How To Run A Hospital In All Wales

Transcription

1 Project Project 1. Background A Strategic Outline Business Case was submitted to Welsh Government by BCU Health Board in April 2013 to secure capital funds for the development and provision of services to be provided in the coastal locality of including Rhyl, Prestatyn, Rhuddlan, Dyserth and surrounding villages. Approval of this Strategic Outline Case was given in December 2013 allowing the Health Board to proceed to Outline Business Case. Submission of Outline Business Case to Welsh Government is scheduled for January The Project (referred to as the Project) is a Welsh Government capital funded project. It should be noted that the project does not include additional revenue to support any service change or developments. This paper sets out the project s governance infrastructure and also compliments the Project Evaluation Plan produced in July 2014 (Version 2.7). 2. Project Objectives Note: the Investment Objectives below were approved at the Strategic Outline Case stage and will be reviewed as part of the development of the Outline Business Case. The Project has had a number of overarching objectives which include: Deliver best use of multi-agency resources, in line with the BCUHB 5 year plan, through: - Provision of a modern Community Hospital by 2015 / Delivery of more effective community hospital bed provision for the population through repatriation of patients and freeing up of resource in district hospitals

2 - Enabling infrastructure to be more efficiently utilised through colocation of teams Facilitate effective patient flow and enhance patient experience through improved co-ordination of care, continuity of care, straightforward and consistent referral and communication systems and access to services, achieving key recommendations from: - Together for Health: A Five Year Vision for the NHS in Wales, 2012, (Welsh Government) - Setting the Direction: Primary and Community Services Strategic Delivery Programme 2010, (Welsh Government) - The Management of Chronic Conditions by NHS Wales, (2008), Wales Audit Office Provide a holistic model of care closer to home and reducing unnecessary hand-offs in the patient pathway through optimisation of services based in the hospital and in the community by providing care pathways that encompass self-management (well-being services, information, education and advice) through to in-patient bed based care and that is responsive to the demographic and health profile of the locality, achieving compliance with the following key strategic recommendations: - BCUHB 5 year plan, Together for Health: A Five Year Vision for the NHS in Wales, 2012, (Welsh Government) - Setting the Direction: Primary and Community Services Strategic Delivery Programme 2010, (Welsh Government) - Designed to Add Value: A Third Dimension for One Wales: A strategic direction for the third sector in supporting Health and Social Care, 2008, (Welsh Government) - The Management of Chronic Conditions by NHS Wales, (2008), Wales Audit Office - Beyond Boundaries: Citizen Centred Local Services for Wales, 2005, (Welsh Assembly Government) Provide a range of integrated, co-located health, social care and third sector services that work flexibly across functions in line with the BCUHB 2

3 Operational Plan and recommendations from key all Wales strategies, specifically: - The development of integrated service delivery bases and co-location of staff to develop community campuses of care - The integrated delivery of services across health, social care, other local authority functions and the voluntary sector - Flexible working across professions and organisations to ensure that skills are utilised to maximum effect and that services meet the need of the citizen - Systems and processes that guide people through services where individual elements of care are joined up and easily navigated - Building capacity and capability within the community will require the development of joint Health and Social Care Teams such that truly integrated services can be delivered to the citizen - Strengthen multi-disciplinary and joint working through the core community team across the many agencies involved in providing care, including local authorities and the voluntary and independent sector Provide a Community Hospital that reduces the need for patients and their families to travel to other locality areas for in-patient bed based care as specified in Together for Health (2012) and Design for Life (2005). Specifically: - Everyone should have easier access to a wide range of safe, effective, well-run integrated services, sustainable over the longer term - The highest standards of care are available locally and promptly where needed - More services provided in or closer to people s homes 3. Review of Governance Structure The project governance document outlines the formal project structure, established to oversee and ensure delivery of the project s stated aims and objectives. The Project Evaluation Plan (Version 2.7, dated July 2014) includes an outline of the roles and responsibilities of key individual personnel and organisations who are together responsible for delivering the project. 3

