SERVICE CONTINUITY PLAN. Pharmacy CHAIR S SIGNATURE:

Transcription

1 SERVICE CONTINUITY PLAN Pharmacy V1 START DATE: NEXT REVIEW: COMMITTEE APPROVAL: COMMITTEE: Emergency Preparedness Steering Group DATE: February 2013 CHAIR S SIGNATURE: Thérèse Davis, Chief Nurse, Accountable Emergency Officer DISTRIBUTION: LOCATION: RELATED DOCUMENTS: ENDORSED BY: Mike Weston Divisional Medical Director Karen Robertson Divisional Director of Operations COMMITTEE: Clinical Support Services Quality Meeting DATE: Divisional Directors, General Manager, Emergency Planning Steering Group, authors for wider distribution of dependent services, Clinical Site Manager, Head of Emergency Preparedness and Business Continuity Trust Intranet Emergency Planning folder Trust Business Continuity Policy 2013, Trust Corporate Business Continuity Plan 2013, Trust Major Incident Plan 2011 AUTHOR / FURTHER INFORMATION: STAKEHOLDERS INVOLVED: Katey Hewitt, Deputy Chief Pharmacist Operations Deidre Linnard, Head of Pharmacy Emergency Preparedness Steering Group Karen Robertson, Divisional Director, CSS DOCUMENT REVIEW HISTORY: Date Version Responsibility Comments 07/03/ K Hewitt Initial Draft 26/03/ K Hewitt Further updates 14/06/ K Hewitt Further updates 18/11/ K Hewitt Mobile telephone numbers removed 15/02/ K Hewitt Extemporaneous preparations service removed after sign-off by CSS Quality Committee 26/02/13 1 Catherine Sands Head of Emergency Preparedness and Business Continuity Introduction updated with BS25999 removed and ISO replaced, reporting an incident updated, recovery deadlines added from BIA and signed off. DATE EXPIRED February 2016

2 Table of Contents Format TOC INTRODUCTION... 3 SERVICE DELIVERY... 4 DEFINITION OF THE SERVICE... 4 CRITICAL ACTIVITIES IN ORDER OF PRIORITY... 4 NON-CRITICAL ACTIVITIES... 4 SERVICE LOCATIONS... 4 SERVICE MANAGEMENT CONTACTS... 6 SERVICES THAT DEPEND UPON THIS SERVICE... 7 REPORTING AN INCIDENT... 8 ACTION CARD - INCIDENT ALERT PROCEDURE... 9 ACTIVITY AND RESOURCE REQUIREMENTS ACTIVITIES AND RESOURCES ALTERNATE RESOURCES PLAN FOR LOSS OF PHARMACY STAFF ACTION CARD LOSS OF PHARMACY STAFF PLAN FOR LOSS OF MAIN PHARMACY ACTION CARD LOSS OF MAIN PHARMACY PLAN FOR LOSS OF IT IN PHARMACY ACTION CARD LOSS OF PHARMACY ROBOT ACTION CARD LOSS OF JAC ACTION CARD LOSS OF LASTWORD PLAN FOR LOSS OF PRODUCTION UNIT ACTION CARD LOSS OF PRODUCTION UNIT PLAN FOR LOSS OF MEDICINAL SUPPLIES (INCLUDING MEDICAL GASES AND TPN) ACTION CARD LOSS OF MEDICINAL SUPPLIES APPENDIX 1 CONTACT LISTS Page 2 of 38

3 PHARMACY CONTINUITY PLAN Introduction Chelsea and Westminster Hospital NHS Foundation Trust has a duty to prepare for emergencies, maintain plans for preventing emergencies, and for reducing or controlling the effects of emergencies. It also has a responsibility to cooperate with other agencies to ensure the plans will be workable and effective if activated in a real situation. Alongside dealing with an emergency, the Trust must continue to deliver its most critical services at or above a pre-defined, acceptable level and return to Business as Usual working as soon as possible after service disruption ends. The Trust has therefore developed Business Continuity plans to support these objectives. Each critical service delivered by the Trust has been identified within its Business Impact Analysis. This Service Continuity Plan documents the response to interruption of Pharmacy, which is a critical service, such that it may be returned to at least an acceptable minimum level of delivery within a predictable timeframe. The Plan also contains actions required to return the service to Business as Usual delivery once the resource(s) that caused the original disruption have been restored or replaced. This Service Continuity Plan is an integral part of the Trust s strategic Business Continuity Plan. This Plan has been developed to meet the guidance of the Department of Health and NHS London and to be aligned with the International Standard for "Societal security -- Preparedness and Continuity Management Systems", ISO Page 3 of 38

