Pre Qualification Questionnaire for Short listing Providers to

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					        Pre Qualification Questionnaire for Short listing
     Providers to enter into Competitive Dialogue with NHS
       Harrow to provide a Referral Management Service




                     19TH OCTOBER 2009




October 2009   -1-         NHS HARROW REFERRAL MANAGEMENT SERVICE PQQ
    NHS HARROW REFERRAL MANAGEMENT SERVICE PRE QUALIFICATION QUESTIONAIRE


Please complete this document electronically. Please refer to the notes of guidance in the accompanying
Memorandum of Information for further information about the process, evaluation criteria and timelines.

Please append requested number Annexes for requested documents, the table cells are highlighted in Yellow for
these requirements and a checklist is provided at the end of this questionnaire.



       1   BASIC DETAILS OF YOUR ORGANISATION

 1.1       Name of the lead organisation:

 1.2       Names of supporting organisations or
           material subcontractors

 1.3       Contact name for enquiries about this
           PQQ application:

 1.4       Contact position (Job Title):

 1.5       Address:
           Post Code:

 1.6       Telephone number:

 1.7       E-mail address:

 1.8       Website address :

 1.9       Company Registration number (if this
           applies):

 1.10      Charities or Housing Association or other
           Registration number (if this applies).
           Please specify registering body:

 1.11      Date of Registration:

 1.12      Registered address if different from the
           above:
           Post Code:

 1.13      VAT Registration number:

 1.14      Is your organisation:                          i) a public limited company
           (Please tick one)
                                                          ii) a limited company

                                                          iii) a partnership




    October 2009          -2-                      NHS HARROW REFERRAL MANAGEMENT SERVICE PQQ
                                                         iv) a sole trader

                                                         v) GP or clinician acting
                                                         independently

                                                         vi) other (please specify)

1.15      Name of (ultimate) parent company (if this
          applies):

1.16      Companies House Registration no. of
          parent company (if applicable):

1.17      Please state any material subcontractors
          or consortia arrangements stating scope
          and responsibilities for each part of the
          service

1.18      Do you envisage their could be any
          vertical integration conflict issues through
          your organisation having established
          relationships with referrals to Harrow
          clinicians and consultants (acute and
          primary care)

1.19      Have you, or any member of your
          organisation any conflict of interest to
          declare that relate to the PCT or Practice
          Based Commissioning Groups?
          If yes please give details.




      2   FINANCIAL INFORMATION

2.1       What was your turnover in the last two           £       for year ended     £     for year
          years (if this applies)?                                                    ended

2.2       Has your organisation met the terms of its banking facilities and loan
          agreements (if any) during the past year?

2.3       If “No” what were the reasons, and what has been done to put things right?


2.4       Has your organisation met all its obligations to pay its creditors and
          staff during the past year?

2.5       If “No” please explain why not:




  October 2009           -3-                      NHS HARROW REFERRAL MANAGEMENT SERVICE PQQ
2.6       What is the name and branch of your         Name:
          bankers
                                                      Branch:

                                                      Contact details:

2.7       Please confirm that we may contact your bank for a reference should
          this be deemed necessary by the PCT Finance Evaluator.

2.8       Please supply at least one of the following, in electronic format if possible

          A copy of your most recent audited accounts (for the last two years if
          this applies) and mark as Annex 2.8.1

          A statement of your turnover, profit & loss account and cash flow for the
          most recent year of trading and mark as Annex 2.8.2

          A statement of your cash flow forecast associated with a proposed
          business plan and a bank letter outlining the current cash and credit
          position and mark as Annex 2.8.3



      3   BUSINESS ACTIVITIES

3.1       What are the main business activities of your organisation?




3.2       What is your current annual turnover for Referral Management Services




3.3       How many staff does your organisation have? How many are
          engaged in Referral Management Services?




      4   REFERENCES

          Please provide details of three recent contracts that are relevant to the PCT’s requirement.
          Where possible at least one should be from the public sector.


          If you cannot provide three references, please explain why:


                                           Reference 1              Reference 2           Reference 3



  October 2009           -4-                      NHS HARROW REFERRAL MANAGEMENT SERVICE PQQ
4.1       Customer Organisation
          (name):

4.2       Customer contact name
          and phone number:

4.3       Date contract awarded:

4.4       Contract reference and
          brief description:




4.5       Value:

4.6       Date contract was
          completed:
          Have you had any contracts terminated for poor performance in
4.7
          the last three years, or any contracts where damages have been
          claimed by the contracting authority?
4.8       If “Yes”, please give details:




      5   INSURANCE
                                            Cover per incident             Expiry Date
          Please provide details of your
          current insurance cover

5.1       Employer’s Liability:             £

5.2       Public Liability:                 £

5.3       Professional Indemnity            £

5.4       Other (please provide details):   £




      6   QUALITY ASSURANCE

6.1       Is your organisation registered with the Healthcare Commission
          Those organisations not registered with the Health Care Commission are
          required to meet Healthcare Commission Standards




