The "How-To" Guide to Hospice Palliative Care Twinning Projects

This content was archived on June 24, 2013.

This publication was produced with funding from Health Canada.
The views expressed herein do not necessarily reflect the official views of Health Canada.

Prepared for Health Canada by:
Susan Breiddal
Bruce Breiddal

Help on accessing alternative formats, such as Portable Document Format (PDF), Microsoft Word and PowerPoint (PPT) files, can be obtained in the alternate format help section.

Table of Contents

• About the Author
• Acknowledgements
• Introduction: Making a Difference - One Community at a Time
  • The Purpose of this Guide
  • A Practical Four-Phase Approach
  • Principles of Successful Twinning
  • Twinning Progress Flow Chart (Phases 1-4)
• Phase 1: Preparation
  • Getting Started
  • Building Support and Participation / Tapping Into People Power
  • Taking Care of Business
  • Making a Project Plan
  • Phase 1 Checklist
• Phase 2: Partnership
  • Finding a Twinning Partner
  • Defining Your Partnership
  • Signing an Agency Agreement
  • Acting with Sustainability in Mind
  • Phase 2 Checklist
• Phase 3: Implementation
  • Financial Accountability / Managing Donations
  • Fundraising
  • Planning Visits and Exchanges
  • Keeping Communication at the Forefront
  • Phase 3 Checklist
• Phase 4: Completion
  • Progress Review
  • Project Report
  • Project and Partnership Evaluation
  • Planning for the Future
  • Phase 4 Checklist
• Conclusion
  • A Practical Tool Kit for Your Organization
• Appendices
  1. Twinning Project Guiding Principles - a Personal Perspective
  2. Volunteer Application Form
  3. Letter of Interest
  4. Friendship Agreement
  5. Needs Assessment
  6. Agency Agreement
  7. Pledge Form
  8. Progress Review
  9. Project and Partnership Evaluation
• Web References
  1. Sample Completed Project Plan
  2. Sample Letter of Interest
  3. Sample Friendship Agreement
  4. Sample Agency Agreement
  5. Sample Priority List

About the Author

Susan Breiddal, author of the "How-To" Guide to Hospice Palliative Care Twinning Projects, has served as a counselor, teacher and trainer at Victoria Hospice for ten years, and is the project manager of the hospice's twinning project.

Through her company, Manual Dexterity, she has authored several Leader and Participant manuals. Her work with the Hold Me Africa hospice care project strengthened her desire to promote hospice palliative care across Canada and worldwide.

Using her 25 years experience as a counselor in private practice, she helped develop and is presently teaching the online John D. Morgan Certificate program in Death, Dying, Palliative Care and Bereavement.

She hopes to promote hospice palliative care through the Canadian Hospice Twinning Initiative "A Twin for Every Canadian Hospice".

Acknowledgements

The author would like to thank the following people for their contributions to this project:

• Michael Sharpe
  Manager, Palliative and End-of-Life Care Unit,
  Chronic and Continuing Care Division, Health Canada
• Peta Collings
  Volunteer Resources Manager, Hold Me Africa
• Wendy Pratt
  Executive Director, Nanaimo Community Hospice Society
• David Falk
  Physician, Hold Me Africa
• Ricardo Walters
  Coordinator, the Salvation Army Africa

Regional Facilitation Team

• Wayne Petersen
  Executive Director, Victoria Hospice Society
• Dr. Robin Love
  Medical Director, Palliative Care Program,
  Nanaimo Regional Hospital; International Network for Cancer Treatment and Research

The author would also like to thank those who agreed to read the early draft:

• Doug McLaughlin
  Volunteer, Hospice Calgary
• Stuart Brown
  Director Palliative Access (PAX) Program,
  International Network for Cancer Treatment and Research
• Leslie Sundby
  Professor, Faculty of Nursing,
  Malaspina University College

Introduction

Making a Difference - One Community at a Time

Over the past several decades the concept of twinning has assumed increasing importance in the efforts of towns and cities across the globe to collaborate on broad range of social initiatives. In recent years, community palliative care professionals in Canada and other developed countries have adopted twinning as a means of sharing palliative care knowledge, skills and promising practices with colleagues in developing countries. Their efforts are contributing to hospice palliative care twinning initiatives that are making a real difference in the quality of end-of-life care in many communities around the world.

