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Bevan Exemplars

Application Form

Please complete and submit electronicallyto:

[ENTER ORG CONTACT)

By 10 July 2017

Personal Details

Job Title
Forename
Surname
Phone Number(s)
Email(s)
Organisation
Department/Section
Location

Line Manager’s Details

Job Title
Forename
Surname
Department
Phone Number(s)
Email(s)

About your Project/Idea

Project/ Idea Title
Brief Description of your Project/Idea/Technology
[Guide length – 250 words]
What Contribution will your project/idea make to Prudent Healthcare?
  1. Achieve health and wellbeing with the public, patients and professionals as equal partners through co-production.
[Guide length – 150 words]
  1. Care for those with the greatest health need first, making the most effective use of all skills and resources.
[Guide length – 150 words]
  1. Do only what is needed, no more, no less; and do no harm.
[Guide length – 150 words]
  1. Reduce inappropriate variation using evidence based practices consistently and transparently
[Guide length – 150 words]
Plans
[Outline your plans for delivery here. Who? What? When? How?]
Anticipated Benefits / Outcomes / Results
[What will you measure?
Describe how your chosen project might improve existing NHS Wales' resource efficiency; improved healthcare outcomes; improved patient experience etc.]
[Guide length – 250 words]
Evaluation
[How will you measure?
Describe how you will measure your project’s anticipated benefits / outcomes / results]
[Guide length – 250 words]
Funding & Resources
Funding and resource contribution required from your LHB/Trust to deliver your project

Additional Information – for Health Technology Exemplars ONLY

Industry Partner Details (see Guidance Notes)

Organisation
Job Title
Forename
Surname
Phone Number(s)
Email(s)
Location
Funding and Resources – Health Technology Exemplar projects ONLY
What is the resource commitment of the industry partner and how will you utilise the £7500 funding provided by Welsh Government? (e.g. backfill of clinical time, matching partner resource)
Health Technology Exemplar projects ONLY
What is your chosen Health Technology? (100 words)
How did you come to work with your industry partner and under what arrangements will you work with them on this project? (up to 200 words)
CommitmentsPlease Tick to Confirm
I commit to participate fully in the Exemplars Programmes programme of events, networking (up to 10 days)
I commit to preparing an evaluation of my project