response from another state agency, the Incident

Controller, as delegated by the agency, is responsible for all emergency response activities. The Incident

Controller will consult with the CHQ HIC, or as delegated to the relevant. At CHQ owned facilities, the Chief

2 Disaster: definition adapted from section 13 Disaster Management Act, 2003.


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Wardens (at CHQ owned buildings) are responsible for all CHQ resources, assets and / or services involved

in the incident This responsibility includes the facilitation of the CHQ Incident Management Team, and as

required, the Disruption Warden Teams. At non-CHQ owned facilities where the Chief Warden is not an

employee of CHQ, the CHQ responsible officer is the most senior CHQ manager.

Should the incident require the assistance of other agencies and organisations (E.g. QFES), each of these

agencies will have an incident controller to manage their own resources. These incident controllers will be

subordinate to the lead combat agency, which will be determined by the nature of the incident and the

legislative requirements.

Children’s Health Queensland (CHQ)

STATE LEAD

AGENCY

Incident Control –

Other Agencies

Agency Response

Team

Incident

Management

Team

(IMT)

Health Incident

Controller

(HIC)

Disruption Response

Team

(DRT)

or equivalent

- Chief Warden

- Deputy Chief

Warden

- Security

Local Response

- Implementation of

DisMaP

Disruption Warden

Team

- Area Warden

- Wardens

DISRUPTION

OCCURS


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Emergencies requiring a multi-agency response

In the event of an external emergency or disaster which requires a multi-agency response or where there has

been activation of the Queensland Health Disaster Plan and / or the State Counter Disaster Plan, the whole of

government support arrangements will be implemented and CHQ will participate as appropriate (Refer to the

diagram below3).

3 Diagram adapted from the QDMA representation, www.disaster.qld.gov.au

http://www.disaster.qld.gov.au/


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Response and recovery – process overview

General disruption and emergency response procedure (excluding medical emergencies)


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Response – initial response and notification

Prompt and appropriate responses to disruptions or emergency situations are critical to achieving optimum

outcomes.

The general initial response and notification principles for all incidents are outlined in the diagram below.

It is imperative that appropriate emergency responses are implemented for each emergency incident, as

outlined in the specific Disruption Management Plans (DisMaP).

Initial Response and notification Principles

Initial response considerations How to notify What to notify

- Notify immediately

- Remove people from immediate danger

- Prevent entry of unauthorised personnel

- Minimise damage to infrastructure

- Re-establish normal functions as soon as possible

All incidents: - Nature / type of incident

- Location of the incident

- Type of injury(s) and / or type of patient(s), if applicable

- Number of people / patients injured or impacted, if applicable

- Your name and the number of the telephone you are calling from

- QCH precinct: Phone the relevant emergency number (e.g. 555)

- Community: Notify facility Reception and Manager/Team Leader for relevant service

- Phone relevant emergency services as required (e.g. “000”)

Internal incidents (as relevant):

- QCH Precinct: Phone Medirest / Facilities or relevant Help Desk #

- All sites: Activate Manual Call Points / Break Glass Alarms

- Activate Duress Alarms

Emergency contact numbers – Queensland Children’s Hospital and precinct

The emergency contact numbers for Queensland Children’s Hospital (QCH) and Precinct (e.g. CCHR) facilities

as categorised by code type are defined in the table below. Whilst notification of incidents may be received by

any area within CHQ any notification received should be directed to the relevant emergency number, e.g. the

QCH Emergency Department may be notified of an external emergency and would in turn notify the QCH

Emergency Number 555. Should an internal landline not be available, and the use of an external or mobile

phone is required, call either 3068 5990 or 3068 5991. Either of these numbers will provide external access

into the ‘555’ emergency code phone system.

Code type QCH CCHR

Code Red 555 555

Code Yellow 555 555

Code Orange Activated in response to another code type

Code Purple 555 555

Code Black 555 555

Code Brown 555 555

Code Blue / MET 555 000 Adult, 555 Child


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Emergency contact numbers – communities, statewide and mental health services

The relevant emergency contact numbers for each community, state-wide or mental health service are specific

to the location and / or service. These are outlined in the DisMaP for each facility or service. These plans

constitute the Fire and Emergency Plan, other emergency plans and business continuity and recovery plans

for each facility or service.

Response - Communications

Early communication regarding emerging events may facilitate initial actions and risk management strategies

that contain an incident at a local level.

