Page 1 of 52. NHS Midlands and East of England Region CCG Resilience Handbook 11 th May 2017 VERSION 1.0

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1 Page 1 of 52 NHS Midlands and East of England Region CCG Resilience Handbook 11 th May 2017 VERSION 1.0

2 Page 2 of 52 Contents Scope and purpose of the handbook... 3 Introduction: what does good look like?... 6 Part 1: QIPP Design, Planning and Implementation Scoping QIPP opportunities Planning Implementation Part 2: Organisation Accountability and Delivery Organisational Accountability and Delivery... 43

3 Page 3 of 52 Scope and purpose of the handbook Scope This handbook forms part of a set of tools to be used by CCGs to develop quality, innovation, productivity and prevention (QIPP) programmes in their areas. QIPP is a framework used by the NHS to improve quality, innovation and patient experience whilst making efficiency savings. The diagram and table below outline the full set of tools that have been developed to support CCGs to successfully develop and deliver QIPP programmes. Product Menu of Opportunities (MoO) QIPP Opportunity Guides (QOGs) Description The MoO tool summarises the list of QIPP themes that have being worked up into QOGs, and links these themes back to the original list of QIPP schemes and ideas that were captured in the MoO document (please see Appendix M). The QOGs provide further information on the QIPP ideas generated by the MoO and aims to guide the user in a number of areas: 1. Who should consider this QIPP opportunity? 2. What are the potential solutions? 3. How will you measure success?

4 Page 4 of 52 Resilience Handbook 4. What are the key enablers? 5. How will the financial benefits be realised? The handbook provides information on: 1. At an individual project development level how to develop and deliver individual QIPP schemes from generating ideas, planning, implementation, and in monitoring the delivery; and 2. At an organisation level how to lead and govern successfully a large QIPP change programme and ensure the right level of grip and control in managing and monitoring progress. The technical appendices provide supplementary information to the handbook including a prioritisation tool, Project Initiation Document (PID) template, an example project plan, guidance on Procedures of Limited Clinical Value (PLCV), Terms of Reference for Programme Boards, a disinvestment policy, contracting and a glossary of terms.

5 Page 5 of 52 Purpose of the handbook The purpose of the handbook is to provide a best practice guide, including tools, examples and tips which will assist CCGs in the delivery of QIPP. This handbook will be useful for all those within CCGs and partners who are involved in generating, overseeing and delivering QIPP. The handbook is made up of two parts that are divided into four sections as shown below: Part 1 is directed at project and programme leads, commissioning leads and the Programme Management Office (PMO), who are involved in the scoping, planning and implementation of QIPP. Part 2 is directed at an organisational level and those who oversee current governance arrangements. They include the governing bodies, programme leads/directors and the PMO - this focuses on processes around organisational accountability and delivery of QIPP. PART 1 1. QIPP Design 2. QIPP Planning 3. QIPP Implementation For: QIPP Project and Programme Leads, Clinical Leads, Commissioning Leads and the PMO PART 2 4. Organisational Accountability and Delivery For: Governing Bodies, QIPP Programme Directors and the PMO This handbook is directed at individual CCGs in order to develop local processes and ownership for the delivery of QIPP. However, collaboration with other system partners will be key to realising system wide and transformational QIPP. The same principles identified within this handbook should be applied to QIPP realisation across a group of CCGs or system partners. This is an evolving document and will be updated on a regular basis to reflect CCG feedback and best practice delivery.

6 Page 6 of 52 Introduction: what does good look like? Defining QIPP The NHS Five Forward View forecasts that the NHS would have a 30 billion funding gap in 2020/21 if demand trends continue. As demand for NHS services continues to increase CCGs are under increased pressure to deliver savings whilst maintaining or improving patient experience. Consequently, QIPP should not be thought of as a one off exercise that starts in March. It should be part of the annual organisational business planning process that aims to improve the quality of care that is delivered while making efficiency savings. The business plan is an annual operating plan which describes how the CCG will deliver its commissioning priorities on a year by year basis - a fundamental element of this is the long term QIPP planning expectations which should be informed by the direction and travel of the CCG. QIPP programmes should consider all areas of CCG expenditure and be designed to improve quality, innovation, productivity and prevention as outlined in the diagram below: Quality Deliver financial efficiencies whilst improving quality including better clinical outcomes and improved patient experience. Q I Innovation Introduce innovative service delivery models whilst managing risk. Productivity Reduce waste and increase productivity to meet rising demand within the same resource base whilst managing risk. P P Prevention Deliver on prevention activities to prevent more costly poor health in the future. There are a range of ways in which QIPP can be delivered. Common QIPP themes include:

7 Page 7 of 52 Providing care closer to home and moving activity from the acute to a more cost effective and appropriate setting; Reducing demand for acute and urgent care services; Decommissioning services; Supporting self-management; Efficient medicines use; Multidisciplinary integrated approached to service delivery; Streamlining the delivery of care; Variation in prices paid for goods and services (procurement); Reducing unwarranted clinical variation in care; Improving productivity in GP practice; Primary Care demand management; and Primary care access. What does good like? Good QIPP schemes transform clinical services in ways that result in permanent cash releasing savings, whilst improving patient care, satisfaction and safety. More specifically, good practice QIPP schemes are: Aligned to national standards and local strategic plans. Supported by a clear evidence base clinically and financially. Developed and delivered by multi-disciplinary teams from the full range of stakeholders. Monitored by visible, measurable and universally understood Key Performance Indicators (KPIs). Supported by robust governance and clear communications. Quantified based on clearly identified patient cohorts rather than generic demand reduction. Co-designed with partners to create efficiencies across an entire patient journey rather than simply managing CCG costs. Part of an ongoing process throughout the year and embedded in commissioning cycle. Supported by appropriate contract management between partners to ensure all partners are invested in the process.

8 Page 8 of 52 Why does QIPP fail? There are causes of QIPP failure and every failed QIPP project will have its own set of issues, however below are some of the common causes. These should be read and used as early warning signals to prevent future failure: Trying to boil the ocean QIPP programmes can be developed without considering the resource implications to deliver it. Inadequate prioritisation and scoping of each QIPP initiative means the organisational capacity is spread so thinly that little impact is made on delivering QIPP. Poor communication with international and external stakeholders this is particularly true between the CCG and secondary care. This is usually due to a lack of conscious planning over the communication strategy and methods used to communicate through the programme lifecycle. Lack of buy in Many stakeholders, including clinical stakeholders and service users, may resist change because of a lack of engagement at the early stage of scheme development, as such the change may feel imposed which ultimately increases resistance to change. Inadequate project definition and planning Due to the time pressures in CCGs to realise financial benefits there can be a tendency to rush the planning phase and try to implement the solution, without a clear definition of the problem, solution and the success criteria. Lack of clarity over accountability arrangements At a programmes level, when there ambiguity in roles and responsibilities, and a reporting structure which allows people to be held to account for delivery of benefits, accountability for the outputs of QIPP schemes can be absent. Not managing people through change There can be a lack of attention paid to cultural factors that influence service change. Project managers play a critical role in ensuring that people feel listened to and invested so that they feel more positive about change, more empowered and more motivated and productive. Failing to share learning There are many successful QIPP initiatives from across the country that can provide opportunities to learn from, preventing CCGs simply reinventing the wheel. Further, CCGs often fail to share learning internally from successful schemes due to a lack of focus on project evaluation. Lack of pace Reporting structures should be designed to ensure there is appropriate visibility of progress and clear escalation routes with identified executive support to unblock any barriers to delivery and ensure pace is maintained. Project Assumptions Incorrect - All too often schemes fail to deliver as project assumptions are incorrect, timing of financials is different than expected, and scale of proposal is too/not ambitious enough. Not understanding contractual means - Poor understanding of the contractual means (and restrictions) of implementing changes to an existing contract and failing to understand the contractual remedies available to support the implementation.

