- 1 - Report to: Trust Board Date: 1 st September 2016 Report Title Service improvement & sustainability business case. Report from John Quinn, Chief Operating Officer Prepared by Sarah Haspel, Programme Director, Service Improvement & Sustainability Les Higgs, PMO manager List of attached appendices (if applicable) N/ A Reference documents (e.g. previous reports or appendices NOT attached herewith) N/ A 1. Brief Summary of Report The case outlines the request to fund a team who will make up the service improvement and sustainability programme team. It outlines the key work streams that they will provide and outlines the key benefits of the approach. The purpose of this team will be to manage the CIP programme for the Trust and to manage the service improvement programme for the Trust. These programmes will be both for the short term and the longer term. The case also described the need to build capability and capacity within the Trust to develop a method based on continuous improvement within the Trust to support future change. 2. Action Required/Recommendation The Trust Board is asked to consider the business case and support the costs requested. Item 9
Transcript
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Report to: Trust Board Date: 1st September 2016
Report Title Service improvement & sustainability business case.
Report from John Quinn, Chief Operating Officer
Prepared by Sarah Haspel, Programme Director, Service Improvement & Sustainability
Les Higgs, PMO manager
List of attached appendices (if applicable)
N/ A
Reference documents (e.g. previous reports or appendices NOT attached herewith)
N/ A
1. Brief Summary of Report
The case outlines the request to fund a team who will make up the service improvement and sustainability programme team. It outlines the key work streams that they will provide and outlines the key benefits of the approach. The purpose of this team will be to manage the CIP programme for the Trust and to manage the service improvement programme for the Trust. These programmes will be both for the short term and the longer term. The case also described the need to build capability and capacity within the Trust to develop a method based on continuous improvement within the Trust to support future change.
2. Action Required/Recommendation
The Trust Board is asked to consider the business case and support the costs requested.
Item 9
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BUSINESS CASE
Title: Service Improvement & Sustainability Programme Team
Authors: Sarah Haspel, Service Improvement & Sustainability Programme Director Department: Chief Operating Officers’ Department Date: 01 September 2016
SECTION 1: EXECUTIVE SUMMARY
This paper outlines the role the future service improvement & sustainability (SIS) programme team will have in supporting the main transformational change elements and its role in monitoring and providing assurance on improvement as part of the Trusts’ governance framework. The service improvement & sustainability (SIS) programme will focus on making Moorfields ‘fit for today’ and ‘fit for tomorrow’ with the key objectives of the programme being:
1. Deliver operational efficiency improvements, e.g. improve patient waiting times. 2. Deliver annual cashable cost efficiency savings over the next five years through improved
Carter/STP/system wide change. 3. Identify and adopt good practice across the network. 4. Standardising patient pathways. 5. Increase private patients’ income and efficiencies. 6. Build the internal capacity and capability to deliver sustainable change across the Trust, in line with
the Moorfields Way values and behaviours. The service improvement and sustainability programme as of August 2016/17 is broken down into three parts, with part 2 having a number of discrete themes, see below: Part A: Cost efficiency (CIP) delivery of support, guidance and a level of challenge, for each financial year acknowledging that delivery will become more challenging over time. Part B:
1. Outpatients’ pathway redesign. 2. Theatres improvement. 3. Urgent care redesign. 4. Centralised booking and clinical administration. 5. Multi-site review. 6. Nursing productivity. 7. Medical productivity.
Part C: Develop the capacity and capability of the organisation through investment in ways of working that ensure clinical innovation whilst delivering efficiencies in line with the Moorfields Way. Examples include models from the USA which have been adopted in the UK such as Total Quality Management, Six Sigma, Behavioural change. The programme represents a substantial change programme for the Trust over the next three to five years and the development and delivery of the service improvement & sustainability (SIS) programme will require a significant investment on behalf of the Trust to create the internal capacity and capability to deliver the proposed changes. The drive to set up a programme is also to take control internally of both savings and change programmes, particularly in the context of many trusts having control taken from them via turnaround and other mechanisms. The SIS programme team will require additional part-year funding for 2016-17 of £428.3k, of which £204.9k
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would be recurrent funding and £223.5k would be non-recurrent funding. The full year impact for 2017-18 onwards would be £804.0k of which £350.9k would be recurrent funding and £453.1k would be non-recurrent funding. In addition the programme will require an additional investment of £300k spread over the five years of the programme to invest in developing and embedding the methodology for change, supporting innovation and change, and to build the wider infrastructure and capability to deliver sustainable change across the Trust.
