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Code Dark Readiness

Dr. Jeremy Maggin, Regional Physician Director, Emergency Preparedness Francesca Tanglao, Emergency Management Program Leader

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Purpose & Scope

Provide partner agencies with a high-level overview of what a Code Dark means for Kaiser Permanente

Outline anticipated operational and patient care impacts during such an event

Describe how Kaiser Permanente plans and operates during a Code Dark, including strategies for maintaining continuity of care

Support shared situational awareness and effective collaboration

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CODE DARK | What It Is and What It Means

For partner awareness- not for redistribution

Answer:

A Code Dark occurs when a cyber incident or ransomware attack compromises the network, forcing Kaiser Permanente to shut down internal systems to contain the threat. This may block access to systems or encrypt data and can significantly disrupt electronic operations for an extended time

What is Code Dark?

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What is available without the network?

For partner awareness- not for redistribution

Paper documents
New or clean devices will be deployed as they are available (laptops and desktops); priority based
Off-network web/internet access
Downtime computers
Company assigned cell phones & iPads
Personal cell phones
In-person collaboration or work
Remote workers may need to come in and have planned designated space to conduct meetings and work
Off-network collaboration tools (this may be for a select few)
Other off-network alternate technologies to support minimum viable operations

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For partner awareness- not for redistribution

CODE DARK: Response Approach

0-2

hours

Network shutdown. The first moments will be chaotic!

2-48

hours

We will leverage manual and paper workflows

48+

hours

Transition to temporary systems

Recovery

Once the IT outage is resolved, full recovery occurs and back to the main system

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Shared Expectations During a Code Dark

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Shared Responsibility

Maintaining patient safety and continuity of care

Communication

Expect intermittent updates through available channels

Coordination

Increased reliance on direct phone and in-person coordination

Flexibility

Temporary changes to workflows

Recovery

Systems are restored in phases; normalizations occur over time

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Program Implementation Road Map

Establish foundation and validated approach	Build standardized, scalable response tools	Operationalize across the enterprise	Sustain, mature and improve readiness

Engage 3^rdparty healthcare cyber attack expert consultants Identified and analyzed “model” Service areas (LAMC and Hawaii) Conduct Business Impact Analysis to define department-level downtime and recovery needs	Department leaders develop response checklists (Department EOPs): Full downtime period Limited functionality period Recovery and record reconciliation period Create standardized but adaptable EOP framework	Cascade Department EOPs to all Medical Centers Departments reviewed and amended plans based on local capabilities Implemented multi-wave rollout, prioritizing: Clinical operations Critical clinical support services	Achieve uniform yet locally tailored Department EOPs Incorporated feedback and operational learnings Positioned program for future exercises, validation and updates

PHASE I

PLANNING

PHASE II

DEVELOPMENT

GOAL

KEY ACTION

PHASE III

LAUNCH

PHASE IV

OPTIMIZATION

For partner awareness- not for redistribution

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Turning Plans into Practice

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ANNUAL

Plan Development & Readiness

Ongoing Business Continuity Planning Workshops to refine Business Impact Analysis and department level checklists
Continuous plan updates based on operational and cyber risk changes

Planning & Alignment

Regional Code Dark Workshops
Monthly National Code Dark Update meetings

Execution & Practice

Regional SCAL Table-Top Exercise

Two completed exercises (2023, 2024)
Scenario-based cyber downtime response

Real time testing of communication, documentation and recovery workflows

Review & Development

After-Action reviews from tabletops and incidents
Gaps identified: feedback loops into BIAs, checklists and training

Full Scale Validation

Annual National full-scale exercises

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Challenges

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Lack of Clear Downtime Expectations and Preparedness

Inconsistent understanding of roles, responsibilities, and workflows

Communication Breakdowns

Primary communication systems may be unavailable, slowing coordination across teams and facilities

Use redundant communications tools (KP Alert, KPIRS, KP Dev, KP iPhones, red phones and reinforce communication protocols during events