4 Service Delivery Definition of the Service The pharmacy department provides medicines to patients (inpatients and outpatients) and wards and department, both during and outside working hours. The pharmacy department is also responsible for providing a medicines management service which includes procurement of medicines, financial analysis and reporting of drug expenditure and minimising risk to patients and staff from medicines. Critical Activities in Order of Priority Recovery Deadline 1. In-patient Prescription 2. Supply of parenteral nutrition to neonates, paediatric and adult patients Out-patient Prescription 4. Supply of ward/department stock items 5. Chemotherapy production and supply 6. Discharge Prescription 7. Pharmacy supply and advisory service to CNWLMH Trust wards/departments 8. Emergency Department 9. Dermatology creams/ointments production and supply 10. Ordering of medical gases 24 3 days 3 days 5 days 5 days 5 days 5 days 5 days Non-Critical Activities Financial reporting on Trust drug expenditure Daily review in-patient medication charts Medicines advisory service to patients, medical & nursing staff, GPs Pharmacy input to Medicines Committee, Medicines Incident Committee, NMAC etc. Service Locations The table below lists each location where the service is delivered: Location Address Service Manager Site Manager Chelsea and 369 Fulham Road, Deirdre Linnard, Deirdre Linnard, Head of Pharmacy Westminster Hospital London Head of Pharmacy Kobler Pharmacy St Stephens Centre, 369 Fulham Road Deirdre Linnard, Head of Pharmacy Sonali Sonechi, Lead Pharmacist HIV/GUM and Dermatology Dean Street clinic 56 Dean Street, Deirdre Linnard, Sonali Sonechi, Lead Pharmacist HIV/GUM Page 4 of 38

5 West London Centre for Sexual Health Soho, London Head of Pharmacy and Dermatology Charing Cross Deirdre Linnard, Sonali Sonechi, Lead Pharmacist HIV/GUM Hospital Head of Pharmacy and Dermatology Fulham Palace Road London W6 8RF Pharmacy ext Page 5 of 38

6 Service Management Contacts Contact Title Phone Mobile Address Deirdre Linnard Head of Pharmacy Karen Robertson Chief Pharmacist Vanessa Marvin Deputy Chief Pharmacist Clinical Services Katey Hewitt Deputy Chief Pharmacist Operations (Tues, Weds and Thurs) Deirdre Richardson Deputy Chief Pharmacist Operations (Mon & Fri) As above Page 6 of 38

7 Services That Depend Upon This Service The following table lists all critical services that depend upon continuity of the Pharmacy services in order to maintain delivery at an acceptable level. The RTO (Recovery Time Objective) field should contain the time in which Pharmacy services must be recovered in order to meet the continuity objectives of each critical service that depends upon them: Service Location RTO Hours Contact Phone Main Theatres Theatres 2 Odette Ferrao Paediatric Theatres Theatres 2 Odette Ferrao Burns Theatres Theatres 2 Odette Ferrao Surgery Inpatients Surgery, Medicine and Operations 2 Mitch Haines Burns Inpatients Burns Unit 4 Michelle Das General Medicine Inpatients Surgery, Medicine and Operations 4 Tris Mills Stroke (Nell Gwynne Ward) Surgery, Medicine and Operations 4 Tris Mills Gynae Inpatients - Annie Zunz Ward Women's, Children's + Sexual Health 8 Kathryn Mangold EPAU/GRAS Women's, Children's + Sexual Health 8 Kathryn Mangold Assisted Conception Women's, Children's + Sexual Health 8 Kathryn Mangold Outpatients (OP2) Women's, Children's + Sexual Health 8 Kathryn Mangold AAU Surgery, Medicine and Operations 8 Mitch Haines ICU and Burns ITU Intensive Care Unit 24 Jane-Marie Hamil Cancer Services (Adults) Cancer Services 96 Catherine Gillespie Medical Day Unit Surgery, Medicine and Operations 168 Ellie Shepheard Occupational Health (All Services) Occupational Health 336 Desiree Lindsay Lower Ground Outpatients Outpatients 336 Louise Magee/Jo Pierre Medical Outpatients (OP3) Outpatients 336 Zelda Vermaak Ophthalmology Outpatients (OP3) Outpatients 336 Zelda Vermaak Page 7 of 38

8 Reporting an Incident This section details whom to contact in order to report an incident where routine management processes cannot assure service continuity. This may be the result of a significant disruption to your service(s) due to planned or unplanned loss of one or more key activities or resources. TO REPORT AN INCIDENT, PHONE THE CLINICAL SITE MANAGER: BLEEP 0111 Command and Control Team Contact Details Team Role Named Person Work Tel Clinical Site Manager Per rota Bleep 0111 Communication Pod once opened Comms Pod Once opened Ext Silver.control@chelwest.nhs.uk Incident Alert Procedure On-Duty / On-Call Managers have a duty to inform the Trust through the duty Clinical Site Manager of any incident (staff shortage, missed supply delivery, pandemic outbreak among inpatients, etc) that has the potential to disrupt their service(s) beyond the ability of routine management processes to assure service continuity at an acceptable level. An action card containing specific instructions for notifying the Command and Control Team is included in this section of the Plan. Once the duty Clinical Site Manager has been alerted to a potential critical service disruption, continue to execute this Service Continuity Plan unless you are specifically directed to await further instructions by the Gold or Silver Trust Commander or Exec On-Call. Head of Emergency Preparedness and Business Continuity Catherine Sands Ext Bleep 6729 Catherine.Sands@chelwest.nhs.uk Page 8 of 38