Effective and timely communication flows are essential in the management of an incident to enable a cohesive

organisational response which maintains the safety of patients, staff and visitors. The intention is, depending

on the sensitivity of the event, to provide information that facilitates the well-being of staff, patients and visitors

to the facility by reducing concerns regarding the event.

The communication systems, approaches and messaging utilised in an incident are defined in the CHQ

Communications DisMaP.

Response – activation and implementation

Response activation

Response procedures can be activated on advice of either an actual or potential incident which impacts CHQ

and which cannot be contained or controlled at a local level.

Phases of activation

There are four phases of emergency response and a debrief phase, recognised by CHQ in accordance with

the Queensland Department of Health / Queensland State arrangements. These phases do not need to be

actioned sequentially and in some instances, some phases may not be applicable (e.g.: Alert or Lean

Forward) or there may be movement between specific phases (e.g.: Lean Forward, Stand).

Phase Reason Activation Status / Response

Alert Emergency possible • Increase level of preparedness

• Heighten level of vigilance

• Monitor the situation / threat

Lean Forward Emergency imminent • Increase situational awareness

• Prepare for the implementation of a response

Stand Up / Code Activation

Emergency situation exists

• Implement Emergency Response Plans and relevant sub plans

• Prepare for continuity and recovery / implement continuity and recovery plans

Stand down / All clear Emergency abated, recovery commences

• Commence return to normal operations

• Continued implementation of continuity and recovery plans

Debrief Review emergency response, relevant plans and processes

• Formal debrief conducted

• Local area and strategic debriefs undertaken

• Debrief coordinated by Disaster and Emergency Management Team and linked to other related reviews as relevant.

Response implementation


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After initial notification of an incident has been received, the following response and escalation process applies.

These processes are summarised in the Disruption Response Team (DRT) – Assessment and Escalation Tool,

and relevant DisMaPs, for quick reference during an emergency.

Disruption response team

The Disruption Response Team (DRT) will respond to all incidents, except for Code Blue and MET incidents,

and determine the best course of action to safely resolve the situation. If the incident cannot be resolved though

routine management, the Chief Warden will activate a code response or escalate the incident. An incident

management team will be established as required.

DRT members and escalation – QCH precinct

The DRT members for the QCH precinct are as follows:

• Primary members:

– Chief Warden - Patient Flow Nurse Manager (or delegated to the Safety Clinical Nurse Consultant (CNC);

and,

– Communications Officer - Security Team Leader.

• Support members: For incident specific information or support, the primary members should contact the

following personnel as required:

– Facilities Management - Delta;

– Clinical Support Services – Medirest;

– Director ICT Service Delivery (in hours) and ICT on-call (after hours); and / or

– Disruption and Disaster Management Unit representative.

• Escalation: The Chief Warden will notify and / or escalate the incident as follows:

– Executive Director Nursing Services (EDNS) and/or Executive Director Medical Services (EDMS) (in

hours and as rostered on call out of hours).

These personnel will advise the Executive Director Clinical Services – QCH (EDCS-QCH), who will advise the

EDCS and HSCE as appropriate.

DRT members and escalation - Communities

The DRT is facilitated in community settings as follows:

• The primary responder in business hours to a Community site related disruptive incident is the Manager /

Team Leader of the service.

• Out of hours escalation for a Community site related disruptive incident defaults to the existing QCH

Disruption Response Team (DRT) key members e.g. Patient Flow Nurse Manager (Chief Warden) and

contracted Security Team Leader.

• Support: Incident specific information or support can be obtained from facility specific:

– Security services;

– Facilities management;

– ICT providers; and,

– Disruption and Disaster Management representative.

• Escalation: The Chief Warden or Manager / Team Leader of the service will notify the Executive Director of

proxy who is the ‘On Call’ staff member for either the Executive Director Nursing Services (EDNS) or

Executive Director Medical Services (EDMS).


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DRT roles and responsibilities

The role of the DRT is to assess the incident and identify if the incident can be managed and resolved at a

local level using routine management processes.

The DRT will use the Disruption Response Team (DRT) – Assessment and Escalation Tool to both guide and

record the outcomes of the DRT assessment.

At QCH, if the initial notification of the incident was not received via the Emergency Code Phone “555”

Messaging, the Chief Warden is to phone 555, advise of the situation and request a DRT Alert Notification be

sent.

When assessing the emergency incident, the DRT will evaluate both the severity of the incident and / or the

severity of the problems caused by the incident.