9 Page 9 of 52 PART 1 QIPP DESIGN, PLANNING AND IMPLEMENTATION (FOR QIPP PROJECT LEADS, PROGRAMME LEADS, CLINICAL LEADS, COMMISSIONING LEADS AND THE PMO)

10 Page 10 of Scoping QIPP opportunities Generating QIPP ideas Menu of Opportunity (MoO) The Menu of Opportunity (MoO) is a long list of potential QIPP opportunities (91) collated from a number CCGs in the Midlands and East NHSE region. CCGs are encouraged to review this long list of opportunities to identify any gaps in their QIPP plans. The MoO is intended to be an illustrative list thus it is important that opportunity identification is shaped by what is real and relevant for the specific CCG. It is intended to maintain an updated list going forwarded for all CCGs to access. The opportunities identified in the MoO have been aligned to six categories and 31 themes as detailed in the table below. A QIPP Opportunity Guide (QOG) has been produced for each of the themes identified. The QOG provides further detail on the QIPP opportunities identified in the MoO including case studies, Key Performance Indicators, finances, key enablers, commissioning considerations. The QOGs will be useful in directing and developing potential QIPP schemes in detail if appropriate. Category QIPP Opportunity Guide (QOG) Theme Mental Health Acute Primary Care 1 Substance misuse 2 Street Triage 3 Rapid Assessment Interface and Discharge 4 Personal Health Budgets 5 Mental Health Rehab and Recovery 6 End of Life 7 Integrated Locality Team 8 Telehealth 9 Integrated Community Equipment 10 Discharge Pathways 11 Referral Management 12 Frail Elderly 13 Ambulance Conveyancing 14.1 Virtual Ward Care Homes 14.2 Virtual Ward - Community 15 Front Door Models 16 Ambulatory Care 17 Outpatient Procedure Transition 18 Stroke and Neurology Rehabilitation Service 19 Long Term Conditions 20 Paediatric Emergency Pathways 21 Productivity in Elective Care 22 Releasing Capacity in GP Practices 23 Out of Hospital Shift

11 Page 11 of 52 Category QIPP Opportunity Guide (QOG) Theme Direct access Medicines Management Continuing Healthcare (CHC) 24 Secondary Care Efficiencies 25 Pathology Direct Access 26 Therapies Direct Access 27 Radiology Direct Access 28 Review of Repeat Prescribing 29 Over The Counter Medicines Prescribing 30 Medicines Optimisation 31.1 Initial Assessments 31.2 Market Management Care Brokerage 31.4 Quality of Package Reviews Further detail on how the MoO opportunities align to the QOGs is included in Appendix M. Review national sources In addition to the MoO, significant work has been undertaken nationally to identify where the greatest opportunities lie in order to improve both quality and value by doing things differently. Whilst developing QIPP, organisations are encouraged to compare current local practice to identify potential QIPP opportunities against the available national sources and includes: NHS RightCare (Commissioning for Value) comprehensive CCG data packs, atlases, case books, long term condition scenarios, optimal value pathways and Commissioning for Value tools; Programme budgeting framework provides benchmarking information on expenditure across programme categories enabling NHS organisations to make evidence based investment and prioritisation decisions. CCGs should consider comparing spend to ONS comparators in expenditure areas such as Community and Mental Health; Public Health England Spend and Outcomes Tool an essential starting point for identifying opportunities e.g. high spend/poor outcomes areas; CCG outcomes tools includes an extensive set of indicators from both the CCG Outcomes Indicator Set and the NHS Outcomes Framework as well as demographic and disease prevalence (QOF) data; NHS England Learning Environment provides case studies covering a wide range of areas including transformation and service redesign; Reference Costs for finance/ activity benchmarking allows NHS organisations to benchmark specialities by activity, price and bed-days at trust level. NHS Evidence QIPP collection A resource to share examples of successful good ideas with colleagues in the NHS. There are now more than 120 examples of best practice quality and productivity examples available. The King s Fund An independent charity working to improve health and care in England which published innovative research and analysis such as The NHS Productivity Challenge experience from the frontline. NICE Provides quality standards in the form specific, concise statements that act as markers of high-quality, cost-effective patient care, covering the treatment and prevention of different diseases

12 Page 12 of 52 and conditions. NICE also host Shared Learning Awards and publish case studies of the finalists in order to share learning more widely and has published over 500 examples of quality improvement in health and social care service. The NHS Innovation Challenge Prizes The challenge encourages, recognises and rewards front line innovation and shares learning to drive the adoption of these innovations more broadly. Academic Health Science Networks The network aims to improve patient and population health outcomes by translating research into practice, and develop and implement integrated health care services, through partnership working and collaboration between the NHS, academia, private sector and other external partners. Dr Foster healthcare intelligence portal Provides a wide range of key quality and efficiency metrics including analysis of inpatient, outpatient and A&E data. Alongside commissioner specific tools including comprehensive contract monitoring reporting. Keele University Medicines Optimisation Service A not-for-profit organisation which provides tailored, cost-effective, prescribing support solutions to the NHS. Services include prescribing data analysis, clinical evaluation service, medicines optimisation and prescribing education. PrescQIPP An NHS funding organisation which produces evidence-based resources and tools for commissioners. National CHC Programme The national CHC programme provides a resource describing where NHS continuing healthcare can be provided, in particular, eligibility, support and planning. Vanguards/New care models A one-stop shop for support, tools and links to delivering improvements and integration. NHS Productivity and Efficiency Lord Carter Data packs are available at NHS Trusts to review productivity and efficiency opportunities identified by the Carter Review. Getting It Right First Time (GIRFT) Programme - National programme supported by NHS Improvement which engages clinicians working in acute care with their own data to accelerate the adoption of evidence based practice through peer to peer discussion and review. It is important that CCGs with local providers to review opportunities arising from GIRFT and Carter. Review local sources In conjunction with local providers CCGs should also review provider performance data to understand upwards trends in expenditure and activity to identify further QIPP opportunities. The national benchmarking tools identified above may support this activity. In particular acute performance activity should be monitored and areas of outlier performance and unexpected growth areas reviewed and considered, for example: A&E attendances; Unplanned admissions; Excess bed days; Ambulance conveyances; and GP initiated referrals to elective secondary care providers. CCGs should develop a cycle of benchmarking and peer review with their local CSU and providers or inhouse business intelligence service to identify new areas of opportunity using the sources listed above. Last year s lessons learned should be used to inform QIPP plans including areas of budget over performance and underperformance.

13 Page 13 of 52 Scoping QIPP ideas Engagement CCGs should share, test and develop the QIPP ideas generated using the sources outlined above at a series of idea gathering workshops with input from GPs, CCG staff and providers. Engagement is key to developing QIPP programmes and CCGs should ensure: QIPP ideas are developed through engaging with other commissioners, clinicians and providers to ensure the QIPP programme is clinically-led. They work with trusts to identify areas of shared delivery where there is potential to achieve cost efficiencies for both providers and commissioners. QIPP schemes are aligned to the needs of the local heath population, as identified in the Joint Strategic Needs Assessment, and the local Health and Wellbeing Board s (HWBB) priorities. Appropriate engagement sessions with patient and public groups take place to gather user input on proposed service improvement areas. Understanding the baseline position CCGs should gain a detailed understanding of the current or baseline position in terms of service design, activity and costs. It is unlikely that CCGs will be able to do this in isolation on all occasions and therefore it is essential that they work together with providers and other stakeholders from the start. An accurate baseline will support CCGs to understand whether there is scope for improvement and cost savings in their local setting. CCGs will require good quality data on costs, cost drivers and comparative costs. Any assumptions should be realistic and based on accurate information. The finance department or contracted CSU can act as a facilitator by providing data, analysis, training and financial literacy. Process and pathway mapping Process mapping is one of many idea development techniques. CCGs and providers may have existing pathways mapped and described in service specification documents. However, many services develop over time with changing processes, people and costs. CCGs should consider analysing and mapping processes and patient pathways in conjunction with providers during the project scoping stage against best practice delivery models. Process mapping can bring together people who do not necessarily operate as a team, to focus on the patient s journey. It is important to include a wide variety of staff, both senior and junior, to capture the viewpoints of different stakeholders and different aspects of the care experience. The purpose of process mapping is to design a future pathway or service based on analysis of the current strengths and weaknesses of the pathway. The actual process of building the map enables reflection of the patient journey, bottle necks, good practice, wasteful activity and areas for improvement. Mapping is most successful when the team involved in redesign has walked the process being mapped gathering information such as wait times

14 Page 14 of 52 and information flow between disciplines as they progress through the process. Please refer to Process Mapping, The King s Fund for further guidance. Developing a process follows the following steps: 1. Identify the problem the problem that is trying to be solved needs to be outlined in a problem statement. A problem statement is a clear concise description of the issue(s) that need(s) to be addressed by the project team. It should be used to direct and focus the team at the beginning of the process mapping exercise. The problem statement documented in the PID 2. Determine the process scope - what is the start of the process (e.g. visit to GP or referral) and what is the process end (e.g. discharge from hospital). This is determined by the problem statement. 3. List the individual process steps this needs to be written as a verb, and should describe who does it and when it is carried out. The level of detail required for each step will be dependent on the process i.e. High level view will depicts the major elements and interactions. This can be useful earlier in the project when trying to determine the problem but may lack the detail when moving into the improvement phase. Low level depicts specific actions, workflow, rework loops in a process. 4. Sequence the steps - this should capture the sequence of events for how the currently work. Begin to link the process steps and use arrows to determine the process flow. 5. Include basic flowchart symbols - Each process step is represented by a specific flowchart symbol, these symbols together represent process mapping 6. Finalise Process Map Once develop it is helpful to review and validate the process map with other stakeholders who may not have been part of the exercise, to make sure everyone is in agreement. 7. Challenge current state process the current process is the platform to redesign. A technique that can be used is to analyse the current state process and look for activities that add value from the patient s point of view. By removing activities that add no value (or waste), the team can then design the desired future state and work towards a more streamlined and efficient process through a series of prioritised projects. These approach to redesign is called value stream mapping and is useful in particular when mapping a patient journey. 8. Develop Action Plan an action plan should be developed which is based on moving from the current process to the future, more streamlined process. This is a key platform for the project. An example of basic process map is provided in the diagram below, with a description of the basic symbols in Appendix D. There is also a more detailed example of a process map in Appendix E.

