project management manual - west essex ccg

West Essex CCG Programme Management Office

Project Management Manual

Version 2.0 June 2018

Version number

Date amended

By whom Changes made

1 23/08/2017 PMO First edition for publication

2 08/06/2018 PMO Updated to reflect introduction or WE CCG Project Risk Register, changes to Impact Assessments and new Highlight report template

Version Control

2

Contents

3

2 Version Control 26 Additional information for the PIDOP

3 Contents 27 Impact Assessments

4 Acronyms 28 Quality Impact Assessment (QIA)

5 Terms & Terminology 29 Step-by-step: QIA

7 Introduction and Context 30 Equality Impact Assessment (EIA)

8 Purpose 31 Step-by-step: EIA

9 Introduction to Project Management 33 Privacy Impact Assessment (PIA)

10 The five facets of Project Management 34 Step-by-step: PIA

11 The Programme Management Office (PMO) 35 Gateway 2: Approval Criteria

12 WECCG Programme Management Methodology 36 Gateway 2: Decision

13 The WECCG Gateway Process 37 Gateway 3: Development

14 Project Leadership 38 The Workbook

15 Project Governance 39 Step-by-step: Workbook

16 Gateway 1: Idea Generation 43 The Business Case

17 The Idea Template 44 Gateway 3: Decision – Impact Assessment Panel

18 Step-by-step: Idea Template 45 Gateway 3: Decision – Final Approval

19 Gateway 1: Approval Criteria 46 Gateway 4: Implementation

20 Gateway 1: Decision 47 The Highlight Report

21 Gateway 2: Scoping 48 Step-by-step: Highlight Report

22 The Project Initiation Document on a Page (PIDOP) 49 Gateway 5: Closure

23 Step-by-step: PID on a Page (PIDOP) 50 The Evaluation Template

24 PIDOP: Project Roles 51 The Project Lifecycle

Appendix A Introduction to WECCG Projects Risk Register

Acronyms ACP Accountable Care Partnership

CIP Cost Improvement Programme

EIA Equality Impact Assessment

EOG Expert Oversight Group

ICP Integrated Care Partnership

ICS Integrated Care System

PIA Privacy Impact Assessment

PIDOP Project Initiation Document On a Page

PMO Programme Management Office

QIA Quality Impact Assessment

QIPP Quality Innovation Productivity Prevention

SDG Strategic Delivery Group

STP Sustainability and Transformation Partnership

WECCG West Essex Clinical Commissioning Group

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Terms & Terminology

5

The Risk and Issue Register All projects are associated with five constraints:

• Time • Quality • Cost • Scope • Benefit

Risks and Issues are events which may impact on one of these constraints. They may threaten to: • Increase the time required to complete the project • Reduce the quality of the projects outcomes • Increase the costs of the project • Reduce the scope of the project – or increase it thereby threatening the other constraints • Reduce or nullify the benefits of carrying out the project

A risk is usually a threat. A threat is an event which may occur in the future which might be deleterious to the project and must be prevented from occurring through the taking of mitigating actions. However, a risk may also be an opportunity. An opportunity is an event which may occur in the future which could be exploited in order to improve the project outcomes. Risks are measured against two criteria: the likelihood of the occurrence and the impact should it occur. The higher the score, the greater the risk, and the more the effort that should be deployed to mitigate it. The key characteristic of a risk is that it hasn’t happened yet, and can be avoided through good management and mitigating actions, or exploited. An issue is anything that is happening now and adversely affecting one or more of the projects constraints. An issue may be a risk that has materialised, but is characterised by the fact that it has already happened or is occurring now, and needs to be addressed now if the planned outcomes for the project are to be achieved.

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Project Plans Project plans comprise lists of activities, and the products of those activities, necessary to the delivery of the desired outcomes / objectives of the project. These activities are described as tasks. Tasks Tasks are activities which are undertaken by project resources. When a task is completed it usually results in a deliverable. Tasks have three characteristics: duration, effort and resource. The duration is the period of time over which resource will be expended to complete the task. Tasks will usually have a start date and an end date. The effort is the number of hours / days that resources will need to apply themselves to the task in order to complete it. The resource is usually the people who will carry out the work. Resources are usually constrained by the amount of their time they are able to devote to the project task and this is often indicated by the percentage of their working week that they are able to commit to. If a resource is unable to commit the planned time to the task, the end date will start to move into the future Deliverables Deliverables are the tangible results of tasks. They may be concrete (e.g. a report, a documented process, a documented pathway) or more abstract (a committee decision, a manager’s sign-off). Milestones A milestone is a significant step in a plan. It usually coincides with a deliverable, and hence with the end date of the task that produced that deliverable. Milestones usually have no duration and occur on a single date. Milestones are often used to indicate progress in the project timeline. Common criteria – best practice It is important to ensure that all these elements of a project are described using SMART criteria. Thus each Risk, Issue, Task, Deliverable and Milestone should be:

Specific – Measurable – Achievable – Relevant - Time Constrained

Introduction & Context The NHS is undergoing significant change in the way services are provided and delivered. All organisations have to make efficiency plans and deliver savings every year as part of the Department of Health's Quality, Innovation, Productivity and Prevention (QIPP) programme which aims to improve the quality of care the NHS delivers, while making efficiency savings.

West Essex CCG has successfully delivered the required QIPP savings year on year, fully meeting the NHS business rules. However, the year-on-year QIPP/CIP requirement gets harder each year as the level of opportunity for transactional savings and improvements has been eroded by the changes already delivered. This means the scale and complexity of projects is increasing and programmes are being established with local partners across the West Essex health economy as part of the ACP and across the larger Hertfordshire and West Essex STP area.

The challenges are significant: • Balancing quality & cost so that financial savings are delivered without compromising quality of care • The year–on–year QIPP targets get more challenging each year • Maintaining a quality and safety focus despite the need for cost reduction • Balancing viability of providers with viability of services • Balancing QIPP & CIP programmes across a care economy so they reduce cost at a system level • Capacity and capability for programme and project management at this scale • Tough commissioning / contracting decisions • Matrix working across different teams – across multiple geographies and / or organisations • Maintaining day-to-day service levels along with multiple strategic and operational challenges

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Purpose

Best practice for management of complex and interrelated projects is to use a standard programme management framework, supported by a Programme Management Office.

This manual outlines the methodology, systems and processes that West Essex CCG have agreed to ensure a standard and “best practice” approach is taken to project management within the business to make best use of the skills, resources and expertise available.

The first section outlines the programme management methodology that will be used by the CCG, and the associated governance arrangements. The second section works through each stage in detail with step by step guides for each of the tools and templates.

For more information about any of these tools, or advice on programme and project management please contact the PMO team within the CCG.

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Introduction to Project Management

A project has a defined beginning and end in time with defined scope and resources, and is unique in that it is not a routine operation, but a specific set of operations designed to accomplish a singular and time-limited goal. Unfortunately many projects fail to deliver the anticipated benefits and end up costing more money, or dragging on with no defined outcomes.

Project failure is usually caused by disparate project documentation, informal processes, lack of defined outcomes, and poor organisation of tasks, resources and milestones. When organisations allow these behaviours it leads to an uncoordinated approach to project management that blinds leaders to what is actually happening until it is too late to rectify the situation. In order to achieve project goals, tasks must be expertly defined and managed to deliver the outcomes that leaders expect.

Project management is the application of knowledge, skills, tools, and techniques to project activities through the whole project life cycle to deliver a defined goal.

