Expression of Commitment

INSPIRED Approaches to COPD: Improving Care and Creating Value

The deadline for submission of the Expression of Commitment is June 30, 2014 and participants will be notified of decision by July 18, 2014.

The Canadian Foundation for Healthcare Improvement is a not-for-profit organization funded through an agreement with the Government of Canada. The views expressed herein do not necessarily represent the views of the Government of Canada.

Expression of Commitment

INSPIRED Approaches to COPD: Improving Care and Creating Value

This Expression of Commitment constitutes a team application to participate in the Canadian Foundation for Healthcare Improvement (CFHI) and Boehringer Ingelheim (Canada) Ltd. (BICL) quality improvement collaborative focused on implementing a proven approach to chronic obstructive pulmonary disease (COPD) care – the INSPIRED (Implementing a Novel and Supportive Program of Individualized care for patients and families living with REspiratory Disease) COPD Outreach Program. Please refer to the INSPIRED Approaches to COPD: Improving Care and Creating Value Prospectus for detailed information before filling out this application form.

Please Note The deadline for submission of the Expression of Commitment is June 30, 2014 and participants will

be notified of decision by July 18, 2014. Teams will be selected by CFHI faculty and staff based on the strength of their alignment with

requirements described within the Prospectus and CFHI considerations of overall composition of the cohort of teams in terms of diversity of setting and context.

CFHI plans to limit enrolment in the quality improvement collaborative to approximately 10 organizations.

By completing the application form, the organization and team members confirm that they understand CFHI’s Conflict of Interest Policy, including rules regarding eligibility of foundation employees, trustees and agents.

Expressions of Commitment must fully disclose any relationship with the current members of the CFHI Board of Trustees. Organizations from which any members of the CFHI Board of Trustees, or foundation agents or employees receive remuneration are eligible to apply to this competition.

All applicants will receive summary feedback from the reviewers.

Application InstructionsPlease submit, by e-mail only, your completed Expression of Commitment (in PDF and MS Word format) and:

Abbreviated curriculum vitae (CV one-pager) for each team member. Declaration of any potential conflict of interest as per CFHI’s policy. The maximum page limit for Sections A to C of the expression of commitment is 7 pages. All

applications must be on letter-sized paper (8 ½ x 11), single space, with use of the margins and Calibri 11-point font that have been preset into the form.

Assessment CriteriaA summary of criteria against which applicants will be assessed is available upon request.

Questions and completed applications should be directed to Meghan Rossiter, Improvement Liaison, at meghan.rossiter@cfhi-fcass.ca.

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A: Organizational Commitment

Organizational Commitment – must be made by the CEO or person of highest accountability in the organization (e.g. accountable to the board of directors)

Mr./Mrs./Ms./Dr. NameTitle/DepartmentOrganizationMailing AddressCity Province Postal CodeTelephone FaxE-mailOriginal Signature1

1. Explain how reducing reliance on hospital-based COPD care (and, therefore, adapting and implementing the INSPIRED COPD Outreach Program) is linked to your organization’s strategic priorities.

2. Explain how you will ensure adequate time and resources are allotted to implementing and evaluating the success of the initiative.

     

B: Organizational Overview

1. Provide a brief overview of your organization, including the range of respiratory services provided, and the size of the COPD population.

2. The majority of the COPD population in the catchment area of your organization is:

Rural □ Remote □ Urban □

1 Signature on the application form confirms the organization’s commitment to: the adaptation, implementation, evaluation and sustainability of the INSPIRED COPD Outreach Program; protecting participant(s)’ time to conduct the innovation and the evaluation and to attend learning sessions, and; signing an agreement with CFHI, confirming mutual commitments, by August 15, 2014, should the application be

successful.

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3. Provide the number of patients with moderate to severe COPD [stage 4-5, respectively, on the Medical Research Council (MRC) breathlessness scale]. If this population segment has not yet been identified, please describe your plans for identifying this patient population.

4. Provide a brief overview of the severity of the problem, e.g., frequency of ER visits and hospitalizations (and associated costs) for which COPD accounts, especially for those with moderate-severe COPD.