15 Page 15 of 52 Process map example Reducing unwarranted variation Reducing variation is a key enabling strategy for the delivery of QIPP. It is widely acknowledged that there is huge variation in healthcare practice across primary and secondary care resulting in health inequalities, waste of resources and poorer outcomes for patients. There will always be some variation in healthcare due to the complexity of variables within the system, for example, characteristics of the individual patient, complexity of disease or unpredictability of symptoms. Such variation is reasonable and expected. However, unwarranted variation in healthcare is an area for focus. The most widely accepted definition of unwarranted variation is that conceived by John Wennberg 1 : (Unwarranted variation is) variation in the utilization of health care services that cannot be explained by variation in patient illness or patient preferences. (Wennberg, 2010) The Wennberg definition mostly relates to unwarranted clinical practice variation. Besides this, there are different types of unwarranted variation in healthcare, such as in access to care and utilisation of services, variation in outcomes and quality, and variation in activity and productivity. Quite often different types of variations intersect and cluster making it more difficult to identify and reduce the unwanted variation in care. Research indicates that unwarranted variation yields sub-optimal clinical outcomes and significant financial burden. Therefore, in order to identify opportunities for QIPP, variations in performance, quality and accessibility of care services should be considered. Reducing variation and increasing the use of best practice will optimise the delivery of quality care improving the cost of delivering the whole package of care to each patient. The first key step is to undertake 1 Wennberg, J.H. (2010) Tracking Medicine: A Researchers Quest to Understand Health Care, Oxford University Press

16 Page 16 of 52 analysis of current quality, variation, capacity and capability and assess against desired levels. The following areas could be considered: Diagnosis Variation in diagnosis to identify scope to reduce delays and errors in the diagnostic process and focus on assessing and improving the quality of diagnosis. Referral Variation in referral pathways and opportunities for improvements in the appropriateness and quality of referral practice and decisionmaking. Prescribing Variation in prescribing practice means there may be opportunities to reduce medication errors, improve adherence, and rationalise prescribing practices. Long term conditions Variation in practice may present opportunities to develop proactive preventative activities and management strategies. Accessibility to services Variation in practice may present opportunities to ensure consistent access and availability of clinicians. Patient engagement and involvement Variation in patient engagement and involvement may lead to the scope to empower and involve patients in all decisions about their care and treatment and to proactively seek feedback on their experience. Potentially patients can benefit from: Reduced inappropriate hospital admissions resulting in better patient outcomes and experience for those exposed to those preventable admissions; Less duplication of tests and diagnostics from improved systems and processes resulting in better clinical outcomes and patient experience; More robust prescribing processes, delivering better patient safety and experience; and Improved quality of referral and more targeted referral process means increased patient safety and better clinical outcomes. Equally, this could result in a smoother experience for patients with quicker access to the right care and support. Prioritising ideas Many QIPP programmes are unsuccessful due to a lack of available capacity in the organisation and leadership to drive QIPP delivery. This is often a result of CCGs failing to prioritise the vital few QIPP ideas that will yield the greatest benefit. Rather, CCGs stretch themselves too widely and fail to go into the necessary depth in terms planning and engagement in order to realise benefits. A number of key steps should be followed in order to ensure the organisation is focusing on the most valued QIPP ideas that do not compromise patient safety and experience. This process can be facilitated by the PMO (please see Section 4 Organisational Accountability and Delivery for further detail) but managed through the QIPP Programme Board or equivalent. They can

17 Page 17 of 52 provide oversight of all schemes and are able to evaluate it in terms of its strategic fit and potential interdependencies with other schemes. This process will condense a long list of ideas to a prioritised list of schemes. The planning phase describes how these prioritised schemes are than worked up in a PID and taken through Quality Impact Assessment (QIA) before they proceed to delivery. The table below provides detail on the key steps CCGs should follow during the prioritisation process: Key step 1. QIPP opportunity identified 2. Opportunity is validated against agreed framework criteria Detailed description Develop a long list of QIPP opportunities based on the MoO and national and local sources identified above. The long list of potential QIPP opportunities is assessed against a QIPP framework criteria. If not already in place a QIPP framework should be developed with key stakeholders and partners. The framework should be guided by the key strategic objectives of the organisation. Criteria should always include patient quality/safety and patient experience as a priority. Example criteria includes: Strategic fit the proposed service change aligns with strategic direction, vision and values of CCG. Quality and effectiveness what is the impact on the patient, impact on access to healthcare and/or health equality, does the proposed initiative reduce ill health. Risk Does the initiative contribute towards achieving national targets, what are the political and clinical risks of implementing this initiative? Finance and Productivity what is the financial impact of the initiative? What are the timescales for realising those benefits e.g. short term (less than 12 months), medium term (within 1-2 years), or long term (more than 2 years)? Best Possible Value methodology this is about ensuring value is used as the standard currency in evaluating QIPP. Please note this is more relevant for large scale business cases and has been the mandated methodology for Vanguard Value Propositions. Feasibility how feasible is the scheme in terms of implementation, is it likely to deliver its intended purpose? Not all criteria will have equal importance to the organisation therefore it is best to weight the criteria by assigning a numerical value. Again, it is imperative all opportunities satisfy a quality criteria. See example criteria in Appendix A. 3. Opportunity is categorised into the Each QIPP opportunity needs to be categorised into a programme area:

18 Page 18 of 52 appropriate scheme sub-group 4. Opportunities mapped based on the benefit and complexity of implementation Typically QIPP programmes can be divided into the following programme areas: unplanned care, long-term conditions, planned care, prescribing, children, young people and families, primary care, CHC and mental health. It is important to consider the risks associated with different groupings looking at the same patient cohorts and double counting e.g. is a patient with an exacerbation of COPD a LTC or unplanned, is a mental health patient attending A & E for crisis support mental health or unplanned. The level of inter-dependence on other schemes is usually a good method of grouping QIPP opportunities together into subprogrammes. Further work is required post-prioritisation to ensure that the programme structure balances the financial value of the QIPP schemes with the level of programme resource required. Each opportunity is mapped on a prioritisation matrix which helps teams focus and come to a consensus on the vital few QIPP schemes that should be implemented first. The scores associated with the criteria highlighted in point 2 would assist in plotting the schemes on the matrix. The axis for the matrix usually include expected benefit and ease of implementation or complexity of the scheme. An example is provided below. In this instance, prioritisation would focus on those schemes that have high benefit but are relatively easy to implement. Where both the benefit and effort are high the opportunity may need further scoping and support to implement the change. Any opportunities aligned to the bottom two zones should not be prioritised, however they should not be completely discounted as they could be appropriate in the future.

19 Page 19 of 52 Example opportunity mapping:

20 Page 20 of Planning Managing change Many QIPP projects fail to achieve the anticipated results due to a lack of attention paid to the cultural factors that influence the change. In some cases the hard technical solutions are well defined, however, the same level of detail and preparation has not occurred for the soft solutions i.e. people and cultural influences. The process of managing people through change should be central to those QIPP schemes that are transformational in nature and involve altering the processes in which care is delivered. The issues of stakeholder management is considered throughout this handbook. Below are a number of specific points that should be considered during the planning stage: There must be an evidenced based argument that justifies the need for the initiative that appeals to all stakeholders from both a quality and financial perspective. The PID template should be used to provide evidence of the QIPP scheme to stakeholders. Key stakeholders should be defined and active plans developed to manage them. Stakeholders can be defined as anyone who can influence or are influenced by the QIPP scheme. Stakeholders should form part of the design process, in order to promote ownership and accountability for the initiative. Use defined communication channels to engage staff throughout the QIPP programme. These channels should keep them informed of progress, early wins as well as provide a regular forum to input into the programme (see Section 4 Organisational Accountability and Delivery). The PMO can play a role in defining key stakeholders as well as managing interdependencies between projects and programmes (see Section 4 Organisational Accountability and Delivery). Also through the PMO and reporting mechanisms project leads will be able to escalate any obstacles to their Programme Lead or Clinical/Executive Leads. Roles and responsibilities Once a QIPP idea has been prioritised the CCG should establish a Project team. The Project team will be led by a project lead who will be held accountable for the delivery of the QIPP scheme and any identified financial and non-financial benefits. The Project Team will be tasked with ensuring that actions take place between project meetings and will report progress at a programme level. The definition of a project and programme is highlighted below: A project is a temporary group established to deliver specific outputs in line with predefined time, cost and quality constraints.

