DISTRIBUTION LIST. Document Distributed to: Date. Interim Business Continuity Plan V0_1 Draft. Senior Management Team 20 th March 2012

Transcription

1 Corporate Business Continuity Plan Version 0_2 Draft 30 th March 2012 Version 0_2 Draft 1

2 Record of Alterations Version Date Description of Alterations Version 0_1 draft 19 th March 2012 First draft for consultation Version 0_2draft 30 th March 2012 Ammendments following SMT consultation DISTRIBUTION LIST Document Distributed to: Date Interim Business Continuity Plan V0_1 Draft Senior Management Team 20 th March 2012 Version 0_2 Draft 2

3 Table of Content Section Page 1.0 Introduction Background Context of Business Continuity Management Definition of Business Continuity How Business Continuity Planning Differs from 9 Major Incident Planning 1.5 Publication Purpose & Scope Purpose Scope Assumptions Limitations Areas of Responsibility Chief Executive Director of Medical & Governance Trust Directors Head of Corporate Communications Emergency Planning & Business Continuity 13 Manager 3.6 Trust Staff Plan Activation Procedures 4.1 Triggers to Activate the Plan Notification & Activation Procedures Activation of Business Continuity Plan Examples of Disruption resulting in Activation of the Plan 16 Version 0_2 Draft 3

4 Table of Content Section Page 5.0 Response Business Continuity Control & Information Team 17 (BCCIT) 5.2 Command & Control Team (CCT) Location of the Control Room 17 Table 2 BCCIT 18 Table 3 CCT Record Keeping Incident Stand Down Incident Debrief Hot Debriefing Formal Debrief Interpreting Services Cultural Sensitivity Communication Strategy Designated Press Office Centre Prioritisation Criteria for Trust Services Business Prioritisation Criteria Trust Critical & Urgent Services/Products Operational Service Resumption Strategies Training Methods of Training Review & Validation 10.1 Review 28 Version 0_2 Draft 4

5 Table of Content Section Page 10.2 Validation 28 Appendices Appendix 1 Business Disruption Notification Record 29 Appendix 2 Registration Sheet 31 Appendix 3 Log Sheet 33 Appendix 4 Designated Locations 35 Appendix 5 Action Cards - Notifying Manager 38 - Director/Director on call 39 - Information Manager in CCT 40 - Action Manager in CCT 41 - Support Manager in CCT 42 - Corporate Communications 43 - Chair of BCCIT 44 - Team Members of BCCIT 46 - Support Manager of BCCIT 47 Appendix 6 Trust Emergency Planning & Business Continuity 48 Forum Terms of Reference Appendix 7 Accessing Interpreting Services 52 Appendix 8 Business Continuity Control & Information Team 55 Structure Appendix 9 Command & Control Team Structure 57 Appendix 10 Appendix 11 Command & Control Team Information Flow Diagram Trust Business Impact Analysis Paper (To be included) Version 0_2 Draft 5

6 Acronyms Term BCCIT BCM BCP CCD CCT HDU Meaning Business Continuity Control & Information Team Business Continuity Management Business Continuity Plan Corporate Communications Department Command & Control Team High Dependency Unit HSC HSCB ICT ICU PHA NIAS NIF&RS Health & Social Care Health & Social Care Board Information, Communication Technology Intensive Care Unit Public Health Agency Northern Ireland Ambulance Service Northern Ireland Fire & Rescue Service Version 0_2 Draft 6

7 Version 0_2 Draft 7

8 1.0 Introduction The Northern Health & Social Care Trust became operational on the 1 st April 2007, and is one of six provider HSC Trusts in Northern Ireland. Geographically the largest Trust within Northern Ireland, it provides a range of health and social care services across ten local council areas, which includes Antrim, Ballymena, Ballymoney, Carrickfergus, Coleraine, Cookstown, Larne, Magherafelt, Moyle, and Newtownabbey to a population of approximately 443, 000 people. These services include a range of hospital services, including: - acute hospital services provided at Antrim Area Hospital, Antrim; and Causeway Hospital, Coleraine; - sub-acute hospital services in Mid Ulster Hospital, Magherafelt; and Whiteabbey Hospital, East Antrim; and - acute and in-patient mental health services in Holywell Hospital, Antrim; and the Ross Thompson Unit, Coleraine. In addition, there are a wide range of community based services across directorates which include children services, primary care & community older peoples services, and mental health & disability service, which deliver service provision across a range of facilities in approximately 150 locations and including three community hospitals located in Larne, Ballymoney and Ballycastle. The core business of the Northern HSC Trust is to deliver high quality, appropriate, effective and accessible health and social care services. This is underpinned by a commitment to deliver person-centred services, and is reinforced by the Trust mission statement: To provide for all, the quality of service we expect for our families and ourselves. Business continuity management, including processes for recovery and restoration, should be considered as part of all HSC organisations every day processes to ensure that core business services are maintained. Business continuity should be embedded into the culture of the Northern HSC Trust. It provides a framework to enhance the resilience of the Trust to any eventuality and to help ensure continuity of critical service to patients and service users. It provides a basis for planning to ensure long-term survivability following a disruptive event, and protects the reputation of the Trust. The Business Continuity Plan is necessary to enable the Trust to continue to deliver critical activities at an acceptable predefined level during a service interruption and restore normal services as soon as possible. Target Audience This policy is directed to all Northern Health & Social Care Trust staff. Version 0_2 Draft 8