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Project management requires expert leadership on five levels: All management is concerned with these, of course. But expert project management brings a unique focus shaped by the goals, resources and schedules of each project in a highly controlled environment.

The Five Facets of Project Management

1. Project design and control – setting up a governance structure for the project and ensuring everybody understands their roles and responsibilities

2. Planning and reporting – preparation of plans and timelines, co-ordinating tasks and activities, and ensuring progress is monitored and reported

3. Risk and issue management – tracking and monitoring risks and issues as they crop up, and ensuring timely escalation and appropriate mitigation and controls

4. Benefits realisation – ensuring the benefits are defined and measured, and that the project activities achieve the goals set out at the start

5. Project support – making it easy for project teams to do their jobs by reducing bureaucracy, providing training and project management coaching

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The Programme Management Office (PMO)

The PMO establishes a co-ordinated, standard and repeatable project management methodology for all projects from start to finish, in a way that fits with the organisational values and culture. The PMO is not responsible for delivery of projects, but supports project managers and organisational leaders by:

• Establishing a standard approach to project management that is to be used by all project managers, SROs and clinical leads involved in project delivery

• Reporting progress to the organisational leadership team, ensuring they have early warnings of any significant emerging or apparent risks or issues relating to projects, and the mitigating actions being established to address them

• Providing documents and templates for project teams so that all projects follow the same high quality methodology, making it easier to track and monitor project delivery in a consistent way

• Offering guidance and training in the standard project management methodology as agreed by the organisation

• A PMO provides superior project and programme oversight, allowing business-critical information such as performance, risks / issues and benefits realisation to be collated accurately and viewed in near real time.

A PMO is a group or department that underpins project delivery mechanisms by ensuring projects are managed and reported in a standardised and controlled way.

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WECCG Programme Management Methodology West Essex CCG (WECCG) have agreed a formal programme management methodology in the form of a “Gateway” process that tracks projects through the whole project lifecycle. It is important that all projects are managed according to this framework to ensure consistent monitoring, tracking, approvals and reporting, which will increase the chance of success, and give leaders full visibility of progress.

The WECCG Gateway process provides a framework from the initial idea through to scoping, development, implementation and finally project closure. Projects must complete certain tasks before being approved to progress to the next Gateway which provides assurance that the correct controls are in place at each stage of the project lifecycle.

The next page shows the full Gateway Process. Page 51 of this manual is a diagram showing the project lifecycle with lists of activities and outputs for each stage.

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The WECCG Gateway Process

13

Gateway 1 Idea Generation

Gateway 2 Scope

Gateway 3 Development

Gateway 4

Commission /

Implementation

Gateway 5 Project Closure

Initiate PIDOP and impact assessments

Outline idea template and log

with PMO

Agree ongoing

monitoring

arrangements

Approve: Go to Gateway 3

Don’t proceed: Go to Gateway 5

Review provider options, complete

procurement checklist, agree

route to market and conflicts of interest

Initiate workbook: Update impact assessments,

develop business case (if needed) or

update PIDOP

Approve: Go

to Gateway

4

Don’t proceed:

Go to Gateway 5

Formal procurement

Project closure report, capture lessons learned and close project

documentation.

Approve: Go to Gateway 2

Hand over risks & issues

to operational team if

needed

Agree timescale & level of detail required for next decision: Business

case or just workbook

Don’t proceed: Go to Gateway 5

Allocate Clinical Lead & Project Manager, log with PMO for pipeline

Go Live

H&CC Decision

Waiver / SFI / Framework

Go to Gateway 5

Impact Assessment

Panel Exec

Decision

Strategic Delivery Group*

Decision


Decision


Decision

* Note: The Strategic Delivery Group referred to here currently comprises the Commissioners’ Assurance Group (CAG) and the Finance & Operations Group (FODG). It is anticipated that during September 2017 governance arrangements will change.

Programme Leadership WECCG project teams form “triangles,” working in partnership with exec leads, project leads and clinical leads identified for each project. This team may also be supported by a PMO project manager depending on the size and scale of the project.

Project Lead

Clinical Lead

Exec Lead

Project Lead

The project lead is responsible for delivery of the project benefits, overseeing project management and supporting the exec and clinical lead in driving delivery. Project Leads can be anyone who takes responsibility for leading the project, regardless of their usual role and responsibilities.

Exec Lead A lead executive director is the Senior Responsible Officer (SRO) and ultimately accountable for delivery of the project or programme of work. The exec lead will support the project lead and clinical lead in resolving issues and risks, managing stakeholders and holding the wider project team to account.

Clinical Lead The clinical lead is responsible for leading the clinical design, galvanising clinical input from colleagues within the multi-disciplinary team and championing the project as a “figure head.”

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Programme Governance

Strategic Delivery Group (Working Title)

Lead Director

PMO Lead

PMO Support Officer PMO Analyst

Project “Triangles” responsible and accountable for project delivery, supported by the PMO team and other subject matter experts from the Finance, Quality, BI, IT, Estates, Communications, Contracts and Governance teams as required.

H&CCC approve project initiation and oversee

scoping & development up to implementation,

subject to any conflicts of interest.

Health & Care Commissioning

Committee

Finance & Performance Committee

A merged FODG / CAG format to act as programme

board

F&P hold project teams to account

for delivery

ACP Board

Programme Boards & Expert Oversight Groups

Primary Care Committee

Quality Committee

ACP Board provide system-wide

approvals and monitoring

Impact Assessment

Panel

The Impact Assessment Panel

approve EIA, QIA and PIAs.

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Gateway 1: Idea Generation

All projects start with an initial idea or “brief.” This can be to solve a problem, test a theory, or implement something that has been proven elsewhere or mandated centrally. It is important that new ideas are considered by organisational leaders to ensure they fit with the corporate objectives, and can be prioritised with the programme as a whole before people spend significant time developing project documentation.

An idea template is used at this stage. It is a simple one page template that prompts the individual with some key questions about the idea. It should provide enough information to allow leaders to decide whether to invest time and resource into developing a project initiation document for the project.

The idea template allows an individual to put forward an idea even if they don’t have all the details about how it might work, or all the data on benefits and costing. It is deliberately brief so that time is not wasted if the idea doesn’t fit with the organisational strategy and direction of travel.

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What? The ideas template is a simple one page template that captures basic information about a new idea or project proposal. It should provide enough information for leaders to decide whether to invest the time and effort into scoping it out in more detail. Why? Preparing business cases and project initiation documentation is time consuming, and not all ideas fit with organisational objectives or strategic plans. The idea template allows leaders to prioritise projects before staff commit significant time and resource in scoping out the project.

When?

Who? Any person can complete an idea template and put forward a suggestion for a project that could improve patient care, improve safety, save money or improve efficiency.

How? 1. Complete your name and date so you can be contacted for more information or

to update you on any decisions made. 2. Add a brief description of your idea. 3. Include details of any problem or risk that your idea may solve or address. 4. Add any assumptions or interlinked projects that decision makers would need to

be aware of if they take the idea forward. 5. Outline the quality and financial benefits that the project may deliver. This does

not require exact numbers (unless you have them). 6. Indicate whether investment would be required to achieve the project

outcomes. 7. Include any risks that you are currently aware of, and any ideas for mitigation

that you can think of. 8. Finally add your recommended next steps to take the idea forward.

Process:

Anyone

Idea for a project

The ideas template should be completed at Gateway 1 and submitted to the programme board for a decision on whether to proceed or not.

