The hospital’s continuity of operations plan identifies in writing how and where it will continue to provide its essential business functions when the location of the essential or critical service has been compromised due to an emergency or disaster
incident.
Note: Example of options to consider for providing essential services include use of off-site locations, space maintained by another organization, existing facilities or space, telework (remote work), or telehealth.
The UTMB Health System continuity plan identifies in writing how and where it will continue to provide critical missions (delivery of healthcare services) and its essential business functions when the location of the essential or critical service has been compromised (Loss of Work Place) due to an emergency or disaster incident. (Example of options to consider for providing essential services include use of off-site locations, space maintained by another organization, existing facilities or space, telework (remote work), or telehealth.) While Joint Commission requires continuity plans specifically for Loss of Work Place, the full UTMB list for strategies and tactics should address:
- Loss of Workplace (e.g. fire, flood)
- Loss of Workforce (e.g. novel flu outbreak)
- Loss of Technology (e.g. Cyber-attack, elevator failure)
- Loss of Critical Utility (e.g. extended electric power outage)
- Loss of Transportation / Access (e.g. areal flooding)
- Loss or Shortage of Critical Medical Supplies or Equipment
- Loss of Standard Communications (e.g. IP Phones and email down)
SCOPE
The scope of this healthcare continuity plan includes all UTMB Health System functions. This plan provides a set of unifying strategies approved by the Health System leadership that all departments should use to guide the development of their departmental
plans.
This continuity plan augments the UTMB Emergency Operations Plan. The three standing objectives for the UTMB Command Center in response to emergencies are:
- Protect Human and Animal Life
- Protect the Facilities, Infrastructure, and Communications and Computing Networks
- Continue Critical Missions
These objectives provide a unifying framework for emergency planning which addresses the first two objectives; and continuity planning, which addresses the third objective. Therefore, emergency and healthcare continuity plans and response activities should
be integrated through all phases of an emergency preparedness including:
- Prevention
- Mitigation
- Response
- Recovery
UTMB has formally adopted the Hospital Incident Command System (HICS). The UTMB HICS implementation includes a Business Continuity Branch within the Operations Section.
OBJECTIVE
The primary objective of this plan is to better assure that UTMB will be able to continue to provide healthcare despite disruptive incidents including disasters (when healthcare services are generally most needed by the community). If a disaster does
cause sufficient damage to the facilities, the secondary goal of this plan is for UTMB to be prepared to restore full healthcare services as soon as possible.
This plan provides a common set of objectives and response strategies for departmental and business unit plans within the Health System:
- The Health System will coordinate with the Office of the President, Academic Enterprise, Research Enterprise and UTMB Support functions in continuous improvement of emergency and continuity plans.
- The UTMB Command System will be used to coordinate healthcare continuity strategies.
- Per the UTMB Emergency Operations Plan, the Institutional Incident Commander may authorize the Health System to establish a Sub-Command to address healthcare-specific planning. In this case, emergency and continuity planning will still be coordinated
with the UTMB Command Center.
- UTMB may designate a location other than main campus for the institutional command center and healthcare continuity operations based on the nature of the emergency, or they may implement a virtual command center.
- UTMB’s Inclement Weather Policy addresses the need to remain open to serve patients. Staff members are expected to report to work or to remain at work if it is safe to do so. This applies to all Health System hospitals, ambulatory locations,
and support functions.
- If possible, Health System hospitals will remain open. Staff members should always be prepared to remain on duty until relieved. If needed, the Health System will establish a plan to rotate staff and may implement a staff shelter plan.
- The Health System hospitals may implement a Shelter-in-Place with Patients strategy.
- The Health System hospitals may implement a census reduction in anticipation of notice incidents such as a hurricane or other dangerous situation; or on notice of a major regional mass casualty incident using a strategy of Immediate Bed Availability
where the goal is to reduce the census by 20% if possible. If an 1135 waiver is approved because of the incident, appropriate patients may be transferred to long-term care facilities in order to make beds available for incident victims.
- League City Campus, Clear Lake Campus, Angleton Danbury Campus, and Ambulatory Services on the mainland are authorized to establish command centers on mainland locations, and if communication between the mainland and the island are down, those command
centers are authorized to begin recovery and healthcare continuity operations.
- All Health System continuity plans should address loss of: workplace, workforce, technology, critical utility, transportation/access, shortage of critical medical supplies and equipment, and standard communications. More information on each of these
losses is found HERE.
Additional Information on the Business Continuity Planning and Clinical Continuity Planning webpages.