MKBC Theatres & ICU Reconfiguration and Upgrade. Full Business Case

Transcription

1 MKBC Theatres & ICU Reconfiguration and Upgrade Full Business Case

2 Document Control Document Name MKBC Theatres & ICU Reconfiguration and Upgrade Full Business Case Document Version 0.7 Author Kevin Gauld Phone number Document Control Version Date Reason for issue Issued To Issued By th Sep 2014 Layout/ Content agreement CL/RS/BM/FM KG th Oct 2014 AEDET update/ redrafting CL/RS/BM/FM/GM/NR KG st Nov 2014 Further re-drafting FM KG th Nov 2014 Further re-drafting CL KG th Nov 2014 Gateway Review Draft Gateway Review Team; CL/RS/BM/FM KG th Dec 2014 Further re-drafting No Issue KG th Jan 2015 Further re-drafting CL/RS/BM/FM/ KG th Jan 2015 Inclusive of C. Sloey/ Corporate Management Team/ Non Exec Director comments CL/RS/BM/FM/AJ KG 2

3 Contents 1 Executive Summary 1.1 Introduction 1.2 Strategic Context 1.3 Option Appraisal Process 1.4 Commercial/ Financial Position 1.5 Conclusion and Recommendation 2 Strategic Case 2.1 Strategic Context 2.2 Organisational Overview 2.3 Business Strategy and Aims 2.4 Other Organisational Strategies 2.5 Investment Objectives 2.6 Existing Arrangements 2.7 Business Needs Current and Future 2.8 Desired Scope/ Service Requirements 2.9 Benefits Criteria 2.10 Strategic Risks 2.11 Constraints and Dependencies 3 Economic Case 3.1 Introduction 3.2 Critical Success Factors 3.3 Main Business Options 3.4 Preferred Way Forward 3.5 The Short Listed Options 3.6 NPC/ NPV Findings 3.7 Benefits Appraisal 3.8 Risk Assessment 3.9 Preferred Option 3.10 Sensitivity Analysis 3

4 4 The Commercial Case 4.1 Introduction 4.2 Agreed Scope and Service 4.3 Agreed Risk Allocation 4.4 Agreed Charging Mechanisms 4.5 Agreed Key Contractual Arrangements 4.6 Agreed Personnel Implications 4.7 Agreed Implementation Timescales 4.8 Agreed Accountancy Treatment 5 The Financial Case 5.1 Introduction 5.2 Capital/ Funding Requirement 5.3 Revenue Impact 5.4 Impact on Balance Sheet 5.5 Impact on Income and Expenditure Account 5.6 Stakeholder Support 5.7 Overall Affordability 6 The Management Case 6.1 Introduction 6.2 Procurement Strategy 6.3 Project Management 6.4 Change Management 6.5 Benefits Realisation 6.6 Risk Management 6.7 Contract Management 6.8 Post Project Evaluation 6.9 Community Benefits 6.10 Contingency Plans 7 Conclusion 7.1 Summary 4

5 Appendix: 01: Design Statement 02: A+DS/ HFS Letter of Support 03: AEDET Workshop 04: Risk Register 05: Site Plans and 3D visuals 06: Schedule of Accommodation 07: Letter of Financial Support 08: PSCP Stage 2 Programme 09: Schedule of Derogations 10: Benefits Appraisal Workshop 11: Employment and Skills Plan 12: Phasing Plans 13: Communications Strategy 14: Business Continuity Plan 5

6 Glossary of Terms 6

7 1 Executive Summary 1.1 Introduction This Full Business Case (FBC) sets out the strategy for the refurbishment and upgrade to modern standards of the seven operating theatres, intensive care unit and support accommodation at Monklands District General Hospital. A preferred option for the delivery of this work is identified which involves a stepped series of works phases, with the objective of maintaining the full clinical functionality of Monklands throughout the four years of works on site. The completion of the work described in this business case will: address potential environmental risks identified within the theatre and intensive care departments of Monklands District General Hospital; provide improved efficiency and flexibility in the use of ICU and HDU beds across the site creating a safer environment for patients in keeping with 21st century standards provide greater efficiency for the working of the theatre department as a whole, and orthopaedic surgery in particular (2 laminar flow theatres) dramatically improve the working environment for staff. These benefits are entirely in accord with the ambitions of NHS Lanarkshire s strategic plan A Healthier Future. 1.2 Strategic Context Monklands District General Hospital was constructed in 1974 and the theatre areas and ICU are typical of the age of the building. Different elements of the Theatre/ ICU department have been upgraded at several stages in the past, with theatres 4, 7 and Recovery having improvement works delivered more recently however the entire department has not received a co-ordinated overall refurbishment in the recent past. During 2009/10 Health Facilities Scotland (HFS), as part of a Scottish Government funded project, surveyed theatre suites and associated ventilation plant in all Scottish acute hospitals. Using Scottish Health Technical Memorandum (SHTM) Ventilation for healthcare premises a benchmark was created to determine performance and compliance of the 7

8 ventilation plant. Subsequently the outcome of the HFS report advised the Board that the condition of the Theatre ventilation plant was poor. In the review of works required to ensure the Air Handling Units compliance with the SHTM, it was noted in reports provided by Capita Symonds in April and July 2012 that the disruption caused in carrying out any replacement work would be major. The reports also noted that: The current plant room does not lend itself to replacement with removal being very difficult due to close proximity of plant, ductwork or building fabric. Power supply to each theatre to be upgraded and fitted with both UPS and IPS system along with general upgrade work to general and emergency escape lighting which is currently non- compliant Issues with fire compartmentation and escape signage identified in several theatres The overall recommendation from the Capita Symonds reports notes that due to the severe disruption required to the theatre area in order to replace the AHUs initially, and several noncompliances identified in the theatres regarding ventilation ductwork, fire compartmentation, and fabric and architectural items, that a programmed theatre upgrade works package be implemented at Monklands District General Hospital. NHS Lanarkshire s quality vision is to achieve transformational improvement in the provision of safe, person centred and effective care for our patients and for our patients to be confident that this is what they will receive, no matter where and when they access our services. To achieve our quality vision, we are committed to transforming the quality of health care in Lanarkshire through investment in and continuous reliable implementation of patient safety processes. Through this we aim to: be the safest health and care system in Scotland have no avoidable deaths reduce avoidable harm deliver care in partnership with patients that is responsive to their needs meet the highest standards of evidence based best practice be an employer of choice develop a culture of learning and improvement, characterised by our values of Fairness, Respect, Quality and Working Together 8

9 The NHS Lanarkshire Board considered the progression of the future Lanarkshire Clinical Strategy at their meeting in August The potential replacement for the ageing hospital facilities on the Monklands site will be one element of this major planning exercise which is expected to identify a range of future options for hospital services in Lanarkshire. Some options will identify the means of continuing the use of on-site facilities at Monklands (e.g. theatres and radiotherapy) which are in a fully functional condition. These options are expected to be available in early 2016, with the recognition that any replacement facility for the current hospital buildings will not be commissioned until the mid-2020s at the earliest. In this context and timeframe, continued investment to provide safe and effective clinical infrastructure of Monklands Hospital is essential. 1.3 Option Appraisal Process A detailed process to determine a long list of possible options, assessment of these, and the development of a short list of options for the refurbishment and upgrade of the Theatres and ICU has been undertaken. Following a non-financial benefits appraisal workshop and further financial appraisal, a preferred option to meet service objectives has been identified. This full process was set out in detail within the OBC and is summarised in this FBC. The preferred option for the Theatres and ICU has been identified as the full refurbishment of the existing seven theatres and the construction of a 10 bed ICU adjacent to the existing theatre suite. Sensitivity testing has been carried out from both a non-financial and financial perspective to confirm that the identified option does not change under different scenarios and this has been clearly shown to be the case. 1.4 Commercial/ Financial Position The refurbishment and upgrade will be delivered through the Frameworks Scotland 2 procurement route and this FBC has been developed in accordance with those requirements and also the Scottish Capital Investment Manual. 9

10 The Theatres/ ICU Project Team is committed to collaborative working and recognise the wide range of benefits that can be delivered by this approach, that will enhance efficiencies and performance and create value. In addition to the contractual requirements of the NEC3 contract, the NHSL Frameworks Scotland 2 Project Team is developing this collaborative business relationship under the British Standard, BS Executive and Joint Management Teams have been established and a set of joint objectives agreed. An Improvement Team is in place to capture lessons learnt and to identify and implement value creation activities, such as bundling of work tasks and the joint management of risk. These lessons learned will be incorporated in the Post Project Evaluation for the Theatres/ ICU project. The BS11000 standard provides a strategic framework to improve the longstanding collaborative relationships within the project team. Our Health Facilities Scotland Project Advisor and SGHSCD are pro- actively supporting this initiative and will report on the benefits to the Frameworks Scotland Project Board. Capital Costs of the project are as follows: Table 01: Capital Costs of the Refurbishment and Upgrade of Theatres and ICU Total Cost 000 s Works Costs 16,631 Fees 412 Irrecoverable VAT 2,727 Total Capital Cost 19,770 These capital costs will be funded initially through NHSL formula funding, with additional Scottish Government funding being made available in 2016/17 and 2017/18. The total Capital cost of m includes an allowance of 512.2k in respect of risk. Total recurring annual revenue costs of 0.23m are to be funded by the NHSL Board and are included in the board s financial plan. 10

11 1.5 Conclusion and Recommendation Providing the refurbishment and upgrade to the Theatres and ICU at Monklands General Hospital will improve patient experience whilst offering modern services locally to where people live. As a central element of the proposal this will enable the meeting of the challenges of implementing NHS Scotland s Route Map to the 2020 Vision for Health and Social Care (2013). The Preferred Option, to refurbish the existing seven theatres alongside the construction of a new build 10 bed ICU represents the best investment to provide the required services going forward. It is the best value option, as has been demonstrated throughout this document, and would fulfil the drivers identified in this FBC. These new facilities would provide a 21st century environment that would meet the needs and aspirations of the patients within NHS Lanarkshire. Approval of this FBC will ensure that the project can move at pace towards the construction of this critical project.. 11

12 2 Strategic Case 2.1 Strategic Context The Scottish Government published their 2020 Vision in September 2011 which sets out the actions required to achieve sustainable quality in Scotland s Healthcare system. This strategic narrative, set out by the Cabinet Secretary for Health and Wellbeing, provides the context for taking forward the implementation of the Quality Strategy, published in May 2010, and the actions required to improve efficiency and achieve financial sustainability. The vision is shown in the box below. Our 2020 Vision Our vision is that by 2020 everyone is able to live longer healthier lives at home, or in a homely setting. We will have a healthcare system where we have integrated health and social care, a focus on prevention, anticipation and supported self management. When hospital treatment is required, and cannot be provided in a community setting, day case treatment will be the norm. Whatever the setting, care will be provided to the highest standards of quality and safety, with the person at the centre of all decisions. There will be a focus on ensuring that people get back into their home or community environment as soon as appropriate, with minimal risk of re-admission. Source: Scottish Government, September 2011 In response to this vision NHSL has developed and published a framework for Strategic Health Planning: A Healthier Future to support future strategic health planning and to facilitate definition of the actions required to achieve the Scottish Government s 2020 Vision. This strategic framework will support NHSL to achieve the implementation of the 2020 vision and ensure that service change and developments are based upon the three Quality ambitions of Patient Centred, Safe and Effective and enable improved efficiency and financial sustainability within the Board. NHS Lanarkshire s quality vision is to achieve transformational improvement in the provision of safe, person centred and effective care for our patients and for our patients to be confident that this is what they will receive, no matter where and when they access our services. 12

13 We know that following an intensive review by Healthcare Improvement Scotland of NHS Lanarkshire s acute adult patient services in 2013 serious failings and unacceptable practice were identified. We also know that UK and international evidence shows that up to 25 per cent of patients experience a safety incident while in hospital. We do not believe this is acceptable for our patients. To achieve our quality vision, we are committed to transforming the quality of health care in Lanarkshire through investment in and continuous reliable implementation of patient safety processes. Through this we aim to: be the safest health and care system in Scotland have no avoidable deaths reduce avoidable harm deliver care in partnership with patients that is responsive to their needs meet the highest standards of evidence based best practice be an employer of choice develop a culture of learning and improvement, characterised by our values of Fairness, Respect, Quality and Working Together The completion of the work described in this business case will address potential environmental risks identified within the theatre and intensive care departments of Monklands District General Hospital as well as creating a safer environment for patients in keeping with 21 st century standards, the working environment for staff will be dramatically improved. These benefits are entirely in accord with the ambitions of A Healthier Future. 13

14 2.2 Organisational Overview NHSL serves a population of 652,580. The NHS Board is conterminous with North and South Lanarkshire Councils. The legal entity is the Lanarkshire NHS Board. Within this, operational delivery of all clinical services is organised around an Acute Services Division and two Community Health Partnerships one for North Lanarkshire and one for South Lanarkshire. The principal role of the NHS Board is the protection and improvement of the health of the resident population, and the delivery of high-quality, patient-focused services. Specifically, the key functions of the NHS Board, for which it is accountable to the Scottish Government Health & Social Care Directorates, on behalf of the Cabinet Secretary for Health and Wellbeing are: Set the strategic direction of the organisation within the overall policies and priorities of the Scottish Government and the National Health Service in Scotland Define its annual and longer term objectives, and agree plans to achieve them To oversee the delivery of planned results by monitoring performance against objectives and ensuring corrective action is taken when necessary To ensure effective financial stewardship through value for money, financial control and financial planning and strategy To ensure that high standards of Corporate Governance and personal behaviour are maintained in the conduct of the business of the whole organisation To ensure there is effective dialogue between the NHS Board, other agencies, particularly North and South Lanarkshire Councils, and communities, on its plans and performance, and that these are responsive to the communities assessed needs The document which sets out how the NHS Board is expected to ensure the discharge of these responsibilities is the Local Delivery Plan (LDP), constructed around the HEAT targets, issued to the service each year by the Scottish Government Health and Social Care Directorates (SGHSCD). NHSL employs approximately 12,000 staff and provides services in over 100 properties of varying sizes. It has 3 District General Hospitals at Wishaw, Hairmyres (East Kilbride) and Monklands Hospital. The hospitals at Wishaw and Hairmyres were procured through the PFI process and both opened in 2001 the first PFI District General Hospitals in Scotland. The Board has an annual expenditure of 1,074m in the provision of all health services in Lanarkshire. The NHS Board comprising of Executive and Non Executive Directors meets monthly in public and has established a rigorous approach to performance management 14

15 across a wide range of indicators with detailed reports provided either monthly or more frequently as appropriate. Included in the Non Executive membership of the Board is the leader of North Lanarkshire Council and the leader and deputy leader of South Lanarkshire Council. This is a clear demonstration at the highest level of the commitment to integrated working between health and local authorities to improve the health and well-being of the people of Lanarkshire. 15

16 2.3 Business Strategy and Aims The Scottish Government s requirement to take forward the Quality Agenda through the 2020 Vision, the need to achieve financial sustainability and the need for improving the efficiency of service delivery are all key drivers for NHS Boards to implement. A Healthier Future is flexible and has been developed to ensure that service changes and developments can be assessed against a framework of strategic priorities. This will assist with prioritisation and the approach to implementation. This strategic framework will ensure that all service change and developments are assessed against a clear criteria developed and will also ensure that all proposed actions move towards the clear objectives of the 2020 vision. It is not a plan of specific service changes but a framework against which service changes can be clearly and openly tested before implementation. To undertake future changes without such assessment against the criteria will not be acceptable. The framework sets out the aims of NHSL for the period and highlights the intention of the Board to deliver the best quality of services to its patients. The development of the framework for strategic health planning highlights a number of key strategies and documents which set out plans and actions for developing services that underpin the Board s desire to improve patient care and offer improved access to services. These plans will improve and develop clinical services within NHSL to reflect national strategies and priorities. In particular, the strategies include: Diagram 01: Strategies 16

17 These are underpinned by other strategies and plans but are specifically linked to a detailed workforce development plan, the property strategy and a five-year financial plan. The specific detail of individual actions within plans which require to be implemented in 2014/15 is consolidated within the Board s Local Delivery Plan (LDP) which sets out key organisational objectives and provides a mechanism to record progress in achieving and complying with HEAT targets. The method of service delivery is always evolving and the key to successful investment in property is the ability to design facilities which meet our existing needs but can be flexible to change to meet our future needs within the confines of a defined space. Investment should also provide the opportunity for property to be enhanced in future if services needs and resources demand this. NHSL is responsible for the assessment of healthcare needs and for ensuring that a full range of services are in place to meet these needs. This is undertaken against a background of challenges and competing priorities. 17

