emergency management framework islhd corp pd 24 · 2019. 8. 20. · internal only islhd policy...

INTERNAL ONLY

ISLHD POLICY

EMERGENCY MANAGEMENT FRAMEWORK ISLHD CORP PD 24

Revision: 3.1 DX19/409 March 2018

THIS DOCUMENT BECOMES UNCONTROLLED WHEN PRINTED OR DOWNLOADED UNLESS REGISTERED BY

LOCAL DOCUMENT CONTROL PROCEDURES

INTERNAL ONLY

NAME OF DOCUMENT Emergency Management Framework

TYPE OF DOCUMENT Policy

DOCUMENT NUMBER ISLHD CORP PD 24

DATE OF PUBLICATION March 2018

RISK RATING Medium

REVIEW DATE March 2021

FORMER REFERENCE(S)

ISLHD CORP PD 24 July 2017

Area Policy Directive PD 069

ISLHD OPS PD 24 – Sept 2012

EXECUTIVE SPONSOR or

EXECUTIVE CLINICAL SPONSOR

Executive Director Nursing & Midwifery / ISLHD HSFAC

AUTHOR ISLHD Disaster Manager

KEY TERMS

Emergency Management; Disaster, Disaster Management,

Framework, HSFAC

FUNCTIONAL GROUP OR HUB District

NSQHS STANDARD Standard 1

SUMMARY

This document describes the responsibilities of the District

and Facilities as per the ISLHD Health Plan and Facility /

Service Disaster Plans for the prevention, preparation,

response, recovery and management of internal /external

emergencies.

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

1. POLICY STATEMENT

All emergency management plans shall be documented, current and available to all workers

who are responsible for the co-ordination and response to emergencies that arise either

internally, within the organisation, or from an external source affecting a service, group of

services or sites, within the geographical boundaries of the Illawarra Shoalhaven Local Health

District (ISLHD).

In compliance with NSW Healthplan, all emergency management plans are to be structured

under the Incident Command System (ICS), and only the colour codes detailed within the

Australian Standard AS4083:2010 are to be used within ISLHD facilities.

2. AIM

To provide a framework for ISLHD to plan for both internal and external emergencies.

3. POLICY

ISLHD has a responsibility to ensure emergency management plans (Disaster Plans) are

documented and available to all staff responsible for the coordination and response to

emergencies.

The Chief Executive (CE),Operation Managers and Site Managers shall ensure systems for

risk management are available and that staff are appropriately trained to respond to both

internal and external emergencies.

The NSW Health Plan supports the NSW Emergency Management Plan (EMPLAN) and is

responsible for coordinating and controlling mobilisation of all health responses (both public

and private) to emergencies. This response will include hospital, medical, community health,

nursing and first aid, pharmaceutical supplies, public health and mental health services.

ISLHD has the responsibility of developing emergency management plans at the District and

Site/Service level that defines responsibilities of key personnel and includes methods of

communication that are appropriate to manage all emergencies that may impact on the

business continuity of the service/facility.

Emergencies may relate but is not limited to the following:

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

CODE RED Fire and Smoke Emergency

CODE BLUE Medical Emergency / Cardiac Arrest

CODE PURPLE Bomb Threat

CODE YELLOW Internal Emergency / Hazardous Substance Incident

CODE BLACK Armed Holdup / Robbery / Personal Threat

CODE ORANGE Evacuation

CODE BROWN External Emergency – including any local known risks

All emergency response plans will follow the colour codes detailed within the Australian

Standard AS4083:2010. No other colour codes are to be used within ISLHD.

Internal emergencies affecting essential utilities and /or services should be supported by

Business Continuity Plans in addition to the facility / service emergency management plan.

Within ISLHD the Service Continuity Contingency - Hospital Utilities (SCCHU) data base

identifies needs, normal supply options, alternate supply options and emergency contact

information about the 3rd Party external providers. The technical information provided in

SCCHU comes from a sites clinical and engineering management and shall be reviewed

every 12 months.

All ISLHD emergency management plans, sub-plans and business continuity plans will be

available to all staff for reference and can be accessed on the ISLHD Intranet page –

Disaster Management – Disaster Plans.

4. TARGET AUDIENCE

All staff employed by ISLHD

5. HEALTH EMERGENCY MANAGEMENT GOVERNANCE

As documented in NSW HEALTHPLAN, the State Health Emergency Management

Committee (SHEMC) governs NSW Health Emergency Management Arrangements. This

http://islhnweb/Facilities_Services/SCCHU/SCCHU_Home.asp

http://islhnweb/Disaster_Management/plans.asp

http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2014_012.pdf

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

committee is established under the State Emergency Rescue and Management Act 1989

(NSW) (as amended) Section 16 (1) and (2) and is chaired by the State Health Services

Functional Area Coordinator (HSFAC). In compliance with the Health Emergency

Management Governance arrangements as presented in the NSW HEALTHPLAN, ISLHD

shall convene District and Hub Health Emergency Management Committees (HEMCs).