21 Page 21 of 52 A programme is a collection of multiple projects that are managed and coordinated together with the objective of achieving outcomes and benefits for the organisation. QIPP Programme Programme Programme Programme Project Project Project Project Project Project Project Project Project Project Project Project The nature and size of each QIPP scheme will determine whether it requires its own project team or whether it could be combined with other similar QIPPs. Defined below are a number of Key Project and programme and responsibilities are outlined in the table below (see also Appendix H). When defining roles and responsibilities it must be stressed that clinical leaders need to take a central role in leading and driving QIPP delivery. Clinical leads added value is to identify problems on behalf of patients, identify solutions, and support implementation of the solutions (by clinician-patient, clinician-clinician work). Many of the roles described below e.g. Project/Programme Leads and Executive Leads can and should be encouraged to be clinicians where feasible, however, due to capacity constraints this is not always possible. Alternatively many of these roles can be paired with a managerial lead, however responsibility must be jointly owned. Having clinicians in these roles promotes clinical leadership and ensures clinic input is at central to the planning, decision making and delivering QIPP. Project Level Role Responsibilities Project team members Team responsible for planning and executing the project; Consists of project leads and a number of Project Team members, who are brought in to deliver their project tasks according to the project plan. A key member of the project team are process owners, these individuals own and manage the process which is being improved. Accountability for the success of the project sits jointly with them and the project lead; and Some large projects may require project leads who provide task and technical leadership and maintaining the work stream portion of the project plans e.g. HR, procurement and contracting. Project lead Managing the production of all project documentation (including the PID) and managing risks and issues;

22 Page 22 of 52 Managing the project team and delegating tasks to team members; Monitoring progress and updating the PMO; Producing Exception Reports for at risk projects; and Attending Programme Board for confirm and challenge. Finance Lead Support Project leads with financial modelling to develop PIDs; Business Intelligence Lead Provide clear financial and management information to Executive Lead on the financial status and forecast of the project; and Advise on financial risks and issues. Support Project leads to develop PIDs by providing activity and baseline data; Develop the financial and activity trajectories in line with the key milestones to be delivered; and Identify KPIs and methods of measurement/sources. Programme Level Programme Lead* Managerial ownership of the delivery of their programme of projects; Identifying and managing interdependencies between projects; Resolving conflicts and removing obstacles to delivery; Managing their resources and assessing whether resource needs to be moved to support under-performing projects; Attend Programme Board for confirm and challenge; Sign off Exception Reports and attend Finance and Executive meetings to present Exception Reports for scrutiny and approval; and Communicate actions from Finance and Executive meetings to Project Group. *In some cases Programme and Executive Leads can be the same person. For larger portfolios of work the programme leads would report to an executive lead who would play a more strategic, rather than operational role in delivery Executive Lead Responsible Officer for one of the Programmes. In this capacity, they will act as Executive Lead for all projects within their Programme(s) and therefore ultimately accountable for implementation and benefits realisation. Provide strategic insight into developing QIPP schemes Provide executive support to Programme/Project Leads to support project leads to unblock any barriers to delivery; and Agree which projects should be escalated to the Finance and Executive Committee.

23 Page 23 of 52 Clinical and Quality Lead* Identify opportunities for future service developments and improved quality; Involved in the QIA and Equality Impact Assessment (EIA) of QIPP schemes (see page 34); Identify and manage risks to service delivery with the patient in mind; Provide clinical oversight on how to redesign services and clinical accountability for the delivery of QIPP; Attend Programme Boards for quality assurance; Attend clinical network events to provide updates on project status and generate QIPP ideas; Mobilise clinical input to programmes by linking clinicians across the system to ensure sign-up; and Assist in overcoming clinical and operational resistance to change. *Clinical and Quality leads can also work as part of the project team Programme Management Office (PMO) Undertakes a monitoring and escalation role for the overall programme; achieving a balance between enabling local ownership and accountability whilst ensuring sufficient operational grip and focus to deliver actions. Manage and coordinate complex interactions between projects; support projects with a weekly cycle of reporting. Track and provide oversight to the overall programme milestones, risks, success measures (including finance). Support teams in the development of long term improvement plans. Please see Appendix H for a more detailed description. Senior Responsible Officer The visible owner of the overall business change and ensures that the QIPP programme meets its objectives and delivers projected benefits; Works closely with the Head of the PMO to monitor and control the progress of the programme at a strategic level (at an operational level this is the responsibility of the Programme Lead or the Project Lead who are responsible for providing regular reports to the SRO on progress); and The key leadership figure in driving forward the QIPP programme. The Project Lead, with the support of the PMO, will be responsible for identifying and calling on the expertise (or subject matter experts) of individuals who sit outside of the Project team, for example, Procurement, Human Resources, Commissioning, Communications, Equality and Diversity, and Contracting when necessary to support the development of the PID. More detail on the key components of PIDs are described in the sections below. The diagram below articulates the key programme and projects roles and the structure of accountability in which they sit. It also highlights the supporting functions that provide capacity and expertise to support

24 Page 24 of 52 the teams in delivery. Some positions described below can be combined depending on the project size and scope e.g. Programme lead could be an executive lead or sponsor, also finance leads could also be project leads Project Initiation Document (PID) The purpose of the PID is to define the project, in order to form the basis for its management and an assessment of its overall success. It provides the tools to monitor the project and hold the project team to account for delivery. The PID gives the direction and scope of the project and the on-going performance and viability of QIPP schemes will be monitored against this document. The key elements of a PID have been described in the sections below. The PID is a live document which will be reviewed regularly within the programme check and challenge sessions to ensure that the stated outcomes of the project remain realistic, deliverable, and timely and are still necessary. The diagram below outlines the process for developing the PID from idea generation to approval and sign off.

25 Page 25 of 52 A PID template and examples are provided in Appendix B of this document. It is important to consider that the paperwork required should be proportionate to the size/complexity of the scheme e.g. a simple transactional change will not require a detailed PID but a multi-stakeholder scheme will probably require more than a single PID. This section outlines those sections which are more complex to complete and require further attention. Benefits identification The PID template (Appendix B) requires a number of categories of benefits to be calculated: Care and Quality Health and Wellbeing / Service user benefits Finance and Efficiency The example PID in Appendix B provides examples of benefits and associated measures Overarching principles A common characteristic of many unsuccessful programmes is the vagueness with which the expected benefits are defined. In order to define benefits clearly they should be quantifiable and measureable as defined below: Criteria Description Quantifiable A sufficient evidence base should exist to forecast how much improvement / benefit the changes will realise e.g. detailed activity modelling. If a benefit cannot be measured numerically it should not be claimed.