18 2.4 Other Organisational Strategies We are translating our action plan for the Healthcare Improvement Scotland Rapid Review into a three year quality strategy, Transforming Patient Safety and Quality of Care in NHS Lanarkshire, Healthcare Quality Assurance and Improvement Strategy , to support the on-going implementation of A Healthier Future (NHS Lanarkshire s strategic framework taking forward the 2020 Vision) and to deliver against our quality vision. This will be a NHS Lanarkshire wide strategy which will ensure that the initiatives and improvements commenced in the acute hospitals are applied across all of our services. The provision of a safe and effective healthcare environment for the provision of patient care is an essential part of this transformational quality strategy, and is articulate with the Property and Asset Management Strategy 2014 (PAMS). The work of clinicians and support staff in operating theatres and intensive care can be intense and demanding. The current facilities within Monklands do not meet the standards set for a modern healthcare facility. The benefits to be achieved by this programme of works are significant and will also support then ambition of NHS Lanarkshire to be an employer of choice through providing a 21st century working environment for our staff. 2.5 Investment Objectives The proposed investment has a number of key objectives which can be presented in the broad categories of: Diagram 02: Key Objectives 18

19 At an overarching level the proposed investment will: Strategic/ Service: Enable NHSL to achieve the objectives set out in the Scottish Government s 2020 vision Enable NHSL to achieve the objectives set out in A Healthier Future Design: Achieve a high design quality in accordance with the Board s Design Action Plan and guidance available from HFS, A+DS and CABE Meet statutory requirements and obligations for public buildings e.g. with regards to DDA, HEI, HAI Follow NHS Technical Guidance where appropriate Work towards a BREEAM Healthcare rating of Good under the HFS BREEAM Pragmatic scheme Improve flexibility through increased standardisation Sustainability: Deliver more energy efficient facilities within the NHSL estate contributing to a reduction in whole life costs Deliver facilities that provide value for money within the affordability caps set Ensure ongoing financial sustainability in provision of services Patient Experience: Improved service coordination Improved physical environment Quality Strategy The investment objectives have been designed to ensure that the Scottish Government 2020 vision is taken forward effectively and that the three quality ambitions are achieved. The achievement of the three quality ambitions will ensure: Person Centred Implement service models which support the services strategic objectives by optimising the quality of seamless care delivered for patients in Lanarkshire 19

20 Ensure that care is structured around the needs of patients and delivered through an integrated (inpatient and community) pathway as agreed with the NHSL Strategic Programmes Embed integrated health and social care models of care to provide well co-ordinated, flexible and responsive services to patients and their carers Safe To provide a physical environment that complies with modern standards of healthcare and that promotes the safety, dignity, and privacy of all patients in purpose-built facilities that significantly improve the patient experience To create an environment which supports the improvement of HEI standards Effective To provide a therapeutic environment which allows the delivery of more appropriate care that benefits patients and provides staff with improved conditions to deliver clinical care To reduce costs with more efficient/ sustainable facilities and infrastructure, supporting integrated Health & Social Care delivery Specific investment objectives for this project are: Table 02: Investment Objectives Primary Objective Achieved Outcome Measured By Timescale Safe and Compliant Theatres & ICU Compliance with applicable SHTMs & SHFNs (SHTM 02/01; 03/01; SHFN 30) and other statutory requirements i.e. Health and Safety at Work Act/ Environmental Protection Act/ Controlled Waste Regulations/ Fire Scotland Act/ Electricity Work Regulations Improved communication between surgical and critical care teams through provision of facilities Compliance with Building Regulations Design Team Due Diligence CDMc HAI Scribe SHFN 30 NHSL Health and Safety Team Specialist Consultant (Theatres) Risk Register Continual assessment Upon completion of works Monklands Investment Board/ MKBC Project 20

21 Team/ Core Group Improved Audit Outcomes Sustainability of Service in an Energy Efficient manner Whole life cycle costs reduced Reduced Maintenance downtime BREEAM score Whole Life Cycle costs Reduced Carbon Footprint Upon completion of works Redundancy built into system (duality) Building Performance Indicator Operation and Maintenance Manuals Design/Technical/ Energy Team review of Design Clinical Service maintained through Duration of Works Minimised disruption to the Clinical teams in carrying out work 7 Operating Theatres and 6 ICU beds available throughout works Throughout works Maintaining uninterrupted clinical services Separation of clinical and construction egress and access and monitoring of same Clear and workable communications between the site supervisor and clinical team leaders throughout the working day. Efficiency within the department leading to best practice and improved service delivery Improved Patient flow from pre operative to post operative Better bed space size Better decontamination leads to improved productivity in endoscopy Reduced length of stay Improved turnover times in theatre Design team review On completion of works More flexible usage of clinical spaces Each theatre has anaesthetic room Doubling number of laminar flow theatres Reduced HAI Risk Segregated paediatrics 21

22 Providing better working environment Improved patient safety Improved changing facilities Improved catering facilities Improved space utilisation and functional suitability through increased Theatre and ICU space Improved Training facilities Improved control over temperature and air circulation Design Team Due Diligence Compliance with Building Regulations CDM HAI Scribe NHSL Health and Safety Team Specialist Consultant (Theatres) Risk Register On completion of works Improved storage Monklands Investment Board/ MKBC Project Team / Core Group Less down time through on- site training facilities and higher quality training environment Improved facilities for carers and relatives Segregated relative waiting and confidential interview rooms Relative experience surveys Ongoing This investment will undoubtedly facilitate the modernisation of healthcare delivery at Monklands District General Hospital. It is generally accepted that well designed health buildings are conducive to the maintenance of good physical and mental health, and have a positive effect on staff performance and retention. Such facilities should also improve the efficiency of operational relationships and provide better value for money in terms of whole-life costs. The objectives identified in this FBC are set within this context. Design/ Quality Objectives NHSL is committed to the integration of design quality throughout the project. A Design Statement was prepared at IA Stage through consultation and workshops with the key project stakeholders. The design statement set out in detail the specific objectives to be achieved together with a series of key, non-negotiable performance criteria related to patients, staff and visitors. It defined the benchmarks for how the design will help to deliver these objectives. 22

23 The design statement is a key briefing document for the Technical Team and has been used to inform the more detailed briefing documents such as the Schedules of Accommodation, key adjacencies, room data sheets and the layout and flow of the new facilities as the design has progressed into Stage F. All 1:50 room layouts have been signed off by the clinical user group and senior managers. The design statement is attached as Appendix 01. A design submission for the project was made to HFS and A+DS in line with the NHS Scotland Design Assessment process at this Full Business Case stage on 24th October The project team is currently engaged in an open dialogue with the HFS team in order to achieve a supported (verified) status for the scheme. A specialist M&E workshop took place on 26 th November 2014 to review the M&E design with HFS. Colleagues from NHS Highland were invited to this collaborative workshop to allow HFS feedback and lessons learnt to be carried forward to their Theatres Refurbishment Project at Raigmore. The design that has been developed has addressed the Essential Recommendations made by HFS at Outline Business Case Stage. The phasing methodology for the project has been further developed through close collaboration between Graham Construction, the design team and a group of NHSL users over a number of workshops, both informal and formal Over the course of these reviews this group has created the outline for a 12 Phase plan to completion of all works (included as Appendix 12 of this FBC). Decant Strategy meetings are currently on going to finalise the phasing methodology and the Boards decant and recant activities..the methodology that has been developed supports the requirement to maintain 7 theatres for the duration of the construction phase. The main project is due to commence in March 2015 with a completion date of April An enabling works phase is progressing at present to prepare the site. This includes: Contaminated land remediation Services diversion Ground stabilisation Road realignment The NHSL Senior Area Fire Safety Advisor is also key member of the team and has been engaged in the development of the Phasing Methodology. 23

24 An NHS Lanarkshire Business Continuity Group is established and the current version of the Business Continuity Plan is attached as Appendix 13. NHS Lanarkshire is committed to developing excellence in building design and providing fit for purpose facilities for the patients they serve in Lanarkshire. As noted within the OBC, the Project is using the Achieving Excellent Design Evaluation Toolkit (AEDET) to assess design quality throughout the procurement process and a second Workshop was held on Wednesday 08 th October 2014 to review the current design. HFS participated in this workshop. The summary of this AEDET Workshop can be seen below, with the detailed report included in Appendix 03. Diagram 03: AEDET Summary 24

25 A comparison of the OBC and FBC stage AEDET scores is shown below. The scoring against the majority of the categories improved, with the score for urban and social integration remaining the same. Category OBC Score FBC Score Difference A: Character and innovation B: Form and materials C: Staff and patient environment D: Urban and social integration E: Performance F: Engineering G: Construction H: Use I: Access J: Space Sustainability Objective NHS Lanarkshire is committed to developing sustainable, fit for purpose facilities for the communities served in Lanarkshire and to that end a BREEAM Assessor was appointed early in the planning and design process. It has been agreed with SGHSCD that the new BREEAM Pragmatic approach being undertaken by Health Facilities Scotland will apply to the Project. The design team is acutely aware of client requirements, and working in collaboration with both NHSL and HFS throughout the process of sustainable design development, has considered all aspects of the design throughout the life of the proposed works in order to achieve the maximum value for money and energy efficiency to reduce negative impacts on the environment, and improve the health and comfort of building occupants, thereby improving building performance that can be driven through BREEAM. A number of BREEAM workshops have taken place since OBC stage and the team is proceeding on the basis that both the Theatres and the ICU are being assessed under a single BREEAM New Construction 2011 Assessment. HFS has participated in the workshops. The BREEAM Assessor has set up a Tracker Plus portal that circulates a weekly update on the scoring, including where credits have been awarded. The team continue to provide evidence and push the project towards achieving all of the targeted credits. 25

26 The current scoring is as follows: Targeted score : 60.86% Targeted rating : Very Good Potential score : 66.10% An element of ongoing discussion is to ensure that the highest possible score is achieved under the BREEAM Pragmatic route, with a practical view being taken as to which credits are most suitable/ cost effective for the proposed works. A report has been provided to HFS outlining the reasons why certain credits are not targeted. Diagram 04: Current BREEAM Scoring As noted previously, engagement has continued to take place with HFS as part of the NDAP submission for the project. HFS has acknowledged the extensive work undertaken on the project design thus far; a letter of support for FBC stage is awaited. 26

27 2.6 Existing Arrangements Building and Fabric Monklands District General Hospital opened in 1974 and the theatre areas are typical of the age of the building with construction comprising of concrete floor slabs, brickwork walls and metal stud/ plasterboard partitions, waffle concrete soffits/ slab above ceiling voids. Corridor and circulation areas have dated perforated steel ceiling panels spanning the width of the corridor. Different elements of the Theatre/ ICU department have been upgraded at several stages in the past, with theatres 4, 7 and Recovery having improvement works delivered more recently however the entire department has not received a co-ordinated overall refurbishment in the recent past. Alterations have been made to the original layout, some of which have enhanced and some which have detracted from the original systems. The central core area is located between the two circulation corridors adjacent to the north and south theatres and a large proportion of the core area is taken up with the TSSU. The existing AHUs serving the Theatre and associated areas are the original units, in excess of 35 years old and are now beyond the end of their economical lifespan. The Theatres are served by packaged Air Handling Units located in the first floor plantroom. These units provide conditioned supply air to the theatres. Conditioned supply air is introduced into the theatre space via high level linear diffusers. The primary supply air is drawn from a brick built plenum chamber, which is common to all surgical unit AHUs located in the plantroom. Due to the age of the AHUs, spare parts are difficult to obtain and any AHU breakdown has the potential to cause significant business continuity issues. During 2009/10 Health Facilities Scotland (HFS), as part of a Scottish Government-funded project, surveyed theatre suites and associated ventilation plant in all Scottish acute hospitals. The Monklands District Hospital theatre suite was surveyed on 12th January Using Scottish Health Technical Memorandum (SHTM) Ventilation for healthcare premises (awaiting publication at that time) a benchmark was created to determine performance and compliance of the ventilation plant. Subsequently the outcome of the HFS report advised the Board that the condition of the Theatre ventilation plant was poor. NHS Lanarkshire placed the Theatre ventilation risk onto the Monklands Business Continuity Risk register, and put in place interim control measures with Maintenance Services and Infection Control to ensure that any risk exposure to patients was monitored. 27

28 In the review of works required to ensure the AHUs compliance with the SHTM, it was noted in subsequent Capita Symonds reports of April and July 2012 that the disruption caused in carrying out any replacement work would be major. The reports also noted that: The current plant room does not lend itself to replacement with removal being very difficult due to close proximity of plant, ductwork or building fabric. Power supply to each theatre to be upgraded and fitted with both UPS and IPS system along with general upgrade work to general and emergency escape lighting which is currently non- compliant Issues with fire compartmentation and escape signage identified in several theatres The overall recommendation from the Capita Symonds reports notes that due to the severe disruption required to the theatre area in order to replace the AHUs initially, and several noncompliances identified in the theatres regarding ventilation ductwork, fire compartmentation, and fabric and architectural items, that a programmed theatre upgrade works package be implemented at Monklands District General Hospital Theatres: The existing theatres currently provide a range of services to patients undergoing both major and minor surgery, including two centralised services in Urology and Ear, Nose and Throat and Maxillofacial surgery. Since the construction of the theatres there have been many developments in associated technologies such as laparoscopic and lasers which has led to additional items of equipment being added to the existing space. This has impacted the theatres whereby they are no longer of a suitable size to manage all of the required equipment, hindering flow and productivity through the area. There has also been an impact on certain procedures e.g. certain anaesthetic blocks due to the rooms being of inadequate size to accommodate the patient, staff and equipment in the same space. The flow of patients is also problematic as both male and female pre and post operative patients are located in the same area, segregated only by a small partition which brings with it issues around patient privacy and dignity. Similar issues exist with paediatric patients as there is no current area where they can be segregated from adult patients. To compound matters the existing operating theatres are also fully utilised, leaving very limited opportunity for planned maintenance. Loss of any operating rooms through AHU failure would have a considerable impact on NHS Lanarkshire s ability to provide surgical care. This would 28

29 result in cancellation of operations, an increase in waiting times and provide a potential risk to patients ICU Critical Care Needs Assessment: NHSL undertook a comprehensive needs assessment in 2011, the data from which demonstrated an inadequacy of Level 3 beds and Level 1 beds, with a satisfactory availability of Level 2 beds. Critical Care beds are defined as Level 1, 2 or 3. The following is the standard UK definition for the category of patient housed in these beds: Diagram 05: Critical Care Bed definition Level 1: Patients at risk of their condition deteriorating, or those relocated from higher levels of care whose needs can be met on an acute ward with additional advice and support from the critical care team Level 2: Patients requiring more detailed observation or intervention including support for a single failing organ or postoperative care, and those stepping down from higher levels of care Level 3: Patients requiring advanced respiratory support alone, or basic respiratory support, together with support of at least two organ systems. This level includes all complex patients requiring support for multi-organ failure The current situation in Monklands displays a disparate scattering of critical care throughout the hospital: Stand alone 6 bedded ICU (Level 3) situated next to the theatre complex on the ground floor. Stand alone 8 bedded surgical HDU within the surgical tower on the 2 nd floor. Funded for 8 HDU surgical patients from all disciplines within the surgical directorate (Level 2). 4 General medical HDU beds within ward 18 on the medical tower (Level 2). This ward also has 6 CCU beds and step down cardiology beds. 2 renal HDU beds within ward 1 Renal Unit (Level 2). This ward lies separate to the main hospital on the ground floor linked by a glass corridor. 29

30 Analysis of the 2011 study revealed that 50% of patients within surgical HDU actually required Level 1 care. Simply translated this means that 4 out of the 8 beds effectively operate at Level 1. Since the needs assessment was carried out, further pressure on the availability of surgical HDU beds has arisen due to the increase in major operating on the site, particularly within Urology Planned Redevelopment: For the short to medium term, restructuring of beds within the surgical tower at Monklands, in particular ward 4a (Emergency Surgical Receiving Unit), ward 4 (General Surgery), ward 5 (Surgical HDU), ward 6 (Urology) and ward 7 (General Surgery) has started and ongoing discussions are underway to address the following patient centred, safe and effective developments: Introduction of a 4 bedded surgical GP assessment bay within the ESRU (Ward 4a) open Monday to Friday The need for more beds providing heightened level of care post- operatively due to the nature and volume of major surgery on the site The launch of an enhanced recovery programme to improve the perioperative quality of care The requirement to expand the same day admission unit The expansion of in- patient Urology bed numbers There will be no increase in staffing costs as a result of this redevelopment. Physical changes to the wards are currently being scoped and will be factored into future plans for minor works in Monklands Hospital Wide Operational Impact: The CCNA suggests that a number of Level 1 beds are needed on the site and the Enhanced Recovery Programme as applied to major urology and colorectal cases requires support. For the surgical directorate, up to 8 Level 1 beds would satisfy these demands. If 4 of the current Level 2 surgical HDU beds were relocated to a combined ICU/ HDU this would theoretically leave nurse staffing for 4 Level 2 beds on ward 5. This resource would provide the basis for safe staffing of Level 1 beds in the surgical tower. 30