Person with idea

Complete idea template

Person with idea

Submit the form to the PMO team for

inclusion in the SDG agenda

Strategic Delivery Group

Decision on whether to

proceed

Potential outcomes:

Proceed with project and PMO will add to tracker Agree to proceed with project following additional actions/information

Integrate idea into business as usual taking into consideration organisational capacity and capability

Do not proceed with idea – capture reasons why

The Idea Template

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Step by Step: Idea Template Include as much information as you can about the idea and how you feel it could benefit patients, staff or the financial bottom line. If you got the idea from another health community – include a reference to that work and why you think it could work in West Essex. You should be able to complete this quickly, with minimal analytical input. If you do have data then include as much as you can. Supporting documentation can be included along with this template if you feel that would support the decision making process.

Give your idea a name and insert that to the

title section

Add your own name and the date so you can be

contacted with any additional questions, and

to let you know the outcome of the decision

1

2

Include a brief description of your idea /

proposal, this should only take a couple of

sentences.

3

If your idea seeks to solve a problem or

address a risk include details here – explain

why you think this could help

4

Include references to any related projects,

dependencies or key assumptions that must

be considered as part of this idea. For example if

it relies on another project being successful then you need to let the decision makers know!

5

The benefits section has two parts. One relates to quality and safety benefits (for example: patient experience, clinical outcomes or staff

wellbeing). The second relates to financial savings, (for example change of pathway to a cheaper method of delivery). You don’t need exact

numbers, just outline the types of benefits you think could be achieved.

List any resources that might be needed to implement the

idea. Include project management and “set-up” costs

as well as any ongoing costs.

Finally outline your recommendations. This could simply be to approve that the

project is scoped in more detail. Or if you have suggested a couple of options then

highlight your preferred option here.

6 7 8

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Gateway 1: Approval Criteria

Once the idea template has been completed it should be sent to the PMO team for inclusion in the next meeting of the Strategic Delivery Group. You may be called upon to present the template to the group and explain more about your idea so they can consider whether to approve it for the next stage.

The Strategic Delivery Group will review the idea using the following questions:

• Does the idea help to deliver the CCG’s corporate objectives and strategic plan for the next 5 years?

• Is there a reasonable expectation that the idea will improve quality of care for the people of West Essex?

• Does the idea fit with national “must-do’s” or clinical guideline?

• Will the idea support achievement of performance targets or address a performance issue?

• Does the idea present opportunities for financial efficiency, net of any outlay within a reasonable timeframe?

• Does the CCG have sufficient resources to undertake the project?

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Gateway 1: Decision There are three possible outcomes once the idea template has been considered by the Strategic Delivery Group:

Approval

The idea will be allocated a clinical lead, exec lead and

project lead to progress to the next Gateway and be developed in more detail. This still doesn’t

mean it will definitely be implemented, just that it is worth spending time and effort to look into it in more detail. The idea

will progress to the next Gateway: scoping, and the PMO

will update the programme tracker accordingly.

Hold

The idea may be suitable, but will not be taken forward straight away. If this is the case the PMO

will record a review date and hold the idea until that time. It will not progress to be scoped

until it is discussed again and the SDG agree it should be

progressed. This is because things could change over that

period and mean numbers need updating, or the landscape may

change – which would mean that analysis is wasted.

Do Not Proceed

The SDG feel it is not suitable for the business and unlikely to

be within the near future. If this is the case then the PMO

will work with you to complete the project close template and clearly record the reasons why. If the idea is suggested again, then this information will be

used to avoid having the same conversation again unless the situation has changed and it

may now be viable.

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Gateway 2: Scoping

Once an idea has been discussed and approved to proceed by the Strategic Delivery Group, it will progress to Gateway 2 where it will be scoped in more detail.

The key document for this phase is the Project Initiation Document (PID), which has been developed on one page (PIDOP).

A PID defines the project or programme and forms a basis for its management, and an assessment of its overall success. The PID ensures that the project has a sound basis before asking the organisation to make any major commitment to the programme. It will act as a base document against which the PMO can assess progress, change management issues and ongoing viability questions. The PID forms the ‘contract’ between the PMO and the programme sponsors. Any significant change to the material contained in the PID must be referred back to the Strategic Delivery Group.

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What? The PIDOP is a high level document that follows lean principles. It includes everything that a typical Project Initiation Document (PID) would include, but in a simple, visual way that will also serve as a communication tool for the project. Why? The PIDOP provides a high level overview of the project including the governance arrangements (who is involved), the scope and overview, key timescales, risks, quality impact, equality impact, privacy impact, financial overview, non-financial benefits and communications plan. This should be quick and easy to complete, but comprehensive enough to provide the SDG with information to make a decision about whether to proceed and invest resources in developing the project further.

When?

Who? This should be completed by the nominated project lead, with support from the clinical lead, exec lead and PMO team. Other contributors will include the finance team, quality team, governance team and wider project team members.

How? The PIDOP template is relatively intuitive and takes you through the broad headlines required in a PID. Each section of the template covers a different element of the project plan and may require different levels of support from the finance, quality and wider PMO team. Work through the relevant sections with your clinical lead and record the information you have at that time. The PIDOP should be fully complete by the time the project is reviewed by SDG.

Process:

Project Lead

Start to

complete content

The PIDOP should be completed at Gateway 2, once the decision has been made to proceed with the idea. Some background information may be gleaned from the ideas template. Once completed it should be presented to the SDG for decision. If the PIDOP is being used as a communication tool it will need to be kept up to date as the project progresses. If no business case is required then the PIDOP will need to be fully updated for approval purposes.

Project Lead

Discuss with clinical lead

and exec lead – agree content

Project Lead Submit impact assessments to the PMO for forwarding to the

Impact Assessment Panel. Discuss finance, route to market

and comms with relevant departments

Project Lead

Submit to PMO for SDG

meeting

Potential outcomes:

Proceed with project and progress to Gateway 3 Agree to proceed with project following additional actions/information

Integrate idea into business as usual taking into consideration organisational capacity and capability

Do not proceed with idea – capture reasons why

The PID on a Page (PIDOP)

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Step by Step: PID on a Page (PIDOP) Insert project title, date and version control. Then add

the name of people involved in the project in

section 1. Don’t forget to include the current Gateway number

too!

1

Section 2 gives a brief description of the project, its objectives, scope and

any background information you have.

Keep it brief, but give the reader enough information to understand what you are trying to achieve and why. Add any interdependencies

or related project details

2

The timeline needs to show the key milestones with dates. The workbook in Gateway 3 will include a

more detailed project plan – this is just headlines.

3 Outline the key risks that the

SDG need to be aware of. These risks and mitigations

need to be transferred into the formal risk log in the workbook

as the project progresses.

4 Include dates that the

impact assessments were undertaken, the approval

date and any comments or issues that were raised by

the governance and quality teams

5 Add information

about any activity changes that you

expect as part of the project – e.g. reduced

numbers of A&E attendances.

6

If the project is in Gateway 2 include narrative about the scale of the financial savings

you expect to achieve. If it is in Gateway 3 or above copy the financial summary

grid from the workbook.

7

Add contract or procurement information

here – e.g. variation to contract, or new

procurement

8

List the non financial benefits – include quality

outcomes, patient experience, safety, and productivity measures.

9

Complete the communications grid to show who needs to be

included in project updates, and what level of detail they need, or include

narrative if you prefer.

10

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PIDOP – Project Roles Project roles

Project Lead – The project lead is responsible for delivery of the project benefits, overseeing project management and supporting the exec and clinical lead in driving delivery.

Executive Lead - A lead executive director is ultimately accountable for delivery of the project or programme of work. The exec lead will support the project lead and clinical lead in resolving issues and risks, managing stakeholders and holding the wider project team to account.