4 The project governance structure has been reviewed following Strategic Outline Case approval to ensure that it is fit for purpose for the lifespan of the project programme. Terms of Reference are included for all identified project groups within this paper. 4. Project Governance Structure The project structure underpins the governance framework to deliver the stated aims and objectives of the project. Within this, there are four main areas of assurance: - Service continuity: in terms of the quality, safety and volume of services provided - The operational functioning of the building during the project - The delivery of the project to time, cost and quality - The delivery of benefits realisation in the context of continued service change during the lifetime of the project A diagrammatic description of the project structure is given in Appendix One, and in brief comprises: The Project Board which is responsible for ensuring delivery of the project to time, cost and quality. The project board is responsible for ensuring that the benefits outlined in the approved business case are realised and that the project is delivered in such a way as to maintain service continuity on the Royal Alexandra Hospital site throughout the lifetime of the project. The Project Team acts as the key co-ordinating working group for the delivery of the project. It is the principle interface group between BCUHB (the client) and the contractors. The Core Team is a meeting of key senior officers in BCUHB to ensure that all actions required by BCUHB are taken in a timely and co-ordinated manner. The Contract Progress Group has, at its main function, to monitor and ensure delivery of the contract in accordance with the agreed programme and the within the agreed budget. The Asbestos Removal Progress Group is responsible for ensuring the safe removal of asbestos from the RAH site. The Operational Maintenance and Safe Functions Group is responsible for ensuring close liaison between BCUHB operational estates and the 4

5 project to ensure the continuity and safe functioning of services at RAH during the lifetime of the project. The Communications Group is responsible for developing and implementing the Communication Strategy for the project, ensuring, through a variety of means, that public, patients, visitors, staff and key stakeholders are informed of changes / service improvements on the RAH site during all phases of the project s work. The Benefits Realisation Group is responsible for agreeing and monitoring the benefits realised through the project, in addition to providing the foundation for the post-project evaluation. A wide range of User Groups are to be established during the lifetime of the project, to decant / decommission areas on the RAH site (prior to asbestos removal); to agree floor plans / designs when areas are re-instated; and, to commission, as appropriate, new areas created. In addition to the above project groups, there are other important relationships which support delivery of the Project: The Central Hospital Management Team (HMT) receive a regular verbal and / or written brief on the project. Health and Safety is an integral part of the Project and as such, a number of key project groups described in this have BCU Health and Safety representation as part of their core membership: Project Board; Project Team; Asbestos Removal Group; Operational Maintenance and Safe Functions Group; and the Decant Operational User Group. In addition, all user and commissioning groups must ensure that their plans are reviewed and approved by BCU Health and Safety Officers. All relevant Project Groups will have a specific item on their agendas for Health and Safety (this includes the Project Board and Project Team). The Project Director s update for Project Board will include an update from a senior BCU Health and Safety Officer. The role of Corporate Health and Safety is to give advice and attend specific project groups as outlined in this. In order to 5

6 maintain as far as is reasonably practicable a safe environment whilst the Project progresses, it is essential that Project activities and operational activities are monitored by the project managers to ensure continuation of services and also that services are carried out in a safe manner. To assist this process, Corporate Health and Safety will allocate a Health and Safety Adviser to undertake a monthly walk through inspection of the RAH Hospital site to provide an independent overview as to how the Project may be impacting on the hospital s operational activities; the effectiveness of control measures; and, identifying any potentially unsafe conditions observed at the time of the walk through inspection. Specifically, the role of the Health and Safety Adviser is to: Carry out a monthly walk through inspection of the RAH Hospital site Liaise closely with BCU Planning personnel, Contractors and operational staff on matters relating to site development, including any incidents or near misses that have occurred; Report any identified deficiencies in the application of control measures to ensure the safe operation of redevelopment activities; Provide a report to the Project Team/Director on any significant issues identified during the monthly walk through. Advise BCU officers of any aspect of health and safety which may arise prior to or during redevelopment activities; Attend specific Project Groups, including the Decant Operational User Group, to ensure good communications across all parties. In addition, the Health and Safety Manager will: Attend specific Project Groups as identified in this Governance Framework; Advise BCU operational and planning managers of any aspect of health and safety which may arise prior to or during redevelopment activities; Ensure the Head of Health and Safety is fully briefed on any significant issues as they arise; Co-ordinate/manage the work of the Health and Safety Adviser. 6