26 Page 26 of 52 Measureable Timing A common mistake is to identify benefits that are too loosely defined or difficult to measure. Benefits should be expressed in measurable terms against the current baseline position. The unit and method of measurement should be identified alongside the data source, a Business Intelligence lead to support the collection of data, the frequency of data collection (e.g. monthly/quarterly) and the target position. Calculation of benefits should take into account when benefits will occur and over what time period they will occur. The PMO, Project Lead and Programme Lead are responsible for managing inter-dependencies between projects including reducing the potential risk double counting of benefits. In particular where there are benefits relating to the same cohort of patients, care needs to be taken to understand the cause and effect of each scheme and how the benefits should be attributed to avoid double counting. The identification and modelling of benefits will impact all remaining activities in the benefits management lifecycle. It is important that the correct benefits are identified from the start to avoid substantial re-work at a later date e.g. activity modelling. Non-financial and quality benefits Improving quality should be central to any CCG s QIPP programme. CCGs should ensure there is an appropriate focus on quality in the delivery of QIPP by capturing a range of financial and non-financial benefits against each QIPP scheme. Non-financial benefits should where possible still be quantifiable, for example, reduced patient complaints and improvements in health outcomes. Non financial and quality benefits should be visible across the project and programme teams. All impacts on quality both benefits and disbenefits should be considered as part of a QIA. This is described in more detail on page 34. Calculating financial benefits The following key steps should be taken when calculating financial benefits: 1) Identify baseline activity or budget information and understand projected activity growth assumptions. 2) Identify the target reduction using business intelligence information 3) Identify how data will be collected to measure benefits and how frequently. CCGs understand and map the timings of information and any time lags between financial information and how it triangulates to real time budget / activity information. 4) Identify whether financial benefits will be cost avoidance e.g. avoided admissions or cash releasing e.g. reduced medication costs. Cash releasing benefits should be counted as reducing the overall budget impact of a project. These are more likely where commissioner can regulate the flow of payments related to an outcome associated with those inputs or outputs. 5) Identify when the benefits will be realised i.e. how long will it take to implement the scheme and will there be any ramp up in benefits realisation or will it be 100% from month 1 after implementation. The desired outcomes from a project will almost definitely not be achieved on day one and may take more than a year to materialise. Project teams should forecast when a desired

27 Page 27 of 52 outcome is likely to occur and for how long that outcome will be sustained across the beneficiary group. 6) Identify any investment costs and make sure that benefits are shown gross before investment costs. 7) Identify the unit of measurement for example: Prescribing Volume reductions of drugs prescribed Procurement of drugs at a lower cost Continuing Healthcare Reduction in the number of eligible patients Reduction in price Acute Reduced activity volumes Reduction in acuity of case mix Reduction in cost of activity Reduction in acuity of case mix Reduction in tariff Calculating activity reductions A number of financial benefits will be driven by projects which will aim to reduce the cost or change acute activity provision. The CCG Business Intelligence team should support the Project Lead to identify the information required around activity reductions. The following table is an example of calculating activity reductions (please note activity will be dependent on the specific QIPP scheme): Outpatient first Outpatient follow-ups Electives Nonelectives A&E attendance Other (specify) attendance Baseline activity X X X X X X Target activity X X X X X X to be stopped Target activity X X X X X X changed within provider e.g. day case to outpatients Target activity moved to a different setting X X X X X X

28 Page 28 of 52 (e.g. hospital to community) Provide detail on which specialties/hrgs are affected X X X X X X Cost Benefit Analysis and Return on Investment Cost benefit analysis (CBA) and Return on Investment (ROI) are analytical techniques that identify whether the proposed intervention offers value for money. They should be used where the proposed service model or intervention will require additional investment or cost. ROI is calculated by dividing the cash releasing savings generated by a proposed investment over time by the investment value. CBA values the costs and benefits of all groups affected by the proposed investment over time to produce a benefit-to-cost ratio. CBA is important as it measures both the benefits expected and the costs expected to be incurred and identifies whether the benefits exceed the costs. A number a key points should be considered as outlined below: Any model should capture all costs associated with delivering the specific service / intervention. Project teams should look to build a bottom-up cost model. This should be measured against the costs of the no change option in order to demonstrate the net cost of an intervention. The ROI is defined as the ratio of gains to costs e.g. for every 1 spent, of benefits were realised The Finance Lead should support the project team to quantify the full cost of each scheme. The following costs should be considered: Type Capital costs Operating costs Behaviour Fixed Variable Function Development costs Operational costs Time Recurrent. CCGs will need to map the phasing of any costs, investment required and savings against specific dates and milestones. Where investment is required in an alternative service, the phased implementation date for benefits realisation should be realistic and enable the new service to ramp

29 Page 29 of 52 up before savings are anticipated. CCGs will therefore need to consider whether savings will have full year of part-year effect. CCGs should also consider whether costs and savings will be recurrent or non-recurrent. Recurrent costs are regular, fixed expenses an organisation expects to have on an ongoing basis as an ordinary cost of doing business. Transformational programmes are associated with recurrent savings. A nonrecurrent cost or saving is a one-time, extraordinary items incurred by an organisation. Investment costs such as the purchase of a new facility or equipment are examples of non-recurrent costs. ROI / Cost Benefit Analysis Case Study Example Development of a Minor Eye Conditions Service Anywhere CCG identified that approximately 40% of ophthalmology referrals could have been managed by either community optometrists of GPs. In additional 2% of A&E attendances related to eye-related conditions. A minor eye conditions service has been scoped to meet this demand in a more cost effective and clinically appropriate setting. Evidence identified from other best practice sites has identified that 80% of patients can be managed in this service with 25% being referred on to secondary care. Service start date of 1 st May 2017 Costs Identified: The service has no one off fixed set up costs. All costs are variable costs based on the level of activity. All minor eye condition attendances will be charged to the CCG at 64 per attendance It is estimated that there will be 5524 attendances in 12 months. Total cost of 5524 x 64 would be 353,536 per annum Non Financial Benefits: Improved access to high quality eye health care in the community for the management of minor eye conditions. This will be measured by shorter waiting times and the number of patients offered an appointment within 2 weeks. The current baseline performance is 75% for the minor eye conditions identified. This will be improved to 90%. Improvements to the clinical outcomes achieved will be delivered. Improved early detection which will reduce incidents of visual impairment. Financial Benefits: The minor eye conditions tariff of 64 is lower than the ophthalmology outpatient first tariff and A&E attendance tariff: The lowest A&E tariff with treatment (VB09Z) costs 79 Ophthalmology first outpatient attendance costs % of the activity attending the MECS is assumed as saved / diverted activity =

30 Page 30 of of first outpatient attendances x 113 = 399, A&E attendances x 79 = 69,820 Return on Investment Calculations using annualised costs and benefits are shown below: Costs Benefits = ROI % Costs Annualised Costs Annualised Benefits ROI% 469, ,536 32% Cost Benefit Analysis Net benefits = 115,762 Net benefits based on phasing in financial year are shown below: Phasing of Financial Benefits A ramp up of savings have been assumed April May June July Aug Sep Oct Nov Dec Jan Feb Mar Total Costs Benefits Net Saving Financial Risks There is a risk that existing secondary care capacity used for minor eye conditions is substituted for alternative services potentially at a higher cost. Financial benefits will only be realised where the existing secondary care capacity is removed and shifted to the alternative provider. Key Performance Indicators (KPIs) A KPI is a quantifiable metric (financial or non-financial) that can be used to determine whether a project is achieving its intended outcomes. In order to identify KPIs, the first step is to be clear on the projects improvement aim and intended outcomes. Examples of KPIs can be found in the QIPP Opportunity Guide (QOG). KPIs must be specific, measureable, achievable and timed; and should include how much and by when (this may need further baseline data collection to understand current performance and set a target). It is important that KPIs are actual measurable e.g. counts, values, percentages or rates.

31 Page 31 of 52 Scheme level KPIs should be developed to help CCGs track the impact of QIPP on activity and finances. This should include an understanding of how activity reductions will be realised, for example, through budget and contract finance value reductions as well as activity reductions. CCGs should identify a KPI for each QIPP scheme which is a unique identifier of success. Performance against this KPI will signal whether the scheme is having the desired impact. A combination of programme and project KPIs may be helpful where the combination of schemes is required to have the desired effect or where it is not possible to disaggregate the cause and effect on one particular project. For example, four schemes all with a KPI of reduced emergency admissions for the frail elderly. Where possible the KPI needs to be focused on the targeted cohort of patients and the targeted intervention e.g. care home patients, ambulance conveyances, fallers, those with complex conditions, frequent fliers. Progress and delivery against KPIs is often tested using data from providers and KPIs collected as part of routine contract management can be used to monitor progress. It is essential that the project team have ownership of all identified KPIs and understand what other influencers could be impacting of performance, e.g. interdependent QIPP schemes. When defining KPIs it is recommended to use a combination of leading and lagging indicators. Leading KPIs typically refer to input measures that can be difficult to measure but easy to influence. Lagging indicators focus on the output measure and are reactive, these are usually easy to measure but more difficult to influence e.g. reduction in number of admissions for COPD would be a lagging measure, the leading indicators that influence this could include number of COPD reviews carried out by GP. Where KPIs relate to a new service or changes to an existing service, for example with an acute Provider, the CCG should ensure these are contractualised and most importantly agreed with the Provider. From a contractual perspective, if these are not agreed then Appendix 3 of the Dispute Resolution Process applies: Where both parties are in agreement local clauses such as sanctions / KPIs may be included in the contract but if agreement cannot be reached then the default position is that no local arrangements will be included. Further information on this can be found in Appendix N. Project plan and milestones A project plan with detailed milestones outlining when the outcomes will be delivered will need to be developed. A template project plan is included in the Appendix C. When developing a project plan it is important to consider the key deliverables of your project and their expected completion dates. A milestone is a key event selected for its importance in the project, it can be used to monitor progress on the critical path and to show the completion of a major deliverable and/or represent the start of a new phase. They should not be confused with KPIs. Milestones do not have a duration, rather they are placed at a specific point in time. For example, the completion of staff consultation could be considered to be a major deliverable and milestone for a project. The completion date will be recorded as a milestone and all

