CLINICAL GOVERNANCE SUPPORT UNIT
QUALITY IMPROVEMENT PROJECT PLANNING TEMPLATE
This form to be completed jointly by the project lead and CGSU lead supporting the project
SECTION 1: PROJECT LEAD/SPONSOR
1. Name of project lead
2. Project lead base Partnership
GGC North East

GC North West

GC South

Inverclyde





Renfrewshire
East Renfrewshire
West Dunbartonshire
East Dunbartonshire
3. Professional group of project lead
Administration staff

Nursing
Dentist

Occupational Therapist
Dietitian

Optometrist
District Nurse

Pharmacy
Health Improvement

Physiotherapy
Health Visitor

Podiatrist
Medical

Prescribing Support







Psychiatry
Psychology
School Nurse
Specialist Nurse
Speech & Language Therapy
Other (please specify)






Other: ..............................................
4. Work email address
5. Work telephone number
6. Work address
7. Project sponsor
Who commissioned the project and what are their requirements?
Name/Group/Committee
Designation (if applicable) Requirements
SECTION 2: WHAT ARE WE TRYING TO ACCOMPLISH
8. Project background
Briefly describe the problem or issue and the background (including any inequalities issues for consideration)
9. Reason for carrying out project (please tick all that apply)

To confirm that the service is meeting standards

New evidence or best practice guidance has recently been published

Problem identified through risk assessment or risk of litigation

Problem identified through complaints

Problem identified through clinical incidents/ litigation

There are a number of cost implications in this area/ with this service

There is wide variation in practice

Perceived to be a problem
Other (please specify)
.....................................................................................................................................
CGSU QIP Planning Template
Page 1 of 5
10. What evidence is the project based on (please tick all that apply and specify)
Nationally agreed
 ....................................................................................................................................
Royal College
 ....................................................................................................................................
Professional body
 ....................................................................................................................................
Policy
 ....................................................................................................................................
Locally agreed
 ....................................................................................................................................
Other
 ....................................................................................................................................
None
 ....................................................................................................................................
11. Driver for project (please tick all that apply)


National
Other
Organisational

Local

Other, specify .............................................................................
12. Improvement aims
Identify the aims, desired outcomes, targets and timescales (eg what, how much by when)
Is there current baseline data?
Yes

No
If yes, what are the actual baseline measurements?
Aim number
Aim
Target compliance
or level of improvement

By when
(date)
1
2
3
4
5
13. Project focused on which dimension(s) of quality (please tick all that apply)
Person centred

Efficient

Safe
Equitable

Effective

Timely


14. Project title
Verb (Intention for doing project + feature(s) of quality to be measured by the project + subject (specific care or
service that the project is about i.e. the clinical subject of the project)
15. Key words (Specify key words that categorise the project (you can select more than one in each category)
Subject under study based on
body systems/BNF
Classifications
*if the improvement project cannot
be categorised by body systems
/BNF classifications, leave blank*
Aspect of healthcare under study
Group under study
16. Staff groups involved in or affected by the project (please tick all that apply)
All
Medical
Prescribing Support


Administration staff
Nursing
Psychiatry


Dentist
Occupational
Therapist
Psychology


Dietitian
Optometrist
School Nurse


District Nurse
Pharmacy
Specialist Nurse


Health Improvement
Physiotherapy
Speech and Language


Therapy
Health Visitor
Podiatrist
Other (please specify)









Other ....................................................................................................................................................
CGSU QIP Planning Template Updated by CGSU (Partnerships) June 2015
Page 2 of 5
17. Scope of project (please tick all that apply)
All CHCPs
GC North East
GC North West



GC South
Inverclyde
Renfrewshire



East Renfrewshire
West Dunbartonshire
East Dunbartonshire



Services
Addictions
Care Homes
Child Protection Service
Children & Families Service
Community Adult Nursing
Community Pharmacy
Dietetics
Forensics
General Dental Practitioners
General Practitioners
GP Out Of Hours
Health Improvement












Homeless Services
Learning Disabilities
Mental Health
Mental Health Inpatient
Services
Occupational Therapy












