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CIP Governance Process and Procedure

Programme Management Office CIP Governance Process and Procedure V1.0 14Jun17 of 16

Document Control

Title


Author

Author’s job title Head of Compliance Assistant Director of Finance

Directorate Finance

Department Programme Management Office

Version Date

Issued Status Comment / Changes / Approval

0.1 Jun2017 Draft Initial version for consultation

0.2 Jun2017 Revision Amended to read comments added after Consultation.

1.0 Jun2017 Final Final version approved at Tri-U meeting 120617

Main Contact Head of Compliance Suite 8 Munro House North Devon District Hospital Raleigh Park Barnstaple, EX31 4JB

Tel: Direct Dial – 01271 311782

Lead Director Director of Finance

Superseded Documents CIP Governance Process and Procedure

Issue Date June 2017

Review Date June 2020

Review Cycle Three years

Consulted with the following stakeholders:

Finance Team Project Delivery Unit Team Executive Directors

Approval and Review Process

Triumvirate Committee

Local Archive Reference G:\Compliance Team Local Path Finance Filename CIP Governance, Process and Procedure V1.0 14Jun17 (right click above text, to update to new filename)

Policy categories for Trust’s internal website (Bob) Finance

Tags for Trust’s internal website (Bob) Programme, Project, Cost Improvement Plans.



CONTENTS

Document Control........................................................................................................................ 1

1. Purpose ................................................................................................................................ 3

2. Background .......................................................................................................................... 3

3. Definitions............................................................................................................................ 3

4. Development of the Cost Improvement Programme .............................................................. 5

5. Programme Management Office (PMO) ................................................................................ 5

6. Quality Impact Assessment (QIA) .......................................................................................... 6

7. Process for Implementation and Monitoring Compliance and Effectiveness ........................... 6

8. Equality Impact Assessment .................................................................................................. 7

9. References ........................................................................................................................... 7

10. Associated Documentation ................................................................................................... 7

Appendix A – Project Initiation Document (PID) ............................................................................ 8

Appendix B – Quality Impact Assessment ..................................................................................... 9

Appendix C – NHS Improvement ‘Where to look for savings: 10 ways NHS Providers can make cost improvements’ .......................................................................................................................... 11

Appendix D - Annual Planning Cycle…………………………………………………………………………………………….13

Appendix E - Roles and Responsibilities ……………………………………………………………………………………...14



1. Purpose

1.1. The purpose of this document is to detail the process for all staff responsible for a Cost Improvement Programme (CIP) Project to manage a project through to completion.

1.2. The policy applies to all staff leading and managing a project that is part of the CIP programme.

1.3. Implementation of this policy will ensure that:

All CIP Projects are managed through to completion using a similar process and governance procedure

Ensure that the process used in the organisation is based on best practice

Ensures monitoring of projects and the correct escalation procedures are in place for any failing projects

This process defines the framework that supports the CIP by implementing best practice including: - An Executive Director lead for each project - A lead person and timescales for each component of the

programme - Robust set of early warning indicators to identify clinical risk which

will be reported on - Risk rating likelihood of achievement and impact on quality - Structured Quality Impact Assessment (QIA) of each scheme

2. Background

The Trust is required to deliver services commissioned as a healthcare provider to the public of North Devon. Due to challenging financial environment for the NHS in England, all trusts are expected to ensure services are delivered to the best of its capability and capacity, at the same time ensuring cost improvements are made especially in the areas of non-patient focused services.

A well-developed cost improvement programme will reflect the Trusts proposed projects focussed on reducing expenditure and increasing efficiency without impacting on the quality of the services it provides.

3. Definitions

Cost Improvement Programme (CIP) - The identification of schemes to reduce expenditure/increase efficiency.



Key Performance Indicator (KPI) A measurable indicator that will show that the project is having the intended impact operationally and/or in terms of quality

Milestone: A key event that is critical to the completion of a deliverable. It will be expected that if Milestones are missed then there will be a financial impact on the project.

Process: A process is an ordered collection of connected activities that, together, produce a useful output.

Programme: A connected set of projects and activities that are co-ordinated and managed as a cohesive unit such that they achieve outcomes and realise benefits.

Project: A temporary organisation that is created for the purpose of delivering one or more business products.

Project Initiation Document (PID): The PID brings together all of the key information needed to start and run the project on a sound basis. It should be conveyed to all stakeholders and agreed and signed off by the business sponsors. The PID defines all major aspects of a project and forms the basis for its management and the assessment of overall success.