31 As outlined above, existing preliminary plans to redevelop and re- designate beds within the surgical tower would allow the development of a Level 1 surgical HDU which could house appropriate post- operative and emergency non- operative surgical cases. The overall impact is freeing up of beds within the surgical tower proportionate to the number of additional beds provided within a combined ICU/ HDU. Through progression of this FBC an opportunity would arise to improve the standard of critical care delivered on the Monklands site. As part of the essential theatre refurbishment the first major phase of the project would involve the relocation of the current Intensive Care Unit to a 10 bed ICU in a linked building next to the current geographical locus providing the ongoing benefits of a ground floor placement and proximity to the main operating theatre complex. A larger 10 bedded combined ICU/ HDU will afford greater flexibility, greater workforce efficiencies, greater business continuity options, greater training potential and ultimately better patient care in line with the quality ambitions of the Scottish Government Healthcare Quality Strategy. 31

32 2.7 Business Needs Current & Future Current Business Needs The current situation with the 7 operating theatre facilities on the Monklands site is such that scheduled cases are planned across a 6 day working week with evenings and weekends held open for emergency cases. The ICU service is adjacent to the theatre complex. The current service provision is 6 beds in this area. This area is undersized in relation to the healthcare standard Scottish Health Planning Note 27, which consequently has an impact on its operational functionality As part of a Scottish Government-funded project Health Facilities Scotland surveyed theatre suites and associated ventilation plant in Scottish acute hospitals in As part of that initiative the plant serving the Monklands District Hospital theatre suites was surveyed on 12th January Using Scottish Health Technical Memorandum (SHTM) Ventilation for healthcare premises a benchmark was created to determine performance and compliance of the ventilation plant. The subsequent outcome of this report advised the Board in February 2011, that the condition of the Theatre ventilation plant was scored as poor. The exposure to patients and staff is further compounded through non-compliance with other healthcare technical memorandum and healthcare standards such as Firecode, Fabric condition and CIBSE lighting standards. However the standards of Infection Control (Scottish Health Facilities Note (SHFN) 30) are compromised as perioperative infection, staff safety due to the non-compliant size of the theatres and fabric condition have increased the risk rating in conjunction with the ventilation issues to that of High. NHS Lanarkshire placed the Theatre refurbishment onto the Monklands Business Continuity Risk register and subsequently put in place interim control measures of additional environmental monitoring through Maintenance Services and Infection Control to ensure that any risk is minimised. Future Business Needs The number of Theatres remains the same under the refurbishment scheme as the physical footprint available will not permit expansion, however they will be significantly improved with regards to current healthcare guidance post works completion. It is also acknowledged that providing additional theatres within the envelope would also result in smaller theatres and thus non- compliance with the healthcare standards once again. 32

33 To accommodate any expansion in theatre/ patient activity, the existing Day Surgery provision on site will be used to take up any future increase. This will be quantified within the capacity plan developed under the NHSL Clinical Strategy. ICU will be expanded into a combined ICU/HDU with the capacity of 10 beds ensuring compliance with healthcare guidance. The areas that require improvement to ensure that the service and the facilities comply with legislation and healthcare guidance are as follows: Functional suitability Space utilisation Physical Condition Quality of patient care Ventilation HEI Control of Infection Fire Safety Energy use As described earlier, the future business needs (2025 and beyond) for NHS Lanarkshire s clinical services are the subject of a major planning exercise which will progress into 2016 before firm conclusions are reached. It is anticipated that the requirement for full surgical and ICU facilities within the current departments will remain into the mid 2020s until any replacement is delivered, or the existing (refurbished) facilities are integrated into a partial re-build of Monklands Hospital. 33

34 2.8 Desired Scope/ Service Requirements The Theatre suite in Monklands Hospital is now over 30 years old and no longer meets the requirements for patient management in the 21st century. The physical infrastructure including; air handling systems, size of theatres and anaesthetic facilities does not meet current standards. Moreover, the current environment limits both the efficiency of theatre and the type of surgery that can be carried out. The theatre suite has always achieved compliance with Health Environment Inspections (HEI) guidelines and Patient Safety Requirements. However, there are now regular issues with the theatre environment that are cause for concern both in the short and longer term. Maintenance of the theatre infrastructure is now proving more challenging and structural issues are becoming more frequent with a high risk of treatment delays and list cancellations. The main theatre suite accommodates seven theatres (Table 03). A further two Day Surgery theatres are located in a standalone unit in a separate location. The Day Surgery Unit (DSU) is outwith the scope of this project, although the resulting redesign of flow in main theatre will also help improve the use of DSU. Table 03: Theatre Specialty Allocation Theatre Theatre One Theatre Two Theatre Three Theatre Four Theatre Five Theatre Six Theatre Seven Specialty Urology General Surgery Urology Orthopaedics (Laminar flow) Ear, Nose and Throat /Vascular Ear Nose and Throat / Oral and Maxillofacial Surgery Emergency / Trauma All sessions are currently allocated (Table 04) and theatres are generally viewed as at full capacity (for core hours working). The theatres work flexibly to ensure that theatre sessions run as seamlessly as possible. There are some notable restrictions; theatre four is the only theatre with Laminar flow facilities. Theatre Seven is smaller than the other theatres and is reserved for emergency / trauma work. It also does not have an anaesthetic room at present. 34

35 Table 04: Allocated theatre sessions Mon Friday by specialty based on a 42 week year (excludes cepod and on call) Specialty Annual Allocated Theatre Sessions Mon Fri (based on 42 week year) Ear, Nose and Throat 639 General Surgery 651 Oral and Maxillofacial Surgery 168 Orthopaedics 336 Urology 630 Vascular / Cardiology 33 Total: 2,457 The demand for additional operating time continues to increase and the complexity of surgery has also grown over recent years (Table 05). Weekend and evening lists are currently arranged on an as required basis through Waiting List Initiatives. This is to ensure full compliance with 12 Time to Treatment Guarantees (TTG), which is now a legal right for patients. In response to the ongoing demand the organisation is exploring both 3 session days and 7 day working. Whilst this project will not provide any additional theatres, the upgrade in space and infrastructure will provide a stable environment that will facilitate the growing complexity of procedures (accommodating increased number of staff and equipment in theatre) and enable further efficiency gain of services. Table 05: Number of Inpatient Procedures by Specialty and Main Theatre Utilisation April 13 March 14. (Excludes DSU) Specialty Annual Procedures and Theatre Utilisation Elective Main Theatre Emergency Utilisation Ear, Nose and Throat 1,309 92% 957 General Surgery 1,082 96% 2,707 Oral and Maxillofacial Surgery % 244 Orthopaedics % 1,376 Urology 1, % 1,167 Vascular 42 74% 6 Cardiology 34 79% 342 Total Procedures: 4,735 6,799 Surgical Specialties Three concentrated surgical specialties in Lanarkshire have their inpatient base within Monklands Hospital, Ear, Nose and Throat (ENT), Oral and Maxillofacial Surgery (OMFS) and Urology. As a result all inpatient surgery, for these specialties, is restricted to Monklands Hospital. In addition, Urology and ENT are high volume specialties and consequently place a 35

36 high demand on theatre time. This is an important consideration as these services cannot be easily relocated either within Lanarkshire or externally. Urology surgical procedures range in complexity from minor surgery to complex corrective or cancer surgery. The service has seen a major increase in cancer surgery and the incidences of Urology cancer is predicted to increase significantly over the next three years. This includes prostate (49%), Kidney (21%), bladder (13%) and testicular cancer (6%). This has implications not only in terms of the volume of surgery but also in complexity and developing surgical techniques. The wide spread move to laparoscopic surgery has placed considerable demand on theatre time with many Urology procedures now require anything from one to three sessions per patient. The demographic makeup of urology referrals is an indicator for future demand with 74% of patients in the over 50 year age group. Unfortunately, these patients often have other health issues and specific anaesthetic requirements placing additional pressure on ITU /HDU facilities post operatively. In contrast to Urology, Ear, Nose and Throat (ENT) patients span a wide range of ages and Paediatric surgery is a main feature of the ENT workload. This creates additional challenges in achieving appropriate segregation of operating lists and recovery space within the theatre suit to comply with paediatric guidelines. The redesign of patient flow and space included in the project proposals will resolve these issues. One of the main issues for ENT is patient volume with a high number of routine procedures. It is planned to reflow a proportion of ENT procedures to DSU. However, this requires a number of elements to be put in place relating to organisation, flow and recovery space which will be influenced by this project. In addition, 15% of referrals for patients with ear problems convert to surgery. This is intricate surgery (including Myringoplasty and Stapedectomy) with these procedures often taking one session and requiring the continued use of a microscope during surgery. This has been noted as an issue during works, as excessive vibration can disturb these procedures. Three ENT consultants also make up part of the NHS Lanarkshire Head and Neck service. This forms the bulk of major and complex surgery in ENT including; Thyroidectomy and Laryngectomy. NHS Lanarkshire has the third highest incidence of Head and Neck Cancer in Scotland, therefore, this type of surgery will continues to increase. 36

37 Oral and Maxillofacial Surgery (OMFS) is the third concentrated specialty on the Monklands site. This is a much smaller specialty in terms of numbers but treats a high proportion of facial trauma including; fractures to the malar, maxilla and mandible. OMFS makes up the remaining part of the Head and Neck service performing complex surgery on floor of mouth cancer including facial reconstruction. The remaining elective procedures focus on Orthognathic surgery. The procedures undertaken in both types of surgery require one to three sessions per patient. The Orthopaedic department provides a range of joint surgery including knee and hip replacements as well as revisions. This type of surgery is currently restricted within Monklands Hospital as only theatre four contains a laminar flow system. It is proposed that this will be expanded to a second theatre as a result of this project, which will give the clinical team much greater flexibility in the programming of operating lists and sustainability of this core specialty during downtime for maintenance or repairs. Trauma also forms a major part of the orthopaedic workload. Monday to Friday there are 5 morning theatre sessions dedicated to trauma. During their on call week the orthopaedic surgeon s elective lists are backfilled to further increase capacity. General surgery includes a range of sub specialties including colorectal surgery and breast surgery. The increase in colorectal cancer and resulting increase in complex bowel surgery has been an ongoing issue in accessing theatre space. As with other specialties there has been a move to laparoscopic surgery for Gallbladder surgery and Hernia. The benefits in this type of surgery are well known for patients and include a quicker recovery and reduced length of stay in hospital. However, in theatre terms these procedures take longer, demanding more theatre time and require additional equipment and staff in theatre. Trauma and Emergency access is required by all surgical specialties within Monklands Hospital. Theatre 7 accommodates emergency surgery 24 hours a day, 7 days per week. Monday to Friday the morning sessions of the emergency lists are given to orthopaedic trauma. In addition, each surgeon gives up a session of their allocated theatre time on a rotational basis to provide a daily morning CEPOD list. 37

38 Critical Care As part of the refurbishment of theatre the first major phase requires the relocation of the current intensive care unit (ICU). It has been agreed that a ten bedded unit will replace the current 6 bedded ICU. This will move to a combined unit staffed to enable flexing up and down between levels of care depending on site demand both in ICU and in HDU beds. The location of the replacement unit has been identified and construction can take place with minimal disruption to the existing facilities. Critical Care Needs Assessment NHS Lanarkshire undertook a comprehensive needs assessment in This demonstrated a shortfall in Level 3 and Level 1 beds. However, an over provision of Level 2 beds were also identified with 50% of patients within the surgical HDU requiring only Level 1 care. This was further confirmed by local audit including the day of care audit. Therefore, based on the introduction of a minimum of 4 level 1 beds the number of HDU beds could be reduced to 4. ICU beds are staffed to 5 beds for the most part of the year increasing to 6 beds over winter when demand increases. Establishing a joint unit builds in flexibility around the provision of both ICU and HDU beds in response to demand. There has been a noted increase in pressure on HDU beds from elective surgery. This can be found in the increasingly complex surgery performed on site and the additional ongoing health issues which patients present. However, the expectation is that a high proportion of these patients require Level 1 care. It is planned to establish 4 6 Level 1 beds in the current HDU to meet this need. Table 06: Activity for ICU and HDU 2013 Area Admissions Average LOS (Days) Occupancy ICU % HDU % This revised configuration will not lead to an increase in overall staffing costs for the HDU/ ICU at Monklands. Also, the equipping of the increased number of level 1 beds will be managed within the equipment replacement programme for Monklands. 38

39 2.9 Benefits Criteria This section describes the main benefits and outcomes associated with the project and how these will be measured. The table below summarises the benefits identified and carried into the appraisal of the project options: Table 07: Benefits Criteria Category Benefit Definition Realisation Measure Through design development the pathway of the perioperative patients have improved. Operational clinical flows have improved resulting in increased efficiency. 1. Safety and Reduction of Harm Mitigation of risk to patient safety Room relationships, space utilisation and HAI/ Quality along with functional suitability are met through compliance with building, planning notes, health technical memorandum and building control Building fabric finishes and technical standards have resulted in improved control of infection through ease of maintenance and cleaning. Room sizes and relationships to other support space have been designed in line with current healthcare standards, where the requirements of advice notes have not been met a schedule of derogations have been compiled. Commissioned and signed off by Consulting Engineers, Architects and Building Control. User and Infection Control sign off Post Project Evaluation 39

40 Mitigation of fire safety compliance risk Firecode and building control requirements are improved and compliance achieved against standards Fire detection and compartmentation have been improved to meet current fire code standards. Examples include full L1 detection system, fire walls constructed to seal to structural floor slab as well as new fire doors. Commissioned and signed off by building control and Fire safety advisors. Post Project Evaluation Mitigation of AHU failure risk Air handling units and ventilation systems replaced to compliant standards New AHU installed providing both compliant systems as well as ease of maintenance in line with CDM regulations. Commissioned and signed off by Consulting Engineers, Architects and Building Control. Infection Control confirmation that works are satisfactory Post Project Evaluation Mitigation of infection control risk, due to building fabric All fabric replaced/upgraded in line with SHFN 30, HAI Scribe and healthcare compliant supplied materials Building fabric finishes have been carefully chosen to include Jointless wall finishes, floor finishes with butterfly joints, coved flooring, coved upstand to worksurfaces etc. Commissioned and signed off by Consulting Engineers, Architects and Building Control. Infection Control confirmation that works are satisfactory Post Project Evaluation 2. Improve Working Environment/ Operational Efficiency Improving Functionality of ICU Current patient needs will be better met with a flexibility in care in the face of increasingly complex surgery Concentration of Level 1 and 2 beds in the same area Changing disposition of Level 1,2 and 3 beds across the entire Improved access to ICU/ HDU beds Post Project Evaluation 40

41 site Improving supporting accommodation to improve functionality of department Improving Functionality of Theatres Current patient needs will be better met with a flexibility in care in the face of increasingly complex surgery Increased area of operating rooms Improved equipment storage within department Increase from 1 to 2 Laminar flow theatres Increased Theatres throughput Post Project Evaluation Mitigation of risk to clinical continuity maintaining clinical adjacencies and optimising space planning Room relationships and space utilisation along with functional suitability are met through compliance with building, planning notes and building control Strength in Design Coordination/ Cooperation with Service Users External Advice from Consultants Commissioned and signed off by Consulting Engineers, Architects and Building Control. User sign off Post Project Evaluation 3. Business Continuity Minimise works duration/impact on clinical activities No disruption to service or duration to clinical activities Business Continuity Plan HAI Scribe Communications Plan Phasing Plan Decant Strategy Site Supervision Regular User/consultant/cont ractor, liaison meetings HAI Scribe and other risk assessments in place Post Project Evaluation Project Management Structure Regular financial review during project 4. Value for Money Minimise Initial Capital Cost Project is completed on target price Early and consistent reporting Collaborative Working All compensation events scrutinised through change process Post Project 41

42 Evaluation Reduction in revenue costs (Maintenance) Budgets are in line with new facility servicing and operating and life cycle requirements Project Management Structure Early and consistent reporting Collaborative Working Life cycle costs meet the requirements of the new facility Operating and servicing costs meet the actual mode of operation Post Project Evaluation Reduction in revenue costs (staff), including costs for moving services off site The clinical model for staffing is met and on plan Project Management Structure Early and consistent reporting Collaborative Working The new service models scrutinised for effective ICU/HDU integration Theatres model is cost effective against plan Post Project Evaluation The benefits realisation plan has been further developed as the project has moved to FBC to include further description of how the project benefits will be realised and measured. Part of this process has been to include the specific Clinical Benefits discussed through the development of the Project. As these Clinical Benefits have been developed laterally and were not included in the original Option Appraisal exercise, they have been shown separately in the table below: 42