Services that are not represented in either the District or Hub HEMCs shall table disaster

planning and preparedness items at their respective Health & Safety Committees (HSCs) or

if a service does not have a HSC, then they should table in meetings that are documented as

their WHS Consultative arrangements.

5.1 ISLHD HEALTH EMERGENCY MANAGEMENT COMMITTEE

In compliance with NSW HEALTHPLAN, the ISLHD HSFAC chairs the ISLHD Health

Emergency Management Committee (HEMC) which reports to the State Health Emergency

Management Committee.

The ISLHD HEMC responsibilities are to:

Review and update ISLHD HEALTHPLAN;

Provide advice and recommendations regarding the health aspects of emergency

management and accompanying legislation;

Identify health resources within ISLHD;

Regularly review emergency health resources within ISLHD;

Approve plans and Standing Operating Procedures that support ISLHD

HEALTHPLAN;

Approve emergency plans at LHD, Facility and Service levels;

Approve education and training strategies in health emergency management;

Monitor and evaluate health incident management and exercises in health

emergencies; and

Identify the need for, and the preparation and maintenance of, plans that support

ISLHD HEALTHPLAN.

Membership of the ISLHD HEMC will be in accordance with NSW HEALTHPLAN and the

committee may request other persons / representatives to attend the meeting to assist in

discussion on any particular matter. However, those persons do not have membership rights.

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

The ISLHD HEMC shall meet quarterly at minimum, or more often as the committee may

decide.

5.2 ISLHD HUB HEALTH EMERGENCY MANAGEMENT COMMITTEE

ISLHD has a hub service delivery model based around three main population centres. Each

hub, Northern Illawarra Hospital Group (NIHG), Southern Illawarra Hospital Group (SIHG)

and Shoalhaven Hospital Group (SHG), shall convene a Health Emergency Management

Committee (HEMC) to support the District HEMC.

The respective hub HEMCs shall be the governing committee for disaster preparedness and

planning. The aim of the hub HEMC is to oversee the development, maintenance and

exercising of all emergency management plans and sub-plans within the hub. Hub HEMCs

are a supporting committee to the District HEMC. Hub HEMCs shall meet quarterly at

minimum, or more often as the committee may decide.

5.3 HEALTH & SAFETY COMMITTEES AND CONSULTATIVE ARRANGEMENTS

The role of the Health & Safety Committee (HSC) is to facilitate cooperation between ISLHD

and workers on health and safety matters as well as to develop work health and safety

standards, rules and procedures (Work Health & Safety Act 2011). Various HSCs exist

across the ISLHD, however where a HSC does not exist, then the documented consultative

arrangements can be used, these arrangements offer a forum to discuss disaster planning

and preparedness. The Consultative arrangements also provide a forum to oversee the

development, maintenance and exercising of all emergency management plans and sub-

plans within a given workplace or service.

6. RESPONSIBILITIES

District HSFAC and Illawarra Shoalhaven Local Health District (ISLHD) Health Emergency

Management team will:

Ensure that the District HEALTHPLAN is maintained and meets the emergency

preparedness of NSW Healthplan.

https://www.legislation.nsw.gov.au/#/view/act/2011/10/part5/div4/sec77https://www.legislation.nsw.gov.au/

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

Oversee the development, maintenance and exercising of all the Local Health

District (LHD) plans and related sub-plans and provide strategic advice to the

Chief Executive.

Operation Managers, General Managers, Site Managers and Incident Controllers will:

Ensure the development and maintenance of internal emergency management

plans and that these plans support / align with ISLHD HEALTHPLAN.

Provide representation on the ISLHD HEMC.

Support emergency response education and training as per ISLHD Health

Emergency Management Education Framework.

Line Managers:

Will ensure that local emergency response procedures are complied with.

Will allocate staff to the take on the role of Emergency Warden in response to

emergencies at their workplace.

Will support and ensure emergency response training and education (including

Emergency Warden Training) is conducted and completed.

Staff and Contractors employed by ISLHD:

Are required to follow the procedures for that site or service and to follow the

directions of authorised staff in the execution of their duties in the response to an

emergency.

Will maintain currency of emergency response training and education (as per

ISLHD Health Emergency Management Education Framework).

7. PROCEDURE

The framework for emergency management in ISLHD is one of prevention, preparedness,

response and recovery (PPRR).

7.1 PREVENTION AND HAZARD IDENTIFICATION

General Managers and Site Managers shall ensure, in consultation with staff, key

stakeholders and appropriate advisory bodies, that security risks and potential emergencies

are identified, assessed, eliminated where reasonably practicable or effectively controlled.

http://islhnweb/Disaster_Management/education.asphttp:/islhnweb/Disaster_Management/Education/TrainingMatrix-2014-2015.pdf

http://islhnweb/Disaster_Management/education.asphttp:/islhnweb/Disaster_Management/Education/TrainingMatrix-2014-2015.pdf

http://islhnweb/Disaster_Management/Education/TrainingMatrix-2014-2015.pdf

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

Site Managers are responsible for developing, implementing and maintaining emergency

response plans for identified hazards pertinent to their respective facility / service.

The management of general security risks are detailed in Protecting People & Property:

NSW Health Policy & Guidelines for Security Risk Management.

