EMERGENCY PREPAREDNESS POLICY CONTROLLED DOCUMENT CATEGORY: CLASSIFICATION: Policy Emergency Planning PURPOSE This document sets out the strategic framework for the management of emergency preparedness and business continuity at University Hospitals Birmingham NHS Foundation Trust Controlled Document Number: Version Number: 2 Controlled Document Sponsor: Controlled Document Lead: Approved By: 537 Executive Chief Nurse On: 07/01/2013 Review Date: 06/01/2016 Distribution: Essential Reading for: Information for: Associate Director of Nursing (Operations) Emergency Preparedness Steering Group For all Trust Managers For all staff
Contents Paragraph 1 Policy Statement 3 2 Scope 4 3 Duties 4 4 Framework 8 5 Implementation and Monitoring 10 6 References 12 7 Associated Policy and Procedural Documentation 12 Page Emergency Planning and Business Continuity Policy Issued: 24/01/2013 Document Control Number:537 Version No: 2
1. Policy Statement 1.1 Under the requirements of the Civil Contingencies Act 2004, the Trust has a statutory duty to implement arrangements to ensure that it can:- 1.1.1 Respond to an emergency; 1.1.2 Continue to support emergency response partners; and 1.1.3 Continue to provide essential services to the public as is reasonably practicable in the event of an emergency. 1.2 These requirements are met through the implementation of Major Incident and/or Business Continuity plans, which will enable the Trust to respond effectively in emergency situations and continue to deliver its services. 1.3 The Trust must also ensure that it has effective contingency plans in place to enable it to maintain the provision of its services in abnormal circumstances, such as the failure of a supplier or a sudden increase in demand on services. 1.4 The aim of this Policy is to ensure that the Trust has effective arrangements in place to enable it to: 1.4.1 react effectively to a major incident outside of the Trust, providing appropriate medical services and support to emergency response partners; 1.4.2 react effectively to a major incident within/directly affecting the Trust so that it can continue to provide essential services as is reasonably practicable; 1.4.3 minimise disruption when unplanned events have the potential to significantly interrupt normal business; and 1.4.4 Manage impacts on capacity when demand outstrips available capacity and normal contingency plans are insufficient. 1.4.5 React effectively to a situation where there is a significant loss of staff e.g. due to industrial action or Flu Pandemic 1.5 The objectives of the Policy are: 1.5.1 To identify, plan, resource and implement preventative actions and contingency plans which enable the Trust to: 1.5.1.1 react effectively to emergencies; 1.5.1.2 reduce the risk of disruption to essential services; and 1.5.1.3 mitigate any financial impact of such events; 1.5.2 To establish arrangements to determine the occurrence of and to respond to a serious service interruption, alerting appropriate 3
personnel, allocating resources and priorities for action to recover essential services and prepare for return to normal working as quickly as possible. 1.5.3 To identify the potential areas of risk to the Trust s services, in order to implement measures to prevent or minimise disruption. 1.5.4 To support effective communicate during an emergency or service interruption. 1.5.5 To ensure the Trust can continue to exercise its functions in the event of an emergency. 1.5.6 To ensure all departments are involved in the preparation of the plans, so that there is an effective and consistent response to emergencies and/or service disruption. 1.5.7 To ensure that all plans are tested and updated in line with national requirements. 2. Scope This policy applies to all areas and activities of the Trust and to all Trust staff, including bank and agency staff, those on honorary contracts and volunteers, when responding to a major incident or a service interruption. 3. Duties 3.1 Chief Executive It is the Chief Executive's responsibility to: 3.1.1 Ensure that the Trust has adopted effective Major Incident and Business Continuity plans; 3.1.2 Ensure that the Board of Directors receives regular reports regarding emergency and business continuity planning; 3.1.3 Designate an Executive Director to take responsibility for emergency and business continuity planning throughout the Trust; and 3.1.4 Ensure that sufficient resources are available for the Trust to effectively prevent or respond to a major incident or a service interruption. 3.2 Executive Directors 4
3.2.1 It is each Executive Director s responsibility to be prepared to make strategic decisions with regard to the Trust s response to an emergency or service interruption, including responding to media enquiries, in liaison with the Service Interruption Management Team, as identified within the business continuity plan. 3.3 Chief Nurse 3.3.1 The Chief Nurse has been designated by the Chief Executive as the Executive Director with overall responsibility for emergency and business continuity planning throughout the Trust. 3.3.2 The Chief Nurse shall: 3.3.2.1 Provide regular reports to the Board regarding emergency preparedness and business continuity planning; 3.3.2.2 Chair the Emergency Preparedness Steering Group; and 3.3.2.3 With the assistance of the Chief Operating Officer & the New hospital project Director, ensure that: 3.4 Director of Corporate Affairs a) a comprehensive set of contingency plans for the provision of key services are developed and reviewed annually b) that such contingency plans meet national requirements c) that all relevant staff are aware of their responsibilities under those plans; and d) that staff are trained in the application of these plans The Director of Corporate Affairs shall assist the Chief Nurse by overseeing the development of the Trust s processes and plans for business continuity. 3.5 Chief Operating Officer The Chief Operating officer shall assist the Chief Nurse by ensuring that the emergency plans for the Trust are implemented in line with this Emergency Preparedness and Business Continuity policy. In addition the COO will support the development of the heatwave and inclement weather plans, which will form part of the Business Continuity plan. 5