43 Table 08: Clinical Benefits Category Benefit Definition Realisation Measure Clinical Benefits Up to date facilities Providing appropriate clinical space that allows clinical intervention 1. No bed closures due to clinical procedures in adjacent bed spaces. 2. Allow timely intervention though complex procedures 1. Record of number of previous bed closures. 2. Measure time delays. Ability to meet the clinical demand Ability to flex between level 2 and level 3 patients Creation of a shared ICU/HDU facility led by intensivists Measured through SICSAG and by local report by JR Appropriate clinical environment A space that provides appropriate lighting, heating, ventilation, sound proofing to aid clinical functions. Ergonomic bed space that provides improved patient journey Patient surveys and experience Appropriate staff environment Ergonomic design Providing staff with safe and comfortable work environment Records through DATIX Appropriate visitor/family environment Providing holistic patient care Building design will provide the ability to separate bad news situation from others Relatives satisfaction surveys 43

44 HEI Compliance Improved building services and fabric Reduction in HAI incidents National HAI Surveillance programme will record incidents Improved training facilities Dedicated training space within facility Reduction in down time for clinical staff to attend training. Simulation training off site Training records will identify increase in staff training numbers Up to date facilities Patient safety, reduction in same day cancellation Reliable facilities that provides both in-use and back-up services Theatre consistent use with minimal cancellations Appropriate use of clinical staff Trained clinical staff doing clinical rather reactive non-clinical building/facilities functions 1. Staff morale higher due to refocusing on clinical care 2. Reduction in disruption in theatre list 1. Staff survey & staff absence 2. Minimal cancellations Availability of I.T Services Faster access to more comprehensive patient information Point of care information Improved patient safety and flow, recorded through DATIX Improved patient flow within recovery area Establishing dedicated paediatric area Compliance with paediatric and child protection guide lines Compliance with child protection audit 44

45 Improved theatre efficiency Central equipment storage Ease of access to the correct equipment first time Reduction in risk and improved flow 45

46 2.10 Strategic Risks The main project risks and mitigation factors have been identified at a high level within this Full Business Case and are noted below. A Project Risk Register has been developed which details and quantifies project risk. Table 08: Strategic Risks Risk Category Description Mitigation Business Strategy Service Delivery Meeting the future clinical needs of the NHS Lanarkshire population Business Continuity Meeting waiting times standards Maintaining optimal use of beds through utilisation improvements Maintaining a safe clinical environment and reducing perioperative infection Disruption to other services on site Failure to reach Estate Code standards Providing clinical facilities which are aligned to the clinical strategy Redundancy of systems, robust operational policies Maintaining 7 operating rooms and 6 ICU beds through Stage 3 of the project through preplanning, ongoing communication and HAI Scribe Planned logistical phasing of staff/ patients/ equipment External/ Environmental Delayed statutory approvals Adverse patient/ public reaction Issues with neighbours noise/ additional deliveries/ cranes etc Failure to obtain funding Revenue cost implications Increase in inflation Ongoing dialogue with NLC Ongoing dialogue with patients/ public/ neighbours Ongoing dialogue with SGHSCD Continual review of revenue implications PSCP to ensure that inflation is recognised at market testing This FBC details the development of risks into a formal risk register capturing individual risks within each category. The format of the risk register follows the guidance set in the Scottish 46

47 Capital Investment Manual (SCIM) and has been formatted as per the guidance provided in the NHS Health Improvement Standards (NHSHIS). An initial project risk register was established at a Core Team Risk Workshop held on 14/ This Workshop was run by the PSC PM and was attended by a wide audience comprising workgroup representatives from the core team, Clinical staff, and the PSCP and their design team, which fed Risks from each sub group into the Master Register. The risk register continues to be reviewed and updated. The latest Risk Register is attached as Appendix 04. The NHS Health Improvement Scotland (HIS) assessment matrices were used for the scoring of risks. This allows for four categories of risk, identified as follows: Table 09: HIS Rating Table 10: Impact/ Likelihood Pre- Mitigation and Post- Mitigation scores have been included on the Risk Register with an agreed Mitigation strategy. The table below highlights the current risk profile: Table 11: Risk Summary Risk Level Total Number of Risks per Risk Level (Pre- Mitigation) Total Number of Risks per Risk Level (Post- Mitigation) Very High - - High 28 4 Medium Low

48 Further details on the approach to Risk Management moving forward towards Construction are documented within Section 3.8 Risk Assessment and Section 6.6 Risk Management Constraints and Dependencies There are a number of key constraints/ dependencies associated with the delivery of this project: Constraints: Diagram 06: Project Constraints Requirement to deliver a BREEAM healthcare rating of Good under HFS Pragmatic Maintain current service provision whilst carrying out the works in a live environment Lack of available land on site to build new accommodation Requirement to deliver the project within both capital and revenue budgets Impact on Business Continuity Dependencies: Diagram 07: Project Constraints Ability to carry out the works whilst continuing full current service provision Cooperation of staff through the period of disruption Availability of Funding 48

49 3.0 The Economic Case 3.1 Introduction In accordance with the Scottish Capital Investment Manual and the requirements of HM Treasury s Green Book (A Guide to Appraisal in the Public Sector), this section of the FBC documents the process and provides evidence to show that the selection of the preferred option is derived from the most economically advantageous option whilst best meeting the service needs and optimising value for money. The Economic Case sets out: Critical Success Factors; Long Listed Options; Preferred Way Forward Short Listed Options; Economic Appraisal; Qualitative Benefits Appraisal; Risk Appraisal; Sensitivity Analysis; Preferred Option 49

50 3.2 Critical Success Factors The following critical success factors (CSFs) have been established confirming the attributes essential to the successful delivery of the scheme. The CSFs are used in conjunction with the investment objectives to evaluate the Long List of possible options: Diagram 08: Critical Success Factors Strategic Fit and Business Needs Must meet NHS Lanarkshire s investment objectives, business needs and service requirements and allow the delivery of all relevant national and local strategies. Must result in provision of facilities for patients, relatives and staff that is functionally suitable, safe and clinically effective. Supply Side Capacity and Achievability Must optimise the potential return on NHS Lanarkshire s expenditure, business outcomes and benefits Potential Affordability Must meet NHS Lanarkshire s ability to fund the required level of capital Potential Value for Money Must deliver improved and integrated services that provide value for money in terms of clinical efficiency in support of the strategy Potential Achievability NHS Lanarkshire must have the ability to support the service model and maintain service continuity at all times. NHSL s project board must have the ability to manage associated risks and establish a Project Team with the necessary level of skills (capacity and capability) to deliver the project 50

51 3.3 Main Business Options The path to the selection of the preferred option is explained in detail from Section 3.7 (Benefits Appraisal) onwards of the OBC. These sections provide the clear process followed for achieving the preferred option in this technically complex project, following on from the development of the Long List of Options described below. Further to the development of investment objectives, potential benefits and the critical success factors as previously noted within the OBC, a series of discussions and workshops were undertaken with the wider stakeholder group that: Reviewed the existing reports from Capita Symonds/ Interserve on the condition of the existing theatres and associated infrastructure Reviewed the national and global drivers for health service change with a view to developing an understanding of the implications of these on service provision Considered current procurement routes available to NHSL within the economic climate Examined the current services and property provision at Monklands District General Hospital The resultant outcome of these sessions was the following Long List of Options for the project: Table 12: Long List of Options Description 1 Do Nothing pending new build General Hospital: Maintain current maintenance programme 2 Do Minimum: Replace the AHUs for the Theatres as per HFS report recommendation 3 Full renovation works within the existing theatres, whilst maintaining current clinical activity 4 Renovation of a proportion of the department using 3 new operating rooms during and after the works, whilst maintaining current clinical activity 5 New Build Theatre department on site 6 Transfer a large proportion of current activity to elsewhere and renovate the current department A SWOT analysis of the Long List was then undertaken and this is included as Appendix 05 in the OBC. Following on from the SWOT analysis and a concurrent feasibility study to find an appropriately sized construction site within the grounds of Monklands District General Hospital it was decided to remove: 51

52 Option 1 as it will not address the issues currently identified within what would be considered an appropriate timescale: And: Air Handling Units (AHUs) not providing air pressure differentials to current building standards which poses a theoretical risk of cross infection between clean and dirty areas. AHUs are now 35 years old with a heightened risk of component failure which in turn poses an operational risk to business continuity. Option 5 due to the lack of availability of space within the current site to construct a new theatre block 3.4 Preferred Way Forward In preparing the OBC all appropriate funding and procurement options were considered including NPD. The construction costs are identified as 16.63m. and as detailed in SCIM, the minimum level for considering whether projects are suitable for NPD is 20m. Consequently, the guidance contained within SCIM has been followed i.e. the default procurement route for acute construction projects not suitable for NPD is Frameworks Scotland 2. The preferred way forward is therefore to proceed under Frameworks Scotland 2 with funding being provided from NHS Lanarkshire Capital Formula Allocation supported by property sales and additional national funding in years 2016/17 and 2017/ Short Listed Options Following the SWOT analysis carried out on the Long List of Options, a review against the Critical Success Factors (CSF s) and the identification of the Preferred Way Forward, a Short List of Options was recommended to carry forward into an Option Appraisal exercise at OBC stage: Table 13: Short List of Options Description 2 Do Minimum: Replace the AHUs for the Theatres as per HFS report recommendation 3 Full renovation works within the existing theatres, whilst maintaining current clinical activity 4 Renovation of a proportion of the department using 3 new operating rooms during and after the works, whilst maintaining current clinical activity 6 Transfer a large proportion of current activity to elsewhere and renovate the current department 52

53 3.6 NPC/ NPV Findings This section presents the economic appraisal of the shortlisted options and incorporates key elements of the Capital and Revenue implications of each which have been assessed over the anticipated life of the project and discounted to derive a Net Present Cost (NPC) for each viable option Capital Costs At the OBC stage the forecast capital costs for the options were developed and are summarised in the Table below. Table 14: Forecast Capital Costs Option s Option s Option s Option s Works Costs 4,520 15,025 13,200 14,729 Fees Irrecoverable VAT 800 2,470 2,178 2,422 Total 5,550 17,906 15,789 17,562 Included within the Capital Costs for the preferred Option is a Risk Allowance of 0.580m with an additional allowance of 0.802m also included in respect of Inflation. The forecast phasing of this expenditure at OBC is noted in the Table below: Table 15: Indicative Spend Profiles Option Description Total 2013/ / / / / Do Minimum: Replace AHUs for the Theatres as per HFS report recommendation Full renovation within the existing theatres, maintaining current clinical activity Renovation of a proportion of the department using 3 new operating rooms during and after the works, whilst maintaining current clinical activity Transfer a large proportion of current activity to elsewhere and renovate the current department 000's 000's 000's 000's 000's 000's 5, ,055 1, , ,065 7,185 5,905 2,270 15, ,000 7,393 5,915-17, ,000 9,426 5,657-53

54 3.6.2 Revenue Costs The high level indicative revenue costs for the project are forecast as 0.230m Table 16: Revenue Costs Option s Option s Option s Option s Capital Charges - 200, , ,000 Facilities Management - 30,000 30,000 30, Lifecycle Costs Indicative Lifecycle costs for the options have been estimated by the Cost Advisors and incorporated into the economic appraisal when calculating the net present costs. These have been profiled over the life of the Options and the total for the preferred option is 4.172m Table 17: Life Cycle Costs Option s Option s Option s Option s Total Element Cost 2,208 4,172 2,439 4,077 54

55 3.6.4 Net Present Cost (NPC) In line with Scottish Government Guidance the NPC for each option has been computed using discounted cash flow techniques. The capital and associated revenue for each option were used to carry out this economic appraisal using a discount rate of 3.5% over a period of 30 years. The resultant Net Present Cost for each viable option is summarised in the table below: Table 18: Net Present Cost and Ranking NPC Ranking Benefit Score Cost per Point Ranking Option Description 000's Points Do Minimum: Replace AHUs for the 2 Theatres as per HFS report recommendation 13, Full renovation within the existing theatres, maintaining current clinical activity Renovation of a proportion of the department using 3 new operating rooms during and after the works, whilst maintaining current clinical activity Transfer a large proportion of current activity to elsewhere and renovate the current department 16, , ,

56 3.7 Benefits Appraisal A Non- Financial Benefits Appraisal Workshop was undertaken on 12 th September 2012 to explore and examine the short list of options and to inform the development of the preferred option for the project. A group of stakeholders comprising clinical departmental staff, operational staff and representatives from the PSCP and their design team was present to ensure a consistency of approach and appropriate technical input was available. This Workshop took the form of a scoring exercise against the set of benefits criteria established in section 2.9 of this Outline Business Case. The Options appraised were: Diagram 09: Short List of Options Do Minimum: Replace the AHUs for the Theatres as per HFS report recommendation Full renovation works within the existing theatres, whilst maintaining current clinical activity Renovation of a proportion of the department using 3 new operating rooms during and after the works, whilst maintaining current clinical activity Transfer a large proportion of current activity to elsewhere and renovate the current department The full detail of the Workshop can be reviewed in Appendix Ten. 3.8 Risk Assessment Continual risk analysis has been ongoing to identify and assess the impact of all risks during the stages of the project. The Register will continue to be updated and reviewed throughout the course of the project. The various workgroups will feed pertinent Risks in to the Master Register on a regular basis and Board Risk will also be captured and mitigated. An update on the high risks will be discussed at the Core Group Meetings and the Project Board will be kept informed of the highest scoring risks via their Project Board Meeting. Further details of the approach to Risk Management moving towards Full Business Case are documented within Section 2.10 and Section 6.6 of this FBC. 56

57 3.9 Preferred Option The preferred option in terms of non- financial benefits appraisal is Option 3 as can be seen from the table below. Table 25: Non- Financial Ranking weighted score rank option 2: do minimum: replace AHUs only option 3: full refurbishment and upgrade of existing theatres option 4: partial refurbishment with new build theatres option 6: transfer of activity through refurbishment Under Sensitivity Analysis, Option 3 remains the preferred as per the below: Table 26: Non- Financial Sensitivity Ranking equal weight remove 2 &5 replace 6 with '5' weighted weighted weighted rank rank rank score score score option option option option Design Development Further to a preferred option being achieved through the benefits appraisal workshop and the subsequent testing of this option under non- financial sensitivity analysis, Stage D design work has been undertaken to develop a construction programme and phasing for this complex project. Through this work it became apparent that in order to achieve all clinical and technical aspirations for the project alongside the Board s request to maintain service in all seven theatres throughout the construction phase that the option to refurbish and upgrade the theatres would require to be enhanced to include a new ICU built adjacent to the current theatre space. This addition allows the provision of a more clinically effective ICU and provides the necessary space to create theatres in line with current technical guidance. This enhancement of the Option has been undertaken with full participation of the participants involved in the Option Appraisal exercise and has been agreed and ratified as being the preferred option to be carried forward into detailed design work at Stage D. 57

58 The NPC has been used in conjunction with the scoring obtained during the non-financial appraisal workshop to calculate the NPC per benefit point in order to rank the viable options. The final outcomes are summarised in the table below: Summary of Net Present Costs, Benefit Points and Rankings Table 27: Summary of Financial and Non- Financial Rankings Net Present Cost 000 s Benefit Points NPC per Benefit Point 000 s Option 2: do minimum: replace AHUs only 13, Option 3: full refurbishment and upgrade of existing theatres 16, Option 4: partial refurbishment with new build theatres 14, Option 6: transfer of activity through refurbishment 18, Rank 3.10 Sensitivity Analysis As a Business Case is built upon various estimates, it is recommended that a sensitivity analysis is undertaken to assess to what degree the key estimates would need to change in order to alter the investment decision. Consequently sensitivities were performed in order to understand how much each of the key cost components relating to Capital and Revenue costs (excluding VAT) would need to change in order to reverse the rankings of the two viable sites. The outcomes of the sensitivities demonstrate the following: Sensitivity Analysis in respect of Net Present Cost As the Preferred Option is not the one that delivers the lowest NPC no Sensitivity Analysis has been conducted solely on NPC Sensitivity Analysis in respect of Net Present Cost per Benefit Point As noted in Sensitivity Analysis has been restricted to an examination of the rankings of the option in terms of NPC per Benefit Point. The revenue costs of all options with the exception of Option 2 are the same. A comparison of Option 2 and Option 3 has been undertaken to assess what level of increase in the Revenue Costs would be required to rank Option 2 ahead of Option 3. The table below illustrates that an increase in Revenue Costs to a level of 0.3m, a factor of ten times the level assessed, would be required to alter the ranking of Option 3 as the preferred option. 58

59 Table 28: Comparison of Revenue Costs Revenue Cost 000 s NPC per Benefit Point OPTION s NPC per Benefit Point OPTION s OBC Base Position Increase in Revenue Costs to: Increase in Revenue Costs to: Increase in Revenue Costs to: An examination of what level of increase in the Capital Cost of the preferred option would be required to make option 2 rank over option 3 was also undertaken The table below illustrates that an increase in Capital Costs to a level of m, an increase of over 30%, would be required to alter the ranking of Option 3 as the preferred option. Table 29: Comparison of Capital Costs Capital Cost 000 s NPC per Benefit Point OPTION s NPC per Benefit Point OPTION s OBC Base Position 17, Increase in Capital Costs of 10% 19, Increase in Revenue Costs of 20% 21, Increase in Revenue Costs of 30% 23,