C: Organizational Readiness

1. Briefly describe your goals for this initiative and how you will adapt and implement the INSPIRED COPD Outreach Program.

2. Briefly describe other resources or processes that are in place in your organization that will support implementation and evaluation of the initiative (e.g., quality improvement committee, patient advisory committee, IT systems, training sessions, tools, etc.).

3. Provide an example of how your organization has implemented and measured quality improvements.

4. Please describe any past or current quality improvement initiatives in your organization aimed at improving COPD care and the outcomes for patients and families, front-line providers, the system, etc. that came as a result of these initiatives.

5. Provide an example of how your team has established connections from the acute care to community settings? (e.g., if your team is based at an acute facility, how will you involve community partners or demonstrate the ability to provide specialist outreach or at-home services? Similarly, if your team is based in the community, how will you demonstrate the ability to liaise with the acute facility in your region?).

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D. Ethics

1. Is ethics approval required prior to commencement? Yes □ No □ Need more information □Although the work under this collaborative will not be a research project, as patients, families and staff will be involved, expectations for ethics approval vary by location and organization. Applicants should investigate at the application stage what form of ethics approval this project may require (e.g. full ethics approval or approval to conduct a quality improvement project). It is expected that successful teams will begin the process of gaining ethics approval as soon as they are advised of the success of their application.

E. Budget

How does your organization anticipate utilizing the seed money to support adaptation, implementation and evaluation of the INSPIRED COPD Outreach Program? Note that final development of a budget will be informed by answers to this question.

Please complete the budget summary below using the eligible and ineligible expense information provided in Appendix 1.

Budget SummaryCategory Description AmountPersonnelTravelEquipmentSupplies and Service

Total

Budget Justification: The appropriateness of the proposed budget will be assessed by the reviewers. Please provide a detailed breakdown of each budget category by line item below.

Do you have any partnerships or sponsorship agreements in place that will support implementation and evaluation of the initiative? If yes, please describe.

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F: The Team

Your team needs to include the following members:

Clinical and Administrative Leads of the organization, who will ensure top-level organizational commitment in all aspects of the implementation and evaluation of the initiative, including access to the senior executive team, protected time for the work, and support for and active engagement in the organizational or policy change dimensions. These persons will support and be accountable for the overall direction of the project. Example job titles include chief of medicine; medical director; chief of respiratory therapy; VP, acute care, etc. The clinical and administrative leads of the organization are expected to participate in activities related to leadership and change management and, periodically, co-present with the team the results and impacts of the work during scheduled progress-reporting activities (e.g. webinars).

Project Lead, who will be the key coordinator and motivator, ensure milestones are met, and who will serve as a main point of contact for CFHI. This individual will plan for and provide overall guidance and oversight for the spread and will be primarily accountable for the design, implementation, and evaluation of the initiative. This person will lead and coordinate necessary activities with staff, patients and families.

Evaluation and Measurement Lead, who will be accountable for the evaluation of the initiative; support or coordinate/supervise data analysis; regularly communicate results to healthcare teams via brief quarterly reports and through meetings with management, the physician champion(s), COPD educator, and larger multi-disciplinary staff; participate in all activities related to process and outcome measurement (e.g., webinars with evaluation and measurement leaders from other teams; sharing process and outcome results in the context of CFHI’s overall evaluation and performance measurement plan).

Physician Champion(s), who will work with the project lead on the plan for spread, will contribute to the design, implementation, and evaluation of the initiative, and provide necessary clinical support to staff. Multiple physician site champions can be included, but at least one should be a physician leader (e.g., Respirology, Internal Medicine, Palliative Care, Primary Care, Emergency Medicine).

Certified COPD Educator [e.g., Registered Respiratory Therapist (RRT) or Registered Nurse (RN)], who will work with the project lead and physician champion(s) on the plan for spread, will contribute to the design, implementation, and evaluation of the initiative, and provide necessary support to patients and staff.

