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BUSINESS CONTINUITY MANAGEMENT SYSTEM

Barnsley Hospital NHS Foundation Trust

July 2009

Author: Business Continuity Manager Barnsley Hospital NHS Foundation Trust Emergency Planning/Business Continuity Department Trust Headquarters Gawber Road BARNSLEY South Yorkshire S75 2EP [email protected]



Amendments

Section/Para Date Name (Capitals) Signature

Section 11 Contact details

30.09.09 LISA CORBRIDGE


Distribution List

POST HOLDER COPY NUMBERS COPY TYPE/No.

Foundation Trust Executive Team – Trust Headquarters Chairman 1 Hard Copy Chief Executive 2 Hard Copy Deputy Chief Executive/Medical Director 3 Hard Copy Chief Operating Officer 4 Hard Copy Chief Nurse & Director of Quality & Standards 5 Hard Copy Director – Finance 6 Hard Copy Director – Strategy & Business Development 7 Hard Copy Director – Human Resources 8 Hard Copy Non-Executive Director – Emergency Planning 9 Hard Copy Management Team – Trust Headquarters Head of Communications 10 Hard Copy Deputy Chief Nurse 11 Hard Copy Trust Headquarters Administration Office 12 Hard Copy Emergency Planning Officer/Business Continuity Manager - Barnsley Hospital

13 Hard Copy

Emergency Planning Manager – NHS Barnsley 14 Hard Copy Head of Facilities 15 Hard Copy Divisional Medical Directors/Assistant Divisional D irectors Integrated Medicine 16 Hard Copy Emergency Medicine 17 Hard Copy Critical Care 18 Hard Copy Children’s Services 19 Hard Copy Pathology 20 Hard Copy Woman’s Services 21 Hard Copy Medical Imaging 22 Hard Copy Assistant Divisional Director - Surgery 23 Hard Copy Assistant Divisional Director - Medicine 24 Hard Copy Assistant Divisional Director – Imaging & Outpatients 25 Hard Copy Assistant Divisional Director – Women & Children’s Services 26 Hard Copy Divisional Service Manager - Theatres 27 Hard Copy Divisional Service Manager - Surgery 28 Hard Copy Divisional Service Manager - Medicine 29 Hard Copy Assistant Divisional Nurse - Surgery 30 Hard Copy Assistant Divisional Nurse – Women & Children’s Services 31 Hard Copy Assistant Divisional Nurse - Medicine 32 Hard Copy Clinical Nurse Specialist – Infection Control 33 Hard Copy General Management Deputy Director – Human Resources 34 Hard Copy Deputy Director - Finance 35 Hard Copy Manager - IT 36 Hard Copy Manager Supplies 37 Hard Copy General Office Manager 38 Hard Copy Switchboard Switchboard Manager 39 Hard Copy Switchboard 40 Hard Copy Estates Office Estates Manager 41 Hard Copy


POST HOLDER COPY NUMBERS COPY TYPE

Security Contracts Manager 42 Hard Copy Security Office 43 Hard Copy Barnsley Primary Care Trust Director of Public Health 44 Hard Copy Assistant Director in Public Health 45 Hard Copy Emergency Planning Officer (See above) 14 Hard Copy Strategic Health Authority Assistant Director – Emergency Preparedness CD Manager– Emergency Preparedness CD Lead PCT Emergency Preparedness & Resilience Manager CD Barnsley Metropolitan Borough Council (BMBC) Emergency Resilience Department 46 Hard Copy Social Services Department CD South Yorkshire Police (SYP) Operational Planning (Barnsley District) CD Health Protection Agency Consultant in Communicable Disease Control 47 Hard Copy Office - Meadowhall CD Additional Copies Open Intranet Access Major Incident Response Folders/Boxes Duty Director – Call-out Folder 48 Hard Copy Reference Incident Room Folder 49 Hard Copy Incident Room (Battle Box) 50-53 Hard Copies x 4 Incident Room (Battle Box) 54-57 Hard Copies x 4 Spare 58-60 Hard Copies x3 TOTAL Hard Copies 60 CDs 6


Index

SECTION A Page No STATEMENT OF CHIEF EXECUTIVE 9 PREFACE 10 SECTION 1 - INTRODUCTION Introduction to Business Continuity 11 Business Continuity Principles 11 Planning Stages 12 Risk Assessment 13 Site Vulnerability Survey 13 Business Continuity Plans 14 SECTION 2 – LEADERSHIP & COORDINATION General Command & Control Structure 15 Statutory Duties 15 Chief Executive 15 Chief Operating Officer 16 Business Continuity Manager 16 Non-Executive Director 16 Trust Staff 16 Trust Incident Rooms 16 Financial Arrangements 17 SECTION 3 – INVOCATION PROCESS Invocation (Initiation) of the System 18 Trigger Points 18 During Office Hours 19 Out of Office Hours 19 Communications Flow 19 SECTION 4 – INCIDENT RESPONSE Command & Control 20 Incident Management Team - Silver 20 Crisis Management Group - Gold 21 Investigation & Inquiry 22 Grading & Cancellation of Incidents 23


SECTION 5 – TRUST MANAGEMENT RESPONSE Managing Visitors 24 Staff Levels During the Response Phase 24 Staff Skills Audit 24 Induction Programme 25 Staff Issues 25 FamilyFirst 25 Recovery Phase – Staff Considerations 25 Volunteers 26 SECTION 6 – COMMAND PRINCIPLES Bronze or Operational 27 Silver or Tactical 27 Gold or Strategic 27 Financial Arrangements - Command 28 SECTION 7 – STRATEGIC SUPPLIES & SERVICES Supplies & Contracts 29 Mass Fatalities 29 Utilities 29 Information Technology & Telecoms 29 SECTION 8 - MEDIA STRATEGY & COMMUNICATIONS Public Information 30 NHS Barnsley 30 Regional Communication 30 Local Internal Communication 30 SECTION 9 – DEBRIEFING & RECOVERY General Information 32 Exit Strategies 32 Debriefing 32 SECTION 10 – GLOSSARY OF TERMS A-B 33 B-C 34 C 35 D-E 36 E-L 37 M-R 38 R-W 39 SECTION 11 – KEY CONTACT DETAILS 40


SECTION 12 – LOCATION & MAP BHNFT 43 SECTION 13 – REFERENCE MATERIAL & BIBLIOGRAPHY 44

SECTION B

DEPARTMENTAL BUSINESS CONTINUITY PLANS APPENDIX A 48 Service Prioritisation Form APPENDIX B 50 Operational Planning Form APPENDIX C 54 Risk Matrix


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Foreword by Sandra Taylor, Trust Chief Executive

Please just contemplate for a moment that the building or department you regularly work from is out of operation and inaccessible for two hours. Now expand on that thought and consider that access may not be gained for a day, a week or even longer. It may be that this has been caused by fire, weather, bomb threat or any number of reasons. This will mean that the work you do and the daily routines we all undertake will be seriously affected. Our entire individual tasks link into the patient care we provide to the public of Barnsley, our colleagues and our partners. The problem may not be dramatic; it could be colleagues with influenza, a building access problem, or any number of different scenarios. Whatever the circumstances we must be able to continue our business and provide the essential patient care and emergency services that are expected of us as Barnsley Hospital NHS Foundation Trust. Business Continuity Management is the term that essentially means “being able to carry on our business as usual”, no matter what crisis we may face as an organisation. It will ensure we can provide an ‘as near normal’ day to day service when dealing with any serious or major incident. Business Continuity Management is in reality just good management and is about ensuring that we can all continue to work in a safe, healthy and secure environment irrespective of any internal or external issue . I would ask that you open and read this plan and familiarise yourself with its contents and arrangements. By doing so you will ensure that you are well prepared and not end up trying to absorb the details and deal with a business continuity incident at the same time. Prior knowledge is a great advantage when a crisis happens, as they inevitably do. I’d like to refer to two quotes about Business Continuity Planning and Management: “It is probably the most important planning an organisation will undertake – as without it your organisation may simply cease to exist.” “If you can keep your head when all about you are losing theirs, it’s just possible you haven’t grasped the situation.” This plan is one of a number of similar documents being produced by our Emergency Planning team for the Trust that will provide us with the resilience required to face any incident. I commend it to you for reference prior to any incident occurring. Sandra Taylor Chief Executive


