Our Exposure Control Plan (ECP) outlines measures aimed at preventing exposures to, and reducing the transmission of, COVID-19 within Fraser Health workplaces and at all points of care.

There are several documents referenced with a specific hyperlink. Hyperlinks in this document are only accessible through the Fraser Health network. If you are within the network but do not have an electronic copy, or if you are outside the Fraser Health network, please contact Health and Safety. Documents contained in hyperlinks and/or other electronic versions on Fraser Health systems are to be considered the most current version. 

  • 1.0 Introduction

    1.1 Purpose

    The Biological Hazards: Communicable Diseases Exposure Control Program outlines the necessary responsibilities, procedures, and tools to reduce staff and medical staff risk of exposure to communicable diseases. The Program also addresses the requirements to ensure that the risk of exposure to communicable diseases, at all Fraser Health owned and operated sites, is maintained at levels meeting applicable standards and guidelines. 

    During the COVID-19 Pandemic, Fraser Health developed and enacted an Exposure Control Plan (ECP) that outlined measures aimed at preventing exposures to, and reducing the transmission of, COVID-19 within its workplaces and at all points of care.  The ECP was designed to protect our staff, medical staff, students, volunteers and contractors and as such, adherence to the procedures outlined within the document were considered mandatory as they reflected the directives/guidance provided by the Provincial Medical Health Officer (PMHO), Fraser Health’s Medical Health Officers (MHO’s), the Ministry of Health (MoH), the British Columbia Centre for Disease Control (BCCDC), and the Occupational Health and Safety Regulation enforced by WorkSafeBC.

    British Columbia now begins the process of recovering from the Covid-19 Pandemic.  While Fraser Health’s COVID-19 ECP remains in place, this COVID-19 Pandemic Recovery Plan is meant to further address/mitigate the risks associated with increased activity and service delivery within Fraser Health’s workplaces.

    1.2 Scope

    This Pandemic Recovery Plan applies to all Fraser Health staff, medical staff, students, volunteers and contractors completing employer-assigned duties within its workplaces and any other designated points of care. The Exposure Control Program defines Fraser Health overall requirements for identifying, assessing, and controlling staff exposure to communicable diseases.

    Compliance with the program will be monitored by the responsible department manager with assistance from Health and Safety (Client Partner, Prevention and/or Client Partner Exposure Prevention).  Health and Safety will assist with the development, maintenance and administration of The Program.

    The activities and functions occurring within Lower Mainland Health Authority Laboratories (Medical and Research) are out of scope for the purposes of this Exposure Control Program. Refer to the Laboratory Safety Manual and Provincial Health Services Authority Workplace Health Department for more information.

    Several components contained within this Program are not unique to managing Communicable Diseases and are processes that occur on a regular basis within Fraser Health. As such, all related Fraser Health policies, programs, and guidelines remain in effect unless specifically noted in this Program. These policies include:

    1.3 Applicable Regulations and Standards

    Regulations pertaining to communicable disease exposures are contained throughout the WorkSafeBC Occupational Health and Safety Regulation (OHSR) particularly section 5.54 and 6.34 related to the management of Communicable Diseases.  As such, the information contained within this program is related specifically to the elements required to ensure the health and safety of workers while at work and should be considered within the context of supporting those specific elements as part of the larger Fraser Health Communicable Diseases plans and processes.  

  • 2.0 Program administration

    The Fraser Health Emergency Operations Centre has the responsibility to develop and oversee administration of the Pandemic Recovery Plan Addendum to the Exposure Control Plan.  In addition to these responsibilities, various departments and individuals have specific responsibilities to ensure its successful implementation and ongoing maintenance.   