9 Action Card - Incident Alert Procedure IN ALL CASES, call the Clinical Site Manager on BLEEP 0111 Cleary give your name and phone number, your job title and location to the person who answers the phone Explain the incident. Give as much detail as possible, as CLEARLY and SIMPLY as possible, including actions already undertaken and actions you plan to take. Invoke a Service Continuity Plan if not doing so will overwhelm routine management processes and expose staff and/or patients to intolerable risk. Verify that you or the Bronze Commander has a copy of the Service Continuity Plan. The Command and Control Team will provide copies if you cannot locate one. Page 9 of 38

10 Activity and Resource Requirements The tables in this section of the Plan provide details of the activities and resources that the Pharmacy services requires in order for delivery to recover/continue at an acceptable level, the levels at which they are required and how they are to be replaced in the event of their loss. The first table lists each of the activities and resources identified in the Business Impact Analysis and describes for each resource or process: The function of the activities and resource in support of the service The activity and resource level(s) during normal, Business as Usual operation of the service The Minimum Continuity Level - This is the least amount of resource that will allow the service to be continued at a minimally acceptable level Who is responsible for the activity or resource internally Who the external supplier is, where applicable The second table lists alternate resources that may be deployed by this plan, where they will be sourced from, at what levels, who is responsible for them and, critically, how long it will take to deploy them. NOTE: 1. The time taken to deploy alternate resources is critical in determining the invocation threshold for the service. For example, if a service has a Maximum Tolerable Period of Disruption of 3 days and it will take two days to deploy a replacement for a lost resource, the invocation threshold for the Plan must not exceed one day. 2. Do NOT use this table as a wish list ; only resources that you already know will be available when executing this plan should be listed here. Page 10 of 38

11 Activities and Resources Priority Activity/Resource Role Normal Level Continuity Level Supplier / Contact Medicinal supplies (ex medical gases) In-patient Prescription 2 wholesale deliveries per day A-Z supplier 1 delivery per 3-5 working days providing disruption is Buying Office Manager or Purchasing Co-ordinator to Outpatient Prescription deliveries per day due to local issue liaise with suppliers Emergency Department Typically hold min 7 days residual stock of all lines. Discharge Prescription Supply of ward/department stock items Chemo production and 1 supply Pharmacy supply and advisory service to CNWL MH Trust wards/departments Out of Hours Pharmacy Service Page 11 of 38

12 Priority Activity/Resource Role Normal Level Continuity Level Supplier / Contact Main Dispensary In-patient Prescription Normal level = Required 24 hours per day 7 days per As per business as usual Outpatient Prescription week Emergency Department Discharge Prescription Supply of 2 ward/department stock items Pharmacy supply and advisory service to CNWL MH Trust wards/departments Out of Hours Pharmacy Service robot In-patient Prescription Outpatient Prescription Emergency Department 3 robot units 1 robot unit Pharmacy IT systems Manager or Senior Technician inpatients / IT 3 Discharge Prescription Supply of ward/department stock items Out of Hours Pharmacy Service Page 12 of 38

13 Priority Activity/Resource Role Normal Level Continuity Level Internal Contact Pharmacists In-patient Prescription Main: Normal level = 1 from 1 pharmacist or ACT Pharmacy Business Manager pool of 55 or Deputy Chief Pharmacist Outpatient Prescription Main: Normal level = 3 from pool of 55 2 pharmacists Operations Emergency Department Main: Normal level = 1 from pool of 55 1 pharmacist Discharge Prescription Main: Normal level = 1 from pool of 55 1 pharmacist Daily review of med charts Main: Normal level = 41 from pool of 55 (Also covering other roles) 6 pharmacists covering only this role 4 Chemo production and supply Parenteral nutrition Main: Normal level = 3 from pool of 55 Main: Normal level = 3 from pool of 55 (Covering other roles) 1 pharmacist covering only this role 2 pharmacists only covering this role who are appropriately trained Medicine advisory service to Main: Normal level = 1 from pool of 55 1 pharmacists who are appropriately trained Financial expenditure Pharmacy supply and advisory service to CNWL MH Trust wards/departments Out of Hours Pharmacy Service Main: Normal level = 5 from pool of 55 covering this task 1 day per month Normal Level = 6 from pool of 55 Main: Normal level = 1 Resident per night on duty. 10 Resident pharmacists from pool of 55 covering residency rota on a rostered basis 2 pharmacists who are appropriately trained covering this on a full time basis for 3 days. 3 pharmacists 1 Resident per night on duty. 5 Resident pharmacists covering this task on a rostered basis Page 13 of 38