Other security considerations that sites should consider in the development of their

emergency management plans and risk management plans are, but not isolated to:

The possibility that fire / bomb threats are diversionary tactics for criminal activity

Theft or looting during an incident / disaster

The safety and securing of evacuated patients / visitors / staff

Isolating fire / crime scenes until external services arrive

Controlling crowds, traffic or influx of telephone calls

Access to vulnerable areas within facilities to obtain drugs and / or money.

7.2 PREPAREDNESS

ISLHD has established the location and availability of specific resources that may be

required during an emergency or disaster incident. The ISLHD Health Plan, Facility / Service

emergency management plans and sub-plans details these resources and the roles and

responsibilities of key personnel.

In compliance with NSW Healthplan, all emergency management plans are to be structured

under the Incident Command System (ICS) and details the provisions in place to establish a

Health Services Emergency Operations Centre (HSEOC). A HSEOC is established

specifically to provide centralised assessment of operational needs and coordination of

health service resources and responses to any emergency / major incident. A Health

Services Emergency Operation Centre Operating Procedures template is available to use to

detail the administrative arrangements whenever it is necessary to open a HSEOC.

7.2.1 ISLHD HEALTHPLAN

It is the responsibility of the District HSFAC to ensure that ISLHD Healthplan is maintained

and meets the emergency preparedness of the NSW HEALTHPLAN.

http://www.health.nsw.gov.au/policies/manuals/Documents/prot-people-prop.pdf


http://islhnweb/Forms_Templates/Non_Clinical/default.asp#Disaster_Management


INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

The ISLHD Healthplan will be reviewed and/or updated:

At the conclusion of an emergency in which the health emergency arrangements

in this plan were, or could have been, activated; or

With the introduction of any major structural, organisational or legislative changes

which affect NSW Health or key stakeholders; or

Under direction of the ISLHD HSFAC.

7.2.2 ISLHD SITE / SERVICE EMERGENCY MANAGEMENT AND BUSINESS

CONTINUITY PLANS

Emergency Management Plans, Business Continuity Plans and sub-plans shall be presented

in a standardised format. The governance approval process for ISLHD emergency

management and business continuity plans shall be in line with section 7.2.4 Governance

Approval Process for Emergency Management Plans.

Emergency Management Plans, Business Continuity Plans and sub-plans will be reviewed

and/or updated;

At the conclusion of an emergency where plans were, or could have been

activated; or

With the introduction of any major structural, organisational or legislative changes

which affect NSW Health or key stakeholders; or

Under direction of the Executive Sponsor or at the request of the HEMC.

7.2.3 SUPPLEMENTARY PLANS (SUB PLANS)

Hazard analyses / risk assessment shall be undertaken by each Facility / Site / Service. The

outcomes of these analyses should then be included in the respective emergency

management plan or as a Sub- plan i.e. Bush Fire Response Plan, Flood Response Plan.

7.2.4 GOVERNANCE APPROVAL PROCESS FOR EMERGENCY MANAGEMENT

PLANS

As per ISLHD OPS PROC 09 - Policy, Procedure, Business Rule, Guideline and Form

Development. Revision and Approval Process, all documents shall be approved prior to

release on the ISLHD Intranet Site.

http://islhnintranet/Policies_Procedures_Guidelines/Corporate/Governance/documents/ISLHD-OPS-PROC-09-PolicyDevelophttp:/islhnintranet/Policies_Procedures_Guidelines/Corporate/Governance/documents/ISLHD-OPS-PROC-09-PolicyDevelopmentandApproval-17.pdfmentandApproval-17.pdf

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

All ISLHD Emergency Management Plans (disaster plans), Business Continuity Plans and

sub plans shall be developed, revised and approved as per ISLHD OPS PROC 09.

7.2.5 EDUCATION AND TRAINING

Managers are responsible for ensuring that staff receive regular training on emergency

response. The training must be appropriate to the role of the staff member and targeted to

the level and type of security associated with their employment.

Training programs should be designed so that the particular needs of the Facility / Site /

Service is addressed and should be such that an appropriate level of preparedness and

response is maintained (AS 4083-2010).

Emergency Management Training will be as per the ISLHD Health Emergency Management

Education Framework.

The Training program should aim to provide:

A thorough knowledge of the District / Facility / Service Disaster Plan.

Induction training for all new, temporary and casual staff of all emergency

procedures.

Training for all staff to ensure maintenance of knowledge and skills.

Collective training, in the form of exercises, to review emergency management

systems.

Advanced training of key personnel (IMT Members)

7.3 RESPONSE AND RECOVERY

Emergency Management Plans (Disaster plans) must document the coordination

arrangements and responsibilities for responding to, and recovering from an incident /

disaster.

Managers are responsible to ensure that procedures and documentation are current. Plans

should be reviewed following any incident / disaster where the plan has been activated.

http://islhnintranet/Policies_Procedures_Guidelines/Corporate/Governance/documents/ISLHD-OPS-PROC-09-PolicyDevelophttp:/islhnintranet/Policies_Procedures_Guidelines/Corporate/Governance/documents/ISLHD-OPS-PROC-09-PolicyDevelopmentandApproval-17.pdfmentandApproval-17.pdf



INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

Debriefing and post incident reviews should be carried out by the Incident Controller/s and

the relevant key stakeholders i.e. positions that formed the Incident Management Team

(IMT).

