Building A Systems Change Coalition: Fistula First

1. Building A Systems Change Coalition:Fistula First Initial Meeting Minneapolis, MN August 12, 2005

2. Welcome!Thanks for joining us today!

3. Why is Network 11 building a coalition? • Expands capacity to influence improvement • Increases effectiveness by working collectively

4. Why a Fistula First Coalition? • Provider and patient coalition focus • Outpatient dialysis facilities • Surgeon education • Patient education • Systems change coalition focus • System change • Organization-level change

5. COMMUNICATION Systems Change Coalition COLLABORATION Dialysis Units Network 11 Nephrologists Surgeons Patients COOPERATION

6. The Goal: Long-lasting AVF AVF Maintenance AVF Surgery Dialysis Facility Pre-ESRD/CKD Vascular Access Continuum

7. Why are we here? • To enlist your help • To hear your ideas • Brainstorm • Prioritize • Plan • To influence improvement

9. Fistula First: Mission CMS, the ESRD Networks, and the renal community will work together to increase the likelihood that every eligible patient will receive the most optimal form of vascular access for that patient. In the majority of cases, this will be a fistula.

10. PROJECT GOALS: Fistula First Achieve the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) goals for Vascular Access: • AVF rates of 50% for incident (new) patients • AVF rates of  40% for prevalent (existing) patients

11. Fistula First Partners • CMS • The 18 ESRD Networks • Institute for Healthcare Improvement • Dialysis Providers • Professional Associations • Dialysis Corporations • In addition: • Vascular access surgeons • Interventional radiologists • Dialysis consumers

12. Routine CQI review of vascular access Early referral to nephrologist Early referral to surgeon for “AVF only” Surgeon selection Full range of appropriate surgical approaches Secondary AVFs in AVG patients AVF placement in catheter patients Cannulation training Monitoring and surveillance Continuing education: staff and patient Outcomes feedback Fistula First Change Concepts

13. Current typical ESRD patient AVF candidates Pre-ESRD/CKD Expanded ESRD candidates AVF pool Can This Be Achieved?

18. National Project Scope • Program Operations • Payment • Eligibility • Delivery systems • Clinical Practice • Practitioner education and training • Practitioner focus includes physicians, surgeons, nephrologists, technicians • Quality Measurement • Information management • Publications • Evaluation • Patient Education • Education for patients and family

19. Increasing AV Fistulas in Network 11 James Brandes, MD Medical Review Board Chair Network 11

20. Network 11 Goals • December 2002, Network 11 had 31.3% AV fistulas • CMS goal for Network 11 during the 2003 – 2006 contract period = 35.3% AVF • Network 11 MRB goal = 40% AVF • Monthly data collected electronically from Large Dialysis Organizations, manually from independent facilities

21. Network 11 Fistula First Eligible Facilities 320 Facilities 17,209 Patients

26. % AVF by Zip Code • Below K-DOQI Guidelines • Above K-DOQI Guidelines

29. Strategies for Increasing AV Fistula Rates

30. Three Phase Plan Dialysis Facility Workshops Patient Video Surgeon Workshops

31. Next Steps • Continue focus on patient education • Continue support and interventions with dialysis facilities • Target pre-ESRD patients and primary care providers to achieve AVF placement pre-dialysis • Begin data analysis of vascular access placed by surgeon • Start systems change coalition

32. We need your help!

33. Introductions • How do you see your organization contributing to the Fistula First Project? • What experiences, if any, do you have with systems change?

34. Building a Fistula First Systems Change Coalition Renal Network 11 Minneapolis/St Paul Aug 12, 2005 Tom Wolff Ph.D. Tom Wolff & Associates 24 S. Prospect St. Amherst, MA. 01002 413 253 2646 tom@tomwolff.com

35. Coalition Defined A coalition is a group of individuals and/or organizations with a common interest who agree to work together toward a common goal. - S.Fawcett et.al

36. The Continuum of Collaboration Definitions • Networking: Exchanging information for mutual benefit. • Coordination: Exchanging information and modifying activities for mutual benefit. • Cooperation: Exchanging information, modifying activities, and sharing resources for mutual benefit and to achieve a common purpose.

37. The Continuum of Collaboration- cont. • Collaboration: Exchanging information, modifying activities, sharing resources, and enhancing the capacityof another for mutual benefit and to achieve a common purpose by sharing risks, resources, responsibilities, and rewards. From Arthur Himmelman

38. Why coalition building • Fragmentation • Duplication of effort • Focus on deficits • Crisis Orientation • Failure to respond to diversity • Excessive professionalism • Detached from community & clients • Crisis orientation • Competition • Limited and inaccessible information

39. Coalitions Can • Promote planning and creation of a shared vision • Promote comprehensive approach • Increase communication within the system • Increase communication with the community • Encourage collaborative problem solving • Build on the strengths of the systems and the clients • Create culturally competent systems • Increase accessibility to resources for providers and clients

40. Basics of Coalition Building – Key Components • Check on community readiness - start where community is • Develop clear vision, mission and goals • Ensure inclusive and diverse membership • Develop organizational competence • Collaborative Leadership and Facilitation • Decision making • Communication • Planning

41. Key Components – cont. • Identify and use needed resources • Engage in action and advocacy • Promote hope and celebration • Change takes time and persistence • Monitor and evaluate • Get help when you need it

42. Factors Affecting a Coalition’s Capacity to Create Change • Having a clear vision and mission • Action planning for community and systems change • Developing and supporting leadership • Documentation and ongoing feedback on programs • Technical assistance and support • Securing financial resources for the work • Making outcomes matter From Roussus and Fawcett

43. Ten Stagesof Coalition Development • Define agenda & assess readiness • Recruit the right people and convene (forming) • Jointly create preliminary vision, mission, goals, objectives • Re-examine membership – reach out • Create structure, gather needed resources (storming)

44. Ten Stagesof Coalition Development Plan and Act: 6. Achieve early wins, energize the group and the community (norming) 7. Implement changes (performing) 8. Maintain vitality 9. Improve through evaluation 10. Sustain your legacy

45. Barriers • Turf and Competition • Bad history • Failure to Act • Lack of a Common Vision • Failure to provide and create collaborative leadership • Minimal organizational structure • Costs outweigh the benefits • Not engaging self-interest

46. Working with Conflict in Coalitions • Conflict is inherent in Coalitions • It is useful to recognize different types of conflict and conflict behavior: • Power, Accountability, Unity & diversity, Mixed loyalties, Division of labor, Interpersonal conflict • Expression and negotiation of conflicts is healthy coalition behavior. It leads to better results. • Use a variety of approaches to prevent, minimize and resolve conflicts From Beth Rosenthal in Wolff and Kaye From the Ground Up

47. Goals of structure: Clear: • Communication • Decision Making • Roles and responsibilities Capacity to move to action

48. Coalition Task Force Process • Identify stakeholders • Define the problem/issue • Investigate options • Design a response • Secure resources • Implement the plan • Evaluate and adapt • Spin off Source: B.L.Hathaway

49. “Be the change that you wish to create in the world.” - M. Gandhi

50. Ground Rules Everybody participates We agree to disagree Monitor time to accomplish tasks