Corporate Business Continuity Plan
Version 0_2 Draft
Record of Alterations
DISTRIBUTION LIST
Document Distributed to: Date
Interim Business Continuity Plan V0_1 Draft
Senior Management Team 20th March 2012
Version Date Description of
Alterations Version 0_1 draft 19th March 2012 First draft for
consultation
Version 0_2draft 30th March 2012 Ammendments following SMT consultation
Table of Content
Section
Page
1.0 Introduction 7
1.1 Background 8
1.2 Context of Business Continuity Management 8
1.3 Definition of Business Continuity 8
1.4 How Business Continuity Planning Differs from Major Incident Planning
9
1.5 Publication 9
2.0 Purpose & Scope 10
2.1 Purpose 10 2.2 Scope 11 2.3 Assumptions 11 2.4 Limitations 12 3.0 Areas of Responsibility 13 3.1 Chief Executive 13
3.2 Director of Medical & Governance 13
3.3 Trust Directors 13
3.4 Head of Corporate Communications 13
3.5 Emergency Planning & Business Continuity Manager
13
3.6 Trust Staff 13
4.0 Plan Activation Procedures
4.1 Triggers to Activate the Plan 14
4.2 Notification & Activation Procedures 15
4.3 Activation of Business Continuity Plan 16
4.3.1 Examples of Disruption resulting in Activation of the Plan
Table of Content
Section
Page
5.0 Response 17
5.1 Business Continuity Control & Information Team (BCCIT)
17
5.2 Command & Control Team (CCT) 17
5.2.1 Location of the Control Room 17
Table 2 BCCIT 18
Table 3 CCT 19
5.3 Record Keeping 20
5.4 Incident Stand Down 20
5.5 Incident Debrief 20 5.5.1 Hot Debriefing 20 5.5.2 Formal Debrief 20 5.6 Interpreting Services 20 5.7 Cultural Sensitivity 21 6.0 Communication Strategy 22
6.1 Designated Press Office Centre 22
7.0 Prioritisation Criteria for Trust Services 23
7.1 Business Prioritisation Criteria 23
7.2 Trust Critical & Urgent Services/Products 24
8.0 Operational Service Resumption Strategies 26
9.0 Training 27
9.1 Methods of Training 27
10.0 Review & Validation
Table of Content
Section
Page
10.2 Validation 28
Appendices
Appendix 1 Business Disruption Notification Record 29
Appendix 2 Registration Sheet 31
Appendix 3 Log Sheet 33
Appendix 4 Designated Locations 35
Appendix 5 Action Cards
- Notifying Manager 38 - Director/Director on call 39 - Information Manager in CCT 40 - Action Manager in CCT 41 - Support Manager in CCT 42 - Corporate Communications 43 - Chair of BCCIT 44
- Team Members of BCCIT 46
- Support Manager of BCCIT 47
Appendix 6 Trust Emergency Planning & Business Continuity Forum Terms of Reference
48
Appendix 7 Accessing Interpreting Services 52
Appendix 8 Business Continuity Control & Information Team Structure
55
Appendix 9 Command & Control Team Structure 57
Appendix 10 Command & Control Team Information Flow Diagram
Acronyms
Term
Meaning
BCCIT Business Continuity Control &
Information Team
BCM Business Continuity Management
BCP Business Continuity Plan
CCD Corporate Communications
Department
CCT Command & Control Team
HDU High Dependency Unit
HSC Health & Social Care
HSCB Health & Social Care Board
ICT Information, Communication
Technology
ICU Intensive Care Unit
PHA Public Health Agency
NIAS Northern Ireland Ambulance Service
NIF&RS Northern Ireland Fire & Rescue
1.0 Introduction
The Northern Health & Social Care Trust became operational on the 1st April 2007, and is one of six provider HSC Trusts in Northern Ireland. Geographically the largest Trust within Northern Ireland, it provides a range of health and social care services across ten local council areas, which includes Antrim, Ballymena, Ballymoney, Carrickfergus, Coleraine, Cookstown, Larne, Magherafelt, Moyle, and Newtownabbey to a population of approximately 443, 000 people.
These services include a range of hospital services, including:
- acute hospital services provided at Antrim Area Hospital, Antrim; and Causeway Hospital, Coleraine;
- sub-acute hospital services in Mid Ulster Hospital, Magherafelt; and Whiteabbey Hospital, East Antrim; and
- acute and in-patient mental health services in Holywell Hospital, Antrim; and the Ross Thompson Unit, Coleraine.
In addition, there are a wide range of community based services across directorates which include children services, primary care & community older peoples services, and mental health & disability service, which deliver service provision across a range of facilities in approximately 150 locations and including three community hospitals located in Larne, Ballymoney and Ballycastle.