3.6 Medical Director The Medical Director shall ensure that a comprehensive IT disaster recovery plan is developed, updated and implemented. This plan must meet national requirements, and all relevant staff must be made aware of their responsibilities under that plan 3.7 New Hospital Project Director The New Hospital Project Director shall: 3.7.1 support the development of the key services contingency plans, which will form part of the Trust Business Continuity plans; and 3.7.2 Ensure that an estates accommodation contingency plan, which will form part of the Trust Business Continuity plans, is developed, updated and that all relevant staff are aware of their responsibilities under that plan. 3.8 Assistant Director of Nursing (Operations) It is the Assistant Director of Nursing (Operations) s responsibility to: 3.8.1 Ensure that the Trust major Incident plan is updated, ensuring that all staff are aware of their roles and responsibilities. 3.8.2 Ensure that the Business Continuity plan is updated and that all service staff is aware of their responsibilities. 3.8.3 Ensure that key elements of all plans developed under the auspices of the Emergency Preparedness Policy are reviewed annually and that the Major Incident plan and Business continuity plans are tested within the Trust at least annually; 3.8.4 Evaluate the Trust s response and ensure modification to all emergency plans as necessary; and 3.8.5 Ensure that the Trust s response plan is included in the Staff Induction Programme and that staff are aware of their role in the event of there being a service disruption. 3.8.6 Report the above to the Chief Nurse and the Director of Corporate Affairs in order that they may advise the Board of Directors.. 3.9 Divisional Directors of Operations and Divisional Directors It is the Divisional Director of Operations and Divisional Directors responsibility to: 6
3.9.1 Ensure all their staff is aware of their departmental responsibilities to assist Departmental Managers and the Service Interruption Management Team in the Trust s response to a service interruption. 3.9.2 Ensure that all copies of the Major Incident Plan and Business Continuity Plan issued to their department are updated when amendments are issued; 3.9.3 Ensure that all staff are made aware of other related plans and their responsibilities therein. 3.9.4 Ensure that every department or service within their area of responsibility has undertaken a full business continuity risk assessment and that this is reported centrally through the Essential Services Group (sub group of the Emergency preparedness steering group). 3.9.5 Ensure all staff are aware of any Departmental Control Measures and Recovery Plans to prevent and respond to a service interruption and are prepared to implement them; 3.9.6 Ensure that the All Departmental Service Interruption Action (Cards) are included in local induction programmes for all staff; and 3.9.7 Be prepared to assist the Service Interruption Management Team in the response to a serious service interruption. 3.10 All staff All staff has a responsibility to comply with the requirements of this policy and its associated procedures where there are elements that apply to them and their services. 7
4. Framework 4.1 GLOSSARY OF TERMS Service Interruption A service interruption is an event or situation which: Major interruption service Threatens the services, personnel, buildings or the organisational structure of the Trust; and Requires special measures to be taken to respond to the interruption and to restore normality. Major service interruptions are service interruptions which affect one or more critical services of the Trust, and require Trust wide coordination to ensure resolution. Local interruption Major Incident Pandemic (Influenza) service Flu Local service interruptions are interruptions to a service that affect only one area of the Trust and can be resolved at a local level. Any occurrence that presents a serious threat to the health of the community, disruption to the service or causes such numbers or types of casualties as to require special arrangements to be implemented by the hospital trust A global disease outbreak of a new flu virus where there is little or no immunity and no available vaccine. 4.2 FRAMEWORK 4.2.1 This section describes the broad framework for the Trust s Emergency Preparedness and Business Continuity planning. Within this framework, three work streams are identified as follows: 4.2.1.1 Major Incident Planning; 4.2.1.2 Business Continuity Planning; 4.2.1.3 Capacity Planning. 4.2.2 The Trust Business Continuity Plan is separate from the Trust s Major Incident Plan under which the Trust would deliver its emergency response to a major incident, such as a road traffic accident or chemical incident. Therefore, the Business continuity 8