Preface The aim of the business continuity system is to provide a clearly defined framework to ensure the resilience and continuation of the Trust’s critical activities and dependencies. The Trust will meet much of its Risk Management strategic intention by embedding business continuity planning into the culture of the organisation. This will ensure we meet the specific regulatory and contractual requirements of commissioners, contracts, information governance toolkit, Civil Contingency Act 2004, Care Quality Commission Core Standard 24 and National Capabilities survey.

Business Continuity Management (as defined by the Business Continuity Institute 2001) is:

“A holistic management process that identifies potential impacts that threaten an organisation and provides a framework for building resilience with the capability for an effective response that safeguards the interests of its key stakeholders, reputation, brand and value-creating activities.”

Business continuity management is concerned with managing risk to ensure that, at all times, the organisation can continue operating to, at least, a pre-determined minimum level, in the event of a major disruption. These risks can be from the external environment, e.g. power failures, severe weather, or from within the organisation, e.g. system failures, loss of key staff.

Barnsley Hospital NHS Foundation Trust delivers a wide range of services to its local communities. Failure to deliver these services could have a detrimental impact on the health of the public and the viability of our business and our reputation as an organisation.


Section 1 INTRODUCTION 1.1 This Business Continuity System relates how Barnsley Hospital NHS Foundation

Trust (BHNFT) will respond in the event of a major business continuity event impacting on how the Trust delivers its services to the communities of Barnsley and beyond. It is not possible to plan for every service failure, but the plan provides guidance and practical procedures for how the hospital should mobilise and deploy its staff and resources to respond to a business continuity management incident and co-ordinate its response with other agencies if so required.

1.2 This system is based on the five stage process

• of understanding your business, � determining business continuity strategies, � developing and implementing a BCM response, � developing a BCM culture and � exercising, maintenance of plans and audit

These objects will be achieved in line with central government guidance of direction, integration, subsidiarity, preparedness, continuity, communication, cooperation and anticipation.

1.3 This system also describes the agreed procedures and arrangements for the

effective co-ordination of a hospital response in the event of an internal incident or external incident that impacts directly on our ability to deliver essential services. This plan will be exercised at regular intervals in liaison with the Trust and NHS Barnsley emergency planning groups and with other agencies expected to provide assistance. An exercise regime has been established that will include an annual test of this plan and a live response exercise triennially. The live exercise will alternate between a major incident and a business continuity scenario and will be subject of a full report listing learning points and recommendations. Responder and hospital staff training and awareness will be held on a regular basis and be fully documented. This training will reflect the type and variety of business continuity incidents a hospital NHS Foundation Trust could be expected to face.


1.4 This system is not definitive. It is intended to be flexible and act as a guideline so

that it may be adapted to the type and location of the incident and the number of persons involved. The plan has adopted a risk methodology agreed by the Emergency Planning Group which meets regularly and has based its risk assessment on categorised risks as outlined in the Trust risk matrix, regional risk register and national planning assumptions. Advice and guidance is also based on the national security strategy. All these documents identify a number of hazards and threats including risks associated with pandemic, structures, ingress, terrorism, extreme weather and staff losses.

1.5 As appendices this document will contain summaries of the responses and

responsibilities of each critical service area and providers, as well as outlining specific business continuity procedures. These will be known as the business continuity plans. This system document is also designed to complement existing major incident and emergency procedures. Under all service continuity and business impact circumstances it can be considered the initiator to the individual departmental and service operational interruptions. Triggers for invocation have been identified and agreed with each service area.

1.6 Procedures in this document have been agreed inter-directorate and between

other possible assisting agencies. These agencies have been informed of these arrangements particularly in respect of issues of mutual assistance.

1.7 The Trust has adopted the process of embedding Business Continuity

Management through the Business Continuity Lifecycle process, developed by the Business Continuity Institute.

1.8 The first stage of business continuity management for the Trust was to consider the areas of service that are crucial in maintaining during and following a crisis. This step is called the Business Impact Analysis (BIA). The BIA involves identifying the critical service/business activities within the Trust and determining the impact of the service area failing to function. Types of criteria for assessing the impact include:

• Impact on patient care and human welfare • Internal operations • Legal and statutory requirements • Financial impact • Staff welfare and security • Possible environmental impacts

Once care functions have been identified the BIA should assess at the time dependencies for each and assign recovery objectives. This analysis was completed with each head of service using a service prioritisation matrix and will be approved at Board & Director level. A simple quantitative score was assigned to each service area for ease of assessment but underscored by a qualitative background. See Appendix A for a copy of this matrix.

1.9 The second stage in the process was to identify potential risks that could disrupt the Trust’s operations. Most risks were grouped into the following:

• People • Premises


• Information (Electronic & Non-Electronic) • Location/Geographical • Environmental • Utilities / Services

A number of risks including the following were included in the operational planning template and formed the foundation of the service area business continuity plans:

� Accidental Fire or Arson � Evacuation � Criminal Acts � Fuel Shortage � Extreme Weather Events � Structural Damage � Utility or Services Failure � Infection, Infestation, Ingress � Industrial Action � Loss of Staff or Contractors

1.10 Risks identified have been included in the Trust’s Corporate Risk Register and a further linked risk matrix that identifies all associated internal and external hazards and threats. A full site vulnerability survey has been conducted in relation to the hospital site and the results retained in the Emergency Planning Department. Five historical maps dating back to 1855 have also formed part of this research. A number of actions have already been initiated to ensure vulnerabilities identified are reduced to a minimum. Research included enquiries with:

� Local Authority (Land and Emergency Planning) � Environment Agency � Fire Service � South Yorkshire Police (CTSA) � Coal Authority � Library for archive & historical data � Longest serving employees � Three residents who have all lived in the area for at least 30 years. � Past head-teacher – local school.

1.11 The following issues have also been assessed in respect of the hospital site and considered in relation to aspects of business continuity management:

� Flood risks (particularly surface water flooding) � Subsidence � Radon � Coal mining � Landfill and hazardous waste processing sites � Environmental permits � Water quality & pollution control � Waste carriers � Radioactive substances � Historical land use � Pollution � Local facilities � People & Housing � Stand-off attacks � General crime


� Cyber crime � Relationships with Local Authority & NHS Barnsley � Media liaison & local contacts � Past land planning applications

1.12 In developing both this business continuity system and the operation service plans meetings were conducted with service heads, full liaison with members of staff and assistance and direction given when required. Business Continuity awareness forms an integral part of corporate curriculum training and e-learning for all managers and staff. This step of the process ensures the effective management and participation of managers and staff and includes the following:

� The purpose and scope of the plan � System and plan owners complete with business continuity ‘champions’ � Clear roles and responsibilities � Trigger points for the initiation of the business continuity arrangements � Contact details of all key stakeholders and personnel � Clear incident management � A communications strategy

1.13 The final stage is to ensure that this system and service plans are current, fit for purpose and will deliver the required response. The Trust’s business continuity arrangements must be validated either by the response to an actual incident or exercised and proved to be workable. Any exercising regime must involve validation, rehearsing key staff and testing systems and supplies required to assure the Trust’s resilience. As previously mentioned this can be by team, seminar, tabletop or live exercises and set timescales are advised in the NHS Emergency Preparedness Guidance.