If the incident can be managed and resolved at the local level using routine management processes, the Chief

Warden at CHQ is to ensure the relevant Nursing Director and/or Medical Officer/ Director is notified. The

Manager or Team Leader in community facilities is to ensure the Divisional Lead is notified. In both settings,

the Chief Warden completes, or delegates the completion of, the Risk Man incident report.

If the incident cannot be managed at a local level the DRT will escalate the incident as defined below.

DRT assessment principles

The following impact matrix has informed the assessment included in the DRT Chief Warden Assessment and

Escalation Tool. NB: only one point per impact category and level needs to be identified.


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Escalation of incident – QCH

If the DRT identifies that the incident cannot be managed at a local level or has a potential or actual impact

greater than insignificant or minor, the Chief Warden will liaise with the ND Clinical Support Services in hours

or EDNS and/or EDMS (as rostered after hours), Communities Nursing Director should be advised at earliest

opportunity, to determine the appropriate level of code response, activate the Incident Management Team

(IMT) and Health Emergency Operations Centre (HEOC) as required and inform the Executive Director Clinical

Services (EDCS) – QCH.

Relevant code and HEOC messaging are to be actioned via the Emergency Code Phone “555” / 3068 5990 or

3068 5991.

Escalation of incident - Communities

If the DRT identifies that the incident cannot be managed at a local level or has a potential or actual impact

greater than insignificant or minor, in hours the Manager or Team Leader of the service will notify the Divisional

Lead, who will escalate to the Child & Youth Community Health Service (CYCHS) Service Development

Manager or Community, Youth Mental Health Divisional Director as required.

Out of hours this process will default to the QCH existing process with the disruptive incident to be escalated

to key members of the Disruption Response Team (DRT) Patient Flow Nurse Manager (Chief Warden) and

contracted Security Team Leader (Communications Officer), if Community sites have local contracted security

with relevant internal processes, these should be followed as directed and escalation of incident to occur to

EDCS at earliest opportunity.

“In Hours” the Divisional Lead will notify the Executive Director Clinical Services as required. Any incident

where broader CHQ notification or assistance is required, relevant code and HEOC messaging is to be

actioned via the Emergency Code Phone “555” / 3068 5990 or 3068 5991. For Community sites, use relevant

emergency code escalation number.

Incident management team

Once activated, the IMT will override routine organisational structure, and the HIC, on behalf of the Health

Service Chief Executive (HSCE) will take charge of all resources directly involved in combating the incident.

The IMT can be scaled to suit the size and nature of the incident as defined in Incident management team

roles through to Incident management team - collective roles and functions below.

Incident management team structure

The CHQ IMT structure is led by a HIC. The HIC is supported by a range of “cell” which provide support during

an incident response. The HIC also liaises with external agency Incident Controllers as relevant. The structure

is outlined in the diagram below.


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Incident management team purpose

Each cell of the IMT has a specific purpose which enables comprehensive and efficient incident response and

recovery. These purposes are defined in the diagram below.

Incident management team roles

The functions of each IMT Cell are performed or facilitated by an allocated officer for each section. Within some

sections there are several positions and sub positions. These are outlined in the diagram below.

Suggested positions required for a response to a medium or high impact incident is outlined in section 5.2.2.4

below

.


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Medium impact incident - IMT structure and delegates

or an incident assessed as having a medium impact, a consolidated IMT would be established as defined in the

diagram below. This IMT would be a flexible team managing the incident from across operational areas. If

required, a HEOC can be activated to support the incident response in accordance with HEOC establishment

and management. The allocation of CHQ personnel to IMT Roles for a medium incident have been aligned,

wherever possible, with relevant substantive positions from the CHQ organisational structure for in business

hours and after business hours arrangements as outlined in the table below.

CHQ Health

Incident

Controller

Planning &

Intelligence

Operations

& Logistics

Communication

&

Administration

Medium level Incident Management Team

IMT Position In Hours After Hours

Health Incident Controller (HIC) Nursing Director Clinical

Support Services

EDNS or EDMS on-call

Operations, Logistics & Safety Officer

Patient Flow Nurse Manager /

Safety CNC

Patient Flow Nurse Manager / Safety CNC

Planning & Intelligence Officer HIC, Other Nursing Director, and / or relevant Digital Health Service (DHS) or Facilities representative

HIC or Alternate EDNS /EDMS on-call, DHS MIM on-call or relevant Facilities officer on-call.