  October 2009            -5-                   NHS HARROW REFERRAL MANAGEMENT SERVICE PQQ
6.2       Does your organisation have a complaints policy to ensure patient
          concerns are addressed? Please supply a copy and mark as Annex 6.2

6.3       Does your organisation have a system to understand patient satisfaction
          with the services provided? Please provide evidence and mark as Annex
          6.3



      7   HEALTH & SAFETY

7.1       Does your organisation have a written health and safety at work policy?
          (see notes at end of point 7)
          Please supply an electronic copy of your organisational Health and Safety
          General Policy Statement (S ) and mark as Annex 7.1

7.2       If “No”, to the above please explain
          why:



  Notes:
  “system” is defined as meaning processes and procedures to ensure that the subject is properly
  managed. This includes making sure that legal requirements are met.
  Health and Safety Policies
  Any business employing five or more people has, by law, to prepare and bring to the attention of
  employees a written Health and Safety Policy Statement.
  A Health and Safety Policy usually consists of three distinct sections namely:
          General Policy Statement – a short statement outlining the organisation’s commitment to
          Health and Safety, signed and dated by the senior organisation official (for example, the
          Managing Director).
          Organisation – how the organisation addresses health and safety; lines of communication
          between managers and staff; and any specific duties/responsibilities assigned within the
          organisation – this should be relatively straightforward for smaller organisations.
          Arrangements – the systems and procedures in place for ensuring employees’ health and
          safety at work.



      8   PATIENT SAFETY
          Please supply electronic copies as stated


8.1       Does your organisation have an Incident reporting policy; please provide a
          copy and mark as Annex 8.1




  October 2009           -6-                     NHS HARROW REFERRAL MANAGEMENT SERVICE PQQ
8.2       Providers will be required to complete PCT supplied audit at agreed
          intervals to prove their compliance with the policies and the policy
          effectiveness. Please confirm acceptance to this.




      9   HUMAN RESOURCES
          Please supply electronic copies of all relevant policies and procedures.
9.1       Does your organisation have a written equality and diversity policy, to avoid
          discrimination? Please provide a copy and mark as Annex 9.1

9.2       Does your organisation have systems in place to verify the status and
          credentials of individuals on appointment? Please supply a copy of the
          procedures used and mark as Annex 9.2

9.3       Does your organisation have a training policy, encompassing a policy to
          enable continuing professional development of staff? Please supply a
          copy of the procedures used and mark as Annex 9.3

9.4       Does your organisation have a system in place to ensure on an annual
          basis that all employees are registered with the appropriate professional
          body? Please supply a copy of the procedures used and mark as Annex
          9.4

9.5       Does your organisation have a system in place to ensure staff can raise
          concerns (whistle blowing) appropriately? Please supply a copy of the
          procedures used and mark as Annex 9.5



      10 ENVIRONMENTAL MANAGEMENT


10.1      Please confirm the compliance of your organisation with Waste
          Management Regulations relevant to the service being delivered. If you
          have a policy, please supply a copy of the procedures used and mark as
          Annex 10.1



      11 PROFESSIONAL AND BUSINESS STANDING

          Do any of the following apply to your organisation, or to (any of) the director(s) / partners /
          proprietor(s)?

11.1      Is in a state of bankruptcy, insolvency, compulsory winding up,
          receivership, composition with creditors, or subject to relevant proceedings



  October 2009           -7-                      NHS HARROW REFERRAL MANAGEMENT SERVICE PQQ
11.2   Has been convicted of a criminal offence related to business or
       professional conduct

11.3   Has committed an act of grave misconduct in the course of business

11.4   Has not fulfilled obligations related to payment of social security
       contributions

11.5   Has not fulfilled obligations related to payment of taxes

11.6   Is guilty of serious misrepresentation in supplying information

11.7   Is not in possession of relevant licences or membership of an appropriate
       organisation where required by law

11.8   If the answer to any of these is “Yes” please give brief details below, including what has been
       done to put things right.




  12 INFORMATION GOVERNANCE

       Please confirm that your organisation has the following policies in place and a system for
       monitoring the effectiveness of their implementation and provide an electronic copy:

12.1   Patient confidentiality policy, compliant with Caldicott requirements. Please
       supply a copy of the procedures used and mark as Annex 12.1

12.2   A policy to ensure compliance with the Data Protection Act Please supply
       a copy of the procedures used and mark as Annex 12.2

12.3   A policy to ensure compliance with the requirements of the Freedom of
       Information Act Please supply a copy of the procedures used and mark as
       Annex 12.3

12.4   A patient record keeping policy. Please supply a copy of the procedures
       used and mark as Annex 12.4

12.5   A patient records management policy. Please supply a copy of the
       procedures used and mark as Annex 12.5



  13 REFERRAL MANAGEMENT EXPERIENCE AND CAPABILITY

       NHS Harrow is keen to secure a provider with a proven track record of referral management
       supported by excellent clinical triage, IT support, data decision support tools and lean
       administration. Please outline your experience in the following area