Site Managers and Line Managers will ensure that trained Emergency Wardens are

allocated to attend and take the lead role at fire and other emergencies at their workplace.

7.3.1 HEALTH SERVICES EMERGENCY OPERATION CENTRES

ISLHD must establish a Health Services Emergency Operations Centre (LHD HSEOC) to

manage emergencies within the area and provide a point of contact for the State HSFAC,

Ambulance Service and other emergency services for significant events requiring ongoing

coordination.

Additionally, each Facility / Service within the ISLHD shall ensure a Health Services

Emergency Operations Centre (HSEOC) is established specifically to provide centralised

assessment of operational needs and coordination of health service resources and

responses to any emergency / major incident.

Please refer to the ISLHD OPS F 576 – for Health Services Emergency Operation Centre –

Operating Procedures Template.

7.3.2 EXTERNAL EMERGENCY RESPONSE

The ISLHD HSFAC will generally receive notification of an emergency / disaster from the

State HSFAC and activate the ISLHD HEALTHPLAN if required to the appropriate stage

(Alert, Standby, Response or Stand-down).

Alternate sources of notification may occur at site or District level and it is therefore important

that the recipient confirms the information and notifies up and down the line of command

according to the roles outlined in this policy. Please refer to appendix 2

The ISLHD Incident Management Team (IMT) includes the District HSFAC (+/-) Medical

Controller and Controllers for the following main functions:


INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

Mental Health Controller

Public Health Controller

Communications Controller

Corporate Services Controller

Hospital Incident Controllers

The ISLHD HSFAC may also request controllers from the following:

HealthShare

SEALS Pathology

Sydney Children Hospital Network

ISLHD is responsible for mobilising, when requested by either the State or District HSFAC,

health resources as detailed in the ISLHD HEALTHPLAN. Health Response Team - Medical

Equipment Kit (PD2009_080) and Health Response Team Uniform (PD2009_048) provide

details of LHD requirements.

In addition, Mass Casualty Triage – Smart Triage Packs (PD2017_037) provides details of

additional Health Response Team - Medical Equipment Kit requirements.

It is also recommended that Mass Casualty Surge Response Plans are developed to support

the Facility Emergency Management Plan. These plans should include action cards that

document how the facility will respond to an internal or external disaster, resulting in an

abnormally large influx of patients, the supply of resources and personnel or both.

7.3.3 INTERNAL EMERGENCY RESPONSE

Each Facility / Site / Service must have a ‘building specific’ emergency management plan

readily available to staff. Emergency Management Plan template(s) are available to access

on the Disaster Intranet Site.

As per the Australian Standard: Planning for Emergencies – Health care facilities AS 4083-

2010, facilities shall develop standard notification, identification and activation systems to be

used in an emergency. They should also be appropriate to the facility’s size and function,

available technology and communications systems.

http://islhnweb/Disaster_Management/Plans/ISLHD-Healthplan.pdf




http://islhnweb/Disaster_Management/default.asp

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

The Facility should have an emergency planning committee to oversee emergency

prevention, preparedness, response and recovery, relative to its size and function.

Consideration should be given to the following phases:

Alert: Emergency possible – increase level of preparedness.

Standby: Emergency imminent – prepare for implementation of response.

Response: Emergency situation exists – implement response according to

facility plans.

Stand Down: Emergency abated – return to usual business.

Facilities shall dedicate a unique telephone number for the notification of emergencies.

The Emergency Management Plan should include an outline of control and coordination

functions and adapt the concept of the Incident Control System. Facilities shall establish a

Health Services Emergency Operation Centre (HSEOC) from which coordination and

communication functions can be carried out during the emergency / incident / disaster

phase. The HSEOC shall be equipped or capable of being equipped at short notice to allow

for the coordination/control process.

7.3.4 EVALUATION

Incident Controllers / Managers are responsible to organise / facilitate a review and de-brief

to identify areas for improvement and address any necessary changes to the Emergency

Management Plans, sub–plans and Business Continuity Plans following any internal or

external incident / disaster.

Appendix 3 provides a debrief template which may be utilised.

The following measures of performance may be used to assist in the evaluation of individual

incidents or table top exercises.

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

INDICATOR MEASUREMENT ACHIEVED PARTIALLY

ACHIEVED

NOT

ACHIEVED

1. Was the

disaster plan

activated in a timely

manner

Code was declared within 5

minutes of initial notification

2. Disaster

Communication

cascade activated

All key stake holders

informed of disaster

3. Appropriate

Utilisation of Chain of

Command

According to Local disaster

plan

4. Identification of

Resource

requirements

Requests additional

resources as necessary

5. Appropriate

Utilisation of

Workforce

Allocation of staff according

to skills

6. Patient Flow is

Managed

Appropriate time to

definitive care

7. Identification of

patients that can be

discharged,

transferred or delayed

Timely movement of

patients to accommodate

surge

8. DOCUMENTATION

In the event of an incident /emergency /disaster, formal documentation is required. This

documentation will be recorded on ISLHD specific developed forms and templates which can

be accessed via the Emergency and Disaster Management site on ISLHD intranet.