7 5. Terms of Reference and Membership of Project Groups The Terms of Reference and memberships for each of the groups which together form the project structure are presented here. The memberships of the project groups may alter and / or expand during the lifespan of the project, and the Terms of Reference of all project groups will be reviewed 6 monthly (or more regularly if necessary). 5.1 Community Healthcare Service Project Board The project board is responsible for ensuring delivery of the project on time in line with approved project programme and within the overall agreed capital allocation. The project board is also responsible for ensuring that the benefits outlined in the approved business case are realised. The project board will ensure that the project is delivered in such a way as to maintain service continuity on the RAH site throughout the lifetime of the project. The project board is accountable to the Senior Responsible Officer. The project board: Approves the Terms of Reference and membership / of all project groups, and any revisions thereof Approves all formal project documentation, such as any further revisions of the Project Evaluation Plan Approves the overall project plan and timelines, and within this, receives and approves a project plan and timeline for each phase of the project, ensuring delivery of agreed programme of works Receives and approves regular financial reports for each stage of the project and through these, ensures that the total cost of delivering the project remains within the overall approved level of expenditure Receives and approves regular updates from the project team, including regular updates on the progress of all project groups which report to the project team Receives regular reports from corporate BCU Health and Safety Forum to provide assurance that the works undertaken by the project do not compromise the health and safety of patients, staff and visitors on the RAH site 7

8 Receives and reviews the risk register for the project, ensuring that mitigating actions are in place where necessary to ensure the safe delivery of the project and the maintenance of service continuity on the RAH site Identifies any matters outside the control of the project that could compromise delivery of the project on time and in line with approved expenditure, escalating these matters to the Senior Responsible Officer via the Asset Management and Finance committee. Provides a regular written report on progress in delivering the project to the Senior Responsible Officer and Board of BCUHB via the Asset Management and Finance Committee The membership of the Project Board is as follows: Executive Lead Project Director Project Clinical Lead Assistant Medical Director Senior Finance Officer Senior Representative: Nursing Senior Representative: Primary Community Specialist Medicine Head of Operational Estates Site Operational Manager (YGC) Gleeds Project Manager Gleeds Cost Advisor Interserve Project Lead Community Health Council representative (observer with speaking rights) Independent Patient representative Staff Side representative Unison representative Senior BCU Health and Safety Officer Business Case Manager: Planning Project Manager BCUHB GP representative Workforce & OD representative Third Sector representative Local Authority representative 8

9 Changes to the membership of the project board may be agreed following discussion with the Chair, and / or subject to approval by the Chair, specific members may be co-opted for a specific period of time. The Chair of the project board will nominate a Vice Chair in his / her absence. Meetings will be deemed quorate when at least a third of the membership of the project board is present, including the Chair or Vice Chair. The project board will meet on a bi-monthly basis, although there may be occasions at critical stages of the project for the project board to meet monthly. All meetings of the project board will be minuted, with minutes issued within 5 working days of each project board meeting. Agendas and papers for project board meetings will be issued no later than 5 working days prior to each project board meeting. Administration for the project board shall be provided by the Business Case Manager: Planning. 5.2 Project Team The project team is the key co-ordinating working group for delivery of the project. It is the principle interface between BCUHB (the client) and the contractors. All User and other project groups report to the project team. The project team reports to the project board. The project team: Ensures that a detailed project plan for completion of the project is prepared for project board consideration and approval Ensures that individual detailed project plans and timelines are prepared for each specific phase of the project for submission to the project board for consideration and approval Ensures that the total project plan and the subsequent detailed project plans for each specific stage of the project are fully costed for submission to project board for consideration and approval Oversees and ensures that each stage of the project is delivered in line with approved timelines and expenditure 9

10 Ensures that agreed project plans maintain continuity of service on the RAH site Supports the development of detailed design plans Receives regular reports from all project groups which report to the project team, ensuring that the work of the project groups are co-ordinated and their work delivered in line with the agreed project plan(s) / timeline(s) Receives a regular report from Gleeds Project Manager, detailing design and construction status; a review of progress to date; description of any risks; and, provision of a detailed cost report Maintains a project risk register, identifies project associated risks and ensures that plans are in place to mitigate any risks with minimal disruption to the overall project programme and / or service continuity on the RAH site managed and controlled by Gleeds PM Escalates any issues which may compromise the ability to deliver the overall project or any individual stage of the project to the project board, including issues which may compromise delivery of the project on time and within approved expenditure limits The membership of the project team is as follows: Project Director (Chair) Project Clinical Lead BCU Project Manager Business Case Manager Planning Gleeds Project Manager Gleeds Cost Advisor Interserve Project Lead Estates Operational Manager Senior representative: Finance Senior representative: Health and Safety Senior representative: Infection Prevention and Control Senior representative: Primary Community and Specialist Medicine CPG Senior representative: Facilities Senior representative: Mental Health CPG Senior representative: Community Dental Senior representative: Therapies CPG Senior representative: Informatics 10