60 4 The Commercial Case 4.1 Introduction This section outlines the commercial transaction that the board will sign up to and will consider the following: The scope of the services being contracted for The management and allocation of risk Potential charging mechanism Key contractual arrangements Personnel implications Implementation timescales Accountancy treatment 60

61 4.2 Agreed Scope and Services The services to be included within the refurbished Theatres/ ICU are identified below: Diagram 10: Services 10 critical care beds which can be flexibly staffed and equipped for use for either intensive care or high dependency 7 operating rooms (two provided with ultra clean/ laminar flow environment) Support accommodation including staff changing, administration, training and storage The operating department will provide the facilities necessary to maintain surgical specialties on this site. At present this includes a mix of daysurgery and inpatient surgery for orthopaedics, ENT, urology, and general surgery. The ICU accommodates an expansion of ICU beds from 6 to 10. This sits alongside HDU beds in other parts of the hospital for medicine and surgery. All critical care beds on the site will be managed collectively and flexibly to ensure the staffing skill- mix matches the level of care required for the patients at any point in time. The refurbishment will be provided under Frameworks Scotland 2 with the Capital Funding provided through NHSL formula funding initially and treasury funding laterally. Group 1 equipment items, which are generally large items of permanently installed plant or equipment, will be supplied, installed by the PSCP, maintained and replaced by NHSL. Group 2 items, which are items of fixed plant and equipment used in the delivery of engineering services and medical equipment, will be supplied by NHSL installed by PSCP and maintained and replaced by NHSL. Group 3 items will be procured through NHSL Group 4 items, generally smaller and moveable equipment will be supplied, installed, maintained and replaced by NHSL. 61

62 4.3 Agreed Risk Allocation The key features of the New Engineering and Construction Contract (NEC 3 - Option C) contract are: The parties are encouraged to work together as partners in an open and transparent approach and to ensure that this partnering ethos is maintained There is a Gain/ Pain share mechanism to act as an incentive to the delivery team, by rewarding good performance and penalising poor performance A clear and transparent system is on the table to enable negotiation to take place on prices A level of price certainty is determined All price thresholds are set using quantitative risk analysis It is a variant of Maximum Price/ Target Cost (MPTC) approach In accordance with the Frameworks Scotland 2 guidance notes, the NHS Client and the PSCP act as joint owners of the Joint Project Risk Register. Risks will be allocated to the party best able to manage the risk subject to value for money and responsibility for risks will be clearly identified. The table below illustrates the potential allocation of risk: Table 30: Risk Allocation Risk Category Potential allocation of risk NHS Graham Shared Design Development and Construction Transition and Implementation Performance Operating Revenue Termination Technology and Obsolescence Control Financing Legislative 62

63 4.4 Agreed Charging Mechanisms This project is being procured through HFS framework Scotland 2 with design being led by the PSCP and their design team. As such there is no concession period and so no charging mechanism applied. The PSCP shall design & build the project and upon completion hand the building over to the client (NHSL) to manage and operate the facility. It is worth noting that during the design & construction process cognisance shall be given to the whole life costs of the facility in order that the project achieves value for money. The PSCP is also incentivised through the use of a target cost contract NEC3 Option C for Stage 2, which promotes that the PSCP look for efficiencies when carrying out the project. 4.5 Agreed Key Contractual Arrangements The preferred solution is being procured under Frameworks Scotland 2. This framework is founded on collaborative working and the NEC3 form of contract is used to support these principles. Following the SGHSCD s methodology for tendering work through the new Framework for Scotland 2, Graham Construction has been appointed as Principal Supply Chain Partner (PSCP) to work with the Board to finalise design, work up the target cost for the scheme and to construct the building. Graham Construction has been appointed to deliver multiple works task orders for NHS Lanarkshire under the new Health Facilities Overarching Scheme Contract. The Theatres/ ICU work task order is the largest and most complex project currently being delivered under the scheme As noted above, the mechanism for ensuring that this partnership ethos is carried through to the construction of the new facility is through the use of the NEC3 form of contract. The main principles of this procurement methodology are outlined below: The Priced Contract Stage 1B Preconstruction Activity - Designing a Solution The priced contract for the Preconstruction Activity, designing a solution is fixed priced during Stage 1B and before construction is commenced (Stage 2). During Stage 1B the PSCP must deliver a design solution for a priced contract sum NEC Option A. Once agreed the priced contract sum for this stage, my only be revised upward or downward when compensation events occur under the scheme contract. Any estimated costs included within the priced contract sum must be understood together with the potential risks to the project and how they may be removed/ managed. The likely cost consequences and the occurrence of risks that are considered likely to occur will be discussed with a view to agreeing an appropriate contingency in either the priced contract sum (if the PSCP is responsible for the risk) or in NHS Lanarkshire s Budget (if NHS Lanarkshire is responsible for the risk). 63

64 The level of information that the PSCP requires to provide in support of the priced contract with activity schedule for monthly applications for payment will be agreed with the Cost Advisor. The PSCP will provide a fully detailed priced activity schedule breakdown with their application for payment which will be verified by the Cost Advisor. The objective is to work together to agree the completion of each activity as detailed within the priced contract activity schedule, any risk allowances; and the percentage fee (overheads and profit) applied to such sums. The aim underpinning this approach is to reduce costs by understanding the risks that make it higher and managing/ removing those risks and at the same time seeking to plan the services/ works provided by the PSCP and its SCMs so that the Stage will be more effectively carried out Open Book Philosophy - Stage 2 Construction Target Contract with Activity Schedule The target contract for construction following completion of the design is a target price with activity schedule during Stage 2 construction NEC3 Option C. A key principle of the NEC3 Option C contract is the payment of Defined Cost and an open book accounting philosophy. These require a robust, reliable and transparent system to record staff time and manage the invoicing process. This allows the Cost Advisor not only to identify costs but also to establish that the costs have been properly expended on the project and that they are allowable under the NEC3 Option C contract as defined under the schedule of cost components. Project costs must be referenced to items on the activity schedules with detail added against 5 main headings of; labour, plant, materials, sub contractors and preliminaries. Orders, deliveries, invoices for payment, external plant hires and sub-contracts also have to be crosschecked against Goods Received Notes. The PSCP will be required to demonstrate that market testing has occurred at Stage 2 in the order of 80% of the priced contract sum. The target price is key to the cost operation of the contract and is set during the preconstruction phase. This process concludes when the PSCP s proposals are completed for costing and the risk register has been agreed. The target price costing is made up of the following elements: 64

65 Diagram 11: Target Price Costing Elements Within the NEC 3 Option C contact, there is provision to adjust the target price (upwards and downwards) via the compensation event process. Contractors Overheads & Profit Contractor s Share Percentage and Share Range Within clause 53 of the NEC 3 contract, the pain share/ gain share payment mechanism is setout. This clause requires to be read in conjunction with Contract Data part 1 which defines the share percentages and share ranges. The table below outlines the share ranges on Frameworks Scotland: Diagram 12: Pain Share / Gain Share Model >100% Contractor takes 100% of the Pain 100% 95%>100% <95% Target Price Contractor & Employer share the gain 50:50 Employer takes 100% of the Gain below the 95% The key benefit of the introduction of the target price with a pain share / gain share mechanism is the incentivisation on the team and PSCP to control cost Priced Activity Schedule The activity schedule is defined in Clause 11.2(20). Clause 54.1 states that information in the activity schedule is not works or site information. The activity schedule under NEC 3 option C is provided by the PSCP in contract data part 2 as part of the pre-construction phase conclusion. The activity schedule gives a breakdown of the work to be done under the contract and this covers the entire contract price. A key interface within NEC 3 is that the activity schedule must be related to the accepted programme as defined under Clause The principle objective of having the activity schedule and accepted programme linked under NEC 3 option C is not to assess the contractor s payments (these are made on defined cost), but to assist in the assessment of compensation events and contractors share. 65

66 4.5.5 Defined Costs Defined cost is outlined in Clause 11.2(23) and is made of up 3 key elements: The amount of payments due to sub-contractors for work which is subcontracted without taking account of amounts deducted for; retentions, payments to employer for failure to meet key dates, correction of defects after completion, payments to others and supply of equipment etc. The cost of components in the Schedule of Cost Components for other work Less, Disallowed cost (as defined under Clause 11.2(25)) Recording and Collation of Costs Information Clause 52.2 requires the PSCP to keep records of: Accounts of payments of Defined Costs Proof of payments being made Communications about and assessments of compensation events for Subcontractors Other records required by the works information The PSCP will ensure that the Cost Advisor has full and unrestricted access to accounts and records that are required to be maintained in accordance with Clause Compensation Events and the Application thereof Clause 60.1 details 19 compensation events for which the PSCP is entitled to compensation if they occur. The object of the NEC 3 contract is to ensure that all compensation events are listed in one place, expressed clearly to avoid disagreement and to allocate the events in line with modern risk allocation principles. An important aspect of the compensation event (CE) process is that both the Project Manager and PSCP are required to notify them. The Project Manager raises C.E s for instructions or changing decisions. The PSCP notifies a CE if he believes that the event is a compensation event or if the Project Manager has not notified the PSCP. Once compensation event notifications are accepted by the Project Manager, quotations are provided in accordance with Clause 62 and submitted for consideration. These quotations cover cost and time and must be linked to the accepted programme. The Project Manager makes the assessment in accordance with Clause 63 or 64 and they are then implemented in accordance with Clause 65. The key to the entire process within NEC3 is that the process has time constraints to ensure that decisions are made, preventing the process dragging on, allowing the Project to move forward without protracted negotiations. The compensation event process can be simply defined as per the diagram below: 66

67 Diagram 13: Compensation Event Sequence 4.6 BS11000 The Theatres/ ICU Project Team is committed to collaborative working and recognise the wide range of benefits that can be delivered by this approach, that will enhance efficiencies and performance and create value. In addition to the contractual requirements of the NEC3 contract, the NHSL Frameworks Scotland 2 Project Team is developing this collaborative business relationship under the British Standard, BS Executive and Joint Management Teams have been established and a set of joint objectives agreed. An Improvement Team is in place to capture lessons learnt and to identify and implement value creation activities, such as bundling of work tasks and the joint management of risk. These lessons learned will be incorporated in the Post Project Evaluation for the Theatres/ ICU project. The BS11000 standard provides a strategic framework to improve the longstanding collaborative relationships within the project team. Our Health Facilities Scotland Project Advisor and SGHSCD are pro- actively supporting this initiative and will report on the benefits to the Frameworks Scotland Project Board. 67

68 4.7 Agreed Personnel Implications There is no major impact for staff with regard to terms and conditions as a result of the refurbishment and new build work. Some working practices will change by the time the refurbishment is complete but this is work already in progress and has not been initiated as a direct result of the project. The change in flow of both HDU and theatre patients provided by the project will not only facilitate a better patient experience and a higher standard of care but also a greatly improved working environment for staff. The Intensive Care Unit (ward 26) and surgical High Dependency Unit (ward 5) as previously noted in this FBC currently occupy two separate locations within Monklands General Hospital however they are managed as one unit with staff rotating between both. The plan to establish a combined unit will require a change in base ward for some staff. The remaining beds in the existing surgical HDU will revert to Level 1 which is already staffed by nurses with the appropriate training and skills. The proposed combined unit will comprise of 10 beds with a 6:4 split of ITU to HDU. However, the unit will be staffed to enable the beds to flex up and down between dependency levels in response to site demand. Nursing staff with the required skills are currently available to facilitate this but there is also an ongoing training programme for staff working in these areas to ensure all necessary skills are met. Within the existing units the access and discharge criteria are applied quite differently with medical staff fulfilling a gate keeping role. Consultant Intensivists manage both admissions and discharge to ITU beds. The General Surgeons currently agree access to surgical HDU but discharge is left to individual consultants with considerable input from nursing staff. Within a combined unit it is proposed that the Consultant Intensivists will assume the complete role for both ITU and HDU. This role change will provide a consistent standard of care to both Level 2 and 3 patients whilst ensuring efficient bed management. Historically within the theatre suite, staff were employed to work in either the recovery area or theatre. Over the last few years this policy has changed with nursing staff now employed as cover for the complete theatre suite. This ensures flexibility in staffing for both areas as well as the same day admission lounge which is run as part of theatres. A rotational programme is currently in place for all theatre staff and this is embedded within the staff rota therefore no staffing issues are expected as a result of the redesigned flow of patients through the theatre suite. The additional available work space will also create an improved and safer working environment for staff within ITU and Theatres. This will also further promote patient safety and there will be the opportunity to provide additional work based clinical training and education. 68

69 4.8 Agreed Implementation Timescales Following approval of the OBC, a Full Business Case (FBC) has been prepared for SGHSCD CIG approval. Once the FBC has been approved, the construction works to align with the decant strategy will commence. This main construction period is estimated at 40 months culminating with completion in April Table 31: Timescales Stage 1B: FBC FBC Gateway Review December 2014 FBC Submission to CIG 27 January 2015 FBC Approval by CIG 24 February 2015 Stage 2: Construction Start on Site 23 February 2015 Completion 06 April 2018 A separate enabling works Work Task order commenced on 17 November 2014 and will be completed in advance of the Phase 1 of the main project commencing. 4.9 Agreed Accountancy Treatment The capital costs associated with the refurbished Theatres/ ICU will be capitalised in line with all appropriate accounting standards and this FBC is predicated on the appropriate level of Capital Funding being made available through NHSL formula funding and supplemented by national funding in 2016/17 and 2017/18. 69

70 5.0 The Financial Case 5.1 Introduction The financial case for the preferred option sets out the following key features: Potential Capital/ Funding Requirement; Potential Revenue Impact; Impact on Balance Sheet; Stakeholder Support; Overall Affordability 5.2 Agreed Capital/ Funding Requirement 70

71 The potential capital costs and associated funding requirement are considered in greater detail in the following sections. The capital costs for the preferred option are shown below and are derived from cost schedules produced by the Framework PSCP Graham Construction, in conjunction with the cost advisors Currie & Brown Capital Costs The capital costs for the preferred option are shown below and are derived from cost schedules produced by the Framework 2 PSCP Graham Construction, in conjunction with the cost advisors Currie & Brown. The Capital Costs include contingencies and allowance for out of hours working to allow the project to be delivered while the theatres remain in use. A breakdown of the cost movement from OBC compiled by the cost advisor is included in Appendix 15. Table 32: Forecast Capital Costs for the Preferred Option Total Cost 000 s Total Works Costs 16,631 Fees 412 Irrecoverable VAT 2,727 Total Capital Cost 19,770 The build costs represent the cost of construction in respect of a 7 theatre facility with a 10 bed ICU which adds 1,100m² to the current footprint of the hospital. The estimated construction costs have been prepared by the Framework PSCP partners in conjunction with the Cost Advisors using the following assumptions and allowances: The project is planned to commence construction in March 2015 with Clinical Service commencing in May 2018; Costs are based on a 2014 price base; The build up of costs for the preferred option can be viewed in Appendix 11 of this FBC, with advisor costs being developed from Frameworks Scotland 2 rates, and risk having been benchmarked against similar historical projects at this time. A fully costed Risk Register has been developed for the FBC. This represents an increase of 1.87m on the costs included within the OBC, a schedule of the differences is included with Appendix 15. An increase of approx 30% would be required before the preferred option would be altered. This is outlined within the Sensitivity Analysis shown earlier in the FBC Risk Allowance 71

72 A Risk Register for the project has been developed (Appendix 04) as a result of workshops and reviews. The commercial risks for the project have been priced using 3 point estimating technique where a minimum cost, maximum cost and most likely cost has been calculated. These have then been combined with the probability & impact scores in the risk register and run through a Monte Carlo simulation. This has provided us with a average risk estimate of 602,122. Through discussions\negotiations with the PSCP this has been reduced to 512,227. Employer side risks are not included within the OBC figure but are accounted for within the overall Monklands Business Continuity risk budget. As the project progresses the employer risk pot will be released in order to fund other projects on the Monklands site and the risk register has been priced and run through a Monte Carlo Simulation in order to quantify the amount of risk included within the Target Price for the FBC Capital Funding and Procurement As previously noted within this FBC, the remaining construction costs fall below the de minimus level noted within Scottish Capital Investment Manual (SCIM) as being suitable for exploring potential Not for Profit Distribution (NPD) routes. As such, in order to progress the project, it will be necessary for a capital funding contribution to be made available through NHSL formula funding equating to the 19.77m capital value to allow the construction of the facility to proceed under the Frameworks Scotland 2 procurement route. The theatre refurbishment will be constructed within the existing footprint of the current service, with the new 10 bed ICU constructed on land owned by NHS Lanarkshire directly adjacent to the current theatres. The Capital Cost Spend Profile is shown in the table below: Table 33: Indicative Capital Cost Spend Profile Option Description Total 2013/ / / / / /19 3 Full renovation within the existing theatres, maintaining activity 000's 000's 000's 000's 000's 000's 000's 19, ,440 7,415 5,673 4, Joint Procurement Opportunities As noted elsewhere within the FBC, NHS Highland is progressing with a similar project at Raigmore Hospital in Inverness. Graham Construction is also appointed to this scheme and as such it was agreed with all parties that procurement efficiencies should be sought out where possible. If savings are made then this shall be omitted by way of a negative compensation event. 72

