Disasters and emergency incidents

Directive number: QH-HSD-003:2017

Effective date: 5 October 2021

Review date: 5 October 2024

Supersedes: Version 1

On this page:

Purpose

The purpose of this Health Service Directive is to ensure Hospital and Health Services develop and maintain a capability to effectively respond to disasters and emergency incidents, while driving the continual improvement of disaster preparedness arrangements. This is to ensure the continuity of business functions and service to the community to mitigate the impacts from existing and emerging threats, supported by an organisational culture that embraces relevant doctrine and cross-agency and community collaboration [1].

Scope

This directive applies to all Hospital and Health Services.

Principles

Leadership

  • A culture of excellence across the disaster and emergency incident management sector is driven by the Hospital and Health Service executive.
  • Responsibility for disaster and emergency incident preparedness, planning, response and recovery is ingrained in organisational culture at all levels.
  • Strategic planning of resource allocation in the context of risk is crucial to disaster and emergency incident management and should prioritise the enabling of, and positive outcomes for, the community.

Public Safety

  • The safety of the community is the primary driver of continuous improvement of disaster and emergency incident management activities.
  • Ensuring the safety and security of staff and patients and the broader community through the provision of resilient critical infrastructure, supported by effective risk-based plans and arrangements
  • Engagement with disaster management groups ensures a focus on the safety of the community and sharing the responsibility for disaster management through stakeholder and community engagement.

Partnerships

  • Contribute to strong partnerships and true collaboration to improve outcomes and resilience, promoting clear responsibilities across the disaster and emergency incident management sector.

Performance

  • Measurable indicators of productivity and effectiveness, including continuous improvement measurements, promoting a culture of excellence in disaster and emergency incident management.

Outcomes

Hospital and Health Services included in the scope of this directive shall achieve the following outcomes relating to disasters and emergency incidents:

  • Governance: Effective administration of disaster and emergency incident management activities and clear, consistent and appropriate decision-making.
  • Doctrine: Roles, responsibilities, actions and activities are based on relevant doctrine that is agreed and shared between entities, and aligned to legislation and best practice.
  • People: Effective disaster and emergency incident management is supported by the networks, training, skills and experience of individuals who undertake it.
  • Enablers: The physical equipment, assets, systems, data and technologies used by the organisation to undertake disaster and emergency incident management are appropriate to its needs and requirements.
  • Continuous Improvement: Disaster and emergency incident management activities are effectively monitored, evaluated and measured through established and effective lessons management, exercise and activation debrief processes.
  • Achievement of these outcomes ensures the Hospital and Health Service meets the accountabilities of the Emergency Management Assurance Framework, authorised by the Disaster Management Act 2003 s. 16c.

Mandatory requirements

Governance

G1. Establish an emergency management committee, or equivalent, that:

G1.1 has appropriate membership with the authority to make decisions and commit resources on behalf of their function or capability

G1.2 conducts non-extraordinary meetings at least bi-annually, with a quorum of at least one half plus one member or their proxies, and records decisions and business in minutes.

G1.3 provides the Hospital and Health Service executive with adequate oversight of disaster and emergency incident activities through regular reporting [2], including:

  • Activities to build capability of the workforce, such as exercises and training needs analyses
  • Reviews of existing and creation of new disaster and emergency incident plans.
  • Broader reports such as Health Service Directive compliance and maturity assessments
  • Relevant information from external disaster management groups.

G2. Ensure that representatives on local and district disaster management groups [3] understand their responsibilities to work collaboratively with the emergency management committee and fulfil legislated functions of the group [4] on behalf of the HHS.

G3. Ensure the roles and responsibilities of external entities in the Hospital and Health Service response, as outlined in the Queensland State Disaster Management Plan and District Disaster Management Plans, are documented in HHS plans and arrangements [5].

G4. Ensure Health Emergency Operations Centres (HEOCs) are:

G4.1 resourced and maintained well-functioning at Hospital and Health Service levels

G4.2 capable of (when impacted) providing high-level situational reporting and continuous situational awareness throughout disaster events; including ensuring an appropriate level of staffing, coordination of requests for assistance and immediate notice of deaths in their jurisdiction related to the disaster or emergency incident.

G4.3 capable of receiving and responding to requests, and directions through the State Health Emergency Coordination Centre (SHECC) when activated, including external allocation and coordination of resources where capable.