32 Page 32 of 52 of the tasks that go into completing the consultation, along with their duration and expected completion dates, will form part of the project plan. It is also important to consider the order of milestones, for example, is one dependent upon the completion of another before it can be delivered. The diagram below provides an example: The first set of milestones are likely to describe how you scope and set up your project Milestone Start Date End Date Idea (developed QOG) agreed by Programme Board (PB) QIA complete and agreed Financial and clinical benefits case complete Scheme approved by Programme Board MDT identified and ToR agreed PID and Plan complete and agreed Pathway analysis complete Contract agreed Provider completed staff consultation Premises agreed Launch event Milestones don t need start dates These are the dates you expect to reach the milestone, or complete the key event. The following milestones will be the key events specific to your project. Identifying risks, issues and mitigations Risk should be considered from a QIPP delivery perspective at a number of different levels including (but not exclusively): Project and programme risk; Financial risk; and Quality risk. Analysing the likelihood and impact of risk and issues is a key component of successful project management. A risk is something that may or may not happen which could potentially impact on delivery of the project. If something has happened or is happening which will jeopardise the success of the project it should be recorded as an issue. It is also important to evaluate each risk, one way of doing this is by providing a score based on the probability of it occurring and the potential impact it could have on the success of the initiative. The following BRAG status matrix (see box below) can be a helpful guide when scoring the severity of the risk but also how the risk is escalated and managed (Section 4 Organisational Accountability and Delivery describes the risk management process in more detail).

33 Page 33 of 52 BRAG Status Determination BRAG Status needs to be consistently defined and should be based on the management attention needed. Impact Score Range 1 = little or no impact on overall programme or project delivery plan or benefits 5 = Severe impact on programme/project delivery, for example; critical milestones completely missed, benefits not being delivered, political risks Probability Score Range 1= Very unlikely - < 5% 5= Almost certain - > 80% (An issue = 100% probability) Accountable leads should be identified against each risk/issue, they should develop risk mitigation actions to reduce the probability or impact of the risk. Mitigation actions should be carefully planned and detailed to provide assurance to executives that risks and issues are being appropriately managed. It is important that the project/programme risks are monitored through a regular reporting cycle for communication, transferred to another more suitable owner or escalated through the defined governance structure for treatment at a more senior level. It is effective when this is monitored both pre and post mitigation planning. Where project risks are identified, project teams should consider the financial impact of the identified risk. For example, where a risk of slippage in timescales is identified, the financial impact should be taken into account where a revised start date may impact on the total financial savings to be delivered. The project group should be involved in risk management to ensure a well-rounded approach is taken. The table below provides an example risk log: You can use a combined Risks and Issues log to make things easier. Risks and Issues Score Mitigation / Rectification Plan Action by? Action when? Data may not be accurate and will be challenged. Providers may not agree with changes. Patients may feel that they are not receiving correct levels of care due to reduced contact with hospitals. Providers may resist changes due to resulting reductions in income. Administrative processes may lag behind and cause 15 Verify data by audit in partnership with providers. 15 Involve key clinical and non-clinical staff in provider organisations from the start. 15 Involve patient representatives from the start. Ensure that changes encompass preoperative advice and guidance (written and spoken) that sets expectations for patients and staff. 12 Consider incentivising Trusts with Best Practice Tariffs for a limited time. 10 Ensure that an administrative representative is involved from the start of the project. 27/03 JB 7/05 PW 7/05 LM 27/04 PB 7/04 PF

34 Page 34 of 52 confusion for patients. Timescales may slip and benefits and savings may not be realised in the proposed timescales. The Programme Board (PB) ran out of time to look at the project so it wasn t approved as expected. Clinicians have not been able to attend meetings because of clinical commitments. 8 Ensure that appropriate governance is in place to manage the project, make decisions, manage risk and escalate as appropriate. Requested a virtual PB to be convened. If not approved will need to submit to next PB and move timescales accordingly. We didn t give enough notice or provide cover/workaround. We will give 6 weeks notice for all meetings and work with the MDT to ensure continuity of service. 7/04 LD Note the change in language. These are issues that are happening and require action now. Quality and Equality Impact Assessment (QIA and EIA) The QIA should be designed to ensure that the QIPP process is focussed on quality following on from key reviews such as Berwick, Keogh and Francis. QIA is about demonstrating that choices for change are led with the patient at the centre of that change. The QIA should consider the impact of QIPP schemes in terms of the delivery of high quality patient care and the potential impact on other parts of the health and social care system. A QIA and EIA framework should be clearly defined and embedded within the CCGs QIPP governance process. It should not replicate the project development process but sit alongside it to balance the fianancial case development. Please see Appendix K for an example QIA and EIA template. Typically a QIA will assess quality against the following criteria: Patient safety Rating the impact of the proposal on patient safety. Clinical effectiveness Rating the impact of the proposal on the clinical effectiveness of patient care. Patient experience Rating the impact of the proposal on the patient experience of care delivery. Equality and Diversity - Rating the impact on those in a specific group as outlined in the Equality Act 2010 and also including other hard to reach groups. Other impacts Rating the impact of the proposal on other services, patient groups, staff or reputation of the organisation. The impact should be tested through a rated scale against the quality criteria outlined above. The impact might be positive (an improvement) or negative (a risk to our ability to deliver high quality care). Where a risk is identified, the level of risk should be assessed against criteria relating to the impact and likelihood of this risk occurring to determine a risk score. Clear mitigating actions will need be identified. Any risks identified from the QIA must be included and managed through an appropriate risk register.

35 Page 35 of 52 Quality indicators, e.g. patient complaints, should be identified as part of the QIA process and monitored on a monthly basis where possible. This will support the Project Team to understand how the project is impacting on quality and the effectiveness of any identified risk mitigations. Trigger points should be identified so if they are breached, a review can take place and appropriate actions put in place.

36 Page 36 of Implementation This section is divided broadly into two parts, the first focuses on how to commission and contract QIPP. The second section focuses the steps required to test and sustain process and pathway change rather than transactional, commissioning-focused activity type QIPP. Commissioning-contracting for delivery If a scheme requires service change, reconfiguration or development it is only possible for Commissioners to enact QIPP by influencing change within providers. This is implemented and monitored through the contract. Appendix N provides a detailed description of the contracting requirements. However, five key success factors are outlined in the table below: Key success factor Detailed description 1. Identify all parties In the most straightforward of cases the CCG will be the sole commissioner and the entire service will be provided by a single provider. In this case the scheme can be written in to an existing or new single NHS Standard Contract, Short form contract or grant agreement. In the case of multiple commissioners; the above options are still applicable when used in conjunction with a robust collaborative Commissioning Agreement. Alternatively joint commissioning e.g. through the BCF or lead commissioner arrangements can be utilised. In the case of multiple providers (often the case in pathway changes) there is the option to contract through a lead provider/prime vendor type model or the scheme must be written in to each provider contract. 2. Consider level of provider influence QIPP scheme changes for providers can be considered within three categories: Enforceable: This applies to schemes such as the introduction or extension of PLCV policies; where with due notice of policy and process providers must comply with commissioners instruction. Negotiable: This refers to changes that commissioners cannot enforce on providers but would like to be negotiated in to the contract to be thus enforceable. Examples of these would include schemes such moving settings of care e.g. Inpatient to Day case; Outpatient ratios, Local pricing. Requiring Incentives: In many cases there can be QIPP schemes that can give significant benefit to commissioners and no advantage to

37 Page 37 of 52 providers, but need effort or resource investment by the provider. In such cases writing appropriate incentives in to the contact may leverage implementation. The most obvious example is CQuIN, but productivity and quality premiums should be considered as well as progressive tariff or currency payments.eg differential currency for ambulance see and treat vs conveyance. 3. Specify the scheme All providers and commissioners must have absolute clarity on the service commissioners want to buy. The configuration, the quality and performance standards, the volume and population to be treated. Activity type and volume must be specified at HRG or TfC level and any ripple impact on other service areas identified and specified. This information should be contained in the PID and signed off by all partners. 4. Focussing the contract on delivering There are particular parts of the Particulars volume of the Standard Contract that Commissioners can customise to ensure that they have the leverage in place to ensure providers deliver the services and/or changes required. These are summarised below but expanded upon within the technical appendices: Service specifications are to be used to define the precise service that commissioners expect from the provider in return for payment, this should be prepared jointly Indicative Activity Plans (IAPs) are absolutely essential to managing levels of elective activity and implementing elective QIPP. Once baseline activity (at HRG, outpatient or diagnostic level) are agreed in the contract providers are expected to deliver this level and no other without a case for change being made. Activity Planning Assumptions (APAs) are part of the rationale supporting the IAP e.g. outpatient ratios, consultant to consultant referral rates. Business Rules should clarify the financial treatment of the contracts APAs e.g. payment/non-payment for breach of planning ratios. Service Development and Improvement Plans (SDIPs) if QIPP delivery requires time and work to review or change a service opposed to immediate implementation the SDIP should be used. The SDIP can be used to ensuring phased review and change. Any time phased changes that are to be delivered during the time of the contract should be specified within an SDIP. Individual actions and outputs must be specified and measureable in such a way that delivery or non-delivery can be determined objectively. Breach consequences should be assigned to each element of the SDIP.

