Corporate CCG CO 22 Project Management Policy Version Number Date Issued Review Date V2.0 20/05/2016 20/05/2018 Prepared By: Head of Programme Management Office (PMO), NTCCG Consultation Process: Transformation Director Head of Commissioning Project Leads Head of Transformation PMO Programme Officer QPAC Head of Governance Audit Manager Formally Approved: 27 January 2016 Policy Adopted From: New Policy Approval Given By: Clinical Executive Document History Version Date Significant Changes V1-0 27 Jan 2016 Approved by Clinical Executive, subject to edits V1.1 25 Feb 2016 Edits as per Clinical Executive 27 January 2016 V2.0 16 May 2016 Changes to Policy consistent with changes to QPAC Terms of Reference (approved 13.4.16) Equality Impact Assessment Date Issues 18/01/16 None identified. See section 15. POLICY VALIDITY STATEMENT This policy is due for review on the latest date shown above. After this date, policy and process documents may become invalid. Policy users should ensure that they are consulting the currently valid version of the documentation.
Contents 1. Introduction... 3 2. Definitions... 3 3. Governance... 4 4. Roles and Responsibilities... 5 5. Scope... 8 6. Process... 8 7. Training Implications... 8 8. Implementation... 9 9. Documentation... 9 10. Monitoring... 9 11. Equality Analysis... 10 Appendix 1: QIPP Programme Assurance Committee Terms of Reference... 11 CO22: Project Management Policy (2) Page 2 of 14
1. Introduction For the purposes of this policy, North Tyneside Clinical Commissioning Group will be referred to as the CCG. Effective project management ensures the delivery of projects to time cost and quality. This policy sets out the framework for developing, managing and assuring projects in the CCG. Detailed procedures (standard operating procedures) support this policy. 1.1 Status This policy is a corporate policy. 1.2 Purpose The purpose of this policy is to ensure a consistent approach to project management. 2. Definitions 2.1 Project A project is a unique, transient endeavour, undertaken to achieve planned objectives, which could be defined in terms of outputs, outcomes or benefits. A project is usually deemed to be a success if it achieves the objectives according to their acceptance criteria, within an agreed timescale and budget. Association for project management. What is project management? [Online] Available from https://www.apm.org.uk/ [Accessed: 4th December 2015]. 2.2 Project Management Project management is the application of processes, methods, knowledge, skills and experience to achieve the project objectives. 2.3 Project Assurance The role of assurance is to provide information to those that sponsor, govern and manage a project to help them make better informed decisions which reduce the causes of project failure, promote the conditions for success and deliver improved outcomes. National Audit Office. Assurance for High Risk Projects. [Online] Available from https://www.nao.org.uk/wp-content/uploads/2010/06/assurance_for_high_risk_projects.pdf [Accessed 7th December 2015]. CO22: Project Management Policy (2) Page 3 of 14
3. Governance Diagram 1 describes the governance arrangements for project management within the CCG. QIPP/Programme Assurance Committee Programme Management Office Diagram 1 NTCCG Governance Project Management CO22: Project Management Policy (2) Page 4 of 14
4. Roles and Responsibilities 4.1 Clinical Executive It is the responsibility of Clinical Executive to approve the QIPP Programme and QIPP projects as indicated by the Clinical Executive Terms of Reference (30 April 2013) relevant extracts as follows: Remit & Responsibilities of the clinical executive (extract) Managing the performance of the CCG against its financial and nonfinancial targets including QIPP, drawing on the work of the localities and individual member practices Oversight and detailed scrutiny of implementation of disinvestment programmes and QIPP delivery Approving business cases and procurement contract awards in line with the CCG s financial scheme of delegation and approved budgets 4.2 QIPP Programme Assurance Committee (QPAC) The QPAC is established as a committee of Clinical Executive. The core functions of the QIPP Programme Assurance Committee (Q-PAC) are: Providing delivery assurance of existing programmes of work and projects monitoring progress against plan, taking action to mitigate risks to delivery, identifying and taking corrective action and escalating issues as required To recommend approval of new programmes of work and projects to Clinical Executive, ensuring that the assumptions made are robust; ensuring fit with organisational strategic and operational priorities; confirming clinical commitment and testing deliverability [Extract from QPAC Terms of Reference approved 13.4.16 with minor presentational edits] The Q-PAC discharges its functions through a rigorous and robust programme management approach. It is supported by a PMO, using the CQI toolkit. When QPAC is satisfied that: The project management policy has been applied; Standing operating procedures (SOPs) have been followed; Assumptions made are reasonable; The project fits with organisational strategic and operational priorities; Clinical commitment exists; and Delivery is feasible; then it may recommend approval of the project to Clinical Executive. CO22: Project Management Policy (2) Page 5 of 14