    2.1 Executive Team and Directors

    Through the direction of the Emergency Operations Centre, Senior Management is responsible for ensuring the health and safety of all Fraser Health staff and medical staff.  Senior Management will:

    • Ensure that risk assessments are conducted at all Fraser Health workplaces to identify areas/activities that may increase the risk of exposure to COVID-19.
    • Modify clinical and work practices, using a risk-based approach, to address identified risks, and ensure that the risk of exposure is mitigated through these modifications.
    • Ensure that Operational leaders (e.g. managers/supervisors) are informed of, and adhere to, the directions provided through the EOC regarding risk mitigation efforts during pandemic recovery.
    • Adhere to the Hierarchy of Controls related to the reduction of exposure risks and ensure necessary resources including, but not limited to, engineering controls, administrative controls, and appropriate Personal Protective Equipment (PPE), are made available as required. 
    • Support necessary stakeholder groups, including the Joint Occupational Health and Safety (JOH&S) Committees in the risk assessment and risk mitigation processes.
    • Re-evaluate this plan as necessary to ensure that it remains viable and appropriate; in the event of a disruption/failure in this plan, advise the appropriate Agency (Agencies) and re-evaluate/revise as necessary.

    2.2 Managers and Supervisors

    Management / Supervisors will:

    • Adhere to the directions provided by the EOC, organizational stakeholder groups (e.g. Safety & Prevention, IPC, JOH&S Committees, etc.), and external stakeholder groups (e.g. WorkSafeBC).
    • Share awareness and informational resources with staff and medical staff and others within departments/sites under his/her leadership.  
    • Ensure that risk assessments are conducted within their department(s) to identify areas/activities that may increase the risk of exposure to COVID-19. (see Appendix A: COVID-19 Pandemic Recovery Plan Risk Assessment)
    • Facilitate the development/provision of risk mitigation as identified through the Risk Assessments in their departments including Safe Work Procedures (SWP’s) and ensure work is conducted in a manner that minimizes/eliminates exposure risks to staff and medical staff.
    • Provide appropriate Personal Protective Equipment (PPE) and other equipment/controls.
    • Facilitate staff and medical staff education/training pertaining to the selection, care, maintenance and use of any PPE (including fit testing for those staff and medical staff who may be issued a respirator).
    • Ensure all staff and medical staff follow SWP’s and appropriately use PPE   (e.g. gloves, gowns, eye protection, masks/respirators, etc.).
    • Ensure all staff and medical staff screen themselves for symptoms prior to starting work.
    • Provide information/feedback regarding  employee comments/concerns to site/portfolio 

    2.3 Staff and Medical Staff

    Fraser Health Staff and Medical Staff will:

    • Reference FHPulse for signs and symptoms of Covid-19 and how to conduct symptom checks
    • Follow directions provided by departmental/site/program leadership, organizational stakeholder groups (e.g. the Safety & Prevention, IPC departments, JOH&S Committees, etc.), and external stakeholder groups (e.g. WorkSafeBC).
    • Attend and participate in education/training/instruction sessions (including respirator fit-testing, where applicable).
    • Review and adhere to applicable SWP’s.
    • Select, care, maintain and use PPE as per education/training.
    • Understand how exposures can occur and when/how to report exposure incidents.
    • Report feeling unwell to leadership immediately and follow directions regarding isolation, etc.
    • Direct questions to leaders and/or appropriate stakeholder groups.
    • Use all required safety equipment, devices and personal protective equipment as directed.
    • Report all unsafe acts and/or conditions.
    • Conduct point of care risk assessments (PoCRA)/appropriate screening of patients at all points of patient entry.

    2.4 Volunteers

    • Do not volunteer if FEELING UNWELL
    • Follow directions provided by departmental/site/program leadership and attend and participate in education/training/instruction sessions where required.

    2.5 Joint Occupational Health and Safety Committee (JOHSC)

    Committee members will:

    • Be available to answer question from staff.
    • Support review and development of resources.
    • Participate in Risk assessment process.

    2.6 Lower Mainland Integrated Services (i.e. Other Health Authorities)

    Health Authorities on Fraser Health sites providing clinical and clinical support services have primary responsibility to ensure that their work is carried out in a safe manner and in compliance with the WorkSafeBC Occupational Health and Safety Regulation and specific Fraser Health policies and procedures as outlined in this Addendum to the ECP. They are responsible for the conduct and work practices of their workers and any contractors they may bring on-site and to coordinate the work activities of workers and contractors.