38 Page 38 of 52 Reporting Requirements and Data Quality Improvement Plan (DQIP). Schedule 6 of the contract permits commissioners to specify exactly what information they wish to receive from providers to support performance monitoring but also to gather further data to undertake service review and improvement initiatives. Where new standards or data is are requested; a lag or change period may be required by providers. In these cases a DQIP analogous to an SDIP should be included. Policies and protocols. To deliver QIPP across multiple providers, or to ensure providers engage in multidisciplinary initiatives such as discharge or shared care appropriate policies should be written in to the contact. Typical examples would include transfer of care policies, information sharing agreements and prescribing agreements PLCV and Individual Funding Requests are part of a number of typical QIPP schemes and it is important to remember that the policies must be included in the contract but for them to be enforceable it is also essential to define a clear process for providers to follow. 5. Monitoring and ensuring adherence The National Contract consists of three parts; the General Conditions; the standard Conditions; and the Particulars. It is the particulars that are customised locally; consequently many commissioners tend to focus on this part. However, for robust management and leverage of the contract all parts are equally important. To deliver QIPP Good Contract monitoring and management is important. A provider performance management framework should be in place and monthly performance management cycle and governance structure should be in place to cover: finance, activity, quality service delivery operational performance and SDIP and DQIP implementation. Suggestions are included in Appendix N. Common Pitfalls to Implementation At this stage a project team has been mobilised and a detailed PID has been created (see Section 2 Planning). The team are now ready to test and implement the proposed improvements. At this stage there are a number of potential pitfalls that CCGs should be aware of: The project has failed to win adequate support and acceptance for the change initiative resulting in a lack of engagement from those key stakeholders involved. Once the solutions have been defined and agreed there is a natural urge to implement the solution on a large scale; Inadequate preparation to ensure adequate measurement systems is in place which capture actual progress made, and failure to keep an eye on unintended consequences e.g. increase in activity in other areas, overspends and;

39 Page 39 of 52 A lack of focus and care on the processes that have been changed and altered. Careful attention is required to ensure that new processes are standardised and made visible to ensure any deviations from the standard are transparent. Managing people through change The planning section highlighted the importance of having a plan to manage key stakeholders through change. In many cases these key stakeholders for QIPP are clinical staff, at this stage it is important to leverage these early clinical adopters and pilot the QIPP scheme where there is the least amount of resistance, allowing the team to learn from mistakes. From the momentum and knowledge gained from these early wins, the project is ready to implement a broader rollout. It is important here to use those key clinical stakeholders as vocal and visible champions in promoting the initiative to their peers, celebrating the success and championing the wider roll out. This process can be managed through Section 4 Organisational Accountability and Delivery. Testing solutions With solutions in place it is important to consider whether implementation should be rolled out or tested first. Piloting a solution should be considered when: The scope of the work is large and influences many people; Significant redesign to a patient service; Significant investment is required, and The change to the service will be difficult to reverse. Initiatives that fall outside of this criteria may not require a pilot and can be implemented quickly. Piloting the proposed solution provides an opportunity to implement a new process on a small scale and receive feedback. Any limitations in the process can be addressed before full scales implementation. Pilots should test the solution in only one area/department or alternatively test the changes for a limited time period. As eluded to above, one criteria for choosing the pilot area is the level of engagement present from those key stakeholders, this gives the project the best chance of succeeding to gain early momentum. The testing period will need to be determined by the nature and complexity of the initiative, however it needs to be time limited and aligned to the plan of when the full financial benefits will be realised. Each pilot should go through an evaluation process to assess whether sufficient benefits have been accrued. The evaluation finding should determine whether the pilot is fully implemented and rolled out or that it should be stopped e.g. it is not delivering sufficient benefits and resources can be redeployed to more effective projects. Monitoring progress It is imperative that pilots are monitored jointly by all stakeholders and partners and evaluated effectively. Section 2 Planning described the importance of developing and establishing clear KPIs. Monitoring against KPIs enables teams to celebrate the successes of early wins as well as hold teams to account for lack of progress. Monitoring progress will fall in line with the reporting mechanisms described in the governance section and should happen at both project and programme level. Before the testing stage commences the following should be developed:

40 Page 40 of 52 Create a data collection plan - This documents who will collect what data, when and how for each improvement measure. A good collection form helps to ensure that the pilot is measuring the right things and measuring them correctly. The form should include operational definitions of the measures and any sampling plans and defined baseline measures (see Appendix I for an example template). Monitoring Pilot outputs teams involved in the pilot should meet together at pre-determined intervals to review progress. This allows a systematic way to report any issues raised and ensures there is a feedback loop in the process which can improve the pilot outputs. It is important to document the lessons learned from the pilot test and the subsequent plans for roll out of full scale implementation. This should follow the standard project management documentation that is highlighted in Section 4 Organisational Accountability and Delivery. Sustaining the improvement Delivering at scale Once a pilot has clearly highlighted benefits and the successes have been shared throughout the organisation and with partners, there is a justification to roll out the initiative at an organisation wide level. Before rolling out the pilot in full, the newly designed process must be standardised and rolled out at pace and scale. It is important that teams are not simply left alone to roll out the service change or initiative following a successful pilot, success will be achieved when individuals receive effective instruction and coaching. Learnings from a pilot phase should be developed into a service specification document to record important process steps, key points of each step and reasons behind each step. Post Implementation Review The post implementation phase is an important part of the project life cycle that is often overlooked. Its purpose is to check that the project has reached its desired objectives and that the outcomes have been accepted and formally approved. It should also consider any learning to be applied across to the delivery of other QIPP projects. Considerations for post implementation include: Handing over the deliverables to those stakeholders that are leading and working in the newly designed process or service e.g. make sure that all project documents and deliverables are collected and stored on a central project server or a network drive. Create list of outstanding project actions seek approval from the sponsor than work with the team to closeout as quickly as possible. Work with the finance and contracting teams (this could be the CSU) to ensure that all QIPP related contract and commissioning commitments are finalised and closed. After the project has been closed, a post implementation review document is completed to ultimately determine the project success and identify the lessons learned (See example template in Appendix L). Part of the post implementation review is to capture the lessons learned. This can be done through a formal lessons learned meeting or through a questionnaire which should be given to all project stakeholders.

41 Page 41 of 52 Communicate the Project Closure process to all Stakeholders. Make sure all Stakeholders know that the project is coming to a close, with the approval of your customer and your Project Sponsor Formally close the project and then report its overall level of success to the sponsor.