For the avoidance of doubt: QPAC recommends approval of projects to Clinical Executive. Clinical Executive approves projects and associated costs/investments. The Terms of Reference for QPAC is attached at Appendix 1. 4.3 Project Lead The Project Lead is responsible for the day to day management of the project, ensuring that the project delivers its objectives and targets and does not exceed approved costs. 4.4 Chief Finance Officer The Chief Finance Officer is responsible for ensuring that the Project Management Policy is maintained, updated and adhered to. The Chief Finance Officer is responsible for the effective operation of the PMO and line manages the function. The Chief Finance Officer monitors approved project expenditure and the delivery of financial targets, reporting exceptions to Clinical Executive. The Chief Finance Officer, or their deputy, signs off project financial targets. 4.5 Head of Commissioning The Head of Commissioning supports the commissioning managers (where they are Project Leads) to deliver the agreed project outcomes. 4.6 Executive Sponsor The Executive Sponsor is the Director lead for the project that has overall responsibility for the delivery of the project objectives and for ensuring that costs do not exceed the approved limit. CO22: Project Management Policy (2) Page 6 of 14
4.7 Clinical Sponsor The Clinical Sponsor has overall responsibility for assessing the clinical impact of the project and overall responsibility for the delivery of stated clinical outcomes. 4.8 Contract Manager On receipt of a project proposal from the Project Lead, the Contract Manager will review the commissioning intentions to determine the impact of the project on existing contracts. Where a contract currently exists, the Contract Manager must advise whether the project proposals are consistent with the contract e.g. notice periods, restrictions in contracts. The Contract Manager must advise requirements to include in new or revised contracts that protect the CCG s interests, e.g. penalties, linking activity to payment. For NTCCG the Contract Manager is provided from North East Commissioning Support (NECs). 4.9 The Head of Governance The Head of Governance ensures that this policy meets the CCG s standards (e.g. version control, equality assessed etc.) and remains current. 4.10 Head of PMO The Head of PMO is responsible for providing a comprehensive assurance and enabling mechanism for the delivery of CCG corporate objectives via the CCG programme management office (PMO). The Head of PMO ensures that all projects are developed in line with standard operating procedures and assures that projects are delivered in line with agreed milestones and targets, providing exception reports and remedial actions as necessary. 4.11 Programme Management Office (PMO) The PMO provides direction to Project Leads and the wider organisation through the development and sharing of a project management policy, process and procedures. The PMO supports Project Leads by providing advice on project development and delivery and encourages a continued focus on project delivery. The PMO challenges the pace and appropriateness of remedial actions and may recommend remedial actions and/or escalation. The PMO provides assurance to the Clinical Executive that projects are delivering to plan and are on track to deliver the agreed outputs, outcomes and targets. The assurance is provided by regular reports to Clinical Executive QPAC and Finance Committee. The PMO escalates to Directors any projects which are red RAG rated providing assurance that remedial actions are in place to address the shortfalls. The escalation may also request director intervention where the threat to project delivery is significant and/or where intervention at director level is likely to unblock blockages. CO22: Project Management Policy (2) Page 7 of 14
5. Scope All QIPP schemes are covered by this policy. It is for the Lead Director/Executive to Sponsor to determine whether non QIPP schemes are covered by this policy. As a guide, the Lead Director/Executive Sponsor is likely to determine that the following projects need not fall within the scope of this policy: The project will be delivered from existing resource within a team; and Is self-sufficient (i.e. does not require staff resources out with the team to deliver); and Does not incur costs other than costs that can be met within the team s budget allocation; and Will not adversely impact on the CCG s reputation; and Is not material to the delivery of the CCG s corporate objectives, although all projects must support corporate objectives; and The timescale for the planned project delivery is less than 3 months. 6. Process The CCG has in place a process for project management. The process is supported by standard operating procedures and templates. The key requirements are as follows: All projects which fall within the scope of this policy must be documented on a Plan on a Page (PoaP) and be supported by a project plan. The viability of all projects must be tested through CQI to sift out unsuitable projects. Project plans must identify key stages, key milestones and timelines. Projects must show the method of measuring success, usually, but not necessarily KPIs. All projects must have Clinical Sponsor and Executive Sponsor sign off. All projects must have Financial Sign off (and where appropriate Contract Manager sign off to ensure that contract restrictions have been considered and that the contract protects the CCG s interests) using the standard financial template (supplied by the PMO). All projects must have a signed off Quality Impact Assessment (QIA) and signed off Equality Assessment (EA). The status of projects is reported to QPAC regularly using a RAG rating system. Those projects RAG rated red must be supported by key actions (i.e. remedial actions) to get back on track. Red RAG rated projects are escalated to directors where their input is required to correct slippage. 7. Training Implications It has been determined that there are no formal training requirements associated with this policy. However, the PMO will provide local training on the CO22: Project Management Policy (2) Page 8 of 14