Documents included are:

Action Plan

Activity Log

Situation Report (SitRep)

http://islhnweb/Forms_Templates/Non_Clinical/Disaster_Management_Emergency_Procedures/OPS-F141-ActionPlanTemplate.doc

http://islhnweb/Forms_Templates/Non_Clinical/http:/islhnweb/Forms_Templates/Non_Clinical/Disaster_Management_Emergency_Procedures/ISLHD-OPS-F142-ActivityLogTemplate.docdefault.asp#Disaster_Management

http://islhnweb/Forms_Templates/Non_Clinical/Disaster_Management_Emergency_Procedures/ISLHD-OPS-F-146-SituationReport.docx

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

Attendance Register

Facility System Status Report

Hospital Resource Summary

Message- Record of Conversation

Task Resource request Form

Patient Tracking Sheet

All emergency incidents related documentation must be retained for a minimum of 7 years and

then destroyed (General Disposal Authority 2005 - GDA21/5.11.2).

9. DEFINITIONS

Business

Continuity Plan

A collection of information and Business Unit/ Service Line procedures that

is developed, compiled and maintained in readiness for use in the event of

an emergency or disaster. These plans have previously been referred to as

Critical Operations Standing Operating Procedures (COSOPS).

Code Red The specific colour for internal emergency for Fire & Smoke Emergency as

per Australian Standard AS 4083 – 2010.

Code Blue The specific colour for internal emergency for Medical Emergency / Cardiac

Arrest as per Australian Standard AS 4083 – 2010.

Code Purple The specific colour for internal emergency for Bomb Threat as per Australian

Standard AS 4083 – 2010.

Code Yellow The specific colour for internal emergency for Hazardous Chemical Incidents

/ Internal Emergency as per Australian Standard AS 4083 – 2010.

Code Black The specific colour for internal emergency for Armed Holdup / Robbery /

personal Threat as per Australian Standard AS 4083 – 2010.

Code Orange The specific colour for internal emergency for Evacuation as per Australian

Standard AS 4083 – 2010.

Code Brown The specific colour for internal emergency for External Emergency as per

Australian Standard AS 4083 – 2010.

http://islhnweb/Forms_Templates/Non_Clinical/default.asp#Disaster_Managementhttp://islhnweb/Forms_Templates/Non_Clinical/Disaster_Management_Emergency_Procedures/ISLHD-OPS-F420-ISLHDEmergencyOperationCentreAttendanceRegister.docx

http://islhnweb/Forms_Templates/Non_Clinical/Disaster_Management_Emergency_Procedures/OPS-F144-FacilitySystemStatusReport.doc

http://islhnweb/Forms_Templates/Non_Clinical/default.asp#Disaster_Managementhttp://islhnweb/Forms_Templates/Non_Clinical/Disaster_Management_Emergency_Procedures/ISLHD-OPS-F416-HospitalResourcesSummary.docx

http://islhnweb/Forms_Templates/Non_Clinical/default.asp#Disaster_Managementhttp://islhnweb/Forms_Templates/Non_Clinical/Disaster_Management_Emergency_Procedures/ISLHD-OPS-F422-ISLHDMessage-RecordofConversation.docx

http://islhnweb/Forms_Templates/Non_Clinical/default.asp#Disaster_Managementhttp://islhnweb/Forms_Templates/Non_Clinical/Disaster_Management_Emergency_Procedures/ISLHD-OPS-F421-ISLHDTask-ResourceRequestForm.docx

http://islhnweb/Forms_Templates/Non_Clinical/Disaster_Management_Emergency_Procedures/ISLHD-OPS-F140-PatientTrackingSheet.doc

http://www0.health.nsw.gov.au/policies/ib/2005/pdf/IB2005_027.pdf

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

Emergency

Management Plan

A document that details the necessary management arrangements to

coordinate the resources to assist in the preparation for, response to, and

recovery from the impact of a major incident/disaster.

Emergency

Warden

Emergency Wardens (EW) are those employees that, as a part of their

normal duties, attend and take the lead role at fire and other emergencies at

their place of work in line with AS 3745 and AS4083.

Facility Within ISLHD a Facility indicates Hospitals within the District e.g.

Wollongong Hospital

HEOC The Health Emergency Operation Centre (HEOC) is a specially equipped

room from which an emergency /disaster incident is controlled.

HRT Health Response Team (HRT) is made up of two medical officers and four

registered nurses. The HRT may be mobilised to provide a range of health

and medical support to a major incident or disaster site under the direction

of the State or District Health Services Functional Coordinator (State

HSFAC).

HSFAC An appointed position at LHD Service level that has the authority to

coordinate and commit all health resources within the LHD during activation

of the Healthplan. The LHD HSFAC will be the State HSFAC point of contact

within the LHD.