42 Page 42 of 52 PART 2 ORGANISATIONAL ACCOUNTABILITY AND DELIVERY (FOR GOVERNING BODIES, PROGRAMME DIRECTORS, AND PMO)

43 Page 43 of Organisational Accountability and Delivery Introduction This section outlines the best practice elements that are required to successfully deliver a major change programme such as a QIPP programme. It should be used to ask questions about existing arrangements and to consider whether there are gaps, appropriate areas of focus and areas to potentially strengthen. Governing Body Grip and Control Whilst most of this section focuses on what is required at the programme level it is important that this sits within the CCGs overarching governance framework which should be designed to ensure that the QIPP programme is fully integrated into the CCGs established governance systems and processes. This ensures that there is alignment between the CCG s strategy and objectives and the QIPP programme. The ownership and drive to deliver QIPP needs to be embedded and owned throughout the organisation but should be led by the Governing Body. The Governing Body will have a key role in 1) ensuring QIPP delivery is sustained and 2) driving QIPP as its organisational strategy The Governing Body needs to ensure that the right environment and constructs are in place to deliver QIPP The Governing Body are accountable for the delivery of the QIPP plan and should commit to its delivery The Governing Body should ensure that appropriate governance and control mechanisms are in place to enable the Governing Body to perform its roles and responsibilities The Governing Body should oversee and support delivery of QIPP action plans and assist to resolution of any risk Executive Level Grip and Control This section outlines the key building blocks that are required to deliver a robust and effective programme governance framework in managing and monitoring the successful delivery of QIPP. This section will describe each building block, examples of good practice and a number of considerations that will need to

44 Page 44 of 52 be taken into account when reviewing or designing your current governance arrangements. A summary these building blocks and best practice is provided in the table below: Best Practice Summary Programme Design and Control The overall programme is designed to support the organisation s objectives for change a clear governance structure is in place to support and control this change Stakeholder Engagement and Communication There is a central communication strategy for the overall programme with channels of communication clearly defined from governing body to service. Key stakeholders are identified and managed through the programme Programme Governance Programme Management Office Suitable delivery governance tracks progress against plan and holds key staff to account for delivery. A streamlined structure would provide a consistent level of assurance and enable reporting to the agreed forums within one month which is in line with good practice Undertakes a monitoring and escalation role for the overall programme. Manage and coordinate complex interactions between projects, support projects with a weekly cycle of reporting and provide oversight to the overall programme Outcome Management The overall programme is designed to support the organisation s objectives for change a clear governance structure is in place to support and control this change Risk Management There is a clear process of managing risks and issues with a defined escalation route for unmanaged risks There are a number of practical steps required when setting up a programme governance framework. The sequence and detail behind each step will be dependent on the maturity of your current arrangements. The practical steps are outlined below:

45 Page 45 of 52 Programme design and control The QIPP programme is designed to align and support the CCG s objectives to improve the health system locally and achieve financial sustainability. A clear governance structure is in place to support and control this change. Considerations for Programme design and control: Vision/strategy Is there a vision for the QIPP programme which has been directed by Clinical leadership and the needs of the local health system? What are the core strategic strands in the organisation and do the QIPP programmes of work align to them? Portfolio design Do each of the QIPP schemes/initiatives organise themselves into clear programmes of work? Are the schemes within each programme highly inter-dependent? Is there a balance and equity between programmes in regards to the scale of change? Control (see prioritisation and controls sections)

46 Page 46 of 52 Are there clear scope boundaries of what's in and out of the QIPP portfolio of programmes? Is there a defined eligibility criteria for QIPP? E.g. impact on quality, financial value, alignment to strategy. Is there a project approval process? Is there a programme Management Framework in place which sets out the programme approval process and project lifecycle? The QIPP opportunities within each of the programmes should have a high level of inter-dependence and there needs to be a balance and equity between programmes in regards to the scale of change i.e. financial outputs and resources required to deliver. Designing the programmes with these elements in mind allows for better resourcing planning. Stakeholder management and communications A central communication strategy exists for the overall QIPP programme with channels of communication clearly defined from Governing Body to service teams. Key stakeholders are known to the team and are carefully managed through the programme. Considerations for stakeholder management and communications: Communication strategy Is there coordination of communications and engagement with key stakeholders, partners and patient groups? Is there an agreed communication strategy? What communication channels are available? Stakeholder management How are difficult people managed within the project? Do you know who all your stakeholders are? Have the relevant clinical leads be identified? Programme governance Suitable delivery governance tracks progress against plan and holds key Project roles to account for delivery. A streamlined structure would provide a consistent level of assurance and enable reporting to the agreed forums within one month which is in line with good practice. The programme governance structure needs to be robust but also flexible to allow it to act quickly when project go off track. It is important that the structure encourages teams to escalate when they themselves cannot resolve the issue or blocker that is causing delay.

47 Page 47 of 52 Suggested Terms of Reference for the Programme Management Board and Programme Confirm and Challenge meetings are included in Appendix G. Traditional project meetings tend to focus on discussions around project detail which can detract from seeing the important issues that need to be addressed. Reporting by exception focuses discussion on directly tackling or mitigating the issue at hand. This is central to tracking project progress and in visually indicating (through a RAG status) that a project may require support from the sponsor or steering group. The weekly project status report (please see Appendix I) is a key document used in the reporting process. This is the project team s opportunity to highlight and address any concerns to the programme lead. It provides a platform for the project lead to escalate any project risks and to get the steer and support that is required to deliver the project successfully. A vital part of this report and the overall reporting process is the RAG status of the QIPP initiative, defining RAG would broadly include: Green - On target, no issues to report Amber -Off plan, plan in place to catch up needs highlighting to Executive Lead Red - Off plan, no plan to catch up, requires escalation (this is when an exception report is required)

48 Page 48 of 52 Often BRAG can be used with Blue representing completion or QIPP transacted (For further detail on RAG definitions, please see Appendix I). Below are some useful tips when using a RAG status: Make sure there is a common understanding of RAG and that is it used consistently across programmes the PMO should play an active role in monitoring and challenging this. Having a standard definition for each status will reduce reporting inconsistencies in reporting from project leads. Use a common and clear criteria that determine overall project or programmes status e.g. are QIA and PID signoff, milestones, KPIs (including financial benefit), risks and issues. Determine a process to aggregate project RAG up to a sub programme and overall programme level determine the overall QIPP programme status. When aggregating projects RAG to a programme level it is important that organisations do not get hung up on the science behind the overall status, as it can become an industry in itself. The overall status needs to reflect the level of support the programmes needs from the forum that it is reporting too. Ultimately red means the programme needs immediate support and intervention, amber means we are off track but we have plans in place to be and green means that we are on track to deliver and nothing to report. It can be common for a project to start move to Amber and then remain at Amber for the duration of the project. This makes it difficult to monitor progress. To overcome this you can look to define further granularity for each RAG setting e.g. you can combine Red, Amber, Green with an arrow: o o o Up Arrow = status improving Down Arrow = status deteriorating Side Arrow = status remains the same Considerations for QIPP programme governance: Is there a defined governance process in place that, reviews, challenges and approve the programme objectives and deliverables? What reporting mechanism is in place, is exception reporting used? Are roles and responsibilities within the QIPP programme defined with clear lines of accountability for development and delivery? Are there processes in place for decision-making and escalation? Are the QIPP projects being reviewed at defined points in time (End Stage Reviews)? Are there escalation routes to the appropriate management groups? Are there clear roles and responsibilities within the governance structure?

49 Page 49 of 52 PMO and programme support The most successful PMOs undertake a monitoring and escalation role for the overall programme; achieving a balance between enabling local ownership and accountability whilst ensuring sufficient operational grip and focus to deliver actions. They manage and coordinate complex interactions between projects; support projects with a weekly cycle of reporting. Track and provide oversight to the overall programme milestones, risks, success measures (including finance). However, the role and level of impact of the PMO can vary between organisations, this is driven by available resource and the organisational/culture and approach to Programme Management. Usually the PMO is seen to do one or both of the functions below: Keeping score - At its basic level the PMO would establish a control environment to track the status of projects under its remit, and support teams in providing the necessary reports to support governance forums - in many cases, usually for larger QIPP programmes this alone is an insufficient level of support and lacks the oversight and insight required to support decision making for the senior leadership. Supporting delivery - A more extended role the PMO provides a flexible and focused resource to support individual Project leads in the delivery of their schemes. As well as providing a challenge role, this includes supporting the sharing of good practice across the CCG and, where necessary, the provision of targeted resources to accelerate the delivery of projects. PMO structure (example) Please see Appendix H for more detail on PMO roles and responsibilities. Key Points: The PMO team will be lead up by a Head of PMO with responsibility for delivering CCG QIPP and transformation agenda. The local landscape and the nature of the PMO will determine who the Head of PMO reports to e.g. S/he may report to director of planning and strategy or director of commissioning and quality but have dotted line reporting to the Chief Finance Officer. Dedicated PMO Business Partners, provide a range of project management support functions. Responsibilities relate to the centralised and coordinated management of those projects under the Programmes Usually, the Directors are the Responsible Officer for one of the QIPP Programmes. In this capacity, they will act as Executive Lead for all projects within their Programme(s) and therefore ultimately accountable for implementation and benefits realisation. The Project lead is responsible for ensuring that the project outputs meet the business requirements and are delivered on time and within budget. S/he attend the monthly Confirm and Challenge meeting and also attend the TPB (for projects in Exception Reporting mode, if requested by the Chair of the Confirm and Challenge meeting). The Project Leads are supported by the PMO and Business Intelligence, Finance and the CSU to track delivery and QIPP forecasting. S/he have a dotted line of reporting to the head of the PMO.