14 Priority Activity/Resource Role Normal Level Continuity Level Internal Contact Technicians (or assistants in In-patient Prescription Main: Normal level = 2 from 1 technicians or 2 technicians case of ward stock) pool of 45 if no robot Outpatient Prescription Main: Normal level = 3 from pool of 45 2 technicians or 4 technicians if no robot Pharmacy Business Manager or Deputy Chief Pharmacist Operations Emergency Department Main: 1 from pool of 45 1 technicians or 2 technicians if no robot Discharge Prescription Main: Normal level = 1 from pool of 45 1 technicians or 2 technicians if no robot 5 Supply of ward/department stock items Main: Normal level = 6 from pool of 45 4 assistants / technicians or 6 if no robot Chemo production and supply Main: Normal level = 3 from pool of 45 1 technician who is accredited to make chemo PC Workstations with access to JAC, EPR, Printer (Zebra + Laser), , Intranet/Internet Pharmacy supply and advisory service to CNWL MH Trust wards/departments Medical gases In-patient Prescription Outpatient Prescription Normal Level = 2 from pool of 45 Normal level = 1 from pool of 45 covering this task 1 hour per week Normal level = 1 workstations Normal level = 2 workstations 1 Technician As per business as usual 1 x workstation with Zebra printer and access to JAC 1 x workstation with Zebra printer and access to JAC IT Helpdesk 6 Emergency Department Discharge Prescription Supply of ward/department stock items 1 workstation undertaking other work Normal level = 2 workstations Normal level = 2 workstations Daily review of med charts Access to workstations on wards 2 x workstation with access to EPR Page 14 of 38

15 Priority Activity/Resource Role Normal Level Continuity Level Internal Contact Chemo production and supply Normal level = 2 workstations 1 x workstation with Zebra printer and access to JAC and EPR Parenteral nutrition Normal level = 2 workstations Medicines advisory service to Trust staff and patients Pharmacy supply and advisory service to CNWL MH Trust wards/departments Normal level = 1 workstations Normal level = 2 workstations 1 x workstation with access to JAC, EPR and external phone line 1 x workstation with Zebra printer and access to JAC Medical gases Normal level = 2 workstations As per business as usual 7 Consumables supplies Out of Hours Pharmacy Service In-patient Prescription Outpatient Prescription Emergency Department Discharge Prescription Chemo production and supply Pharmacy supply and advisory service to CNWL MH Trust wards/departments Normal level = 1 PC Workstation with access to JAC, EPR, Printer (Zebra + Laser), , Intranet/Internet 1 delivery every 14 days Typically hold min 14 days supply residual stock 1 x workstation with Zebra printer and access to JAC As per business as usual Buying Office Manager or Purchasing Co-ordinator to liaise with suppliers Page 15 of 38

16 Priority Activity/Resource Role Normal Level Continuity Level Internal Contact Label supplies In-patient Prescription 1 delivery once per month As per business as usual or alternative supplier Buying Office Manager or Purchasing Co-ordinator to Outpatient Prescription liaise with suppliers Emergency Department Discharge Prescription Chemo production and 8 supply Pharmacy supply and advisory service to CNWL MH Trust wards/departments Admin and Clerical Staff In-patient Prescription Outpatient Prescription Normal level = 1 from pool of 12 1 A&C staff during busy periods Pharmacy Business Manager or Deputy Chief Pharmacist Operations 9 Discharge Prescription Portering service Medical gases In-patient Prescription Normal level = 1 from pool of As per business as usual 12 covering this task for 30 minutes per week 1 x porter 10am-6pm Use of pneumatic air tube and self collection Jacinto Jesus 10 Discharge Prescription Supply of ward/department stock items 1 x porter 10am-6pm Use of pneumatic air tube and self collection 1 x porter 10am-6pm As per business as usual Page 16 of 38