    2.7 Contractors/Consultants and Service Providers

    • Contractors have primary responsibility to ensure that their work is carried out in a safe manner and in compliance with the WorkSafeBC Occupational Health and Safety Regulation. They are responsible for the conduct and work practices of their workers and any sub-contractors they may bring on-site and to coordinate the work activities of workers and contractors. Issues of non-compliance will be dealt with directly with the principal contractor or service provider as they are noted.
    • Fraser Health is regarded as both the owner and prime contractor at Fraser Health owned facilities with the exception of Abbotsford Regional Hospital and Cancer Centre for the purposes of the Workers Compensation Act and Occupational Health and Safety Regulation.
    • The Contract Manager must ensure that all work carried out in Fraser Health facilities is in compliance with the WorkSafeBC Occupational Health and Safety Regulation and Fraser Health requirements as outlined in this Addendum to the ECP.
    • Contractors, consultants and service providers will comply with specific safety requirements and procedures based on information provided by Fraser Health of any known Covid-19 risks including exposures.

    2.8 Infection Prevention and Control (IPC)

    IPC will:

    • Identify outbreaks and facilitate response in  Fraser Health acute care sites including processes/protocols to mitigate further spread of Covid-19.
    • Declare the start and end of outbreaks.
    • Ensure Infection Control policies and procedures related to this Program are current and accessible to staff and medical staff.
    • Collaborate with managers, health care providers, Public Health, supervisors, Health and Safety and the JOHSC representatives to provide education and training on the following topics:
      • Signs and symptoms of Covid-19.
      • Modes of transmission.
      • Written infection control policies and procedures that direct the employee on how to eliminate or minimize exposure for them to other staff, patients or visitors. 
      • Proper use and selection of Personal Protective Equipment (PPE).

    2.9 Public Health

    Public Health will:

    • Receive reports from Infection Prevention & Control (IPC) of all suspect reportable diseases in patients and carry out case investigations to assess if patient(s) meet BCCDC case definition and if contact tracing/notification is required. Liaises with the Medical Health Officer.  Public Health will follow BCCDC guidelines for case and contact management.
    • Liaise with IPC to determine if any inpatients or discharged patients require follow up.
    • Notify Provincial Workplace Health Call Center of a case that was in a Fraser Health facility so Health and Safety can determine if any follow up is required for staff and medical staff.
    • Conduct contact tracing, active surveillance of close contacts and recommend self-isolation of community contacts when required.

    2.10 Health and Safety

    Health and Safety will:

    • Consult in Covid-19 risk assessment and mitigation with regard to appropriate exposure control measures and best practices.
    • Coordinate and facilitate fit-testing sessions for staff, medical staff and Respirator Train the Fit-Tester sessions where necessary and advise on other personal protective equipment best practices.
    • Ensure a copy of the ECP and Addendum is available to managers, and workers.
    • Ensure the exposure control plan for COVID-19 response is reviewed and updated as necessary.
    • Support the development of supporting resources, as needed.
    • Ensure a system for documenting instruction, training and fit testing is in place.
    • Assist with the risk assessment process and consult on risk controls, as needed.

    2.11 Provincial Workplace Health Call Centre Occupational Health Nursing (PWHCC OHN)

    PWHCC OHN will:

    • Consult with Infection Prevention and Control and Public Health to confirm communicable disease incidents in the workplace and to determine the exposure criteria for Health Care Workers.
    • Identify staff who are in direct contact with the source of a communicable disease and who meet the exposure criteria.
    • Provide post exposure follow up for staff including recommendations for work restrictions and/or further medical care.
  • 3.0 Risk identification, assessment and control of COVID-19

    COVID-19 (“Corona Virus Disease of 2019”) is the disease caused by the novel coronavirus, SARS-CoV-2.

    The novel coronavirus, COVID-19, is spread from an infected person (patient, worker or visitor) through droplets and contact with contaminated surfaces, such as:

    • respiratory droplets generated when they cough or sneeze;
    • close, prolonged personal contact, such as touching or shaking hands; or
    • touching something with the virus on it, then touching your mouth, nose or eyes before washing your hands.

