Guidance for the Development of a Sustainable Improvement
Programme (Inc Quality Impact Assessment)
Version
2
Name of responsible (ratifying) Committee
Governance and Quality Committee
Date ratified
4th March 2014
Document Manager (job title)
Head of Transformation
Date issued
13th March 2014
Review date
November 2015 (unless requirements change)
Electronic location
Management Policies
CIP, Quality Impact Assessment, service development,
improvement
In the case of hard copies of this guidance the content can only be assured to be accurate on the
date of issue marked on the document.
Key Words (to aid searching)
For assurance that the most up to date guidance is being used, staff should refer to the version held
on the intranet
Guidance for Development of Improvement Programme (inc QIA):
Review date March 2015
Version 2 13/03/2014
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CONTENTS
1.
INTRODUCTION………….………………………………………………………………………………4
2.
PURPOSE …………………………………………………………………………………………………4
3.
SCOPE …………………….…………………………………………………………………………..…..4
4.
DEFINITIONS………………….…………………………………………………………………………..4
5.
DUTIES AND RESPONSIBILITIES……………………………………………………………………..4
6.
PROCESS …………………..…………………………………………………………………………….5
7
EQUALITY IMPACT ASSESSMENT………………………………………………………………….12
8
INFORMATION GOVERNANCE……………………………………………………………………...12
9
REFERENCES………………………………………………………………………………………….12
Appendices
Appendix A: Examples of Methods for Reviewing Efficiency to Identify Potential Service and Cost
Improvement Schemes
Appendix B: CIP Scheme, Service Developments and Improvement Projects Quality Impact Assessment Template
and Completion Guidance
Appendix C: Monitor’s guide for foundation trust applicants and highlights good practice and suggestions
for identifying, planning, managing, delivering and assessing Service and Cost Improvements
Appendix D: Policy Flow Chart
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QUICK REFERENCE GUIDE
Flow Chart for a successful Cost Improvement Programme
Planning
Strong leadership and robust governance and accountability arrangements
Full staff (and particularly clinical) engagement)
An effective communications strategy and meaningful language
Robust programme management, challenge and support
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Set out the Trust’s vision, policy and strategy for service and cost improvement
Develop five-year forecasts and ensure consistency with other plans
Involve a wide range of local health economy stakeholders early on
Agree how Service and Cost Improvements will be managed within the Trust
Identify CIP and other benefit targets for each Clinical Service Centre / Trust-wide
Identification
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Identification of schemes, and projects
Review of relative efficiency and other measures by e.g. benchmarking and SLR information
Business cases prepared and reviewed where necessary
Individual plans reviewed and assessed for cumulative impact
Assessed for achievability and potential impact on quality
Ensure consistency with overall strategy of trust and local health economy
Delivery
Monitoring and Reporting

Draw up detailed plans for each scheme valued at
greater than £100k, with clinical and financial
input
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Regular monitoring and reporting on Service and
Cost Improvements delivery
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Clarity of responsibility and accountability for
delivery
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Use of high quality financial and non-financial
indicators
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Peer challenge to drive performance management
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Monitoring and reporting undertaken at CSC,
organisational and Board levels
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Approved savings removed from departmental
budgets
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Service and Cost Improvement performance
accurately reflected in performance reports
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Following review, withdraw or amend schemes
that are not delivering
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Corrective action taken where necessary
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Focus on current and future longer-term Service
and Cost Improvements
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Management of risks
Evaluation
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Evaluation of overall Service and Cost Improvement process
Consider using internal audit to provide assurance on the overall programme and recommend
improvements
Use findings to apply lessons learned and inform the development process for future Service and
Cost Improvements
Source: Audit Commission and Monitor (amended to fit Trust Processes)
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1. INTRODUCTION
Some Trusts are moving away from using the term cost improvement programme (CIP) because it is
considered that it may not help to engage clinical staff. Instead terms such as ‘improvement change
programmes’ and ‘improvement programmes’ are being used. In this guidance, the term Service and
Cost Improvement encompasses all efficiency and improvement programmes, as there is a wider
understanding of that term.
Improvement is integral to trust financial and performance planning and requires good, sustained
performance in order to be achieved. The NHS needs to save £20 billion by 2015, an average of 5%
per year; the biggest efficiency challenge it has faced. As time moves forward, trusts will encounter a
national tariff with built-in efficiency savings, reducing contract volumes with Commissioners and
rising inflation. There will also be fewer opportunities to use income generation to offset savings
requirements. Therefore, to succeed in making sustained annual savings of 5%, boards will need
plans for significant improvement programmes and will face difficult choices about the services they
provide.
There is no single approach that works for all organisations. However, several factors are common if
the Trust is to perform well in improvement planning, delivery and sustainability. A successful cost
improvement is not simply a scheme that saves money. The most successful way forward is the
development of long-term plans to improve clinical and non-clinical services that not only result in
permanent cost savings, but also improve patient care, satisfaction and safety.
2. PURPOSE
The purpose of this guidance is to:

Better equip staff at all levels to ask challenging questions about aspects of improvement and to
review their approach against the good practice identified.
3. SCOPE
This guidance should be read by Executive, Non-Executive Directors (NEDs), CSC Management
Teams, PMO staff, Finance staff and all those with responsibility for delivering or supporting
improvements.
4. DEFINITIONS
Service-Line Reporting (SLR)
SLR measures a trust’s profitability be each of its service-lines, rather than just at an aggregated level
for the whole trust. SLR helps trusts develop a better understanding of the operational and financial
performance of their various services and hence improve their strategic and clinical decision making.
(Further information on implementing and using SLR can be found in two documents published by
Monitor: Guide to Developing Financial Data for Service Line Reporting (“the Guide”) and the Toolkit
for Presenting Service-Line Reporting Data (“the Toolkit”))
5. DUTIES AND RESPONSIBILITIES
SMT will:
 Ensure overall governance of both CSC and Trust wide improvement projects
 Approve and prioritise improvement projects with a value of greater than £250k, aligned with the
strategic goals of the Trust and the annual business plan.
Improvement Project Steering Groups will:
 Drive delivery of Trust wide improvement projects so that effective plans are developed, supported,
monitored and deliver agreed benefits
 Monitor and report to the Senior Management Team on progress
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Manage issues, risks and dependencies of, and between projects
Finance Committee will:
 Scrutinise cost improvement projects/schemes, to ensure the Trust delivers its financial objectives within
agreed financial parameters
 Receive report on the delivery of CIP’s monitored through the Performance Assurance Meetings and
recommend actions with regard to under delivery
Governance and Quality Committee will:
 Be assured that there is an appropriate Quality Impact Assessments (QIA) process undertaken for each
improvement scheme/project valued at greater than £25k
 Receive bi-annual reports from Steering Groups/CSCs on new and existing Trust wide schemes/projects
to ensure risk planning is robust and the impact on quality and performance is being thoroughly assessed
and negative impact mitigated.
Risk Assurance Committee will:
 Scrutinise the risk management processes of improvement schemes/projects
 Ensure that the Trust’s Assurance Framework and/or Risk Register are updated with relevant risks from
CSC and Trust wide improvement schemes/projects
Programme Management Office (PMO) will:
 Coordinate Project Initiative Document (PID) development and updates
 Provide coordination between projects
 Ensure project reports are delivered monthly to Steering Groups
 Hold and manage all project documentation
 Hold risk, issues and dependency logs
 Escalate concerns regarding Trust wide projects delivery to SMT via the Project Sponsor
 Provide updates to the Governance and Quality and Risk Assurance Committees on the QIA process.
Project Sponsor will:
 Own the objectives
 Approve and review the project plan
 Hold Project Steering Group meetings at least monthly and where applicable more frequently with the
Project Manager and key project team members
 Represent the project at SMT
Project Manager will:
 Create the project plan
 Own the deliverables
 Manage any sub-projects
 Lead the project team
 Manage risks, issues and dependencies
 Produce a project report at least monthly or more frequently to align with Project Steering Group
meetings
6. PROCESS
6.1
There is no single approach to developing an improvement scheme/project. However, trusts
that develop, deliver and have a sustainable programme have several common factors. They
have effective, coordinated and well-executed leadership and management which impacts
positively on the organisational cultural and mean that organisational performance is strong and
consistent. To ensure the Trust is successful it must:
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Set out clearly its overall vision, approach to improvement and philosophy;
Commit to ensuring that the organisational culture facilitates the improvement of services and
improves patient experience;
Develop a five-year forecast that supports the need to plan longer-term improvements;
Involve all local health economy stakeholders at an early stage;
Identify suitable, tailored CIP targets for each Clinical Service Centre (CSC) or department that
reflect their relative efficiency, using benchmarking data; and
Set up a progamme management office to oversee improvement, and/or define clear
governance and lines of accountability.
6.1.1 Planning
Service and Cost Improvement planning should start as early as possible and planning
and delivery viewed as a continual process, rather than a short-term, in-year project.
Cost Improvement planning often starts in the finance department. Finance staff
produces a five-year, long-term financial plan that models the forecast activity, income
and expenditure, taking into account inflation and capital plans. The plan identifies the
scale of cost savings required each year to meet financial targets and the Trust’s
strategic plans. The finance department can also act as a facilitator by providing data,
analysis, training and financial literacy. However, detailed service planning must be led
by CSCs, including appropriate clinical input. CSC engagement ensures the schemes
are realistic, owned by the CSCs and, as such, are more likely to be successful.
There are three important aspects to planning:
6.2