Communication & Administration Officer

Disruption & Disaster Management Unit (DDMU) Representative / Communications & Engagement (C&E) Officer

C&E Officer on-call

** Communities incident should include relevant key staff

High impact incident - IMT structure and delegates

For an incident assessed as having a high impact, it is likely that a full IMT structure would be implemented.

Positions are activated at the discretion of the HIC. In the event of a mass casualty event or other incident

requiring short duration high intensity response it is likely that the response would require larger operations

and logistics cell. Public health events or other prolonged incident would be likely to require larger planning

and intelligence cell. The allocation of CHQ personnel to IMT Roles for a high incident have been aligned,

wherever possible, with relevant substantive positions from the CHQ organisational structure for in business

hours and after business hours arrangements as outlined in the table below. Key Subject Matter experts will

be engaged as required.


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High level Incident Management Team

IMT Position In Hours After Hours

Health Incident Controller (HIC)

EDNS, EDMS, EDCS-QCH, EDCS, HSCE

EDMS (On-call); EDNS (On-call); EDCS- QCH

Operations Officer Divisional Director, Nursing Director, Operations Manager

EDMS

on call

EDNS

(On-

call)

PFNM

Safety Officer Director Patient Safety Quality Service, EDMS on call

Continuity of Operations Officer

DDMU Representative

Disruption Warden Team

As per team allocation

As per team allocation

Logistics Officer

CRS Manager, Manager Property & Leasing, Senior Director Facilities Management, DHS or DHS MIM, CFO

Divisional Directors, Community Services

EDNS (On-call); EDMS (On-call); DHS MIM on-call, PFNM

Planning Officer

Divisional Director, Nursing

Director, Operations Manager

Intelligence Officer

CHQ Director of Service Delivery,

Director of ICT Operations,

Customer Engagement & Business

Relationship Manager

Communication & Administration Officer

SDCE, Director Administration

Services, Manager Media &

Communications, Snr Communications

Officer

C&E Officer on call

HEOC Liaison / Duty Officer

DDMU Representative, Director Office of HSCE or BPIOs

DDMU Representative

HEOC Duty Officer Director Administration Services

HEOC Administration Officer

Administration Officer/s

HEOC Remote Switchboard Operator

Switchboard Services Operator/s or Manager of Switchboard Services

Incident management team - collective roles and functions

Whilst each cell and officer within the IMT has specific roles and functions, some responsibilities are shared

across multiple cell, bringing different foci and expertise. Additionally, the IMT collectively, has roles and

functions.


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The collective role and function is primarily assessment and coordination: collective ongoing assessment of

the incident in terms of both the impact and consequence (potential or actual) and coordination of the response

required

This is achieved by completing the following requirements:

• Definition of incident objectives. The broad objective of any incident response is to stabilise the situation

while minimising personal injuries and property destruction and commencing business continuity and

recovery activities.

• Development of an Incident Action Plan. This can be initially a verbal plan but should be documented for all

Medium or High-Level Incidents on the Incident Summary and Action Plan (ISAP). The plan will be utilised

by each cell to inform: Objectives and strategies, including alternatives; Composition of the appropriate IMT;

Safety considerations; Specifying and managing the required resources; and, Implementing continuity and

recovery plans / measures. These plans should be informed by the relevant DisMaPs.

• Facilitation and participation in regular briefings and / or planning meetings. The provision of regular

information updates enhances the response and coordination. For medium level incidents briefings may be

presented verbally at the formal briefing and should utilise the SMEACS-Q format as outlined below:

– Situation − the current and predicted situation of the event;

– Mission − event or activity objective of the group;

– Execution − how the mission will be accomplished; what agencies are involved?

– Administration and Logistics − recording requirements, logistical arrangements.

– Command and Communications – Emergency Operation Centres activated, business continuity plans in

place.

– Safety − hazards (known and potential)

– Questions − from the audience, to the audience (to confirm understanding).

For high level incidents, a Situational Report (SITREP), should be completed by each IMT cell and submitted

to the HIC prior to the formal briefing and planning meeting. The briefing is to be conducted by the HIC or a

Cell Officer who has the relevant authority, and understanding of the incident, and the ability to manage

group processes and communications. A formal record of each briefing is to be documented on the briefing

template See Appendix Two. Briefing requirements are further outlined in the HEOC procedure.