The core business of the Northern HSC Trust is to deliver high quality, appropriate, effective and accessible health and social care services. This is underpinned by a commitment to deliver person-centred services, and is reinforced by the Trust mission statement:
“To provide for all, the quality of service we expect for our families and ourselves.”
Business continuity management, including processes for recovery and restoration, should be considered as part of all HSC organisations every day processes to ensure that core business services are maintained.
Business continuity should be embedded into the culture of the Northern HSC Trust. It provides a framework to enhance the resilience of the Trust to any eventuality and to help ensure continuity of critical service to patients and service users. It provides a basis for planning to ensure long-term survivability following a disruptive event, and protects the reputation of the Trust.
The Business Continuity Plan is necessary to enable the Trust to continue to deliver critical activities at an acceptable predefined levelduring a service interruption and restore normal services as soon as possible.
Target Audience
1.1 Background
The British Standard BS25999-1:2006 defines business continuity management as “a business-owned, business-driven process that establishes a fit-for-purpose strategic and operational framework that:
• proactively improves an organization’s resilience against the disruption of
its ability to achieve its key objectives;
• provides a rehearsed method of restoring an organization’s ability to supply
its key products and services to an agreed level within an agreed time after a disruption; and
• delivers a proven capability to manage a business disruption and protect the
organisations reputation and brand”
Business Continuity Management (BCM) enables organisations to identify their critical functions and to plan for and respond to incidents and business disruptions in order to continue business operations at an acceptable pre-defined level.
1.2 Context of Business Continuity Management
In preparation of the Trust Corporate Business Continuity Plan due recognition has been given to the requirements identified in the following documentation:
- The Northern Ireland Civil Contingencies Framework 2005 - British Standard for Business Continuity - BS 25999
- The Business Continuity Institute The Good Practice Guidelines 2010 - NHS Emergency Planning Guidance 2005
The Trust Chief Executive has overall responsibility for ensuring the implementation of and continued success of BCM within the Trust.
The Emergency Planning and Business Continuity Manager is responsible for writing and implementing the Corporate Business Continuity Plan and ensuring it is operational through distribution, promotion, training of staff, exercising, review and validation. This includes the responsibility for ensuring it is compliant with current legislation, national guidance and examples of good practice.
1.3 Definition of Business Continuity
BS 25999 defines BCM as
“the capability of the organisation to plan for and respond to incidents and business disruptions in order to continue business operations at acceptable pre-defined levels within agreed time frames”.
For HSC organisations, interruption may be defined as:
“Any disruptive challenge that threatens personnel, buildings or the operational procedures of an organisation and which requires special measures to be taken to restore normal operating functions”.
BCM is concerned with ensuring that, at all times, the Trust can continue operating at a pre-determined level in the event of a major disruption.
1.4 How Business Continuity Planning Differs from Major Incident Planning The Trust defines a Major Incident as ‘ An incident which, because of the number or severity of casualties, will have an overwhelming impact on the normal emergency department and other hospital services and which requires the extraordinary mobilisation of medical, nursing, social services staff and other services.’
Emergency Planning guides the Trust response as part of a multi-agency response to an unexpected incident which is external to the Trust and has a severe impact on the general public.
Business Continuity Planning is planning to respond to a business disruption which primarily affects the ability of the Trust to do business, and ensuring the capability of the Trust to continue critical activities at an acceptable pre-defined level.
1.5 Publication
This plan will be published and shared in its entirety. Publication will be by means of the Trust intranet site, and hard copies issued to the Trust Senior Management Team and Assistant Directors.
Alternative Formats
This document can be made available on request on disc, larger font, Braille, audio cassette and in other minority languages to meet the needs of those who are not fluent in English.
Sources of Advice in relation to this document
The Policy Author, responsible Assistant Director or Director as detailed on the policy title page should be contacted with regard to any queries on the content of this policy.
Equality, Human Rights and DDA
This policy has been drawn up and reviewed in the light of Section 75 of the Northern Ireland Act (1998) which requires the Trust to have due regard to the need to promote equality of opportunity. It has been screened to identify any
adverse impact on the 9 equality categories and no significant differential impacts were identified, therefore, an Equality Impact Assessment is not required.
2.0 Purpose and Scope
2.1 Purpose
The purpose of this Corporate Business Continuity Plan is to provide an overarching strategic framework to support the Northern HSC Trust (the Trust) to identify as far possible, the actions and resources that are needed to enable it to manage a major disruption whatever its cause, back to a position where normal business can be resumed following a disruption which may be:
- ‘Internal’ to the organisation eg, loss of key building due to fire or flooding, loss of utilities, or a staffing crisis
- ‘External’ to the organisation eg, loss of power supply, prolonged disruptions due to strikes, severe weather.