1. The Purpose of This Guide

The purpose of this Guide is to assist Canadian organizations to develop hospice palliative care twinning projects with partner health care organizations in developing countries. The benefits of these projects - shared insights and experiences, intercultural collaboration and understanding - are important for palliative care practitioners, volunteers and supporters in Canada and elsewhere.

2. A Practical Four-Phase Approach

The "How-To" Guide to Hospice Palliative Care Twinning Projects offers a practical four-phase approach to successful twinning, including:

1. advice on preparing your organization for the twinning opportunity (with particular emphasis on volunteer input and participation);
2. choosing an appropriate twinning partner and setting up effective collaborative agreements;
3. implementing and managing your partnership relationship; and
4. reviewing your progress and evaluating your project and partnership success. Special features include a Twinning Progress Flow Chart; a step-by-step Project Plan; inspirational examples from previous twinning projects; and forms and legal documents to help you get started.

3. Principles of Successful Twinning

So what are the guiding principles of successful twinning? The 'How To' Guide to Hospice Palliative Care Twinning Projects asked veterans of successful twinning initiatives to share their principles for success. These principles fall into seven general categories:

1. Patience and Flexibility
   Be open to letting the process unfold. Canadian expectations regarding planning, government functioning and communications may be different from those in other parts of the world.
   
   Being open to process and recognizing uniqueness are underlying emotional and spiritual values of hospice palliative care. In other words, the same patience and flexibility that hospice palliative care workers offer to patients and families on a daily basis can be transferred to the twinning partnership itself.
2. Sensitivity and Respect
   You must be open to examining your own attitudes and behaviour. Reflect honestly on your willingness to wait and watch (when appropriate), to learn from your twinning partner, to refrain from "fixing" and giving advice, and to become aware of assumptions or prejudgments. You must make a conscious commitment to be respectful at all times
3. Sustainability
   Plan your twinning project with sustainability in mind. If you begin with a big splash and then quickly drop out, you may do more harm than good. Sustainability may not necessarily mean long-term direct involvement; it means that people and resources are in place to continue effective programming after your personal involvement has ended. You should therefore work towards solutions that can be maintained in the long run without outside help.
4. Reciprocity
   A twinning partnership is a reciprocal relationship. Each partner must identify what it wishes to gain from the partnership and what it has to offer. The challenge for the established organization is to share experience and expertise in a way that is empowering for the twinning partner. Plan for an equal exchange and assume that control and responsibility will also be equitable. Do not be surprised by the tremendous amount to be learned from your new partner.
5. Funding
   Make a little go a long way. You do not have to be rich to be effective. A monthly commitment of $20 can help to make significant improvements in the quality of end-of-life care in a developing country.
6. Assistance
   Provide assistance on a manageable scale. Many project participants feel overwhelmed by the magnitude of needs in developing countries. By pooling resources and talents you can start small and work your way up to bigger things.
7. Communication
   Connect with others. Twinning is about developing friendships with like-minded people around the globe. Your participation can make a real difference in someone's life. On-site visits can also bring insights into the ways care is delivered in resource poor areas. This not only increases your sense of the value of your partnership but brings renewed appreciation for the richness of your home environment.

A Personal Perspective

For an enlightening personal take on guiding principles for successful twinning, see the comments of Dr. David Falk of the Hold Me Africa hospice palliative care twinning project (Appendix A).

4. Twinning Progress Flow Chart

Phase 1: Preparation

1. Getting Started

Sharing Your Vision

It only takes one enthusiastic person with an idea to get a twinning project started. Talk to people in all areas of your organization. Your commitment will inspire others. Before long, word will spread and you will have an enthusiastic team.