Section 2 LEADERSHIP & COORDINATION 2.1 GENERAL COMMAND & CONTROL STRUCTURE

Barnsley Hospital NHS Foundation Trust is a standing member of the local Emergency Planning Group and also has a Hospital Emergency Planning Group which would form part of any Incident Management Teams during any incident. The Hospital Trust team is coordinated by the Chief Operating Officer assisted by the Business Continuity Manager with key clinical and management leads forming the core planning and response input.

2.2 NHS Barnsley will be informed to ensure local communication and implement any

preparatory actions in respect of support or patient care. Barnsley Hospital staff and resources will at all times be managed and coordinated internally.

2.3 Details removed from public copy 2.4 The declaration of a business continuity incident will be the trigger for activating a full time BHNFT Incident Management Team and initiation of this plan in a phased response to any increasing requirements 2.5 STATUTORY DUTIES

Under the Civil Contingencies Act 2004, Barnsley Hospital is a Category 1 responder and has a statutory responsibility to provide a full response to any business continuity incident. The Trust has six core duties that are outlined and must be fulfilled under the Act. Business Continuity arrangements are one of these duties.

2.6 CHIEF EXECUTIVE

The Chief Executive of the Trust has overall responsibility for resilience arrangements. They will ensure that the organisation has business continuity plans in place, and that the Board receives regular updates on all emergency preparedness including reports on exercises, training and testing undertaken by the organisation. The Chief Executive will also ensure that appropriate resources are made available to allow the discharge of these responsibilities.

The Chief Executive must ensure that Board level responsibility for Business Continuity Management is clearly defined and there are clear lines of accountability throughout the organisation leading to the Board. The Chief Operating Officer is designated to take responsibility for Trust resilience and is supported by Directors of the Trust (This plan should be read in conjunction with the Trust's Major Incident Plan and Influenza Pandemic Plan).


2.7 CHIEF OPERATING OFFICER

The Chief Executive has appointed an Executive Team member who will have lead responsibility for all resilience arrangements within the organisation. The Chief Operating Officer is currently the nominated member, accountable to the Trust Board for producing and testing the business continuity arrangements. This plan will be reviewed regularly. All service divisions should be parties to the review and any amendments made.

The Chief Operating Officer will ensure that the Board is updated and informed on issues relating to Business Continuity and will support the nominated manager in the execution of their duties.

2.8 BUSINESS CONTINUITY MANAGER

The designated Business Resilience Manager is responsible for ensuring plans are updated, reviewed and distributed on a regular basis. This includes ensuring that the system and service plans link directly into the Trust’s other resilience arrangements and are also regularly updated and tested, and that new plans are developed as necessary to meet any newly identified risks and threats.

The Manager will be responsible for internal liaison and with other local and regional agencies to ensure that planned responses to business continuity incidents are coordinated and complementary.

The role involves arranging and coordinating the training necessary to ensure that staff across the Trust are aware of the response expected of them in the event of any service interruption. The Business Continuity Manager will also liaise with other local agencies in arranging inter-agency training exercises and ensure participation as required by Trust staff.

During an incident the Manager will be available to provide tactical or strategic guidance to senior management at the most suitable location.

2.9 NON-EXECUTIVE DIRECTOR

The Trust has designated a non-executive member of the Board to have an active oversight of all the resilience arrangements. The identified member receives regular briefings in respect of Emergency Planning and Business Continuity and would assume a community advisory role during any incident response.

2.10 TRUST STAFF

All members of staff are responsible for familiarising themselves with the business continuity arrangements and the required roles pertinent to their specific post or department. Trust Directors are responsible for ensuring that they have up-to-date cascade systems for staff in their Directorate. Individual members of staff who may be called upon during any incident are also responsible for reporting any change in their home address or telephone number to their head of department to enable out of hours contact lists to be maintained.

2.11 TRUST INCIDENT ROOMS

Details removed from public copy


2.12 FINANCIAL ARRANGEMENTS



Section 3 INVOCATION PROCESS 3.1 INVOKING OR INITIATING A BUSINESS CONTINUITY IN CIDENT

Minor service and business interruptions occur on a daily basis and are dealt with using normal services and resources. Bed Managers and Estates Department deal with service issues on a very regular basis. A business continuity incident will require to be declared when a possible serious threat to the Trust’s service provision is identified. A declaration will also ensure all staff are aware of a potential serious problem. The duty hospital manager will oversee any response to the incident once a confirmation is received that the incident cannot be dealt with at ward or departmental level. A possible trigger is that the departmental business continuity plan is unable to staff or resource the particular incident at Bronze level and further coordination and assistance is required at Silver level.

3.2 In the event of minor incidents or ones that can be resolved using normal services and resources the relevant manager or supervisor will deal with the affected service or area by referring to the operational business continuity plan if required. The role will include overseeing any departmental response and ensure a full decision making process to reduce impact along with keeping a full log of actions. The nature of the incident will affect the length of time it could take to recover ‘normality’. A localized flood may be resolved in a matter of hours but an extended cleanup take weeks. These issues could be the trigger for the incident to be escalated to the Silver level of incident management or even Gold.

3.3 All managers must ensure that health and safety leg islation is strictly adhered to and that staff welfare is considered par amount. Staff should not enter any area without a full briefing, training and correct personal protective equipment. Contractors may be required to deal with particular structural or ingress incidents prior to the re-entry of Trust staff.

3.4 If the incident cannot be suitably resourced using normal procedures and the criteria on escalation on the relevant business continuity plan and recovery are triggered then consideration must be given to declaring a Trust based major incident and immediate escalation invoked. It must be emphasised in all communications that this is a Barnsley Hospital Trust internal Major Incident but it may be necessary to inform our multi-agency partners particularly Yorkshire Ambulance Service, NHS Barnsley and Barnsley Metropolitan Borough Council.


3.5 On severe escalation the following procedure will be followed and reference made to the Trust Majax:

“Internal Major incident declared – activate plan” to indicate that the major incident plan should be activated.

“Internal Major incident stand down” when the major incident response is not longer required. This can follow either of the above alerting messages.

The main route by which Barnsley Hospital may be made aware of a serious or major incident will generally be via another agency usually but not exclusively Yorkshire Ambulance Service, in the case of a serious business continuity incident it will be via a Trust manager or supervisor. The procedures for notifying the PCT


and Hospital Senior Managers are outlined below. Hospital Switchboard are in possession of a current callout list and internal cascade matrix.

3.6 DURING OFFICE HOURS

During normal working hours, a member of staff (or other agency) declaring a potential incident should first contact Barnsley Hospital switchboard to ensure that the established internal cascade system is initiated.

The hospital switchboard staff will also alert the NHS Barnsley Duty Director and Emergency Planning Manager as soon as possible.

3.7 OUT OF OFFICE HOURS

Outside normal working hours, a member of staff (or other agency) that identifies a potential business continuity incident must contact the hospital switchboard and request the hospital senior manager and possibly the Duty Director be alerted.

3.8 COMMUNICATIONS FLOW

In the event of a Trust business continuity incident requiring any South Yorkshire response agency to either activate their incident plans or be on standby Yorkshire Ambulance Service will inform switchboard staff (or in reverse) and any cascade will be activated accordingly.