LHD ISLHD Services are the administrative units of the NSW Ministry of Health,

defined by geographical boundaries, which are responsible for the

administration of the NSW Ministry of Health’s policies and responsibilities in

that LHD.

Internal

Emergency

A sudden event that arises internally and which may be caused by an

internal or external source and may adversely affect the safety of persons in

the health care facility requiring an immediate response by the occupants.

IMT The Incident Management Team (IMT) is a team of key personnel within the

ICS structure; i.e. Command, Operations, Planning, Logistics and Public

Information as a supportive Function

Services Within ISLHD services provide specific medical treatment to individuals. E.g.

Mental Health Services, Maternity Services, Renal Services, Oral Health

Services.

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

Subplans A sub plan is an action plan for a specific hazard, critical task, or special

event. Sub plans are prepared when the management arrangements

necessary to deal with the effects of the hazard, or the requirements due to

an event, differ from the general coordination arrangements in the main or

supporting plans for the area e.g. bushfire response plan.

10. REFERENCES

External References

NSW Healthplan

Healthplan – Medical Services Supporting Plan

Healthplan – Mental Health Services Supporting Plan

Protecting People /Property: NSW Health Policy / Guidelines for Security Risk

Management in Health Facilities IB2013_024

Incident Management

ACHS EQuIP 5: Section 5 Criterion 3.2.4 – Emergency and Disaster Management

Supports Safe Practice and a safe Environment.

General Retention & Disposal Authority - Public Health Services: Administrative

Records - GDA 21

Fire Safety in Healthcare Facilities PD2010_024

Internal References:

Security Risk Management Framework

Fire Safety Management

Fire Safety Compliance

Policy, Procedure, Business Rule, Guideline and Form Development, Revision

and Approval Process

https://shems.nogginoca.com/contacts/contacts.html?op=op_newrecord&ContactTypeID=1&select=true&Name=&kw=&searchgroups=&communication%5B0%5D=&communication%5B1%5D=&value=4501&label=SHEMS+System+Administrators+Group&label_path=SHEMS+System+Administrators+Group&_t_=He_qEkxV

http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2010_011.pdf

http://www.health.nsw.gov.au/policies/gl/2012/GL2012_006.html



http://www0.health.nsw.gov.au/policies/ib/2005/pdf/IB2005_027.pdf


http://islhnweb/Policies_Procedures_Guidelines/Corporate/Security/documents/ISLHD-OPS-PD-12-SecurityRiskManagementFramework.pdf

http://islhnintranet/policies_procedures_guidelines/Corporate/Fire_Safety/documents/ISLHD-OPS-PD-06-FireSafetyManagement.pdf

http://islhnintranet/Policies_Procedures_Guidelines/Corporate/Governance/documents/ISLHD-OPS-PROC-09-PolicyDevelopmentandApproval-17.pdf

http://islhnintranet/Policies_Procedures_Guidelines/Corporate/Governance/documents/ISLHD-OPS-PROC-09-PolicyDevelopmentandApproval-17.pdf

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

11. REVISION & APPROVAL HISTORY

Date Revision No. Author and Approval

September

2012

0 ISLHD Disaster Manager

Approved by ISLHD HSFAC, September 2012

September

2014

1 ISLHD Disaster Manager

Endorsed by ISLHD HEMC

July 2017 2 ISLHD Disaster Manager


January 2018 3 ISLHD Disaster Manager


March 2018 3.1 Minor amendments at request of ISLHD Corporate Governance

Committee

Approved by ISLHD HSFAC, 26/03/18

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

Appendix 1: WARDENS ROLES & RESPONSIBILITIES

Appendix 1(a): EMERGENCY WARDENS are assigned to each ward/area within a building

to ensure that all people are aware of an emergency situation. Following direction from either

the Floor Warden and /or Incident Controller, they will direct the evacuation of their assigned

ward/area to the nearest emergency exit; checking to ensure that all people have left the

area as they themselves exit the ward / area. Emergency Wardens prevent people from

using elevators and help ensure an orderly and safe stair evacuation; enlist help to assist

any disabled person, and direct people to the building’s assigned evacuation Emergency

Assembly Area.

Emergency Wardens appointed to ward/area should:

o Be capable of performing their duties;

o Have leadership qualities and the ability to command authority;

o Display effective decision making skills;

o Demonstrate the capability to remain calm under pressure;

o Be available to undertake their appointed duties;

o Be capable of effectively communicating with staff, patients and others persons as well

as Floor Warden (where applicable) / Incident Controller

o Be able to attend relevant training

(AS 3745-2010)

Responsible To:

o Floor Warden (where applicable)

o Fire Panel Warden (where applicable)

o Incident Controller

Pre-Emergency Responsibilities

o Review emergency procedures and know the location of the Emergency Assembly

Area/points; and

o Be familiar with the locations of the following on assigned floor:

fire alarm(s)

fire extinguisher(s)

Warden Intercommunication Point Phones(WIP Phones)

Manual Call Points (MCP)