plan and Major Incident plan can be implemented independently of each other. 4.2.3 However, a service interruption may occur simultaneously to a Major Incident or an event or situation in the wider environment which requires the Major Incident response may also cause an interruption to the Trust s services or functions. 4.2.4 In such circumstances the Business Continuity Plan may need to be implemented in addition to and independently of the Major Incident Plan, but there would need to be co-ordination between the Trust s response to the Major Incident and the service interruption to ensure there is a co-ordinated response and decision making process, and to avoid duplication of effort. 4.2.5 The Chief Nurse, through the Emergency Preparedness Steering Group, will oversee the work carried out under each work stream to ensure that the plans and procedures in each are coordinated and that work programmes are adhered to. 4.3 Major Incident Planning 4.3.1 The Chief Nurse will ensure that the following plans are prepared and submitted to the Board of Directors for approval: 4.3.1.1 Major Incident Response Plan; 4.3.1.2 Chemical, Biological, Radiological and Biological (CBRN) Response Plan; These plans shall be reviewed by the Board of Directors every three years. 4.3.2 Detailed instructions and guidance for implementation of the above plans are provided in associated procedural documents, which the Chief Nurse has the authority to approve or amend. 4.4 Business Continuity Planning 4.4.1 Business continuity management is a process that helps manage risks to the smooth running of an organisation or delivery of a service, ensuring continuity of critical functions in the event of a service interruption, and effective recovery afterwards. Business Continuity Management is a generic management framework that is valid across the public, private and voluntary sectors. It is an ongoing process that helps organisations anticipate, prepare for, prevent, respond to and recover from service interruptions, whatever their source and whatever aspect of the organisation they affect. 4.4.2 The Trust shall develop plans to deal with service interruptions that would affect multiple services of the Trust as set out in the Business Continuity plan, such as staff shortages, interruption to IT services and power failures. 9
4.4.3 The Chief Nurse and Director of Corporate Affairs will ensure that the Trust Business Continuity Plan is prepared and submitted to the Board of Directors for approval and subsequent reviewed every three years. 4.4.4 The Chief Nurse and Chief Operating Officer will ensure that the following plans are prepared and submitted to the Emergency Preparedness Steering Group for approval: as part of the Business Continuity plan. 4.4.4.1 Heatwave Plan; 4.4.4.2 Inclement Weather Plan; 4.4.4.3 Winter plan 4.4.4.4 Fuel plan 4.4.4.5 Accommodation contingency plan and 4.4.4.6 Key services Contingency plans 4.4.5 Detailed instructions for Business Continuity Planning are provided in the plan and its associated procedural documents, which the Chief Nurse and Director of Corporate Affairs have the authority to approve or amend, including: 5. Implementation and Monitoring 5.1 Implementation 4.4.5.1 Business Continuity Planning procedures; 4.4.5.2 Procedure for Notification of a Service Interruption 4.4.5.3 Service Interruption Action (Cards) details specific actions for all staff and key position. 5.1.1 Awareness Training 5.1.1.1 An outline of the Trust's Emergency preparedness plans (including Business Continuity) will be incorporated within: a) The Trust induction programme for all new staff; b) The Junior Doctors induction programme; c) All local/departmental orientation programmes to an appropriate level (including Facilities Service Providers). 10
5.1.1.2 At least annually, all staff will be given an update on the Trust's plans through a publication within the Trust's newsletter and/or as an attachment to payslips. 5.1.2 Departmental Training 5.1.2.1 Each department will be responsible for identifying the training needs of their own staff and this should be built into individual and departmental training programmes. 5.1.3 Individual Training 5.1.3.1 All individuals with specific responsibilities under the Major Incident or Business Continuity plans shall undergo training specific to their role. The Associate Director of Nursing (Operations) shall ensure that a central record is maintained of such training. 5.1.4 Exercising of the Major Incident and Business Continuity Plans 5.2 Monitoring 5.1.4.1 Regular exercising of all plans is necessary to ensure that the plans are fit for purpose. 5.1.4.2 All Trust Emergency preparedness plans will be tested in line with national guidance; specific testing regimes are indicated within each plan. 5.2.1 The Emergency Preparedness Steering Group shall monitor implementation of and compliance with this Policy, Trust Emergency preparedness plans and associated procedural documents. 5.2.2 The Emergency Preparedness Steering Group shall be chaired by the Chief Nurse. Membership and role of the EPSG is set out in its terms of reference at Annex A. 5.2.3 The Associate Director of Nursing (Operations) will agree a schedule of audits with the EPSG each year relating to the implementation of this policy and shall report the results of such audits to the EPSG. 5.2.4 Divisions will provide quarterly reports to the EPSG, stating the level of compliance with the requirements of this policy. 5.2.5 The Chief Nurse shall provide the Board of Directors with a 6 monthly report summarising the work of the EPSG and the outcomes and responses to testing completed 11
5.2.6 Any serious concerns regarding compliance with this policy shall be raised with the Chief Nurse who will be responsible for bringing such matters to the notice of the Chief Executive/Board of Directors as appropriate. 5.3 Review of the Major Incident and Business Continuity Plans 6. References 5.3.1 It is the responsibility of the Emergency Preparedness Steering group in conjunction with any sub groups to review the plans on an annual basis. 5.3.2 This review will take into consideration any action arising from the evaluation of any incident or exercise, changes within the Trust, and of any new guidelines that may have been issued. 6.1 Civil Contingencies Act 2004 7. Associated Policy and Procedural Documentation The following controlled documents should be read in conjunction with this policy 7.1 Business Continuity Plan and procedural documents 7.2 Major Incident Plan and procedural documents 12