Information
The Trust needs good quality data on costs, cost drivers and comparative costs for
planning and making decisions about service delivery. Assumptions must be
realistic and based on accurate information. Long-term financial planning and an indepth understanding of costs are both important elements at this stage.

Consistency and collaboration with local partners
The Trust should not plan to increase activity where, for example, the
Commissioners are putting in place demand management plans. Similarly, the Trust
should not plan to close a service where there is no alternative option. Ideally,
responsibility for delivering Quality, Innovation, Productivity and Prevention (QIPP)
schemes should be shared between the Trust and the Commissioners.
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Building in Contingency
The Trust is more likely to be successful if it identifies more schemes than required
to meet the CIP target. Building in contingencies (together with starting the process
early in the year) helps with delivery of the CIP. As there is always slippage, plus
the process usually takes longer than originally planned to agree and finalise.
Identifying Service and Cost Improvement schemes
Whilst there are different approaches for identifying service and cost improvements, most
organisations will know where they need to make changes, but there should be supporting
evidence and involvement from all staff. Seeking input from stakeholders, including PCTs, GPs,
social care and third sector providers is also beneficial. If the Trust is to be successful in
identifying service and cost improvements it should:

Build in dedicated time to enable all staff, clinical and non-clinical, to step back from their day
jobs and produce new ideas for service change;
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Use benchmarking performance data to help identify saving opportunities and engage
clinicians;
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Rigorously appraise potential schemes for achievability and impact on quality;
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Check that schemes are consistent with the overall strategic direction of the organisation and
the plans of partners; and
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Fully engage clinicians and other staff to achieve change that is both improvement and
genuinely produces realistic, sustainable cost savings.
Developing safe, realistic CIPs requires clinical leadership and engagement. Organisations
with a culture of strong clinical leadership develop more rounded CIPs as the individuals
leading the service are also those delivering the care.
6.2.1 Identifying individual Service and Cost Improvement schemes
Well-managed, well-informed trusts recognise the need to provide support to budget
holders where required. There is much variation in the methods employed and no one
system fits all. However, there are several consistent factors and these include:

Developing annual savings targets for each CSC or department. The identification of
plans to meet that target then becomes the responsibility of each budget holder;
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Developing schemes that are balanced between trust-wide/large scale improvement
schemes and smaller CSC or departmental schemes;
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Holding specific sessions for producing ideas through brainstorming using
benchmarking data,(Appendix A lists various sources of benchmarking data available
to the NHS), clinical data and service line reporting information that results in viable
ideas that can be followed up in more detail by individual teams; and
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The finance department providing budget holders with the right information to identify
savings and protect or invest in profitable services.
Learning from what has worked and what has not should be a key part of the process.
For example: reviewing CSC-based service and cost improvement schemes that had
been successfully delivered to see whether similar schemes can be implemented in
other CSCs. Similarly, previously rejected schemes should be reviewed to determine
whether factors had changed sufficiently to enable successful implementation.
SLR and benchmarking information helps budget holders to identify savings, improve
services and present evidence to staff to help engage them in the change process. It
highlights variation within services which supports teams to identify the inefficiencies and
areas for improvement.
By planning in good time and making inroads into years three to five of the CIP, delivery
is much more likely. This is necessary where schemes are improvement and require
lengthy consultation or investment.
6.3
Assessing Individual Service and Cost Improvement schemes
The Board has an obligation to maintain or improve quality. Quality and efficiency should go
hand in hand and improved services often cost less.
Early scrutiny makes it easier to remove unrealistic or unsafe schemes before committing time
and resources. The finance department has a clear role to play in supporting staff to identify
and quantify potential savings, their achievability and risks.
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The PMO coordinate the overall outline planning process to build ideas into assessable
schemes including both service developments and cost improvement opportunities using the
template at Appendix B.
6.3.1 Quality Impact Assessment
The potential risks that cost saving or service improvement schemes can have on the
quality of services must be assessed. The Trust uses a standard Quality Impact
Assessment tool and risks are assessed using the standard 5 x 5 matrix. All schemes that
are worked up in outline and have an impact on workforce and/or clinical services will
undergo a quality impact assessment. To do this effectively, the right information is
needed in order to understand the potential risks to quality and plans must be put in place
to ensure action is taken before quality deteriorates
An impact assessment on quality and safety will be completed in the planning stage and
schemes that are considered unrealistic or that pose a risk to quality will not be put
forward.
In challenging financial times it is increasingly likely that all service and cost improvement
schemes will need some form of quality impact assessment. In addition to doing this
assessment at the planning stage, the Trust should also do this during delivery, at key
milestones and post-implementation to ensure sustainability.
The cumulative impact of service and cost improvements should also be assessed.
Individual schemes at a CSC or departmental level might not appear high-risk but the
overall impact might result in risks to delivery. For example, if a CSC closes some beds
the impact at that CSC level might be minimal, but significant for the organisation if other
CSCs are also closing beds. It may also impact on staffing across the organisation, with
staff needing to be moved to other areas.
If there is a negative impact on quality, the Board must be made aware as soon as it
occurs.
Appendix C is Monitor’s guide for foundation trust applicants and highlights good
practice and suggestions for identifying, planning, managing, delivering and assessing
service and cost improvements
6.4
Approving Schemes
The Trust has developed a gateway process to provide rigour to the Service and Cost
Improvement process.
Gateway 1: Schemes that are valued at £25k or more or are consider by the scheme owner
likely to be assessed as a red risk, need to be written up at outline level that includes section 15 i.e. overview and key objective, expected financial benefits and undergo an initial review by
the Risk Team and feedback to the scheme owner. If the scheme impacts patient care and or
workforce then a full QIA will almost certainly be required therefore sections 6-9 will require
completion.
Gateway 2: Is required for all schemes that the Risk Department have determined required a
full QIA. Therefore all 9 sections require completion prior to submission and include a full risk
assessment using the Trust 5x5 matrix, in addition high-level cost /benefit analysis is completed
with key metrics identified together with the reporting and review forum. The assessment is then
forwarded to the Medical Director and Director of Nursing; in accordance with the Operating
Framework 2012/13 the submitted QIA will be reviewed and signed-off by EMT ensuring that
both the quality and operational impact of the scheme has been assessed and any risks
mitigated. At this stage a meeting with the scheme owner may be scheduled to ensure all facts
are understood. In addition any schemes that are unlikely to deliver, or are not consistent with
the Trust’s strategic objectives, or when reviewed across the organisation collectively have a
negative impact on services are recommended for rejection at this stage.
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Gateway 3: Schemes valued at £100k or more should be developed further by the scheme
owner and a Project Initiation Document (PID) produced which should include key deliverables,
milestones and ownership of actions identified, as well as full costing, risk register entry of all
amber and red risks, with measures developed and linked to the Performance Dashboard in
Kitbag. If required business cases should be developed and approved in line with the agreed
Trust Policy 'Service Change and Business Case Policy'. Approval of the plans will be via the
CSC Performance Management Meetings or if a Trust wide project via the relevant Steering
Group
Gateway 4: All schemes valued at £250k or more should be submitted to SMT for endorsement
with the scheme owner presenting the scheme to SMT
Gateway 5: All schemes valued at £500k or more should be submitted to Trust Board for
approval with the CSC Managing Director or Executive Director Sponsor (for Trust wide
schemes) presenting the scheme as required
The last 12 months have allowed the Trust to refine the Gateway process and streamline it. The
key improvement being early meeting with the scheme owner to avoid repeated updating of the
QIA in readiness for approval.
6.5
Delivering the Service and Cost Improvement
A comprehensive delivery plan for all the schemes valued at greater than £100k is necessary
once an organisation has identified the individual CIP saving schemes/service improvements.
This will set out the details of the scheme, the milestones, a risk assessment if appropriate, a
lead officer and how to measure success. This work is led by the CSCs with established PMO
support.
Delivery of approved savings plans is the responsibility of individual managers or clinicians but
they will not succeed without the support of others. To ensure successful delivery the Trust will:

Have strong leaders who are capable of driving sustained change;
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Use the Project Management Office (PMO), to keep delivery on track, provide challenge
when needed and support staff to manage delivery and mitigate risks;

Write detailed plans, in language that increases clinical and front-line support through an
emphasis on service improvement rather than cost saving;
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Focus heavily on reinforcing an organisational culture that promotes the interest of patients
as well as financial and performance targets;

Clearly identify who is responsible for delivering each Service and Cost Improvement
scheme and how they are accountable for quality, workforce, operations and finance; and

Withdraw Service and Cost Improvements that are not having a positive impact on these
areas.
As well as concentrating on delivering the current year Service and Cost Improvements, the
Trust will take action to ensure that there is a continuous approach to the development of
Service and Cost Improvements as part of the annual business planning cycle with year 1 in
detail and the following two years in outline to support delivery in future years.
6.6
Project Documentation
Delivery of Service and Cost Improvement is most likely when there is a good project plan,
especially for larger value, high-risk or complex Service and Cost Improvements. The Trust
project plans follow an agreed standard
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6.7
Project Management
The PMO provides support to staff to develop and implement project plans, track benefits and
meet milestones. The PMO will not, in itself deliver sustainable, safe Service and Cost
Improvements, although it may support appointed project managers that lead trust wide
improvement or Service and Cost Improvement schemes.
One clear benefit of the PMO is the coordination and review of all schemes across the Trust.
This enables the cumulative impact of schemes to be assessed.
6.8
Building Understanding
Effective Service and Cost Improvement delivery requires staff engagement at all levels. It is
important to be honest about the need for savings and the delivery challenge and there must be
clear communication plans: to ensure the message is recognised and well understood
throughout the Trust.
The Chief Executive Team Brief, articles in Link and poster campaigns in non-patient areas can
be used to spread the message. These should typically include details of the large schemes,
updates on achievements so far and how to get involved and share ideas. Staff suggestion
schemes may also be utilised: whilst all the suggestions may not be large in value, or realistic in
scope, a major benefit is the engagement of staff in the debate about why savings are required
and what they can do to help.
6.9
Monitoring and Reporting
The Trust wide Improvement Projects will report to the relevant Steering Group monthly. The
report will summarise progress and work on an exception basis and will be submitted by the
project manager to the PMO monthly, or more frequently as determined by the Steering Group.
The reports are reviewed formally at the Steering Group meetings. Project reports will cover the
following:

Milestones: progress in period, trajectory of upcoming milestones and any re-scheduling
required;
 Benefits delivery during the progress period, against plan; trajectory and variance from plan
and target;
 Issues: matters requiring resolution by and/or input from the Project Sponsor and/or
reporting to the Steering Group; Risks: material changes to risk status; and any matter
deemed necessary by the project sponsor to escalate formally for review and recommended
action by the Steering Group. If unresolved at this level the established Trust escalation
process will be followed through SMT to Trust Board if unresolved.
 Resources: material changes to resources against plan.
CSC based improvement projects will report through the established performance assurance
framework on an exception basis.
Assuring and Evaluating the Service and Cost Improvement
Evaluation frameworks do not have to be complex but should form a natural part of the
monitoring and reporting cycle. The Trust should:

Seek assurance that the arrangements for delivering the service and cost improvement by
using internal audit or a similar independent and objective reviewer;
 Evaluate the programme; and
 Use the findings to make changes and improve future service and cost improvements
6.9.1 Assurance
SMT will receive reports from the Steering Groups, on progress against the
Improvement Programme and from Finance Committee for the CIP programme.
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The Governance and Quality Committee will monitor and approve amendments to the
policy and will receive risk management reports associated with improvement projects
from either CSCs or project leads.
There will be annual agreement with the CCG quality lead on the Trust’s QIA process.
The Trust may also consider the use of Internal Audit to provide independent assurance
on the development and progress of the Improvement Programme
6.9.2 Evaluation
The Trust must evaluate how the projects have been delivered, including an assessment
of the programme management and whether any lessons can be learned from each
stage.
The Trust should ask itself whether the service and cost improvements for the previous
year were delivered; both in terms of planned benefits and whether the schemes worked
as intended. It is important to compare the plan against the actual position achieved.
Note: in relation to cost improvement many Trusts make non-recurrent savings to
balance the books but fail to deliver what they planned.
Evaluation of management processes has several elements including:



How schemes were set up;
The effectiveness of monitoring and reporting to the board;
Risk identification and mitigation; and
 The efficiency and robustness of the accountability and governance arrangements.
Evaluation must inform future improvements. It can identify where an approach might be
replicated in another service or feature as a regular element in future years’ programme.
Findings should be unlikely to come as a surprise if service and cost improvement
monitoring and reporting has been effective.
6.10 Ongoing Measurement of Impact on Quality
A quality impact assessment is undertaken when both delivering and monitoring service and
cost improvements during delivery. Quality is measured in terms of patient experience, patient
safety and clinical quality. Key Performance Indicators (KPIs) and risk ratings are assigned and
agreed by project leads and executive sponsors.
Quality Indicator Pyramid
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The quality indicator pyramid which provides a framework for developing monthly indicators to detect
the impact on quality and operational delivery is used to provide a balance of information that will
inform the project management and steering groups/SMT of schemes that are having a detrimental
impact.
Regular reassessment of the quality impact of the service and cost improvement must be an integral
part of the Trust’s monitoring arrangements, with clear escalation processes for when quality issues
are identified and risk ratings worsen. This includes taking remedial action to manage risks to an
acceptable level, which may involve tighter management or, if necessary, abandoning a scheme.
7 EQUALITY IMPACT ASSESSMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the
way we provide services to the public and the way we treat our staff reflects their individual needs and
does not discriminate against individuals or groups on any grounds.
This guidance has been assessed accordingly.
8 INFORMATION GOVERNANCE
All scheme owners will be asked to consider whether the scheme impacts on information governance
and record on the QIA form
9 REFERENCES
1. Department of Health, The Operating Framework for the NHS in England 2011/12, 2010
2. Department of Health, The Operating Framework for the NHS in England 2012/13, 2011
3. Monitor, Lessons Learnt from Recent NHS Foundation Trust Applications, 2011
4. Audit Commission, NHS Financial Year 2010/11: A Summary of Auditor’s Work, 2011
5. Monitor, Amendments to Applying for NHS Foundation Trust Status – Guide for Applicants, 2010
6. Monitor/Audit Commission, Delivering Sustainable Cost Improvement Programmes, 2012
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Appendix A
Examples of Methods for Reviewing Efficiency to Identify Potential Service and Cost Improvement Schemes
Method
Source
Details
PbRBenchmarker
Service-Line
Reporting (SLR)
FTN Benchmarking
Productive Ward
Series
Audit Commission
Online tool that compares acute hospital acuity data,
clinical coding and Payment by Results related measures
with other organisations
Monitor
SLR gives a clear picture of how each service is working,
a both operational and financial level
Foundation Trust
Network
NHS Institute for
Innovation and
Improvement
NHS Benchmarking
NHS Benchmarking
NHS Better Care,
Better Value
Indicators
NHS Institute for
Innovation and
Improvement
Analyses trusts’ performance in quality (clinical
outcomes and patient experience), cost effectiveness
and operational management
The Productive Series supports NHS teams to redesign
and streamline the way they manage and work
The NHS in-house benchmarking service cover a range
of quality and productivity measures, in clinical and nonclinical areas
Better Care, Better Value indicators identify potential
areas for improvement in efficiency that may include
commissioners re-designing and shifting services away
from the traditional setting of the hospital and out
towards community based care
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Appendix B
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Appendix B continued
CIP Schemes, Service Developments & Improvement Projects
Quality Impact Assessment (QIA)
Guidance for Staff on Completion
1. Purpose of a QIA :
It is recognised that whilst quality must remain at the heart of everything we do the efficiency requirements
within the NHS are at an historical high. There is an argument that quality can be protected and even
enhanced whilst we work to contain cost but this is not a given and we cannot become complacent in
assuming that because nobody wishes to compromise on quality this will not happen. Therefore it is of
paramount importance that we actively put processes in place to ensure that any service changes do not
have an adverse impact on quality of care delivered to our patients.
The Quality Impact Assessment process has been developed to ensure that we have the appropriate steps
in place to safeguard quality whilst delivering significant changes to service delivery. This process should
be used to assess the impact that any individual CIP, service development or improvement project may
have on the quality of care provided to patients at Portsmouth Hospitals NHS Trust.
2. Process
A full Quality Impact Assessment is to be considered when embarking on any CIP Scheme, Improvement
Project, or Service Development/Improvement valued at greater than £25k.
3. Responsibilities:

The Scheme owner (CSC/Corporate Function) or Project Manager is responsible for ensuring that
all schemes/projects are put through this process prior to implementing the scheme/project. This
enables the assessor to determine whether a full QIA is required through the initial screening step.

The scheme owner/project lead is responsible for ensuring that the paperwork and process is
completed fully

This process will be administrated by the Programme Management Office (PMO).

Chiefs of Service are responsible for signing off the QIA document for all CSC schemes/projects. In
doing so the Chief is ratifying that the paperwork has been completed correctly and full
consideration has been given to potential impacts on quality as well as how ongoing monitoring will
be managed within the CSC

The Project Sponsor is responsible for signing off the QIA document for all Trust wide CIP schemes
or Improvement Projects. In doing so the Project Sponsor is ratifying that the paperwork has been
completed correctly and full consideration has been given to potential impacts on quality as well as
how ongoing monitoring will be managed within the scheme/project

EMTwill then sign off the QIA and be the final arbiters for all QIAs
4. Working Through the QIA Form:
Section 1-4: Scheme/Project Details
Guidance for Development of Improvement Programme (inc QIA):
Review date March 2015
Version 2 13/03/2014
Page 15 of 21
The top section of the template must be completed in full by the scheme owner/project manager at the idea
stage and then submitted to the PMO for recording and coordination of the initial screening stage.
Section 5: Quality Impact Assessment Screening
Not all schemes require a full QIA therefore the screening stage has been built in to determine the need for
a full QIA. To help with this decision a threshold has been set which is detailed below. The Head of Patient
Safety will review all project/schemes at this stage to ensure that this threshold has been applied
appropriately. If the answer is ‘yes’ to either of the questions on the form then a full QIA must be completed.
Threshold:

Any scheme that has the potential to impact on service delivery/care either directly or indirectly e.g.
if achieving savings through changes to product then this may well impact on quality of
care/outcomes.

Any scheme which will have an impact on workforce
If the answer is no to either service impact or workforce impact it is likely that a full QIA is not required. This
will be the minority of cases but may include for example the sale of land, change of transport contract
provider, etc.
It is envisaged that most schemes/projects will need to have a full QIA completed.
Section 6: Quality Impact Assessment:
In carrying out a full QIA the author is being asked to carry out a risk assessment. The author must
consider the impact of the scheme on each of the following:

Patient Safety e.g. potential for increased adverse events, readmissions

Clinical Effectiveness e.g. potential for poor clinical outcomes, not taking up the latest
technology/evidence

Patient Experience e.g. potential for complaints, negative feedback, ability to treat patients with
dignity

Non clinical/Operational e.g. any health and safety issues for staff, any impact on operational
performance both directly or elsewhere in the organisation. Negative impact on reputation.
Impacts in relation to the proposed change can be both positive and negative, clearly marking in the
‘pos/neg’ column whether an impact is positive or negative.
For any impacts deemed to be negative in nature list the current controls in place as well as mitigation that
will be used to reduce the risk.
In order to achieve a risk score for each of the listed domains the author is advised to use the risk scoring
system as detailed within the Risk Assessment Policy (available on the intranet) using the consequence X
likelihood matrix:
http://www.porthosp.nhs.uk/Management-policies/Risk%20Assessment%20Policy%20and%20Protocol.doc
Guidance for Development of Improvement Programme (inc QIA):
Review date March 2015
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Residual risk is the remaining risk score that is estimated following implementation of the proposed
measures or controls to reduce the risk.
Escalation of Risk:

Any risk score of 12 or above must be reflected in the CSC/Improvement Programme risk register.

