Managing Complexity

The Importance of Best Practice Transfer across the

Borders: Setting Core Elements and Driving Local

Adaptations

As pointed out, while different country settings impose different combinations of services and require adaptation to local practices, international clinical outcome guidelines determine the same level of quality care to be delivered. The challenge today is to give the right answer to satisfy the expectations of payers and to achieve the same level of good dialysis outcome that all patients deserve.

In order to successfully manage the different country environments, and in response to the same quality expectations, FME has leveraged the differences, transforming them into strengths which form the backbone for the management of the network [26].

This integrated approach and its development, together with a common set of tools (first and foremost EuCliD® 5 and the ScoreCard) have been rolled out under the umbrella of the NephroCare® Excellence (NCXL) framework. NCXL is a step further towards higher harmonization and quality standards. It defines a structured platform of services for a first-class service provider network.

This standardization, and the way it is built and communicated, is not meant to make the world flat, on the contrary it drives resources on the important issue: managing specific and variable aspects of treating an individual dialysis patient. The NCXL framework system provides solutions to standard problems, so the organization can promptly react to deviations and, as applicable, can redefine the platform.

Variability as the Strength of the Network

In order to transform variability into strength and long-term value creation any organization should align resources to common targets, eliminate possible conflicts between functions or business units, focus on specific (variable) problem areas and, finally, create transparent behavior.

Fresenius Medical Care has followed this strategy, working in the following three steps.

The first step is to define and share 'core' values and technologies on a 'meta-national' basis. Consensus on the 'core' elements was the result of a long process involving FME as a manufacturer of dialysis products, with good relations to the medical community and research centers. The same entrepreneurial spirit [27] was then transmitted to FME's approach to managing its dialysis center network and this together with the experience inherent in the newly acquired clinic network shaped the 'core' elements.

In Europe, where no existing network was acquired, the central functions (in particular quality assurance and clinical management) started to reshape the knowledge of single dialysis centers as they joined the organization. Immediately projects and developments of a common management system were born trans-nationally, and Fre-senius Medical Care's strategy of knowledge sharing and cooperation was a real asset that fuelled the creation of the various elements of the IMS.

In adopting the NXCL tools the development of those systems required a knowledge collection from around the globe, an engineering effort and strong management support both centrally and locally. Thus it was the network of dialysis centers itself which created, developed and reworked the 'core' values and tools which, through interaction with the central functions, were automatically accepted, implemented and improved at local level.

The second step was to mobilize the dispersed knowledge and to create a knowledge-based environment among associates both at center level and throughout the Fresenius Medical Care Network, whilst fully integrated with the external care environment.

A clear example of this is the new EuCliD® 5: developed in Italy, personalized and improved in Portugal, imported in Romania, re-adapted in France. The programming is not based on the prerequisites of one country alone. The legal requirements are specific to each local situation, but the background platform, the workflow safety and the query system are the same.

Clinical governance and managerial entrepreneurship (supported by EuCliD® 5 and the ScoreCard, respectively) have in this way created a common framework and playground: this standardization of language and knowledge has made the focus on patient outcome targets much clearer, for managers and physicians alike.

The last step is to become operational and get started on the local adaptation. This phase is supported by local players who assume responsibility and set specific and relevant targets.

Normally three barriers, deeply rooted in organizational design, structures and corporate beliefs, make it difficult to break free of geography even when a company recognizes the threats of global dispersion of knowledge [28]: (1) the primacy of the home base, while dispersed knowledge needs dispersed 'sensors'; (2) the idea of 'weight equals voice', while nice ideas from small units must be heard, and (3) the assumption that local adaptation is important only locally, while it is in fact an opportunity for learning.

NCXL is about getting operational again at the local level and about bringing the core elements and tools to the local reality. It has to be done everywhere and in a consistent way. The three barriers have not been encountered so far within the culture of FME.

Where Are the Differences between the Different

Solution Approaches of Dialysis Networks?

In Europe there are some important national champions, like the German 'Kuratorium für Dialyse und Nierentransplantation e.V.(KfH)' and the French 'Générale de Santé' or the newly established Euromedic, but alongside FME there are only two other private vertically integrated networks, with transnational operations: Gambro Healthcare and B. Braun's Avitum.

Almost all of these organizations have established CQI programs, certified ISO processes, and medical guidelines integrated in their management systems.

While the ingredients of FME's management system correspond to those of the other organizations, and while the patient population and external obligations are the same for all, FME has a very distinctive approach, and the results achieved come from a few very important differences.

(1) A strong commitment towards the patient, anticipating the rules or reimbursement systems in the implementation of the newest technologies and therapies. This happened, for example, in Portugal in the late 1990s when FME decided to stop reuse without being awarded with additional resources. It happened again with the almost generalized adoption of high-flux dialyzers and it is happening today with the commitment to switch to online HDF for all patients.

(2) The unique possibility, for physicians with EuCliD® 5, to immediately intervene and guide the prescription, thanks to having real online clinical data.

(3) The scientific contribution of the FME network to the evaluation and improvement of therapies and the production of dialysis devices. The combined force of the FME network of nephrologists and EuCliD® 5 producing peer-reviewed and prize-awarded publications.

(4) Finally, the multidisciplinary team approach to care is the only one able to cope with the multifaceted needs of a HD patient.

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