Health Emergency Operations Centre (HEOC)

The Health Emergency Operations Centre (HEOC) is the operational base of the Incident Management Team

(IMT) from which a disruption, emergency or disaster response is coordinated. A HEOC may be activated for

a medium incident and should be activated in the event of a high incident.

HEOC Locations

The location of the HEOC is defined by the level of incident. These locations are defined in the table below:

Incident Level HEOC Location

Medium Fire Indicator Panel / Fire Control Room of relevant building facility; or, Relevant operational areas; or, QCH Level 7, Executive Conference Room; or, Designated HEOC locations within community facilities.

High QCH Level 7, Executive Conference Room; or, Alternate South Brisbane location TBC: or, Designated HEOC location within community facilities (under discussion).


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HEOC establishment and management

The Health Emergency Operations Centre (HEOC) Procedure details the following HEOC establishment and

management activities:

• Process of setting up and establishing the HEOC;

• Required resources;

• Documentation and reporting requirements;

• IMT Cell / officer identification e.g. vests / tabards; and,

• HEOC staffing, shift allocations and handover requirements.

Disruption Management Plans (DisMaPs)

As outlined in CHQ Disruption Management Framework Prevention and Preparedness Procedure, a suite of

DisMaPs will define the strategies to be utilised by the organisation when responding to and / or recovering

from a disruptive or emergency incident or disaster situation.

These plans are developed at an operational, tactical and strategic level. The utilisation of these plans is

defined in the table below:

CHQ Personnel Type of DisMaP Purpose

Local area personnel, team leader, unit manager

Area / Department specific DisMaP (Operational)

Inform local area / operational response and recovery arrangements for business activities and required resources

Specific response teams e.g. Disruption Response Team, Health Informatics Team / Recovery Team, Resource specific teams i.e. Facilities, ICT, Security.

Resource or scenario specific DisMaP e.g. Code Specific DisMaP, ICT and Facilities resource specific response plans. (tactical)

Inform coordinated tactical responses to specific incident types. These plans incorporate or a cognisant of local area operational arrangements.

Incident Management Team / CHQ Executive

Strategic procedures and plans e.g. Response and Recovery Procedure, Incident specific ISAP which is informed by tactical and operational plans.

Coordinate the required tactical

and operational response and

recovery arrangements to inform

appropriate command and

control arrangements for the

incident as a whole.

Response Conclusion

Once the emergency has abated a “stand down” or “all clear” will usually be initiated. At this stage recovery

commences and the organisation should commence the return to normal operations. Continued

implementation of continuity and recovery plans may be required and in this instance the code may be de-

escalated to a lean forward. The IMT may continue to facilitate periodic briefings.

https://qheps.health.qld.gov.au/__data/assets/pdf_file/0026/708128/proc_62430.pdf


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Recovery

Review and evaluation

A review of each disruptive or emergency incident will be facilitated by the Disruption and Disaster Management

Unit. A debrief or review process should attempt to identify the effectiveness of systems, preparedness,

operational responses and identify areas which may require improvement. A summary of the review

requirements for specific activation phase or classification of incident is outlined in the table below:

Review/ Debrief

Hot debrief - Daily After- Action Review (AAR)

Hot debrief - Desktop process implementation review / Post event AAR

Cold Debrief Post Event Analysis

Critical Incident / EAP

Incident phase / classification

Alert ✓

If required

Lean Forward

/ Low Impact

Incident

✓

If required

Code –

Medium Impact Incident

If required

✓

If required

✓

Code – High

Impact

Incident

✓ ✓ ✓ ✓

Disruption and Disaster Management Incident Review and Debrief Survey

A Disruption and Disaster Management incident review and debrief survey will be facilitated after each

activation of the disruption response team or incident management team. (refer to 2). The survey can be sent

to selected recipients, Heads of Departments or all CHQ personnel dependant on the nature, size and impact

of the incident and the level of activation. The survey will be forwarded electronically within 1- 2 business days

after the incident, facilitated by the DDMU and results used to inform the required post event after action review

or analysis.

Hot debrief / daily After-Action Review

For prolonged responses to an incident an after-action review (AAR) of the IMT should be conducted at the

end of each day by the HIC. Based upon the ISAP the AAR should address;

1. What we set out to achieve/incident objectives?

2. What actually happened?

3. What did we do well?

4. What can be done better tomorrow/ next time?


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The findings of the AAR should be documented. These findings can be used to inform the review of the ISAP

and maybe included in the post event analysis.

