APPROACH TO QUALITY IMPACT ASSESSING
PROVIDER COST IMPROVEMENT PLANS
(CIPs)
Version:
0.2
Ratified by:
Date Ratified:
Name of originator/author
Nikki Livermore, Quality and Patient
Safety Manager
Date Issued :
Date Implemented :
Next Review Date:
Target Audience:
CCG staff and Board members
Policy Date:
Review Date:
Page 1
CONTENTS
Contents
1.
INTRODUCTION
Page No.
Page 3
2.
PURPOSE
Page 3
3.
DEFINITIONS
Page 3
4.
ROLES AND RESPONSIBILITIES
Page 3
5.
POLICY PROCEDURAL REQUIREMENTS
Page 4
6.
MONITORING COMPLIANCE
Page 7
7.
ASSOCIATED DOCUMENTATION
Page 8
8.
REFERENCES
Page 8
9.
LIST OF STAKEHOLDERS CONSULTED
Page 8
10.
EQUALITY IMPACT ASSESSMENT (ANALYSIS
OF THE EFFECTS ON EQUALITY)
Page 8
11.
VERSION CONTROL
Page 9
Policy Date:
Review Date:
Page 2
1
INTRODUCTION
The Francis Report (2012) identified how Mid Staffordshire Hospital focussed on
finance and how little attention was paid to the potential impact of proposed
savings on quality and safety. Following Mid Staffordshire, there has been an
increased focus on the impact on quality of Cost Improvement Programmes. The
Planning guidance ‘Everyone Counts: supporting Planning for Clinical
Commissioning Groups 2013/14 also emphasises the need for commissioners to
scrutinise provider cost improvement plans (CIPs) plans, to seek assurance and
ensure the on going monitoring of risks.
The National Quality Board (July 2012 to March 2013): HOW TO: Quality Impact
Assess Provider Cost Improvement Plans guidance recommends a multidisciplinary approach to the assessment and sign off of provider CIPs through the
development of a ‘Star Chamber’. Although the CCG have not adopted the ‘Star
Chamber’ approach in its entirety, the guiding principles, promoting systematic
exploration of quantitative and qualitative intelligence and encourages the orderly
triangulation of information to help assess the quality impact of CIPs.
2
PURPOSE
The following document will outlines the approach that NHS Basildon and
Brentwood Clinical Commissioning Group (the CCG) will take to Quality Impact
Assess the delivery of Cost Improvement Plans and QIPP plans of Provider
organisations with whom the CCG directly commissions services.
3
DEFINITIONS
The CCG
The ‘CCG’ is defined as NHS Basildon and Brentwood Clinical Commissioning
Group.
The Provider
The Provider is defined any providers from whom BBCCG directly commission
services
4
ROLES AND RESPONSIBILITIES
CCG Board
It is the collective responsibility of the Board to ensure that quality impact
assessing the CIP’s is not a one of application, but will require attention
throughout the period of cost improvement once plans have been accepted. Any
work generated by provider boards should be used to inform the external
assurance process rather than taken at face value. The risk of false assurance is
too great unless actual scrutiny by the CCG board or its committees takes place.
Patient Safety and Quality Committee (PSQC)
The PSQC will oversee the CIP process detailed in this document and
will triangulate both soft and hard intelligence to evaluated the QIA process
Policy Date:
Review Date:
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Chief Officer (CO) /Chief Nurse (CN)
The Chief Officer will be required to endorse the approach outlined in section 5
and support the Chief Nurse to work collaboratively with other key colleagues such
as board level clinicians and the Chief Finance Officer to complete the assurance
process.