G4.4 regardless of activation status, capable of providing appropriate situational reporting for Code Activations which have the potential to escalate or require response to media inquiries [6].

G4.5 consistent with current best practice incident management.

G5. Ensure decisions and actions taken are recorded as they are made to assist in debrief, assurance and review activities; including external inquiries.

Doctrine

D1. Develop plans and arrangements, including a Hospital and Health Service disaster and emergency incident plan, that are consistent with:

D1.1 the Queensland Health Disaster and Emergency Incident Plan and its subplans

D1.2 Queensland Health frameworks and guidelines for disaster and emergency incidents

D1.3 relevant district disaster management plans and the Standard for Disaster Management in Queensland [7].

D2. Fulfil Queensland Health’s responsibilities under the Queensland State Disaster Management Plan to provide expert advice on health-related aspects of disasters and emergency incidents.

D3. Ensure Emergency and Incident Plans consider existing hospital and health service business continuity plans that identify area-specific risks and consider responsibilities for hazard management outlined in the Queensland State Disaster Management Plan to support a whole of health management response.

D4. Ensure roles, responsibilities and activities included in planning, preparedness, response and recovery arrangements are communicated to relevant employees, patients and stakeholders through information and awareness activities [8].

People

P1. Establish and maintain cooperative partnerships between the Hospital and Health Service and:

P1.1 other Hospital and Health Services and the department, through engagement with the State Health Emergency Management Committee (SHEMC)

P1.2 hospitals, facilities and health providers within the Hospital and Health Service geographic area

P1.3 disaster management groups; including appropriate linkages and alignment of business continuity and risk management planning.

P2. Ensure roles required to conduct critical business functions [9] and disaster and emergency incident management activities are outlined in the development of risk management, business continuity and training plans and where required, acknowledge dependencies on the roles and responsibilities of partnering entities.

P3. Ensure cooperative partnerships maintained by the Hospital and Health Service adequately enable allocation and coordination of staff during disaster and emergency incidents to district and local disaster management groups, or to external Hospital and Health Services where capable.

P4. Ensure staff have the relevant skills and experience [10] to enable effective communication and information sharing with partnering entities, and the Hospital and Health Service shall conduct training and exercises to foster this capability [11].

Enablers

E1. Ensure material and financial resources required to conduct critical business functions [12] and disaster and emergency incident management activities are documented and considered in the development of risk management and business continuity plans.

E2. Ensure information and communication technologies are consistent and compatible with current best practice incident management systems, and are compatible between Hospital and Health Services and relevant partnering entities and utilise consistent communication mechanisms

E3. Establish and maintain processes to allocate and coordinate the use of material and financial resources during disaster and emergency incidents within the Hospital and Health Service area, and externally where capable.

Continuous Improvement

C1. Regularly review the content and effectiveness of Hospital and Health Service plans and arrangements and its associated hospitals and facilities through:

C1.1 regular review of content either annually or at identified and documented trigger points [13].

C1.2 regular assessment of effectiveness through exercise and evaluation or activation and debrief.

C2. Ensure an established lessons management process is employed following exercise and evaluation or activation and debrief, and that lessons identified and lessons learnt are shared with other entities where relevant [14].

  • Hospital and Health Boards Act 2011 [Qld]
  • Disaster Management Act 2003 [Qld]
  • Disaster Management Regulation 2014 [Qld]
  • Emergency Management Assurance Framework 2.0
  • Standard for Disaster Management in Queensland V2.0
  • AS 3745:2010 Planning for Emergencies in Facilities
  • AS 4083:2010 Planning for emergencies – Health care facilities
  • AS 5050: 2020 Business continuity – Managing disruption-related risk
  • Queensland State Disaster Management Plan
  • Disaster Management Strategic Policy Framework
  • Queensland Disaster Management Lessons Framework
  • Queensland Health Disaster and Emergency Incident Management Plan (QHDISPLAN)
  • QH-IMP-070-2:2017 Business Continuity Management Standard
  • Queensland Health Disasters and Emergency Training Framework
  • Patient Safety Health Service Directive

Business area contact

Health Disaster Management Unit, Aeromedical Retrieval and Disaster Management Branch, Prevention Division

Review

This Health Service Directive will be reviewed at least every three years.