Clinical Lead - The clinical lead is responsible for leading the clinical design, galvanising clinical input from colleagues within the multi-disciplinary team and championing the project as a “figure head.”

PMO team - The internal team that defines and maintains standards for project management within the organisation. The PMO team will support project leads to follow the Gateways structure and assist in the correct use of project management and reporting documentation.

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PIDOP – Project Roles Project roles

Finance Lead – The finance lead will provide support and scrutiny for the development of the project financial measures and provide assurance to the board regarding what financial measure will be used to track the project against target.

Quality Lead – The quality lead provides support and scrutiny for project quality measures, objectives and outcomes, and will oversee the completion of the impact assessments.

Procurement Advisor – The procurement advisor supports the organisation's procurement needs and supports leads to ensure all relevant information has been obtained regarding the viability of the project and ensuring the procurement policies and processes are followed correctly.

Communications Lead – The communications lead provides support and guidance regarding the communications needed for internal projects. For external projects when patients and the public need to be communicated/ consulted with, the communications lead will take responsibility for ensuring the most appropriate communications are undertaken through the communications team.

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Additional information for the PIDOP Route to Market / Procurement

It’s important to have a conversation with the procurement advisor to make sure you have included the relevant information required for the SDG to make a decision on whether the project is viable. The kinds of things you will need to consider are: whether this is already covered by a contract, what flexibility is already built into it for extension, variation or termination.

Financial and Activity Assumptions

As with the items mentioned above you will need advice and input in the activity and financial assumptions section too. Each project should have allocated finance and information leads, and those people should be able to help you gather and check the information you need.

Activity assumptions relate to changes inpatient numbers attending services such as A&E, elective/ non-elective activity and outpatient appointments, and should identify when the expected changes will take place.

Financial assumptions link themselves to activity but show when the financial savings and/ or variations will be achieved.

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Impact Assessments The other requirement at Gateway 2 in the scoping phase is to complete three impact assessments. You will need to discuss the draft impact assessments with the quality and governance teams before submitting the PIDOP for approval. Once the assessments are complete, the PMO will submit them to the IA Panel for approval.

Quality Impact Assessment (QIA) The QIA is used to understand whether the project could have a positive or negative impact on a range of quality and safety criteria. Positive impacts can be used to inform the non-financial benefits metrics and to share good news stories. If any potential negative impacts are highlighted then these must be “risk assessed” to consider mitigation opportunities, or if serious impacts are highlighted then the organisation will take a decision as to whether the project should go ahead. The QIA should be updated regularly as the project progresses through the Gateways and more information is available.

Equality Impact Assessment (EIA) The EIA is used to ensure that a policy, process or project does not discriminate against any disadvantaged or vulnerable people as defined in the Equality Act 2010. The EIA supports evidence-based decision making and helps decision-makers to fully understand the relevance and effect of policies or service changes on the diverse population that the CCG serves. This should be updated at each Gateway to ensure that people with protected characteristics (as defined in the Equality Act 2010) are not disadvantaged.

Privacy Impact Assessment (PIA) PIAs are a tool which can help organisations identify the most effective way to comply with their data protection obligations and meet individuals’ expectations of privacy. An effective PIA will allow organisations to identify and fix problems at an early stage, reducing the associated costs and damage to reputation which might otherwise occur. The PIA will be initiated at Gateway 2 and used throughout the life of the project to ensure that legal obligations are adhered to, both by the CCG and any partner organisations involved in the project.

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Quality Impact Assessment (QIA) What? The QIA is one of three mandatory impact assessments, and part of a continuous process to ensure that quality and safety implications of any service change, and in particular cost improvement or QIPP projects, are understood, and mitigated.

Why? In the current economic climate all NHS organisations are required to make significant cost savings, which inevitably requires service change. It is important that we learn from reports such as Berwick, Keogh and Francis to ensure that in our efforts to save money we do not have a negative impact on quality of care, patient safety or patient experience. Ideally we should aim to improve quality as part of our QIPP process, and the QIA assessment tool provides a structure and clear record of the quality consequences, both positive and negative, of potential change projects to support decision making and mitigation of risks associated with quality.

When?

Who? The QIA should be completed by the Project Lead and Clinical Lead together. This is to ensure that the clinical and non-clinical quality aspects are considered.

How? • The QIA is in two stages. An initial check list to identify where quality may

be impacted – either positively, negatively or to show where there is no expected impact on quality. This stage must be completed for all change projects or programmes.

• The second stage is to add any negative impact areas to the project risk log and prepare a plan for mitigation.

• If the project is in Gateway 2 or 4, the Project Lead should discuss the impact assessments with the quality team before submitting the PIDOP for approval.

• If the project is in Gateway 3, then it will go to the impact assessment panel for formal approval before the project progresses.

• The Project Lead may be required to attend the impact assessment panel to discuss the project and answer any queries.

Process:

The QIA tool should be initiated at Gateway 2, and reviewed at Gateways 3 and 4 to ensure that as the project progresses any changes to the quality impact assessment are understood and managed.

Project Lead & Clinical Lead

Review project brief and complete QIA checklist

Project Lead & Clinical Lead

Record risks in project risk log citing QIA as the source.

Prepare mitigations.

If in Gateway 2 or 4 – discuss with member of the quality

team Update

documentation and proceed to

next step

Repeat process to review the QIA at each Gateway as more detail or new information is available

If in Gateway 3 – send to PMO for inclusion in next impact assessment panel

Present QIA to impact assessment panel

Record comments or concerns on PIDOP and

risk log

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Version

Date

Completed by

QIA Panel members

Date

Positive

Impact

No

Impact

Negative

Impact

Added to risk

log Y/N

Risk log

reference #

QIA Panel

Assessment

Patient safety adverse events including avoidable harm

and Patient Safety Alert Services (PSAS)

Medicine management and safe administration of

medicines

Mortality HSMR/SHMI

Any Infection control issues including MRSA/Cdiff

CQC: Visits and registration

NHSLA / CNST

Safe, clean, comfortable and well maintained

environments/equipment

NICE Guidance and Quality Standards, VTE, Stroke,

Dementia

Helping people recover from ill health/ injury and

preventing people from dying prematurely

Other Outcome Guidance e.g. PROMs

External accreditation e.g. RCN

National clinical audit/research and development

Clinical outcomes

Breastfeeding rates

Emergency bed days

Length of stay

Emergency re-admissions (30 day)

Minor Injuries Standards

Delayed discharges

Day case rates

PATIENT SAFETY

CLINICAL

EFFECTIVENESS

Instructions

Place an "x" against each indicator showing whether your proposed change could cause a positive or negative impact on the indicators below. If it will not affect that indicator put a

"x" in the "no impact" column. Each indicator should have a "x." The QIA will be revisited regularly so you can revise this assessment as more information becomes available.

All indicators highlighting potential for negative impact should be added to the risk log and asigned an owner, review date and mitigation to ensure they are monitored regularly.

Project TitleQuality Impact Assessment

Project Team Comments (if required)Impact area Indicator

APPROVALS

QIA Panel Comments

Quality Impact AssessmentRisk management and

mitigation

Stage 1: Complete the checklist. Review the indicators on the left hand list and put a “cross” against each line to show whether the potential impact is positive, negative or if there should be no impact. Add a comment if you would like to clarify anything for the reviewer.

Stage 2: Review the indicators and add a line to the project risk log for every indicator where the project has potential to have a negative impact. If there are no negative impacts, then it is not necessary to do anything else, unless a query is raised by the quality team or impact assessment panel.