    Airborne transmission of COVID-19 occurs when an AGP is performed on a suspected/confirmed case. When performing an AGP adhere to Fraser Health PPE requirements.

    3.1 Risk Identification and Assessment

    Workplaces must assess the level of risk related to COVID-19 and implement controls to minimize the risk. Fraser Health is using a two-pronged approach, a Facility or Department specific Risk Assessment to evaluate risk and implement controls related to infrastructure, and a Team Level Risk Assessment to examine risks associated with the tasks that individuals and teams do and address them where required. The Team Level Risk Assessment will be done by managers or supervisors with input from staff.

    The BC Government’s Go Forward Strategy [2] uses the following matrix to illustrate level of risk to consider when conducting your risk assessment. The greater the number of contacts and the greater the contact intensity (function of distance and duration), the greater the risk of staff being exposed to and contracting COVID-19. The goal of the risk assessment is to determine the level of risk and implement controls to adequately mitigate that risk.

    The BC Government’s Go Forward Strategy identifies three areas which form the core measures of the “new normal” for which organizations must plan: personal control measures, social interaction measures and organizational practices. Some of these measures are covered in the Facility Risk Assessment, which focusses on infrastructure to complement the Team Level Risk Assessment. The “new normal” is expected to be in place for the next 12 - 18 months, until a safe and effective vaccine or treatment is created or until herd immunity has been reached in the population.

    The risk assessment tools to be completed for each unit or department are checklists that are specific to the type of healthcare facility or service delivery and associated information on the COVID-19 Pandemic Recovery: Key Principles for Safe Returning/Re-opening.  The Infection Prevention and Control COVID-19 Recovery Checklists include:

    • • Corporate/Office/Support Services Settings
    • • Acute Care Settings
    • • Long Term Care
    • • Community Care
    • • Ambulatory Care Settings
    • • Working from Home Safely
  • 4.0 Hazard control

    The Occupational Health and Safety Regulation (OHSR) requires employers to have exposure prevention and infection control measures based on the following hierarchy. For Covid-19, and in absence of a vaccine, the hierarchy has been adopted to include:

    1. Elimination/Substitution; Social distancing/self-isolation
    2. Engineering
    3. Administrative Controls
    4. Personal Protective equipment (PPE)

    For clinical environments, Infection Prevention and Control develops various manuals, guidelines, and associated resources to support and implement available controls. These combine the exposure prevention methods listed above into sets of practices based on mode of disease transmission. These are designed to protect both the health care worker and the patients. Refer to the Infection Control Clinical Practice Guidelines on FH Pulse.

    Most traditional non-clinical office environments, in which 2 m physical distancing is not met, has increased risks owing to the long duration of being within 2 m of a relatively small number of people. Tasks which involve close contact with larger numbers of people increase the risk. There may be some cases in which physical distancing criteria are already met which would place staff and medical staff in a low risk category. Core control measures must be implemented even in workplaces deemed to be low risk.

    In preparation for returning non-clinical staff to the workplace, remote work is the best protection against COVID-19 exposure; physical distancing is next best; and introducing physical barriers between staff follows in terms of effectiveness and practicality. Efforts must focus on these approaches progressively giving consideration in this hierarchical fashion.

    Hierarchy of Controls –COVID 19 Related


    • Elimination of face-to-face contact is the preferred control, using services such as telehealth medicine, or promotion of work from home options where possible.


    • Use of social distancing, maintaining a distance of 2m from others reduction in contact density and number of contacts.

    Engineering controls

    • Examples may include negative pressure rooms and other physical barriers to maintain social distancing.

    Administrative controls

    • Informational and directional signage;
    • Hand hygiene protocols, cough/sneeze etiquette;
    • Allow a reasonable personal distance space to reduce human-to-human transmission;
    • An increase in cleaning frequencies for shared work surfaces and equipment;
    • Cohorting patients with like symptoms;
    • Staff who become symptomatic with Influenza-like symptoms need to remain off work for the prescribed period of time.