Section 4 INCIDENT RESPONSE 4.1 COMMAND & CONTROL – BUSINESS CONTINUITY INCIDENTS



Details removed from public copy Details removed from public copy Details removed from public copy


Section 5 TRUST MANAGEMENT RESPONSE

5.1 This plan provides a basic system for the Trust’s response to and the management

of the consequences of any business continuity incident that could affect the Trust’s ability to sustain both statutory requirements and day to day business continuity.

In tandem with this framework, a series of actions and strategies have also been developed to provide an underlying infrastructure to the plan, and ensure that distinct steps and actions are taken to manage and sustain a coordinated response to the incident. Each service area is finalising a business continuity plan that links with this document and this individual plan will be utilised as an anchor to further actions and possible escalation.

The principal actions and strategies that have a direct effect on the Trust’s ability to

manage a business continuity incident are outlined in this section.

The expected staff response, roles and recovery policies are outlined in detail in those plans.

5.2 MANAGING VISITORS Depending on the circumstances of any serious incident visitors may be restricted

access to certain areas of the building(s)

Also depending on further advice and information BHNFT may face the difficult decision to impose further restrictions or outright exclusion to the visiting of patients

This may be particularly relevant during any serious structural damage to the building.

5.3 STAFF LEVELS DURING RESPONSE PHASE

In order to manage the effects of the event it will be necessary for the Trust’s

Management Teams to adopt a command orientated management structure if essential services are to be sustained. Decisions may include: -

• Non-essential/non-critical services are discontinued

• Staff re-deployment to address any acute staff shortfall

• Staff displacement over an extended period whilst recovering and restoration takes place.

5.4 STAFF SKILLS AUDIT

To ensure that as an organisation the Trust utilises all the skills and abilities of staff to ensure that critical services are delivered working with the Electronic Staff Records (ERS) the Human Resources Department have developed an accurate database of all staff that includes: -

• Accurate staff information – including all contact details

• Staff information to include any previous skills and areas of working


• Accurate information as to current residential details and all means of transport into work. This information will support cross-tier decision-making regarding the utilisation of hospital based transport if it is required. A transport profile is also being conducted with a view to pooling coach transport between Trusts.

5.5 INDUCTION PROGRAMME

To ensure all staff are aware of the possible consequences of dealing with business continuity incidents and to be assured of staff and patient safety, the Emergency Planning Department, along with the Education & Learning Team have developed a be-spoke Trust awareness programme to address business continuity issue. This includes: -

• 2 hour statutory training – including Incident Response, Multi-agency Awareness, Business Continuity and Influenza Pandemic readiness

• An E-Learning Package – includes the principles of the Civil Contingencies Act 2004, Core & Supporting Responders, NHS Resilience and Business Continuity.

• Departmental, Senior Management & Board presentations and tabletop/team exercises

5.6 STAFF ISSUES DURING ANY SERIOUS INCIDENT During any serious incident including business continuity, staffing levels within

services are likely to be fluid. All staff are encouraged to consider their ‘family first’ commitments now and certainly prior to any incident response in line with central government’s ‘Preparing for Emergencies’ guidance.

5.6.1 ‘FAMILYFIRST’ ‘FamilyFirst’ is an encouragement for all staff to consider ‘Resilience at Home’ in

organising domestic circumstances now and therefore reducing stress and worry during the hospital’s response to serious incidents. By arranging care for their family members at an early stage either by contact with trusted relatives and carers or more formal arrangements the essential elements of anxiety can be reduced and confidence in attendance at work better assured. The Trust will assist and advise should further guidance be required.

5.7 RECOVERY PHASE – STAFF CONSIDERATIONS

The Trust recognises that during the response to a serious business continuity incident staff may have worked over contracted hours to ensure that our services are delivered. Hours worked above contracts will be paid as outlined within the Agenda for Change guidelines for over-time rates. Continuing the hospital’s core service provision is however paramount, and must not be compromised. During the management of a business continuity incident, consideration should be given to


planning current and subsequent staff rotas should the incident be ongoing for an extended period of time.

5.8 VOLUNTEERS

BHNFT makes a strong commitment to support and encourage the contribution volunteers make to the organisation recognising how they enhance and add value to the services and activities the Trust provides. This includes supporting the provision of services which are funded such as befriending and chaperone services. The ongoing arrangements with Trust volunteers are one of a composite set of strategies that underpin the Trust’s commitment to community Involvement in its services. Volunteers have a huge potential in providing a more flexible response during any serious incident, and can play a crucial role, providing mutual benefit to staff, volunteers and service users within the Trust.

5.9 Recognising the importance of volunteers, BHNFT is engaged with a large number of volunteers through the Voluntary Services Manager, to identify and develop a strategy with the Trust’s volunteers, for their continued support a number of crucial business areas. Our volunteers alongside PALS form an essential area critical to the Trust’s response to internal and external incidents

5.10 Business Continuity Management has enabled the creation of a prioritisation list of

the support delivered by volunteers. This list may be enhanced or suspended in the event of a serious business interruption due to volunteer availability. Areas subject of volunteer prioritisation will be:- • Continued non-clinical assistance to wards

• Assistance with communications teams

• Assistance with administration teams

5.11 Barnsley Hospital highlights the importance of volunteers by:- • Recognising that those who volunteer are a part of the service in which they

volunteer. Therefore, those who volunteer in the NHS become part of the NHS and they also become a member of the “NHS Volunteers”.

• Offering support and supervision to volunteers wherever the volunteer works

• Appropriately matching our volunteers and opportunities to ensure that volunteers are comfortable and confident to deliver their respective service.

These principles will continue to be applied to volunteers supporting the Trusts services throughout the period of response to any service interruption.


Section 6

COMMAND PRINCIPLES

6.1 A three tiered command and control structure, developed by the police service, known as 'Gold', 'Silver' and 'Bronze' reflecting the strategic, tactical and operational levels of management has been adopted by most responding agencies and private operators. For business continuity incidents within the Trust this will be based on an escalation principle.

6.2 BRONZE or OPERATIONAL – PERSONNEL IN WARDS/DEPA RTMENTS

Operational supervisors/managers within the Trust, who implement tactics, deploy resources and achieve the objectives of their service area. Due regard must be made to risk reduction methods and the health and safety of personnel. Based within or near to the affected service area.

On escalation to:

6.3 SILVER or TACTICAL – HOSPITAL INCIDENT MANAGER & TEAM Tactical managers provide an overall management of the

response by determining priorities, obtaining further resources, plan and coordinate the response. They are also responsible for assessing prevailing risks and managing those risks by taking the appropriate reduction methods and giving due regard to the health and safety requirements of staff and public.

On escalation to:

6.4 GOLD or STRATEGIC – CRISIS MANAGEMENT GROUP The strategic level of management establishes a

framework of policy within which tactical managers will work by establishing an overall management framework for the business continuity incident, determining and reviewing the strategic aim and objectives. This level of management also coordinates communication and media policy and ensures long term resourcing and expertise. It is essential to avoid engagement in details and decisions more properly managed at lower levels.

The type and scale of the incident will determine who should carry out these

functions, which are not RANK orientated but based on the ROLE and expertise of the individual. A major advantage of this is the ability to establish an instant framework of command that can be easily and immediately implemented without having to rely upon a prepared order or instructions, whilst allowing flexibility to change the personnel performing these roles. It is paramount that there is a clear understanding that the management levels do not necessarily predetermine the rank, or seniority of the individual discharging the functions.