This team will be responsible for ensuring that 1) there are established structures for advancing the initiative; 2) the initiative is a recognized organizational priority; and 3) the appropriate amount of time, resources, and accountability are in place to promote performance measurement and overall success. Note that there is no limit to the number of team members and a single person can play multiple roles (e.g., the Evaluation and Measurement Lead might also be the Project Lead). Please list all members of your team and complete the information that follows:

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Clinical LeadMr./Mrs./Ms./Dr. NameTitle/DepartmentOrganizationMailing AddressCity Province Postal CodeTelephone FaxE-mailOriginal Signature

CV one-pager attached Yes □ Language of Correspondence English □ French □

Administrative LeadMr./Mrs./Ms./Dr. NameTitle/DepartmentOrganizationMailing AddressCity Province Postal CodeTelephone FaxE-mailOriginal Signature

CV one-pager attached Yes □ Language of Correspondence English □ French □

Project Lead (overall project team lead for all communications with CFHI)Mr./Mrs./Ms./Dr. NameTitle/DepartmentOrganizationMailing AddressCity Province Postal CodeTelephone FaxE-mailOriginal Signature

CV one-pager attached Yes □ Language of Correspondence English □ French □

Evaluation and Measurement LeadMr./Mrs./Ms./Dr. NameTitle/DepartmentOrganizationMailing AddressCity Province Postal CodeTelephone Fax

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E-mailOriginal Signature

CV one-pager attached Yes □ Language of Correspondence English □ French □

Physician ChampionDr. NameTitle/DepartmentOrganizationMailing AddressCity Province Postal CodeTelephone FaxE-mailOriginal Signature

CV one-pager attached Yes □ Language of Correspondence English □ French □

Certified COPD Educator Mr./Mrs./Ms./Dr. NameTitle/DepartmentOrganizationMailing AddressCity Province Postal CodeTelephone FaxE-mailOriginal Signature

CV one-pager attached Yes □ Language of Correspondence English □ French □

Other Team MembersTeams are encouraged to include additional team members beyond those listed above. Access to social work or spiritual care with demonstrable experience in advance care planning is advisable as is access to timely patient and family involvement throughout the project. Access to other allied health professionals such as mental health support, palliative care, physiotherapy, kinesiology or pulmonary rehab support is also desirable.

Please copy and paste as many team member boxes as you require — all other contact information for team members must be provided on their CV one-pager.

Team Member NameAffiliationOriginal Signature

CV one-pager attached Yes □

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Curriculum Vitae (CV) One-Pager

Please copy and paste as many CV boxes as you require.

Mr./Mrs./Ms./Dr. First Name Last name

Title Department

Organization

Mailing Address City

Province Postal Code

Phone Preferred Language

Email

Health Discipline

Role on the Team

Experience Relevant to this Initiative

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APPENDIX 1: Eligible and Ineligible budget expenses

CATEGORY ELIGIBLE INELIGIBLE**Personnel(up to 100% of eligible expenses)*

release time for team members whose regular job description will be amended to allow them to work on the quality improvement initiative

funds to hire additional staff to backfill the jobs of team members who are being released to work on the quality improvement initiative

salary replacement costs to allow providers to participate in the quality improvement initiative (not including delivery of services)

eligible release time charged at rates above existing salary

service delivery costs release time related to the

financial administration of collaborative funds

Travel for Educational Purposes(up to 10% of eligible expenses)*

travel costs for team members between quality improvement initiative site(s)

travel, accommodation and meals for team members required to attend meetings, including the collaborative in-person workshop in February 2015

travel costs not directly related to the conduct of the quality improvement initiative

Equipment** computer and other capital purchases

cost of equipment directly required for the quality improvement initiative

Supplies and Services(up to 10% of eligible expenses)*

cost of producing materials required for the quality improvement initiative (photocopies, printing, office supplies, etc.)

costs relating to communication of the quality improvement initiative results, such as meetings and videoconferences

cost of supplies and services not directly related to the conduct of the quality improvement initiative

* Use as a guide** Under usual circumstances, items listed here will be deemed ineligible. CFHI recognizes, however, that unusual situations exist. Please contact CFHI staff for clarification and interpretation.

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