11 Locality Matron Deputy Area Operational Manager IT Engineer Membership of the project team may be further extended and / or other members coopted as and when necessary at the discretion of the Chair. The BCU Project Manager will also meet monthly with Infection Prevention and Control colleagues. The need for these separate meetings to continue will be reviewed throughout the lifespan of the project. The Chair of the project team will nominate a Vice Chair in his / her absence. Meetings will be deemed quorate when at least a third of the membership of the project team is present, including the Chair or Vice Chair. The project team will meet monthly. All meetings of the project team will be minuted, with minutes issued within 5 working days of each project team meeting. Agendas and papers for project team meetings will be issued no later than 5 working days prior to each project team meeting. Administration for the project team shall be provided by the Business Case Manager: Planning 5.3 Community Healthcare Service Core Team The Core Team is a meeting of key BCU senior officers to ensure that all actions required by BCUHB as the client are completed in a timely and co-ordinated manner. The core team meeting provides the forum for key BCU personnel to highlight issues of concern for resolution which do not require decisions by the project team. The core team will highlight items for the project team which cannot be resolved by BCUHB as the client and / or which pose a risk to delivery of either the project or to the continuity of services on the RAH site. The Core Team meets weekly and supports the work of the project team. The membership of the core team is: Project Director (Chair) Project Clinical Lead BCU Project Manager 11

12 Business Case Manager Planning Other members may be co-opted onto the core team as and when required at the discretion of the Chair. Action notes of the weekly meeting will be maintained and circulated after each meeting. 5.4 Contract Progress Group The Contract Progress Group has, as its main function, to monitor and ensure delivery of the contract to time, cost and quality; and, to monitor contracts for the reinstatement of areas in line with floor plans and service / area designs as agreed by the relevant User Group. All contracts must be delivered on time in line with the agreed specification, agreed project timelines and approved expenditure. A regular report is produced by the contract progress group for the project team, providing details of progress made and escalating any issues of concern for resolution by the project team. The contract progress group will meet on a monthly basis and reports to the project team. The group is chaired and administered by the Gleeds PM. All meetings are minuted. The membership of the Contract Progress Group is: Gleeds Project Manager (Chair) Gleeds Cost Advisor Interserve BCU Project Manager Business Case Manager Planning 5.5 Asbestos Removal Progress Group The Asbestos Removal Progress Group is responsible for ensuring the safe removal of asbestos from the RAH site. This group will meet on a fortnightly basis. The asbestos removal progress group reports to the contract progress group. The group is chaired and administered by the Gleeds PM and all meetings are minuted. The membership of the asbestos removal progress group is: Gleeds Project Manager (Chair) LARC: Asbestos Removal Interserve Representative 12

13 Environmental Essentials Ltd CDM Co-ordinator BCU Project Manager BCUHB Health and Safety Officer 5.6 Operational Maintenance and Safe Functions Group This group acts as a core liaison group between BCU Operational Estates and BCU Project Manager to ensure continuity and safety of core functional services on the RAH site during the lifetime of the project. The operational maintenance and safe functions group reports to the project team and is chaired by the Head of Operational Estates. Its core functions are to: Receive a regular report on the asbestos removal programme Receive a regular report on infrastructural work taking place on the site through the project Identify the impact of the project on the safe operation of the site and agree joint actions where required to ensure continuity of service and minimisation of risk. This will include but is not be limited to: security (buildings and personnel); car parking, access routes; electrical and mechanical infrastructure; fire alarm system; environmental cleanliness; and, infection control Ensure that the work of the project is co-ordinated with other routine or planned operational estates works for the site, including routine maintenance or small capital schemes to address live operational estates issues pertaining to the RAH site Escalate any matters of concern which cannot be resolved by the group to the project team for resolution Provide a regular written report to the project team. The membership of the Operational Maintenance and Safe Functions Group is: Head of Operational Estates (Chair) TBC Estates Operational Manager TBC Chief Engineer, BCUHB, TBC Senior Operational Estates Officer TBC Site Security Officer TBC Infection Prevention and Control Officer 13