17 Priority Activity/Resource Role Normal Level Continuity Level Internal Contact Medical gases 1 x porter 1 hour per week As per business as usual 11 Transport Supply of ward/department stock items Parenteral nutrition Transport Transport delivery service from production unit to C&W Transport delivery service provided to CNWL off-site wards 9am-6pm 5 Deliveries per week 1 delivery per 3-5 working days Distribution Production unit with environmental conditions and monitoring Licensed supplier/production of TPN that meets legal and pharmaceutical requirements Licensed supplier of medical gases Pharmacy supply and advisory service to CNWL MH Trust wards/departments Supply of ward/department stock items Transport delivery serice provided to CNWL off-site wards 9am-6pm Normal level = Required 24 hours per day 7 days per 1 delivery per 3-5 working days week Chemo production and supply Dedicated sterile unit Sterile until environmentally tested decant to Royal Marsden or Royal Brompton or outsource Parenteral nutrition Medical gases Resupply of tanks per telemetry. Holds approx 18 days supply Resupply of cylinders in 24 hours. Stock approx 10 days supply Marie Courtney As per business per usual Normal level = Required 24 hours per day 7 days per week Outsource to alternate licensed supplier Resupply of O 2 cylinders on same day (8-12 hours) Resupply of Medical Air in 48 hours AirProducts (tanks) BOC (cylinders) Page 17 of 38

18 Alternate Resources Resource Supply Level Location Contact Deployment Time Pharmacist list Approximately 50 pharmacists on list (employed). Full supply level may not be available at any one time due to annual / sickness leave. Refer to department diary and sickness book Dept secretaries + back-up on call Phone + senior managers (lists offsite) Pharmacy Office, Ext Backup Pharmacist, Bleep 5686 (OOH) 2 to 4 hours Contact details of all other (nonpharmacist) current staff members Approximately 70 nonpharmacists on file (employed). Full supply level may not be available at any one time due to annual / sickness leave. Refer to department diary and sickness book Bank staff 1 pharmacist and 1 technician A&C / assistants staff depending on suitable people on staff bank register Procedure 9.05 Booking Bank and Agency Staff Pharmacy Pressure Surge Plan Standard operating procedures Power contingency folder Procedure for organising police escort / blue light Dept secretaries Pharmacy Office, Ext to 4 hours Staff bank Ext to 5 days Pharmacy intranet Pressure Surge Plan Intranet and procedure folders Dispensary above screening bench Pharmacy intranet Resident folder Page 18 of 38

19 Plan for Loss of Pharmacy Staff First Steps 1. Assess available staff levels 2. If minimum staff levels cannot be reached by routine management processes, find the Incident Alert Procedure Action Card and follow the instructions. 3. If you are unable to find the Incident Alert Procedure Action Card, call the Clinical Site Manager on Bleep Invoke the remainder of this Plan at your discretion in order to avoid significant impact to the most critical services. The following table lists the resources that will be used during continuity operation of the service Alternate Resources Preparing for Continuity Resource Quantity Location Contact Pharmacist contact details list Contact details of all other (nonpharmacist) current staff members Approximately 50 depending on annual / sickness leave. Approximately 70 non-pharmacists on file (employed), depending on annual / sickness leave. Bank staff 1 pharmacist and 1 technician A&C / assistants staff depending on suitable people on staff bank register Procedure 9.05 Booking Bank and Agency Staff Pharmacy Pressure Surge Plan Dept secretaries + back-up on call phone + senior managers (lists offsite) Dept secretaries Staff bank Pharmacy intranet Pressure Surge Plan Secretaries ext Back up on call pharmacist Bleep 5686 Secretaries ext Staff bank extension Follow instructions in the Response section on the Loss of Pharmacy Staff action card. Continuity Procedures Refer to the Pharmacy Pressure Surge Plan to prioritise activities at staffing levels below Business as Usual Follow standard operating procedures for managing scheduling staff Recovery Follow instructions in the Recovery section on the Loss of Pharmacy Staff action card Page 19 of 38

20 Response Action Card Loss of Pharmacy Staff Using initial assessment of available staff, move staff between sections as needed Re-prioritise tasks within pharmacy and inform relevant staff. Use the Pharmacy Pressure Surge Plan Depending upon which activities must be continued, determine the minimum staffing levels required. The Service Continuity Plan and Pressure Surge Plan can guide your decisions. If you still cannot meet minimum staffing requirements, start calling off duty staff using contact details held by Pharmacy Secretaries on Ext (in hours). Out of hours contact the back up on call pharmacist on Bleep 5686, to contact staff using the contact details in the back up mobile phone. If you will still be unable to meet minimum numbers for longer than 1 to 5 days, refer to pharmacy procedure 9.05 Booking bank and Agency Staff If you still cannot meet minimum numbers, escalate to the Chief Pharmacist, Karen Robertson on Ext Recovery Assess whether or not you need to assign additional staff to catch up on activities that have been suspended or scaled back Assess what your staffing needs will be if staff involved with Continuity will require time off post-recovery Ensure all relevant stakeholders are contacted and informed when services have returned to business as usual Page 20 of 38