Quality Impact Assessment: A mechanism to quantify the potential impact on quality.

Stage: A stage is a section of a project or programme that achieves a major step towards achieving the goal of the project or programme.

Task: A task is an activity that needs to be accomplished within a defined period of time or by a deadline.



4. Development of the Cost Improvement Programme

Once the annual savings requirement has been identified, each directorate is expected to identify areas where efficiencies and savings can be made. Areas for increased focus are also identified at that point. These will include divisional and corporate plans, procurement detailed plans, job planning, outpatient and theatre efficiency opportunities as well as Community opportunities. (Appendix C shows NHS Improvement “where to look for savings” categories)

A visual representation of the annual planning cycle is shown in appendix D Each divisional lead will be required to work with their teams to identify the individual projects and work to produce a Project Initiation Document (PID) that describes the project in detail (Appendix 1).

The PID will provide enough detail to provide a full description of:

Project Title

Project Lead

Description of the project

The savings

The Red/Amber/Green status

Resources required

Constraints and risks

Timescales/Key milestones/Date of Delivery

KPI’s

Tasks against person responsible (Individually RAG rated)

Quality Impact Assessment

The PID will be the tool used to keep the project on target for the project lead and to keep the Project Management Office informed of progress of the project, enabling the finance trackers to be used to track the savings being received. It is the responsibility of the project lead to update the PID frequently and ensure the project is kept on track and to inform the Executive sponsor and PMO if any slippage occurs. If the project is deemed to not be delivering the projected savings it is the project lead’s responsibility to notify the Executive sponsor and the PMO.

Roles and responsibilities of the different project roles are shown in table form in appendix E

5. Programme Management Office (PMO)

The PMO will develop the annual Cost Improvement Programme in association with the Divisional Management teams, track the progress of the programme and report progress to the Triumvirate and Executive Committees.



The PMO will provide support to the project leads to ensure the right documentation is completed (PID/QIA) and that all the prompts have been considered.

A record of progress of the projects will be maintained in the form of a CIP Tracker which will be used to report to the Triumvirate committee against and to the Executive Directors.

The PMO will provide regular (monthly) follow-up visits to the project leads to ensure the projects remain on track or discuss additional actions, or to report by exception to the relevant Executive lead of any shortfalls in progress.

The PMO will provide updates to the Executive project Sponsors and project leads in advance of the monthly project steering group escalating concerns as they become apparent.

The PMO will ensure each CIP project has a Quality Impact Assessment (Appendix B) completed and signed off by the Director of Nursing and the Medical Director as per the Management of Quality Impact Assessments Procedure published on the Intranet.

Any new projects identified will be added to the CIP and CIP Tracker and reported as required.

6. Quality Impact Assessment (QIA)

Quality Impact Assessments are required for CIP Projects to ensure all aspects of the project are reviewed to identify any risks are mitigated and any impact on the quality of patient care is assessed.

The QIA’s are reviewed and signed-off by the Director of Nursing and Medical Director to ensure all aspects of the project have been reviewed.

7. Process for Implementation and Monitoring Compliance and Effectiveness

7.1. Detail here the Implementation process.

The CIP programme is developed at the start of the financial year to enable the savings to be spread across the months enabling the project lead the maximum time to ensure the projections are reached.

7.2. Detail here the monitoring process:

Monthly follow-up meetings will be made by the PMO to ensure the projects are on the correct timescales

All information will be entered onto the CIP tracker used to report the current financial position.



This will be presented to the monthly Triumvirate and executive Committee.

The responsible Executive Director will be informed of any project slippage.

The responsible Executive Director will provide the project updates for their respective projects at the monthly project steering groups.

8. Equality Impact Assessment

Table 1: Equality impact Assessment

Group Positive Impact

Negative Impact

No Impact

Comment

Age X

Disability X

Gender X

Gender Reassignment X

Human Rights (rights to privacy, dignity, liberty and non-degrading treatment), marriage and civil partnership

X

Pregnancy X

Maternity and Breastfeeding

X

Race (ethnic origin) X

Religion (or belief) X

Sexual Orientation X

9. References

NHS Improvement web pages https://improvement.nhs.uk/resources/10-ways-nhs-providers-find-savings-and-make-cost-improvements/

10. Associated Documentation

Management of Quality Impact Assessments Procedure

https://improvement.nhs.uk/resources/10-ways-nhs-providers-find-savings-and-make-cost-improvements/

https://improvement.nhs.uk/resources/10-ways-nhs-providers-find-savings-and-make-cost-improvements/



Appendix A – Project Initiation Document (PID)

PROJECT TITLE

Project Description Project Lead/Support lead

Red/Amber/Green (Project delivery status)

Anticipated Savings £anticipated savings FYE

Resources required

Clinical support:

Management support within division:

Management support from other depts / divisions:

Pump-prime £: describe what for, and justify

Constraints and risks

Constraints

Risks

Timescales (insert key milestones, as well as date of delivery)

- -

Will a QIA or EQIA be required?

No

KPIs (how do we demonstrate success / lack of negative impact post-implementation?)

Timescales (insert key milestones, as well as date of delivery)

Actions

Person Responsible

By when? RAG

LAST: Adjust budgets in ledger (DO NOT DELETE)

Finance Manager

-

REMEMBER TO COMPLETE A QUALITY AND EQUALITY IMPACT ASSESSMENT



Appendix B – Quality Impact Assessment

Quality Impact Assessment & Project PrioritisationCompletion notes:

1. Input your assessment in column M against each of the criteria

2. Add justification for selection

3. Identify the KPI(s) to be measured before and after implementation to monitor impact on quality

4. Once reviewed this page will be locked to prevent changes. If this page needs to be updated a request must be made to the PMO.

2.00

6

Project Title

Assessed by (lead assessor)

Assessor job role

Assessment date

Major positive

Impact

Minor Positive

ImpactNeutral Impact

Minor Negative

Impact

Major Negative

Impact

0 1 2 3 4

Major positive

Impact

Minor Positive


Minor Negative

Impact

Major Negative

Impact

0 1 2 3 4

Major positive

Impact

Minor Positive


Minor Negative

Impact

Major Negative

Impact

0 1 2 3 4

Critical link to

strategy or

supports

delivery of

multiple

strategic

priorities (>3)

Directly links to

strategy or

supports the

delivery of

multiple

strategic

priorities up to 3

Minor link to

strategy or

supports the

delivery of 2

strategic

priorities

Tenuous link to

strategy or

supports the

delivery of a

single strategic

priority

No link to

strategic

priorities but

will enhance

operational

efficiency.

0 1 2 3 4

Relatively

simple and likely

to be delivered

within planned

parameters

Low complexity

should be

delivered within

planned

parameters

Moderate

complexity

spanning

multiple

departments

Very Complex

spanning the

majority of the

organisation

Highly complex

across the

majority of the

organisation and

third party

organisations

0 1 2 3 4

Substantiated

evidence to

support

projected

outcomes and

approach

Substantiated

evidence to

support the

projected

outcomes

Documented

evidence to

support some of

the projected

outcomes

Unsubstantiated

evidence to

support

projected

outcomes

No evidence

base to support

projected

outcomes

0 1 2 3 4

4. Return on Investment

Positive ROI

≥ 9% <5 years

Positive ROI

≥ 9% >5 years

Makes a positive

return of < 9%

The project is

cost neutral

There will be a

negative return

on investment

0 1 2 3 4

Total Project Prioritisation Score 2.00 This score will be used to prioritise projects across the organisation 0.00

Quality Impact Assessment Score 6 Project could have an impact on some elements of quality 2.00

LOS, Patient satisfaction

Comments

Green 0 2 No negative impact on quality identified

Amber 3 8 Project could have an impact on some elements of quality

Red 9 12 All elements of quality will be impacted

Strategic Objectives

1

2

3

4

5

6

Prioritisation Score

Quality Impact

e.g. Length of stay to be monitored before during and after implementation of CIP

1.Quality

1.1 Patient Safety

1.2 Patient Experience

1.3 Clinical Effectiveness

2. Strategic Fit

3. Risk

3.1 Complexity

3.2 Evidence Base

Quality KPI Selected before and after

implementation e.g.

e.g. Length of Stay to be monitored

Quality Governance Assessment

Boundary

We will be recognised for delivering care of the highest quality, measured in terms of clinical effectiveness, patient safety and the patient We will ensure access to a sustainable range of services that are delivered locally through established partnerships, and clinical networks with

other organisations where necessary

We will maximise the benefits derived from an integrated model of health and social care that provides the right care at the right time in the

right place at the right level for the individual.