14 Health and Safety Officer Fire Officer BCU Project Manager Interserve representative Gleeds Project Manager CDM Co-ordinator All meetings of the operational maintenance and safe functioning group are minuted, with agendas and papers issued no later than 3 working days prior to each meeting. Administration for the operational maintenance and safe functioning group is provided by through the office of the Head of Operational Estates. 5.7 Communications Group The Communications Group is responsible for developing and implementing the Communication Strategy for the project, ensuring, through a variety of means, that the public, patients, visitors, staff and key stakeholders are informed of changes and service improvements on the RAH site during all phases of the project s work. The communications group reports to the project team and is Chaired and administered by a nominated BCU Communications Manager. Agendas and minutes are produced for each meeting, the timescale for issuing these prior and after each meeting being determined by the frequency of the meetings. The communications groups will meet fortnightly but increase to weekly in the run up to key project milestones. The core membership of the communications group includes: BCU Communications Manager (Chair) Project Clinical Lead Site Operational Manager, BCUHB Interserve representative BCU Voluntary Sector Relationships Manager TBC Independent Patient representative TBC Deputy Area Operational Manager At each successive stage of the project, representatives of CPGs and Departments will also join the communications group. The communications group will: 14

15 Develop and implement a robust communications strategy for the project, ensuring this is reviewed and updated on a regular basis throughout the lifetime of the project Develop robust communication action plans to ensure delivery of the communications strategy Ensure that a communications plan is developed at each key project milestone, working with the user and other project groups to ensure consistency of communications Develop and enhance working relationships with the local media to support the promotion of the project to the local population and key stakeholders Identify key dates and times for the release of project information to patients, visitors, staff and key stakeholders Develop a range of communications media to disseminate key project messages to all audiences in a user friendly and bi-lingual format Develop and maintain a project Webpage on both the BCUHB intranet and the internet Consider and make use of developments in information technology, including the advent of Wifi, Facebook and Twitter and other digital media to promote communications about the project Responds to all external media and other enquiries relating to the project Arrange and manage engagement events for patients, the public, visitors, staff and key stakeholders Arrange and manage open days / sessions to support the commissioning of new areas / services created through the project Evaluate the impact of all communications at key stages in the project, using feedback to inform and improve communications on an on-going basis Monitor expenditure on project communications, ensuring the most cost effective communication channels are being deployed Escalate any significant communications concerns are escalated to the project team for consideration Produce a regular written report for the project team 5.8 Benefits Realisation Group The Benefits Realisation Group is responsible for identifying specific benefits for each phase of the project and will monitor performance against the project s benefits 15

16 plan. It will update the plan as the project develops to take account of changing circumstances. The group will also co-ordinate the post project service evaluations for each relevant phase of the project, as outlined in the NHS Capital Programme guidance. Core membership of the Group is: Project Director (chair) Project Clinical Lead Finance Project Lead Patient Representative The Benefits Realisation Group will: Ensure the identification of specific benefits for the project Ensure success criteria are identified Ensure that performance indicators / measures are agreed Agree the team that will be responsible for undertaking the evaluation and their respective roles Ensure that the delivery of these benefits is monitored Develop a dissemination plan for ensuring the results from the evaluation are used to re-appraise the project and that lessons are learned for future phases Agree the timing of the post evaluation (expected start and finish dates) Consider any potential changes to the benefits plan as the project develops and escalate this to the Project Board as appropriate The Group will meet a minimum of bi-monthly and will report to the Project Team User Groups Three types of User Groups will be formed during the lifetime of the project. Each user group exists for a given period of time until its specific remit and focus has been completed. Irrespective of the type of user group established, all user groups report to the project team Decant Operational User Groups 16