21 Plan for Loss of Main Pharmacy First Steps Alternate Resources 1. Assess which specific areas of main pharmacy are affected and approximate time to return to business as usual 2. If only part of main pharmacy is affected, assess which services can continue to operate as usual and which are affected 3. Consider if affected services can continue if (feasibly) moved to a different location in main pharmacy and co-ordinate accordingly 4. If services are affected and cannot continue by routine management processes, and you anticipate a significant period of disruption, find the Incident Alert Procedure Action Card and follow the instructions. 5. If you are unable to find the Incident Alert Procedure Action Card, call the Clinical Site Manager on Bleep Invoke the remainder of this Plan at your discretion in order to avoid significant impact to the most critical services. The following table lists the resources that will be used during continuity operation of the service Resource Quantity Location Contact Standard operating procedures Intranet and procedure folders Pharmacy Pressure Surge Plan Pressur e Surge Plan Preparing for Continuity Follow instructions in the Response section on the Loss of Pharmacy Medicinal Supplies action card. Continuity Procedures Refer to the Pharmacy Pressure Surge Plan to prioritise activities at staffing levels below Business as Usual Follow standard operating procedures Recovery Follow instructions in the Recovery section on the Loss of Pharmacy Staff action card Page 21 of 38

22 Response Action Card Loss of Main Pharmacy If there is likely to be an impact on outcome of service, for example waiting times, or the disruption is likely to be prolonged, escalate to the Chief Pharmacist, Karen Robertson on Ext Use the Pharmacy Pressure Surge Plan to assess priority services and determine which services must continue. Reprioritise activities as needed and inform staff If there is likely to be an impact on service, for example prescription waiting times, or the disruption is likely to be prolonged, inform the Each Divisional Medical Director and Divisional Director of Operations Clinical Site Manager and Trust Executive on call (out of hours) via switchboard Using initial assessment of services affected, cause of disruption and approximate timescales, determine if services need and can be safely moved to a different location within pharmacy or outside pharmacy if needed. For example, Kobler pharmacy or AAU and other TTO cupboard dispensing areas with JAC facilities Organise movement. Draft in extra staff from other sections if assistance is needed Ensure adequate communication is provided to wards and patients, where applicable, to inform them of the change If essential services cannot be moved to another area or the disruption is likely to be extensive / prolonged consider mutual aid from other Trusts. Nearest Trusts are: The Royal Marsden (Chief Pharmacist Ian Costello tel ) and Royal Brompton (Chief Pharmacist Richard Goodman tel ) Consider use of FP10(HP) prescriptions and for outpatient prescriptions limiting prescriptions to only new non-urgent Page 22 of 38

23 medicines Investigate with wholesalers if support can be provided for ward box consolidation of stock medicines Keep a log of equipment and supplies transferred out Recovery If services have been moved to a different location, organise movement back to original location Assess whether or not additional staff is needed to catch up activities that have been suspended or scaled back Ensure all relevant stakeholders are contacted and informed when services have returned to Business as Usual. Check in equipment and supplies returned to recovered site using the log created when relocating to temp site Page 23 of 38

24 Plan for Loss of IT in Pharmacy First Steps 1. Assess which IT service(s) is / are affected, timescales for availability and alternatives. 2. If you are unable to access or use the EPR, call the IT Support Helpline on ext If minimum IT level cannot be reached by routine management processes, find the relevant Incident Alert Procedure Action Card(s) and follow the instructions. 4. If you are unable to find the Incident Alert Procedure Action Card (s), contact the Clinical Site Manager on Bleep Invoke the remainder of this Plan at your discretion in order to avoid significant impact to the most critical services. The following table lists the resources that will be used during continuity operation of the service Alternate Resources Resource Quantity Location Contact Standard operating procedures Intranet and procedure folders Power contingency folder Dispensary above screening bench Pharmacy Pressure Pressure Surge Plan Surge Plan EPR laptop computer (standalone) 1 IT Dept On-duty IT manager Preparing for Continuity Follow instructions in the Response section on the relevant action card(s) Continuity Procedures Refer to the Pharmacy Pressure Surge Plan to prioritise activities Follow standard operating procedures Recovery Follow instructions in the Recovery section on the action card(s) Page 24 of 38

25 Action Card Loss of Pharmacy Robot Page 25 of 38

26 Response Note: This would be followed if routine management processes have been implemented but the robot is completely unavailable and ARX have not managed to resolve the issue remotely and therefore waiting for an engineer to rectify the problem on site Use the Pharmacy Pressure Surge Plan to assess priority services and determine which services must continue. Reprioritise activities as needed and inform staff If there is likely to be an impact on service, for example waiting times or the disruption is likely to be prolonged, escalate to the Chief Pharmacist, Karen Robertson on Ext Ensure adequate communication is provided to wards and patients, where applicable, if there is likely to be an impact on service If there is likely to be a significant impact on service, for example prescription waiting times and the disruption is likely to be prolonged, inform the Recovery Each Divisional Medical Director and Divisional Director of Operations Clinical Site Manager and Trust Executive on call (out of hours) via switchboard Assess which services or routine tasks were suspended and identify if any catch up is required. Determine if extra staff is required and draft in as needed Consult IT / ARX to determine cause of problem and any recovery actions needed to ensure integrity of system and to prevent similar problem in future Ensure all relevant stakeholders are contacted and informed when services have returned to business as usual. Action Card Loss of JAC Page 26 of 38

27 Response Note: This would be followed if routine management processes have been implemented but both live and fallback JAC are not working / cannot be accessed Use the Pharmacy Pressure Surge Plan to assess priority services and determine which services must continue. Reprioritise activities as needed and inform staff If there is likely to be an impact on service, for example waiting times, or the disruption is likely to be prolonged, escalate to the Chief Pharmacist, Karen Robertson on Ext Ensure adequate communication is provided to wards and patients, where applicable, if there is likely to be an impact on service If there is likely to be a significant impact on service, for example prescription waiting times and the disruption is likely to be prolonged, inform the Each Divisional Medical Director and Divisional Director of Operations Clinical Site Manager and Trust Executive on call (out of hours) via switchboard Refer to the power contingency folder (located in dispensary above screening bench) Recovery Assess which services or routine tasks were suspended and identify if any catch up is required. Determine if extra staff is required and draft in as needed Ensure all medicines supplied and orders are retrospectively booked out on JAC Consult IT / JAC to determine cause of problem and any recovery actions needed to ensure integrity of system and to prevent similar problem in future Ensure all relevant stakeholders are contacted and informed when services have returned to Business as Usual. Page 27 of 38

28 Response Action Card Loss of Lastword IT will provide a laptop computer that has a stand-alone copy of the EPR installed on it The IT department support team will provide an estimated delivery date for the stand-alone laptop Allocate a safe, lockable location for the laptop to be stored when not in use Once the laptop is delivered, the IT support team will provide training in the use of the laptop and the stand-alone EPR software to the Head of Pharmacy / nominated deputy Head of Pharmacy / nominated deputy must ensure relevant staff receive training in the use of the laptop, the stand-alone EPR software and procedures for storage and retrieval of the laptop Alternatively, obtain the tablet device from the Medicine Office. This can receive the EPR via Wi-Fi (in the dispensary) if the network is down Data Synchronisation and recovery If a laptop running a stand-alone version of the EPR had been issued the IT support team will inform you of the day and time when the laptop will be collected and by whom. Do not release the laptop to anyone not identified to you by the IT department or Silver Trust Command as authorised. Once the IT department has retrieved the laptop, the data transcribed onto it will be transferred electronically to the live EPR system. The IT department will inform you when this data transfer has been completed and all patient records are available on the primary EPR Page 28 of 38

29 Plan for Loss of Production Unit First Steps 1. If minimum level cannot be reached by routine management processes and Technical Services SOPs, find the Incident Alert Procedure Action Card and follow the instructions. 2. If you are unable to meet minimum requirements, find the Incident Alert Procedure Action Card and follow the instructions. 3. Invoke the remainder of this Plan at your discretion in order to avoid significant impact to the most critical services. The following table lists the resources that will be used during continuity operation of the service Alternate Resources Resource Quantity Location Contact Technical Services Technical Services Office SOPs Pharmacy Pressure Pressure Surge Plan Surge Plan Preparing for Continuity Follow instructions in the Response section on the Loss of Pharmacy Production Unit action card. Continuity Procedures Refer to the Pharmacy Pressure Surge Plan to prioritise activities Follow standard operating procedures Recovery Follow instructions in the Recovery section on the Loss of Pharmacy Production Unit action card Page 29 of 38

30 Response Action Card Loss of Production Unit Determine expected time scale for loss of facilities If there is likely to be an impact on service or the disruption is likely to be prolonged, escalate to the Chief Pharmacist, Karen Robertson on Ext If there is likely to be a significant impact on service and the disruption is likely to be prolonged, inform: MacMillan and Oncology Clinical Nurse Specialist on ext or bleep 4518 Oncology Consultants: Professor Mark Bower on ext or mobile via switchboard Dr Newsom-Davies on ext or mobile via switchboard Acute Oncology Lead via switchboard Discuss planned chemotherapy and options for delaying, depending on timescales If there is likely to be a significant impact on service and the disruption is likely to be prolonged, also inform those below where applicable: Each Divisional Medical Director and Divisional Director of Operations Clinical Site Manager and Trust Executive on call (out of hours) via switchboard Where workload cannot be delayed, consider mutual aid with other Trusts and outsourcing e.g. Hospira UK (tel ); ITHpharma (tel ). Nearest trusts: The Royal Marsden (Chief Pharmacist Ian Costello tel ) and Royal Brompton (Chief Pharmacist Richard Goodman tel ) Page 30 of 38