It is characteristic of the command and control chain that it tends to be created

from the bottom up. At the start of any business continuity incident where there has been little or no warning, the 'Operational' level will be activated first, with the other levels coming into being with the escalation of the incident. It is possible that with


some incidents, particularly those where there is a threat of a potentially serious problem, the activation of the three levels will be concurrent. It should be noted that the Trust regularly refers to the Silver level of incident management without the need to establish the full response arrangements. Dependant on the type and seriousness of the incident the Silver team could work from any location, have flexible membership and meet only when required. Weather related incidents could dictate this style of operation. It is essential that all staff involved in the response are aware of this and have ready contact with the Hospital Incident Manager.

6.5 FINANCIAL ARRANGEMENTS



Section 7 STRATEGIC SUPPLIES AND SERVICES

7.1 SUPPLIES & CONTRACTS Supplies Department with the Trust Estates and Facilities team have assurance

arrangements that contracts with suppliers and providers of services to the organisation, have built in business continuity arrangements in the event of a prolonged response to a major incident. However this requires detailed examination and testing via table top-exercises to be completed in a partnership preparedness approach to sustaining critical supplies and service provision to the organisation. These issues are currently subject of an ongoing Business Impact Analysis & Service Prioritisation included in this Business Continuity Management System.

It is expected that all suppliers and contractors to the Trust will engage in a 2nd

level supply chain enquiry and all single points of failure will be identified and vulnerabilities addressed

7.2 MASS FATALITIES

The Department of Health, Home Office and Cabinet Office continues to review these issues nationally and issue guidance where appropriate. The Trust Business Continuity has addressed issues relating to a large number of deceased, transport and storage.


7.3 UTILITIES

The Estates and Facilities Department have established and tested procedures for the loss of electricity, water, vacuum and medical gases. These arrangements form part of their individual business continuity plans.

7.4 INFORMATION TECHNOLOGY & TELECOMS

Established disaster recovery and information technology resilience has been adopted by the Trust including the hardening of the IT and Telecoms infrastructure underground. A number of continuity incidents have previously tested arrangements that are included as part of the service area plans.


Section 8 MEDIA STRATEGY & COMMUNICATIONS 8.1 PUBLIC INFORMATION

During any serious service interruption or incident direct contact and interviews may be required with members of the media and other local representatives

8.2 The aim of these outputs will be to:-

• improve general awareness and understanding of any incident • re-assure patients, staff and the general public • the possible need to arrange alternative care and welfare • keep the area around the hospital clear of attendance and traffic • minimise impact on other service providers

8.3 Local messages should localise and reinforce any other given messages and

should be part of a joint media protocol with partner agencies and approved by the Hospital Crisis Management Group. The Hospital Communications Manager will be the liaison point for all public information and messages.

8.4 NHS BARNSLEY NHS Barnsley is a key stakeholder and can coordinate local communications

during any business continuity related healthcare issues. They can: • ensure that relevant messages are cascaded and reinforced • provide information to patients and public regarding any changes in primary and secondary care, including any local disruption to healthcare services • provide advice and information to staff, primary care contractors and other partners • collect, collate and disseminate information on the local health situation

8.5 REGIONAL COMMUNICATION

Links will need to be established with the Strategic Health Authority particularly if any service interruption affects the ambulance service or emergency care and treatment.

8.6 LOCAL INTERNAL INFORMATION

During the event of a serious business interruption, the internal communications mechanisms and role will be vital to the contribution of a well-informed staff. It is worth noting that any messages that are being publicised on local media will influence the attitude and perceptions of staff and therefore this will need to be monitored. Consideration must be given to regular briefings via the Incident Management Team (Silver) or Crisis Management Group (Gold).

8.7 Most importantly, regular and consistent updates will need to be circulated to staff

in an accessible manner. Ultimately, the line manager to employee relationship will become the key to successful communications in this situation particularly within any affected service area.


8.8 The key form of communication will be via the Trust email system and Intranet. This allows department specific information to be targeted to managers or matrons as appropriate. The requirement for a staff ‘dark site’ is currently under construction.

8.9 Barnsley Hospital email users will receive relevant email information, backed up by

all departments/wards/offices receiving printed bulletins if required. These bulletins will include: -

• An update on the situation affecting the Barnsley community

• An update on the Trust situation

• Information about whether elective procedures cancellations

• General patient care information

8.10 Every 24 hours the manager/matron or senior member of staff will be provided support in producing an area specific update, which will inform staff of:

• The situation of the specific area of service

• Possible changes in practice or duties in response to the situation/staffing levels.

• The projected likelihood of continuation of business (elective clinical areas)

• Other services within the Trust that are going to be discontinuing for a period due to any ongoing situation


Section 9 DEBRIEFING & RECOVERY

9.1 GENERAL INFORMATION

Following the response phase of a business continuity incident there will need to be a full review, detailed de-brief and evaluation of what worked well and what requires revision prior to any other incident response. It should be recognised that staff may have been working under considerable pressure during a serious business continuity incident which could involve work colleagues and will need to recover before they can return to full efficiency. Also members of staff may have been affected by the incident, either directly or through family and friends. Welfare support should be considered where appropriate. This support should have been provided during the main response phase and must be considered to be a continuation of that process.

9.2 EXIT STRATEGIES

An exit strategy is defined as a means of withdrawing from a given situation. During the initial phases of an incident and the first meetings of the Hospital Crisis Management Group an exit strategy needs urgently identifying and to be planned alongside the staff and service recovery issues. This strategy could entail equipment, staffing, resource considerations, specifications and key points for debrief and continuing organisational continuity. Any identified personnel could prove invaluable at any debriefs and a key resource for the Hospital Incident Management Team (Silver)

9.3 DEBRIEFING

Consideration must be given to debriefing relevant staff involved in the Trust’s response to an incident. This will identify lessons learnt, assist in adopting future good practice, highlight ‘near miss’ scenarios, validate planning considerations and secure resilient business continuity and recovery arrangements. Hot team debriefs should be held as soon as working arrangements allow, preferably within 14 days. A full major organisational debrief should take place within 6 weeks of stabilisation and a review report submitted with recommendations by the Business Continuity Manager for the attention of the Chief Executive as soon as practicable.


Section 10 GLOSSARY OF TERMS

Alert

A warning of a potential or imminent incident prior to it actually occurring

Alternate Site

See Standby Site

Back-up Generator

A source of power independent of the main electricity grid and which can be 'switched-in' to replace lost power supply. These generators can be purchased, leased or hired.

Backups

See data backup

BCP

See Business Continuity Planning

BC Manager

A role within the Business Continuity team to administer and maintain records, plans, actions etc. relating to the development of the BCP. This may be a seconded or recruited post, or may be amalgamated into the Head of Business Continuity depending on the size and complexity of your business, operation or business continuity plans

BC & EP Department

Headed by the Business Continuity Manager and including Emergency Planning this function is responsible for the production, testing and training of the BCP.

BIA & Service Prioritisation

See Business Impact Analysis

Business Continuity Management Committee (Emergency Planning Group)

Depending on the size and complexity of your business or business continuity plans you may decide to form a Steering Committee (called the BCMSC) to oversee the work of the Business Continuity Unit and any project management function you have created to ensure timely, cost effective and high quality output. This function is coordinated by the Trust’s Emergency Planning Group.


Business Continuity Management System

The organisation staff roles and responsibilities that will have to implement the Business Continuity Plan (see also Crisis Management Group)

Business Continuity Plan

The documents that provide a framework for dealing with an emergency, disaster or crisis. Developed at Ward/Department level.

Business Impact Analysis and Service Prioritisation

The Business Impact Analysis (BIA) identifies what would be the impact upon the organisation’s goals if critical processes and functions were disrupted or lost and what the recovery time scales and requirements are

Call Tree

An organisation chart indicating who contacts whom in the event of an emergency. Often represented as a tree structure or hierarchy chart.

