Submit your Project Step 1 of 2 50% This proposal template is divided in 2 parts: Part A: Provides a general overlook of the proposals you are submitting. You must complete Part A in order to complete Part B. You are not required to complete Part B at the same stage at Part A, but it would be ideal if you did so. This will guarantee that the Department has all information required to evaluate your proposal internally, optimizing everyone’s time and efforts. Part B: It will guide you to provide the granular information required from all PHC structure in order to implement the proposal. Proposal ScopeYour Name First Last Division Title Introduction / Background / RationaleObjective / SolutionStrategic and Innovation Aspects Patient Centred Care Innovation Interdivisional / Interdepartmental Collaboration Research Potential / Ramification Strategic importance / Redevelopment potential: How is your project align with PHC Strategic Plan ? Financial implications / feasibility ConstraintsHow are do you plan to measure the results of the changes proposed? Part BPart B: This form will guide you to provide a deeper level of details regarding your proposal. 1. Who is the executive sponsor that will support your proposal?The executive sponsor is usually the management person that will help you navigate throughout the organization, facilitate approvals or decisions. He/She will ensure that your proposal satisfies your “customer” and the organizational need. Senior Leadership Team Program Director Department Head Division Head Other 2. Is the scope and reach of your proposal:(please select all that apply) Regional Provincial Local (within a specific site i.e. SPH. MSJ. HF). Research Educational Innovation Enhance Patient Care Other Q2 | Other 3. Who are the stakeholders of your proposal?Those who are invested, participates and is in the chain of accountability for the proposal. You may be in contact with them in a regular basis. Examples: Anesthesia, Emergency, Family Medicine, Midwifery, Obstetrics and Gynecology, Orthopedics, Ophtamologhy, Pathology and Lab. Medicine, Pediatrics, Psychiatry, Radiology, Surgery, PHC Programs (Heart and Lung, Renal, medicine, etc.). Which one?, SPH Foundation, UBC DivisionDEPARTMENTSTAKEHOLDER Full Name Add RemoveOTHERWho? ( i.e. VCH, Renal Agency, BC Cancer, Foundation, ect.)WhoWhat do you need them to do?How much time do you need from them?What is their level of support and engagement for the idea? Add Remove4. How much time do you anticipate it will take to implement your solution?5. Please inform the staff that will be required for the operation: Not required Subspecialists Project Manager to write the operation documentation Nurse Clerks/MOAs Patient Care Manager Medical Director Allied Health Care Professional Others SubspecialistsHow many (Subspecialists) ? Who (Subspecialists) ? Specify FTE/Hrs per week (Subspecialists) ? NursesHow many (Nurses) ? Specify FTE (Nurses) ? Clerks/MOAsHow many (Clerks/MOAs) ? Specify FTE (Clerks/MOAs) ? Patient Care ManagerSpecify FTE (Patient Care Manager) ? Medical DirectorSpecify FTE (Medical Director) ? Allied Health Care ProfessionalWho (Allied Health Care Professional) ? Specify FTE (Allied Health Care Professional) ? OthersWho (Others) ? Q5 Notes6. Please inform if the proposal will cause an increase of volume of tests, procedures, therapies or service? Tests (eg. Laboratory, Radiology), etc. - specify and estimate volume/month Diagnostic Procedures – specify and estimate volume/month Therapies – specify and estimate volume/month: Use of allied health professional and other support services – specify and estimate volume/month Surgical or interventional procedures - specify (e.g. estimate volume/month) Research activities – specify type and estimate time/month PLEASE OUTLINE OTHER ANTICIPATED REQUIREMENTS: In-patient bed requirements ICU beds Operating Rooms Patient days per week In-patient bed requirements ICU beds (Hours per week) Operating Rooms Patient days per week (In-patient) Patient days per week (Day Care) Q6 Notes7. Please inform if the purchase of clinical equipments is required:The purchase of new equipment that requires maintenance should be quoted through Biomed. The cost of disposables should always be forecasted. (please select all options that apply) No Yes Is it a new equipment? Is it a replacement equipment? Does the equipment produces disposable material? Does the equipment requires regular maintenance? Other Q7 | Yes Q7 | Is it a new equipment? Q7 | Is it a replacement equipment? Q7 | Does the equipment produces disposable material? Q7 | Does the equipment requires regular maintenance? Q7 | Other Q7 Notes8. Please specify clinical and administrative space required:For PHC on site space The Space Committee will need to be consulted Not required Structure already in place Exam rooms Registration Desk Is renovation required? PHC on site space will be required Structure already in place Exam Rooms Registration Desk Is renovation required? PHC on site space will be required Q8 Notes09. Patient Volume(for outpatient settings) Volume of Patient will remain the same Volume of Patient will increase How many patient will be seen per half day clinic?How many patients are in your waiting list(if applicable)?10. What infrastructure and services will be required? Nothing Computers Phone Lines Furniture Medical Supplies Office Supplies Will you need IMTIS services? Facility Renovation Computers Phone Lines Furniture Medical Supplies Office Supplies IMTIS services Facility Renovation Q10 Notes11. Funding Physician will be compensated by MSP (fee for service) Will your proposal generate funds to be used towards its operation? Does your division/program have funds available? Please inform your funding sources Please inform funding strategy, including timeline Does your division/program have funds available? Please inform your funding sources Please inform funding strategy, including timeline Q11 NotesNotes: What is the total amount of your request? What is the time frame (duration) for your request? Are there additional one-time costs (eg. facility renovation, project management)? Are there any ongoing operational costs (eg. staff, maintenance contracts, etc.)? If so, what is the funding source? Have you explored any other funding sources? (eg. have you applied for a grant; have you submitted a request through the internal capital process?) Are there any funding matching opportunities? If no, are you aware of any organization that might consider providing funding if approached with a proposal? Is there a save cost opportunity for the hospital?12. Please inform what will be required in terms of Communication Development of a communication plan (deliverables, outcomes) Website Referral forms, clinical care pathway (intake, discharge), clinic protocols, triage protocol Development of quarterly/biannual reports to stakeholders Development of a communication plan Website Referral forms, clinical care pathway (intake, discharge), clinic protocols, triage protocol Q12 NotesDescription of RisksRisks associated with implementing the ideaRisks if the idea is not implemented