9 1.1 Background The British Standard BS :2006 defines business continuity management as a business-owned, business-driven process that establishes a fit-for-purpose strategic and operational framework that: proactively improves an organization s resilience against the disruption of its ability to achieve its key objectives; provides a rehearsed method of restoring an organization s ability to supply its key products and services to an agreed level within an agreed time after a disruption; and delivers a proven capability to manage a business disruption and protect the organisations reputation and brand Business Continuity Management (BCM) enables organisations to identify their critical functions and to plan for and respond to incidents and business disruptions in order to continue business operations at an acceptable pre-defined level. 1.2 Context of Business Continuity Management In preparation of the Trust Corporate Business Continuity Plan due recognition has been given to the requirements identified in the following documentation: - The Northern Ireland Civil Contingencies Framework British Standard for Business Continuity - BS The Business Continuity Institute The Good Practice Guidelines NHS Emergency Planning Guidance 2005 The Trust Chief Executive has overall responsibility for ensuring the implementation of and continued success of BCM within the Trust. The Emergency Planning and Business Continuity Manager is responsible for writing and implementing the Corporate Business Continuity Plan and ensuring it is operational through distribution, promotion, training of staff, exercising, review and validation. This includes the responsibility for ensuring it is compliant with current legislation, national guidance and examples of good practice. 1.3 Definition of Business Continuity BS defines BCM as the capability of the organisation to plan for and respond to incidents and business disruptions in order to continue business operations at acceptable pre-defined levels within agreed time frames. Version 0_2 Draft 9

10 For HSC organisations, interruption may be defined as: Any disruptive challenge that threatens personnel, buildings or the operational procedures of an organisation and which requires special measures to be taken to restore normal operating functions. BCM is concerned with ensuring that, at all times, the Trust can continue operating at a pre-determined level in the event of a major disruption. 1.4 How Business Continuity Planning Differs from Major Incident Planning The Trust defines a Major Incident as An incident which, because of the number or severity of casualties, will have an overwhelming impact on the normal emergency department and other hospital services and which requires the extraordinary mobilisation of medical, nursing, social services staff and other services. Emergency Planning guides the Trust response as part of a multi-agency response to an unexpected incident which is external to the Trust and has a severe impact on the general public. Business Continuity Planning is planning to respond to a business disruption which primarily affects the ability of the Trust to do business, and ensuring the capability of the Trust to continue critical activities at an acceptable pre-defined level. 1.5 Publication This plan will be published and shared in its entirety. Publication will be by means of the Trust intranet site, and hard copies issued to the Trust Senior Management Team and Assistant Directors. Alternative Formats This document can be made available on request on disc, larger font, Braille, audio cassette and in other minority languages to meet the needs of those who are not fluent in English. Sources of Advice in relation to this document The Policy Author, responsible Assistant Director or Director as detailed on the policy title page should be contacted with regard to any queries on the content of this policy. Equality, Human Rights and DDA This policy has been drawn up and reviewed in the light of Section 75 of the Northern Ireland Act (1998) which requires the Trust to have due regard to the need to promote equality of opportunity. It has been screened to identify any Version 0_2 Draft 10