Limited Access to Critical Documents

Digital systems may be unavailable, delaying access to procedures, forms and reference materials

Store downtime-critical documents in multiple locations and maintain downtime computers with offline access

Restricted or Unsafe Internet Access

Security incidents may require rapid isolation of systems, limiting connectivity and access applications

Implement network segmentation and failover networks to enable safe, limited access for critical operations

Documentation & Record Integrity Risks

Manual documentation during downtime can increase risk of errors, delays or lost information

Use standardized paper downtime forms, HealthConnect read-only access and for record review within 48-72 hours

Recovery & Reconciliation Delays

Re-entering data and reconciling clinical records post downtime can be labor intensive and time sensitive

Establish structured recovery workflows and secure PACS transfer via USB where needed

Mitigations

Maintain department –level Emergency Operations Plan, Business Impact Analysis, and response checklists; conduct ongoing BCM workshops to reinforce expectations

Description

Limited Availability of Clean Devices

Infected or restricted devices may impede access to essential systems during recovery

Maintain prioritized backup laptops and a defined device cleaning and restoration process (48-72 hours)

Disruption of Critical Support Services

Primary communication systems may be unavailable, slowing coordination across teams and facilities

Use redundant communications tools and reinforce communication protocols during events

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High Risk Departments to be Considered

For partner awareness- not for redistribution

Inpatient
Admitting Office/Patient Financial Services Cardiac Services (Cardiac Procedures, Echo, Cath Lab) Continuum, COC Emergency Department Engineers/Plant Operations Environmental Services (EVS) Labor/Delivery Pediatric Unit PICU L&D NICU Post Partum Laboratory Services Nutritional Services/Food Services/Cafeteria Nursing Units Critical Care / Intensive Care Medical/Surgical Neurology Unit Perioperative Services Surgical Services/Surgery Central Sterile/Sterile Processing PACU, OR, Anesthesiology Pathology Pharmacy Radiology (Imaging, Diagnostic Imaging, Interventional) Respiratory Therapy Security Supply Chain Telecom (operator services)

Outpatient
Call Centers Clinic General (primary care, family medicine, internal medicine etc.) Oncology/Infusion Services OB/GYN Mental Health/Behavioral Health/Psychiatry Complex Case Management (CCM) Dialysis Home Health Lab – Ambulatory Pharmacy Outpatient Home Infusion Mail Order Outpatient - Oncology Radiation Oncology Radiology – Outpatient Registration Urgent Care

Call Centers
Claims
Communications/Public Affairs
Continuum

DME
Transport

Ethics/Compliance/Legal
Facility Management
Finance
Government Relations
HTM (Clin Tech)
Human Resources
Infectious Diseases
Lab – Core
Member Services
Nutritional Services
OURS/EPRP/Case Management
Payroll/TIME
Pharmacy

Central Services
Home Infusion

Quality/Risk
Revenue Cycle
Security
Supply Chain

National / Regional Functions

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Code Dark Tools: Business Impact Analysis & Checklist

For partner awareness- not for redistribution

BIA: Business Impact Analysis

Points of Contacts
Critical Processes
Critical Applications
Inter-dependencies

Checklist

Pre-work
Immediate Actions = 0 to 2 hours of event
Intermediate Actions = 2 to 12 hours
Extended Actions – Greater than 12+ hours
Recovery – post event when systems are back up

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Sample ED Code Dark Checklist

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BIA Worksheet – Tab 1

For partner awareness- not for redistribution

DEPARTMENT INFO TAB

Worksheet Will Jump Start Code Dark Checklist Development and IT System Prioritization

Tab 1 – Departmental Information. This is also an opportunity to make sure that your EOP/BCPs has the correct owner contact information.
Tab 2 – Departmental Processes
Tab 3 – Application Ranking
Tab 4 – Inter-Departmental Dependencies