SECTION 2: BACKGROUND
Delivery to date: The programme has an interim programme manager lead from March 2016, and the main focus has been on part A, setting up the Cost Improvement Programme for the trust for 16/17. Approx. 220 projects have been identified across corporate and clinical directorates, delivering a plan for the target as set and delivery now being monitored through the programme board. This focussed approach has led to £8.8m of identified cost improvement schemes. The interim lead also set up a strong governance structure and documentation for the programme plus designing and delivering five training modules on project management (approx. 150 attendances were recorded for the sessions run over the summer). In addition work was done to support Part B, the cross cutting thematic programmes through support to the identified leads in terms of defining the programmes and setting up working groups and work-streams. Key outcome of the clinical work streams are
Patient waiting times through the Glaucoma service have now been mapped at a granular level for the first time.
Uveitis are able to stratify their patients into complex or simple uveitis which then makes future clinical pathway design more tailored to the needs of the patients.
Lessons learnt: In the past change and service improvement has been challenging to deliver within the Trust. Part of the challenge has been that without a team to provide the level of support required for operational staff to lead change, transformation has proved difficult to deliver. In addition there are issues related to the trust structure and ways of working, such as the networked nature of the trust and complexity of specialities which has reduced the ability for standardisation, cross fertilisation, engagement with agendas and prioritisation. The initiation of a programme approach with a support team replicates the process that a number of trusts have gone through recently; particularly to ensure that organisations have their own capacity to manage versus having a team imposed on them when in financial difficulty. Future Challenge: The Trust has managed to deliver its statutory requirements over the past few years in-spite of the issues listed above, but has done so at the margins of delivery in some cases. The financial challenge is predicted to become more of a constraint on the trust with the implications of less favourable tariff and increased demand through aging population imminent. From the prospective of programme approach, Moorfields Eye Hospital (MEH) the proposal is to change current practice whereby outcomes are delivered through directorate led change processes, to more progressive and universally understood and accepted improvement methodology that builds continuous improvement into the change process. Projects should be developed to solve a problem, need or opportunity, supported by a culture of constant review and adjustment thereby delivering sustainable continuous improvement. This paper outlines the role the SIS programme team will have in supporting the main change elements of
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the service improvement and sustainability programme, together with its role in monitoring and providing assurance to the Trust Board on delivering successful change.
SECTION 3: REASONS FOR CHANGE
Building on delivery of savings and change projects: The service improvement & sustainability (SIS) programme will focus on making Moorfields ‘fit for today’ and ‘fit for tomorrow’ with the key objectives of the programme being:
1. Deliver operational efficiency improvements, e.g. improve patient waiting times. 2. Deliver annual cashable cost efficiency savings over the next five years through improved
Carter/STP/system wide change. 3. Identify and adopt good practice across the network. 4. Standardising patient pathways. 5. Increase private patients’ income. 6. Build the internal capacity and capability to deliver sustainable change across the Trust in line with
the Moorfields way. This will be done through a three part programme: Part A: Savings schemes The SIS programme will support the delivery of savings required by the Trust For this financial year over 220 projects have been identified, with approx. 50 corporate projects and approx. 170 projects in clinical areas; 40% of these have already achieved. For future years, the target has not been tightly scoped but based on current savings targets would be circa £10 million a year for the next 5 years. Thus the programme would be supporting a minimum £50 million savings schemes. Part B: Change programmes There are specific Trust-wide and local health economy factors that point to developing a core SIS programme team to support performance, quality and continuous improvement and deliver cost efficiencies:
Ongoing efficiency requirements to deliver more with less resources
The Trusts’ multi-site structure.
MEH being a highly complex organisation due to the variety and location of ophthalmic services it delivers and the fact that we are a people based organisation and our staff have a high 'emotional' focus towards the care provided for its patients.
