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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.
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
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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.
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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
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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
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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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