Cascade Chart

See Call Tree

Category A

Definition of recovery requirements for a unit, function or department within the BCP, A represents those areas where there is No tolerance for disruption

Category B

Definition of recovery requirements for a unit, function or department within the BCP, B represents those areas where the requirement is for Resumption within 24 hours

Category C

Definition of recovery requirements for a unit, function or department within the BCP, C represents those areas where the requirement is for Resumption within 48 hours

Category D

Definition of recovery requirements for a unit, function or department within the BCP, D represents those areas where the requirement is for Resumption within one week

Category E

Definition of recovery requirements for a unit, function or department within the BCP, E represents those areas where the requirement is for Resumption after one week


Checklist

A common form of document that presents a set of issues to be addressed or to allow you to identify which issues have/have not been addressed

Cold Site

An expression often used in Business Continuity Planning for an alternative or standby site that can be called in to use when a BCP is invoked but must have the IT, telecoms, office facilities etc. installed at the time of invocation. Invariably this is a less expensive option than a warm or hot site where the IT, telecoms and office facilities are ready at all times.

Command Centre

Location where the Crisis Management Group will operate from in the event of the invocation of the Business Continuity Plan.

Contingency

Actions taken as part of risk management to be taken in the event of a disaster, emergency or crisis

Contingency Planning

Often used as an alternative name for Business Continuity Planning this is the process of defining and establishing the actions required by an organisation in the event of an emergency, disaster or crisis.

Crisis

A critical event that may have an impact on the business such as to significantly reduce its ability to operate, its reputation or its financial security

Critical Data

See Critical Functions

Critical Functions

Used to categorise those business units, activities or areas (or their data) that cannot be interrupted for a noticeable period without significantly affecting an organisation's ability to operate, its reputation or its financial security

Critical Infrastructure

Those systems or facilities that cannot be interrupted for a noticeable period of time without significantly affecting the organisation's ability to operate, its reputation or its financial security

Critical Systems

See Critical Infrastructure


Damage Assessment

An assessment by qualified professionals of the degree of damage to Critical Infrastructure following an incident. This will include an estimate of the time required to repair the damage and allow resumption of use of the facilities/infrastructure

Data Backup

The storage of critical and operational data to ensure that it is not lost in the event of a disaster, emergency or crisis.

Deliverables

Outputs from a project. In terms of Business Continuity Planning the principal outputs are the planning documents themselves, and the RIA and BIA that were carried out to arrive at the plan and implemented recovery facilities

Desk Check

A review or test of a plan by one or more people reading and discussing the contents of the plan. Possibly involving a discussion through a scenario and taking the invocation of the plan in a sequential order. See also Peer Review

Disaster 1

Any incident that causes a severe disruption to the working environment of a business or organisational unit, as defined by the facilities and personnel, which results in an inability to function or to provide service to internal or external customers

Disaster 2


Disk Mirroring

A technical IT process that allows data to be held concurrently on two separate physical units (potentially at different sites)

Document Registry

A list of all key documents within Business Continuity Planning including information such as location, authorship, date of last update etc.

Emergency


Emergency Operations Centre

See Command Centre


Evacuation Procedure

Instructions to staff of what to do in the event of a disaster, emergency or crisis.

Hazard Identification

See Risk Identification and Assessment

Head of Business Continuity or BC Manager

A high profile role to ensure that company, operation or site is well prepared and able to respond to both internal and external events and incidents which may impact on its continued business operations

Health Check

A document that enables you to test your own readiness to deal with a disaster and to identify key elements of business continuity and best practice.

Hot Site

An expression used in Business Continuity Planning for an alternative or standby site that can be called in to use when a BCP is invoked and already has the IT, telecom’s, office facilities etc. installed and available at the time of invocation. Invariably this is a more expensive option than a cold site where the IT, telecom’s and office facilities are must be installed when the plan is invoked.

Incident Command Centre

See Command Centre

Incident Management Team

The designated staff members who will lead the response in the event of an emergency, disaster or crisis and implement the Business Continuity arrangements. Within this team and reporting to it will be a range of other teams and function depending on the complexity of your business and business continuity plans.

Integrated Test

A test that is carried out across several if not all functions to test recovery of the en-to-end business processing

Interim Site

See Standby Site

Loss Reduction

See Mitigation


Mitigation

Action taken as part of risk management to reduce the likelihood and/or impact of a risk

Mock Disaster

See Scenario Testing

Objectives of BCP

Should include as a minimum I) Staff safety, welfare and internal communications, 2) Resumption of critical business functions, 3) Meeting contractual obligations, 4) Management of risk, 5) Maintenance of customer confidence and reputation, 6) Meeting all legal and regulatory requirements

Ownership

Ownership within Business Continuity Planning is a very important concept and must rest with the most senior management within an organisation.

Peer Review

Review of a part of the Business Continuity Plan by a group of staff to evaluate its likely effectiveness

PLAN-IT-CONTROL-IT

A resource or toolbox of documents that enables you to develop your own BUSINESS CONTINUITY PLANS by tailoring a series of plans, checklists, spreadsheets, report layouts, training guides, templates and forms

Project Structure

Projects should be divided into the following structure: Phases, then Activities within Phases, and Tacks within Activities

Quick Hits Document

A series of simple and easy to implement actions that if followed will allow a measure of control and containment in the event of an emergency, disaster or crisis.

Reciprocal Agreement

A procedure sometimes used by two or more comparable organisations (or units within the same organisation) to provide 'cover' for each other in the form of potential standby sites, data back-up etc.

Resumption

A measurement of how quickly a department, unit or area will need to be operating again in order to minimise the impact to the business


RIA

See Risk Identification and Assessment

Risk Identification and Assessment

Risk Identification and Assessment (RIA) is used to determine the internal and external threats that could cause loss or disruption and their likelihood of occurrence

Risk Register

Register of risks identified within RIA and determining likelihood, impact and actions to be taken.

Scenario Testing/Exercising

Testing of a Business Continuity Plan through a realistic feigned disaster, emergency or crisis. Staff act their roles as if a real emergency had occurred.

Standby Site

A location with contracted or prearranged facilities that can be used as an emergency location in to which to move key staff in order to resume some degree of trading. This standby site may be externally contracted or be another location within the organisation.

Supplier List

A register of all key suppliers identified from within the business as part of BIA and RIA, and detailing key information about each supplier on the supplier list. This will include contact details, owner within your organisation, extent of supplier BCP's etc.

Version Control

Information added to a document to allow the latest version/update to be identified. This should include version number and issue date.

