TRANSFORMATION PROGRAMME DEVELOPMENT POLICY
Guidance for the Development of a Sustainable Improvement Programme (Inc. Quality Impact Assessment)
Version / 3Name of responsible (ratifying) committee / Governance and Quality Committee
Date ratified / 12 October 2017
Document Manager (job title) / Programme Manager – Delivery Unit (DU)
Date issued / 23 January 2018
Review date / 11 October 2019
Electronic location / Management Policies
Related Procedural Documents / -
Key Words (to aid with searching) / CIP, Quality Impact Assessment, service development, improvement
Version Tracking
Version / Date Ratified / Brief Summary of Changes / Author3 / 12/10/2017 / · Changes in team names to reflect recent structure changes
· Updated with information on Workbooks needed for Cost Improvement Programmes / Rachel Weeks
2 / 04/03/2014 / - / Head of Transformation
CONTENTS
QUICK REFERENCE GUIDE 3
1. INTRODUCTION 4
2. PURPOSE 4
3. SCOPE 4
4. DEFINITIONS 4
5. DUTIES AND RESPONSIBILITIES 5
6. PROCESS 6
7. TRAINING REQUIREMENTS 12
8. REFERENCES AND ASSOCIATED DOCUMENTATION 13
9. EQUALITY IMPACT STATEMENT 13
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS 14
EQUALITY IMPACT SCREENING TOOL 15
APPENDIX A: Maturity of schemes and sign off flow 17
APPENDIX B: Guidance for staff on completion of QIA 18
APPENDIX C: Illustrative action plan for applicants 21
APPENDIX D: Additional guidance on recommended analytical approaches 22
QUICK REFERENCE GUIDE
Planning· Set out the Trust’s vision, policy and strategy for service and cost improvement
· Develop five-year forecasts and ensure consistency with other plans
· Involve a wide range of local health economy stakeholders early on
· Agree how Service and Cost Improvements will be managed within the Trust
· Identify CIP and other benefit targets for each Clinical Service Centre / Trust-wide
Identification
· Identification of schemes, and projects
· Review of relative efficiency and other measures by e.g. benchmarking and SLR information
· Business cases prepared and reviewed where necessary
· Individual plans reviewed and assessed for cumulative impact
· Assessed for achievability and potential impact on quality
· Ensure consistency with overall strategy of trust and local health economy
Delivery / Monitoring and Reporting
· Draw up detailed plans for each scheme valued at greater than £100k, with clinical and financial input
· Clarity of responsibility and accountability for delivery
· Peer challenge to drive performance management
· Approved savings removed from departmental budgets
· Following review, withdraw or amend schemes that are not delivering
· Focus on current and future longer-term Service and Cost Improvements
· Management of risks / · Regular monitoring and reporting on Service and Cost Improvements delivery
· Use of high quality financial and non-financial indicators
· Monitoring and reporting undertaken at CSC, organisational and Board levels
· Service and Cost Improvement performance accurately reflected in performance reports
· Corrective action taken where necessary
Evaluation
· Evaluation of overall Service and Cost Improvement process
· Consider using internal audit to provide assurance on the overall programme and recommend improvements
· Use findings to apply lessons learned and inform the development process for future Service and Cost Improvements
1. INTRODUCTION
Some Trusts are moving away from using the term cost improvement programme (CIP) because it is considered that it may not help to engage clinical staff. Instead terms such as ‘improvement change programmes’ and ‘improvement programmes’ are being used. In this guidance, the term Service and Cost Improvement encompasses all efficiency and improvement programmes, as there is a wider understanding of that term.
Improvement is integral to trust financial and performance planning and requires good, sustained performance in order to be achieved. As time moves forward, trusts will encounter a national tariff with built-in efficiency savings, reducing contract volumes with Commissioners and rising inflation. There will also be fewer opportunities to use income generation to offset savings requirements. Therefore, to succeed in making sustained annual savings of 6%, boards will need plans for significant improvement programmes and will face difficult choices about the services they provide.