This Plan sits at the top of a hierarchy of Business Continuity Plans that include Directorate Plans and Departmental Plans.
The objectives of the Trust Corporate Business Continuity Plan are:
- to facilitate an organised and co-ordinated response to a serious or major business disruption
- to provide clear procedures for the invocation of the Trust incident management structure in the event of a business disruption that impacts on key services - to outline the Trust strategic and tactical command structure to a disruptive
incident affecting critical activities/services
- to identify the communication strategy throughout the incident
- to identify the critical services to be maintained within each directorate - provide clear guidance of roles and responsibilities to Trust staff
- to outline service resumption strategies to be considered during a service disruption
This Plan details strategic arrangements to protect the time critical key functions of the Trust, with the principle that critical services should be maintained to a pre- defined level for a period of seven days.
It should be noted that Business Continuity responses may extend beyond the length of the interruption until such times as services/activities can be restored to their pre-defined levels.
This plan fulfils the requirements of the BS25999, and the Trusts Business Continuity Management Policy. In addition it compliments the Trust Major Incident Plan (Version 1_0), and existing suite of business continuity plans already within each Directorate.
2.2 Scope
The scope of this plan encompasses the Trust services within the following Directorates:
- Acute Hospital Services
- Primary Care & Community Older Peoples Services - Children Services
- Mental Health & Disability Services
- Planning, Performance Management & Support Services - Finance
- Human Resources
- Nursing & User Experience - Medical & Governance
2.3 Assumptions
The assumptions on which this plan is based are that:
- It is a corporate responsibility that every directorate and department within the Trust should be involved in BCM. The level of involvement is dependent on the number of critical activities performed by the directorate or department.
- The Emergency Planning Manager will assist in supporting all directorates to develop, review and maintain their BCPs, however overall responsibility for developing and maintaining plans remains firmly with each directorate.
- The workload of the Trust and the availability of any vacant space will vary at any given moment. The Corporate BCP therefore sets out general strategic directions and guidance rather than defined solutions.
- Unless required (by PSNI or otherwise) to relocate staff elsewhere, it is assumed that there is a requirement for staff to be located in another Trust facility. This will be reviewed depending on the nature and location of the incident.
- There is an assumption that all key roles will have an appointed Deputy, who has been previously briefed and understands what their role is and the actions they must undertake for the best interests of the work area or responsibility, in the absence of the primary key role holder.
- All staff have read the plan, understand their likely role/working position given the need to implement this plan.
- It may be necessary to instruct those staff considered to be non-critical to front-line staff to go home or remain at home, for a limited time, in order to accommodate those staff considered key to service provision.
- It is assumed that mobile communications will be operating during the extent of the incident and will not be limited by network coverage or contract.
2.4 Plan Limitations
This Plan is not designed to:
- Be fully prescriptive in the event of contingency activities being undertaken, as the situation may require localised and reactive actions.
- Take effect where relatively minor disruption is experienced and the considered option is that resolution is within a reasonable timescale for the nature of the incident.
- Account for or cover the acquisition of additional permanent office or other specialised accommodation.
3.0 Areas of Responsibility
3.1 Chief Executive
The Chief Executive has overall accountability for ensuring that the Trust has in place effective arrangements to respond to an incident that has potential to affect service provision.
3.2 Director of Medical & Governance
The Director of Medical & Governance has responsibility for the successful implementation of business continuity management arrangements within the organisation.
3.3 Trust Directors
Directors are responsible for ensuring that:
• Business continuity plans are completed for each risk identified;
• Business continuity plans are cascaded to appropriate staff within the
directorate who are given appropriate training;
• Plans are reviewed annually or sooner as appropriate; and • The correct response is provided to the disruptive incident.
3.4 Head of Corporate Communications
The Head of Corporate Communications is responsible for:
• Ensuring appropriate, timely and clear communication with staff, patients
and carers on the status and progress of disruptions and any changes to service delivery taking into account the communication needs of affected equality groups, ie older people, people with a disability, ethnic groups and dependents.
• Liaising with public representatives and the media throughout the incident
with the release of regular press statements and arranging press conferences if required.
3.5 Emergency Planning & Business Continuity Manager
The Emergency Planning & Business Continuity Manager is responsible for:
• Ensuring business continuity plans are developed, maintained, validated
and reviewed;
• Ensuring training is provided for personnel who have been assigned
business continuity responsibilities.
• The Corporate Business Continuity Plan;
• Individual directorate business continuity plans.
