Download A: Organizational Commitment

Expression of Commitment
Reducing Antipsychotic Medication Use in Long Term
Care (LTC):
Spreading an approach from CFHI’s EXTRA Program
for Healthcare Improvement
The deadline for submission of the Expression of Commitment is
April 15, 2014, or when CFHI determines that the program has
reached capacity, meaning that a cohort of teams has been
identified that meets CFHI individual and overall criteria.
Expression of Commitment
Reducing Antipsychotic Medication Use in Long Term Care (LTC):
Spreading an approach from CFHI’s EXTRA Program for Healthcare Improvement
This Expression of Commitment constitutes a team application to participate in the CFHI Quality
Improvement Collaborative to implement and evaluate the antipsychotic medication reduction innovation
that has demonstrated success through CFHI’s EXTRA program. Please refer to the Reducing Antipsychotic
Medication Use in Long Term Care (LTC) Prospectus for detailed information before filling out the
application form. 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.
Please Note
 The deadline for submission of the Expression of Commitment is April 15, 2014, or when CFHI
determines that the program has reached capacity, meaning that a cohort of teams has been
identified that meets CFHI individual and overall criteria.
 Expressions of Commitment must fully disclose any relationship with the current members of the
CFHI Board of Trustees.
 CFHI plans to limit enrollment in the QI Collaborative to up to 10 organizations; therefore, you are
encouraged to apply well before the deadline.
 Expressions of Commitment (applications) will be reviewed and screened on a rolling basis and
readiness interviews conducted. Applicants who meet written eligibility and readiness criteria will be
interviewed by phone by a CFHI quality improvement advisor to further assess organizational and
team readiness.
 Teams will be selected by CFHI and advisors based on the strength of their applications as aligned
with characteristics described within the Prospectus and on CFHI considerations of overall
composition of the cohort of teams in terms of diversity of setting and context.
 Note that this QI Collaborative going forward depends on the identification of a strong, willing and
able cohort.
 Decisions will be communicated to applicants by April 20, 2014.
 All applicants will receive summary feedback from the reviewers.
Application Instructions
Please submit (by e-mail only) this Expression of Commitment and
 Abbreviated curriculum vitae (1 page or less) for each team member.
 Declaration of any potential conflict of interest as per CFHI policy.
Email completed applications to Jennifer Major at [email protected].
If you would like to speak with someone about the application, please email or call Linda Piazza at
[email protected] or 613-728-2238 (347) or Jennifer Major at the email above or 613-728-2238 (217).
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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.
Title/Department
Organization
Mailing Address
City
Telephone
E-mail
Original Signature1
Name
Province
Postal Code
Fax
1. Explain how reducing antipsychotic medication use in Long Term Care (LTC) 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 innovation
B: Organizational Overview
3. The majority of the LTC population in the catchment area of your organization is:

Rural

Remote

Urban
□
□
□
4. Provide a brief overview of your organization, including the umbrella of LTC services provided and
the size of the LTC population.
1
Signature on the application form confirms the organization’s commitment to:
the development, implementation, evaluation and potential sustainability of the innovation project;
protecting applicant(s)’ time to conduct the innovation project and the evaluation, and to attend the learning sessions. These
include a 1-hour opening webinar May 7 2014 and – at the organization’s expense - the attendance of at least two team members
at the June 4 2014 CFHI workshop Spreading healthcare innovations in a land of pilot projects following the National Health
Leadership Conference (NHLC) in Banff Alberta.

signing an agreement with CFHI, confirming mutual commitments, by June 30, 2014, should the application be successful.