There is no single approach that works for all organisations. However, several factors are common if the Trust is to perform well in improvement planning, delivery and sustainability. A successful cost improvement is not simply a scheme that saves money. The most successful way forward is the development of long-term plans to improve clinical and non-clinical services that not only result in permanent cost savings, but also improve patient care, satisfaction and safety.
2. PURPOSE
Better equip staff at all levels to ask challenging questions about aspects of improvement and to review their approach against the good practice identified.
Make clear the process for designing Cost Improvement Schemes, achieving their sign off and the templates that need to be used and maintained for their ongoing governance.
3. SCOPE
This guidance should be read by Executive, Non-Executive Directors (NEDs), CSC Management Teams, Delivery Unit staff, Organisational Development & Improvement team, Finance staff and all those with responsibility for delivering or supporting improvements.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’
4. DEFINITIONS
List and describe the meaning of the terms used in the context of the document.
Service-Line Reporting (SLR)
SLR measures a trust’s profitability be each of its service-lines, rather than just at an aggregated level for the whole trust. SLR helps trusts develop a better understanding of the operational and financial performance of their various services and hence improve their strategic and clinical decision making.
(Further information on implementing and using SLR can be found in two documents published by Monitor: Guide to Developing Financial Data for Service Line Reporting (“the Guide”) and the Toolkit for Presenting Service-Line Reporting Data (“the Toolkit”))
CIP Workbooks
CIP Workbooks refer to excel workbooks which are designed to capture the key objectives, assumptions, milestones and financial savings forecast that will deliver a Cost Improvement Scheme. They also contain a Quality Impact Assessment Tool which should be completed for every scheme above the value of £25k to ensure that all potential impacts on quality both positive and negative are considered. Where a negative impact is considered a possibility as a result of the scheme the steps to mitigate the risk of the negative impact occurring must be captured in the workbook.
Quality Impact Assessment
The Quality Impact Assessment is an evaluation of the potential impact a scheme may have on patient safety, clinical effectiveness, patient experience plus any operational impacts or risks to the project being successful. It is a key part of the Trust’s assurance mechanism to make sure that any schemes will not have a significant detrimental impact on patient safety and any risks or potential impacts are clearly mitigated.
5. DUTIES AND RESPONSIBILITIES
SMT will:
· Ensure overall governance of both CSC and Trust wide improvement projects
· Approve and prioritise improvement projects with a value of greater than £250k, aligned with the strategic goals of the Trust and the annual business plan.
Improvement Project Steering Groups will:
· Drive delivery of Trust wide improvement projects so that effective plans are developed, supported, monitored and deliver agreed benefits
· Monitor and report to the Senior Management Team on progress
· Manage issues, risks and dependencies of, and between projects
Finance Committee will:
· Scrutinise cost improvement projects/schemes, to ensure the Trust delivers its financial objectives within agreed financial parameters
· Receive report on the delivery of CIP’s monitored through the Performance Assurance Meetings and recommend actions with regard to under delivery
Governance and Quality Committee will:
· Be assured that there is an appropriate Quality Impact Assessments (QIA) process undertaken for each improvement scheme/project valued at greater than £25k
· Receive bi-annual reports from Steering Groups/CSCs on new and existing Trust wide schemes/projects to ensure risk planning is robust and the impact on quality and performance is being thoroughly assessed and negative impact mitigated.
Risk Assurance Committee will:
· Scrutinise the risk management processes of improvement schemes/projects
· Ensure that the Trust’s Assurance Framework and/or Risk Register are updated with relevant risks from CSC and Trust wide improvement schemes/projects
Delivery Unit will:
· Coordinate Project Initiative Document (PID) development and updates
· Provide coordination between projects
· Ensure project reports are delivered monthly to Steering Groups/Delivery Units
· Hold and manage all project documentation and CIP workbooks
· Hold risk, issues and dependency logs
· Provide updates to the Executive Team on the progress of the CIP programmes
· Escalate concerns regarding Trust wide projects delivery to SMT via the Project Sponsor
· Provide updates to the Governance and Quality and Risk Assurance Committees on the QIA process.