11 adverse impact on the 9 equality categories and no significant differential impacts were identified, therefore, an Equality Impact Assessment is not required. 2.0 Purpose and Scope 2.1 Purpose The purpose of this Corporate Business Continuity Plan is to provide an overarching strategic framework to support the Northern HSC Trust (the Trust) to identify as far possible, the actions and resources that are needed to enable it to manage a major disruption whatever its cause, back to a position where normal business can be resumed following a disruption which may be: - Internal to the organisation eg, loss of key building due to fire or flooding, loss of utilities, or a staffing crisis - External to the organisation eg, loss of power supply, prolonged disruptions due to strikes, severe weather. This Plan sits at the top of a hierarchy of Business Continuity Plans that include Directorate Plans and Departmental Plans. The objectives of the Trust Corporate Business Continuity Plan are: - to facilitate an organised and co-ordinated response to a serious or major business disruption - to provide clear procedures for the invocation of the Trust incident management structure in the event of a business disruption that impacts on key services - to outline the Trust strategic and tactical command structure to a disruptive incident affecting critical activities/services - to identify the communication strategy throughout the incident - to identify the critical services to be maintained within each directorate - provide clear guidance of roles and responsibilities to Trust staff - to outline service resumption strategies to be considered during a service disruption This Plan details strategic arrangements to protect the time critical key functions of the Trust, with the principle that critical services should be maintained to a pre- defined level for a period of seven days. It should be noted that Business Continuity responses may extend beyond the length of the interruption until such times as services/activities can be restored to their pre-defined levels. This plan fulfils the requirements of the BS25999, and the Trusts Business Continuity Management Policy. In addition it compliments the Trust Major Incident Plan (Version 1_0), and existing suite of business continuity plans already within each Directorate. Version 0_2 Draft 11

12 2.2 Scope The scope of this plan encompasses the Trust services within the following Directorates: - Acute Hospital Services - Primary Care & Community Older Peoples Services - Children Services - Mental Health & Disability Services - Planning, Performance Management & Support Services - Finance - Human Resources - Nursing & User Experience - Medical & Governance 2.3 Assumptions The assumptions on which this plan is based are that: - It is a corporate responsibility that every directorate and department within the Trust should be involved in BCM. The level of involvement is dependent on the number of critical activities performed by the directorate or department. - The Emergency Planning Manager will assist in supporting all directorates to develop, review and maintain their BCPs, however overall responsibility for developing and maintaining plans remains firmly with each directorate. - The workload of the Trust and the availability of any vacant space will vary at any given moment. The Corporate BCP therefore sets out general strategic directions and guidance rather than defined solutions. - Unless required (by PSNI or otherwise) to relocate staff elsewhere, it is assumed that there is a requirement for staff to be located in another Trust facility. This will be reviewed depending on the nature and location of the incident. - There is an assumption that all key roles will have an appointed Deputy, who has been previously briefed and understands what their role is and the actions they must undertake for the best interests of the work area or responsibility, in the absence of the primary key role holder. - All staff have read the plan, understand their likely role/working position given the need to implement this plan. Version 0_2 Draft 12

13 - It may be necessary to instruct those staff considered to be non-critical to frontline staff to go home or remain at home, for a limited time, in order to accommodate those staff considered key to service provision. - It is assumed that mobile communications will be operating during the extent of the incident and will not be limited by network coverage or contract. 2.4 Plan Limitations This Plan is not designed to: - Be fully prescriptive in the event of contingency activities being undertaken, as the situation may require localised and reactive actions. - Take effect where relatively minor disruption is experienced and the considered option is that resolution is within a reasonable timescale for the nature of the incident. - Account for or cover the acquisition of additional permanent office or other specialised accommodation. Version 0_2 Draft 13

14 Version 0_2 Draft 14

15 3.0 Areas of Responsibility 3.1 Chief Executive The Chief Executive has overall accountability for ensuring that the Trust has in place effective arrangements to respond to an incident that has potential to affect service provision. 3.2 Director of Medical & Governance The Director of Medical & Governance has responsibility for the successful implementation of business continuity management arrangements within the organisation. 3.3 Trust Directors Directors are responsible for ensuring that: Business continuity plans are completed for each risk identified; Business continuity plans are cascaded to appropriate staff within the directorate who are given appropriate training; Plans are reviewed annually or sooner as appropriate; and The correct response is provided to the disruptive incident. 3.4 Head of Corporate Communications The Head of Corporate Communications is responsible for: Ensuring appropriate, timely and clear communication with staff, patients and carers on the status and progress of disruptions and any changes to service delivery taking into account the communication needs of affected equality groups, ie older people, people with a disability, ethnic groups and dependents. Liaising with public representatives and the media throughout the incident with the release of regular press statements and arranging press conferences if required. 3.5 Emergency Planning & Business Continuity Manager The Emergency Planning & Business Continuity Manager is responsible for: Ensuring business continuity plans are developed, maintained, validated and reviewed; Ensuring training is provided for personnel who have been assigned business continuity responsibilities. 3.6 Trust Staff All staff must make themselves familiar with: The Trust Business Continuity Management Policy; Version 0_2 Draft 15

