Table 2.

Elements of the Pathways intervention determined on the basis of Institute for Healthcare Improvement Collaborative Model for Achieving Breakthrough Improvement

Intervention ElementDescriptionPurpose
Start-up
 Change package (Supplemental Material 2)Set of 14 evidence-based best practices developed through literature review and input of technical expert panel, guiding improvement efforts designed to improve kidney supportive care and to achieve goal-concordant care, especially at the end of life.Provide written guidance as to what to do, how to do it, and why
 Change team and charterDesignated team from each participating dialysis center or CKD clinic that has agreed to work toward improvement of supportive care at their site. Each team develops a charter that specifies their goals, objectives, and plans. Teams needed to have at least one nephrologist “champion.” Other disciplines participated on the basis of site and personal preference and included social workers, nurse practitioners, administrators, patient advocates, and palliative care physicians.Clearly identify who is going to lead change at clinical site and foster agreement on change team about their plans
 Expert facultyInterdisciplinary experts in supportive kidney care serve as faculty. Disciplines include nephrology, palliative medicine, social work, nursing, dialysis center administration, quality improvement, public health, and patient expertise.Teach and mentor content and skills needed to implement kidney supportive care
 Resource-rich intranet website and listservWebsite accessible to Pathways participants where all resources introduced during learning sessions or activity periods are housed for reference by teams. Also includes YouTube channel with videos produced by Pathways team and listserv for use by all Pathways participants.Foster ongoing communication between teams and with faculty; promote easy access to information and tools that teams may need for implementation of supportive care
Learning sessions during collaborative
 Learning sessionsThree in-person, 2-d mini conferences where teams gather to learn content, practice skills, share learning, and plan improvement activities. Each learning session has a mix of didactic teaching from experts, opportunities to practice skills, and time to share innovations with other teams.Foster sharing of innovations through the “All Teach, All Learn” approach of the collaborative; purpose is to provide both content knowledge about how to make change, and emotional support for the process of incrementally pushing change forward
 Communication-skills trainingTrained communication facilitators, from the Veterans Administration Goals of Care Conversations Skills Training for Clinicians program, delivered 7 h of content in learning session 1. This content is based on the VitalTalk model and was explicitly adapted to nephrology concerns and situations (14).Bolster communication skills to enable participants to increase confidence and competence in conducting goals-of-care conversations, including both shared decision making and advance care planning
In learning sessions 2 and 3, Pathways faculty provide additional communication-skills exercises to continue building skills with goals-of-care conversations using the Ask-Tell-Ask model.
 Storyboard sessionsEach team prepares a poster that explains their progress, barriers, and key innovations. These are shared in a poster session at the learning session.Foster sharing and spread of innovations; build team pride and enthusiasm for their work through presentation to peers
Activity periods between learning sessions
 Pathways action calls (monthly)Monthly videoconference call with faculty and all change teams. Teams report on successes and frustrations. Faculty provide additional teaching, especially focused on communication skills and symptom management. Cases teams have encountered are debriefed.Reinforce skills; exchange strategies between teams for overcoming obstacles; celebrate successes to build shared commitment to change
 Quality-improvement indicator reportsMonthly reports provided to sites showing data on set of commonly collected quality indicators.Helps sites benchmark and see progress of their site; monitoring quality indicators helps sites recognize areas of success and areas for improvement
Individual trend reports provided to each site showing their own trend month to month.
 Improvement-advisor monthly callsImprovement advisor on the faculty holds call with each team separately each mo to discuss progress and plan for tests of change.Provide technical assistance to sites on quality-improvement process using small tests of change; encourage sites to embed successful practices into standard workflows and processes
 Site visitsSmall teams of faculty (two to three faculty) visit each site for approximately half a day to meet with change team and other staff. Faculty consult with change team on their progress. Faculty model goals-of-care conversation with patient(s) and debrief with change team. All nephrologists (not just the champion[s]) are invited to lunch or dinner meeting with faculty nephrologist for talk on supportive kidney care and discussion of how this affects their practice.Builds rapport between faculty and change team; allows faculty to better understand environment at each site;modeling goals-of care conversation in person with patient at the site helps change team to see how to move from the role plays practiced in the learning sessions to actually integrating the conversations in their work setting;meetings with other nephrologists helps the champion build support among colleagues and center leadership
 Newsletter and email noticesPeriodic newsletters with information, new relevant evidence, and reminders.Keep Pathways participants up to date on latest evidence related to kidney supportive care and help them see the rich variety of resources available in this area; also builds connection and a sense of belonging to a larger mission
 Faculty consultation as neededAs requested by local sites, faculty consult via phone or videoconference.Provide ready access to expert consultation as needed
 Customized tools and resources as neededAs sites identify areas of need, Pathways team develops additional tools or resources. For instance, a pocket card using Ask-Tell-Ask communication cues was developed after faculty observed the need for a reminder staff could keep with them on the floor (see Supplemental Material 3).Provide targeted help as additional areas of need are identified