4.0 Plan Activation Procedures
4.1 Triggers to Activate the Plan
The Trust may experience various levels of disruption that will have differing levels of impact on core business areas. The response invocated by the Trust will be dependant upon the level of disruption experienced. To assist in the management of the disruption, there are three defined levels of incident disruption that will influence and assist in the decision making regarding the level of response required. This is outlined in Table 1 below.
Table 1: Levels of Disruption
Level Category Definition: One or more of the following apply Response Level 1 Minor
Disruption •
A local incident that is not an emergency and does not cause serious physical threat to people or property.
• Results are likely to be limited disruption
services.
• The disruption can be dealt with by local
management.
Immediate notification to:
Line Manager
Manage the incident through the respective Directorate BCP
Level 2 Serious Disruption •
A disruptive incident that could pose an actual threat to people and property, but not seriously affect the overall functioning of the Trust.
• The disruption is likely to last no more than
one working day
• Access to one or more sites may be
denied
• The disruption affects more than one
Directorate Immediate notification to: • Line Manager • Director/Director on call Potential activation of the BCCIT (5.0) Manage the incident through the respective Directorate BCP.
Level 3 Major
Disruption •
A disruptive incident causing a significant disruption to the Trust’s operations.
• A number of services seeking to activate
their BCP
• A serious or destructive loss of a major or
multi- occupancy site
• Major wide scale incident in a geographical
area affecting several services/sites
• Major disruption to business activities /
Emergency Plans and lower level BCPs inadequate to deal with incident
Immediate notification to: • Line Manager • Director/Director on call Activation of the BCCIT & CCT (5.0)
NB. Both line Manager and Director to complete a Business Disruption Notification Record (Appendix 1) on notification of a business disruption.
Appendix 5 outlines Action Cards for both the notifying Manager & Director at the notification stage of a business disruption.
4.2 Notification & Activation Procedures
The following flow chart outlines the Trust response to the levels of disruptive incidents that may occur.
Level 2 Serious Disruption
Level 3 Major Disruption
Disruption escalates
Report to Director immediately Report to Director-on-call immediately
Assess the severity of the incident disruption and determine the appropriate
response LEVEL 2 LEVEL 3 RESPONSE Activate: • BCCIT • CCT RESPONSE Activate: • BCCIT • Inform CCD • Director to monitor the YES NO Incident Identified
Inform Line Manager immediately
Line Manager assesses the potential level of disruption (Table 1)
Level 1 Minor Disruption
Activate
Directorate BCP Monitor for signs of escalation
Is it during office hours?
4.3 Activation of the Corporate Business Continuity Plan
As outlined in 4.1, the strategic management and response to a Level 3 major disruption will be achieved principally through invocation of this Plan.
The following outlines in more detail when the Trust classifies an incident as a Level 3 major disruption resulting in the need to activate the Plan:
• Normal operational procedures or the implementation of Directorate BCPs do not
manage the disruption
• One or more critical or urgent services cannot be maintained locally
• There is a need for special arrangements to be implemented across multiple sites by
the Trust to deal with the disruption
• The need to evacuate a site that accommodates multiple services for a prolonged
period of time
• There is a corporate wide co-ordinated response required to deal with the disruption • An issue is likely to cause more widespread disruption within other areas of the
Trust
• A minor disruption escalates into widespread disruption that can no longer be dealt
with by the directorate BCP
• Prompt, co-ordinated action by the Trust could prevent minor disruption escalating
into serious disruption
4.3.1 Examples of Disruptions resulting in Activation of the Plan
The following are examples of major disruptions that may have sufficient impact to result in consideration to activate this Plan:
• Severe weather conditions
• Widespread pandemic illness resulting in reduction of available staff resources • An incident which has the potential to effect the reputation of the Trust
• Large Industrial action
• Significant/prolonged loss of IT/communications
• Loss of utility supplies, such as electricity, gas, fuel and water
• An incident with the potential to affect multiple buildings or the welfare of staff • Natural disasters eg floods
It is important to note that both Level 1 and Level 2 disruptions have the potential to escalate to a Level 3 disruption. For this reason ongoing review of the disruption is the responsibility of the Director, or delegated other.
5.0 Response
In the event of a business continuity disruption, the Director/Director-on-call is responsible to make the decision regarding the required response. This will be determined by the level of disruption as identified in paragraph 4.1.
The membership of each team will be determined by the type, duration and services affected by the disruption.
5.1 Business Continuity Control & Information Team (BCCIT)
In response to a Level 2 and Level 3 disruption, the Director will activate the Business Continuity Control & Information Team to tactically manage, direct, co-ordinate and lead the operational response. Table 2
The location in which this Team is based is flexible, and dependant on the location of the business continuity disruption.