16 The Corporate Business Continuity Plan; Individual directorate business continuity plans. 4.0 Plan Activation Procedures 4.1 Triggers to Activate the Plan The Trust may experience various levels of disruption that will have differing levels of impact on core business areas. The response invocated by the Trust will be dependant upon the level of disruption experienced. To assist in the management of the disruption, there are three defined levels of incident disruption that will influence and assist in the decision making regarding the level of response required. This is outlined in Table 1 below. Table 1: Levels of Disruption Level Category Definition: One or more of the following apply Response Level 1 Minor Disruption Level 2 Serious Disruption Level 3 Major Disruption A local incident that is not an emergency and does not cause serious physical threat to people or property. Results are likely to be limited disruption services. The disruption can be dealt with by local management. A disruptive incident that could pose an actual threat to people and property, but not seriously affect the overall functioning of the Trust. The disruption is likely to last no more than one working day Access to one or more sites may be denied The disruption affects more than one Directorate A disruptive incident causing a significant disruption to the Trust s operations. A number of services seeking to activate their BCP A serious or destructive loss of a major or multi- occupancy site Major wide scale incident in a geographical area affecting several services/sites Major disruption to business activities / Emergency Plans and lower level BCPs inadequate to deal with incident Immediate notification to: Line Manager Manage the incident through the respective Directorate BCP Immediate notification to: Line Manager Director/Director on call Potential activation of the BCCIT (5.0) Manage the incident through the respective Directorate BCP. Immediate notification to: Line Manager Director/Director on call Activation of the BCCIT & CCT (5.0) NB. Both line Manager and Director to complete a Business Disruption Notification Record (Appendix 1) on notification of a business disruption. Version 0_2 Draft 16

17 Appendix 5 outlines Action Cards for both the notifying Manager & Director at the notification stage of a business disruption. Version 0_2 Draft 17

18 4.2 Notification & Activation Procedures The following flow chart outlines the Trust response to the levels of disruptive incidents that may occur. Incident Identified Inform Line Manager immediately Line Manager assesses the potential level of disruption (Table 1) Level 1 Minor Disruption Level 2 Serious Disruption Level 3 Major Disruption Activate Directorate BCP Monitor for signs of escalation Disruption escalates Is it during office hours? YES NO Report to Director immediately Report to Director-on-call immediately Assess the severity of the incident disruption and determine the appropriate response LEVEL 2 LEVEL 3 RESPONSE Activate: BCCIT Inform CCD Director to monitor the incident for signs of escalation. RESPONSE Activate: BCCIT CCT Version 0_2 Draft 18

19 4.3 Activation of the Corporate Business Continuity Plan As outlined in 4.1, the strategic management and response to a Level 3 major disruption will be achieved principally through invocation of this Plan. The following outlines in more detail when the Trust classifies an incident as a Level 3 major disruption resulting in the need to activate the Plan: Normal operational procedures or the implementation of Directorate BCPs do not manage the disruption One or more critical or urgent services cannot be maintained locally There is a need for special arrangements to be implemented across multiple sites by the Trust to deal with the disruption The need to evacuate a site that accommodates multiple services for a prolonged period of time There is a corporate wide co-ordinated response required to deal with the disruption An issue is likely to cause more widespread disruption within other areas of the Trust A minor disruption escalates into widespread disruption that can no longer be dealt with by the directorate BCP Prompt, co-ordinated action by the Trust could prevent minor disruption escalating into serious disruption Examples of Disruptions resulting in Activation of the Plan The following are examples of major disruptions that may have sufficient impact to result in consideration to activate this Plan: Severe weather conditions Widespread pandemic illness resulting in reduction of available staff resources An incident which has the potential to effect the reputation of the Trust Large Industrial action Significant/prolonged loss of IT/communications Loss of utility supplies, such as electricity, gas, fuel and water An incident with the potential to affect multiple buildings or the welfare of staff Natural disasters eg floods It is important to note that both Level 1 and Level 2 disruptions have the potential to escalate to a Level 3 disruption. For this reason ongoing review of the disruption is the responsibility of the Director, or delegated other. Version 0_2 Draft 19

