The Quality & Safety Challenge 2012

This full proposal template must be completed if your proposal is shortlisted for further investigation. Do not fill this in unless you are contacted by the Commission.

Full Proposal Template Please complete all sections and email to: info@hqsc.govt.nz by 10 November 2011. Please use the text boxes below each section and expand as required.

In some cases we have asked for you to repeat the information provided in your original EOI, adding more detail where appropriate.

Section 1. Project Details

1. Short title of project for reference purposes.

Section 2: Applicant’s Details

2. Legal entity applying

3. Name of primary contact person

4. Contact’s details: Phone Cell Email Address

5. Name of person who will be delivering the project (if known)

6. Are there any conflicts of interest you are aware of in this proposal? If so please declare these.

Section 3: Project Information7. What are you proposing to do?

8. When will you deliver the project?

9. Which of the three categories does this project relate to? How?

10.What is the problem you are trying to address?

11.How widespread is the problem? What is the scale and scope of the problem?

12.How will you deliver the project? What resources will you use? What methodologies will be utilised?

Section 4. Project Objectives13.How does your project align with the Commission’s objectives?

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14.Describe the most important result that this project will deliver:

15.How will you monitor your project delivery and success?

16.What timeframe will you need to implement your project and make a difference?

17.How will you know if you have made a difference?

18.How well would your project transfer to other health providers? (other regions, over services, other sectors?)

Section 5: Risks19.What risks are there in this proposal? What can be done to mitigate these

risks?

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Section 6: Budget20.What are the estimated full costs for implementation of this project across the

sector if the initial project was successful?

21.We need to know, accurately, how much your project will cost. Use the template below for developing and explaining your budget. If a budget line does not apply, simply write N/A next to it.

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Budget Template

This template is also available in Excel from the Commission website (www.hqsc.govt.nz). Examples are provided in italics.

Project Costs Description Quantity Item cost Total HQSC request

Personnel costs: (wages, salaries, allowances etc)

eg administrator, eg 30 hours per week or 0.5 FTE for 5 weeks

eg $25 per hour

$3750 $2000.00

Project manager 1 FTE for 8 weeks

@$80 per hour

$25,600 $25,600

TOTAL PERSONNEL COSTS $29,350.00 $27,600.00

Incidentals: (travel, IT, data requirements, accommodation, room hire etc)

eg flights 3 times from Auckland to Rotorua for 2 people

6 $300 return

$1800 $1800.00

Car hire 3 days $150 per day

$450 $450

Accommodation Rotorua $175 per night

2 nights for 2 people

TOTAL INCIDENTALS $1800.00 $1800.00

Materials (eg medical consumables, training materials, pamphlets, printing etc)

eg printing flyers 250 $2.50 ea $625.00 $625.00

folders 100 $10.00 $1000.00 $1000.00

TOTAL MATERIALS $1625.00 $1625.00

Other costs (eg conference room hire, workshop facilitator)

eg guest speakers’ fees

30 mins $250.00 $250.00 $250.00

TOTAL OTHER COSTS $250.00 $250.00

TOTAL ALL COSTS $33,025.00

TOTAL AMOUNT REQUESTED $31,275.00

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Section 7: Certification

I, _____________________________, certify that this application to the Quality & Safety Challenge 2012 is authorised by the legal entity specified above.

Requirements - Content Please

1. Proposal is explicitly linked to one or more of the three categories identified as priorities for this fund?

2. Problem definition is provided

3. Each proposal clearly explains how its success will create an improvement in quality, safety or consumer engagement.

4. Proposal demonstrates clear intervention logic

5. Providers have the capacity and capability to undertake the project

6. Project management principles are built-in

7. Costs- budget/ cost benefit equation is explained

8. Expected timeframes are outlined

9. There is the potential for wider application to the remainder of health sector

10. Performance measurement and indicators are developed

11. Confirm not funded by another public source

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