Provider Responsibility
It is recognised that the quality impact assessments of CIP’s is the primary
responsibility of provider boards. Providers will manage their CIP process through
implementing the four stages outlined by Monitor;


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5
Identify potential CIPs
Assess potential impact on quality and cost
approve plans
assess actual impact on quality
POLICY PROCEDURAL REQUIREMENTS
CCG Approach
To assist the CCG in satisfying that providers have adequately designed and
applied CIPs with due regard to quality, a ‘Star’ type ‘Chamber’ will be established
using appropriately an attended existing CCG Committee, namely, the Patient
Safety and Quality Committee (PSQC)
The CCG will ensure that as part of the process for overseeing CIPs, it will:
 Operate within the standards set out in the NHS Early Warning Systems
publication
 Be clinically led but not unduly dominated by clinicians – quality is
everyone’s business
 Involve a broad range of contributors
 Ensure all contributions are valued and have currency
 Provide a solid basis for peer review and critique which supports open and
constructive challenge
 Facilitate comparative analysis of information and trends to create an
informed picture based on facts and appropriate judgement, including
consideration of soft intelligence
 Enable exploration of the inter-relationship between variables and the
resultant testing of hypotheses i.e. using data/intelligence to identify lines of
enquiry, cues for action or prompts for intervention
 Offer a transparent and timely process for the validation of plans in the
context of assumptions applied by providers
 Challenge the efficacy of CIPs in the context of any as possible unintended
or adverse consequences for patient care
 Provide a reliable audit trail for future reference
when reviewing CIPs, the CCG should consider whether the provider CIPs
Policy Date:
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reflect the following:












Track record of delivery of savings plans – specifically in terms of the
proportion of the plans for previous years delivered
The relative scale of the CIP in terms of cash value, CIP as a % of turnover
(as an indicator of the challenge presented by the scale of the CIP required)
and the level of unidentified CIP as an indicator of the level of planning
already undertaken
Triangulation of available data to ascertain whether the reported numbers
align
Whether activity, workforce and savings plans are aligned – do the
assumptions correlate?
Do CIP plans, as presented to the provider board, contain sufficient
granularity?
Has each CIP scheme been risk assessed and RAG rated? Has the risk
assessment been reviewed for impact on staff, impact on quality of
services, ability to deliver, ensuring that all 3 areas have been separately
assessed?
Evidence of comprehensive risk assessment process on the quality impact
assessment completed for schemes with a potential impact on quality. This
should include assessment of schemes in terms of patient experience,
safety and clinical outcomes
Have organisations used the Monitor Quality Assessment Framework to
quality assure their CIPs?
Evidence that unintended consequences have been assessed and
mitigating actions clearly expressed for the risks identified
Have the trust medical and nurse directors explicitly and formally signed off
the CIP?
Has the provider board formally approved the detail and risk assessment of
the CIP?
Is there sufficient level of transparency with regard to public, staff and
patient engagement?
Delivery of the CCG approach
The CCG will follow a 3 stage approach;
Stage one
At the outset of the financial year, the CCG’s will create a baseline against which
the CIP can be judged as plans unfold in the year.
Stage Two
a) For initial evaluation the Chief Nurse will, with the provider, review the CIP
programme for the following financial year. At this point, a review of the
associated QIAs will have been undertaken by the provider. This will include
an understanding of which CIPs have been carried forward and those which
have not due to failing the QIA. This exercise will be undertaken with access
to the Deputy Director of Finance, Director of Nursing and Medical Director of
Policy Date:
Review Date:
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the Trust should there be any concerns.
b) The Provider will then be invited to present the CIP’s to the CCG. The CCG
will use the following prompts (but not limited to) to review the CIPs presented;

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Has the provider chief executive agreed the governance arrangements and
secured board endorsement?
Are the medical and nurse directors engaged and leading the process?
Is the board reporting regime clear and widely promoted i.e. is there
transparency of process?
Are the arrangements for providing assurance to the board, commissioners
and Monitor in the case of NHS Foundation Trusts, both about the delivery
of the CIP and the ongoing validity of the quality impact assessment clear
and documented?
Is the management team formally engaged and committed to matrix
working / information exchange?
Are quality impact assessment reports generated and circulated regularly to
stakeholders? Are all stakeholders such as Healthwatch, overview and
scrutiny committees, social partnership forums briefed and engaged?
Are arrangements in place to ensure that quality is assessed as part of
monthly performance reviews to ensure integration with finance, workforce
and performance assessment?
Is there a robust facility for front line staff to confidentially report concerns
about CIP schemes and their potential negative impact on quality, patient
experience or safety or indeed on staff?
Any CIPs assessed by the CCG as high risk will undergo a ‘deep-dive’ to ensure
no negative impact to quality of care.