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

emergency exits(s)

evacuation route(s)

first aid arrangements

emergency supplies

spill kits

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

Emergency Checklist

An Emergency Warden, on becoming aware of an emergency, should implement the emergency

procedures for their ward/area which should include the following actions:

□ Ensure that appropriate notifications/alerts have been made, and emergency procedures

are being followed

□ Retrieve emergency bag and put on Floor Warden ID tabard (RED);

□ Observe any hazardous conditions and/or damage;

□ Keep unnecessary personnel away from scene of emergency;

□ If evacuation is indicated or ordered:

o Alert all personnel on assigned ward/area

o During evacuation, quickly check floor, restrooms and closed work areas to ensure

that all personnel have evacuated

o Close all doors when ward/area is evacuated (Except for Code Purple emergencies)

o Post “area evacuated” sign on door once ward/area is cleared-if time allows

o Assign personnel to assist any disabled or injured persons

o Provide Floor Warden (where applicable), Incident Controller with status report of

condition of assigned ward/area.

o Provide information and directions to ward/area persons, as directed by the Floor

Warden (when applicable) / Incident Controller.

Post-Emergency Responsibilities

□ Hold ward/area debrief following emergency response to determine what did and did not

work well and what needs to be improved.

□ Participate in facility/site debrief

□ Disseminate information to ward/area staff as warranted

□ Maintain Emergency Warden competency every three (3) years

□ Attend training and emergency exercises as required

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

Appendix 1(b): FLOOR WARDENS are assigned to each floor of a building to control the

emergency procedures for their floor. It is important that the Floor Warden or a Deputy Floor

Warden be available for each floor or zone during periods of occupancy.

Floor Wardens appointed should:







as the Floor Warden (where applicable), Fire Panel Warden (where applicable) / Incident

Controller


(AS 3745-2010)

Responsible To:

o Fire Panel Warden (where applicable)



o Review emergency procedures and know the location of the Emergency Assembly Areas

/points.

o Floor Wardens must be familiar with:

the operation of the fire alarm system, the emergency warning system and any other

equipment used to assist in the operation of emergency procedures for the building,

the floor or zone they represent, including

all means of egress and alternative escape routes,

the existence and positions of rooms leading off blind passages, doors leading to

dead-ends and any other confined areas in which persons could be located,

potentially hazardous materials or operations undertaken in their zone,

the location and operation of fire doors, smoke doors, fire blankets, portable fire

extinguishers and fire hoses on their floor or zone,

the number and location of mobility-impaired persons on their floor or zone

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

Emergency Checklist

A Floor Warden, on becoming aware of an emergency, should implement the emergency

procedures for their floor which should include the following actions:


are being followed;

□ Attend the WIP phone (where applicable) to communicate with Fire Panel Warden (where

applicable)

□ Retrieve emergency bag and put on Floor Warden ID tabard (YELLOW);

□ Observe any hazardous conditions and/or damage;

□ Keep unnecessary personnel away from scene of emergency;

□ If the circumstances on their floor warrant it, order the evacuation of the occupants of their

floor by communicating with Emergency Wardens;

□ Communicate with the Incident Controller / Fire Panel Warden (where applicable) and act

on his or her instructions;

□ Direct wardens to check the floor for any abnormal situation; and

□ Advise the Incident Controller as soon as possible of the circumstances on their floor and

of the action taken.






INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

Appendix 1(c): FIRE PANEL WARDENS (where applicable) are assigned to attend the fire

panel in response to emergency alarm activation, to communicate and provide updates and

information to Floor Wardens (where applicable), Wardens and Incident Controller. It is

important that the Fire Panel Warden is available to attend the panel at all times.

Fire Panel Wardens appointed should:


o Know how to operate and read the Fire Indicator Panel;

o Be available on site to undertake their appointed duties;





o Be the liaison between the site and the Emergency Service personnel


as the Floor Warden (where applicable) / Incident Controller; and


(AS 3745-2010)

Responsible To:



o Review emergency procedures and know the location of the Emergency Assembly

Areas /points.

o Be familiar with and have an understanding of the workings of the Fire Indicator Panel

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

Emergency Checklist

A Fire Panel Warden, on becoming aware of an emergency, shall take the following actions:


are being followed;

□ Attend the Fire Indicator Panel to ascertain the area that triggered the alarm;

□ Attend the WIP phone to communicate with Floor Warden (where applicable) /Emergency

Warden;

□ If the circumstances warrant it, order the evacuation of the occupants of the affected

floor/area by communicating with Floor Wardens (where applicable) / Emergency

Wardens;

□ Communicate with the emergency Service personnel;

□ Communicate with the Incident Controller and act on his or her instructions; and

□ Advise the Incident Controller (if not already aware) as soon as possible of the

circumstances and of the action taken.