The principles of this team are similar to the Control & Information Team (CIT) outlined in the Major Incident Plan.
The BCCIT will be led by the BCCIT Chair, and supported by Team Members, and a Support Manager; administrative support will be provided by Personal Assistants of team members involved. (Outlined in Appendix 8)
(Please refer to: Action Cards for each role -Appendix 5) 5.2 Command & Control Team (CCT)
In the event of a Level 3 disruption, the Director will make the decision to activate the Command & Control Team to strategically manage the Trust response. Table 3
To maintain consistency, again the principles and structure of this Team is similar to the Command & Control Team that is identified within the Major Incident Plan. At times it may be that this team is required to co-ordinate the strategic response to both a Major Incident and Business Continuity disruption.
Each member of this Team has the responsibility to ensure that they have identified a nominated Deputy to represent them, in the event that they are not available to respond.
Clearly defined roles within this team include Information Manger, Action Manager, and Support Manager; secretariat support will be provided from Personal Assistants from Trust HQ. (Outlined in Appendix 9)
(Please refer to: Action Cards for each role – Appendix 5; Information Flow – Appendix 10)
The locations of the Control Room to facilitate Command & Control Team meetings are available in Appendix 4
NHSCT Business Continuity Control & Information Team (BCCIT)
Location: To be decided when the incident occursPurpose Membership
The BCCIT will provide tactical response to the management of a Level 2 or Level 3 business continuity disruption.
This will include directing and
co-ordinating the operation response to the disruption, and providing leadership and support to staff.
During a Level 3 disruption, this team will support the CCT in ensuring strategic decisions are implemented at an operational level.
• Assistant Director for the service
area affected
• General Manager for the service
area
• General Manager for Support
Services
• Corporate Communications
• Assistant Director of ICT or deputy
(if appropriate)
• Head of Estate services or deputy
(if appropriate)
• Administrative support
• Co-opted members as required
Table 2: Business Continuity Control & Information Team
NHSCT Command and Control Team (CCT)
Location: The Boardroom, The Cottage OR The Boardroom, Holywell
Purpose Membership (as appropriate)
The CCT has responsibility for strategic direction and support to all
Directorates/Departments involved in the response to a Level 3 business continuity disruption.
The main objective is to provide strategic direction and leadership to the BCCIT, in order to manage the disruptive incident and restore the Trust to normal operating
conditions.
• Chief Executive • Director of Medical &
Governance
• Director Acute Hospital Services • Director of Nursing & User
Experience
• Director of Planning,
Performance Management & Support Services
• Director of Finance
• Director of Human Resources • Director of Mental Health &
Disability
• Director of Children Services • Head of Corporate
Communications Administrative Support • Will take lead responsibility for the management and co-ordination of the
directorate/department operational response
• Establish and maintain communication with the Command & Control Team (if activated) for support and strategic guidance
• Assess the impact on services – patient services, staff, building infrastructure etc
• Direct and co-ordinate the activation of all Directorate BCPs
• Provide advice, guidance and leadership to staff involved in the response • Ensure there are sufficient staffing levels and resources available to respond to
the disruption, including the direction and co-ordination of resource deployment across the Trust
• Ensure open channels of communication and coordination to the response with other external agencies as appropriate, which may include PSNI, NIAS, NIF&RS and PHA/HSCB
• Follow direction from Trust Corporate Communication in response to media, public and staff communication
• Maintain a written log of messages sent or received, decisions made and actions taken by all personnel
• Secure all written logs and forward to the Emergency Planning Office following the response
• Manage the resumption of service delivery
• Decide at what stage to declare ‘Incident stand-down’, and notify Trust staff involved in the response; and
• Participate in review, evaluation and formal post incident debriefing of the Trust response to the incident.
• Co-opted members as
required
Responsibilities during the Business Continuity Disruption:
• Take strategic command of the Trust response to the business continuity disruption
• Liaise with and support the BCCIT
• Manage and approve the request for additional resources as requested by the BCCIT to manage the disruption
• Monitor the response, co-ordinating the resources to match the needs at various stages of the response
• Ensure the establishment of effective communication and take the lead in directing the Trusts responses to partners and agencies as required, including the Trust Board, HSCB, PHA, DHSSPS, other Trusts
• Monitor the progress of the response, and brief the BCCIT with regular updates. • Identify and mitigate clinical and non-clinical risks to staff, patients and the
public
• Follow direction from Trust Corporate Communication in response to media, public and staff communication in a timely manner
• Ensure welfare and safety of patients, staff and wider stakeholders are given uppermost consideration during and after the response
• Maintain a written log of messages sent or received, decisions made and actions taken by all personnel
• Secure all written logs and forward to the Emergency Planning Office following the incident response
• Decide at what stage to declare ‘Incident –stand down’, and notify Trust staff Table 3: Command & Control Team
5.3 Record Keeping
Records during the response are legal documents which are legally recoverable and discoverable documents in the event of a subsequent inquiry or legal review. It is therefore essential that all records created during the response are maintained and securely retained.