implementation of this policy, its associated processes and standard operating procedures on request and as part of its support role. Where project management qualifications are required, these will be stated in the relevant Job Specifications and Job Descriptions. 8. Implementation All managers are responsible for ensuring that relevant staff within the CCG have read and understood this document. 9. Documentation Project Management documentation is maintained on CQI. This is the CCG s Service Improvement & Project Management tool (software). 10. Monitoring The QPAC will agree a method for monitoring the dissemination and implementation of this policy. Monitoring information will be recorded in the policy database. 10.1 Review The Head of Governance will ensure that this policy document is reviewed in accordance with the timescale specified at the time of approval. No policy or procedure will remain operational for a period exceeding three years without a review taking place. Staff who become aware of any change which may affect a policy should advise their line manager as soon as possible. The Head of Governance will be advised and will then consider the need to review the policy or procedure outside of the agreed timescale for revision. For ease of reference for reviewers or approval bodies, changes should be noted in the document history table on the front page of this document. NB: If the review consists of a change to an appendix or procedure document, approval may be given by the sponsor director and a revised document may be issued. Review to the main body of the policy must always follow the original approval process. 10.2 Archiving The Head of Governance will ensure that archived copies of superseded policy documents are retained in accordance with Records Management: NHS Code of Practice 2009. CO22: Project Management Policy (2) Page 9 of 14
11. Equality Analysis Equality Analysis Screening Template (Abridged) Title of Policy: Short description of Policy (e.g. aims and objectives): Directorate Lead: Is this a new or existing policy? CCG CO22 Project Management Policy The Policy sets out the mechanisms that the CCG will adopt to ensure that its projects are managed effectively. Irene Walker, Head of Programme Management Office (PMO) New Equality Group Age Disability Gender Reassignment Marriage And Civil Partnership Pregnancy And Maternity Race Religion Or Belief Sex Sexual Orientation Carers Does this policy have a positive, neutral or negative impact on any of the equality groups? Please state which for each group. Screening Completed By Job Title and Directorate Organisation Date completed Pauline Fox Head of Governance North Tyneside CCG 21/12/15 Directors Name Directors Signature Organisation Date Deborah Hayman Chief Finance Officer North Tyneside CCG 18/1/16 CO22: Project Management Policy (2) Page 10 of 14
Appendix 1 QIPP Programme Assurance Committee Terms of Reference 1. INTRODUCTION The QIPP Programme Assurance Committee (the committee) is established as a committee of the Clinical Executive. It oversees the CCG s programme of service planning, reform and quality management work, using a robust programme management approach. These terms of reference set out the membership, remit, responsibilities and reporting arrangements of the QIPP Programme Assurance Committee. 2. PRINCIPAL FUNCTION The QIPP Programme Assurance Committee (Q-PAC) oversees the CCG s programme of service planning, reform and quality management work. This includes, but is not limited to a key role in overseeing the development and delivery of the CCG s Quality, Innovation, Productivity and Prevention (QIPP) programmes of work. The core functions of the QIPP Programme Assurance Committee (Q-PAC) are: Providing delivery assurance of existing programmes of work and projects monitoring progress against plan, taking action to mitigate risks to delivery, identifying and taking corrective action and escalating issues as required To recommend approval of new programmes of work and projects to Clinical Executive, ensuring that the assumptions made are robust; ensuring fit with organisational strategic and operational priorities; confirming clinical commitment and testing deliverability The Q-PAC discharges its functions through a rigorous and robust programme management approach. It is supported by a Programme Management Office, using the CQI toolkit. In discharging its duties, the committee will seek to promote a culture of continuous improvement and innovation with respect to safety of services, clinical effectiveness and patient experience. The committee will also seek to secure public involvement and to promote research and the use of research. It will provide assurance to the Clinical Executive, Finance Committee and Governing Body about the robustness of the projects of work to deliver the CCG s statutory duties, including the Financial Recovery Plan and sustainable financial balance. CO22: Project Management Policy (2) Page 11 of 14