20 5.0 Response In the event of a business continuity disruption, the Director/Director-on-call is responsible to make the decision regarding the required response. This will be determined by the level of disruption as identified in paragraph 4.1. The membership of each team will be determined by the type, duration and services affected by the disruption. 5.1 Business Continuity Control & Information Team (BCCIT) In response to a Level 2 and Level 3 disruption, the Director will activate the Business Continuity Control & Information Team to tactically manage, direct, coordinate and lead the operational response. Table 2 The location in which this Team is based is flexible, and dependant on the location of the business continuity disruption. The principles of this team are similar to the Control & Information Team (CIT) outlined in the Major Incident Plan. The BCCIT will be led by the BCCIT Chair, and supported by Team Members, and a Support Manager; administrative support will be provided by Personal Assistants of team members involved. (Outlined in Appendix 8) (Please refer to: Action Cards for each role -Appendix 5) 5.2 Command & Control Team (CCT) In the event of a Level 3 disruption, the Director will make the decision to activate the Command & Control Team to strategically manage the Trust response. Table 3 To maintain consistency, again the principles and structure of this Team is similar to the Command & Control Team that is identified within the Major Incident Plan. At times it may be that this team is required to co-ordinate the strategic response to both a Major Incident and Business Continuity disruption. Each member of this Team has the responsibility to ensure that they have identified a nominated Deputy to represent them, in the event that they are not available to respond. Clearly defined roles within this team include Information Manger, Action Manager, and Support Manager; secretariat support will be provided from Personal Assistants from Trust HQ. (Outlined in Appendix 9) (Please refer to: Action Cards for each role Appendix 5; Information Flow Appendix 10) Location of the Control Room Version 0_2 Draft 20

21 The locations of the Control Room to facilitate Command & Control Team meetings are available in Appendix 4 NHSCT Business Continuity Control & Information Team (BCCIT) Location: To be decided when the incident occurs Purpose The BCCIT will provide tactical response to the management of a Level 2 or Level 3 business continuity disruption. This will include directing and coordinating the operation response to the disruption, and providing leadership and support to staff. During a Level 3 disruption, this team will support the CCT in ensuring strategic decisions are implemented at an operational level. Membership Assistant Director for the service area affected General Manager for the service area General Manager for Support Services Corporate Communications Assistant Director of ICT or deputy (if appropriate) Head of Estate services or deputy (if appropriate) Administrative support Co-opted members as required Responsibilities during the Business Continuity Disruption Version 0_2 Draft 21

22 Will take lead responsibility for the management and co-ordination of the directorate/department operational response Establish and maintain communication with the Command & Control Team (if activated) for support and strategic guidance Assess the impact on services patient services, staff, building infrastructure etc Direct and co-ordinate the activation of all Directorate BCPs Provide advice, guidance and leadership to staff involved in the response Ensure there are sufficient staffing levels and resources available to respond to the disruption, including the direction and co-ordination of resource deployment across the Trust Ensure open channels of communication and coordination to the response with other external agencies as appropriate, which may include PSNI, NIAS, NIF&RS and PHA/HSCB Follow direction from Trust Corporate Communication in response to media, public and staff communication Maintain a written log of messages sent or received, decisions made and actions taken by all personnel Secure all written logs and forward to the Emergency Planning Office following the response Manage the resumption of service delivery Decide at what stage to declare Incident stand-down, and notify Trust staff involved in the response; and Participate in review, evaluation and formal post incident debriefing of the Trust response to the incident. Table 2: Business Continuity Control & Information Team NHSCT Command and Control Team (CCT) Location: The Boardroom, The Cottage OR The Boardroom, Holywell Purpose Membership (as appropriate) The CCT has responsibility for strategic direction and support to all Directorates/Departments involved in the response to a Level 3 business continuity disruption. The main objective is to provide strategic direction and leadership to the BCCIT, in order to manage the disruptive incident and restore the Trust to normal operating conditions. Chief Executive Director of Medical & Governance Director Acute Hospital Services Director of Nursing & User Experience Director of Planning, Performance Management & Support Services Director of Finance Director of Human Resources Director of Mental Health & Disability Director of Children Services Head of Corporate Communications Administrative Support Version 0_2 Draft 22

23 Co-opted members as required Responsibilities during the Business Continuity Disruption: Take strategic command of the Trust response to the business continuity disruption Liaise with and support the BCCIT Manage and approve the request for additional resources as requested by the BCCIT to manage the disruption Monitor the response, co-ordinating the resources to match the needs at various stages of the response Ensure the establishment of effective communication and take the lead in directing the Trusts responses to partners and agencies as required, including the Trust Board, HSCB, PHA, DHSSPS, other Trusts Monitor the progress of the response, and brief the BCCIT with regular updates. Identify and mitigate clinical and non-clinical risks to staff, patients and the public Follow direction from Trust Corporate Communication in response to media, public and staff communication in a timely manner Ensure welfare and safety of patients, staff and wider stakeholders are given uppermost consideration during and after the response Maintain a written log of messages sent or received, decisions made and actions taken by all personnel Secure all written logs and forward to the Emergency Planning Office following the incident response Decide at what stage to declare Incident stand down, and notify Trust staff Table 3: Command & Control Team 5.3 Record Keeping Records during the response are legal documents which are legally recoverable and discoverable documents in the event of a subsequent inquiry or legal review. It is therefore essential that all records created during the response are maintained and securely retained. Detailed and accurate logs (Appendix 3) must be completed by Trust staff of information received, advice given, action taken and discussions held. These logs will be secured immediately after the incident response is stood down and forwarded to the Trust Emergency Planning & Business Continuity Manager for retention. Version 0_2 Draft 23