Date of last review: 27/07/2021

Supersedes: Health Service Directive Disasters and Emergency Incidents QH‑HSD‑003:2017 – Version 1

Approval and implementation

Directive Custodian

Chief Health Officer and Deputy Director-General, Prevention Division

Approval by Chief Executive

Director-General. Queensland Health

Approval date: 14 September 2021

Issued under section 47 of the Hospital and Health Boards Act 2011.

Definitions of terms used in this directive

Term Definition / explanation / detailsSource
Business continuity

The uninterrupted availability of essential business functions.

QH-IMP-070-2:2017 Business Continuity Management Standard

Business continuity management

A holistic management process that allows an organisation to identify potential threats and impacts to business operations, if realised, might cause, and which provides a framework for building organisational resilience with the capability to effectively manage disruption related risks against critical business functions.

QH-IMP-070-2:2017 Business Continuity Management Standard

Business continuity plan

Documented procedures that provide guidance on how to prepare, prevent, respond and recover from a disruptive event. This includes business activities associated with maintaining availability of people, assets and property vital for the continuity of critical business functions.

QH-IMP-070-2:2017 Business Continuity Management Standard

Consequence Outcome of an event affecting objectives
  • an event can lead to a range of consequences
  • consequence can be certain or uncertain and can have positive or negative effects on objectives
  • consequences can be expressed qualitatively or quantitatively
  • initial consequences can escalate through knock-on effects

ISO Guideline 73:2009 Risk Management Vocabulary

Continuous Improvement Continuous Improvement refers to how entities monitor, evaluate, measure and improve disaster management activities.
  • An established lessons management process is being undertaken
  • The capabilities required have been identified, documented, and aligned to recognised and accepted training methodology
  • A variety of exercising and testing methods are being conducted and evaluated
  • Insights are included in a lessons management process
  • Lessons identified are shared with other entities, and with the community when relevant

Improvements are made based on insights gained through testing, exercises and operational activity

 
Critical Business Function “A business function, or part of a function (process) without which the organisation will suffer significant impact. If a critical business function or process is non-operational, the organisation could suffer serious legal, financial or reputational damage”

Queensland Standard for Disaster Management

Disaster
  • A serious disruption to a community caused by the impact of an event that requires a significant coordinated response by the state and other entities to help the community recover from the disruption.
  • Serious disruption means:
  • loss of human life, or illness or injury to humans
  • widespread or severe property loss or damage
  • widespread or severe damage to the environment

Disaster Management Act 2003 (Section 13)

Disaster (Event)
  • A cyclone, earthquake, flood, storm, storm tide, tornado, tsunami, volcanic eruption or other natural happening
  • an explosion or fire, a chemical, fuel or oil spill, or a gas leak
  • an infestation, plague or epidemic
  • a failure of, or disruption to, an essential service or infrastructure
  • an attack against the state, or
  • another event similar to an event mentioned.

An event may be natural or caused by human acts or omissions.

Disaster Management Act 2003 (Section 16)

Disaster (and emergency incident) management

Arrangements about managing the potential adverse effects of a disaster event, including mitigation, prevention, preparedness, response and recovery arrangements.

Disaster Management Act 2003 (Section 14)

Disaster (and emergency incident) operations

Activities undertaken before, during, or after a disaster event happens to help reduce the level of serious disruption to the community.

Disaster Management Act 2003 (Section 15)

Doctrine Doctrine refers to the ideas, strategies and guiding principles contained in the documents that guide disaster management. These align with legislation, reflect good practice, and include guidelines, policies, plans and procedures.
  • Roles and responsibilities are based on relevant doctrine
  • The action or activity is based on relevant doctrine
  • Doctrine is agreed and shared between entities

Common language being used, and common terminology is agreed and consistent with doctrine.

 
Effective (relating to disaster and emergency incident management operations and plans)
  • Scalable – able to be applied to any size or type of event
  • Comprehensive – consider prevention, preparedness, response and recovery phases of disaster management
  • Interoperable – able to operate seamlessly between entities
  • Value for money – enable the best outcome and performance for money spent
  • Adaptive – flexible to the needs of all stakeholders

Note: Effectiveness can only be determined during application of a plan or arrangement through exercise or activation.