Ensure you have cited the source of the risk as “QIA” on the risk log and added the reference number for the risk to the QIA sheet so the risk can be easily

identified and tracked in the future.

Put a “cross” (“x”) if you feel the project should have a positive or negative impact on

the relevant indicator.

If you feel there should be no impact on that indicator, or if it is not relevant for your project put a “cross” (“x”) in the centre

column to show “no impact.” Every indicator should have one “x.”

Step by Step: QIA 1

2

3

4

29

Equality Impact Assessment (EIA)

What? The EIA is the second of the three mandatory impact assessments, and part of a continuous process to meet the CCG’s legal duties under the Equality Act 2010. The aim is to review any service changes to make sure they do not impact adversely on any vulnerable or disadvantaged people, or those with protected characteristics under the Act.

Why? The CCG has a legal duty to eliminate unlawful discrimination, to advance equality of opportunity and to foster good relations on the basis of protected characteristics such as gender, race, disability and age. These duties do not prevent the CCG from reducing services where necessary, but they ensure that any proposals consider the needs of all members of the West Essex community.

When?

Who? The EIA should be completed by the Project Lead and wider project team.

How? • The EIA is in two stages. An initial check list to score the project or policy

against each of the protected groups. This stage must be completed for all change projects, programmes or new policies.

• The second stage is only required if the score is over 9 or if there are individual scores above 1.

• If the project is in Gateway 2 or 4, the Project Lead should discuss the EIA with the governance team before submitting the PIDOP for approval.



Process:

The EIA tool should be initiated at Gateway 2, and reviewed at Gateways 3 and 4 to ensure that as the project progresses any changes to the equality impact assessment are understood and managed.

Project Lead & project team

Review project brief and

score the EIA

Project Lead

Record risks in project risk log citing EIA as the source.


If in Gateway 2 or 4 – discuss with member of the

governance team Update


next step

Repeat process to review the EIA at each Gateway as more detail or new information is available


Present EIA to impact assessment panel


risk log

30

Stage 1: List the changes that will be made as part of your project or policy.

There may be more than one, depending on the project.

The first section considers people with protected characteristics as defined by the Equality Act 2010.

Allocate a score against each column to show whether there could be a negative impact on each group – and whether that could be high, medium or low. High negative impact scores 3, medium scores 2 and low scores 1.

If there would not be a negative impact then score 0.

Then list any positive impacts in the box below. This should refer to positive impacts, or benefits for people with those

characteristics, or people that could be considered vulnerable or disadvantaged.

Step by Step: EIA (stage 1) 1

3

Score

3

2

1

0

Age Disability GenderGender

Reassignment

Pregnancy &

Maternity

Marriage &

Civil

Partnership

RaceSexual

Orientation

Religion/

Belief

Human

RightsScore Issues & rationale for scoring

0

0

0

0

0

Project Title Key Instructions

Equality Impact Assessment High negative impact List each aspect of the project or change you wish to make and allocate a score against the protected groups to show the

level of impact the change could have for that population. Use the scoring matrix shown in the key. Then outline your

rationale for that score in the comments section.Version v0.2 Medium negative impact

Date Low negative impact

Updated by No negative impact

1. Project aspect or change area - Could the strategy / policy / plan / proposal /

decision have a negative impact on any of the protected characteristic groups

(i.e. it could disadvantage them) or could it have a positive impact on any of the

List any positive impacts on equality and diversity, and the measures that can be used to demonstrate that.

Outline what is being done to promote equality and diversity within the project, and how you will evaluate how effective this has been?

Outline any specific aspects of the project that promote

equality and diversity.

2

3 4 The score will calculate automatically. If the overall

score is less than 9 and there are no individual scores above 1 then you can stop here and discuss with the

governance team.

5

31

Stage 2: If your initial assessment scores over 9 for any of the changes that have been listed or have individual scores of 2 or more then you need to follow instructions for the next section. This will consider who needs to be consulted to support mitigation or minimisation of the impact, and what changes may need to

be made to the project or policy to reduce the potential for discrimination. Once this has been done it will ask you to re-score against the protected characteristics.

The governance team will support you with completing this stage of the impact assessment. These risks and mitigations must be added to the project risk log.

Step by Step: EIA (stage 2)

Note who should be consulted in order to identify how the negative impact can be

removed/ reduced. Include how long the consultation is likely to

take.

1

32

Once the consultation has taken place, enter the recommended

actions in to this box.

Re-score the change against the protected characteristics.

Update the risk log with the mitigating action(s)

Additional comments and recommendations can be added

to this box

2 3 4 5

Privacy Impact Assessment (PIA)

What? The PIA is the third of the three mandatory impact assessments, and is part of the project initiation documentation for all new information systems which involve the use of person confidential / sensitive data or business sensitive data or a change that will significantly amend the way in which person confidential / sensitive data or business sensitive data is handled.

Why? The CCG has a legal duty to ensure the processing and storage of all personal / sensitive data is handled securely. By using the PIA process, privacy concerns or risks can be identified to assist the project team in determining how best to manage them.

When?

Who? The PIA should be completed by the Project Lead with assistance from the Information Lead and wider project team.

How? • The PIA is in two stages. An initial screening check list is completed to

identify if any risks to information governance exist. This stage must be completed for all change projects, programmes or new policies.

• The second stage is only required if a “yes” response has been identified within the screening questions of section 1.

• If the project is in Gateway 2 or 4, the Project Lead should discuss the PIA with the information governance (IG) team before submitting the PIDOP for approval.



Process:

The PIA tool should be initiated at Gateway 2, and reviewed at Gateways 3 and 4 to ensure that as the project progresses any changes to the privacy impact assessment are understood and managed.

Project Lead & project team

Review project brief and

answer PIA screening questions.

Project Lead

Record risks in project risk log citing PIA as the source.


If in Gateway 2 or 4 – discuss with member of the IG team Update


next step

Repeat process to review the PIA at each Gateway as more detail or new information is available


Present PIA to impact assessment panel


risk log

33

Step by Step: PIA Section 1: Answer all of the screening questions; answering “yes” or “no” by placing an “x” in each of the corresponding boxes.

1

If you have answered "no" to all the questions, there is no need to continue with the privacy impact assessment.

If a "yes“ answer has been given to any of the questions, a potential IG risk factor exists. Section 2 of the impact assessment must then be completed.

2

Section 2 Assessment: If a "yes“ answer has been given to any of the questions, the impact assessment will need to be answered in full.

Some questions will require answers to be typed into the boxes. Other questions simply require a yes/ no/ N/A

reply. Where this type of question exists, a drop-down box has been provided to aid the speed of completion.

If an answer is unknown at the time of completion, there

are boxes available to state when the information is likely to become available.

3

If you have any questions or need to contact the Essex IG Team, they can be contacted at; [email protected] 4

34

Gateway 2: Approval Criteria Once the PIDOP has been completed it should be sent to the PMO team for inclusion in the next meeting of the Strategic Delivery Group. You will be called upon to present the PIDOP to the group and explain more about the project so the group can agree whether it should progress to the next stage.

The Strategic Delivery Group will review the PIDOP using the following questions:

• Is the project in line with the CCG’s corporate strategy for the next 5 years?

• Are the non-financial benefits SMART and comprehensive enough to justify the project?

• Are the proposed mitigations appropriate to cover the level of risk identified?

• Does the financial overview indicate that the project will provide an adequate return on any investment required (including time and effort as well as financial outlay)?

• Does the CCG still have the resources to carry this out?