There is momentum presently within the Trust to deliver change and a number of cross cutting theme programmes. However, there is a sense that successful delivery of the projects will require significant support from a programme team which can support at the front line and provide flexible inputs. In addition by providing a team there will be an opportunity for oversight and good governance. From a broader perspective of the Trusts’ strategic agenda, service improvement of the clinical operations is an integral part of the development of the capital projects being undertaken, namely Project Oriel, Moorfields East and Moorfields St Georges. Part C: Capacity and Capability with governance: The SIS programme team will be focusing on building sustainable change management capacity and capability into the Trust through developing and embedding the methodology for change and to build the wider infrastructure for change across the Trust. Ideas are being considered from both the USA and the UK in areas such as Total Quality Management and Six Sigma. The team are considering if the funding for the investment would become a proposal to one of MEH’s charities. The programme will provide backfill for staff including clinicians to work on service improvements so that the capabilities can be developed and
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then feedback via people moving back into their business as usual roles. By having a programme approach, there will be a stronger governance and also ability to harness energy for change whilst reducing overlap and improving standardisation. The intention will be to deliver a suite of benefits in terms of cash releasing, non-cash releasing, tangible and non-tangible. As an example non-cash is used to describe productivity savings which can be reallocated. Tangible will include patient improvements such as staff morale or patient experience, whilst non-tangible will include reputation and commissioner & regulator confidence. Benefits will also include contributing to the Moorfield Way commitments and the trust being able to demonstrate that developments are in line with the values of the trust. Internal control There is an additional aspect to consider. The impact of a programme approach managed internally, versus an imposed regime of change with control from outside of the trust. This has been the experience of a number of London acute trusts in recent times through turnaround etc.
SECTION 4: DESCRIPTION OF PROPOSAL
The SIS programme team will encompass a number of functions. These can be flexed in terms of resourcing and prioritisation as the programme evolves. At this point the team has two new staff members, a permanent programme director and a project manager for governance (the project management office). Additional functions are support and facilitation of change through input of project management into programmes of change and support to build capacity and capability within trust teams. Principles: The programme principles encompassed within the SIS programme will be:
Service improvement across MEH will best be served by integrating aspects of change delivery and cost efficiency, managed by a single programme management team.
The central role of the programme team will help ensure continuous improvement and cost efficiency projects are resourced, prioritised and supported to deliver the Trusts’ strategic objectives.
Cost efficiency and quality improvement are managed as one and are simply different aspects of change.
Developing a coherent three – five year programme of cost efficiency and sustainable service improvement.
Ensuring governance structures are well defined and managed to support delivery in an increasingly challenging context.
Developing in a way that builds on national policy and review, such as Carter Review and contributes to system wide change programmes such as NWL Integrated Care.
Adhering to the Moorfields Way and the commitments
To build the future change capacity and capability required by the Trust requires an approach on three separate fronts to function effectively, with appropriate roles being fulfilled by other clinical, operational and corporate teams. Part A and Part B: Savings and Service Improvements: To support the savings programme and the service improvement programmes, the SIS team will need to work at the front line to support staff to deliver change whilst providing governance and assurance into the organisation. The team is proposing to build it’s own capability to deliver financial and business informatics alongside programme management office functions. The intention is to develop an ability to challenge back into the organisation as required, to pull on benchmarking data nationally and internationally and provide a level of analysis and insight back into the trust. The project management input will be through service improvement leads and project support workers; these posts can be flexed according to need and can
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support a number of projects at any one time. By providing funding for clinical time too this will augment capacity and capability in “business as usual” to deliver change; again provided where there is a significant need outside of regular job planning. If staff members are able to be seconded into the team then also they will return to posts with the knowledge and understanding they have gained to provide more sustainable change capacity in the trust. Part C: Building on the desire to develop a high standard programme and ensure capacity and capability within MEH, the proposal is to invest in a methodology for the trust. The ideas mooted include adopting best practice internationally, making consideration for which methodologies have been successfully implemented in the NHS. Ideas from the following USA and UK organisations are those which have been identified so far:
Virginia Mason Medical Centre (Lean Healthcare) and adopted in 5 trusts in the UK
Intermountain Healthcare (Total Quality Management) and promoted by the Kings Fund in the UK
ThedaCare (Lean Healthcare).
