Patient Flow and Escalation Management Policy (Operational Pressures Escalation Framework) Version 1.3 Review: December 2018

Livewell Southwest Patient Flow and Escalation Management Policy (Operational Pressures Escalation Framework) Version 1.3 Review: December 2018 Notice to staff using a paper copy of this guidance The policies and procedures page of Intranet holds the most recent version of this guidance. Staff must ensure they are using the most recent guidance. Author: Community Urgent Care Services Manager Asset Number: 942 Page 1 of 20

Reader Information Title Patient Flow and Escalation Management Policy (Operational Pressures Escalation Asset number 942 Rights of access Public Type of paper Policy Category Non clinical Document purpose/summary To provide a local framework for system escalation in line with National guidance. Author Sarah Pearce, Community Urgent Care Services Manager Ratification date and December 2017. Policy Ratification Group group Publication date 4 th January 2018 Review date and One year after publication, or earlier if there is a change in frequency (one, two or evidence three years based on risk assessment) Disposal date Job title Target audience The PRG will retain an e-signed copy for the archive in accordance with the Retention and Disposal Schedule. All copies must be destroyed when replaced by a new version or withdrawn from circulation. Sarah Pearce, Community Urgent Care Services Manager All Livewell Southwest staff Electronic: Livewell Southwest (LSW) intranet and website (if applicable) Circulation Written: Upon request to the Policy Co-ordinator at livewell.livewellpolicies@nhs.net Please contact the author if you require this document in an alternative format. Stakeholders Consultation process Equality analysis checklist completed Is the Equality and Diversity Policy referenced Is the Equality Act 2010 referenced All staff working in patient flow areas in LSW and in in PNHT Consultation via email with Localities, Executive Team, local A+E Board, PHNT Yes [NA] [NA] References/sources of information Associated NHS England Operational Pressures Escalation (OPEL) Framework, October 2016 N/A Page 2 of 20

documentation Supersedes document Escalation Policy v1.2 By post: Local Care Centre Mount Gould Hospital, 200 Author contact details Mount Gould Road, Plymouth, Devon. PL4 7PY. Tel: 0845 155 8085, Fax: 01752 272522 (LCC Reception). Document review history Version no. 0.1 1 Type of change New Policy to replace Escalation Policy Minor amends 1.1 Minor amends 1.2 1.3 Amendments to format and detail Minor amendments Date November 2016 December 2016 January 2016 April 2017 October 2017 Originator of change NHS England revised guidance. PRG PRG Alignment of Policy with PNHT. Community Urgent Care Services Manager Description of change Old policy replaced in line with revised national guidance. Minor amends Minor amends Amendments to triggers to set OPEL levels. Change of format to Appendix A into action cards Appendix C and D removed as contained in Appendix B. Amendments to triggers and actions in line with Winter planning. Removed action cards from Appendix A as actions already within the main body of the policy Page 3 of 20

Contents Page 1 Introduction 5 2 Purpose 5 3 Definitions 5 4 Duties & Responsibilities 5 5 Business as Usual Schemes and actions in OPEL that support Resilience across the system 6 6 The Escalation Framework 6 7 Escalation Management and Process 7 8 Business Continuity and Major Incidents 16 9 Training implications 17 10 Monitoring compliance 17 Appendix A Risk Assessment for OPEL Actions 18 Appendix B NHS England Operational Pressures Escalation Framework, Oct 2016 20 Page 4 of 20

Patient Flow and Escalation Management Policy (Operational Pressures Escalation Framework) 1 Introduction 1.1 Livewell Southwest (LSW) is committed to supporting the health and social care system to manage patient flow in and out of hospital. This document describes a series of schemes to support the patient flow across the whole system, and should be read in conjunction with wider system escalation plans for the system. 2 Purpose 2.1 This policy sets out LSW response to escalation and resilience planning and managing capacity across the system. It contains business as usual actions to maintain flow and our resilience plan to use in times of escalation across the system. This policy brings all resilience and escalation planning actions into one document. 3 Definitions 3.1 LSW: Livewell Southwest 3.2 IHDT: Integrated Hospital Discharge Team 3.3 UC-CCC: Urgent Care-Commissioning Control Centre 3.4 CCG: Clinical Commissioning Group 4 Duties & responsibilities 4.1 The Chief Executive is ultimately responsible for the content of all policies, implementation and review. 4.2 The Board of Director(s) have overall responsibility and accountability for ensuring resilience and capacity arrangements described in this policy are in place and effective within the organisation. The Devon A+E Delivery Board is represented at Director Level. 4.3 Responsibility of line managers All members of the organisation s Senior Management Team are responsible for the operational implementation and maintenance of resilience management arrangements in their individual areas of responsibility. 4.4 Responsibility of the Tactical Control Centre (TCC) The TCC lead will implement actions within the policy, dependent on organisational and system OPEL status on a daily basis and monitor the impact of actions taken to de-escalate. Page 5 of 20