Warm Site

A standby site which had facilities in place which are partly configured but which will need additional work following an incident to become fully operational. An intermediate state between a Cold Site and a Hot Site


Section 11

KEY CONTACT DETAILS Details removed from public copy


Section 12




Section 13

Reference Material & Bibliography

British Broadcasting Corporation (2003) Connecting In a Crisis, London: BBC Business Continuity Institute (2008) Good Practice Guidelines 2008-2, Camberley: BCI British Standards Institute (2006) BS 25999-1:2006 Business continuity management. Code of practice, London: BSI British Standards Institute (2007) BS 25999-2:2007 Business continuity management. Specification, London: BSI British Standards Institute (2008) BS 25777:2008 Information and communications technology continuity management. Code of Practice, London: BSI Cabinet Office (2005) Emergency Response & Recovery Guidance on response to and recovery from emergencies: the replacement for ‘Dealing with Disaster’, London: Civil Contingencies Secretariat Cabinet Office (2005) Emergency Preparedness Guidance on Part 1 of the Civil Contingencies 2004, its associated Regulations and non-statutory arrangements, London: Civil Contingencies Secretariat Cherry, D. (2008) An informal report on current major incident requirements, Barnsley: Barnsley Hospital Department of Health (2005) The NHS Emergency Planning Guidance, London: Department of Health Department of Health (2005) Critical Care Contingency Planning in the event of an emergency where the numbers of patients substantially exceeds normal critical care capacity, London: Department of Health Department of Health (2007) A national framework for responding to an influenza pandemic, London: Department of Health Department of Health (2007) Guidance on preparing acute hospitals in England, London: Department of Health Department of Health (2007) Strategic Command Arrangements for the NHS During a Major Incident, London: Department of Health Department of Health (2007) Core elements, Health Building Note 00-07: Resilience planning for the healthcare estate, London: Department of Health Department of Health (2007) Mass Casualties Incidents – A Framework for Planning, London: Department of Health Department of Health (2008) Human resources guidance for the NHS, London: Department of Health


Department of Health (2008) Pandemic influenza: Guidance for infection control in critical care, London: Department of Health Department of Health (2008) Pandemic Influenza: Guidance on preparing maternity services in England, Draft for comment, London: Department of Health Department of Health (2008) Resilience and business continuity management guidance 2008, Interim strategic national guidance for NHS organisations, London: Department of Health Department of Health (2009) Planning for the evacuation and sheltering of people in health sector settings: Interim strategic national guidance, London: Department of Health Hall, P. (2004) South Yorkshire Inter-Agency Media Plan, Sheffield: South Yorkshire Media Forum Home Office (1999) Bombs, Protecting People and Property, London: Home Office Communication Directorate Home Office (1999) Business as Usual. Maximising business resilience to terrorist bombings, London: Home Office Communication Directorate Home Office (2003) Dealing with Disaster (Revised Third Edition), Liverpool: Brodie Publishing Home Office (2003) Dealing with Fatalities During Disasters, London: HMSO Joint Standards Australia/Standards New Zealand Committee (2004) Risk Management and Risk Management Guidelines, Sydney/Wellington: Standards Australia/New Zealand Royal Society Report (1992) Risk Analysis Perception and Management, London: The Royal Society


SECTION B

DEPARTMENTAL BUSINESS CONTINUITY

PLANS

For a serious Business Continuity Incident consider

immediate escalation


Departmental Plans

The Trust’s departmental and service area business continuity plans are currently under preparation and will be reviewed by the Trust Board in November 2009.


APPENDIX A

Business Continuity Management Strategy Service Prioritisation Matrix

Interview ................................... Service Area(s) ................................ .......... Time/Date ........................................ .....

Service Impact Analysis Score 1. How would an immediate closure/loss of service impact on human

welfare?

• Seriously

• Moderately

• Minor

• Little or None

2. Following a loss of service what are the timescales before a

substantial impact is felt?

• Immediately

• 2 hours

• 8 hours

• 24 hours

• 7 days

• Longer than 7 days

3. Does the particular service area work on Christmas Day? 4. The consequences if the service area loses power at 2pm Monday to

Friday?

• Serious

• Moderate

• Slight

• None

5. The consequences if the service area loses power at 2am?

• Serious

• Moderate

• Slight

• None

6. The consequences if the service area loses power during the

weekend?

• Serious

• Moderate

• Slight

• None


7. What would be the economic impact to the Trust of a loss of the

service area?

• Serious

• Moderate

• Slight

• None

8. What would be the reputational impact to the Trust of a loss of the

service area?

• Serious

• Moderate

• Slight

• None

9. What would be the environmental impact to the Trust of a loss of the

service area?

• Serious

• Moderate

• Slight

• None

10. Would a loss of the service area have a statutory or legal impact to

the Trust?

11. Would a loss of the service area have a regulatory/standards impact

to the Trust?

12. Comments...


APPENDIX B

Business Continuity Management – Operational Planni ng

Lead Director – Business Continuity David Peverelle – Chief Operating Officer

Trust Service Area:

Location(s):

Service Priorities:

Impact of general loss of service to patients, staff, the Trust:

Plan Owner:

Deputy/BC Champion:

Business Continuity Manager: Mike Lees X2310 Completion Date:

Return by:

Checked by:

Date:


How to complete the plan : To ensure that the Trust has a workable business continuity strategy it is recommended that time is allotted to complete the sections and there is an active dialogue with all staff to ensure feedback on the planning process.

1. Consider the list of possible disruptions to service and add others you may believe relevant

2. How would that particular disruption impact on the individual service area?

3. Plot each disruption against the 3 ‘Ss’ a. STAFF, b. SPACE (patient and workplace), c. SUPPLIES (medical, gases, consumables etc)

4. Once plotted, actions to resolve issue? STAFF - Call in other staff, arrange cover etc. Consider such issues as contact lists for staff, the time to attend and method of travel to work. SPACE - What possible alternative locations would be available as space for patients or workplace space for staff? SUPPLIES– IT, telephones, electricity, water, gases, suction, medical supplies etc. How would the loss or shortage be resolved in the short term? Plan to recover your service with associated timesc ales. State what gaps or vulnerabilities are exposed by the process, how they can be addressed and any resourcing implications. Strict return by the stated date.


Type of disruption/event

Impact on Trust of this disruption/event

Impact on this service area of this disruption/even t

Risk rating of this event

Planning assumptions of this event

INITIAL ACTIONS DURING EVENT

COMMUNICATIONS & MANAGEMENT CONTACTS Detail trigger points for events and list management contacts

ACTIONS IN RELATION TO STAFF Include details of contact lists held and the communications process with members of staff.

ACTIONS IN RELATION TO SPACE Include details of accommodation for patients, visitors and staff


workplace areas.

ACTIONS IN RELATION TO SUPPLIES & SERVICES Include details of supply lines and actions following loss of service or utility.

PLANNING VULNERABILITIES & GAPS

REMEDIAL ACTIONS

OTHER ACTIONS/COMMENTS


APPENDIX C

Barnsley Health Sector – Emergency Planning – Risk Assessment

April 2009

This Risk Assessment has been carried out in compliance with the provisions of the Civil Contingencies Act 2004 and the Civil Contingencies Act 2004

(Contingency Planning) Regulations 2005. Account has been taken of the South Yorkshire Local Resilience Forum, Community Risk Register.

Barnsley Hospital Trust & NHS Barnsley – Emergency Planning – Risk Assessment is documented at Table 1 below. The purpose of this Risk

Assessment is to identify possible hazards which could impact on the communities of Barnsley, and thereby inform contingency planning arrangements.

It is not an exhaustive list of every conceivable event, rather it is those events which would constitute an “Emergency” for Barnsley Health Sector within

the meaning of the Civil Contingencies Act. It also concentrates on events that remain within our functions to act in order to prevent, reduce, control or

mitigate the effects of that event. It includes some events, which may not occur in Barnsley, but could nevertheless have an impact on local people or

organisations, such as an interruption to international oil supplies.

“Overall Risk” ratings for each type of hazard are given in the Risk Assessments listed below. This is obtained by multiplying ratings for impact (Table 2)

and likelihood (Table 3) together to produce an “Overall Risk” rating as shown in Table 4. These ratings are in accordance with national guidelines, NB

descriptions of the potential scale of each hazard are not predictions relating to particular incidents or sites, but indicate the potential maximum scale of

problems relating to that hazard.



