working day the persons Trust NHS Acute Trust Improvement outlined in column B informs Initial RCA analysis to be completed on all 12hr breaches within and for this to be – Director On-call their respective regional body in Portfolio Director shared with the NHS England Regional Director of Delivery and NHS England Regional Column C Team Senior Manager On-call and NHS Improvement Portfolio Director. FORMAL ACCOUNTABILITY PROCEDURE FOR A 12HR TROLLEY BREACH If a 12hr breach has NHS NHS Inclusion of information in activity report been confirmed: England England DCO Team Regional Summary of numbers; details for all waits >12hr plus any clinical harm impact and report on In-hours (i.e. 9am -5pm Director Director mitigations that are in place. On-call and the Monday to Friday) Regional Director of Persons outlined in column B Delivery informs immediately their respective regional body in Acute Trust NHS Column C Chief Improvement Executive Director of Delivery and Development NHS NHS England Inclusion of information in overnight activity report England Regional Senior DCO Team Manager On-call Out of Hours (i.e. 5pm Summary of numbers; details for all >12hr plus any clinical harm impact and report on – Director 9am Monday to Friday, mitigations that were put in place. On-call Weekends and Public Holidays) Trust Trust CEO is requested to personally telephone NHS Improvement Director of Delivery and NHS By 1100hrs the following Chief Development in order to explain the reason for the breach, on the day it happens (or if a breach Improvement working day the person Executive occurs out of hours an update is required the following morning by 11.00am). Director of outlined in column B informs Summary of the numbers and details regarding any 12hr breaches plus any clinical harm Delivery and their respective regional impact and report on mitigations that were put in place. Development director outlined in Column C
working day the persons outlined in column B informs their respective regional body in Column C Initial RCA analysis to be completed on all 12hr breaches within – and for this to be shared with the NHS England Regional Director of Delivery and NHS England Regional Team Senior Manager On-call and NHS Improvement Portfolio Director. Acute Trust Director On-call Trust NHS Improvement Portfolio Director FORMAL ACCOUNTABILITY PROCEDURE FOR A 12HR TROLLEY BREACH If a 12hr breach has been confirmed: In-hours (i.e. 9am -5pm Monday to Friday) Persons outlined in column B informs immediately their respective regional body in Column C NHS England DCO Team Director On-call NHS England Regional Director and the Regional Director of Delivery Inclusion of information in activity report Summary of numbers; details for all waits >12hr plus any clinical harm impact and report on mitigations that are in place. Acute Trust Chief Executive NHS Improvement Director of Delivery and Development Out of Hours (i.e. 5pm – 9am Monday to Friday, Weekends and Public Holidays) By 1100hrs the following working day the person outlined in column B informs their respective regional director outlined in Column C NHS England DCO Team Director On-call NHS England Regional Senior Manager On-call Inclusion of information in overnight activity report Summary of numbers; details for all >12hr plus any clinical harm impact and report on mitigations that were put in place. Trust Chief Executive NHS Improvement Director of Delivery and Development Trust CEO is requested to personally telephone NHS Improvement Director of Delivery and Development in order to explain the reason for the breach, on the day it happens (or if a breach occurs out of hours an update is required the following morning by 11.00am). Summary of the numbers and details regarding any 12hr breaches plus any clinical harm impact and report on mitigations that were put in place.
EN%20Herts%20CCG%20Surge%20Escalation%20and%20Capacity%20Plan%20V21.docx