4.5 Responsibility of all staff To work within the requirements of the policy. To report any clinical incidents that arise due to escalation actions as per incident reporting process. 5 Business as Usual, risk assessment and actions in OPEL that support Resilience across the system 5.1 LSW has a range of teams that support patient flow across the system. Actions taken in business as usual (OPEL1) and in escalation are described in section 7.5. Risk assessment around actions is described in Appendix A. 6 The Operational Pressures Escalation (OPEL) Framework 6.1 The purpose of this escalation framework is to describe the procedures for managing significant surges in demand across the system. The plan follows NHS England Operational Pressures Escalation (OPEL) Framework, October 2016. (Appendix B). 6.2 All communications within and across organisations will adhere strictly to four levels of escalation as set out in the National Guidance: Page 6 of 20

6.3 The OPEL levels replace the previous escalation descriptor levels of Green (OPEL 1), Amber (OPEL 2), Red (OPEL 3) and Black (OPEL 4). 7. Escalation Management and Process 7.1 Each organisation is responsible for defining their triggers and actions within the organisational framework in terms of their internal responses at each level of escalation. If their escalation plans seek or require mutual-aid or recognised assistance from another organisation this must be formally agreed with that organisation and set up with trigger levels and communication channels and signed-off by the relevant A+E board. NHS England guidance to define escalation levels and triggers is described in Appendix B. 7.2 Each organisation will submit a self-declared OPEL Status based on their Organisational triggers to the Urgent Care-Commissioning Control Centre D-CCG.urgentcare-control@nhs.net by 10.00hrs. Within LSW this is completed by the Tactical Control Centre team. 7.3 Each A+E Board is responsible for setting the locality triggers for the locality, so that there is a clear equivalency and understanding between organisations for communication purposes. The Chair of the A+E Board will assure the CCG that there are robust plans agreed by organisations and will delegate responsibility to named officers (and deputies) for examining OPEL self-declared reports from organisations and set the OPEL for the Locality. Previous guidance states this should be based on triggers across at least two organisations for the locality. The Locality OPEL must be confirmed to the UC-CCC by 10.30am. 7.4 The UC-CCC will publish, by 11am a Monday to Friday a daily dashboard with the Locality declared OPEL status. On the basis of these three locality OPELs the UC- CCC will declare a CCG-wide OPEL communicating this clearly to CCG on-call directors and NHS E along with the planned Escalation Management. 7.5 LSW Local Triggers and Actions: OPEL 1 (All statements to be met for OPEL 1) Community capacity available across the system: Alternatives to admission (A2A) running as planned opening and staffing capacity: Community Crisis Response Team open as planned Acute Care at Home running as planned Robin unit running as planned OOH DN running as planned with 2 overnight teams Acute GP running with 3 GPs across AGP and Robin Planned community hospitals discharges (general beds) >2 D2A capacity (Home first and bedded) No infection control outbreaks across LSW services Page 7 of 20

Referrals to discharge teams are allocated same day Community Hospital (LCC, Stroke, Plym Neuro, Kingsbridge and Tavistock) DToCs are not above 4 Acute delays for Plymouth and Devon are <23 Same day response available from duty functions across services Locality and urgent care ASC teams running as planned No social work assessment delays in acute/community hospitals 5+ met to confirm OPEL 1 Local Actions for OPEL 1 Action By Whom? Daily review of system capacity Bronze template and Daily Alamac lighthouse report to inform system performance, escalate to CCG as needed Overview of community capacity Coordinate and source care home placements in conjunction with brokerage function Daily patient flow/delay sign off meeting and adherence to Internal Professional Standards Long stayers pull list Participate in Grand rounds at PHT Lead Grand Rounds at MGH site Escalation of any brokerage waiters using agreed process Attend Ops meetings and give community overview and issues for escalation Caseload review with IHDT of anyone outside internal professional standards Daily update of community hospital waiting lists by matrons/senior nurses TCC Professional triage of referrals to include challenge and discussion with referrer around best pathway Agree pathway with referrer signposting, accepting Confirm agreed pathway with patient Appropriate clinician response within specified timeframe Daily waiting list/caseload management and review and discharge planning Capacity; identification of and forward planning (staffing and resources) Alamac kitbag performance measures Services have capacity/ability to manage planned nonclinical work e.g. supervision, team meetings, training, risk register etc. Identification of people who could move through the system with additional support/change of pathway in times Patient Flow and Discharge Services (Livewell Southwest Community Hospitals, ESDT, Therapy Unit, Neuro Psychology, Complex Discharge Team and Discharge to Assess Team) Page 8 of 20

of escalation Single point of access for A2A services to ensure person gets to right service first time (professionals referrals) Professional triage to include challenge and discussion with referrer around best pathway Agree pathway with referrer signposting, accepting Confirm agreed pathway with patient Appropriate clinician response within specified timeframe Daily caseload management and review and discharge planning Capacity; identification of and forward planning (staffing and resources) Alamac kitbag performance measures Services have capacity/ability to manage planned nonclinical work e.g. supervision, team meetings, training, risk register etc. Capacity in the team for Daily caseload management and liaison with in-hospital teams, allocation of workload, check Salus for any new referrals Contact the relevant Wards /ED/CDU To arrange when appropriate to assess Prioritise patients according to flow paying attention to the pressures on the ED & CDU Ward & Lounge to free up flow; review workload priority at mid-day to reassess focus as needed Services have capacity/ability to manage planned nonclinical work e.g. supervision, team meetings, training, risk register etc. Timely signposting and referring on to internal services through SystmOne Timely signposting and referrals to external agencies in accordance with their referral systems. This includes out of area patients Liaise with appropriate care/discharge teams for Plymouth, Devon and Cornwall Provide telephone advice as requested to wards and departments within the acute hospital Offer help and support to the acute general hospital in relation to Mental Health Act issues, Mental Capacity Act and DOLs Information gathering and Professional triage to include challenge and discussion with referrer around best pathway Agree pathway with referrer signposting, accepting Confirm agreed pathway with patient Appropriate clinician response within specified timeframe Daily waiting list/caseload management and review and discharge planning Capacity; identification of and forward planning (staffing Alternatives to Admission Services (Robin Community Assessment Hub, Acute GPs, Community Crisis Response Team, SHWD Rapid Response Team, Acute Care at Home Team) Psychiatric Liaison Team Locality Teams Page 9 of 20

and resources) Alamac kitbag performance measures (for teams using Alamac) Services have capacity/ability to manage planned nonclinical work e.g. supervision, team meetings, training, risk register etc. Locality teams use community RAPA and admissions list to pull people from the acute and community hospitals OPEL 2 <2 community hospital discharges (general beds) identified <5 medically fit on community hospital (general beds) waiting list Reduced staffing capacity identified on Alamac but ability to maintain services Infection Control outbreaks emerging across LSW services DToCs in community hospitals are between 4-6 (LCC, Stroke, Plym Neuro, Kingsbridge and Tavistock) DToCs in acute are between 23-30 for Plymouth and Devon Referrals to discharge teams are allocated within 24hrs rather than same day Community D2A caseload 250-300 people IHDT caseload 65-90 5+ met to confirm OPEL 2 Local Actions at OPEL 2 Action Review all actions above and ensure they have been completed Direct all community hospitals to complete an additional board round via matrons and to feedback impact to TCC Request matrons to review community hospital waiting lists and identify alternative pathways wherever possible Ensure all OPEL level 1 actions have been completed and: Inform TCC if service is showing signs of pressure e.g. reduced staffing and agree actions to be taken Use performance data (kitbag) to inform and prepare wherever possible to support demand/capacity Carry out an additional caseload review with a focus on freeing up capacity to prevent further escalation and surge This will include reprioritising the work for the day, deferring and rearranging planned visits where needed and non-clinical work. Ensure all OPEL level 1 actions have been completed and: Inform TCC if service is showing signs of pressure e.g. reduced staffing and agree actions to be taken Use performance data (kitbag) to inform and prepare By Whom? TCC Patient Flow and Discharge Services (Livewell Southwest Community Hospitals, ESDT, Therapy Unit, Neuro Psychology, Complex Discharge Team and Discharge to Assess Team) Alternatives to Admission Services (Robin Community Assessment Hub, Acute GPs, Page 10 of 20

wherever possible Carry out an additional caseload review with a focus on freeing up capacity to prevent further escalation This will include reprioritising the work for the day, deferring and rearranging planned visits where needed and non-clinical work. Ensure all OPEL level 1 actions have been completed and: Inform TCC if service is showing signs of pressure e.g. reduced staffing and agree actions to be taken Ensure all OPEL level 1 actions have been completed and: Inform TCC if service is showing signs of pressure e.g. reduced staffing and agree actions to be taken For teams on Alamac: Use performance data (kitbag) to inform and prepare wherever possible to support demand/capacity Carry out an additional caseload review with a focus on freeing up capacity to prevent further escalation and surge. This will include reprioritising the work for the day, deferring and rearranging planned visits where needed and non-clinical work Work with TCC to redirect locality staff where needed to support community hospital delays and free up community capacity Community Crisis Response Team, SHWD Rapid Response Team, Acute Care at Home Team) Psychiatric Liaison Team Locality Teams OPEL 3 Actions at OPEL 2 failed to deliver capacity and Community capacity full: A2A teams unable to meet same day referral No community hospital discharges planned (general beds) >5 medically fit on community hospital waiting list (general beds) Complex discharge target not met previous day Discharge Team caseload >90 DToCs in acute are between 30-38 for Plymouth and Devon Community delays >6 Community D2A caseload >300 people Home first reablement slots not available same/next day No D2A1 OT capacity same day No D2A block beds available CCRT not able to respond in 2hrs Reduced staffing identified on Alamac which is significant enough to impact flow: Reduced AGP staffing, RN levels below safe staffing, Reduced MIU staffing Acute at OPEL 3 or 4 in the last 24hrs requiring system response which takes community staff from business as usual impacting planned work 1 or more outbreak across LSW services 6+ met to confirm OPEL 3 Page 11 of 20

Local Actions at OPEL 3: Action By Whom? Review all OPEL 1 and 2 actions and ensure they have been completed Contact all team leads to inform of OPEL status and ask for OPEL 3 level actions to be implemented and monitor impact Escalate to system wide level and ask for CCG chaired call Cancel non-essential training where staff are needed to be redirected for escalation work and communicate this with Professional Training and Development Pull together an additional escalation team to focus on achieving same day discharges using staff from A2A services, localities and patient flow services Work with reablement provider and Red Cross to bring forward planned discharges Identify where community teams can support e.g. support workers to bridge, DNs to complete fast tracks, wards to screen for AC@H and then pull in required LSW staff to support e.g. DNs, CUCs Managers, A2A teams, Team Managers, Admin support Instruct discharge teams to prioritise discharges that will achieve same day results Set up additional board rounds and re-prioritise EDDs and same day discharges, seek alternative pathways to achieve discharges Review all failed RRT discharges (report in SALUS) for discharge opportunities Open up D2A 3 at MGH Instruct use of Robin Kingfisher beds if free Request additional community capacity from CCG/PCC if needed Ensure OPEL 1 + 2 actions are completed and: Cancel training and meetings where staff are needed to be redirected for escalation work Team manager to liaise with TCC to agree focus and actions for teams If an escalated number of discharges are required across the system then TCC will instruct an escalation team to achieve this (to be captured on TCC discharge sheet). TCC Patient Flow and Discharge Services (Livewell Southwest Community Hospitals, ESDT, Therapy Unit, Neuro Psychology, Complex Discharge Team and Discharge to Assess Team) Page 12 of 20

Patient flow services will be required to identify staff to join the team Use DToC info to identify potential patients in community hospitals to pull Teams to deploy staff to pull patients from D2A, community hospital and acute beds Conduct additional whiteboard/caseload review to free up capacity wherever possible CCG approval for spot purchase PoCs/placements via TCC Release Robin Kingfisher beds at 17:00 if available Team manager to be freed up to support TCC in pulling patients or Team Manager(s) to work clinically where appropriate to increase capacity in the service D2A Team manager to be diverted to authorisations where appropriate to increase capacity in the service System wide conversation around safe staffing and divert staff where appropriate Extend times when patients are accepted for transfer until 8pm Ensure OPEL 1 + 2 actions are completed and: Cancel training and meetings where staff are needed to be redirected for escalation work Redirect staff from planned work to escalation work Conduct caseload review to free up capacity wherever possible If an escalated number of discharges are required across the system then TCC will instruct a team to achieve this (to be captured on TCC discharge sheet). A2A services will be required to identify staff to join the team Use DToC info to identify potential patients in community hospitals to pull A2A teams to deploy staff to pull in conjunction with established discharge services. Include PHNT RRT CCG approval for spot purchase PoCs/placements via TCC Release Robin Kingfisher beds at 17:00 if available A2A team manager to be freed up to support TCC in pulling patients or to work clinically where appropriate Clinical conversation to consider use of Robin for ACU patients to commence investigations Offer ACU/PIU capacity at Robin for appropriate nursing Alternatives to Admission Services (Robin Community Assessment Hub, Acute GPs, Community Crisis Response Team, SHWD Rapid Response Team, Acute Care at Home Team) Page 13 of 20

procedures to free up ACU space System wide conversation around safe staffing and divert staff where appropriate Ensure OPEL 1 + 2 actions are completed and: Cancel training and meetings where staff are needed to be redirected for escalation work Clinical focus is urgent so all training and meetings will be rescheduled according to this response Re-Triage current caseload to determine whether priorities could be changed. Work with PHNT to identify priorities The team manager may become clinical to assist with throughput however, this will be balanced with the managerial demand on the service as a whole Ensure OPEL 1 + 2 actions are completed and: Cancel training and meetings where staff are needed to be redirected for escalation work Team manager to liaise with TCC to agree focus and actions for teams DN hub manager to contact the referral hub and community phlebotomy to alert them of OPEL status and potential for unplanned/urgent visits Conduct additional whiteboard/caseload review to free up capacity wherever possible In-reach to pull known locality patients and explore early discharge from hospital Redirect staff from planned work to escalation work Team Manager(s) to work clinically where appropriate to increase capacity in the service System wide conversation around safe staffing and divert staff where appropriate Agreement via LM/DLM to use pathways outside of usual inclusion criteria such as intermediate care Psychiatric Liaison Team Locality Teams OPEL 4 Actions at OPEL 3 failed to deliver capacity and no community capacity to support discharges Reduced levels of staffing that impact on the safety of patients and inability to flex staff across services DToCs in acute are between >38 for Plymouth and Devon All met to confirm OPEL 4 Local Actions at OPEL 4: Action By Whom? Page 14 of 20

Review all OPEL 1,2 and 3 actions and ensure they have been completed Contact all team leads to inform of OPEL status and ask for OPEL 4 level actions to be implemented and monitor impact Cancel mandatory training and communicate with Professional Training and Development Offer additional/overtime if agreed with Director Direct the additional escalation team to continue with their in-reach to pull additional discharges from the acute/community hospital sites Consider asking LSW staff to work at PHT; involve governance in this Bring in Red Cross to work with Discharge Teams Consider use of OPMH beds on the MGH site via citywide Locality Manager/Director on Call Risk assess and place outliers in community hospitals if there are any beds available Ensure OPEL 1, 2 + 3 actions are completed and: Continue additional patient pull work as part of the additional escalation team Consider additional staff to increase capacity; agree at Director level Consider extending geographical area for services if capacity to do so Risk assess current caseload/planned work and defer where deemed safe to do so Weekends only: Offer staff additional hours over weekend to provide continued therapies Further extend times when patients are accepted for transfer until 10pm TCC Patient Flow and Discharge Services (Livewell Southwest Community Hospitals, ESDT, Therapy Unit, Neuro Psychology, Complex Discharge Team and Discharge to Assess Team) Ensure OPEL 1, 2 + 3 actions are completed and: Continue to free up staff to be part of the additional escalation team to pull additional discharges AGPs to risk assess with community GP ability to keep person at home with community support and delay admission where safe to do so Consider additional staff to increase capacity; agree at Director level Consider extending geographical area for services if capacity to do so Clinical staff to interrogate ED screen to pull people directly from ED Where capacity allows consider AGP in ED supporting decision making (to be agreed with AGP Clinical Director) AGPs to be available to offer support and alert hospital colleagues to the availability of community resources Weekends only: Offer staff additional hours over weekend Alternatives to Admission Services (Robin Community Assessment Hub, Acute GPs, Community Crisis Response Team, SHWD Rapid Response Team, Acute Care at Home Team) Page 15 of 20