· Ensure CIP programmes follow the governance process as outlined in this document
Project Sponsor will:
· Own the objectives
· Approve and review the project plan
· Hold Project Steering Group meetings at least monthly and where applicable more frequently with the Project Manager and key project team members
· Represent the project at SMT
Project Manager will:
· Create the project plan
· Own the deliverables
· Manage any sub-projects
· Lead the project team
· Manage risks, issues and dependencies
· Produce a project report at least monthly or more frequently to align with Project Steering Group meetings
6. PROCESS
There is no single approach to developing a cost improvement scheme/project. However, trusts
that develop, deliver and have a sustainable programme have several common factors. They
have effective, coordinated and well-executed leadership and management which impacts
positively on the organisational cultural and mean that organisational performance is strong and
consistent. To ensure the Trust is successful it must:
· Set out clearly its overall vision, approach to improvement and philosophy;
· Commit to ensuring that the organisational culture facilitates the improvement of services and improves patient experience;
· Develop a five-year forecast that supports the need to plan longer-term improvements;
· Involve all local health economy stakeholders at an early stage;
· Identify suitable, tailored CIP targets for each Clinical Service Centre (CSC) or department that reflect their relative efficiency, using benchmarking data; and
· Set up a progamme management office to oversee improvement, and/or define clear governance and lines of accountability.
6.1.1 Planning
Service and Cost Improvement planning should start as early as possible and planning and delivery viewed as a continual process, rather than a short-term, in-year project.
Cost Improvement planning often starts in the finance department. Finance staff produces a five-year, long-term financial plan that models the forecast activity, income and expenditure, taking into account inflation and capital plans. The plan identifies the scale of cost savings required each year to meet financial targets and the Trust’s strategic plans. The finance department can also act as a facilitator by providing data, analysis, training and financial literacy. However, detailed service planning must be led by CSCs, including appropriate clinical input. CSC engagement ensures the schemes are realistic, owned by the CSCs and, as such, are more likely to be successful.
There are three important aspects to planning:
Information
The Trust needs good quality data on costs, cost drivers and comparative costs for planning and making decisions about service delivery. Assumptions must be realistic and based on accurate information. Long-term financial planning and an in-depth understanding of costs are both important elements at this stage.
Consistency and collaboration with local partners
The Trust should not plan to increase activity where, for example, the Commissioners are putting in place demand management plans. Similarly, the Trust should not plan to close a service where there is no alternative option. Ideally, responsibility for delivering Quality, Innovation, Productivity and Prevention (QIPP) schemes should be shared between the Trust and the Commissioners.
Building in Contingency
The Trust is more likely to be successful if it identifies more schemes than required to meet the CIP target. Building in contingencies (together with starting the process early in the year) helps with delivery of the CIP. As there is always slippage, plus the process usually takes longer than originally planned to agree and finalise.
6.2 Identifying Service and Cost Improvement schemes
Whilst there are different approaches for identifying service and cost improvements, most organisations will know where they need to make changes, but there should be supporting evidence and involvement from all staff. Seeking input from stakeholders, including CCGs, GPs, social care and third sector providers is also beneficial. If the Trust is to be successful in identifying service and cost improvements it should:
· Build in dedicated time to enable all staff, clinical and non-clinical, to step back from their day jobs and produce new ideas for service change;
· Use benchmarking performance data to help identify saving opportunities and engage clinicians;
· Rigorously appraise potential schemes for achievability and impact on quality;
· Check that schemes are consistent with the overall strategic direction of the organisation and the plans of partners; and
· Fully engage clinicians and other staff to achieve change that is both improvement and genuinely produces realistic, sustainable cost savings.
Developing safe, realistic CIPs requires clinical leadership and engagement. Organisations with a culture of strong clinical leadership develop more rounded CIPs as the individuals leading the service are also those delivering the care.
6.2.1 Identifying individual Service and Cost Improvement schemes
Well-managed, well-informed trusts recognise the need to provide support to budget holders where required. There is much variation in the methods employed and no one system fits all. However, there are several consistent factors and these include:
· Developing annual savings targets for each CSC or department. The identification of plans to meet that target then becomes the responsibility of each budget holder;