24 5.4 Incident Stand down The CCT or BCCIT will determine when the Trust can stand down its response and communicate accordingly. 5.5 Incident Debrief Hot Debriefing Managers should make arrangements for staff to have an initial debriefing at the end of their shift as a means of acknowledging staff contribution to the response and identifying any outstanding tasks to be complete. The BCCIT will conduct a hot debrief when the decision is made that the incident response is stood down. This is an informal discussion to provide recognition and praise to staff for their contribution to the response Formal Debriefing Formal debriefing both internal and with external agencies involved will occur within one month following the incident response, and will be led by the Medical Director as the Director with responsibility for Emergency Planning & Business Continuity. A Formal Post Incident Debrief Report will be produced by the Emergency Planning & Business Continuity Manager identifying areas for consideration and recommendations following the Trust response. This is forwarded to the Medical Director to present to the Senior Management Team and Trust Board as appropriate. The Report will be also be presented to the members of the Trust Emergency Planning and Business Continuity Forum. 5.6 Interpreting Service Interpreting support will be provided for those involved in the incident whose first language is not English. The Trust has access to face to face interpreters in an emergency through the Trust s Equality Unit or if the incident occurs outside office hours through the Regional Interpreting Service. The Trust also has access to a telephone interpreting service which can be accessed immediately, 24 hours a day. Sign Language interpreters can be accessed through the Equality Unit or Action on Hearing Loss if the incident occurs outside office hours. Full details of the interpreting support available and how to access it are available in Appendix Cultural Sensitivity Communities are made up of people from differing religious and cultural backgrounds. Whilst health and safety is always of paramount importance for people affected by a Major Incident, it is important that Trust staff deal with casualties and their families appropriately and in the most sensitive and thoughtful way as possible. This will include cultural considerations in respect of medical treatments and sensitivity to different cultural attitudes and requirements when Version 0_2 Draft 24

25 dealing with the deceased. Specific advice on cultural issues can be found in the Trust s Multi Cultural Handbook. Version 0_2 Draft 25

26 6.0 Communication Strategy Good communication is vital to the successful handling of any business continuity disruption. The key communications objective must be to deliver accurate, clear and timely information and advice to all relevant target audiences. Liaison with media during the response can assist in external communication to both service users and members of the public to inform them of the Trusts response to the disruption, the impact on normal services, and assist in timely updates on how the Trust is dealing with the response. The Trust Head of Corporate Communications as a member of the Command & Control Team or the BCCIT (if Command & Control not established), will be responsible for leading the Trusts media response, and advising senior managers on the structure and content of any press releases. The following principles apply in relation to the Trust liaison with the media during a business continuity disruption response: All communication with the media will be via the Corporate Communications Department No member of Trust staff will provide any information to the media unless under the direction of the Head of Corporate Communication All telephone enquiries from the media will be directed by switchboard to the command and control centre at the relevant site; and All Trust staff will adhere to the normal procedures regarding confidentiality of information and identity of attendees. 6.1 Designated Media Press Office Centre In response to a disruptive incident, the Trust designated Press Offices may be required to be established. The purpose of these Centres is to brief media, run press conferences etc. External Media Officers will be directed to the designated Media Press Office Centre if opened. There will be a member of Trust Corporate Communications within the Media Press Office Centre at all times, who will liaise with and take direction from the Head of Corporate Communications. The location of the designated Media Press Office Centre is identified in Appendix 4 Portering Services will ensure that these rooms are set up and equipped with additional telephone sets if required. If the location of the Media Press Office Centres is not appropriate to the response required, the Head of Corporate Communications may identify an alternative appropriate location. Direction will be provided to the Trust Corporate Communications Department from the Command & Control Team (if operational) /BCCIT/Chief Executive s Office as Version 0_2 Draft 26