to provide continued therapies Ensure OPEL 1, 2 + 3 actions are completed and: Contact staff off duty to check availability to come into work and offer overtime as appropriate; permission to be sought from DLM or LM Liaison with HTT, CCRT and Hospital Discharge Team to consider a joined up approach in managing flow to avoid duplication and waste of resources. Need agreement with TCC as to how best to approach this on the day Request support of On-call SHO, if available Ensure OPEL 1, 2 + 3 actions are completed and: Consider additional staff to increase capacity; agree at Director level Consider extending geographical area for services if capacity to do so Complete a further risk assessment of the re-prioritised caseload/planned work and defer where deemed safe to do so Weekends only: Offer staff additional hours over weekend to provide continued therapies Psychiatric Liaison Team Locality Teams 8. Business Continuity and Major Incidents 8.1 Out of Hours Escalation: LSW Director on Call to be contacted through switchboard: 01752 268011. 8.2 Bank Holiday actions: Communications are agreed with the CCG and providers, and released to encourage patients to access their health and social care providers before bank holidays to reduce demand during the holiday period. Communications via CCG to include options for patients to Choose Well. Before each set of bank holidays the CUCs management team collates BH availability for LSW services and submit to the UC-CCC when requested. 8.3 Please follow the link to healthnet for LSW: Business Continuity and Service Recovery Policy and Major Incident and Business Continuity Response Plan http://lswnet.derriford.phnt.swest.nhs.uk/documents/policies,pgdsandprotocols.a spx Page 16 of 20

9. Training implications Staff should familiarise themselves with this policy on induction to post and read key documents included in this policy. 10. Monitoring compliance There are no audit or compliance requirements for this policy. It will require annual update as escalation protocols are updated annually. All policies are required to be electronically signed by the Lead Director. Proof of the electronic signature is stored in the policies database. The Lead Director approves this document and any attached appendices. For operational policies this will be the Locality Manager. The Executive signature is subject to the understanding that the policy owner has followed the organisation process for policy Ratification. Signed: Director of Operations Date: 22 nd December 2017 Page 17 of 20

Appendix A: Risks to Consider when taking OPEL actions: Action Benefit of undertaking this action Risk of this action Instruct discharge teams to only focus on same day discharges. Implement additional escalation team by redirecting staff from community and alternatives to admission teams from their planned clinical work to pull additional discharges. Consider AGP in ED supporting decision making (to be agreed with AGP Clinical Director). Increase in same day discharges. Increase in same day discharges. Primary care support to ED to support streaming and community alternatives. DTOCs will increase as the more complex cases that are already delayed will not be worked on. LoS for more complex cases will increase. A2A services will not have usual capacity so decrease in numbers avoided. D2A will not complete planned work so backlog will increase. Planned work will need to be rebooked alongside usual caseload next day. Risk that people in the community may deteriorate if planned visits are delayed or cancelled. Reduced AGP capacity may impact on an increase on ED attendances. Release Kingfisher Robin beds for general patients. Admit outliers across the MGH site into available OPMH, Stroke and Plym Neuro beds where there are no suitable/fit patients on waiting lists. Potential to increase bed capacity by 2 beds. Potential increase in discharges from the acute if any beds are available. Robin will not have beds to use for alternatives to admission which could result in an emergency admission. People will be in the wrong category of bed. CQC will need to be informed. NHSE will need to be informed if outliers on Plym as specialist commissioning. Risk to waiting lists as people become fit; will increase delays. Consider extending geographical Increase in same day discharges. Overall team capacity will be reduced due to increased Page 18 of 20

boundaries for community services if there travel time. are out of area referrals e.g. acute care at home. Cancel mandatory and essential training. Release additional staffing capacity. Staff will be out of date with training and will need to be rebooked. Page 19 of 20

Appendix B: NHS England Operational Pressures Escalation (OPEL) Framework, October 2016 Operational Pressures Escalation Levels Fram Page 20 of 20