Detailed and accurate logs (Appendix 3) must be completed by Trust staff of information received, advice given, action taken and discussions held. These logs will be secured immediately after the incident response is stood down and
5.4 Incident Stand down
The CCT or BCCIT will determine when the Trust can stand down its response and communicate accordingly.
5.5 Incident Debrief 5.5.1 Hot Debriefing
Managers should make arrangements for staff to have an initial debriefing at the end of their shift as a means of acknowledging staff contribution to the response and identifying any outstanding tasks to be complete.
The BCCIT will conduct a hot debrief when the decision is made that the incident response is stood down. This is an informal discussion to provide recognition and praise to staff for their contribution to the response.
5.5.2 Formal Debriefing
Formal debriefing both internal and with external agencies involved will occur within one month following the incident response, and will be led by the Medical Director as the Director with responsibility for Emergency Planning & Business Continuity.
A Formal Post Incident Debrief Report will be produced by the Emergency Planning & Business Continuity Manager identifying areas for consideration and recommendations following the Trust response. This is forwarded to the Medical Director to present to the Senior Management Team and Trust Board as appropriate.
The Report will be also be presented to the members of the Trust Emergency Planning and Business Continuity Forum.
5.6 Interpreting Service
Interpreting support will be provided for those involved in the incident whose first language is not English. The Trust has access to face to face interpreters in an emergency through the Trust’s Equality Unit or if the incident occurs outside office hours through the Regional Interpreting Service. The Trust also has access to a telephone interpreting service which can be accessed immediately, 24 hours a day.
Sign Language interpreters can be accessed through the Equality Unit or Action on Hearing Loss if the incident occurs outside office hours.
Full details of the interpreting support available and how to access it are available in Appendix 5.
5.7 Cultural Sensitivity
Communities are made up of people from differing religious and cultural backgrounds. Whilst health and safety is always of paramount importance for people affected by a Major Incident, it is important that Trust staff deal with
casualties and their families appropriately and in the most sensitive and thoughtful way as possible. This will include cultural considerations in respect of medical treatments and sensitivity to different cultural attitudes and requirements when
dealing with the deceased. Specific advice on cultural issues can be found in the Trust’s Multi Cultural Handbook.
6.0 Communication Strategy
Good communication is vital to the successful handling of any business continuity disruption. The key communications objective must be to deliver accurate, clear and timely information and advice to all relevant target audiences.
Liaison with media during the response can assist in external communication to both service users and members of the public to inform them of the Trusts response to the disruption, the impact on normal services, and assist in timely updates on how the Trust is dealing with the response.
The Trust Head of Corporate Communications as a member of the Command & Control Team or the BCCIT (if Command & Control not established), will be responsible for leading the Trusts media response, and advising senior managers on the structure and content of any press releases.
The following principles apply in relation to the Trust liaison with the media during a business continuity disruption response:
• All communication with the media will be via the Corporate Communications Department
• No member of Trust staff will provide any information to the media unless under the direction of the Head of Corporate Communication
• All telephone enquiries from the media will be directed by switchboard to the command and control centre at the relevant site; and
• All Trust staff will adhere to the normal procedures regarding confidentiality of information and identity of attendees.
6.1 Designated Media Press Office Centre
In response to a disruptive incident, the Trust designated Press Offices may be required to be established. The purpose of these Centres is to brief media, run press conferences etc. External Media Officers will be directed to the designated Media Press Office Centre if opened. There will be a member of Trust Corporate Communications within the Media Press Office Centre at all times, who will liaise with and take direction from the Head of Corporate Communications.
The location of the designated Media Press Office Centre is identified in Appendix 4
Portering Services will ensure that these rooms are set up and equipped with additional telephone sets if required.
If the location of the Media Press Office Centres is not appropriate to the response required, the Head of Corporate Communications may identify an alternative appropriate location.
Direction will be provided to the Trust Corporate Communications Department from the Command & Control Team (if operational) /BCCIT/Chief Executive’s Office as
to when it is appropriate to close the Centre. Upon closure all media enquiries will be managed through the Corporate Communication office.