 Queensland Emergency Management Assurance Framework
(Good practice attributes)
Enablers Enablers refer to the resources that assist entities in undertaking disaster management activities. This includes both the physical equipment and assets, and the systems, data and technologies.
  • Enablers are in place, are fit for purpose, and are being used in line with agreed protocols
  • Enablers are accessible to the relevant entities, including the community if necessary
  • Enablers meet the needs and requirements of all relevant entities
  • Benchmarks for the performance of enablers have been established and are being met
  • Alternatives or backups are in place
 
Event Occurrence or change of a particular set of circumstances
  • An event can be one or more occurrences, and can have several causes
  • An event can consist of something not happening

An event can sometimes be referred to as an incident or accident.

 ISO Guideline 73:2009 Risk Management Vocabulary
Governance Governance refers to how entities administer their disaster management responsibilities and ensure decision making is appropriate, clear and consistent.
  • Roles and responsibilities have been identified, agreed to, and documented
  • Entities have been authorised to carry out their delegated responsibilities
  • The authorising environment for decisions and approvals has been identified and agreed to, and is being utilised
  • Arrangements are in place for reporting on and monitoring the outcomes of decisions and actions

Decisions are recorded as they are made, and their implementation is monitored

 
People People refers to the relationships and networks, training, skills and experience that enable the individuals who undertake disaster management to do so effectively.
  • Enabling networks and relationships between individuals and entities, both formal and informal, have been established and maintained
  • Training requirements are documented, and the necessary skills and knowledge are being met
  • Opportunities are provided for on-the-job training and development
  • Upskilling and cross-training provide a reserve of personnel
 
Risk Effect of uncertainty on objectives
  • An effect is a deviation from the expected - positive and/or negative
  • Objectives can have different aspects (such as financial, health and safety, and environmental goals) and can apply at different levels (such as strategic, organization-wide, project, product and process)
  • Risk is often characterized by reference to potential events and consequences or a combination of these
  • Risk is often expressed in terms of a combination of the consequences of an event (including changes in circumstances) and the associated likelihood of occurrence.
 ISO Guideline 73:2009 Risk Management Vocabulary
State Health Emergency Management Committee A committee established as a mechanism to support and enable a collaborative approach across the Department of Health and Hospital and Health Services in the development of emergency management arrangements and promote consistency of operations across Queensland Health. State Health Emergency Management Committee Terms of Reference

Version control

VersionDate Prepared by Comments
1.0 January 2017 Health Disaster Management Unit First Issue
2.0 July 2021 Health Disaster Management Unit Scheduled review.

Changes to the Emergency Management Assurance Framework (EMAF) V2.0 have been aligned to the Health Service Directive.

Changes made to implement findings of the Health Service Directive Evaluation undertaken in late 2019, in direct collaboration with Hospital and Health Services.

Footnotes

  1. The principles, outcomes and requirements in this directive align to the principles and accountabilities in the Queensland Inspector-General Emergency Management’s Emergency Management Assurance Framework V2.0.
  2. In line with the Queensland Disaster Management Lessons Framework sourced from https://www.igem.qld.gov.au/sites/default/files/2020-07/IGEM%20Lessons%20Management%20Framework.pdf
  3. In line with AS 3745:2010 Planning for Emergencies in Facilities, Section 2 Emergency Planning Committee; and DM Act Part 3 Business and meetings of disaster management groups.
  4. In line with DM Act s. 55 & 59 regarding reviewing and renewing district and local disaster management plans; and QHDISPLAN s 1.6 Review requirements.
  5. In line with DM Reg. s. 5 Membership of district groups – DM Act s. 24.
  6. In line with DM Act s. 23 & 30 regarding functions of district and local disaster management groups.
  7. In line with DM Act s. 53 & 57 regarding district and local disaster management plans.
  8. See AS4083:2010 Planning for emergencies – Health care facilities, Section 5 Responding to Emergencies
  9. These documents are to be consistent with the Queensland State Disaster Management Plan, the Disaster Management Strategic Policy Framework, and the DM Act. The Standard for Disaster Management in Queensland is contained within the Emergency Management Assurance Framework
  10. See DM Act s. 23 & 30 regarding functions of district and local disaster management groups.
  11. Queensland Standard for Disaster Management, the Queensland State Disaster Management Plan, and the DM Act.
  12. Queensland Health Disasters and Emergency Incidents Training Framework
  13. See DM Act s. 23 & 30 regarding functions of district and local disaster management groups.
  14. Queensland Standard for Disaster Management, the Queensland State Disaster Management Plan, and the DM Act.

Last updated: 5 October 2021