17 Decant Operational User Groups ensure the safety of patients, visitors and staff when planning and implementing a decant programme to release areas ready for redevelopment prior to being re-designed and re-occupied. Decant Operational User Groups (DOUGs) will oversee, plan and secure the safe decant of each identified area to ensure areas can be asbestos stripped (where required) and redesigned in line with agreed project timelines The DOUGs will meet as frequently as required, and on occasions weekly. The Decant Groups will be chaired by a senior member of the Hospital Management Team and the administration for these meetings provided by DOUG Chair. The membership of each Decant Group includes a cross section of clinical and non-clinical representatives from the service / departmental areas which need to be relocated. Those attending the Decant Group meetings must be able to speak with full authority for their service / departmental areas and must therefore actively engage with all relevant staff in their area(s) prior to and between meetings. Each Decant Operational User Group will comprise: - Senior Officer from the Hospital Management Team (Chair) TBC - Cross section of clinical and non-clinical staff working within the areas affected, including the Departmental Manager(s) - Cross section of clinical and non-clinical staff who provide support services for the areas affected - BCUHB Project Manager - The Clinical Lead / for the Project or the Site Operational Manager TBC - Estates Operational Manager TBC - Infection Prevention and Control - Health and Safety Officer - Fire Officer - Communications Manager Each Decant Operational User Group will: 17

18 - Agree a plan with milestones and dates to ensure that their respective areas are safely vacated in line with the overall project plan decant / decommissioning, including the decommissioning of the respective areas required prior to asbestos removal - Identify alternative areas for the temporary or permanent relocation of services / departments - Ensure an impact assessment is carried out as part of the decant planning process to minimise operational disruption and to ensure safety of patients, visitors and staff during the decant process and subsequent period when services / departments will be working in an alternative location - Maintain a risk register and ensure that the risks are regularly reviewed and any mitigating actions agreed - Ensure the full involvement and engagement of all clinical and nonclinical staff working in or providing support services to the service / departmental areas affected - Ensure that plans for the decant and the temporary / permanent relocation of services / departments are co-ordinated across CPG, clinical service and departmental areas - Develop and implement a Communications Action Plan to support the decant process which is informed by the overall Project Communication Strategy, and which includes the provision of key messages to patients, visitors, staff and key stakeholders and the provision of temporary signage and way finding as appropriate - Escalate any issues which cannot be addressed by the Decant User Group to the Project Team - Provide a regular written update on progress to the Project Team Agendas and papers for each meeting of a Decant Group will be issued and minutes taken. Papers will be issued prior and following each meeting as soon as practical taking account of their specific frequency Design User Groups As with the Decant User Group(s), Design User Groups are multi-professional groups with clinical and non-clinical representation to redesign services / 18

19 departments. During the lifetime of the project, there will be a large number of design user groups established. These are temporary groups, established for a limited period of time to deliver signed off new designs for each specific service area. Each design user group is chaired by the Gleeds PM and its membership will reflect a cross section of staff working in or providing support services to the area to be redesigned and reoccupied. Each design user group will meet as frequently as required, and in some cases, will meet weekly. The membership of each design user group will reflect the specific areas / services affected and include a cross section of clinical and nonclinical representatives from these areas. Those attending the design user group must be able to speak with full authority for their service / departmental areas and must therefore actively engage with all relevant staff in their areas prior to and between meetings. The membership of each design user group comprises - Gleeds PM (Chair) - Cross section of clinical and non-clinical staff in the areas affected, including the Departmental Manager - Cross section of clinical and non-clinical staff who provide support services for the areas affected - BCUHB Project Manager - The Clinical Lead for the project or the Nurse Lead for the Project or the Site Operational Manager - Supply Chain Partners (including architects, planners and contractors) Each design user group must also ensure that plans / layouts being developed are reviewed and approved by Infection Prevention and Control; Health and Safety; Fire Officer; and Operational Estates. Each design user group will: 19