 October 2009         -8-                      NHS HARROW REFERRAL MANAGEMENT SERVICE PQQ
13.1   Please provide details of existing clients and locations that you deliver
       referral management services for, stating number and types of referral
       dealt with each year

13.2   For the specific area of referral management services, please state your
       organisations staff currently engaged with
          •   Clinical triage
          •   Referral Administration and Patient Advisors
          •   IT Development and Support
          •   Data analysis
          •   Clinical governance

13.3   Evidence of an established Referral Management IT systems and
       highlights of their functionality

13.4   Clinical triage capability and clinical governance to ensure patient safety

13.5   Data driven clinical support tools

13.6   Please confirm that your organisation has experience of administrating
       Choose and Book

13.7   Ability to attract, develop and retain a motivated administration support
       team

13.8   Evidence of the ability to quickly engage with local GPs and stakeholders
       to work with the referral management service

13.9   Approach to ensure that you have adequate knowledge about the local
       Harrow health economy including treatment centre options and local travel
       arrangements from Day 1 of service delivery

13.10 Approaches to encourage GPs and the acute to conform to referral
      management centre processes

13.11 Suggestions to resolve potential disputes between the GP referrer and the
      Referral Management Centre clinicians

13.12 Evidence of a proven track record of managing patients, booking
      administration, patients records and choose and book

13.13 Please indicate whether you have a referral management reference site
      that NHS Harrow evaluation team could visit if your organisation is
      successfully shortlisted. Please provide details and location of your
      proposed reference site.




 October 2009         -9-                     NHS HARROW REFERRAL MANAGEMENT SERVICE PQQ
  14 COMMERCIAL PRINCIPLES

       NHS Harrow is keen to secure a provider who will work with the PCT on a partnership basis
       and is willing to receive a base fee and a performance fee for their services. Please provide a

14.1   Confirmation that you are willing to enter a performance fee/risk sharing
       commercial arrangement

14.2   An outline of how the PCT’s investment in Referral Management Services
       could reduce overall clinical costs and deliver better patient outcomes

14.3   A commitment to take over transferred staff under TUPE

14.4   Confirmation that you are willing to enter into a 2 year contract with a
       potential 3 year extension at the PCTs discretion

14.5   Confirmation that if your organisation is shortlisted to participate in a
       streamlined “lean” Competitive Dialogue process, and it will have sufficient
       resource to dedicate to the process. Providers will be required to fund all
       costs associated with bidding for this opportunity and these costs will not
       be reimbursable by NHS Harrow.

14.6   Please provide an indicative annual price along with any assumptions to
       deliver a referral management service handling 40,000 a year. Please refer
       to the Memorandum of Information for details of the initial specification.
       The price needs to be inclusive of IT system, clinical triage and governance
       staff, administration staff and other office overheads (facilities, telephone
       costs etc)

14.7   Please indicate what percentage of the indicative fee expressed in 14.6
       that you would want to link to performance and what percentage of the fee
       you would want guaranteed (fixed)

14.8   A confirmation that your organisation is able to mobilise admin and clinical
       resources and IT systems to be able to deliver the new service from the 1st
       February 2010.




 October 2009         - 10 -                    NHS HARROW REFERRAL MANAGEMENT SERVICE PQQ
13   DECLARATION
     I declare that to the best of my knowledge the answers submitted in this Application and Self
     Assessment document are correct. I understand that the information will be used in the
     evaluation process to assess my organisation’s suitability to be accredited to the Willing
     Provider list for a clinical service. I also understand that further evidence may be requested by
     the PCT at a future point.
     I understand and accept that if I withhold information or provide false or misleading information I
     may be liable to prosecution and or civil proceedings. I consent to the disclosure of relevant
     information for the purpose of validating this assessment in relation to the prevention and
     detection of fraud.
     FORM COMPLETED BY

     Name:

     Position (Job Title):

     Date:

     Telephone number:

     Signature:




 October 2009        - 11 -                  NHS HARROW REFERRAL MANAGEMENT SERVICE PQQ
                 CHECKLIST OF REQUIRED DOCUMENTS (Please Indicate whether they are
Annex No         included in your submission by determining YES or NO)

2.8.1            Recent Audited Accounts

2.8.2            Financial Statement (Turnover, profit &loss accounts and cash
                 flow)

2.8.3            Bank letter outlining current cash and credit position

6.2              Patients Complaints Policy

6.3              Patient Satisfaction Survey

7.1              Health and Safety Policy

8.1              Incident Reporting Policy

9.1              Equality and Diversity Policy

9.2              Credential Verification Policy

9.3              Staff Training Policy

9.4              Employee Registration (with suited professional body) Policy

9.5              Staff Concerns (Whistleblowing) Policy

10.1             Environmental Policy

12.1             Caldicott Requirements Procedure

12.2             Data Protection Act policy

12.3             Freedom of Information Act Policy (FOI Scheme)

12.4             Patient Records keeping Policy

12.5             Patient Records Managements Policy




  October 2009        - 12 -                      NHS HARROW REFERRAL MANAGEMENT SERVICE PQQ

				
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Description: Pre Qualification Questionnaire for Short listing Providers to