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C: Organizational Readiness
1. Please confirm that your organization has implemented the Resident Assessment Instrument
(RAI)/Minimum Data Set (MDS)2. How long have you been using this tool and to what extent are
front line staff involved in using the data?
2. Briefly describe other resources or processes that are in place in your organization that will support
implementation and evaluation of the innovation (for example, quality improvement committee,
patient advisory committee, IT systems, training sessions, tools).
3. Provide an example of how your organization has implemented and measured quality improvements
(e.g., through the Accreditation Canada process, has the organization submitted and/or had
approved leading practices in any areas?)
4. Please describe any past or current quality improvement initiatives in your organization aimed at
reducing the use of antipsychotic medications. (NOTE: CFHI wishes to initiate or accelerate
improvement in this area).
5. Are you using the P.I.E.C.E.S. (Physical, Intellectual, Emotional, Capabilities, Environment and Social)3
model of care in your organization? If not, are you using a similar care model? If so, please describe.
D. Ethics
1. Is ethics approval required prior to commencement? Yes
□ No □ Need more information □
2
The Resident Assessment Instrument – Minimum Data Set (RAI-MDS) is one of the interRAI instruments
implemented to improve the care of frail elderly and disabled adults in chronic care and institutional long-term care
homes by standardizing the assessment and care planning process. http://www.hqontario.ca/publicreporting/long-term-care/information-about-quality-indicators
3
P.I.E.C.E.S. website:
http://www.piecescanada.com/index.php?option=com_content&view=article&id=1&Itemid=3
4
Although this initiative is not a research project, 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. External Partnerships or Sponsors
1. Do you have any external partnerships or sponsorship agreements in place that will support
implementation and evaluation of the innovation? If yes, please describe.
F. Budget
1. How does your organization anticipate utilizing the seed money to support implementation and
evaluation of the innovation? (e.g. for time release of clinicians or personal support workers;
education costs; project manager; travel; etc). Note that final development of a budget will be
informed by answers to this question and by the pre-work for the QI Collaboration. Successful
applicants will submit budgets to CFHI in time for approval by June 30, 2014.
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G: The Team
Your team needs to include the following members:
 Executive Sponsor4, who will ensure top-level organizational commitment in all aspects of the
implementation and evaluation of the innovation, 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. This person will support and be accountable for the overall direction,
implementation, and management of the project. Example job titles include chief of medicine; vice
president; CEO; COO. The Executive Sponsor is expected to co-present with teams the results and
impacts of the work during scheduled progress reporting webinars and participate in activities
related to leadership and change management.

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
engagement with staff (e.g., run educational sessions; carry out activities related to person-centred
models of care that help identify residents for whom to try reducing antipsychotic medications and
develop associated non-pharmacological treatment plans; plan and coordinate involvement of
families in antipsychotic medication reduction plans).

Evaluation and Measurement Lead, who will be accountable for the design, implementation and
evaluation of the innovation; support or coordinate/supervise data analysis; regularly communicate
results to healthcare teams via brief quarterly reports and through meetings with management,
prescribers, and the 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).

Clinician Champion(s), who will work with the project leader and provide necessary clinical support
to staff. Multiple clinician site champions can be included, but at least one should be a physician
leader (e.g., medical director).
This team will be responsible for ensuring that 1) there are established structures for advancing the
innovation; 2) the innovation is a recognized organizational priority, supported by its governing board; 3)
that 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). You may elect to include,
for example, mid-level administrative or managerial leaders; senior medical, nursing, and pharmacy
leadership; a quality improvement leader. Applying organizations are encouraged to include patient,
family and community representatives or other relevant partners as active team members.
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In addition to explicit support from the most senior level (e.g. CEO) of the organization, there must be an
Executive Sponsor (who could be the same person, e.g. CEO; or someone who reports directly to the CEO) on the
team.
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Please list all members of your team and complete the information below:
Executive Sponsor
Mr./Mrs./Ms./Dr.
Title/Department
Organization
Mailing Address
City
Telephone
E-mail
Original Signature
Name
Province
Postal Code
Fax
□
Project Lead (overall project team lead for all communications with CFHI)
Mr./Mrs./Ms./Dr.
Name
Title/Department
Organization
Mailing Address
City
Province
Postal Code
Telephone
Fax
E-mail
Original Signature
Language of
CV one-pager attached
Yes
English
French
Correspondence
□
Yes
□
Language of
Correspondence
French
CV one-pager attached
English
□
Evaluation and Measurement Lead
Mr./Mrs./Ms./Dr.
Title/Department
Organization
Mailing Address
City
Telephone
E-mail
Original Signature
CV one-pager attached
Clinician Champion
Mr./Mrs./Ms./Dr.
Yes
□
□
□
Name
Province
Postal Code
Fax
Language of
Correspondence
English
□
French
□
Name
7
Title/Department
Organization
Mailing Address
City
Telephone
E-mail
Original Signature
CV one-pager attached
Province
Postal Code
Fax
Yes
Language of
Correspondence
□
English
□
French
□
Other Team Members
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 Name
Affiliation
Original Signature
CV one-pager attached
Yes
□
Yes
□
Yes
□
Team Member Name
Affiliation
Original Signature
CV one-pager attached
Team Member Name
Affiliation
Original Signature
CV one-pager attached
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