Any risk score of 15 or above i.e. red must be reflected on the Trust Risk Register
Section 7: Performance Metrics:
It is vitally important that there are ongoing measures in place to monitor the potential impact of
schemes/projects on clinical services. The above risk assessment framework provides an indication of risk
level at the beginning but this must not be a one off process and risks should be reviewed throughout the
scheme/project life.
The author must identify performance metrics which are sensitive to the impact risks and therefore can be
used to monitor any ongoing impact. Performance metrics which are currently in use can be identified for
example readmission rates, specific adverse event rates etc.
Section 8: Project Structure and Arrangements
The reporting and review arrangements must be identified so that it is clear how the risks and performance
metrics are going to be monitored and where necessary escalated, and which group(s) has responsibility
for this action.
5. Useful Sources of Guidance:

Risk Management Team

Programme Management Office

In order to ensure that this guide is as useful as possible we would welcome any
comments/suggestions for the future which can be emailed to lorna.wilkinson@porthosp.nhs.uk or
deborah.burrows@porthosp.nhs.uk
6. References

Monitor (2012) Delivering Sustainable Cost Improvement Plans

National Quality Board (2012) How To: Quality Impact Assess Provider Cost Improvement Plans
Guidance for Development of Improvement Programme (inc QIA):
Review date March 2015
Version 2 13/03/2014
Page 17 of 21
Appendix C
Illustrative action plan for applicants
2. Assess potential impact on
quality and cost
1. Identify potential
CIPS
 The majority of CIPs should be
based on changes to current
processes, rather than ‘topslicing’ current budgets
 Where possible, Service and
Cost Improvements should be
expected to have a neutral or
positive impact on quality as
well as reducing costs
3. Approve plans
 Service and Cost Improvements should
be categorized by potential impact on
quality
 Service and Cost Improvements with
significant potential impact on quality
should be subject to an assessment of
their impact on quality covering
safety, clinical outcomes and patient
experience, which could include
- Analysis of current processes
 At a minimum, CIPs should not
put registration at risk by
bringing
quality
below
essential common standards
- KPI benchmarking
- Historical evidence
 All Service and Cost Improvements
should be subject to a detailed
assessment of their financial impact in
line with current practice
 Clinicians understand and
accept Service and Cost
Improvements and approved
plans
have
appropriate
clinical
ownership
(e.g.
relevant clinical director)
 Board assurance is required
that Service and Cost
Improvements have been
assessed
for
quality
(potentially
via
direct
approval
for
highest
potential impact Service and
Cost Improvements)
 There
must
be
an
appropriate mechanism in
place for capturing front-line
staff concerns
4. Assess actual
impact on quality
 All
CIPs/
Service
Developments should be
subject to an ongoing
assessment of their impact
on quality, post-roll-out.
- Identify key measures
of quality covering
safety,
clinical
outcomes and patient
experience
- Monitor each measure
before
and
after
implementation
- Take
action
as
necessary to mitigate
any negative impact on
quality
Additional guidance on recommended analytical approaches
Approach
Current
processes
Description
Comments
 Review of current processes to identify where
waste exists and how it can be eliminated to
reduce costs without compromising quality

Could include Lean analysis, time and motion studies

Generally considered to be the most insightful piece of
analysis

Nurse/bed ratio, average length of stay1, bed
occupancy, bed density and doctors/bed are examples
of operational efficiency metrics which can be markers
of quality

Useful as a prompt for discussion (e.g. ‘Is it really
feasible to reduce nurse headcount when our
nurses/bed ratio is already in the bottom decile relative
to our peers’)

However, limitations of this approach must be
recognized: no direct link between operational inputs
and quality outputs; hard to set peer group; generally
poor quality data
 Reducing variation is also very powerful
 Benchmark analysis of relevant operational
‘inputs’ to quality relative to peers and
guidance (e.g. Royal Colleges)
KPI
benchmarking
Title of Policy : Issue Number Issue Date
(Review date: (unless requirements change)
Page 18 of 21

Historical
evidence
1 Relevant
Analysis linking operational changes (e.g.
nurses/bed reductions) to quality outputs

Currently, benchmarking data is generally more
available and useful for acute trusts

Analysis could be based on internal evidence (e.g.
historical trends or on different wards) or external
evidence (e.g. published reports on experience in other
trusts/countries)

However, important to recognize limitations of links
between operational inputs and quality outputs
as an indicator of quality when paired with readmission rates
Title of Policy : Issue Number Issue Date
(Review date: (unless requirements change)
Appendix D
Title of Policy : Issue Number Issue Date
(Review date: (unless requirements change)
Title of Policy : Issue Number Issue Date
requirements change)
(Review date: (unless