Dartmouth Institute (Psycho behavioural)n and adopted by Sheffield Hospitals in the UK.
Kaiser Permanente (Quality improvement).
Key factors for success will include trust board level buy-in and support, time for staff to be trained and posts where staff can take time to become experts. Other factors including moving to matrix working across the trust rather than silo working whilst ensuring ways of working are developed that support Moorfields Way (culture, values and behaviours) will also be critical. There is a potential for the development to be “sellable” outside of MEH and consideration of how it would build the quality of services and brand would be a decision making factor in choosing a methodology.
Overall the programme would offer governance of savings and change programmes whilst fitting in the existing governance of the trust, reporting in the present structure into the Trust’s Management Board.
SECTION 5: OPTIONS APPRAISAL
Options evaluated
Option 1 – Do nothing
The pace and scale of change required to ensure MEH maintains financial sustainability over the next three to five years, coupled with the need to improve operational performance and patient experience of the services we deliver means that this volume of change cannot be developed and delivered using the current resources available within the Trust. Additional resources will be required to coordinate and support delivery of the individual change projects. It is important that MEH adopts a best practice service improvement methodology that will provide the vehicle for the planned changes. Failure to learn from those organisations currently delivering widespread service improvement will severely limit MEH ability to deliver the scale of change needed at the required pace.
Option 2 – Establish the core programme team plus the capability and capacity building elements The development of a separate SIS programme team that can coordinate the development and delivery of the service improvement and sustainability programme will ensure that the pace and scale of change can be delivered and will support delivery of the Trusts strategic objectives. Including capacity and capability building in the trust will ensure sustainability.
The option 2 to establish the core programme team plus the programme support roles is the option that has been selected.
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SECTION 6 – BENEFIT ANALYSIS – Option 2
The benefits of the SIS programme are outlined below. The benefits are described qualitatively and have yet to be fully quantified over the course of the investment. To date the programme has identified £8.8million of CIP and will identify and manage future CIP programmes. In addition all projects managed through the SIS programme will quantify the savings opportunities as part of delivering that project. Benefits will start to be described as cash releasing, non-cash releasing, quantifiable and non-quantifiable. These descriptions are already used in the trust, for example with IMT projects. For the programme there would be a mix of benefits to deliver. Appendix C describes the type of benefits that could be expected, for example improved patient experience (quantifiable) and staff efficiency/productivity (non-cash releasing). Benefits - Strategically – A central part of the programme is to support the strategic aim of the Trust in making the necessary changes to support key capital projects and the new ways of working that this requires. The changes required for this are large and complex and cannot be achieved easily without a resources to support existing teams to deliver this. In the shorter term the investment will support key organisational priorities such as improving patient waiting time and delivery of cost improvement programmes. The investment requested supports the strategic aims of the Trust. Economically the investment required helps keep the change projects on track and are more likely to deliver within shorter timescales than projects without support. Currently the 220 CIP projects would have been more difficult to deliver if there had not been a programme director ensuring that project briefs and milestones were being adhered to. The level of work required to coordinate this level of complexity between operational teams and finance would not have been able to be appended to current roles without significant delay in delivery or even risk to delivery. The investment requested is believed to be value for money in terms of ability to deliver a larger number of complex projects over time. The investment is also intended to build organisational capability to provide an organisation that can continuously improve hence the investment will have economic benefit beyond the investment period. Financially Cash releasing savings are expected year on year as part of the annual CIP process and the PMO function of the SIS programme team will manage this. Other efficiencies will be identified for each project and these will be quantified. Current year CIP is £8.5m and it is expected that next year and future years will be similar or slightly more hence the SIS programme will be managing and delivering these identified CIP over this period. Based on current year CIP £8.5m and delivery of £6.6m to date and the costs described below - extrapolated over 5 years the return on investment is 7.2 based on current delivery. Detailed costs for the service improvement and sustainability programme are provided in appendix 1 and 2. The part year funding for 2016-17 and the full year funding for 2017-18 has been costed in detail. Future years’ requirements, including those elements that are funded non-recurrently will need to be fully quantified during development of the 2017-18 budget. By seconding internal staff, or offering fixed term contracts to external candidates, into the SIS programme team it allows for the team to be flexed according to the needs of the overall programme, whilst building internal capacity and capability to deliver change.