7.0 Prioritisation Criteria for Trust Services
Responding effectively to a Business Continuity disruption is underpinned by a sound understanding of the organisation. In complying with the BS 25999
requirements, the Trust has completed a Business Impact Analysis (BIA), with the aim to identify and understand:
• The Trusts time critical services, and the priority of each
• The maximum tolerable period of disruption, and recovery time objectives • The dependencies that exist, both internal and external, which are required to
provide the critical services
• The impact if the service/function was interrupted as a result of a business
continuity disruption
• Areas of risks within each service area
• The resources required to maintain the pre-defined acceptable level of
business for each key service.
Further commitment is required in the analysing and consolidation of the findings within the BIA. In the interim, a BIA Paper has been completed. (Appendix 11 still to be included pending further consultation with Directors)
The information captured within the BIA identifying key services and products to be maintained through a service disruption was correlated, and a series of interviews with the Trusts Directors and key staff initiated to approve these for inclusion into this Plan.
7.1 Business Prioritisation Criteria
The following prioritisation criteria have been applied to identify those time critical business operations within the Trust that must be recoverable to an acceptable level as a matter of priority.
This information is a starting point to assist the CCT to prioritise the Trust response required in the early stages following a Level 3 disruption to business.
Priority Service must be resumed within
Description Priority 1:
Critical
0-1 hour Those services/products that need to
continue operating with little or no interruption or the impact would be catastrophic/life threatening.
Priority 2: 1-24 hours Those services/products that can tolerate an
Priority 3: Moderate
1-3 days Service must be resumed within 3 days. It is envisaged that these services/products need to be restored as soon as practicable within the 1st or 2nd day following the interruption.
Priority 4: Low
7.2 Trust Critical and Urgent Services/Products
A brief analysis of the Trust services within each of these criteria is included in Appendix 11 (still to be included pending further consultation)
A summary of the services that have been assessed as critical and urgent using the above criteria are outlined on the following table.
Priority 1 Critical
Directorate Service/Product Name
Acute Hospital Services • Radiology
• Obstetrics - Labour wards; Maternity
ward; Community Midwifery
• Laboratories
• Theatre - Emergency Theatres;
Maternity Theatres
• Emergency Department
• Inpatient Care - Unscheduled care,
medical and surgical specialities
• ICU & HDU
Children’s Service • Neonatal Unit
• Inpatient Care - Children's Paediatric
wards
• Residential Child Care including
access to secure units
• Complex Care - Complex illnesses;
Complex Care in the Community Mental Health & Disability • Crisis Resolution Home Treatment
Service
• Provision of Inpatient acute care
services, rehabilitation and crisis accommodation for patients, Mental PICU, EMI Units
• Maintain Supported Living Units
Primary Care & Community Older
Peoples Service •
Internal Homecare services
• Residential care; Intermediate Care
Beds; Respite Care
• Community Hospitals
• Intermediate Rehab & Stroke Service • Palliative Care, Support & Macmillan
Unit Antrim
• Hospital Diversion Nursing Team
Nursing & User Experience • Infection Prevention/Control - Advisory and managerial support;
Decontamination/Sterile Services
• Domestic Services -Theatre Services • Porter services
Planning, Performance Management
& Support Services •
Still to be included
Chief Executives Office • CEO's office and Corporate Communications
Priority 2 Urgent
Directorate Service/Product Name
Children’s Service • Central Support - Out Of Hours Social Work Service
• Safeguarding and Corporate Parenting
- Gateway Services, Family Support Intervention & Disability Teams & Teams supporting Looked After Children
Mental Health & Disability • Community Mental Health Services - Domiciliary Care Packages
Primary Care & Community Older
Peoples Service •
Community Integrated Teams - Community Nursing Services;
Treatment Room Services; Social Work Assessments/Commissioning of
services; Safeguarding of Vulnerable Adults; Community Equipment
Services; Acute OT Services Nursing & User Experience • Functional Support – Catering
(Patient/Client feeding across all Directorates. Staff feeding - hospital sites)
• Hospital Security Service
• Transport services - Labs and Medical
Instruments, Clinical Waste collection, HDSU runs etc.
Planning, Performance Management & Support Services
Still to be included
Medical & Governance • Pharmacy - Aseptic Services; Chemotherapy; Distribution of Pharmaceuticals; Clinical Pharmacy Services
Human Resources • Occupational Health Service - Management of sharps
8.0 Operational Service Resumption Strategies
In the event of a major or severe disruption, there are various options to be
considered and applied in order to resume the provision of a service/product. The following strategies are generic high level options within good practice that should be considered and built into the operational level business continuity resumption plans.
Each Directorate may also have to develop options that are specific to their areas of service provision.