Be sure to make use of group talents and community connections. Collect e-mail addresses and phone numbers from people who show interest. Remember: you do not need large groups; you just need people who share your twinning vision.

Developing a Vision Statement

Your vision statement should be inspiring and energizing. It should open people's eyes to the vast potential of your project, painting a mental picture that will motivate them to participate. Summarize your vision using a powerful phrase in the first sentence. Write your statement in the active voice as if you were reporting what you actually see, hear, think and feel after your ideal outcome is realized. You can combine your Vision Statement with a values statement that reflects your organization's project priorities.

Define who you are, what you have to offer, and what you would like to gain. Take a flexible approach: the details will likely change as your project develops.

2. Building Support and Participation - Tapping into People Power

Recruiting Volunteers

People around you will have heard about the project and will want to get involved as project volunteers. Ask them to fill out a Volunteer Application Form (see Appendix B). Keep track of specific skills that volunteers are willing to provide and file volunteer reference and contact information in one place.

It is important to identify and assign specific jobs to project volunteers so that they feel they are contributing in a meaningful way. Once expectations and roles are clarified, you may wish to ask your project volunteers to begin networking with people in the community who might be in a position to offer resources or services.

Reaching out to the Hospice Palliative Care Community

Make a list of your hospice palliative care networks. Contact other community members, including hospice staff and volunteers, community response teams, home care nurses, hospital staff and palliative care physicians, board members and agency leaders.

Establish a contact person within each of these groups and keep them up to date on your activities. Keep in mind that these people are busy. If they are going to get involved they will want to have a meaningful role. As with your project volunteers, be sure you have specific jobs for your hospice volunteers, otherwise you may lose their interest. Look specifically for those who can provide expertise in leadership, supervision, financial accountability, communications and outreach.

Make a point of being welcoming and inclusive. Everyone has something valuable to offer. At your first meeting, review the background material included in the Introduction and Principles of Successful Twinning section of this guide. Invite each person to talk about what motivated them to come to the meeting, and then plan your next steps. Sometimes the idea and the plan may be great, but the timing may not be right. You may have to accept this and wait. Be patient.

Getting Assistance from Your Organization

Although your project is volunteer-driven, you may still need staff input and supervision on administrative, logistical and financial matters. Ask your organization what it is willing to provide to your project.

Speak with your hospice palliative care community leaders on an informal basis. Seek advice and direction from people such as your Executive Director or senior officials of your hospice, the Medical Director of your palliative care unit, managers of volunteers, nurses, counsellors and spiritual care workers, and your Director of Home Care Nursing.

3. Taking Care of Business

Reviewing Basic Legal Issues

Once you have obtained support for the idea of twinning, you can review some basic legal issues that may affect your organization. Take a look at your provincial Societies Act and your organization's constitution and by-laws. The project will need to be in line with your organization's constitutional mandate. If an amendment to your constitution is needed to allow for international work, you may need to wait until your annual general meeting. Be sure to provide information well in advance of the meeting so that your board members can make an informed decision.

Make a Preliminary Presentation to the Board

At this point you have not made a commitment to a specific partner but you may have a number of potential partners in mind. Keep your options open until you have established your priorities, written your Project Plan (see page 15) and visited prospective project sites.

Even without a specific contract you will want to get agreement from your governing board to gather resources and work out the specifics. You can assure your board members that you have sufficient guidance and support by showing them this 'How -To' Guide to Hospice Palliative Care Twinning Projects.

Expect and welcome questions and concerns from the board; it's their job to act as a watchdog and to set the direction for your organization. Use their input as fuel for further "due diligence". Once you secure the board's agreement in principle, be clear that you will come back with more details before seeking final project approval.

Choose a Steering Committee

The purpose of the Steering Committee is to take responsibility for making decisions for the project "as a whole". Include leaders, such as a board member or your executive director, on your Steering Committee.

In the early stages you may need to meet as often as once a week. Each member will contribute time between meetings. If your group members are from different agencies you may find it difficult to meet in person and decide to do business by phone or e-mail. Once the project is in place, meetings can become more infrequent.

