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Thursday 20 October 2016
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Build up

It takes great organisational skills to manage a building project, but it's essential to do it properly when it's for a GP surgery

Changes within your practice are inevitable, whether it is because your premises are out of date or you are trying to keep up with the ever-changing increasingly unsustainable pressures on general practice transformation.
In a previous employment I was involved with a practice based over two floors, the reception area was small and crowded, there was no lift facility for patients with disabilities and some of the consulting rooms were housed upstairs. The practice was in a university town and the population was made up primarily of students and an ageing population (i.e. 45 plus).
Following discussions with the GPs it was agreed that the reception area would be changed to allow better entry and egress, and research would be undertaken to determine the feasibility of adding a lift to the surgery to improve physical access within the practice premises in line with the Equality Act (2010). It was often difficult to accommodate wheelchair users downstairs without prior planning and a lift would eliminate these problems.
A full business case was requested by the GPs, together with an understanding of the funding streams available to support the improvements. Practical implications of the proposed improvements would need to be included in the business case along with an understanding of the professional services required to ensure the work would be carried out to the necessary building regulations and/or planning approval requirements.

What works for your building
Depending on your surgery premises you may have to consider listed building approval or conservation area consent. In addition if you are housed within a leasehold property then you would need to check the terms of your lease and whether you require the landlord’s permission to carry out any improvements or alterations to the premises. If consent to alterations is required they are usually given in the form of a licence and should not be unreasonably withheld by the landlord.
Even if the building is owned by the partnership it would make sense to check the title documents in case there are any restrictions (covenants) on the title that may hinder the planned improvements or require consent from a third party.
As part of the planning process it is important to ensure you are continuing to manage the current state, i.e. what needs to be done to keep the reception area functioning effectively throughout the process. Starting the changes without a plan will cause added pressures to everyone in the surgery and to patients visiting for appointments etc.
Some key elements to take into account for the planning stages include:

  • Good communication throughout the project

It is not reasonable to make change for changes’ sake and if a change is required within your surgery then it has to be planned accordingly ensuring all key stakeholders are kept up to date. If you perceive there is a need for change then it is important that others are made aware of the issues before you go ahead and implement the solution. Before any work starts let people know that changes are being planned and the form they are going to take. Keep key stakeholders abreast of progress and once completed announce the end of the project and thank everyone affected by the alterations for their patience. Use your website to keep people up to date with progress. Include a link to any working plans of the changes and allow open access to this information.

  • Funding for the project

Identify how the project will be funded and whether external funding is available for the type of project being undertaken, for example the Primary Care Infrastructure Fund. Research the application process for any funding stream that you identify. It is important that every ‘i’ is dotted and every ‘t’ is crossed because there will be a huge draw on funds and you need to make sure your application is accurate, timely and stands out from the rest.

  • Professional input

Identify if you require professional input into the project, for example architects or solicitors. It is generally good practice to consult with them at the beginning of the project to save time and effort once work is underway.

  • Health and safety requirements

Health and safety is important at any time for an organisation, however, more so during an improvement project. It is the responsibility of the practice manager to ensure that contractors are safe while on site and the safety of all staff, visitors and patients is upheld during the project.

The challenge of changes

Change can be unsettling, threatening and disturbingly unpredictable, for long standing patients of the surgery. They may see the project as a bad thing because they like things as they are, so they may resist it.
For practice managers already running a busy practice changing things can double your workload. However, it doesn’t have to be difficult and introducing improvements can provide an opportunity for creativity, learning new skills, and developing the existing skills of you and your colleagues. It can improve working conditions and increase efficiency. Get colleagues involved with the planning, by delegating some responsibilities to others, such as keeping the website up to date with progress information, maybe using a pictorial story of the changes.
An effective practice manager is one who can recognise that change is required, and identify improvements and then engage with colleagues and other key stakeholders to make them feel that they are partners in the initiative. What may seem obvious to you as a manager may not be obvious to everyone and that is why effective communication is paramount when undertaking any project work.
Within this context the output of our planned change would be a refurbished, larger, better organised reception area with a lift to transport patients to the second floor consulting rooms.
The project plan would work back from the desired outcome and identify key steps to making the change happen. (See Figure 1.)

When in action
A project initiation plan is the document that sets out the requirements of the project, how it will be implemented and the resources required to complete the task. Once the project initiation plan had been signed off by the partners, we planned our communication with key stakeholders. We used:

  • Website notifications.
  • Footers on emails being sent from the surgery.
  • Internal notice boards.
  • Staff meetings.

The planning, research and design stage allows the project manager to identify resources, such as funds available; engage with key professionals to ensure the design of the project is adequate and meets all legislative requirements.
As part of this step we sought architectural advice on whether the building was suitable to include a lift and, due to the age and structure of the building, it wasn’t. The decision was taken to continue with the changes to the surgery reception area as this would enhance the flow of traffic in and out of the building. It also gave us the opportunity to replace old and damaged timbers and incorporate double glazing to the front aspect of the building, making it weather and sound proof, thus improving efficiency.
Once approval has been given then the project gets underway and is monitored and controlled at all times.
Monitoring and controlling is about ensuring work has been complete including costs, risks and other issues to the desired time scales. For larger more involved projects this can take the form of key reports at intervals defined by the project initiation plan. Controls will be identified at the beginning of the project to establish the control and delivery of the project’s outputs – these are usually event driven or time driven.
Monitoring and control is a continual loop to ensure that improvements identified throughout the project are acknowledged and if required implemented as part of the project.
Closing the project will happen once the project manager and colleagues are comfortable that everything has been carried out to the standards identified in the project plan then the work is signed off as complete to a satisfactory standard.
The changes we implemented within our reception area were quite rudimentary, changing a door to open a different way, moving a wall out slightly and changing the flow to and from the reception area.
Sometimes, simple changes are all that is required to achieve a much more efficient and effective way of working.

Dawn Stott, chief executive of the Association for Perioperative Practitioners (AfPP).

Further reading
NHS England – Primary Care
Infrastructure Fund (January 2015).
NHS Project Improvement Grants (2013). Wikipedia, Project Management (approaches).