Renovations and Repairs Contract Template by gcp93149

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									Health System Improvement Pre-Proposal




Health System Improvement Pre-Proposal (HSIP)

Insert Pre-Proposal Name
Insert Submitting Organization Name




Submission Date: Month Day, Year




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Health System Improvement Pre-Proposal




Table of Contents:
Table of Contents: ................................................................................................................................................................... 2
Section 1: Submission Contact Information ............................................................................................................................ 2
Section 2: Partners in this Pre-Proposal ................................................................................................................................. 2
Section 3: Pre-Proposal Overview and Scope ........................................................................................................................ 2
Section 4: Alignment with WWLHIN IHSP Priorities ............................................................................................................... 3
Section 5: Expected Service Outcomes and Volumes ........................................................................................................... 3
Section 6: Proposed Timeline ................................................................................................................................................. 4
Section 7: Funding Details ...................................................................................................................................................... 4
Section 8: Stakeholders Analysis ............................................................................................................................................ 6


           Please obtain the HSIP Submission Guide for assistance completing this form from the WWLHIN Website,
            www.wwlhin.on.ca – follow the home page navigational menu to the “for health service providers” page.



Section 1: Submission Contact Information

Contact Name:                                                                                       eMail Address:

Address:                                                                                            Phone:

Has this Pre-Proposal has been approved by submitting Agency‟s Signing Authority : Yes/No




Section 2: Partners in this Pre-Proposal
Identify those who have agreed to actively partner on this pre-proposal.
See Submission Guide for description of partner. Please note that the partners may be contacted to confirm their participation.



 Organization                                            Contact Information                 Nature and Objective of the Partnerships




    Add rows if necessary



Section 3: Pre-Proposal Overview and Scope

Proposal Overview:            In a maximum of 100 words, please provide a clear and concise overview of your proposal, i.e. what do you want to do?


  Type here – Boxes expand as you type



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Health System Improvement Pre-Proposal



Proposal Scope :        : Describe „what is‟ and „what is not‟ included as part of the work to be performed.

Consider specific features, functions, qualities, needs or other “must have” requirements and place them in the “IN” Scope section.
Consider anything that will deliberately avoided and/or work that will not be performed, in the “OUT” of Scope section.


“IN” Scope                                                                                “OUT” of Scope
  Describe specific items that WILL be included as part of the work performed               Describe specific items that WILL NOT be included as part of the work performed

             Text here                                                                                Text here



Section 4: Alignment with WWLHIN IHSP Priorities and Strategic
Dimensions
Place an X in the white space beside the IHSP priorities this pre-proposal supports

Improving access to primary care                                              Improving chronic disease prevention and management

Decreasing alternate level of care days                                       Improving access to emergency department care

Improving patient safety and enhancing quality                                Improving access to, and coordination of, addictions and mental
of care                                                                       health services

                                                                              Improving outcomes for stroke patients through integrated
Improving wait times for MRI exams
                                                                              programs

Explain how the proposal will support the WWLHIN‟s IHSP priorities according to the following dimensions

Please see the Submission Guide document for a list of probing questions to assist you in completing this section.




Population Health : maximum of 150 words


             Text here


System Performance : maximum of 150 words


             Text here


Community Capacity : maximum of 150 words


             Text here


Strategic Fit : maximum of 150 words


             Text here



Section 5: Expected Service Outcomes and Volumes & System Outcomes

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Health System Improvement Pre-Proposal




Service Outcomes:

In serving these people what are the expected outcomes : maximum of 150 words

            Text here


What are your planned volumes: e.g. Number of clients or units of service


Client or Service Type                                                            Volume & Unit of Measure

            Add rows if necessary                                                     

                                                                                      

                                                                                      

System Outcomes:

Describe the expected impact on the local healthcare system : maximum of 150 words

            Text here



Section 6: Proposed Timeline

Please provide a high-level activity list with associated timeline that reflects the process to develop an implementation plan
through completion of the project.

i.e. High-Level work plan from start (date „0‟) to when it is fully operational




     Activity                                                                              Timeline in months

        Add rows if necessary




Section 7: Funding Details


Please indicate to which other potential funding sources (other than WWLHIN) this proposal has been submitted?


  Type Here - Box expands as you type




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Health System Improvement Pre-Proposal




If the proposal depends on a capital project, provide a brief description of the capital project and indicate if you have
submitted a capital request to the Ministry of Health and Long-term Care (MoHLTC).

Please provide the date and if available the MoHLTC Capital Branch consultant assigned to your request.

 Type Here - Box expands as you type




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Health System Improvement Pre-Proposal


                                                One-Time /   Annual/
Item                                                                        Total             Notes and Comments
                                                Start Up     Ongoing

REVENUE

Funding Requested from
WWLHIN

Funding from Other Sources (1)

In-Kind Contributions (2)

TOTAL REVENUE

EXPENSES (3)

Salaries and Benefits
(Permanent and Contract Staff)

Program Costs
(Program-related expenses such as
materials, resources, transportation,
promotion)

Administration
(Rent, insurance, office supplies, fax/phone,
internet and accounting and legal fees)

Capital
(Computers, office furniture, equipment,
renovations, repairs)



Evaluation

Miscellaneous
(Please specify)



TOTAL EXPENSES (4)

REVENUE less EXPENSES                                                                         Should be zero

*Footnotes
     1.    Please include sponsorships, donations grants and other financial assistance, and indicate proposed funders in notes and
           comments.
     2.    Include your own contributions to the cost of the initiative and those in-kind contributions of your donors and community
           partners.
     3.    Itemize all costs over $1,000 and, provide notes that explain the details of these costs (e.g. salary $12,480 = 20 hrs/week @
           $12/hr for 52 weeks; or $5,000 flooring at 250 square feet at $20/sq ft.)
     4.    Your total expenses should balance with the total of all income and contributions




                                                                                                               Page 6 of 7
Health System Improvement Pre-Proposal




Section 8: Stakeholders Analysis
Stakeholders are individuals, communities, political entities or organizations that have a stake in the outcome of the proposal.

       Stakeholders are anyone who either is affected by, or can have an affect on, the proposal or its outcome.
       Stakeholders are anyone whose interests are affected positively or negatively by the proposal or its outcome.
       Stakeholders are anyone that may exert influence over the proposal or its outcome.
       Please identify all potential stakeholders.



Stakeholder                      Level of Outcomes                 Level of Influence on               Level of Concern or             Issue of greatest
                                 Impact                            outcomes                            Interest                        concern or opportunity
                                 Low, Moderate, High, Unknown      Low, Moderate ,High, Unknown        Low, Moderate, High, Unknown
                                                                                                                                       to stakeholder

                                 and indicate Positive             and indicate Positive
                                 or Negative impact                or Negative influence
                                 Positive, Negative                Positive, Negative

 Add rows if                       E.g. Low/Positive
 necessary




*NB – “none” indicates a group that requires education relative to the purpose of the proposal and how they are affected by outcomes.




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