If the SDG agree to progress the project then a decision will be made, on a case by case basis, as to whether a full business case is required. If the project has comprehensive options for consideration, or may result in a public consultation then a business case will definitely be required. If a business case is not required then the Project Lead should update the PIDOP for consideration by the H&CCC or the Exec at the next Gateway.

35

Gateway 2: Decision There are three possible outcomes once the PIDOP has been considered by the Strategic Delivery Group, and these are the same outcomes as listed in Gateway 1:

Approval

The PIDOP will progress to the next stage. A decision will be

made as to whether the project requires a full options appraisal / business case, or if an updated

PIDOP and the workbook will be sufficient.

The PIDOP will progress to

Gateway 3: Development, and the PMO will update the

programme tracker accordingly.

Hold

The idea may be suitable, but will not be taken forward straight away. If this is the case the PMO

will record a review date and hold the idea until that time. It

will not progress to be developed until it is discussed again and the

SDG agree it should be progressed. This is because

things could change over that period and mean numbers need updating, or the landscape may

change – which would mean that analysis is wasted.

Do Not Proceed

The SDG feel it is not suitable for the business and unlikely to

be within the near future. If this is the case then the PMO

will work with you to complete the project close template and clearly record the reasons why. If the idea is suggested again, then this information will be

used to avoid having the same conversation again unless the situation has changed and it

may now be viable.

36

Gateway 3: Development

Gateway 3 is where the project will require a lot more detail and provide the information required to make the final decision about whether to authorise the project for full implementation.

All projects in Gateway 3 require a workbook, and some may also require a business case depending on the scale and scope of the project. The workbook includes detailed sections on each of the elements of the PIDOP and keeps all project documentation in one place so versions are updated and kept together.

Once documents are embedded into the workbook they can be kept updated in that file, so changes made to the document will be saved within the workbook copy.

37

What? In Gateway 3 the Workbook becomes the repository for documentation relating to the project, including the idea template and PIDOP. It is an excel workbook with different tabs for each of the key elements of the project.

Why? Much more information is required at this stage, and it is essential that all documentation is kept together and updated with the correct versions. The workbook has been designed to be easy to use, but very thorough. This means if the project is unlikely to require a detailed options appraisal or case for change then a business case might not be needed as all the other content is included in the workbook.

When?

Who? This should be completed by the Project Lead and will be “owned” by the Project Lead throughout the life of the project. The PMO will require latest versions of the workbook so it can be used for reporting and monitoring purposes.

How? The workbook includes detailed instructions on each tab, which takes the Project Lead through each stage. The PMO are on hand to support and advise in general, and the wider project team members will support with the technical elements of each tab. The tabs include: • Cover • Overview of Gateway process • Library / document repository • Project plan (Gantt chart) • Risk log • Non-financial benefits • QIA, EIA, PIA • Procurement checklist • Communications and Engagement Plan • Financial summary, Savings Analysis, Cost Analysis, Phasing

Process:

Project Lead

Initiate workbook

The workbook will be initiated in Gateway 2 as the impact assessments are completed in first draft, however the remaining sheets might not be used until Gateway 3 depending on the scale of the project.

Project Lead

Work through content with wider project

team and complete in draft

Project Lead

Send updated workbook to the

PMO for checking and challenge.

The Workbook

PMO

Check content of the workbook and provide

feedback to Project Lead as to readiness for

approval

Project Lead

Submit impact assessments for

impact assessment

panel

Potential Outcomes:

Approval, progress to implementation.

Hold or Do not proceed.

Project Lead

Submit to PMO for SDG

meeting

38

All workbooks and highlight reports must be saved in the central folder below: T:\PCT\Delivery Teams\Transformation\Projects\Workbooks

Include title in the top section (this will auto-populate the other sheets). Make sure you update version control every time you update the workbook so the history and changes are clear. Add the names of the other people involved in the project.

Step by Step: Workbook

There is nothing to complete, this is just a reminder of the Gateway process for your reference.

Add previous documentation here. To insert a file select the “insert” tab at the top. Then click on “object” to bring up an options box. Click on the “create from file” tab and click “browse” to allow you access to your files. Find the file you wish to insert and then click “display as icon,” this will bring up a picture of the document. Click “change icon” and this will allow you to give the document a caption / name. Give the document a brief name and click “ok” on both pop up boxes. Move the icon into one of the green boxes and add a title above to outline what the document is. Do this for all files that are relevant for the project.

Cover

Gateways

Library

The workbook includes detailed instructions on each tab, however some top tips are included here:

This is the gantt chart. Use this to prepare a detailed project plan with milestones. Start by updating the version number and author. Do this every time you update the project plan. If the project has separate work streams then include the title of each work stream in a green box at the top of each section. This is not necessary if there is only one key work stream. Add details of the task as briefly as possible, and if it’s a key milestone then include a “y” in the milestone column. There should only be a small number of milestones. Add a start and finish date for each task (this could be the same day). Include the name of one owner per task, and add status. At the start all actions are likely to be “open” but as the project progresses then some will be completed and close. The gantt chart should populate automatically using the dates you have included. Milestones will be shown in red, and other tasks in blue. If it does not populate then the formula has been lost. To restore the formula click on the top left box on the gantt area (under the first date) and right click (or press control and “c”) to copy the formula. Then right click (or control “v”) to paste it to all the other cells. This should restore the formatting. If no cells include the formula then contact the PMO for assistance.

Project Plan

39

The Risk register is no longer included in the workbook but may be accessed using the Project Risk Register Application. This will ensure that all Project Risks and Issues are maintained in a single, central repository. Full details of the Risk Register and the associated application may be found in Appendix A.

Step by Step: Workbook continued…

Risks

The non-financial benefits are all the quality, safety and patient experience benefits that you aim to achieve. All projects should aim to achieve quality benefits as well as financial savings. The template is straightforward and asks you to identify metrics, baselines and targets. If you struggle to think of metrics, discuss the project with your information lead and look through the existing quality dashboards for any relevant metrics that are already captured and reported. It is much easier to monitor and track metrics that are already measured and reported! If you want to capture metrics that are not currently reported, these could be included in the service specification once the service is implemented.

Non financial benefits

40

The QIA “step guide” is included earlier in this manual.


QIA

This section outlines the options around contracting and procuring the new service. It could be a variation to an existing service, or a brand new service altogether. Either way a contract will be needed, and the CCG’s statutory obligations around competition and procurement will need to be upheld. Complete the template including as much information as possible, and then discuss the options with your procurement advisor. It is critical that any conflicts of interest are managed carefully and that options around the route to market are assessed carefully to avoid any challenges later in the process. The following sourcing options will be considered: 1. Contract variation, extension or management 2. Tendering (competition for the market or through an existing framework) 3. Any qualified provider (competition in the market accreditation) 4. Single tender process (where there are no other capable providers)

The procurement advisor will support the options appraisal and advise on the most appropriate procurement route for the project. Including consideration as to the competition procedure.

Route to Market

The EIA “step guide” is included earlier in this manual. EIA

The PIA “step guide” is included earlier in this manual. PIA

41

The communications and engagement plan uses a basic RACI (Responsible, Accountable, Consult, Inform) grid to outline what the key messages and methods of communication will be used for different groups of stakeholders. Start by listing the stakeholders and their titles – then allocate a category to each one. There should only be one person that is ultimately Accountable, but other categories could have multiple people. Then move to the right hand side of the spreadsheet and follow the instructions to outline the purpose, key messages, method and frequency of communication for each group. If your project is particularly complex, or may require a full public consultation you may wish to use a more detailed communication and engagement plan. The PMO have examples of more complex tools.