20 - Discuss, evaluate and describe how patients / relatives and staff will make use of the respective area / ward / department, incorporating affordable service changes and improvements - Ensure that any redesign of an area is affordable both in terms of the project capital cost as well as in terms of revenue neutrality, unless an alternative source of revenue funding can be identified and secured by the service to support desired changes - Consider how best to ensure that the design is informed by the users of the service (patients and / or their carers). This may involve the creation of specific focus groups or inviting a patient representative to join a design user group - Ensure that as wide a range of views are gathered to inform the design process which will include ensuring that the views and advice of clinical and non-clinical support departments inform the design. This will include but not being limited to: IM and T; Infection Control; and Facilities - Ensure that the principles of inclusive design including colour contrast, provision of accessible signage and hearing loops form part of designs as these are mandated as explicit for new developments and major refurbishments. - Ensure that the Service Modelling Principles endorsed by the North Denbighshire Project Reference Group are incorporated into the estate / service design. - Develop sequential iterations of the design for the respective area, progressing to more detailed floor and layout plans - Ensure that, as a minimum, the design is reviewed and approved by Infection Prevention and Control, Health and Safety and the Fire Officer - Ensure that designs take account of the needs of the diversity of patients using the service(s), and the support of the Equality and Human Rights Department should be engaged as part of this - Highlight any impact there may be on the staffing required for the new areas in order that the respective CPG s / Departmental areas can consider these and, where necessary, identify how the CPG / Department will fund any additional revenue funding that may be required 20

21 - Ensure all design plans are signed off by the relevant department. - Where appropriate, ensure liaison and co-ordination with other concurrent design user groups, particularly for those areas which coexist and which may have the opportunity to share facilities and make the most efficient use of collective space - Provide a regular written update for the project team - Responsible for the development and implementation of the operational policy Commissioning User Groups During the lifetime of the project, a number of Commissioning User Groups will be established to ensure that the smooth transition of services (which may also have been temporarily relocated) into areas which have been redesigned or newly built. These are temporary groups, established for a limited period of time to commission these new areas and ensure any teething issues are resolved. It is expected that each commissioning user group will be established in advance of the redesigned or new build area being handed over to BCUHB for use. Each commissioning user group is chaired by the Gleeds Project Manager who will also provide administrative support. Agendas and papers for each meeting of a commissioning group will be issued and minutes taken. Papers will be issued prior and following each meeting as soon as practical taking account of their individual frequency. Each commissioning user group will meet as frequently as required, and in some cases, will meet weekly. The membership of each commissioning user group comprises: - Gleeds Project Manager (Chair) - Cross section of clinical and non-clinical staff in the areas affected - Cross section of clinical and non-clinical staff who provide support services for the areas affected - BCUHB Project Manager - The Clinical Lead for the Project or the Nurse Lead for the Project or the Site Operational Manager - All relevant clinical and non-clinical support departments 21

22 Each commissioning user group must ensure Infection Prevention and Control; Health and Safety; Fire Officer; and Operational Estates are fully engaged in the commissioning process. Those attending a commissioning user groups must be able to speak with full authority for their service / departmental areas and must therefore actively engage with all relevant staff in their areas prior to and between meetings. Each commissioning user group will: - Develop an action plan for the tasks required to physically commission the respective area - Ensure there are sufficient management arrangements in place for all aspects of the commissioning process - Develop and agree a commissioning timetable, ensuring commissioning remains within this timeframe - Develop and agree any new operational policies and procedures for the use of the commissioned areas - Develop and agree any induction and training programmes required for staff - Identify and register existing equipment for transfer - Ensure that any new equipment agreed is ordered, delivered and installed in line with the agreed commissioning action plan - Maintain a risk register (managed by Gleeds PM), ensuring this is kept up to date, and that any risks identified in the commissioning process have mitigation actions agreed to minimise risks - Develop and implement a Communications Action Plan to support the commissioning process which is informed by the overall project communication strategy, and which includes the provision of key messages to patients, visitors, staff and key stakeholders and the provision of signage and way finding as appropriate - Escalate any issues which cannot be resolved within the commissioning group to the project team - Provide a regular written report on progress to the project team 6. Summary 22

23 This paper outlines the project structure which provides the underpinning governance framework for the Community Healthcare Project. It has provided the terms of reference and memberships of all project groups. The governance Framework will be reviewed on a six monthly basis by the project board to provide assurance that the project arrangements remain fit for purpose for the lifetime of the project. 23

24 BCUHB Senior Responsible Officer Finance Committee Hospital Management Team (Central) Community Healthcare Project Board Community Healthcare Project Team Asset Management Committee Core Team BCU Health and Safety Forum Contract Progress Group Operational Maintenance and Safe Functions Group Communications Group Benefits Realisation Group User Groups Asbestos Removal Progress Group NB Those Project groups which form part of the formal project structure are denoted by a solid line; those groups denoted by a broken line are not part of the formal project structure but have key relationships with the Project 13 th August 2014 Version