73 5.3 Revenue Impact Total Revenue Costs The high level indicative revenue costs are forecast at 230,000. Further commentary on the Revenue costs by category is included below Pay Costs There are no anticipated increase in pay costs with all cost expected to be met from existing resources Non Pay Costs There will be a minor increase in facilities management costs as a result of the increase the 1,100 m2 of the footprint for the ITU. This has been estimated at 30,000, p.a Depreciation For forecasting and appraisal purposes, the building depreciation has been calculated over 25 years. Following completion of the ICU it is anticipated that the new building will be valued by the appointed valuer at which time an appraisal of the added value of the facility will be assessed and a building specific Assessed Life will be allocated Overall Recurring Revenue Costs These costs represent the additional recurring revenue costs associated with the refurbishment project. As the project will be constructed on land owned by NHS Lanarkshire, ownership and responsibility for the facilities management, support services and clinical services support will rest with NHSL. In conformance with the guidelines issued by SGHSCD, a statement of sustainable financial support for the revenue costs associated with the preferred option is contained Appendix Agreed Impact on Balance Sheet The capital costs associated with the refurbished and upgraded theatres and ICU will be capitalised in line with all appropriate accounting standards and this FBC is predicated on the appropriate level of Capital Funding being made available Major Medical Equipment The equipping of the increased number of level 1 beds will be managed within the equipment replacement programme for Monklands Construction Costs of the Facility As responsibility for the construction and provision of the facility at Monklands District General Hospital will lie with NHSL, the capital funding for the construction, including appropriate fees etc., will be met within NHSL s formula capital funding with additional funding made available by Scottish Government in 2016/17 and 2017/18. On completion of the ICU, it is proposed that the new building be subjected to an initial valuation by the District Valuer. As the project will 73

74 result in the construction of a new building it is anticipated that the vast majority of the construction investment will add value to NHSL s existing estate, however any impairment value will be communicated to the SGHSCD through completion of the annual AME Impairment Return Initial Expenditure up to Stage 1B of the Project In order to progress the design and development of the facility a Principal Supply Chain Partner (PSCP), Project Managers and Cost Advisors were appointed to progress the initial designs for the facility. NHSL has progressed these aspects of the scheme and has therefore incurred some early capital costs associated with this work. As these costs are an integral part of the scheme, they have been included in the construction expenditure noted in this document. Additionally work to the value of 0.8m has been advanced to prepare the area on which the extended ICU will be built. This includes the removal of contaminated soil, diversion of services, road and path realignment and grouting works. The cost of this is included within the Capital Costs contained within this FBC and were approved in order to ensure that the programme outlined within the OBC is maintained. 5.5 Impact on Income and Expenditure Account The Recurring Revenue Costs associated with the FBC are included within NHSL s financial plan. 5.6 Stakeholder Support The development of the Theatres & ICU refurbishment is supported by the following: Diagram 14: Supporting Parties Acute Division Operating management committee NHS Lanarkshire Capital Investment Group NHS Lanarkshire Monklands investment Board A Letter of support is provided within Appendix Overall Affordability The Financial Case has highlighted the overall capital and revenue affordability of the preferred option and identifies a requirement for: A total forecast Capital cost of 19.77m to be funded through NHSL formula funding through with additional Scottish Government capital being provided from to completion. Total recurring annual revenue costs of 0.23m including 0.2m of Capital Charges to be funded by NHSL. 74

75 6.0 The Management Case 6.1 Introduction This section of the FBC sets out the management arrangements that are in place to ensure the successful delivery of the MKBC Theatres project. Areas covered include: Procurement Strategy Project Management Change Management Benefits Realisation Risk Management Post Project Evaluation 6.2 Procurement Strategy The preferred option of refurbishment and upgrade of the theatres has been procured under Frameworks Scotland 2. This framework is founded on collaborative working and the NEC3 form of contract is used to support these principles. Following the methodology for tendering work through Frameworks Scotland 2, a Principal Supply Chain Partner (PSCP) Graham Construction was appointed to work with the Core Team to finalise design, work up the target cost for the scheme and to construct the building. 6.3 Project Management Project Management Approach To successfully manage and deliver the MKBC Theatres Project, clearly defined project management arrangements have been established and experienced personnel identified to implement them Project Management Structure The diagram below represents the current NHSL FS2 overarching scheme contract, with Graham Construction being the PSCP appointed to deliver construction. Currie & Brown provides Lead Advisor services to NHSL on their Frameworks Scotland 2 Scheme. Diagram 15: NHSL Overarching Scheme Contract 75

76 The below diagram provides a further breakdown which shows that due to the complexity of the Theatres and ICU project it has its own Core Group that sits outwith the main Monklands WTO Core team structure. Diagram 16: Meeting Structure This development has been led by the Monklands Investment Programme Board. The Investment Board is comprised of the following representatives: Diagram 17: Investment Board Project Owner: Colin Sloey Project Director Colin Lauder Project Technical Director: Robert Spencer Senior User: Andrea Fyfe NEC3 Project Manager: Fiona McDade General Manager PSSD John Paterson Director of Finance Laura Ace Chief Doctor Rory Mackenzie Chief of nursing services Ruth Thompson The MKBC Project Team represents the wider ownership interests of the project and maintains co-ordination of the development proposal. 76

77 Diagram 18: MKBC Project Team Project Director: Colin Lauder Project Technical Director: Robert Spencer NHSL Project Manager: George Reid NEC3 Project Manager: Fiona McDade General Manager PSSD John Paterson Finance Representative Brian McWatt Clinical Lead Nicola Ruddy Health and Safety Gordon Gray Control of Infection Richard Fox PSCP Project Lead Keith Barclay PSCP Project Manager David Swanson PSCP Contracts Manager Pat O Hare CDM Coordinator Allan Dick Communications Officer Craig McKay Health Facilities Scotland Stuart Brown A Project Core Working Group has managed the day to day detailed information required to deliver the project. This comprises the following representatives: Diagram 19: Core Group Project Technical Director Robert Spencer General Manager PSSD John Paterson Surgical Services Manager Graeme McGibbon Head of Health and Safety Gordon Gray Finance Representative Brian McWatt Consultant Anaesthetist Dr Jim Ruddy Clinical Lead Nicola Ruddy NHSL Project Manager George Reid NEC3 Project Manager Fiona McDade PSCP Project Lead Keith Barclay PSCP M&E Manager Brian Thomson PSCP Design Manager Stephen Bradley Infection Control Senior Nurse Richard Fox The project has also been supported by a series of sub groups/ task teams as required and identified in the Guide to Frameworks Scotland published by Health Facilities Scotland. These task teams will include Technical User Group; Business Case Development; IM&T; Equipment; Commissioning and Finance. 77

78 This can be simplified in the diagram below: Diagram 20: Project Governance Project Management Framework The diagram below outlines the stages for the implementation of the project under SCIM, HFS and RIBA stages: Diagram 21: Project Management Framework 78

79 6.3.4 Programme and Milestones Further to the Outline Business Case being approved in August 2014, work has progressed on this FBC for submission to the SGHSCD CIG meeting in January The indicative timetable for the project following this is shown in the table below: Table 34: Indicative Project Timetable OBC SGHSCD CIG Approved August 2014 Enabling Works 17 th November 2014 FBC SGHSCD CIG Submission 27 th January 2015 FBC SGHSCD CIG Approval 24 th February 2015 Construction Start on Site 16 th March 2015 Construction Completion 25 th May 2018 Post Project Evaluation Post Occupancy Evaluation +12 months from occupation +2-5 years from occupation The dates noted in the above table will be subject to further development/ agreement as the project progresses. The Stage 2 Construction programme will be submitted for acceptance by the Project Manager as part of the Graham Construction Target Price Submission. The programme will then become a contract document. 79

80 6.3.5 Stakeholder Consultation and Engagement The MKBC project team has identified the key stakeholders with an interest this project as being: Surgeons Anaesthetists Theatre and recovery nursing staff Control of infection team Managers within the acute division Managers within support services (estates and hotel services) Patient representatives. Over the past two years a series of meetings and discussions has taken place with these stakeholders. This has included workshops to develop potential options and scoring of these options. Stakeholders are represented on the Core Group and as such have an active input into elements of the design of the proposed departments. The design stages have been driven by the requirements of the clinical teams. Given that patients are generally unaware of their environment when in theatre or ICU, patient representatives have not yet been engaged with the design/ build process. It is intended that patient/ public input will be sought (via PPFs) during the next stage Collaborative Working with NHS Highland, Clinical Care Upgrade at Raigmore Through engagement with HFS, a collaborative working group has been established with NHS Highland who is currently developing the Clinical Care Upgrade Scheme at Raigmore in Inverness. A significant element of this scheme is a Theatres Upgrade project which will address similar issues to the Monklands Theatres. Both Boards have appointed Graham Construction as their PSCP and have identified opportunities for knowledge sharing and lessons learnt across the project teams. A joint procurement strategy will be developed to allow both Boards to gain commercial advantage through this collaborative approach. An initial workshop with HFS and NHSH took place on 4th November and a programme of further engagement is now in preparation which will include: M&E Workshops Commercial/procurement workshop Clinical user workshop/engagement 80

81 6.3.6 Communications Strategy During the Stage 2 construction Graham Construction will implement a system of communication to ensure all parties and stakeholders are fully aware of the construction process in an appropriate timescale and its potential implications to the staff and patients within the live sections of the hospital. Weekly progress/ technical meetings will be held with the design teams, subcontractors and NHSL Clinical liaison s and Supervisor. These meetings will be used as a platform to discuss construction progress, coordination and potential implications on existing services and mutual agreement of shutdown periods to facilitate construction. These meetings will also be bolstered by the issue of fortnightly programme snapshots to all parties detailing intended work areas including durations of specific activities. This communication process will be absolutely critical during the theatre refurbishment where discussions will be complemented by specific decant meetings to ensure seamless transitions of staff and equipment after the completion of one theatre refurbishment and the initiation of another. A construction display will be installed in the theatre lobby including plans, programme snapshots and live pedestrian management schematics to inform staff of how the refurbishment is progressing and detailing future programmed works including any changes to staff and patient navigation through the theatre suite. This display will also be complimented by a monthly Graham Construction newsletter including narratives on progress and any changes affecting the theatre operations due to the status of the phased works. This project will have a dedicated Project Manager assisted by a dedicated Contract Planner who will chair these meetings and control the information flow between all parties involved in the contract progress. The PM will also maintain daily liaisons with the NHS Supervisor to ensure both parties are fully aware of that days planned operations. Regular meetings will be held to inform staff of the works due to be carried out in the period one or two weeks ahead. These will be accompanied by a look ahead programme detailing the works in graphical form. An integral part of these communications will be the NHSL Project Manager who will form the interface between construction and clinical activities, ensuring that the project runs smoothly for all parties concerned. NHSL has developed a full communications strategy for the duration of the Project. This has been provided within Appendix 13 of this FBC. 81

82 6.4 Change Management The project will utilise the processes from the Frameworks Scotland 2 procurement route which uses the NEC3 Engineering and Construction Contract with Activity Schedule. This creates a structure and a discipline to manage change via the use of Early Warning Notices and Compensation Events and ensures change is identified early and is proactively managed by the project team. 6.5 Benefits Realisation The main benefits for the MKBC Theatres Project are noted within section 2.9 of this OBC Benefits Criteria. These will be reviewed as an integral part of the Post Project Evaluation work to ascertain if the benefits identified against the objectives of the business case have been met as a result of the project. 6.6 Risk Management A Risk Register has been developed that is reflective of the Preferred Option and that includes contributions from all key stakeholders. The Risk Register continues to be developed in accordance with SCIM guidance. Risk Workshops have been held on 14/02/2014, 09/06/2014 and 04/11/2014 in order to establish and maintain the project specific Register. Each identified risk is assessed, quantified, managed and a designated risk owner/ manager assigned. The Register is routinely reviewed and updated to minimise the level of risk. It will be updated for each early warning during the construction phase. The Risk Register is an Agenda item at the Core Team Meetings, with all high priority risks subject to review and a general overview of all other risks to ensure that their impact on the project is not escalating. The Risk Register will be a key tool in the ongoing management of the Project with a risk management strategy being employed to ensure: 82

83 Risks are identified in advance and mitigation strategies are agreed A process is in place to monitor risks and keep them up to date Agreement as to the right balance of control to mitigate against the adverse consequences of the risk should it materialise A decision making process is implemented, supported by a framework of risk analysis and evaluation 6.7 Contract Management The overarching aim of Contract Management is to ensure that project needs are satisfied and that the client receives service in line with what is being paid for within the boundaries of the contract whilst achieving value for money. This will be achieved through optimising efficiency, effectiveness and economy of the service or relationship described by the contract, balancing costs against risk and actively managing the customer- provider relationship. Contract Management also involves recognising the balance of the roles and responsibilities as defined under the contract and aiming for continuous improvement over the life of the Project. Good Contract Management will: Maximise the chances of contractual performance in accordance with the contract requirements by providing continuous and clear contract management which supports both parties; Optimise the performance of the project; Support continuous development, quality improvement and innovation throughout the Project; Ensure delivery of best value; Provide effective management of commercial risk; Provide an approach that is open to scrutiny and audit; Support the development of effective working relationships between both parties; Encourage effective and regular communication underpinned by clear communication mechanisms Allow flexibility to respond to changing requirements; Demonstrate clear roles, responsibilities and lines of accountability; Ensure that all works and services are in compliance with the Authority s Requirements, current legislation, relevant changes in Law and Health and Safety requirements, and NHS Scotland policies and procedures In order to facilitate effective Contract Management, competent and appropriate management resource is in place to establish that the services which the client has procured are delivered and that the contract continues to provide a high level of compliant service to its end users and wider stakeholders. 83

84 6.8 Post Project Evaluation In order to assess the impact of the project, an evaluation of activity and performance must be carried out post completion. This is an essential aid to improving future project performance, achieving best value for money from public resources, improving decision making and learning lessons. The PPE shall follow the guidance as detailed in the Scottish Capital Investment Manual and will be implemented six months after completion, appraising all stages of the Project from preparation of the business case through construction to occupation and service. A Post Occupancy Evaluation will be implemented 2-5 years after completion to appraise whether the project has delivered its anticipated improvements and benefits. 6.9 Community Benefits The cornerstone of Community Benefits is the provision of employment & skills opportunities. The approach to delivery of this on the NHSL Monklands programme of works is based on the following key elements; A Dedicated Resource Partnership Working Engagement Of Supply Chain Setting Clear Achievable Targets Monitoring & Reporting Dedicated Resource There is recognition that the successful delivery of employment outcomes does not happen by chance and therefore a dedicated resource to have overall responsibility for the planning and management of the project requirements will be committed. Supported by Graham Construction Human Resources Manager (Michael Smith) and Training Officer (Helen Vint) the Regional Community Benefits Co-ordinator (Debbie Rutherford) will have responsibility for the management and delivery of activity. 84

85 Partnership Working The approach to delivering employment opportunities in any locality is always based on identifying and partnering with appropriate organisations. North Lanarkshire s Working (NLW) has been identified as a key local stakeholder in relation to linking with local people to provide employment & skills outputs. In line with arrangements on existing projects, including existing HFS2, our CBC will act as point of contact to ensure that NLW are given the opportunity to provide candidates for any suitable opportunities created by the project. Engagement of Supply Chain There is understanding that overall engagement is the main contractor responsibility, however the nature of the industry means that in addition to direct opportunities many of the targeted outputs on the project will be through the supply chain and therefore it is essential that subcontractors take ownership of the part they have to play in the successful delivery of opportunities for apprentices. All relevant sub-contractors will be required to enter into a contractual agreement which will be monitored by the CBC. On appointment a meeting will be facilitated with the CBC to discuss how each sub-contractor will contribute to the overall scheme. Setting Clear Achievable Targets The proposal for the project is to deliver targets as set out by the National Skills Academy more specifically the benchmarks for Healthcare projects and cover the following outcome areas; Work Placements Curriculum Support Activities Apprentices Jobs advertised through local employment vehicles Training Outcomes In line with the guidelines outcome numbers will increase in direct proportion to construction spend. Where possible stretch targets will be sought, particularly in the work placement and jobs advertised outcome areas. 85