27 to when it is appropriate to close the Centre. Upon closure all media enquiries will be managed through the Corporate Communication office. 7.0 Prioritisation Criteria for Trust Services Responding effectively to a Business Continuity disruption is underpinned by a sound understanding of the organisation. In complying with the BS requirements, the Trust has completed a Business Impact Analysis (BIA), with the aim to identify and understand: The Trusts time critical services, and the priority of each The maximum tolerable period of disruption, and recovery time objectives The dependencies that exist, both internal and external, which are required to provide the critical services The impact if the service/function was interrupted as a result of a business continuity disruption Areas of risks within each service area The resources required to maintain the pre-defined acceptable level of business for each key service. Further commitment is required in the analysing and consolidation of the findings within the BIA. In the interim, a BIA Paper has been completed. (Appendix 11 still to be included pending further consultation with Directors) The information captured within the BIA identifying key services and products to be maintained through a service disruption was correlated, and a series of interviews with the Trusts Directors and key staff initiated to approve these for inclusion into this Plan. 7.1 Business Prioritisation Criteria The following prioritisation criteria have been applied to identify those time critical business operations within the Trust that must be recoverable to an acceptable level as a matter of priority. This information is a starting point to assist the CCT to prioritise the Trust response required in the early stages following a Level 3 disruption to business. Priority 3: 1-3 days Service must be resumed within 3 days. It is Priority Moderate Service must be Description envisaged that these services/products need resumed within to be restored as soon as practicable within Priority 1: 0-1 hour Those the 1 st or services/products 2 nd day following that the need interruption. to Critical Priority 4: 4-7 days continue Service must operating be resumed with little within or no 4-7 interruption days. Low or the impact would be catastrophic/life threatening. Priority 2: Urgent 1-24 hours Those services/products that can tolerate an interruption for an extremely short period of time. Version 0_2 Draft 27

28 7.2 Trust Critical and Urgent Services/Products A brief analysis of the Trust services within each of these criteria is included in Appendix 11 (still to be included pending further consultation) A summary of the services that have been assessed as critical and urgent using the above criteria are outlined on the following table. Priority 1 Critical Directorate Acute Hospital Services Children s Service Mental Health & Disability Primary Care & Community Older Peoples Service Nursing & User Experience Service/Product Name Radiology Obstetrics - Labour wards; Maternity ward; Community Midwifery Laboratories Theatre - Emergency Theatres; Maternity Theatres Emergency Department Inpatient Care - Unscheduled care, medical and surgical specialities ICU & HDU Neonatal Unit Inpatient Care - Children's Paediatric wards Residential Child Care including access to secure units Complex Care - Complex illnesses; Complex Care in the Community Crisis Resolution Home Treatment Service Provision of Inpatient acute care services, rehabilitation and crisis accommodation for patients, Mental PICU, EMI Units Maintain Supported Living Units Internal Homecare services Residential care; Intermediate Care Beds; Respite Care Community Hospitals Intermediate Rehab & Stroke Service Palliative Care, Support & Macmillan Unit Antrim Hospital Diversion Nursing Team Infection Prevention/Control - Advisory and managerial support; Version 0_2 Draft 28

29 Planning, Performance Management & Support Services Chief Executives Office Priority 2 Urgent Directorate Decontamination/Sterile Services Domestic Services -Theatre Services Porter services Still to be included CEO's office and Corporate Communications Service/Product Name Children s Service Central Support - Out Of Hours Social Work Service Safeguarding and Corporate Parenting - Gateway Services, Family Support Intervention & Disability Teams & Teams supporting Looked After Children Mental Health & Disability Community Mental Health Services - Domiciliary Care Packages Primary Care & Community Older Peoples Service Nursing & User Experience Planning, Performance Management & Support Services Community Integrated Teams - Community Nursing Services; Treatment Room Services; Social Work Assessments/Commissioning of services; Safeguarding of Vulnerable Adults; Community Equipment Services; Acute OT Services Functional Support Catering (Patient/Client feeding across all Directorates. Staff feeding - hospital sites) Hospital Security Service Transport services - Labs and Medical Instruments, Clinical Waste collection, HDSU runs etc. Still to be included Medical & Governance Pharmacy - Aseptic Services; Chemotherapy; Distribution of Pharmaceuticals; Clinical Pharmacy Services Human Resources Occupational Health Service - Management of sharps Finance Processing of Payroll Version 0_2 Draft 29