We will recruit and develop a flexible and multi-skilled workforce fully engaged in turning our vision into a reality.

We will efficiently and effectively run our services; generating surpluses to reinvest in services to benefit our local community and

underpinning all we do with systems and processes which deliver safe, high quality services

We will be the local provider of choice; working in partnership with the public and commissioners to promote independence and well being

and meet the needs of our community.

0

0

0

Enter

Score

2

2

2

0



Supporting statements for criteria selection

1.1 Patient Safety

1.2 Patient Experience

1.3 Clinical Effectiveness

2 Strategic Fit

3.1 Complexity

3.2 Evidence Base

4 Return on Investment

Clinical Sign off

Version Reviewed Date of ReviewDesignation Name Signature

Director of Nursing

Medical Director

Director of Nursing

Medical Director

Medical Director

Director of Nursing



Appendix C – NHS Improvement ‘Where to look for savings: 10 ways NHS Providers can make cost improvements’



Appendix D – Annual planning cycle



Appendix E – Roles and Responsibilities

Roles Key Responsibilities

CIP Programme Board Ensure the continuous improvement programme aligns to the overall strategic objectives of the Trust.

To commission and de-commission individual projects within the programme.

Ensure the financial outcomes from the continuous improvement programme are sufficient to deliver the Trust’s Cash Releasing Efficiency Targets.

To provide a source of challenge and support to the programme and project leads.

To ensure continuous improvement projects have appropriate leadership and clinical engagement

To risk assess the individual projects impact on quality.

Review and monitor programme risk log.

Identify programme risks.

Escalate risks to corporate risk register.

Provides assurance to the Finance Committee

Review and identify trust wide interdependencies

Tri U Monitor project to ensure timely delivery of objectives within budget whilst maintaining quality within agreed levels.

To provide a source of challenge and support to the project lead and project teams.

Monitor and review key project risks

To ensure project has appropriate leadership and clinical engagement

Identify additional actions and/or key individuals to be involved to keep projects on track.

Senior Responsible Officer Executive Sponsor accountable for overall project delivery.

Present Project stage reports to CIP Steering Group.

Provide feedback and additional actions to the Project lead.

Provide assurance on project delivery to CIP Steering Group.

To remove strategic barriers to project delivery.

Provide support and guidance to the project lead.

Chair project steering groups.

Escalate key risks and issues to the CIP Steering Group and report to the PMO.



Project Lead Responsibility for drafting and maintaining up to date PID

Record completed actions on PID in real time.

Monitor and update risk log, closing down risks as appropriate.

Maintain and update KPI tab of PID on a monthly basis.

Responsible for overall project delivery.

Identify and secure project resources.

Manage day to day delivery of project.

Prepare stage reports for presentation by the SRO

Organise project steering groups,

Provide support and guidance to workstream leads

Deputise for SRO at CIP Steering Group.

Escalate key risks and issues to the Senior Responsible Officer and report to the PMO.

Engage with other project leads to understand and document interdependencies.

Engage with other specialists (i.e. IT /facilities) as required.

Finance Lead Provide financial support and guidance to the project lead.

Populate and maintain finance information of PID on a monthly basis.

Remove monies from budget when savings are realised.

Inform PMO when money is removed from budgets.

Identify and monitor key financial performance indicators.

Escalate key risks and issues to the Project Lead.

Engage with other finance leads to understand and document interdependencies to reduce the risk of double count.

Clinical Lead Provide clinical advice and guidance to the project lead.

Complete quality impact assessments

Identify and monitor key quality performance indicators.

Escalate key risks and issues to the Project Lead.

Engage with other clinical leads to understand and document interdependencies.

HR Lead Provide HR support and guidance to the project lead.

Providing specific advice on workforce impacts including consultation.

Engaging with other workforce leads to understand and document interdependencies.

Escalate key risks and issues to the Project lead.

PMO Provide support and guidance on all elements of project management to the project teams.

Provide quality assurance on projects.



Collate PID and supporting evidence centrally.

Update and maintain CIP trackers.

Provide programme assurance reports to the CIP steering board, including CIP trackers.

Identify and flag CIP interdependencies.

Identify additional actions and mitigations.

Identify programme and project risks.

Receive regular project updates from project leads and SROs.

Maintain programme risk log.

Escalate key risks to Tri U and CIP Programme Board.