Stage Three
The CCG will continue with the routine monitoring of performance against plan
through the application of performance and patient safety/experience dashboards
through the Patient Safety and Quality Committee
The provider will share any internal reports about the impact of CIPs on Trust
delivery of care. These reports will be taken through the internal governance of
the CCG via the Patient Safety and Quality Committee
The Chief Nurse will attend the Trust on a quarterly basis thereafter to review and
assess any new CIPs and their associated QIAs. To gain assurances around the
extent of any negative impact yielded from the implemented CIPs. The quarterly
review will include;


evidence of provider review of QIA for CIPs
assessment of whether there been a drop in performance during the
quarter, as measured by the CCG quality dashboard and other indicators
(If there has been a drop in performance, is the reason for the change clear
and unrelated to the CIP?)
Policy Date:
Review Date:
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
Assessment of whether any further review is required
The provider will also present a quarterly report to PSQC.
The initial and quarterly review along with any subsequent feedback will be
documented to provide an audit trail of the process followed and track progress
made towards their agreement and ultimately their sign-off and implementation.
Time line
Date
April/May
June/July
July/ongoing
August/November/
February
6
Action
CN to attend Trust CIP/QIA
discussion for following financial
year
Presentation of QIA/CIPs to
CEG for review by CCG
Follow up of any concerns
regarding QIA/CIPs to enable
CCG agreement
Quarterly monitoring of provider
review of CIPs
owner
Provider/CN
CCG
Provider/CCG
CCG/Provider
MONITORING COMPLIANCE
This Policy will be monitored by the Patient Safety and Quality Committee.
The CCG Executive Officer who has overall responsibility for monitoring the policy
is the Chief Nurse.
7
ARRANGEMENTS FOR REVIEW
If only minor changes are required the Governance Committee has authority to
make these changes without referral to the CCG Board. If more significant or
substantial changes are required, the policy will need to be ratified by the relevant
committee before final approval by the CCG Board.
If only minor revisions are made then version number for the policy will be updated
by ‘.1’ e.g. from version 1.0 to 1.1.
If significant amendments need to be made then the version number would
increase to the next whole number e.g. from version 1.1 to 2.
7
ASSOCIATED DOCUMENTATION
National Quality Board; HOW TO Quality Impact Assess Provider Cost
Improvement Plans (July 2012 – March 2013)
Policy Date:
Review Date:
Page 7
Monitor & Audit Commission; Delivering sustainable cost improvement
programmes (January 2012)
NHS Early Warning Systems www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGu
idance/DH_113020
8
REFERENCES
National Quality Board; HOW TO Quality Impact Assess Provider Cost
Improvement Plans (July 2012 – March 2013)
9
LIST OF STAKEHOLDERS CONSULTED
Date
Policy
circulated
Name of
individual
Or Group
Title
Were
Were comments
comments incorporated
received
into the policy
Yes/No
Tom Able
Dr. Anil
Chopra
Tracey
Easton
Lisa Allen
Diane
Sarkar
Celia
Skinner
10
If No – Why
Not?
Yes/No
Chief Officer
Chair
Chief Finance
Officer
Chief Nurse
BTUH Director of
Nursing
BTUH Medical
Director
EQUALITY IMPACT ASSESSMENT
BB CCG is committed to carrying out a systematic review of all its existing and
proposed policies to determine whether there are any equality implications.
This policy has been assessed using the CCG’s Equality Impact Assessment framework which
identified the following impact/s upon equality and diversity issues:
Age
Marital
Status
Disability
Gender &
Pregnancy
Race
Sexuality
Religion
Human
Rights
Total
Points
Impact
2
2
2
2
2
2
2
2
16
HIGH
Points
3 – This area has a high relevance to equalities
2 – This area has a medium relevance to equalities
1 – This area has a low relevance to equalities
0 – This area has no relevance to equalities
Policy Date:
Review Date:
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Scoring
13-18 points – high impact
7-12 points – medium impact
0-6 points – low or no impact
Rationale:
Ensuring sound processes around Provider services QIA’s and CIPS is likely to
have a positive impact on all the protected characteristics. Using the
framework, any impact to particular groups of people will be highlighted
through the process which will, where appropriate, enable the CCG to ensure
equitable delivery of services.
11
VERSION CONTROL
Version
0.2
Author:
Name & Title
Nikki Livermore
Date Policy
Issued
Date Policy Due to
be Reviewed
Policy Date:
Review Date:
Page 9