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Staffing the team The Programme Director and PMO Manager have been substantively appointed to start the management of the CIP part of the programme and internal recruitment for the remaining roles will start in early September. The proposed structure for the SIS programme team is:
Staff AfC
Band WTE
2016-17 WTE
2017-18 WTE
2018-19 WTE
2019-20
Programme Director 8d 1.0 1.0 1.0 1.0
PMO Manager 7 1.0 1.0 1.0 1.0
Business Intelligence Manager 8a 1.0 1.0 1.0 1.0
PMO Co-ordinator 5 1.0 1.0 1.0 1.0
Finance Manager 8a 1.0 1.0 1.0 1.0
Service Improvement Managers - on flexible resourcing patterns
7/8a 4.0 4.0 4.0 4.0
Project Support Officers 4 4.0 4.0 4.0 4.0
Total 13.0 13.0 13.0 13.0
The SIS programme team will include service improvement managers and project support officers who will support the delivery of individual pathway redesign programmes and associated change initiatives. The intention (where possible) is to have project support officers will initially be graduate apprenticeships (on an agreed project management development pathway); thus allowing MEH to externally source talented individuals who can be developed through training, mentoring and role development to provide a project support function either to one of more of the cross-cutting themes or to support the larger CIP projects that require support, but do not justify the need for a project manager. The intention is that with the exception of the Programme Director and PMO Manager the remaining posts in the team will be sourced internally in the first instance, within MEH through the use of secondments with backfill of the relevant post holder to ensure business continuity. However external options such as FTCs/secondments could be considered. Capacity and Capability Resourcing staff within the trust to become change agents, trained on models of delivery such as TQM, would be the third part of the programme. The intention is to consider a bid for charitable funding for this as a training and capacity for staff initiative. There is also a potential to sell on that capacity to other parts of the health care system and consider linkages with system wide change programmes for example. Non pay - items of investment: Equipment The members of the core programme team and the project managers will require laptop computers equipped with relevant project management software. Project management information system (PMIS ) Provision in the financial model (appendix A2) has been made for the adoption of a project management information system (PMIS) to provide and improve centralised monitoring, reporting and control of the
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individual cost efficiency and cross-cutting themes that make up the overall programme. The IT department currently utilised a specialist web-based project management software package called Concerto that is used to provide a single project management environment for development and delivery of the IT suite of projects. The proposal is that the SIS programme adopts the Concerto system for the management of the programme. The costs included allow for the partitioning of the software system and for the additional software licenses required; the costs are relatively low on the basis that the trust is already using the system. Management of the Concerto system will be undertaken by the PMO Manager who has the relevant experience of managing the software package. Training for front-line staff on the Concerto system will also be provided by the PMO Manager thus minimising the set-up and implementation costs for the system compared to adoption of a new PMIS such as Microsoft Project Online or Primavera.
SECTION 7: RISK ASSESSMENT
Risk(s) of Not Proceeding: The service improvement and sustainability programme represents a major change programme for the Trust over the next three to five years. It will contribute to ensuring the Trust remains financially sustainable during this period and supports major service improvements in advance of capital developments, e.g. Project Oriel, Moorfields East and Moorfields St. Georges This level of change cannot be developed and implemented without a significant investment in project and programme management resources. Existing BAU resources have neither the capacity, nor capability to deliver such a wide reaching programme of change. Therefore the risk of not proceeding with this business case is that the service improvement and sustainability programme will not deliver the required changes in clinical and operational practice, nor deliver the scale of benefits, both financial and non-financial that is required. In that instance there is a risk that, as with other NHS Foundation Trusts, a team is imposed on the trust to deliver savings for example and MEH control would be lost. Risk(s) of Proceeding: The major risk is that the Trust does not have sufficient internal staff of the required capability to be able to deliver the proposed changes and that the capability and capacity resourcing does not deliver this capability. In this instance, the likelihood would be that the trust would source externally. That may incur higher costs, though the use of NHS FTC should mitigate the financial risk.