30 Version 0_2 Draft 30

31 8.0 Operational Service Resumption Strategies In the event of a major or severe disruption, there are various options to be considered and applied in order to resume the provision of a service/product. The following strategies are generic high level options within good practice that should be considered and built into the operational level business continuity resumption plans. Each Directorate may also have to develop options that are specific to their areas of service provision. Required resource Strategies (options) to consider include: People Premises Technology Supplies Prioritisation of key service areas Diversion and redeployment of staff from other areas within the Trust Multi-skill training of staff to perform outside their normal role to ensure skill met flexibility Alternative staffing, including use of third parties, increasing staff hours, secondment, etc Alternative premises within the Trust, including prioritisation and displacement of non-critical activities; Alternative premises provided by other organisations eg another Trust Alternative premises provided by third party specialists Portable premises eg portacabins Staff working from home or at remote sites Re-direction of services eg regional networking/ escalation Revert to use of manual system Holding older equipment as emergency replacement or spares Use back up sources either on Trust site or brought in Restore IT records from back-ups, create and manage records using paper systems Storage of additional supplies at another location Arrangements with third parties for delivery of stock at short notice Identification of alternative/capable suppliers Increasing the number of suppliers that deliver products required for critical services In terms of the Trust overall, the loss of wards at the key sites e.g. ICU/HDU or Theatres remain the highest risk to the Trust as these are at a premium within the NI Healthcare system and suitable temporary facilities off-site would be extremely difficult to establish. Mitigation for the these critical services will be dependent on establishing networks e.g. (CCaNNI) with neighbouring Trusts to expedite the transfer of service users to suitable facilities in the event of a serious or major disruption where current capacity is overwhelmed or removed. In the event of an incident requiring the extensive reliance upon other Trusts it is worth noting other Version 0_2 Draft 31

32 networks already exist for neonatal care, adult intensive care, cancer and pathology services. Version 0_2 Draft 32

33 9.0 Training Trust staff have a responsibility to ensure that they are both aware of and follow correct procedure during any level of disruptive incident. The Trust must support staff in understanding their role through education and training. Robust training mechanisms are in place to ensure that staff must have access to the information they need to undertake this role. Managers and staff must take responsibility for familiarising themselves with the Corporate Business Continuity Plan and undertake appropriate training as and when indicated by the Trust. 9.1 Methods of Training The Trust will make arrangements for maintaining awareness and for training with regard to the organisations response to a business continuity disruption and the role of Trust staff in delivering this response in line with the following principles: On appointment as part of an induction process it is the responsibility of the line manager in raising awareness of the Corporate Business Continuity Plan and the individual s key role and responsibility during any business continuity disruption; each Department is responsible for ensuring that staff receive training appropriate to their involvement in the business continuity response on a regular basis; Awareness raising sessions will be held annually for Senior Management Team; and Key staff will develop their competencies and practise their role as identified in the Corporate Business Continuity Plan through participating in exercises. The Plan will be available on the Trust intranet site. Evidence of any training given at a Departmental level will be submitted to the Emergency Planning and Business Continuity Manger. It is anticipated that when possible staff should have received training before participating in exercises or tests of the Trusts Plan. Version 0_2 Draft 33

34 10 Review & Validation 10.1 Review To ensure that the Trust BCM process is adequate and effective, this Corporate Business Continuity Plan will be reviewed and updated on an annual basis, or more frequently if required following activation of the plan or an exercise, or significant organisational change. It is the responsibility of the Emergency Planning & Business Continuity Manager to amend this Plan as required. It is the responsibility of Directors and Managers to amend and review the Directorate and Departmental BCPs within the same principle. The Trust Emergency Planning and Business Continuity Forum has been established under the Chairmanship of the Assistant Medical Director with a remit to ensure the Trusts Major Incident Plan and Business Continuity Plans are reviewed, updated, and maintained. The terms of reference are included in Appendix 6. It is anticipated that a Trust Business Continuity Management specific group will be established to support the development of Directorate and Departmental Plans to support this plan Validation This Plan will be validated through BCM exercising, which is conducted to ensure that staff with an identified role is fully aware of their role in the event of any level of disruption, and to identify any areas within the Plan that needs to be addressed or improved in a safe and controlled environment. Exercising helps to build confidence in Trust staff, by clarifying roles and responsibilities, and providing valuable experience to responding to a disruptive incident; it also provides Trust confidence and assurance that the Plan is effective competent and that capability remains effective, fit-for purpose, and up-to-date. The types of exercises will include communication, table-top, and live exercises. It is the responsibility of each Director and Departmental Managers to ensure that Directorate and Departmental BCPs are validated regularly. A post-exercise debrief will be completed following each live/table top exercise. These will allow for participants to comment on the effectiveness of the Plan and to identify lessons learnt from the exercise. The Emergency Planning & Business Continuity Manager will complete a post exercise report which will include recommendations for improvement. This report is forwarded to the Medical Director for presentation to the SMT, and Trust Board. Version 0_2 Draft 34