3. ACCOUNTABILITY The QIPP Programme Assurance Committee is a committee of the CCG Clinical Executive Committee. 4. MEMBERSHIP Membership of the Committee is: Chief Operating Officer Executive Director of Nursing and Transformation (Vice Chair) Chief Finance Officer (Chair) Head of PMO Head of Commissioning The Chair has the responsibility to ensure that the Committee obtains appropriate advice in the exercise of its functions. Officers, employees, and practice representatives of the CCGs and other appropriate individuals may be invited to attend all or part of meetings of the committee to provide advice or support particular discussion from time to time. This may include, for example, representatives from the North of England Commissioning Support (NECS). 5. ROLES AND RESPONSIBILITIES 5.1 To ensure that arrangements are in place for the CCG to delivery against key milestones, through assuring the delivery of an agreed range of projects and to provide exception reports to the Clinical Executive with mitigation plans where there is variance against the plan 5.2 To review existing programmes of work and projects to ensure that there is a comprehensive project plan in place, detailed in the CQI Toolkit 5.3 To review, challenge and take appropriate escalation action in relation to existing projects, with particular reference to the CCG Financial Recovery Plan 5.4 To identify programmes of work against the five year forward plan and ensure that all associated project plans are completed, with project sponsors identified 5.5 To consider and recommend approval to Clinical Executive new projects, including reviewing the assumptions made, ensuring fit with organisational strategic and operational priorities, confirming clinical commitment and testing deliverability 5.6 To hold to account project sponsors for the delivery of individual plans and challenge where necessary 5.7 To receive exception reports from the programme management office (PMO) where projects are deviating from their plan together with remedial actions by project sponsors CO22: Project Management Policy (2) Page 12 of 14
5.8 To oversee the Programme Management Office function to ensure concordance with the organisational approach 5.9 To provide and ensure that there is adequate support provided to delivery teams for the approved plans 5.10 The Committee can pursue any reasonable activity within these Terms of Reference including being able to: (i) (ii) (iii) Seek any information it requires from CCG employees, and those working on CCG projects (for example NECS officers engaged in CCG work) in line with its responsibility; Require all CCG employees and those working on CCG projects (for example NECS officers engaged in CCG work) to co-operate promptly with any reasonable request made by the Committee; Review and investigate any matter within its remit, with access to the organisation s records, documentation and employees. The Committee must have due regard to the Information Governance Policies of the CCG at all times when exercising its authority. 6. ADMINISTRATION The Head of Governance will ensure that a minute of the meeting is taken and provide appropriate support to the Chair and Committee members. 7. QUORUM The quorum shall be two members of the committee, (or their delegates), one of which must be a Director (and not a delegate). 8. DECISION MAKING It is expected that decisions will generally be reached by consensus. Should this not be possible then a view of members will be required. In the case of an equal vote, the person presiding (i.e. the Chair of the meeting) will have a second, and casting vote. 9. FREQUENCY AND NOTICE OF MEETINGS Meetings will be held not less than monthly and more frequently if necessary to ensure projects are reviewed and progressed in a timely and robust way. 10. ATTENDANCE AT MEETINGS Committee members are required to attend each meeting or, if apologies are made, any information they are expected to contribute must be supported either through sending a delegate or in writing to the Chair. Delegates should not be sent routinely. CO22: Project Management Policy (2) Page 13 of 14
11. REPORTING ARRANGEMENTS The Q-PAC reports to the Clinical Executive, which will receive the approved minutes of the Q-PAC as assurance that the committee is delivering on its remit and responsibilities. A copy of the approved Q-PAC minutes will also be submitted to the Finance Committee, for information. The Chair of the committee shall refer to Clinical Executive projects for approval (or changes therein) and draw to the attention of the Clinical Executive any issues that require executive action or other escalation. 12. CONDUCT OF THE COMMITTEE All members of the committee and participants in its meetings will comply with the Standards of Business Conduct for NHS Staff, the NHS Code of Conduct and the CCG s Policy on Standards of Business Conduct and Declarations of Interest which incorporate the Nolan Principles. 13. DATE OF REVIEW The committee will review its performance, membership and these Terms of Reference at least once per financial year. It will make recommendations for any resulting changes to these Terms of Reference to the Clinical Executive for approval. No changes to these Terms of Reference will be effective unless and until they are agreed by the Clinical Executive. V1 Original ToR approved May 2015 V2 Revised ToR approved 13 October 2015 V3 revised ToR approved January 2016 This revised set agreed by Clinical Executive: 13 April 2016 Due for review: January 2017 Minor edits made for presentational purposes. CO22: Project Management Policy (2) Page 14 of 14