INTERNAL ONLY

ISLHD POLICY

EMERGENCY MANAGEMENT FRAMEWORK ISLHD OPS PD 24


THIS DOCUMENT BECOMES UNCONTROLLED WHEN PRINTED OR DOWNLOADED UNLESS REGISTERED BY LOCAL DOCUMENT CONTROL

PROCEDURES

INTERNAL ONLY

Emergency Response

EXTERNAL EMERGENCY - CODE BROWN i.e Bush Fire; Sorm; Flash flooding; Wind storm that may impact on Facility / Service / building

or business

Recieves notification from internal source/ HSFAC /

Disaster Manager

Respond as required +/-Contact Emergency Service for assistance AND Informs

Line Manager (if not already aware)

Receives direct notification from Emergency Service Personal

(NSW Police; Fire Rescue NSW; RFS; NSW SES) i.e. doorknocked

Follows recommendations and informs /updates Line Manager when able / ASAP

Recieves notification i.e. text message / phone call of Code

Brown Emergency

Contacts Line Manager +/- / HSFAC / Disaster Manager (Ph: 4221 6889)

INTERNAL EMERGENCY- i.e. Code Red; Code Blue; Code Black; Code Purple; or Code Yellow

Refer to Site/Facility/ Service Emergency Management Plan /

Emergency Flip Chart

Respond as required +/- Contact Emergency Service for assistance

AND Inform Line Manager

Evacuate / Relocate

‘CODE ORANGE” as Required /

Shelter in Place and continue

business as required / directed

Emergency abated → return

to “Business as Usual”

(BAU).

Operational Debrief / Review /Update Emergency Management Plans and Supporting Plans

No

tifi

cati

on

:

Ale

rt

Acti

vati

on

an

d E

scala

tio

n:

Sta

ndby / R

espo

nse

Sta

nd

-dow

n:

Reco

ve

ry

OR OR

Appendix 2

Confirms information received

from Emergency Service/s

http://islhnweb/Disaster_Management/plans.asp

INTERNAL ONLY

ISLHD POLICY



THIS DOCUMENT BECOMES UNCONTROLLED WHEN PRINTED OR DOWNLOADED UNLESS

REGISTERED BY LOCAL DOCUMENT CONTROL PROCEDURES

INTERNAL ONLY

Appendix 3: Debrief

Introduction

After an incident, a debrief should be carried out within two weeks. The After Action Review

(AAR) process is a structured approach for undertaking a debrief and is a constructive way of

identifying lessons identified from the incident. The AAR process detailed below has been

adapted from the national process to assist with the de-briefing of business continuity related

incidents.

An AAR is constructed of four questions:

1. What was expected to happen?

2. What actually occurred? 3. Why was there a difference? 4. What can be learned?

AARs are usually conducted by a facilitator, who was not involved in the incident and usually

ensures that there is:

An open discussion held

Everyone in the room participates

Development of learning points

Time allowance

The time required to undertake an AAR can be 15 minutes to two hours long.

Planning an AAR

Once a facilitator has been identified, they should be provided with an overview of the incident

prior to the AAR.

It is important that the correct amount of time has been allocated to the AAR and that a suitable

venue is available to conduct the AAR in.

Conducting an AAR

There are a number of ground rules that all participants in the AAR should be aware of and

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

agree to, prior to the start. These include:

Leave hierarchy at the door Everyone should contribute and everyone’s contribution should be respected The purpose of the AAR is to learn No blame, discussing any potential mistakes made should not lead to blame Everyone will have a different truth to share of the same event Contributions should be through what people know, feel and believe Respect time pressures but all must be fully present - no use of mobile phones Make no assumptions, be open and honest

The AAR discussion

What was expected to happen?

This question is asked to the group for their discussion. The following sub questions could

be utilised (if suitable) to aide group discussion:

Was there a planned response? What was the planned response? What was your personal expectation to happen in this type of incident What was the expected timeline?

What actually occurred?



Each participant should describe - what they did, saw or experienced, during the incident. The participants should not be discussing what was good or bad at this stage.

What went well and why?



Was there a difference between what was expected and what actually happened?

What were the good points and what didn't work so well?

INTERNAL ONLY

ISLHD POLICY





INTERNAL ONLY

What can be learned or identified?



With the benefit of hindsight - what could have been done differently/better?

Does anything need to be changed to improve future responses?

Closing the AAR

The key learning points should be summarised from the discussion held, focusing on what

lessons have been identified.

Inform participants of what are the next steps i.e. report writing. If actions have arisen in the

AAR, it is the responsibility of the AAR participants to take the actions forward and ensure

they are brought into the existing reporting mechanisms within their organisation.

Sharing the Report

Once the report has been completed share it with members of the AAR and ask if the group

are happy to share the lessons identified.

An example of a report template is shown below.

INTERNAL ONLY

ISLHD POLICY

Emergency Management Framework ISLHD OPS PD 24


THIS DOCUMENT BECOMES UNCONTROLLED WHEN PRINTED OR DOWNLOADED UNLESS REGISTERED

BY LOCAL DOCUMENT CONTROL PROCEDURES

INTERNAL ONLY

AFTER ACTION REVIEW REPORT TEMPLATE

Name of Facilitator:

Date of AAR:

Time AAR commenced:

Time AAR completed:

Attendees:

Apologies:

Overview of Incident:

Lessons Identified:

1.

To be actioned by:

Date for Completion:

2.

To be actioned by:


3.

To be actioned by:


4.

To be actioned by:


Signature: TRIM No: