CENTRAL ALERTING SYSTEM (CAS) POLICY
DOCUMENT CONTROL:
Version: 4
Ratified by: Risk Management Sub-Group
Date ratified: 27August 2013
Name of originator/author: Head of Health Safety & Security
Name of responsible committee/individual:
Risk Management Sub-Group
Date issued: 11 September 2013
Review date: August 2016
Target Audience Directors, Assistant Directors, Chief Pharmacist and
Medical Director, and other staff with responsibility for identifying the relevance of alerts to their services, taking action and providing assurance for monitoring purposes.
CONTENTS
SECTION PAGE
1. INTRODUCTION
1.1 Definitions
2. PURPOSE
3. SCOPE
4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES
4.1 Chief Executive
4.2 Director of Performance and Assurance 4.3 Directors and Assistant Directors
4.4 Nominated CAS Liaison Officer (Head of Health Safety & Security) 4.5 Nominated Managers
4.6 Chief Pharmacist 4.7 All Staff
5. PROCEDURE/IMPLEMENTATION
5.1 Categories of Alerts 5.2 Action Deadlines
5.3 Safeguard Risk Management Web Alert Module (The Alert Module) 5.4 Dissemination
5.5 Action Required by Managers 5.6 Reminders of the deadline 5.7 Action Upon Completion
6. TRAINING IMPLICATIONS
7 MONITORING ARRANGEMENTS
8. EQUALITY IMPACT ASSESSMENT SCREENING
8.1 Privacy, Dignity and Respect 8.2 Mental Capacity Act
9. LINKS TO ANY ASSOCIATED DOCUMENTS
10. REFERENCES
11. APPENDICES
App. 1 Safeguard Risk Management Web Alert Module User Guide App. 2 CAS Process Flow Chart
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1. INTRODUCTION
The Department of Health (DoH) Central Alerting System (CAS) is a web-based system for issuing patient safety alerts and other critical safety guidance to the NHS and other health and social care providers.
The CAS was introduced in September 2008 and brought together the Chief Medical Officer (CMO) Public Health Link (PHL), the Safety Alert Broadcast System (SABS) and the Electrical Safety Notifications systems to provide a robust and streamlined means of distributing safety alerts to the NHS and other health and social care providers, with the potential to expand as needs arise. It enables alerts and urgent patient safety specific guidance to be accessed at any time and communicates vital information to Trusts to enable them to take action to improve safety.
The alerts are based on national learning and issued in areas of great risk, indicating where practices should be stopped or modified, or medical devices withdrawn. They are a critical tool in the delivery of safe care.
While not exactly safety outcomes in themselves, implementation of these alerts, where relevant, will help prevent potential adverse outcomes for patients in the future.
Safety alerts, emergency alerts, drug alerts, Dear Doctor letters and Medical Device Alerts are available on the CAS website. They are issued on behalf of the Medicines and Healthcare products Regulatory Agency, the National Patient Safety Agency, DH Estates & Facilities and the Department of Health. The alerts are given timescales for Trusts to acknowledge and respond to electronically, and require Trusts to establish effective internal procedures for addressing the requirements.
1.1 Definitions
THE DEPARTMENT OF HEALTH (DH)
The Department of Health is accountable to the public and the Government for the overall performance of the NHS, adult personal social services and the work of the Department itself. The Department itself does not directly deliver healthcare and social care services to the public. Instead the Department works, at both a national and a regional level, with many different external partners: other government departments, the NHS, local authorities, arm’s length bodies and other public and private sector organisations.
THE NATIONAL PATIENT SAFETY AGENCY (NPSA)
The National Patient Safety Agency (Part of the NHS Commissioning Board Special Health Authority) are an Arm’s Length Body of the Department of Health and lead and contribute to improved, safe patient care by informing, supporting and influencing organisations and people working in the health sector. They have developed the following four formats to disseminate its advice and solutions to NHS staff:
THE MEDICINES AND HEALTHCARE PRODUCTS REGULATORY AGENCY (MHRA)
The Medicines and Healthcare products Regulatory Agency (MHRA) is the executive agency of the Department of Health charged with protecting and promoting public health and patient safety by ensuring that medicines,
healthcare products and medical equipment meet appropriate standards of safety, quality, performance and effectiveness, and that they are used safely. NATIONAL REPORTING AND LEARNING SYSTEM (NRLS)
The National Reporting and Learning System (NRLS) is a central database of patient safety incident reports. Since the NRLS was set up in 2003, over four million incident reports have been submitted. All information submitted is analysed to identify hazards, risks and opportunities to continuously improve the safety of patient care.
MEDICAL DEVICES
Medical devices and equipment are items used for the diagnosis and/or
treatment of disease, for monitoring patients, and as assistive technology. This does not include general workshop equipment such as power or machine tools, or general purpose laboratory equipment. Examples of medical devices can be found in the Trust’s Medical Device Management Policy.
MEDICAL DEVICE ALERTS (MDAS)
Medical Device Alerts (MDAs) are the Medicines Healthcare products
Regulatory Agency (MHRA) prime means of communicating safety information to medical device users in health and social care.
MEDICAL DEVICE LIAISON OFFICER (MDLO)
MDLOs encourage and train staff and users to report adverse incidents. CAS LIAISON OFFICER (CASLO)
The CAS Liaison Officer performs an important risk management role by disseminating safety alerts and completing electronic feedback forms to acknowledge alerts and indicate, where relevant, what action has been taken. PATIENT SAFETY ALERT (PSA)
Requires prompt action to address high risk safety problems. SAFER PRACTICE NOTICE (SPN)
Strongly advises implementing particular recommendations or solutions. DH ESTATES AND FACILITIES ALERTS (EFA & EFN)
A prime means of communicating safety information relating to non-medical equipment, engineering plant, installed services and building fabric.
PATIENT SAFETY INFORMATION (PSI)
Suggests issues or effective techniques that healthcare staff might consider to enhance safety.
RAPID RESPONSE REPORT (RRR)
May require prompt action or raise awareness of a current issue for which there may not currently be an identifiable resolution.
2. PURPOSE
The purpose of this policy is to set out the Trusts arrangements for managing the risks associated with safety alerts issued by the CAS. As such, it supports the implementation of the Trust’s Risk Management Framework.
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guidance, being aware of the safety issues that might emerge and making the safety of patients an integral part of everything they do.
The policy sets out procedures for responding appropriately to, and monitoring action on alerts issued through the CAS within the defined timescales.
3. SCOPE
The policy applies to alerts issued through the CAS. It applies to all staff and departments throughout the Trust, and identifies key staff with specific duties and responsibilities.
4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES
4.1 Chief Executive
The Chief Executive is accountable for the Trust having the necessary management systems in place for CAS alerts, including the nomination of a responsible Director.
4.2 Director of Performance and Assurance
The Director of Business Assurance is the nominated Director responsible for the implementation and monitoring of the CAS Policy including the nomination of a CAS Liaison Officer to support the Trust to comply with the required standards.
4.3 Directors and Assistant Directors
Directors and Assistant Directors are responsible for; • The processing of CAS Alerts within their service
• Nominating a suitable manager within their services to receive CAS alert notifications from the CAS Liaison Officer via the Safeguard Alerts Module.
• Allowing the nominated managers the authority to take the required action as stipulated within the CAS Alert
• Following up and managing the occasions when the Nominated Manager fails to respond to an alert notification within the given time frame.
4.4 Nominated CAS Liaison Officer (Head of Health Safety & Security)
The Head of Health Safety & Security is the nominated CAS Liaison Officer and is responsible for:
• Receiving the CAS alerts and acknowledging them on the CAS website • Logging all alerts on the Safeguard Alerts Module
• Assessing the relevance of alerts - seeking guidance where required - and distributing them via email to the relevant managers with a request for a response within the identified timeframe
• Maintaining accurate and timely records of dissemination and response • Monitoring the responses to CAS alerts within the required time frame • Sending a reminder for a response where a response has not been
received within the identified timeframe
response
• Updating the CAS website within the Action Complete required deadline • Producing a monthly monitoring report for the Health, Safety & Security
Forum
• Producing a monthly monitoring report for commissioners
• Arranging training programs on the use of the Safeguard Alerts Module web interface as required.
Some of this function may be delegated to a member of the Safety Team.
4.5 Nominated Managers
Managers nominated to receive the CAS Alert notifications are responsible for: • Implementing and monitoring the CAS policy within their services
• Receiving alerts and deciding as appropriate whether any further dissemination is necessary
• Accessing and completing the relevant sections of the Safeguard Alert Module web interface
• Providing a single completed response on behalf of their service to the Head of Health, Safety & Security within the required timeframes • Having in place a robust monitoring process and evidence of action
plans and their completion per each relevant alert available to feed into the Alert Module.
• Evidence of compliance with the relevant standards set out within alerts being available for monitoring purposes
• Making all staff both current and new aware of their responsibilities in relation to CAS Policy
• Making sure that any bank/agency or other contractors working for the Trust under their jurisdiction, are aware of their requirements in relation to the CAS Policy
4.6 Chief Pharmacist
The Chief Pharmacist are responsible for:
• Receiving alerts relating to medicines and drugs and decide as appropriate whether any further dissemination is necessary • Taking any further action to ensure the effective dissemination of
information to medical, prescribing and pharmaceutical staff
• Accessing and completing the relevant sections of the Safeguard Alert Module web interface
• Providing a single completed response on behalf of their service to the Head of Health, Safety & Security within the required timeframes • Having in place a robust monitoring process and evidence of action
plans and their completion per each relevant alert available to feed into the Alert Module.
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• Making all staff both current and new aware of their responsibilities in relation to CAS Policy
• Making sure that any bank/agency or other contractors working for the Trust under their jurisdiction, are aware of their requirements in relation to the CAS Policy
4.7 All Staff
All staff where appropriate will be are aware of their responsibilities in relation to the CAS Policy and act accordingly:
• On receipt of an alert, they take the necessary actions within the
required timeframes and submit responses via the identified processes • Inform managers where any gap in knowledge or skills are identified in
relation to the CAS Policy or specific alerts
5. PROCEDURE/IMPLEMENTATION
When a new alert is added to the (CAS) web page, an e-mail notification is also sent to the Safety Team for the nominated Trust CAS Liaison Officer (the Head of Health, Safety & Security).
Following the e-mail notification of a new alert, the Safety Team member accesses the CAS web page, using a dedicated user name and password where the full alert can be viewed and downloaded.
Upon receiving the alert, the Safety Team member sends an electronic acknowledgement of receipt back to the DoH through the CAS web page. The Trust has a specified time frame in which to assess the relevance of the alert and decide on the appropriate course of action identified on the alert.
5.1 Categories of Alerts
Immediate action: used in cases where there is a risk of death or serious injury and where the recipient is expected to take immediate action
Action: used where the recipient is expected to take action on the advice where necessary, to repeat warning on long standing problems, or support or follow-up manufacturer’s modifications
Update: used to update the recipient about previously reported incidents or series of incidents and where further follow-up safety information is judged to be beneficial
Information Request: used to alert users to specific issues that may become a problem and where the DoH requests feedback information.
5.2 Action Deadlines
All CAS alerts are issued with action deadline requirements which relate to the seriousness of the identified safety issue. The Trust is responsible for updating the CAS website in relation to all action deadlines.
Action underway: at the time of acknowledgment of the alert the Trust registers that it is assessing relevance, after it has been established the Trust is responsible for the issues raised. Deadlines are set by the DoH for this part of the process.
Action completed: the date the DoH requires the Trust to have had completed any necessary action.
5.3 Safeguard Risk Management Web Alert Module (The Alert Module)
All the alerts are entered onto the Alerts Module by the Safety Team, with a short summary of the issue and action required, as well as web links to the relevant CAS online pages.
5.4 Dissemination
The Safety Team assesses the relevance of the alert to the Trust, and sends a notification to the nominated managers in the areas that the alert is relevant to. This enables the managers to investigate and assess the implications within their services.
If the Safety Team are unable to identify whether an alert is relevant or not, the alert is sent to all nominated managers to ensure any areas of concern are identified.
5.5 Action Required by Managers
Nominated managers receive the alert via email and are to;
Examine the information provided on the alert and decide if the alert is relevant to their area, obtain further information to ascertain if the alert is relevant, or begin to implement the action required to comply with the alert if it is relevant. This is to be completed within the specified timeframe (see Appendix 2 flow chart as a guide).
The manager should oversee the action being taken, and report via the alerts module that the alert is not applicable, the action is underway and/or the action is complete.
5.6 Reminders of the deadline
Two weeks before the deadline, or less for shorter action periods, the Safety Team will issue a reminder to all managers who have not responded via the Alerts Module.
Non-responses following the deadline will be escalated to the relevant Assistant Director / Head of Business Support and reported to the Health, Safety & Security Forum.
5.7 Action Upon Completion
The Head of Health, Safety & Security, through the CAS web page, notifies the Department of Health of actions completed or non-applicability of the alert to the Trust. The response from the Trust is recorded against the particular alert on a Trust specific page on the CAS web site.
6. TRAINING IMPLICATIONS
There are no specific training needs in relation to this policy, but the following staff will need to be familiar with its contents:
All Nominated Managers and managers responsible for safety and any other individual or group with a responsibility for implementing the contents of this policy).
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covers. Staff can be made aware through a number of means such as
newsletters, team briefings and associated training programs such as Health & Safety & Security.
7. MONITORING ARRANGEMENTS
Area for
Monitoring How Who by Reported to Frequency
KPI - Completeness of record of external monitoring
Monitoring report
Head of Health, Safety &
Security
Commissioners Monthly
Compliance with Timeframes
Monitoring report
Head of Health, Safety & Security Assistant Directors and Heads of Business Support, and bi-monthly to Health, Safety & Security Forum Monthly and bi-monthly
8. EQUALITY IMPACT ASSESSMENT SCREENING
The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website click here
8.1 Privacy, Dignity and Respect
The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, ‘not just clinically but in terms of dignity and respect’.
As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if
relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex
accommodation is provided).
Indicate how this will be met
No issues identified
Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to
participate in the decision making process.
Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court
Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible.
Indicate How This Will Be Achieved
No issues identified
9. LINKS TO ANY ASSOCIATED DOCUMENTS
Risk Management Framework
10 REFERENCES
CAS can be found at https://www.cas.dh.gov.uk/Home.aspx
Medicines Healthcare Products Regulatory Agency http://www.mhra.gov.uk National Patient Safety Agency http://www.npsa.nhs.uk
11 APPENDICES
App. 1 Safeguard Risk Management Systems Web Alert Module User Guide
Appendix 1
Safeguard Risk Management Systems
Web Alert Module
Contents
1. Introduction ... 13
2. The Alerts Module ... 14
2.1. Alerts main window ... 14
2.2. Filter Overview ... 14
2.3. The Alert List ... 15
3. The “Tree Structure” ... 16
3.1. Tree Structure ... 16
3.1.1. Orientation within the Tree View - Distributions ... 17
3.1.2. Orientation within the Tree View - Actions ... 17
3.3. Explanation of Icons ... 19
4. The Alert Tabs ... 20
4.1. Details ... 20
4.2. Distribution (How to distribute/cascade Alerts) ... 20
4.3.1. Adding your Actions (upwards to your sender) ... 23
4.3.2. Adding Actions (downwards to your recipients) ... 23
5. The Filters ... 25
6. The Progress Bar ... 26
7. Creating Filters (Supervisor only) ... 27
PROCEDURAL DOCUMENT CHECKLIST AND TRACKING DOCUMENT ... 30
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Introduction
The Safeguard Web Alerts module is designed for staff involved in responding to Alerts of all types, whether from CAS, dissemination of NICE guidance or other documentation. As well as documenting their own response, alerts can be cascaded to other staff within the organisation where appropriate. Where an alert is cascaded, the system manages the responses for each subsequent recipient and it enables the sender to track where they are waiting for responses, or where all responses are received at all levels.
The system is also installed with automatic email reminders. This means that when the user cascades information downwards, target dates for response are also given. Once those dates pass without response, the system automatically sends out email reminders. When you first log on to Safeguard click on “Alert” to go to the Alerts web form.
1.
The Alerts Module
2.1. Alerts main windowThe main Alert window is split into two panels. To the left is a “tree view” of the alerts that have been sent to you. To the right is either the alert list, or the selected alert record. Note that the right hand panel is empty to start with, until the user selects to view an individual alert, or to see the whole alert list.
The tree view, described in more detail later in this document, provides an overview of the number of records outstanding, and an “at a glance” view of where the user is with each alert.
2.2. Filter Overview
The filter (Open Actions is selected below) changes the tree view and by default there are the options of:
- Open Actions
A list of alerts where some Action needs to be taken and it is still ongoing - Closed Actions
A list of alerts where some action had to be taken, that action was taken (even if just “No Action”) and the alert is now closed
- Information Only
A list of alerts that were sent to the user for “information only” and no action had to be taken apart from acknowledgement
- Copy & BCC
A list of alerts that were sent to the user as “copy”, no action or
acknowledgement was required. This would be for higher level managers. As indicated above, these options reflect the user’s role within the alert and whether any action was required, or the user was sent it just for information. In addition, the system supervisor can set up additional filters and this is explained in more detail later in the document.
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2.3. The Alert List
To see a list of Alerts on the right hand screen, select the top item of the tree “Alerts: (Click for table of Alerts)”
Click on a row in the Alert list to show the details of the alert record on the right side of the screen, or select the alert from the tree view.
2.
The “Tree Structure”
3.1. Tree StructureBy drilling down within the tree view the user can see who they have cascaded the alert to, and in turn whether that recipient forwarded the alert. The trail can be followed downwards as far as it goes, and the user can see the activity and actions recorded for all users further down the line from their initial cascade.
Click on the plus sign to open up the tree.
The tree opens and shows the distribution lists and the status of the people that have been cascaded onwards from the user. The red triangle on record number “CEM/CMO/2009/15” comes from the Windows system where the central administrator may want to draw user’s attention to a specific record. A tooltip is shown if the cursor is passed over the flag displaying its meaning.
The Distribution tab shows more information about the status of each recipient within the distribution trail, see below.
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3.1.1. Orientation within the Tree View - Distributions
In the above example, note where the cursor is in the tree. It is at Alert Number MDA/2011/054, just above the words “Distributed To”. The distribution tab in this instance shows who the person logged in, Peter Pearce, has sent this to. Note that if we move the cursor to Samantha Adams (see below), the Distribution tab shows who Samantha herself has cascaded the alert to – no one in this case.
It is important that the user understands how to orient themselves from the tree view.
In summary:
• From the alert reference number, communication is between the user and the person that sent the alert to them
• From one of the user’s recipients, it is between the user and the name of the person selected, in the above case Samantha Adams.
3.1.2. Orientation within the Tree View - Actions
Note the position of the cursor in the tree view; it is on the Alert number. Therefore the Actions shown here were sent by the user logged in, Peter Pearce, to the person that sent them the alert. When the user selects to <add> an action the entry window shows From him to Alert Administrator.
In the example below, note the position of the cursor in the tree view, it is on Paula Low. At this point, we are looking at the Actions sent by Paula Low to Peter Pearce (we are logged in as Peter Pearce). Note that the New Action button is not available at this point, see section 4.3. for more information on adding actions.
Click on the plus sign next to the recipient’s name to see whether they have cascaded the alert onwards as well, in this example Paula has not.
3.2. How to Acknowledge
From the tree view right click on the Alert you wish to acknowledge and then select “Acknowledge this Alert”.
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3.3. Explanation of Icons
For information only, Copy and Action, not e-mailed
For information only, Copy and Action, e-mailed. Note: Copy go straight to closed when e-mailed.
For information only, Copy and Action, e-mailed and
acknowledged where necessary. Note: For Info Alerts go straight to closed when acknowledged.
For information only, Copy and Action, e-mailed and
Acknowledged where necessary. Ongoing action sent for Action Alert.
For information only, Copy and Action, e-mailed and Acknowledge where necessary. Action Closed.
For information only and Action, e-mailed and not acknowledged by date set.
4.
The Alert Tabs
4.1.DetailsThe main details of the alert record are shown under this tab. The page can be configured by the system supervisor who may wish to hide some fields if your organisation is not using them. The fields on this tab are:
Received From
The member of staff that sent you the alert. Date Issued
The date this was issued to the organisation. Title & Details
Both these fields are populated by the main system user and should explain what the alert is about to both the current user, and any staff included in the trail. This is in addition to the attachments. Speak to the system supervisor if you feel better use could be made of these fields.
Note that the Title field is included as the Subject of all emails so the content should identify what the Alert is about as Staff scan through their inbox. The Details field is included in the body of the email, so again should explain what needs to be done and include any other useful information to help staff respond to the alert.
Type
Typically shows whether this record relates to CAS, NICE or any other type of alert disseminated through the system.
Target Dates
These target dates indicate the time frame that the person logged in needs to work to. The Complete By date is the date by which the alert should be closed, and you could start to receive automated email reminders if this date passes and the alert is still open.
4.2.Distribution (How to distribute/cascade Alerts)
First enter the dates for Acknowledge, Underway and Completed By. These dates should include some provision for time to feed back the status of the Alert. For example if you have been sent the alert to be completed by 2nd May, you could enter a date for completed by of 31st April. This would give yourself a couple of days to compile replies and ensure you meet your completion date (My Target Dates from Details Tab).
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Click on <Add Person>, this opens the window where staff are selected.
The names listed in the Distribution List box are staff that have been included in your distributions previously, and the system remembers them for quick selection and use in future alerts. Only names on the left are included in this specific alert, so in the window below no one has been selected as yet. To select a member of staff that has not been used before, start typing in the name box and as you type, possible matches will appear (surname followed by first name).
The message next to the name (Sonia Cryer) changes to Add Person to List. Click on “Add Person to List” and the name is added to the list on the left.
As discussed before, the people you have previously sent Alerts to can be seen in the right hand side of the window.
Click on the plus sign to add these people to your list.
You can now select Alert, Copy or Info from the dropdown next to the person’s name. If the “Automatically send Emails” box is ticked, the system sends the emails as soon as <OK> is selected. If it is not selected, the <Send Email> button can be used on the distribution tab itself, and an email will be sent to any staff in the list that have not received one already. The Distribution tab shows the status of each person clearly in relation to emails.
To remove the person from the left hand list, click on the minus sign and the name is removed. Note that the number of people on the list is updated once the user selected the <OK> button.
4.3.Actions (how to Add Actions)
There are two ways to add actions to the alert. This is because the user will add their own actions to the alert, as well as sending actions to someone they have cascaded to, reminding them to respond or giving more information.
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4.3.1. Adding your Actions (upwards to your sender)
To Add or Send your own actions, move to the Action tab and click on the <New Action> icon. This will open a window with the “to” and “from” sections automatically completed. Select from the Type of Action dropdown, and depending on the Action Type selected, the status of the alert may change.
In the example below, the Alert will be closed because an Action Type indicating closure is selected. The wording of the Action Type will indicate the status that the alert will be put to and examples include “Ongoing”, “Action Started” and so on. If you are unclear, contact the system administrator who can discuss the options available.
You can then type into the details section any message that you wish to send. To e-mail this message ensure that you have put a tick in the send ee-mail box.
4.3.2. Adding Actions (downwards to your recipients)
To Add or Send an action to one of the people you have cascaded to, go to the Distributions tab and click on the Send an Action icon in the Actions column next to the person required. This will open a window with the “to” and “from” sections automatically completed. Select the required Action Type from the drop down. To e-mail this message ensure that you have put a tick in the send e-mail box.
4.4.Documents
This section contains documents and/or Web links that were attached to the original alert record, containing all the information upon which appropriate action should be based.
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5. The Filters
There are standard filters for Open Actions, Closed Actions, for Information Only and Copy/BCC. Use the dropdown to select a filter, the list of Alerts will update according to the filter selected.
Open Actions
Closed Actions
Information Only
Copy
6. The Progress Bar
The progress bar shows the percentage of Acknowledged and Completed Alerts from your Distribution List. In the example below, the user has cascaded the alert to three other members of staff and two have acknowledged, only one has completed.
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7. Creating Filters (Supervisor only)
By clicking on the icon you can set up filters.
Click on “New” enter a name for your filter and then click on OK.
Click on Add Row and then use the dropdowns to select the fields and values to match.
Select if this is a Public or Default Filter Select whether the filter should match on all these conditions, or can just match on one of them. Matching on all will mean that the Alert has to match on all rows. Matching on any will mean that the alert only has to meet the condition of one of the rows.
Public Filter
A public filter will be seen by all staff. If this is not selected, this filter will only be seen by the member of staff currently logged in.
Default Filter
The default filter will be used as a default filter for all users if the filter is public, or just the user logged in if the filter is not public.
There is a tick box for “Allow sending of Alerts to Staff that are on Distribution List (but have not been sent)”. We recommend that this box is ticked.
Appendix 2
CAS ALERT ACTION FLOW CHART
MANAGER ARRANGES FOR REQUIRED ACTION TO BE CARRIED OUT WITHIN
THE TIME SCALE SPECIFIED
The alert is examined and the required action identified, implemented and completed as described in the alert. It is the responsibility of the manager to ensure the action is satisfactorily completed
and the issue closed.
MANAGER CLOSES ALERT ON SAFEGUARD ALERTS MODULE
The manager who received the alert, is responsible for closing the alert using the
web interface of the Alert Module.
CAS ALERT CLOSED ON CAS WEBSITE
On or just before completion due date, CAS Liaison Officer accesses CAS alert website
and closes the alert
‘REMINDER TO COMPLETE’ SENT TO MANAGERS BY CAS LIAISON OFFICER
At least two weeks (shorter if required) before completion due date, CAS Liaison Officer will send a reminder to those managers who have
not completed the required action.
ALERT RECEIVED FROM CAS SYSTEM BY CAS LIAISON OFFICER
DECISION TO DISSEMINATE
The CAS Liaison Officer decides if and who, to disseminate the alert to. If there is any doubt, the alert is disseminated to all Alert
recipients.
ALERT DISSEMINATED AS REQUIRED
The module entry is created and activated and disseminated.
RECEIVED BY MANAGER
The manager nominated to receive Alerts decides what action is required in their
service, it will be one of three;
NO ACTION REQUIRED
After examining the Alert, it is assessed that the alert is not
applicable to this service. Either the service is not provided, the item is not used, does not fit the specific criteria or is not under the control of
the service.
NEED TO CHECK
The receiving manager is not sure if the alert applies and so
is going to investigate within the service.
ACTION IS REQUIRED
After examining the alert it is assessed that the alert does apply to items held / services provided within the service.
PROCEDURAL DOCUMENT CHECKLIST AND TRACKING DOCUMENT
Document Title:
CENTRAL ALERTING SYSTEM (CAS) POLICY Category of Procedural
Document : Policy
Name of Originator/Author: Head of Health, Safety & Security
Accountable Director: Director of Business Assurance
Name of Responsible
Committee Risk Management Group
Members of Authorship Group (where relevant):
Names Titles
Please provide details of the consultation process (i.e. Individuals / groups consulted):
Group or Individual
Date requested and method
Comments made Were amendments
made in response to the comments? If not, explain why
A. Irwin By Email 30/07/13 J Mouncher By Email 30/07/13 G Fagan By Email 30/07/13 J McDonough By Email 30/07/13 I Joustra By Email 30/07/13 D Graham By Email 30/07/13 C Williams By Email 30/07/13 L Endersby By Email 30/07/13 K Etheridge By Email 30/07/13 C Harrison By Email 30/07/13 J Smith By Email 30/07/13 P Barratt By Email 30/07/13
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Checklist for the Review and Approval of Procedural Documents
Yes/No/ Unsure
Comments
1. Title
Is the title clear and unambiguous? Y Is it clear whether the document is a strategy,
policy, procedure, framework, guideline, protocol or standard operating procedure?
Y
2. Rationale
Are reasons for development of the document stated?
Y
Is this an NHSLA policy document? N If yes, has it been checked for compliance
against the minimum requirements set out within the criterion?
N/A
3. Development Process
Was the document reviewed before the agreed review date expired?
N
If not please state reason for delay? New system in place Do you feel a reasonable attempt has been
made to ensure relevant expertise has been used?
Y
Is there evidence of consultation with relevant stakeholders and users detailed in the tracking document?
Y
Have the following been considered as part of the development of this document:
• Mental Capacity Act
• Privacy, Dignity and Respect • Safeguarding
• Fraud
• Infection Control • Training requirements • Other relevant documents
Y
4. Content
Is the scope of the document clear? Y Is the target population clear and unambiguous? Y
Is the policy written in a style which is concise and clear?
Y
Is the policy written in the approved template? Y Is the policy formatted in Arial Font size 12? Y Is the document referenced using the Harvard
reference system?
Y
Is the document numbered using the page x of y convention?
Y
5. Introduction
Does this section introduce the topic and include references to and applicability of any relevant legislation, national policy guidance, external agency recommendations, definitions and explanation of terms used?
Y
6. Purpose
Does this section outline the objectives and intended outcomes of the process/system being described?
Y
7. Scope
Are the target audience and activities covered by the document clearly stated?
Y
8. Responsibilities, Accountabilities and Duties Does this section provide an overview of the individual, departmental and committee duties including levels of responsibility for document development?
Y
9. Procedure/Implementation
Does this section detail the actual procedural guidance?
Y
If lengthy, is it presented in subsections to make it easier for the user to refer to?
Y
10. Training Implications – where training needs have been identified has either: A training needs analysis has been completed; N
The Trust Mandatory Risk Management Training statement added; or
N
Where training is not required details of how staff will be made of the policy and its implications for their working practice.
Y
Has the Head of Learning and Development reviewed the TNA?
N
Page 33 of 34 Are there measurable standards to support monitoring compliance of the document?
Y
Is there a plan to review or audit compliance with the document?
Y
Has any plan to use clinical audit been discussed with the Clinical Audit Department and included in the Trust Clinical Audit Forward Programme?
N
12. Equality Impact Assessment Screening
Has an Equality Impact Assessment been completed as part of the document
development/review process?
Y
Has the EIA been approved by the Trust Equality and Diversity Lead?
Y
Have any privacy, dignity and respect issues been identified within the document and does the document indicate how these will be met?
N
13. Mental Capacity Act Statement
Have the provisions of the Mental Capacity Act been considered and any issues identified addressed within the document?
Y
12. Links to any associated documents
Are local/organisational supporting documents referenced?
Y
If the document details any associated
documents are these referenced in section 9?
Y
13. Referencing
Is the type of evidence to support the document identified explicitly?
Y
Are key references cited? N
Are the references cited in full using the Harvard referencing style?
N/A
14. Approval/Ratification
Does the document identify which
committee/group is responsible for ratification of the document?
Y
If appropriate, have the joint Human
Resources/staff side committee (or equivalent) approved the document?
N
Has the policy been checked by the Clinical Effectiveness Lead (clinical documents) or Policy and Standards Officer (non-clinical documents) – refer to appendix 4.
15. Dissemination and Implementation
Is there an outline/plan to identify how this will be done
Y
Does the plan include the necessary training/support to ensure compliance?
N
16. Document Control
Is the correct version number recorded on the policy?
Y
Is the document control box completed accurately?
Y
Is the review date identified? Y
17. Overall Responsibility for the Document
Is it clear who will be responsible for coordinating the dissemination, implementation and review of the documentation?
Y
Date document presented to Trust Committee/Group with delegated responsibility for ratification
Outcome Ratified Ratified subject to
recommendation
Not ratified (provide reason)