SECTION 8: FINANCIAL SUMMARY
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Savings to be achieved This programme will support the delivery of cost efficiency savings required by the Trust. For the financial year 2016-17 this is £8.5m and for 2017-18 this will be £11.75m. It is expected that savings in future years will be circa £10 million a year. Thus the programme would be supporting a minimum of £50 million savings schemes over five years. In addition the programme will be supporting service improvements which will be considered in light of ability to deliver savings whilst adding value through different types of benefits. Costs The SIS programme team will require additional part-year funding for 2016-17 of £428.3k, of which £204.9k would be recurrent funding and £223.5k would be non-recurrent funding. The full year impact for 2017-18 onwards would be £804.0k of which £350.9k would be recurrent funding, based on a number of roles as permanent, and £453.1k would be non-recurrent funding. In addition the programme team propose an additional investment of £300k spread over the five years of the programme to invest in developing and embedding the methodology for change and to build the wider infrastructure for change across the Trust. Potential loss of income – There is no potential loss of income associated with this business case.
SECTION 9: SUMMARY & RECOMMENDATION
In summary this paper presents a case for change for MEH to develop it’s own programme approach and supporting team to deliver savings, service improvements and develop capacity and capability in change methodology. The programme team has already supported savings for 16/17 and development of cross cutting them programme work. Subject to the proposal being accepted by Trust Management Board then MEH should aim to move to the proposed way of working with immediate effect. This will ensure clarity and consistency of message across the organisation, and give the best chance of successful delivery of plans. The Trust Board is asked to:-
Support the development of an SIS programme team to enhance the Trusts capacity and capability to deliver major transformational change projects.
Approve the allocation of additional part-year funding for 2016-17 of £428.3k, of which £204.9k would be recurrent funding and £223.5k would be non-recurrent funding. The full year impact for 2017-18 onwards would be £804.0k of which £350.9k would be recurrent funding and £453.1k would be non-recurrent funding to establish the SIS programme team.
Approve the allocation of additional investment of £300k to be spread over the five years of the programme to invest in developing and embedding the methodology for change and to build the wider infrastructure for change across the Trust. Noting that this may be proposed as an investment option for charitable funds.
Approve the recruitment to the remaining programme team roles as identified in section 6.
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Appendix A1 – Service improvement and sustainability programme financial model (WTE’s)
Appendix B – The services to be delivered by the wider SIS programme team and PMO
Services Pro
gram
me
Leve
l
PM
O
Sup
po
rt
1. Develop and implement a standard project and programme management (PPM) methodology, common tools and processes and associated governance mechanisms
2. Develop project management competences and skills through provision of training, with coaching and mentoring available for Project Managers and Project Leads
3. Monitor, control and report project and programme performance and status using an agreed project dashboard
4. Coordinate and integrate the projects across the wider programme; managing interdependencies and rebalancing projects as required
5. Promote programme awareness and engagement across the Trust
6. Identification, selection and prioritisation of new projects
7. Manage an intranet based central PMO document repository and physical filing system
8. Audit the completion and maintenance of project and programme documentation
9. Manage the quality impact assessment process ensuring that all projects have a robust assessment completed as part of the approval process
10. Manage the impact of changes to individual projects and the wider programme implications; ensure project closure occurs in a consistent manner with a focus on benefits realisation
11. Provide independent assurance and challenge role, including direct Board assurance
12. Implement and manage the programme wide risk and issues database
13. Overall organisation change programme plan in place
14. Ensure post-project reviews are undertaken and implement a database of lessons learned
15. Ensure lesson learned are communicated Trust-wide and used to develop future best practice
16. Resource allocation model held centrally with decisions facilitated via PMO
17. Ensure programme benefits realisation is completed
18. Participate in strategic planning
19. Internal and external benchmarking, and integration of programme execution with local health economy partners
20. Implement and operate an online project management information system, with direct links into finance system.
21. Recruit, select and evaluate all project management resources across the Trust; establish a project management career path
22. Internally generated improvement idea system installed and operating, and is a major contributor to improvement