Where 24-hour operations are occurring, an AAR should be conducted at the shift change to enable incoming

and outgoing personnel to be involved where possible.

Hot debrief / post event after action review

For low and medium impact incidents, the DDM incident review and debrief survey findings will be used to

inform a desktop process implementation review using the ‘Disruptive Incident: Review and Debriefing

Summary Tool” (refer to Appendix 2).

For high level incidents a face to face hot debrief may be conducted within 72 hours of the stand down of the

response phase at the direction of the HIC. All staff involved in the response should have an opportunity to

attend.

The DDM Incident Review and debrief survey questions should be used to inform the face to face debrief

agenda. The debrief facilitator will be the HIC, DDMU Portfolio Lead or delegate. The findings will be

documented on the Disruptive Incident: Review and Debrief Summary (refer to Appendix 2).

The completed summary should reference and reflect any relevant clinical review findings or DHS/ Facilities

Management Post Incident review findings. Completed summaries with issues/ risks identified as low – medium

should be forwarded to the relevant Director Nursing, Divisional or Executive) for review and endorsements.

The facilitation of Recommendations will be the responsibility of the relevant operational area/ Divisional Lead

supported by the DDMU.

Completed summaries with issues/risks identified as high or above should be directed to the chair of the DDMC

or SC as relevant for immediate review and tabled in the monthly DDMC or SC as relevant for immediate

review and tabled in the monthly DDMR and addressed at the next scheduled meeting at the Committee/

Subcommittee. Management of and progress with recommendations will be reported in the DDMR and

monitored by the relevant Emergency Management Committee or Sub Committee.

Cold debrief / Post Event Analysis (PEA)

For high level events or strategic level exercises a post event analysis will be conducted within the weeks

following the incident. This analysis may involve input from multiple stakeholder agencies. The focus of the

PEA is on improvements, systems, processes and human factors not individuals. The review should consider

the effectiveness of;

• Prevention: any applicable preventative strategies.

• Preparedness: education, training, procedure plans and arrangements.

• Response: notification, communication, command, control, collaboration, specific response strategies.

• Recovery: Recovery arrangements and implemented strategies.

The PEA facilitator / lead evaluator should be approved by the HIC or DDMU Portfolio Lead. It is recommended

that the facilitator / Lead Evaluator be someone external to the organisation who has appropriate training or

experience in the conduct and facilitation of debriefs.

This report will be submitted to the chair of the relevant DDMC or subcommittee and tables at the appropriate

meeting. The report will be included in the monthly DDMR. Specific escalation to the ECT will be facilitated by

the DDM portfolio lead if required.

Critical incident debriefs – EAP

Children’s Health Queensland provides support for personnel following a critical incident via the Employee

Assistance Program.


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Access to the EAP and establishment of critical incident support will be in accordance with the CHQ People

and Culture Employee Assistance program processes.

Recovery – Service Continuity and Recovery

The continuity, recovery and resumption efforts for any emergency incident are to be based upon the corporate

and relevant unit and resource DisMaP developed through the Disruption and Disaster Preparedness Program.

Activation of these plans, as early as possible during the response phase will enable the organisation to have

a streamlined progression from response to recovery and resumption, and to potentially minimise and mitigate

the impact and consequence of the disruption. Agreed priorities and recovery strategies defined within the

DisMaPs may need to be revised to consider seasonal changes, business conditions or the strategic direction

of the IMT.

The IMT Continuity of Operations Officer has responsibility for the initial activation of these plans.

A designated recovery team will be established for recovery efforts which require ongoing management. The

HIC and Continuity of Operations Officer will liaise with the Recovery Team Leader to facilitate the transition.

Supporting documents

Authorising Policy and Standard/s

• Managing Organisational Disruption Policy (CHQ-POL-62427)

Procedures, Guidelines and Protocols

• Disruption and Disaster Management Assurance Procedure (CHQ-PROC-62431)

• Disruption and Disaster Management Prevention and Preparedness Procedure (CHQ-PROC-62433)

Forms and Templates

• IMT Job Action Cards (Appendix 1)

• Debrief Summary Tool (appendix 2)

• Org Disruption – Warden Assessment and incident log (Appendix 3).