Required resource Strategies (options) to consider include: People • Prioritisation of key service areas
• Diversion and redeployment of staff from other areas
within the Trust
• Multi-skill training of staff to perform outside their normal
role to ensure skill met flexibility
• Alternative staffing, including use of third parties,
increasing staff hours, secondment, etc
Premises • Alternative premises within the Trust, including
prioritisation and displacement of non-critical activities;
• Alternative premises provided by other organisations eg
another Trust
• Alternative premises provided by third party specialists • Portable premises eg portacabins
• Staff working from home or at remote sites
• Re-direction of services eg regional networking/ escalation
Technology • Revert touse of manual system
• Holding older equipment as emergency replacement or
spares
• Use back up sources either on Trust site or brought in • Restore IT records from back-ups, create and manage
records using paper systems
Supplies • Storage of additional supplies at another location
• Arrangements with third parties for delivery of stock at
short notice
• Identification of alternative/capable suppliers
• Increasing the number of suppliers that deliver products
required for critical services
In terms of the Trust overall, the loss of wards at the key sites e.g. ICU/HDU or Theatres remain the highest risk to the Trust as these are at a premium within the NI Healthcare system and suitable temporary facilities off-site would be extremely difficult to establish. Mitigation for the these critical services will be dependent on establishing networks e.g. (CCaNNI) with neighbouring Trusts to expedite the transfer of service users to suitable facilities in the event of a serious or major disruption where current capacity is overwhelmed or removed. In the event of an
networks already exist for neonatal care, adult intensive care, cancer and pathology services.
9.0 Training
Trust staff have a responsibility to ensure that they are both aware of and follow correct procedure during any level of disruptive incident. The Trust must support staff in understanding their role through education and training.
Robust training mechanisms are in place to ensure that staff must have access to the information they need to undertake this role.
Managers and staff must take responsibility for familiarising themselves with the Corporate Business Continuity Plan and undertake appropriate training as and when indicated by the Trust.
9.1 Methods of Training
The Trust will make arrangements for maintaining awareness and for training with regard to the organisations response to a business continuity disruption and the role of Trust staff in delivering this response in line with the following principles:
• On appointment as part of an induction process it is the responsibility of the line manager in raising awareness of the Corporate Business Continuity Plan and the individual’s key role and responsibility during any business continuity disruption;
• each Department is responsible for ensuring that staff receive training appropriate to their involvement in the business continuity response on a regular basis;
• Awareness raising sessions will be held annually for Senior Management Team; and
• Key staff will develop their competencies and practise their role as identified in the Corporate Business Continuity Plan through participating in exercises. The Plan will be available on the Trust intranet site.
Evidence of any training given at a Departmental level will be submitted to the Emergency Planning and Business Continuity Manger.
It is anticipated that when possible staff should have received training before participating in exercises or tests of the Trusts Plan.
10 Review & Validation
10.1 Review
To ensure that the Trust BCM process is adequate and effective, this Corporate Business Continuity Plan will be reviewed and updated on an annual basis, or more frequently if required following activation of the plan or an exercise, or significant organisational change.
It is the responsibility of the Emergency Planning & Business Continuity Manager to amend this Plan as required.
It is the responsibility of Directors and Managers to amend and review the Directorate and Departmental BCPs within the same principle.
The Trust Emergency Planning and Business Continuity Forum has been established under the Chairmanship of the Assistant Medical Director with a remit to ensure the Trusts Major Incident Plan and Business Continuity Plans are reviewed, updated, and maintained. The terms of reference are included in Appendix 6.
It is anticipated that a Trust Business Continuity Management specific group will be established to support the development of Directorate and Departmental Plans to support this plan.
10.2 Validation
This Plan will be validated through BCM exercising, which is conducted to ensure that staff with an identified role is fully aware of their role in the event of any level of disruption, and to identify any areas within the Plan that needs to be addressed or improved in a safe and controlled environment.
Exercising helps to build confidence in Trust staff, by clarifying roles and responsibilities, and providing valuable experience to responding to a disruptive incident; it also provides Trust confidence and assurance that the Plan is effective competent and that capability remains effective, fit-for purpose, and up-to-date.
The types of exercises will include communication, table-top, and live exercises.
It is the responsibility of each Director and Departmental Managers to ensure that Directorate and Departmental BCPs are validated regularly.
A post-exercise debrief will be completed following each live/table top exercise. These will allow for participants to comment on the effectiveness of the Plan and to identify lessons learnt from the exercise.
The Emergency Planning & Business Continuity Manager will complete a post exercise report which will include recommendations for improvement. This report is forwarded to the Medical Director for presentation to the SMT, and Trust Board.