Table 1

No. Hazard Description Control Measures Impact Like lihood Risk rating

1

Influenza pandemic – Potential for loss of life or illness. Increased demand for all NHS services. Numbers of staff affected and unable to attend work. Disruption to other services and supply chain.

Pandemic Flu Plan

Business Continuity Strategy

Staff awareness & training

Vaccination against seasonal flu

Vaccination for poultry workers

Significant Possible Very High

2

Zoonotic notifiable animal disease, such as Highly Pathogenic Avian Influenza, Anthrax – potential for human infection causing increased demand for NHS services

Mass Treatment Plan

Pandemic Flu Plan


Vaccination for poultry workers

Minor Rare Low

3

Infectious disease outbreak – deliberate or naturally occurring. Potential for loss of life or serious illness. Possible long term health consequences. Increased demand on all NHS services

Major Incident Plan

Mass Treatment Plan Significant Rare High

4

Unplanned closure of hospital – potential evacuation of in-patients. Need to transfer A & E services to other locations. Cancellation of routine activities


Major Incident Plans Significant Rare High

5 Staff assault – includes hostage taking. Potential injury and distress to staff. Disruption to activities

Security procedures

Staff awareness and training Minor Rare Low

6 Employee shortage – Disruption to all activities, financial implications to BHNFT / partners / service providers


H.R. Policies

Mutual Aid agreements

Significant Unlikely Very High


7

Industrial Action – internal, potentially reducing numbers of staff at work or external affecting service providers. Both have the ability to disrupt our normal service provision


Agenda for Change Significant Unlikely Very High

8

Damage or loss of building – deliberate or accidental, caused by structural failure, fire or flood etc. Short or long term disruption to service and displacement of staff. Potential for loss of life or injury to staff and patients


Estate policies

H & S fire drills

Moderate Negligible Medium

9

Failure of Utilities (electric, gas, water, telecoms) – Potential disruption to all service activities with financial implications to BHNFT / partners / service providers. Damage to infrastructure, equipment.


Estates policies Moderate Possible High

10

Internal I.T.C. failure – Potential to disrupt all service activities with financial implications and impacts on the health of the community


I.T.C. procedures Minor Possible Medium

11

Supply chain failure – failure on the part of our partners or suppliers can disrupt our own service and impact on the health of the community


Suppliers BCP Plans

Contracts with suppliers

Moderate Rare Medium

12

Fuel shortage – Potential disruption to all activities with staff not being able to get to work. Restrictions on transport for GP’s, District Nurses etc affecting community care


Fuel planning arrangements Moderate Unlikely High

13 Fraud – Potential to cause financial loss to BHNFT / partners / service providers and loss of business

SMS & Fraud procedures

Security procedures Moderate Rare Medium


14

Storms & Gales – Potential for loss of life or injury. Structural damage to estates and facilities. Disruption to all activities. Adverse effects on transport and other services.

Met Office Severe Weather Warning Service

Internal communications


Minor Possible Medium

15

Low temperatures & Heavy snow – Potential for loss of life or injury. Disruption to all activities. Adverse effects on transport and other services. Numbers of staff unable to attend work.

Winter Plan & leaflets




Minor Possible Medium

16 Heatwave – Potential for loss of life or injury. Increased demand for primary care services.

Heatwave Plan Moderate Unlikely High

17

Flooding / inundation – Potential for illness or injury. Damage or loss of buildings. Disruption to all activities. Adverse effects on transport and other services. Numbers of staff unable to attend work.




Significant Possible Very High

18 Drought – Potential for increased disease. Disruption to routine services.




Minor Rare Low

19

Major transport incident – road, rail or air. Potential for loss of life or serious injury. Possible long term demand for health care. Disruption to transport networks and services

Major Incident Plan Moderate Rare Medium


20

Fire or explosion – deliberate or accidental. Potential for loss of life or serious injury. Possible long term demand for health care for blast or burn injuries

Major Incident Plan Significant Rare High

21

Toxic chemical release – deliberate or accidental. Potential for loss of life or serious illness. Possible long term health consequences. Increased demand on all NHS services

Major Incident Plan Significant Rare High

22

Radiation release – deliberate or accidental from incorrectly handled or disposed of sources. Potential for loss of life and long term health consequences. Long term contamination of affected area

Major Incident Plan Significant Negligible Medium


Table 2

Impact scoring scale – qualitative measures Level Descriptor Categories of Impact Description of impa ct

Health Insignificant number of injuries or impact on health

Social

Insignificant number of persons displaced and insignificant personal support required

Insignificant disruption to community services, including transport services and infrastructure

Economic Insignificant impact on local economy

1 Insignificant

Environment Insignificant impact on environment

Health Small number of people affected, no fatalities, and small number of minor injuries with first aid treatment

Social

Minor damage to properties

Minor displacement of a small number of people for up to 24 hours and minor personal support required

Minor localised disruption to community services or infrastructure for up to 24 hours

Economic Negligible impact on local economy and cost easily absorbed

2 Minor

Environment

Minor impact on environment with no lasting effects


Health Sufficient number of fatalities with some casualties requiring hospitalisation and medical treatment and activation of MAJAX procedures in one or more hospitals

Social

Damage that is confined to a specific location, or to a number of locations, but requires additional resources

Localised displacement of up to 100 people for 1–3 days

Localised disruption to infrastructure and community services

Economic Limited impact on local economy with some short-term loss of production, with possible additional clean-up costs

3 Moderate

Environment Limited impact on environment with short-term or long-term effects

Health

Significant number of people in affected area impacted with multiple fatalities, multiple serious or extensive injuries, significant hospitalisation and activation of MAJAX procedures across a number of hospitals

Social

Significant damage that requires support for local responders with external resources

100 to 500 people in danger and displaced for longer than 1 week. Local responders require external resources to deliver personal support

Significant impact on and possible breakdown of delivery of some local community services

Economic Significant impact on local economy with medium-term loss of production

Significant extra clean-up and recovery costs

4 Significant

Environment

Significant impact on environment with medium- to long-term effects


Health Very large numbers of people in affected area(s) impacted with significant numbers of fatalities, large number of people requiring hospitalisation with serious injuries with longer-term effects

Social

Extensive damage to properties and built environment in affected area requiring major demolition

General and widespread displacement of more than 500 people for prolonged duration and extensive personal support required

Serious damage to infrastructure causing significant disruption to, or loss of, key services for prolonged period. Community unable to function without significant support

Economic Serious impact on local and regional economy with some long-term, potentially permanent, loss of production with some structural change

Extensive clean-up and recovery costs

5 Catastrophic

Environment Serious long-term impact on environment and/or permanent damage

It should be noted that where the descriptor “insignificant” or “minor" is used, this refers to the level of impact on an overall basis. It is not intended to diminish the scale of any impact on the lives of individuals.


Table 3 Likelihood scoring scale Level Descriptor Likelihood over 5 years Description of L ikelihood over 5 years

1 Negligible Estimated at 0.005% It is a conceivable but highly remote possibility

2 Rare Estimated at 0.05% No significant incidents of this type have occurred in South Yorkshire, but it is capable of happening

3 Unlikely Estimated at 0.5% Has occurred in South Yorkshire and is capable of happening again

4 Possible Estimated at 5% Has occurred on multiple occasions in South Yorkshire and is capable of happening again

5 Probable Estimated at 50% Has occurred on multiple occasions in South Yorkshire and is expected to occur in the future.


Table 4

Cat

astr

ophi

c

Overall Risk Rating

Very High

Sig

nific

ant

High

Mod

erat

e

Medium

Min

or

Low

Insi

gnifi

cant

Negligible Rare Unlikely Possible Probable

I

mpa

ct

Likelihood

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