31 Recovery Organise re-commissioning monitoring where applicable of equipment and environmental Assess which services or routine tasks were suspended and identify if any catch up is required. Determine if extra staff is required and draft in as needed Ensure all relevant stakeholders are contacted and informed when services have returned to Business as Usual Page 31 of 38

32 Plan for Loss of Medicinal Supplies (including medical gases and TPN) First Steps 1. If minimum level cannot be reached by routine management processes, find the Incident Alert Procedure Action Card and follow the instructions. 2. If you are unable to meet minimum requirements, find the Incident Alert Procedure Action Card and follow the instructions. 3. Invoke the remainder of this Plan at your discretion in order to avoid significant impact to the most critical services. The following table lists the resources that will be used during continuity operation of the service Alternate Resources Resource Quantity Location Contact Pharmacy Pressure Pressure Surge Plan Surge Plan Procedure for organising police escort / blue light Pharmacy intranet Resident folder Preparing for Continuity Follow instructions in the Response section on the Loss of Pharmacy Medicinal Supplies action card. Continuity Procedures Refer to the Pharmacy Pressure Surge Plan to prioritise activities Follow standard operating procedures Recovery Follow instructions in the Recovery section on the Loss of Pharmacy Medicinal Supplies action card Page 32 of 38

33 Response Action Card Loss of Medicinal Supplies Identify which medicinal supplies and particular supply chain (s) is /are affected Conserve existing supplies where necessary. For example, only supply absolute minimum to patients, consider alternatives and only supply on discharge, medicines patients do not have at home and cannot obtain Contact regional procurement: Kevan Wind (Tel: Fax ) Determine if it is a local or regional / national issue and discuss potential solutions, including alternative suppliers If supply affected is a medical gas, discuss with Nick Fauvel bleep 4917, David Bushby ext and Trust Authorised Person Nick Webb ext Consider mutual aid with other Trusts / organisations The Royal Marsden (Chief Pharmacist Ian Costello tel ) and Royal Brompton (Chief Pharmacist Richard Goodman tel ) If a supply is required as matter of urgency and requires a police escort, refer to procedure Organising police escort / blue light Recovery Assess which services or routine tasks were suspended and identify if any catch up is required. Determine if extra staff is required and draft in as needed Ensure all relevant stakeholders are contacted and informed when services have returned to Business as Usual Page 33 of 38

34 Page 34 of 38

35 Appendix 1 Contact Lists Internal Contacts Contact Title Location Phone Fax Mobile Address Karen Robertson Chief Pharmacist and Chelsea and Karen.robertson@chelwest.nhs.uk Divisional Director of Operations Clinical Support Westminster Hospital Deirdre Linnard Head Of Pharmacy Chelsea and Deirdre.linnard@chelwest.nhs.uk Westminster Hospital Vanessa Marvin Deputy Chief Vanessa.marvin@chelwest.nhs.uk Pharmacist Clinical Services Katey Hewitt Deputy Chief Katey.hewitt@chelwest.nhs.uk Pharmacist Operations Miriam Bent Buying Office Miriam.bent@chelwest.nhs.uk Manager Lisa DiStefano Business Manager Pharmacy secretaries Ext Jacinto Jesus Portering Manager IT Helpdesk Catherine Gillespie MacMillan and Oncology Clinical Nurse Specialist Ext or bleep 4518 Professor of Oncology Professor Mark Bower Via switchboard Oncology Consultant Dr Newsom-Davies Via switchboard Back up on call Bleep 5686 pharmacist Dr Nick Fauvel Consultant Bleep 4917 Anaesthetist David Bushby Resuscitation Officer Nick Webb Medical Gas Authorised Person Divisional contacts: Page 35 of 38

36 A. Clinical Support Karen Robertson Divisional Director of Operations Clinical Support See above Page 36 of 38

37 Contact Title Location Phone Fax Mobile Address Dr Mike Weston Divisional Medical Director Clinical Support B. Medicine and Surgery Debbie Richards Divisional Director of Operations Medicine and Surgery Jeremy Thompson Divisional Medical Director Medicine and Surgery or (PA) or (PA) C. Women Services; Children s, Young People & Neonatal Services; HIV, GUM & Dermatology Zoe Penn Divisional Medical Director Women or (PA) Services; Children s, Young People & Neonatal Services; HIV, GUM & Dermatology Jen Allan Robert Hutchinson Interim Divisional Director of Operations Women Services; Children s, Young People & Neonatal Services; HIV, GUM & Dermatology (PA) Page 37 of 38

38 External Agencies Agency Contact Phone Fax Mobile Address Kevan Wind Medicines Procurement Specialist Pharmacist London & East of England ITHPharma Hospira Royal Brompton Hospital Ian Costello Royal Marsden Richard Goodman Page 38 of 38