Comms Plan

The final sheet requires a detailed break-down on the phasing for the costs and savings. It is likely some costs will be incurred before all the financial benefits are achieved, so be clear when you expect both to kick in. All financial sheets should be discussed and validated by the finance team or PMO to ensure the numbers and assumptions are correct.

Phasing

There is nothing to complete, this sheet draws from the other financial sheets to provide a summary of the financial position for the project. Financial Summary

This section focuses on the costs that will be required to implement the project. It is likely that there will be some costs, even if they are short term project management costs, or one-off equipment purchases. Include as much information as possible so the SDG are able to make a decision about the cost / benefit ratio.

Cost Analysis

This section outlines the financial savings that will be generated through the project. The template asks for information on the unit of change (for example reduced numbers of people attending a clinic will mean less tariff payments for those attendances and therefore the unit would be HRGs which drive the tariff payments). Complete the columns including as much information as possible, including details of assumptions – why you think it would work. There is room to add other information at the end of the row. If you need help, discuss with your financial lead or the PMO team.

Savings Analysis

42

What? The business case offers an expanded narrative based document that includes more information on the case for change and options appraisal. All other information is also included in the workbook, so it will not always be required.

Why? A business case will be required when a project is particularly complex and requires more narrative in order to make a decision or justify a decision in the future. The additional information focuses on the case for change and options appraisal. This will be useful if the project is likely to require a public consultation, or a very detailed options appraisal scoring process.

When?

Who? This should be completed by the Project Lead and will draw from information within the workbook. It should be embedded within the workbook as part of the document library and shared with the PMO for reporting and monitoring purposes.

How? The business case includes prompts at each section which outline what is required. Information in the workbook can be used to inform the business case and it should be read alongside the workbook to avoid unnecessary duplication. The business case requires some additional information to the workbook: • Purpose and proposal • Case for change • Options considered including those dismissed • Interdependencies

Process:

Project Lead

Initiate workbook

The business case will be used in Gateway 3 if required by the SDG. Prepare it after the workbook is complete as you will need to use some of the workbook content.

Project Lead

Prepare draft business case and submit to the

PMO

The Business Case

PMO

Check content of the business case and provide feedback to

Project Lead as to readiness for approval

Project Lead

Submit business case through wider project board / EOG

Potential Outcomes

SDG recommend to H&CC for approval

Hold or do not progress

Project Lead

Present to SDG for approval to take to H&CC

43

Gateway 3: Decision – Impact Assessment Panel There are two decision points in Gateway 3. The first is by the Impact Assessment Panel who will review the three impact assessments and discuss them with the project lead. Impact Assessment Panel The Impact Assessment Panel is made up of representatives from the quality team, governance team and information governance team. Their role is to review the impact assessments and confirm / challenge the project team to ensure that the project team have considered and managed any risks to quality, equality or privacy. The panel meet formally and require the Project Lead and any chosen members of the project team to provide a brief overview of the project and answer questions about the impact assessments. Once the panel are satisfied that any risks or issues are being managed appropriately, they will provide approval for the project to proceed. If the panel have serious concerns about any of the impact assessments, they can request more information, or even propose that the project should not go ahead. They report to the Quality Committee and have an overview of all projects.

44

Gateway 3: Decision – Final Approval The final decision is taken by the Health and Care Commissioning Committee, following a recommendation from the Strategic Delivery Group. If there is a conflict of interest with members of the H&CCC (for example in relation to a primary care project) then the decision will be taken by the Exec Committee. Final Decision The Health and Care Commissioning Committee or Exec Committee will review the workbook, documentation and PIDOP or business case (if required) to assess the cost / benefit of the project and agree whether it should be taken forward.

45

Gateway 4: Implementation

Gateway 4 launches the procurement / commissioning / implementation phase of the project. If the project requires a competitive process then a number of options will be considered:

• Open procedure - all those interested may respond to the advertisement in the OJEU by submitting a tender for

the contract • Restricted procedure - a selection is made of those who respond to the advertisement and only they are invited

to submit a tender for the contract • Competitive dialogue procedure - a selection is made of those who respond to the advertisement and the

contracting authority enters into dialogue with potential bidders, to develop one or more suitable solutions for its requirements and on which chosen bidders will be invited to tender

• Competitive procedure with negotiation - a selection is made of those who respond to the advertisement and only they are invited to submit an initial tender for the contract. The contracting authority may then open negotiations with the tenderers to seek improved offers.

• Innovation partnership procedure - a selection is made of those who respond to the advertisement and the contracting authority uses a negotiated approach to invite suppliers to submit ideas to develop innovative works, supplies or services aimed at meeting a need for which there is no suitable existing ‘product’ on the market. The contracting authority is allowed to award partnerships to more than one supplier.

46

What? The highlight report is a single-page document that is used to report on the critical elements of the project and helps to pinpoint current challenges that may be hampering project progression.

Why? The highlight report is narrative-light but provides information in a highly visual way. The structure of the highlight report helps to drive the conversations when reporting but also helps the Project Lead to raise issues that are potentially putting the project at risk of successful delivery.

When?

Who? This should be completed by the Project Lead and will draw from information within the workbook. The highlight report is a stand-alone document and should be shared with the PMO prior to reporting to the SDG or F&P.

How? The highlight report is broken down into 7 sections: Governance – This section enables the project lead to RAG rate and comment on the project for each of the governance indicators. Milestones – This area is used to highlight any milestones that are behind plan and are at risk of being delayed or not achieved. If milestones are on track there is no need to add any information to this section. Financial position – provides a graphical summary of the financial position. The PMO will complete this section from the latest available activity and financial data. Metrics – provides the current position of project KPIs Risks – This will be populated by the PMO with Red and Amber risks from the Projects Risk Register. Action required – This box provides a space to add further comments.

Process:

Project Lead

Create new highlight report

The highlight report will be used in Gateways 3 and 4 when required by the SDG or F&P according to the transformation reporting schedule. Prepare it prior to attending a reporting board and submit it through the PMO.

Project Lead

Prepare highlight report and submit to

the PMO

The Highlight Report

PMO

Check content of the highlight report and provide feedback to Project Lead as to readiness for

submission

Potential Outcomes

Capture actions and update workbook risk

log.

Project Lead

Present highlight report to required

reporting board 47

All workbooks and highlight reports must be saved in the central folder below: T:\PCT\Delivery Teams\Transformation\Projects\Workbooks

Step by Step: Highlight Report

48

West Essex CCG Monthly Project Highlight Report

Month

2

Status

Status 5

Status

G

g

G

G

R

G

Status

Plan Revised Completed Status Workstream FY Target (£k) LTF (£k) Actual(£k) Variance (£k) Status30/03/2018 30/03/2018 Shared Decision Making 314 314 105

30/06/2018 Rheumatology 94 94

30/06/2018 GP Referral Guidelines 80 80

488 488 105

Score

Key Performance Indicator Target LTFCurrent

Position

%

Complete (M)Status

58 58 29 100.00%

29 29 15 100.00%58 58 29 100.00% Issue Title Impact

735 735

469 469

4Overall

Status Highlight Report Q1811

ICP MSKMay-18 Author: Anthony Hale Gateway

Insert Graph here

Project Management

Governance

Milestones

Financial Position

Financia l and non-financia l benefi ts

identi fied with monitoring mechanism

CommentsIndicatorProject team in place and meetings scheduled

Project Meetings attended by a l l key parties

Project Plan in place with key mi lestones and

workstreams

Description

ACP Finance and Contracting Framework Agreed

Referral Guidelines Agreed

Comments

Until end of September

From September

Activity Metrics Status

From July

There may be waiting l i s ts in the Rheumatology cl inics and a

backlog of patients waiting to be seen

The service wi l l not achieve anything

Obtain waiting l i s t numbers ; Clear patients on backlog through nurse;