• DRT Assessment and Escalation tool (Appendix 4)

• ISAP (Appendix 5)

Consultation

Key stakeholders who reviewed this version:

• Chief Finance Officer

• Executive Director Clinical Services

• Executive Director Clinical Services – Queensland Children’s Hospital

• Executive Director Medical Services

• Acting Divisional Director Child and Youth Community Health Service (CYCHS)

• Nursing Director Clinical Support Services

• Children’s Health Queensland Emergency Management Committee

• Communities, Mental Health Statewide Services – Emergency Management Sub-Committee



https://www.childrens.health.qld.gov.au/wp-content/uploads/PDF/covid-19-extranet/governance-docs/proc-62431.pdf




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• Queensland Children’s Hospital – Emergency Management Working Group

Definition of terms

Term Definition Source

Business as

Usual (BAU)

used to say that something is working or continuing in the normal or

usual way

Merriam-Webster

Website

Contingency

Planning

A process that analyses potential events or emerging situations that

might threaten society or the environment and establishes arrangements

that would enable a timely, effective and appropriate response to such

events should they occur. The events may be specific, categorical, or all-

hazard. Contingency planning results in organized and coordinated

courses of action with clearly identified institutional roles and resources,

information processes and operational arrangements for specific

individuals, groups or departments in times of need (1).

World Health

Organisation

Disruption

Management

Any event or series of events causing a serious disruption of a

community’s infrastructure – often associated with widespread human,

material, economic, or environmental loss and impact, the extent of

which exceeds the ability of the affected community to mitigate using

existing resources (1).

World Health

Organisation

Preparedness The knowledge and capacities developed by governments, professional

response and recovery organizations, communities and individuals to

effectively anticipate, respond to and recover from the impacts of likely,

imminent, or current hazardous events or conditions (1).

World Health

Organisation

Response The provision of emergency services and public assistance during or

immediately after a disaster in order to save lives, reduce health

impacts, ensure public safety, and meet the basic subsistence needs of

the people affected (1).

World Health

Organisation

Recovery Restoring or improving the functions of a facility affected by a critical

event or disaster through decisions and action taken after the event (8).

World Health

Organisation

References

1. Disaster Management Act 2003

2. Disaster Management Act Regulations 2014

3. Building Fire Safety Regulations 2008

4. Health Service Directive QH-HSD-003:2017 Disaster and Emergency Incidents

5. AS 4083:2010 – Planning for Emergencies in Health Care Facilities

6. AS 3754:2010 – Planning for Emergencies in Facilities

7. ISO 22301:2012 – Business Continuity Management Systems

8. ISO 22317:2015 Societal Security Business Continuity Management Systems Guideline for Business

Impact Analysis

9. Good Practice Guide 2018

https://www.merriam-webster.com/dictionary/business%20as%20usual

https://www.merriam-webster.com/dictionary/business%20as%20usual

http://www.euro.who.int/__data/assets/pdf_file/0008/268766/Hospital-emergency-response-checklist-Eng.pdf











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Audit/evaluation strategy

Level of risk Very High

Strategy evaluate effectiveness of procedure, observe, train, practice, educate review annually

or post incident

Audit/review tool(s)

attached

N/A

Audit/Review date Annually – March

Review responsibility Disruption & Disaster Management Unit (DDMU)

Key elements /

Indicators / Outcomes

KPIs will measure efficacy, performance, fir for purpose, assessed against Australian

Standards AS3745:2010 & AS4083:2010, Disaster Management Act 2003, Ravenshoe

Review Recommendations.

Procedure revision and approval history

Version No. Modified by Amendments authorised by Approved by

1.0

04/03/2020

CHQ Emergency

Management Coordinator

Chief Finance Officer Chief Finance Officer

2.0

21/09/2021

Reviewed without change Executive Director Corporate

Services/Chief Finance

Officer

Keywords Disruption, Disaster, Emergency Management, Response, First Responders, Disruption

Response Team, Emergency Codes, Code Notification, Incident Management, Event,

Decontamination, Assurance, Prevention, Preparedness, Response, Recovery,

Organisational Disruption, Business Disruption, Business Continuity, ISAP, 62434

Accreditation

references

NSQHS Standards (1-8):

• Standard 1: Clinical Governance

ISO 9001:2015 Quality Management Systems: (4-10)


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Appendix 1: Incident Management Team (IMT) Job Action Cards


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Appendix 2: Debriefing Summary Tool


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Appendix 3: Org Disruption – Warden Assessment and Incident Log


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Appendix 4: Disruption Response Team (DRT) Assessment and Escalation Tool


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Appendix 5: Incident Action Summary Plan (ISAP)


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disruption and disaster management – response and recovery

Documents