    Personal Protective Equipment (PPE)

    PPE must be worn as required. Fraser Health has a variety of PPE available for staff when providing care for patients. Information on what types of PPE are required with contact, droplet, or airborne transmission can be found in the IPC Clinical Practice Guideline: Selection and Use of Personal Protective Equipment for Infection Prevention and Control.   

    Fraser Health is taking measures, as directed by the Provincial Health Officer, to preserve PPE while maintain staff safety. We are implementing prioritization measures and conservation protocols to ensure that adequate supplies of reliable PPE remains available to protect healthcare workers and their patients.

    PPE recommendation tables have been developed by the EOC in collaboration with Infection Prevention and Control, Clinical Operations, Professional Practice, Health & Safety, and Medical Affairs with guidance taken from BCCDC and Ministry of Health to provide clear guidance to care providers on appropriate PPE. These PPE requirements can be found in the applicable PPE Framework documents:

  • 5.0 Exposure reporting

    Communicable Disease hazard concerns should be reported using the Workplace Hazard Report.

    All inadvertent communicable disease exposures and breeches of PPE must be reported to the Provincial Workplace Health Call Centre at 1-866-922-9464. 

    Required follow-up and corrective actions will occur as outlined in the documentation associated with these processes.

  • 6.0 Health protection (post exposure management)

    Occupational exposure to communicable diseases will be managed confidentially through the Provincial Workplace Health Call Centre, Occupational Health Nurse (1.866.922.9464) in conjunction with Infection Prevention & Control and Public Health and according to the Health and Safety Policy & Protocol for the Prevention and Management of Occupational Exposure to Communicable Diseases

    Further information regarding specific post exposure management of communicable diseases can be found on the FH Pulse Communicable Disease Exposures page.

  • 7.0 Education and training

    Fraser Health will inform occupationally exposed staff and medical staff about the contents of the Covid-19 Pandemic Recovery Addendum to the Exposure Control Program.

    Education and training will be provided prior to work assignment wherever possible when potential communicable disease exposure could occur. This education and training must also be provided to staff and medical staff returning to a workplace where exposure hazard to infectious agents may have changed during the employee’s absence. The training will be reviewed if any changes to the Exposure Control Program or work procedures that could affect exposure potential occur. 

    Departments will provide notification (during report) at the start of the work assignment detailing applicable infection control precautions in place. 

    7.1 Contents of Training 

    Education and training will include the following: 

    • Explanation of: COVID-19 modes of transmission; symptoms; and treatment
    • Control options: Infection Control Precautions and engineering, work practice and personal protective equipment to eliminate or minimize exposure. 
    • Demonstration of how to utilize established controls (e.g. how to check negative pressure rooms are functioning, proper donning and doffing of personal protective equipment).
    • Labelling and identification of materials containing biological hazards. This includes laboratory specimens, sharps containers, and waste. 
    • Hand Hygiene Annual module
  • 8.0 Documentation and recordkeeping

    8.1 Exposure Records 

    All known infectious agent exposures will be documented on the Occupational Health Employee File. 

    As part of the post-exposure follow-up, the Provincial Workplace Health Call Centre Assistant or Occupational Health Nurse may collect and document specific information on the exposure. This information will be documented in the confidential Workplace Health Incident Tracking and Evaluation Database (WHITE).

    8.2 Education / Training Records

    A database and record for all staff and medical staff trained in the elements of Communicable Disease exposure prevention is maintained for courses in the Course Catalogue Registration System (CCRS), PHSA Learning Hub and when the training is provided by Health and Safety on WHITE.

    New employee orientation (NEO) records will be maintained for at least 3 years by People and Organizational Development, including tracking of OHS related training from Acute New Employee Orientation (NEO) in WHITE. Department managers are required to maintain departmental training records, including NEO, for at least 3 years.

    8.3 Work Procedures

    Written work procedures are to be maintained by the department manager/supervisors.

  • 9.0 Program evaluation

    The Program will be evaluated on an ongoing basis to ensure compliance with applicable regulations and standards.  Full review of the program will occur on an annual basis.

  • 10.0 References