Prescribing Support
Prison Service
Psychiatry
Public Dental Service
Rehab & Enablement Service
Sandyford Initiative
Specialist Childrens Services
Speech & Language Therapy
Other, please specify









Older Peoples Mental Health
Optometry
Oral Health
Other
Palliative Care Services
Physiotherapy
Podiatry
Other ...............................................
Other ...............................................
Other ...............................................
18. Project improvement team
Name
Job Title
Speciality
Contact Details
(email/phone no)
19. Indicator/measure selection Connect indicators/measures to the improvement aims of the project (Q 12)
Operational definitions for each indicator /measure
Aim
Type (process,
Indicator/measure number
 Describe numerators and denominators
outcome, balancing)
from Q 12
 Specify inclusions and exclusions
A
B
C
D
E
20. Data collection plan Connect data collection plan to each of the indicator/measures detailed in Q19
Plan
A
B
C
D
E
Person responsible
for data collection
Data collection
frequency (how
often)
Data collection
duration
Data source(s)
Does the data
collection plan
require sampling?
If yes, please
describe the
sampling plan
Yes  No 
Yes  No 
Yes  No 
CGSU QIP Planning Template Updated by CGSU (Partnerships) June 2015
Yes  No 
Yes  No 
Page 3 of 5
21. Indicator/Measure Analysis and Interpretation / Describe the analysis plan
What descriptive statistics will be used?
Mean

Median

Mode
Percentages

Minimum 
Maximum
Range

Tabular analysis 
Other (list)

What graphs/charts will be used to display data?
For measures (A-E in
Type of chart/graph
section 19 of form)
Bar Chart

Pie Chart

Run Chart

Shewart Charts (control)
Pareto Diagram

Histogram

Line graph

Other (list)

Describe the data reporting plan
 Who will receive the results?
 How often will they receive the results?


Results to project lead as they are available.
22. Project Timeline
Is this project time limited or ongoing?
For all projects, please indicate the planned start date
For time limited projects, please indicate the planned end date
Time limited 
Planned start date
Planned end date
Ongoing 
23. Key milestones/deliverables (start from the final milestone/deliverable and work backwards)
Planned Start
Planned end
Key milestones/deliverables
Responsible
date
date
SECTION 3: WHAT CHANGES CAN YOU MAKE THAT WILL LEAD TO AN IMPROVEMENT
24. Can you predict the findings, and what changes/ interventions may be required for improvement?
Please specify which aim each change proposed will be linked to.
25. Constraints Consider any project constraints, financial limitations, and what is not to be addressed (e.g.
time, money, resources, capacity, access to records etc)
CGSU QIP Planning Template Updated by CGSU (Partnerships) June 2015
Page 4 of 5
SECTION 4: SUPPORT REQUIRED FROM THE CLINICAL GOVERNANCE SUPPORT UNIT
26. Support required (please tick all that apply)
Development of improvements (e.g. patient leaflets, care

Advice on project design
pathway, guideline development, checklists )
 Facilitation of a project group
Advice on measurement plan
 Member of a project group
Advice on sampling
 Implementation of improvements e.g. patient leaflets, care
Design of data collection tools
 pathway, guideline development, checklists )
Data entry
Data analysis
Report writing
Presentation of data








Educational support regarding improvement methods

Other (please specify)
..............................................................................................................
27. Any other relevant information
SECTION 5: PROJECT SIGN OFF
28. Sign off
Name
Date plan reviewed
and agreed
Signed
Project Lead
...........................................................................
Senior Clinician/Manager/Approving Group
.............................................................
...........................................................................
Clinical Effectiveness Co-ordinator
.............................................................
...........................................................................
.............................................................
SECTION 6: RETURN DETAILS
29. Quality Improvement Planning Template to be returned to:
Susan Harvey, Clinical Effectiveness Co-ordinator, Clinical Governance Support Unit, Ward 15, Dykebar
Hospital, Paisley, PA2 7DE (Tel: 0141 314 0347)
susan.harvey@ggc.scot.nhs.uk
SECTION 7: PROJECT DIRECTORY ASSIGNED UNIQUE IDENTIFIER NUMBER
30. Project Directory assigned unique project identifier number:
CGSU QIP Planning Template Updated by CGSU (Partnerships) June 2015
Page 5 of 5