Direction: Owner to complete all information on this tab. Some of the information should be in your Business Continuity Plan (BCP) or Emergency Operations Plan ( EOP) if you have one in the system. If the information in your EOP/BCP is incorrect. Please perform the following: 1) Fill out the information and this should match your existing BCP/EOP (if you have one in the system).
National Business Unit:
Department/Service/Function Name:
Customer:
Patient Care Responsibilities:
Business Unit Description / Primary Functions:
Contact Information	Name	Title	Work Phone	Email
Primary Contact
Secondary Contact
Alternate Contact

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BIA Worksheet – Tab 2

For partner awareness- not for redistribution

Function/Application/Workaround

Worksheet Will Jump Start Code Dark Checklist Development and IT System Prioritization

Tab 1 – Departmental Information
Tab 2 – Departmental Processes – identify key processes, supporting applications, workarounds while systems are down.

Teams will draft manual workarounds which becomes the beginning of the Code Dark checklist.

Tab 3 – Application Ranking
Tab 4 – Inter-Departmental Dependencies

Directions: Column A: List all functions in your department. Column B: For each function, list the operational processes Column C: List any application/technology that supports each process or function. Column D: Please describe the workaround that you would use in the event that this system is not available. This should include multiple steps where appropriate.
List the department/Service/Fun ction ( owner completes)	Describe each function/process within your department. ( owner to complete)	Name the application or technology that supports this function/process.	Describe the workaround necessary if this application/technology does not work.
Example: Payroll	Process time off accruals, and other TIME entries for staff bi-weekly pay.	TIME HR Connect	^{Distribute paper timecards for managers to}use. Have managers fax the approved paper timecards to fax #

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BIA Worksheet – Tab 3

For partner awareness- not for redistribution

PRIORITY RANKING

Worksheet Will Jump Start Code Dark Checklist Development and IT System Prioritization

Tab 1 – Departmental Information
Tab 2 – Departmental Processes
Tab 3 – Application Ranking; Discuss with your functional teams and agree on the rank of the most important IT systems and applications they feel should be recovered on a priority basis (1 – 10).
Tab 4 – Inter-Departmental Dependencies

Directions: Column A: Please ensure all the applications that support business operations are listed on the worksheet. Column B: Update the ATLAS Application IDs for each application as best as you can Column C: Please rank the top 10 systems/applications in order of importance to your function. 1 is the most critical and 10 is the least critical. " What is the order in which you would ideally need these systems restored in the event of an IT Outage?
List all the applications used by the department to provide for operations ( IT to Complete)	Application ID ( Complete in partnership with your IT Partners)	Application ranking ( 1 to 10 ONLY with no duplicates; even if you have over 10 applications, Owner to complete)
EXAMPLE: TIME		1
		2
		3
		4
		5
		6
		7
		8
		9
		10

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BIA Worksheet – Tab 4

For partner awareness- not for redistribution

INTERDEPARTMENTAL DEPENDENCIES

Worksheet Will Jump Start Code Dark Checklist Development and IT System Prioritization

Tab 1 – Departmental Information
Tab 2 – Departmental Processes
Tab 3 – Application Ranking
Tab 4 – Inter-Departmental Dependencies – Functional teams will list and describe those departments they interact with and describe those inter-department needs.

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Next Steps: Cyber Downtime Readiness

For partner awareness- not for redistribution

Foundation & Alignment

Establish consistency and shared understanding

Continue socializing expectations across the region and Service Areas
Continue refining BIAs and downtime checklists
Baseline current gaps in communication, access and tools

Implementation & Enablement

Strengthen tools and operational capability

Secure additional access to off-network collaboration tools
Socialize and operationalize alternative communication channels
Integrate these tools into tabletop exercises and training

Scaling & Integration

Embed practices into operational rhythm

Standardize use of alternative communication and document storage tools across the Region and Service Areas
Incorporate lessons learned into BIAs, Department checklists and exercise design and scenarios

Sustained Resilience

Advance long-term solutions for critical dependencies

Support development of improved applications to mitigate loss of critical support interfaces
Validate solutions through full scale exercises and real-world activation
Sustain continuous improvement through governance and feedback loops

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Thank you!