86 Monitoring & Reporting All activities carried out and outcomes will be monitored through reports that will be submitted on a regular basis by the CBC. Each sub contractor will be required to submit information detailing training & labour activity which will be used to form the overall project report. In addition to being a useful reporting tool this will allow shortfalls to be highlighted in any particular area or with an individual trade contractor. An early stage recovery plan can then be constructed where appropriate to ensure that overall delivery outcomes are maintained. The CBC will ensure that the relevant Evidential Requirements (as advised the National Skills Academy) are adhered to and submitted appropriately. A specific Employment and Skills Plan is included as Appendix 11 in this FBC which details clear targets for the Project using key elements of the National Skills Academy approach as a guide Contingency Plans Detailed arrangements on two levels are in place to assure the completion of the project. The primary focus has been to make significant efforts to establish a highly effective and responsive Project Management structure with efficient communication processes to ensure that any programme issues are identified quickly and swiftly mitigated. This is a key strategy and reflects the level of importance placed upon the delivery of the project within the agreed timeline. A Business Continuity document has been developed by NHSL in order to ensure that the full effects of the Theatre/ ICU construction project are understood by all stakeholders. This has been included as Appendix 14 in this FBC. A full Business Continuity plan has been created and published to demonstrate that NHSL understand and can react to the risks and possible repercussions arising from the project in the operational environment, should BC be compromised. 86

87 7. Conclusion Providing the refurbishment and upgrade to the Theatres and ICU at Monklands General Hospital will improve patient care whilst offering modern services locally to where people live. As a central element of the proposal this will enable the meeting of the challenges of implementing NHS Scotland s Route Map to the 2020 Vision for Health and Social Care (2013). The Preferred Option, to refurbish the existing seven theatres alongside the construction of a new build 10 bed ICU represents the best investment to provide the required services going forward. It is the best value option, as has been demonstrated throughout this document, and would fulfil the drivers identified in this FBC. These new facilities would provide a 21st century environment that would meet the needs and aspirations of both staff and patients within NHS Lanarkshire. Approval of this FBC will ensure that the project can move at pace towards the Construction Phase of this critical project. 87

88 Appendix 01: Design Statement 88

89 MKBC Theatres & ICU refurbishment and upgrade: Design Statement Introduction: This Design Statement has been created to support the development of the above new and refurbished facilities and acts as a key briefing document for the project Technical Team. It will be used to enhance the design process to ensure that the project primary objectives are delivered. The key design principles and non- negotiable performance criteria are set out below: Key Design Principles: Provide Services that are safely and easily accessible Improve and maintain retention and recruitment of staff Provide an environment that supports service delivery, clinical effectiveness and integrated service provision Provide a quality of clinical environment that promotes the health and wellbeing of the staff and patients Develop theatre designs that will improve surgical services, storage and support. Provide facilities that are both sustainable and flexible to support service provision in the future Encourage a learning environment for staff through the provision of dedicated training facilities 89

90 1. The Non- Negotiables for Patients Agreed Non- Negotiable Performance Criteria (investment objective/ customer quality expectation) The experience of waiting must feel secure, pleasant and calming Benchmarks The standard to be met and/ or some views of what success might look like Space must allow staff to provide positive distraction appropriate to different groups of people The patient journey from entering the perioperative environment should be as streamlined as possible Point of entry to point of treatment should flow in a linear fashion Essential services for patients should be capable of being maintained without being openly visible to the individual Patient front line services if taken off line have a back up provision to ensure continuation of service Maintenance works can be carried out invisibly as much as possible where required 90

91 2. The Non- Negotiables for Staff Agreed Non- Negotiable Performance Criteria (investment objective/ customer quality expectation) The development must be efficient with rooms and circulation routes configured to allow flexibility in use. Benchmarks The standard to be met and/ or some views of what success might look like Clear definition of patient areas from back of house/ staff areas Design to ensure optimal flexibility and efficiency Staff must be able to rest/ debrief/ relax away from the service provision spaces with access to daylight Staff rest space, in addition to providing for tea/ lunch prep must provide: Space for coming together to chat Space for quiet thought Good daylight Be an attractive and restful space Ensure the most efficient use of space and that the use of shared space is optimised. Efficient space allocation and ability to respond to future service changes effectively is to be promoted. The layout of the facility must encourage and facilitate co-ordinated working and communication between disciplines on a formal and informal basis Office space should be shared wherever possible limit one person offices Space should allow long term flexibility of use without fundamental physical change Spaces should be set out logically in relation to each other and should be capable of long term flexibility Staff routes should encourage interaction between services rather than isolate them Common facilities such as staff rest and meeting rooms should be provided as a shared resource 91

92 Working environments must promote a feeling of safety and wellbeing, aiding concentration and effective working. The development should be both easy to maintain and to clean The environment should have good thermal comfort, air quality and daylight (where required) There should be good visual connections to other staff areas so as not to feel isolated or vulnerable with a route to escape attack Consideration to be given to finishes and fixings and any proposed new products should receive NHSL approval prior to selection Positioning of essential maintenance items should be outwith important patient areas 92

93 3. The Non- Negotiables for Visitors Agreed Non- Negotiable Performance Criteria (investment objective/ customer quality expectation) Carers/ Family members accompanying patients must be able to find information and additional support to assist them Benchmarks The standard to be met and/ or some views of what success might look like Information and signposting points available Space should be provided to accommodate and occupy dependants while patients are being treated Waiting areas should be attractive and restful with daylight Carers/ Family members accompanying patients should have access to an interview room that provides a confidential environment for discussion Carers/ Family members accompanying patients should have the ability to access assistance if required Interview room should be within easy access of the relative waiting area Staff should be within easy reach of Carers/ Family Members if assistance is needed 93

94 4. Alignment of Investment with Policy Agreed Non- Negotiable Performance Criteria (investment objective/ customer quality expectation) Site position, massing and visual appearance of the ICU must provide a positive addition to the hospital site, setting a precedent for future development. Facility should be designed to be sustainable in construction, use and decommissioning/ demolition Benchmarks The standard to be met and/ or some views of what success might look like Building should have a suitable presence that is both welcoming and modern Building should enable appropriate massing to achieve a coherent and economic use of space Building should be designed with appropriate privacy in terms of overlooking and closeness BREEAM Good (Assessed under HFS BREEAM Pragmatic) Social, Economic and Technical sustainability to be considered in the design Facility must be designed to allow future adaptation Facilities to be designed such that they may be re-aligned to meet changes in future service The form of construction adopted will maximise the ease of alteration 94

95 5. The Self Assessment Process (IA Stage) Decision Point Authority of Decision Additional Skills or other perspectives How the above criteria will be considered at this stage and / or valued in the decision Information needed to allow evaluation Site Selection Decision by NHSL with advice from Project Board Risk/ Benefit analysis considering the capacity of the sites to deliver a development that meets the criteria above. Site feasibility studies (including sketch design to RIBA stage B) for alternate sites or completed masterplan (for site with the potential for multiple projects). Cost estimates (both construction and running costs) based on feasibility. Completion of brief to go to the market Decision by Project Board with advice from Project Manager HFS Frameworks Scotland 2 Work will progress with existing FS2 Partner Market Testing will be undertaken prior to acceptance of the Stage 2 price Selection of Delivery/ Design team Decision by Project Board with advice from Project Manager HFS Frameworks Scotland 2 Quality cost ratio to be at upper level of guidance for complex projects contained in Annex A, para A.3.5 of Scottish Construction Procurement Manual CEL (2009) 50. Design Team selection has been in compliance with NHSL SFI s. Design Statement principles have been adopted by design team. Selection of early design concept from options developed Decision by Project Board with advice from Project Manager Comment to be sought from A+DS through the NDAP process Assessment of options using AEDET or other methodology to evaluate the likelihood of the options delivering a development that meets the criteria above Sketch proposals developed to RIBA Stage C coloured to distinguish the main use types (bedrooms, day-space, circulation treatment, staff facilities, usable external space). Rough Model 95

96 Approval of design proposals to be submitted to planning authority Decision by Project Board with advice from Project Manager Assessment of options using AEDET or other methodology to evaluate the likelihood of the options delivering a development that meets the criteria above Formal process to approve Stage D will be agreed with project board Approval of detailed design proposals to allow construction Decision by NHSL with advice from Project Board Assessment of options using AEDET or other methodology to evaluate the likelihood of the options delivering a development that meets the criteria above Post Occupancy Evaluations Consideration by NHSL - lessons fed to SGHSCD Design and Healthcare advisors external to the team Assessment of completed development by representatives of the stakeholder groups involved in establishing the above against goals they set. 96

97 Appendix 02: A+DS/ HFS Letter of Support [will be provided for SGHSCD submission] 97

98 98

99 Appendix 03: AEDET Workshop Summary 99

100 100

101 101

102 102

103 103

104 104

105 105

106 106

107 107

108 108

109 109

110 110

111 Appendix 04: Risk Register 04/11/

112 112

113 113

114 114

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116 116

117 117

118 118

119 119

120 Appendix 05: 3D Views 120

121 Theatres Ward 121

122 ICU Ward 122

123 Appendix 06: Schedule of Accommodation 123

124 Schedule of Accommodation: Theatres 124

125 125

126 Schedule of Accommodation: ICU 126

127 127

128 Appendix 07: Board Letter of Support [will be provided for SGHSCD submission] 128

129 129

130 Appendix 08: PSCP Programme Stage 2 Construction 130

131 131

132 Appendix 09: Schedule of Derogations 132

133 133

134 134

135 135

136 Appendix 10: Option Appraisal 136

137 The Workshop The Workshop began with an introduction to establish the outline for the session and key elements for consideration. There was then a short presentation to refresh key project elements for the audience prior to moving to the scoring process. Weighting The next part of the process, facilitated by the PSC Project Manager, saw the undertaking of an exercise to establish a weighting of the benefits to carry forward to scoring the options. A full description of the criteria can be found in Section 2.9 of this OBC, however a summary is provided below: Table 19: Description of Benefits 1 Mitigation of Fire Safety Compliance risk 2 Mitigation of AHU Failure risk 3 Mitigation of Infection Control risk due to building fabric 4 Mitigation of risk to Clinical Continuity 5 Mitigation of risk to Patient Safety 6 Initial Capital Cost 7 Minimise works duration/ impact on clinical activities 8 Maintain clinical adjacencies and optimise space planning 9 Reduction in Revenue Costs (Maintenance) 10 Reduction in Revenue Costs (Staff), including costs for moving services off site 11 Ability to Future Proof / Expand Post considered discussion the weighting to be carried into the scoring of the options was as follows: Table 20: Benefits Weighting

138 This weighting reflects the relative importance of ensuring patient safety and AHU failure within the total range of benefits agreed for the project. The Scoring Having confirmed the weighting for the criteria the short listed options were subject to scoring under a range of 1-10 as per the below guide: Table 21: Scoring Guide Scoring Guide 1-2 Very Poor 3-4 Poor 5-6 Satisfactory 7-8 Good 9-10 Very Good A complete summary of the scores can be seen in Table 22 below: Table 22: Benefit Scores When the weighting established in the previous exercise was applied to the scores, the results were as follows: 138

139 Table 23: Weighted Scoring Results Sensitivity Analysis In order to test the results of the Benefits Appraisal it is useful to assess the sensitivity of the scores to changes in key variables and assumptions. This exercise provides an indication as to the elements of the evaluation that are critical to influencing the outcome. Sensitivity Analysis should therefore be undertaken to evaluate what the ranking might be if some of the weights and/ or scores were changed as follows: Equal weighting applied to all criteria i.e. all 11 criteria were weighted at 10 Excluding benefit scores for the top ranked criteria i.e. remove scores for criteria 2 & 5 Altering the scores of the criteria with the greatest scoring range so that all options score the same mid- range value i.e. replace criteria 6 scores with a 5 for all options In doing so, the following results were produced: 139

140 Table 24: Non- Financial Sensitivity Analysis equal weight remove 2 &5 replace 6 with '5' weighted weighted weighted rank rank rank score score score option option option option The Sensitivity Analysis shows therefore that despite changing the weights and scores, Option 3 (full renovation works) remains ranked first at all times 140

141 Appendix 11: Employment and Skills Plan 141

142 We have now set clear targets for the project by using key elements of the National Skills Academy approach as a guide, more specifically the benchmark for Healthcare projects. The nature of the contract has been considered when setting the targets EMPLOYMENT SKILLS PLAN Target Achieved 1.Work placements persons Curriculum Support Activities individual engagement Apprentice Starts persons Existing Apprentices persons Jobs Created Corporate Volunteering Days Work placements These will be offered to people who are looking to gain experience within a construction environment. For this project, we will not be able to offer work placements onsite without first of all carrying out extensive risk assessments and consulting with the client as to the appropriateness of the placement, as it is a live Hospital environment. The type of placements on offer will be within the following teams, administration, management, quantity surveying, planning, and procurement. There has been 1 work placement to date. 2. Curriculum Support Activities Engagement with the local primary and secondary schools, in partnership with CITB, delivering construction modelling activities. Expected to commence 1 st quarter 2015 when the majority of the construction work commences. 3. Apprentice Starts Currently clarifying movement on this, will report back on this within the two weeks and then quarterly, thereafter 4. Existing Apprentices 3 apprentices have transferred over from other Community Benefits sites, all at different stages. This have given sustainability to the apprentices and also allowed them the experience of working in the live site. 5. Jobs Created There is a partnership agreement with the local authority, North Lanarkshire Working (NLW). Relevant opportunities generated from this site, will be advertised through NLW. NLW then promote opportunities to Routes to Work North, and local colleges. This has proved to work well in our sites and we will continue this approach. As with apprentice starts further movement through supply chain currently being clarified. 6. Corporate Volunteering Days One day carried out Aberlour Children s Charity in conjunction with other framework contracts Additional Information Assistance was given to local charity Hope With Autism with joinery work to the value of circa 2k Graham has recently commissioned training for both Graham and supply chain employees, on fire extinguishers. 19 sub-contractors based within a 20 mile radius of the works have been appointed so far., 15 of which are within the Lanarkshire area 142

143 The table below shows that currently we are using 48% of our sub-contractors from the Lanarkshire and there are 58% within a 20 mile radius. When we begin the theatres project we assume this will lower as we will be using much more specialist contractors but for all other projects throughout Lanarkshire we will strive to use as many local contractors as possible. We have been given a list of the contractors whom are currently used by NHS Lanarkshire who we will endeavour to use if they meet the selection criteria of the framework and of graham construction. Nr Company Project On site week ending Office Base 1 Taylor & Fraser LWBC Ward 24 Monklands YES Wishaw Lanarkshire 1 2 MJ Cladding LWBC Ward 24 Monklands yes Wishaw Lanarkshire 2 3 Contract Flooring Services LWBC Ward 24 Monklands Yes Cambuslang Lanarkshire 3 4 Carella Laminate Systems Ltd. LWBC Ward 24 Monklands Yes Londonderry Co Londonderry 5 SLD Painters LWBC Ward 24 Monklands YES Airdrie Lanarkshire 4 6 Moorcon Ltd LWBC Ward 24 Monklands NO Claudy Co Londonderry 7 Parkhall Civils LWBC Ward 24 Monklands No Barrhead Glasgow 8 Rhodar LWBC Ward 24 Monklands No Glasgow 9 Tandragee Roofing Company MKBC Monklands Flat Roof Repairs Yes Tandragee Co Armagh 10 Oricom Limited MKBC Monklands Flat Roof Repairs Yes Uddingston Lanarkshire 5 11 BritPlas LTD MKBC Monklands Flat No Warrington 143

144 Roof Repairs Cheshire 12 Workspace design LWBC Monklands labs No Perth Perthshire 13 AC electrics Pathology enabling Yes Motherwell Lanarkshire 6 14 David Lawire Pathology enabling Yes Mauchline, East Ayrshire 15 Wilson Ingles Pathology enabling yes Wishaw Lanarkshire 7 16 McGarry Flooring Pathology enabling Yes Wishaw Lanarkshire 8 17 DNS MKBC Fire Safety works yes Airdrie Lanarkshire 9 18 Scotshield MKBC Fire Safety works yes Airdrie Lanarkshire Chubb Fire & security Pathology enabling yes Glasgow 20 ADT fire & security LWBC Fire Safety works NO Livingstone, West Lothian 21 Stothers M&E MKBC IT room overheating YES Glasgow 22 Kerr Roofing LWBC Kello hospital No Symington South Lanarkshire