Conduct cl inica l audits in order to identi fy patients who can be removed

from the l i s t

Enter narrative here

Issue Description

Action Required

Rheumatology OPFU

GP Referral Guidelines OPFA

Actions Taken

It may not be poss ible to establ ish the ful l amount of opportunity

as a cash va lue, as identi fied by the Right Care packs and Mi l l iman

It wi l l not be poss ible to identi fy the potenta l savings

Request additional expert resource from NHS Right Care

15

Rheumatology Service business case

Impact Assessments completed and s igned off

Leaders engaged

Risks & Issues

15

SDM Electives

SDM OPFA

SDM OPFU

Risk Description Risk Mitigation

0

100

200

300

400

500

600

Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19

Planned v Actual 2018-19 (£000s)

Actual (M)

Plan

LTF

Actual

Maintained by the PMO – Both the Month and

Date are used in the RAG status Calculations

Arrow indicates direction of travel: Horizontal = same as last month Up = Deteriorating Down = Improving

Completing the Report: Governance: Assess the level of compliance for each item: If the item is not yet required it should be left blank; Then, for each RAG status enter: G - Fully compliant A - Partially compliant R - Non-compliant / not started Enter comments only where absolutely necessary Milestones: A milestone is a specific event – usually the delivery of a project objective or component – which is planned for a specific day. Slippage will result in a higher RAG rating (Amber after 7 days and Red after 21 days) Activity Metrics: These will be collected and updated by the PMO %age complete reflects the Year to Date position against the forecast Action Required: State here the action(s) that you want senior management / Exec to take to help you get the project on track

Financial Position: The graph is automatically generated from the Data tab which is maintained by the PMO The Workstreams indicate the YTD position for each financial (savings) target being tracked. Comments will indicate, briefly, reasons for changes or lack of activity. Risks and Issues: These are generated directly from the Projects Risk Register from a report which will be run each month by the PMO. Only Red and Amber risks are ported, and then only the highest scoring three. New risks and issues, or changes to existing risks and issues must be recorded in the Risk Register prior to the publication of the report.

The Highlight Report is intended to convey -‘at a glance’- the status of the project at the end of the previous period (month). Recipients are expected to respond according to the Overall RAG status of the project. If it is Green, no response is

expected. If it is Amber, this indicates that project is in difficulty and not performing well, but that the project team are coping. If it is Red, this indicates that the project is in serious trouble and senior management intervention may be required

to bring it back on track, or determine alternative courses of action. All projects with an overall Red status must include information in the Action Required section.

It is expected that more detailed reporting of project activity will take place at Project Boards and EOGs, and within the individual team line management meetings, hence the inclusion of key indicators or highlights only.

Gateway 5: Project Closure

Gateway 5 signifies the end of the project “as a project.” There are two reasons a project will progress to Gateway 5; either it has finished being managed as a project and is now part of the operational “day to day” business, or it was not approved to proceed at one of the earlier Gateways. Either way the project must be closed appropriately, evaluated and learning must be captured.

There are several reasons why it is important not to skip Gateway 5:

• If a project was not approved at an earlier Gateway it is important to capture the reasons why. Otherwise it might be raised again in the future and time will be wasted developing the idea only for it to be refused again. If a clear rationale is recorded then the PMO can share that with anyone who raises the idea. Unless new information is available, or the context has changed then the idea should not be discussed again.

• Learning from previous projects can save a lot of time and effort if it is shared with new project managers, particularly if similar projects are in the pipeline, or if projects deal with the same partners.

49

What? The evaluation template captures learning and outcomes from the project to evaluate the effectiveness, efficiency, and appropriateness of the project to date, review progress and recommend how the project should be developed going forward to achieve / improve outcomes.

Why? It is important to reflect back over the project to understand the reasons why the project did/ did not go as well as planned. It also provides an opportunity to capture what key learnings to take forward improve project delivery in the future or to share the project achievements with other CCGs/ organisations.

When?

Who? The evaluation template should be completed by the project lead with input from all project team members.

How? The evaluation template includes prompts at each section which outlines the type of evaluation questions. Information from the workbook will provide certain facts but it is useful to arrange a meeting with the project team and stakeholders to reflect on the overall delivery of the project and capture all perspectives.

Process:

This should be completed in Gateway 5, using information from the workbook.

The Evaluation Template

Project Lead

Create new evaluation template

Project Lead

Complete factual information obtained from the workbook

Project Lead

Undertake a lessons learned/ project reflection exercise with

team

PMO

File evaluation template, ready for sharing. Update PMO project

tracker. Close project.

Project Lead

Complete evaluation template and submit to

PMO

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The Project Lifecycle

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WE CCG Projects Risk Register An Introduction

Programme Management Office January 2018

Rev. February 2018

Appendix A

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Projects Risk Register – MS Access Application

• The shared database (only) is stored on a network drive to enable multiple simultaneous user • The application needs to be available to each user either on their local machine or from their personal network drive. Each user must use a unique

instance of the application

• This is achieved by copying the Application from a central location to a local location to which individual end-users have sole access by following these steps:

• Locate the application file using Windows Explorer at: T:\PCT\Delivery Teams\Transformation\Projects\Risk Register\Application\WECCG Projects Risk Register.accde

• Whilst holding down the Right Mouse Button, drag this file to a location of your choice and choose Copy from the options. You could place it on your Desktop, but it will be lost if you replace your machine or have work done on it such as a rebuild. The better location would be your personal network drive – P: .

• You may, if you wish, now create a shortcut to this file on your Desktop (Right click anywhere on the desktop and select New / Shortcut and browse to

the file you just created.

• If you would like to make this new shortcut more obvious, Right Click it, select properties, select change Icon, browse to the folder where you found the application and select QRR.ico . (This will show up as having a black background on the Desktop.)

This same procedure should be followed whenever a new version of the application is released, to ensure that you are running the latest version.

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Main Menu

The application is designed to be self-explanatory and intuitive. However, command buttons are explained below.

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Adding a new Risk

Title, Detail, Consequence, Likelihood and Impact must be entered Clears the current form

Saves the Risk data as a new record if valid

Exits the form without saving any data

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Sample ‘Edit’ form with standard command button (Exit)

Exits the form with all changes saved

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Sample Report

Print – defaults to end-user’s default printer and settings

Saves the report as a pdf. File – prompts the end-user for the filename and location

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Selecting Projects for Risk Register Report Project Titles have been structured in such a way that reports can be generated at Portfolio (Board), Programme and Project Levels. Examples: The Adult Board Project Title’s structure is: AB – programmename – projecttitle Where the programmename is one of: • Cardiology • Dermatology • Diabetes • Gastroenterology • MSK • Ophthalmology • Respiratory • Etc. And the projecttitle follows.

When selecting a report for one or more projects you will be asked to enter any unique part of the Project Title(s) you wish to report on. If you enter “AB” the report will include all Adult Board projects. If you enter “Cardio” the report will include all Cardiology projects only. The simplest way to access a single project is to enter the Project’s reference number – e.g. Q1803

Published by West Essex Clinical Commissioning Group Programme Management Office Building 4, Spencer Close, St Margaret’s Hospital, The Plain, Epping CM16 6TN – T: 01992 566140

www.westessexccg.nhs.uk

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project management manual - west essex ccg

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