145 Appendix Twelve Phasing Plan 145

146 INTRODUCTION The scope of works associated with the construction of the Theatre Refurbishment and new 10 beds ICU ward has been planned around the condition that 7 working theatres must be operable throughout the construction process. This results in a number of challenges to ensure Business Continuity is maintained for the hospital, whilst allowing a degree of construction continuity. To address these, the current Phasing Strategy detailed below, and on the separate drawings attached (Appendix 1), has been developed in close consultation with the NHSL core team. The resultant strategy consists of 12 phases, stretching over a 163 week period, commencing in March 2015 and lasting until April Each Phase has been reviewed by the core team to ensure the construction activities are completely separate from the hospital activities, minimising any potential disruption to the hospital s business continuity. The detail of the logistics, planning, decant, recant and overall phase by phase management are discussed at regular meetings of the core team, attended by GC personnel and the Project managers, Currie and Brown. The resultant conclusions and plans have been used to create the stage 2 construction programme (Appendix 2) To enable the commencement of the construction phase, we are required to carry out a 12 weeks Enabling Works programme including, service diversions, ground stabilisation, road realignment and ground contamination, all programmed to commence 17 th November 2014 (programme Appendix 3). 146

147 Phase 1 New ICU construction: Ref Drw No 1960 (2-)501 E Upon completion of the enabling works, including certification of the ground stabilisation process, we will construct the 10 bed ICU unit. This is an independent steel frame structure positioned west of the existing theatres building, supported on piers to achieve a level access into the existing proposed refurbished theatre block by way of a new link bridge and indirectly via a connection to the existing glass link corridor. Concurrently, works will also commence on the external structure of the existing theatres building to facilitate the positioning of 7 new AHUs, one for each new theatre. The plant deck for the AHUs, consists of extended steel columns and a steel support framework which needs to be fully constructed ahead of the first AHU requirement, at phase 4. In Phase 1 we must breach the roof to the north and south of the theatre block, extending the columns up through the weathered structure, and subsequently then re-place the roof around each. Each column extension will then be modified to allow connection to the AHU support steel frame. All access to the roof will be from perimeter scaffold to each elevation and via the existing plant room. The columns to be extended are located in a live hospital corridor to the north, and the theatre service corridor to the south. By means of some temporary hoarding, we have planned to isolate this area from the public and staff ensuring that patient flow to recovery and theatres remains unchanged. 147

148 Phase 2 New Reception, Recovery & Endoscopy services: Ref Drw No 1960 (2- )502 F With the new ICU complete in the previous phase, the patients, staff and all equipment can now be transferred into the ICU, freeing up the space in the existing building. The construction of phase 2 is further separated into three distinct sub phases, A, B and C. In 2A, the new Endoscopy Cleaning and storage rooms are created in the location of the existing female staff room and the theatres Dirty utility for the proposed recovery are constructed. Endoscopy facilities must be available uninterrupted throughout the project. When Phase 2A is complete, the existing Endoscopy facility can be removed, which allows the formation of the new access corridor into the refurbished theatres area (Phase 2B). At this time, the construction team must take partial possession of the hospital corridor north of the theatre dept. This is to continue the exercise started in phase 1, of extending existing columns for the AHU deck above. The works, will consist of three column extensions and an element of wall removal to introduce a steel bracing support structure for above. Upon completion, the steel work installed will be built within a wall and the corridor can then be fully reopened. In the interim, it has been agreed all patient flow can be redirected via the main corridor local to this one. Phase 2C, is the bulk of the second phase construction work and consists of the creation of the new 9 bed recovery area and the Theatres reception, in the footprint of the old ICU department. To minimise disruption, it has been agreed that construction access will be via an external breach in the old ICU dept. external wall, maintaining the necessary construction separation. 148

149 Phase 3 Temporary Bulk supplies and Support Facilities: Ref Drw No 1960 (2- )503 E On completion of Phase 2, the new Reception and recovery can be occupied releasing the area currently being used for this service. The proposed staff room and theatres equipment store will eventually occupy this space, but to facilitate the 7 theatres being operational throughout the project, at this time we need to create a temporary Bulk Storage Supplies Store instead of the staffroom. The designed Support facilities rooms will however be constructed in their permanent position. The existing SCN office will be maintained throughout the phase, isolated from all construction activity. The area of construction work for phase 3 is located in the SW corner of the existing theatres department, which, to maintain business continuity, will be accessed from a new construction breach on the south elevation. This access point will be reused in a further 3 phases later in the project. There is an element of unavoidable services Enabling Works required in the live corridor directly adjacent to the construction area. This is the redirecting of existing ventilation systems to generate space for the new systems in ongoing phases. This work will be carried out out of hours and in agreement with the hospital staff, over a short period of time. 7 Theatres are in operation at all times. 149

150 Phase 4 Form new Theatres T5 (n) & T6 (n): Ref Drw No 1960 (2- ) 504 E With the completion of Ph3, the support services and existing TSSU service can be moved into this area, releasing this space for the creation of 2 new theatres, T5 and T6. Upon possession, the construction team will access the works from the existing stairwell to the East of the theatre dept. As before, there are 6 columns requiring to be extended and a steel support bracing arrangement for the steel deck above, but as these works are within the construction footprint, no temporary measures or partial corridor possessions are required, therefore maintaining patient flow. In tandem with the activity within the theatres building, it is worth note that the steel cradle on the roof above will be erected at this stage, consisting of a network of large steel beams slung into position by crane. When the deck is complete, all 7 AHUs required for the project will also be lifted onto this and placed in their final positions. In this way, at the end of Phase 4, all the necessary Plant and heavy lifting over the theatres will be complete for the whole project. To facilitate the next phase, there will also be structural steel introduced into the existing plant room above the proposed T7 (n) location. This is required to carry the weight of the ultra clean canopy. This will be erected high level in the plant room with drop rods attached during the next phase. 7 Theatres are in operation at all times. 150

151 Phase 5 Form new UC Theatre T7(n) & Staff Offices: Ref Drw No 1960 (2-)505 E The first of the 2 new Ultra Clean Theatres are constructed in Ph 5. Through the successful completion of the previous phase, existing theatres No1 and No7 can now be removed and there still be 7 theatres in operation. This allows the creation of theatre T7(n) and the new SCN and staff offices near the new theatres entrance. The construction access to the north theatres was initially problematic but this has been resolved through access and use of one of the passenger lifts for the construction team, at agreed times, to transport materials and staff. This also requires a shared use of the north corridor during these times. Within the theatres department, there is no effect on patient flow. The Ultra clean canopy can now be attached to the pre-erected plant room steel work above; all other construction activity will be confined to the area of possession. 7 Theatres are in operation at all times. 151

152 Phase 6 Form new UC Theatre T4(n): Ref Drw No 1960 (2-)506 E Working progressively, upon completion of T7(n), the construction team can now take possession of existing theatre No2. With this and the balance of the area remaining from possession of theatre no 1 above, we can now construct the second Ultra Clean theatre, T4(n). The construction access point and access arrangements are the same as the previous phase. The ultra clean canopy support in this theatre is designed to be hung from the new roof cradle above and therefore needs no further works other than already installed. Although patient flow is unaffected, the position of the construction possession of T4(n) means that the service corridor to T7(n) is blocked. The removal of waste from the dirty utility in T7(n) has been agreed by the core team, to be transported via the Recovery Dirty Utility on a temporary basis. Normal waste removal into the service corridor can start upon completion of the phase. 7 Theatres are in operation at all times. 152

153 Phase 7 Form new Theatre T3(n): Ref Drw No 1960 (2-)507 E With 2 Ultra Clean theatres now in operation from the previous phases, the existing laminar flow theatre 4, can be decommissioned and new T3(n) can be formed. Construction access will be via the previously created breach on the south elevation. Patient flow is unaffected and 7 Theatres will be operational throughout. Phase 8 Form new Theatre T2(n): Ref Drw No 1960 (2-)508 E 153

154 Using a similar plan as in Phase 7, existing theatre 5 can now be decommissioned and new T2 (n) can be formed. The construction access point is the same, but as in Phase 6, this creates a problem for dirty waste disposal from new T7 (n). As such, the Core team have agreed that the dirty utility provision necessary for T7 (n) can be routed via the Recovery Dirty Utility, as per previous phases. Patient flow is unaffected and 7 Theatres will be operational throughout. Phase 9 Form new Theatre T1(n): Ref Drw No 1960 (2-)509 F 154

155 This phase methodology is similar to the above, with existing theatre No6 being decommissioned upon successful completion of Ph 8, and the area being developed into new theatre T1(n). The same problem with regard to dirty utility provision exists now for Theatres T3(n) and T2(n). The same methodology of using the recovery Dirty Utility previously agreed has now to be extended to include T2(n). Patient flow is unaffected and 7 Theatres will be operational throughout. Phase 10 Form new Bulk Supplies Store: Ref Drw No 1960 (2-)510 F 155

156 At this stage all the theatre refurbishments are complete and the last few support items are required to be moved to their final locations. The creation of the Bulk Supplies Store will be in the location of the last old theatre No 3. When possession is complete, the construction activities will prevent the north service corridor being used for waste disposal from T7 (n) and T4 (n). The core team have agreed that the disposal for these can be via the recovery dirty utility, as before. Patient flow is unaffected and 7 Theatres will be operational throughout. Phase 11 Permanent Staff room and Equipment store: Ref Drw No 1960 (2-)511 E 156

157 As noted in Ph 3, the permanent location for the staff room and the equipment store, can now be created following the movement of all temporary supplies into the new Bulk Supply store completed in the phase above. Construction access to this last area, will require to be via a separate breach in the SW corner of the building, accessed via scaffold, to ensure separation between the construction and the hospital activities. Patient flow is unaffected and 7 Theatres will be operational throughout. Phase 12 Theatre corridors: Ref Drw No 1960 (2-)512 E 157

158 Due to the necessity to have 7 theatres operational at all times throughout the project, and there being no space above the clean corridor ceilings for parallel service installation, it is unavoidable that a large quantity of the existing services will not be able to be removed from the ceiling space during the completion of each of the phases. In Phase 12 the construction team will take possession of small sections of clean corridor, all out of hours to strip out the now redundant services, replace existing ceiling finishes with new, replace floor coverings and erect any other essential services / signs. This work will be coordinated fully through the core team to ensure all corridors are available for patient flow during normal working hours. Appendix Thirteen 158

159 NHSL Communications Strategy 159

160 Communications Plan Monklands Theatres and ICU WHO Message Method of Communication JULY - OCOTBER 2014 When/Status Lead All staff Board approves outline business case Staff briefing Pulse 18/7/14 Sept/Oct C McKay C McKay Public Board approves outline business case NHSL public website 16/7/14 C McKay MSP Board approves outline business case Press release 16/7/14 C McKay Press/Media Board approves outline business case Press release Facebook Twitter 16/7/14 16/7/14 16/7/14 C McKay C McKay C McKay Enquiry re. timeline for business case and construction from Airdrie and Coatbridge Advertiser Press response 22/9/14 C McKay 160

161 NOVEMBER 2014 INTERNAL Theatre/ICU staff Preparatory works to begin to ICU and theatre staff All in Monklands Staff briefing Poster display in rest areas 6/11/14 6/11/14 C McKay C McKay C McKay 7/11/14 Introduction to the theatres and ICU (including images and timeline). to ICU and theatre staff View ahead/work planned for week Business Continuity Plan to ICU and theatre staff and host on FirstPort Host on FirstPort and to staff 7/11/14 14/11/14 21/11/14 28/11/14 28/11/15 C McKay/G Reid/N Ruddy C McKay/G Reid/N Ruddy Development of FAQs 28/11/15 C McKay/G Reid/N 161

162 Ruddy Monklands staff Preparatory works to begin Introduction to the theatres and ICU All in Monklands Staff briefing Pull up banner in restaurant/main entrance Electronic display at main 6/11/14 7/11/14 C McKay C McKay Board Members Preparatory works to begin 7/11/14 C McKay All staff Preparatory works to begin Staff briefing 7/11/14 C McKay GPs Preparatory works to begin Staff briefing 7/11/14 C McKay EXTERNAL Public Preparatory works to begin Introduction to the theatres and ICU Press release NHSL public website Facebook Twitter Pull up banner in restaurant and w/c 17/11/14 C McKay 162

163 main entrance Electronic display at main Patients and carers Preparatory works to begin Press release w/c 17/11/14 C McKay Introduction to the theatres and ICU NHSL public website Facebook Twitter Pull up banner in restaurant and main entrance Electronic display at main PPFs Preparatory works to begin w/c 10/11/14 C McKay MSPs Preparatory works to begin Press release w/c 10/11/14 C McKay SHC Preparatory works to begin Staff briefing 7/11/14 C McKay DECEMBER 2014 INTERNAL Theatre/ICU staff View ahead/work planned for week to ICU and theatre staff 5/12/14 12/12/14 19/12/14 C McKay/G Reid/N Ruddy 163

164 JANUARY 2015 INTERNAL Theatre/ICU staff Full Business Case to NHS Lanarkshire board for approval All in Monklands Staff briefing 28/1/15 C McKay C McKay C McKay View ahead/work planned for week to ICU and theatre staff 9/1/15 16/1/15 23/1/15 30/1/15 C McKay/G Reid/N Ruddy Monklands staff Full Business Case to NHS Lanarkshire board for approval All in Monklands Staff briefing 28/1/15 C McKay Board Members Full Business Case to NHS Lanarkshire board for approval Board meeting C McKay 28/1/15 C McKay C McKay 164

165 ACF/APF/ Full Business Case to NHS Lanarkshire board for approval All staff Full Business Case to NHS Lanarkshire board for approval Staff briefing 30/1/15 C McKay Staff briefing 30/1/15 C McKay GPs Full Business Case to NHS Lanarkshire board for approval Staff briefing 30/1/15 C McKay EXTERNAL Public Full Business Case to NHS Lanarkshire board for approval Press release NHSL public website Facebook Twitter 30/1/15 C McKay C McKay C McKay C McKay Patients and carers Full Business Case to NHS Lanarkshire board for approval Press release NHSL public website Facebook Twitter 30/1/15 C McKay C McKay C McKay C McKay 165

166 PPFs Full Business Case to NHS Lanarkshire board for approval Press release 30/1/15 C McKay MSPs Full Business Case to NHS Lanarkshire board for approval SHC Full Business Case to NHS Lanarkshire board for approval Press release 30/1/15 C McKay Press release 30/1/15 C McKay FEBRUARY 2015 INTERNAL Theatre/ICU staff Full Business Case to Scottish Government for approval View ahead/work planned for week Overview of theatres/icu programme All in Monklands Staff briefing 3/2/15 6/2/15 13/2/15 20/2/15 27/2/15 C McKay C McKay C McKay Formal presentation in 12/2/15 166

167 conference room C McKay/G Reid/N Ruddy Monklands staff Full Business Case to Scottish Government for approval All in Monklands 3/2/15 C McKay Overview of theatres/icu programme Drop in session in lecture theatre 13/2/15 C McKay/G Reid/N Ruddy Board Members Full Business Case to Scottish Government for approval Board meeting 3/2/15 C McKay C McKay ACF/APF/ Full Business Case to Scottish Government for approval Overview of theatres/icu programme Staff briefing Formal presentation 3/2/15 February meeting C McKay C Lauder/G Reid/ N Ruddy Medical Staff Association Overview of theatres/icu programme Formal presentation at site meeting February meeting C Lauder/G Reid/ N Ruddy 167

168 All staff Full Business Case to Scottish Government for approval Overview of theatres/icu programme Staff briefing Drop in session in lecture theatre 3/2/15 13/2/15 C McKay C Lauder/G Reid/ N Ruddy GPs Full Business Case to Scottish Government for approval Overview of theatres/icu programme Staff briefing Formal presentation to LMC 3/2/15 February meeting C McKay C Lauder EXTERNAL Public Full Business Case to Scottish Government for approval Overview of theatres/icu programme Press release NHSL public website Facebook Twitter Stand at hospital main entrance 3/2/15 w/c 16/2/15 C McKay C McKay C McKay C McKay C McKay/G Reid/N Ruddy 168

169 Patients and carers Full Business Case to Scottish Government for approval Press release NHSL public website Facebook Twitter 3/2/15 C McKay C McKay C McKay C McKay Stand at hospital main entrance C McKay Overview of theatres/icu programme w/c 16/2/15 PPFs Full Business Case to Scottish Government for approval Overview of theatres/icu programme Press release Drop in session in lecture theatre 3/2/15 13/2/15 C McKay C Lauder/G Reid/ N Ruddy MSPs Full Business Case to Scottish Government for approval Overview of theatres/icu programme Press release Drop in session in 3/2/15 13/2/15 C McKay C Lauder/G 169

170 lecture theatre Reid/ N Ruddy SHC Full Business Case to Scottish Government for approval Overview of theatres/icu programme Press release Drop in session in lecture theatre 3/2/15 13/2/15 C McKay C Lauder/G Reid/ N Ruddy NB. The communication plan will be updated over the duration of the construction programme and opening of the facilities. This will take planned proactive and reactive communications activities. 170

171 Appendix 14 Business Continuity Plan 171

172 THEATRE/ICU Construction/ Refurbishment BUSINESS CONTINUITY PLANNING 27 th November 2014 Revision 6 GR BC Planning Rev Page 172