Sustainability

Sustainability is an important theme in twinning. Consider what will happen when the person who is the "driving force" behind your Steering Committee steps down. You will need to identify a plan for the future that is not dependent on one person. Electing a Steering Committee Co-Chair is one option.

Project Steering Committee: Key Players

The Project Manager...

ensures that the project is on time and within budget as outlined in the project agreements.

The Chair...

books group meetings, sets the agenda, keeps the meeting focused, facilitates discussion and ensures that discussion leads to a conclusion or resolution.

The Secretary...

records the minutes of the meetings and sends them to the Chair. The Secretary is in charge of any part of the project that requires written communication.

The Fundraiser...

is in charge of managing fundraising projects

The Accountant...

manages the project's bank account, receives, and sends money and materials, keeps detailed, accurate records and has signing authority on project cheques.

Group members...

participate at meetings, volunteer for and complete assigned tasks and may supervise volunteers or serve on subcommittees.

4. Making a Project Plan

A step-by-step Project Plan is essential to the success of your twinning initiative. The Project Plan helps you to work together as a team by thinking and talking about who does what and when. It also demonstrates to your supporters that you have thought through the details.

Step #1: Define Your Purpose

1. What is your project designed to accomplish?
2. How does this project reflect your Vision Statement?
3. How will this project bring mutual benefits to you and your twin organization?
4. What do you and your twin have to offer?

Step # 2: Identify Your Goals

Your statement of objectives should be clear, specific, measurable and attainable. It should include activities that your organization will carry out, financial commitments / investments, and organizational time commitments.

Step # 3: Define Your Scope

Define your project scope in terms of your activities. Decide what is to be included and excluded. Remember that you are still talking about the project as a whole and not about the specifics. Your scope should reflect your project goals, define the actions you will undertake to meet these goals, and establish limits in terms of work to be undertaken.

Step # 4: Identify Project Benefits

Make a list of ways in which the project will benefit your organization, including what you hope to learn and how it will impact on your understanding of and approach to the practice of palliative care.

Step #5: Establish Criteria for Choosing a Twin

It is important to establish social, cultural, linguistic and operational criteria for choosing your twinning partner. Consider language. Is English / French a commonly spoken language within your twin organization? Think about the language strengths in your organization. Also, when you consider cross-cultural communication, it's important to be mindful of local context.

Be sure to evaluate the size and type of service level you want to establish between your two organizations, as well as commonalities between your respective goals and visions. This will help you keep your project focused.

Step #6: Identify Stakeholders

Specify people or groups who have a stake in the outcome of the project. They should include your organization's staff, board members, volunteers and community partners, and others as your project grows in size.

Step #7: Identify Project Constraints

Constraints are uncontrollable elements that impact your project. They are not necessarily problems; however, you should be aware of them because they represent potential limitations on your project. Two of the most prevalent constraints are time and monetary resources.

Step #8: Identify Major Deliverables

Make a list of tangible deliverables (actions / products) that will satisfy the scope of the project.

Step #9: Outline Milestones

Milestones mark the dates on which deliverables are to be completed. Be sure to include dates when the project requires further authorization. Milestones are critical to ensuring that tasks are completed on schedule and are in line with commitments or agreements. Remember: some flexibility is required when setting milestones as you'll often face changing circumstances. (Experienced twinning participants identify communication breakdown, political unrest, extreme weather or change of personnel as typical causes of project delays).

Step # 10: Define a Project Management Budget

What are the costs of managing the project? Anticipated project management costs may include:

• staff working on the project on paid time;
• meeting space;
• supplies and the use of office equipment;
• travel to a twinning site;
• training in cultural awareness; and
• bank charges at home and in your partner's community.

If you have no budget for these items because you are counting solely on volunteer work and donated resources, you must clarify:

• which donations will support which team members;
• who can apply for international travel grants;
• who can travel as a team member; and
• what kinds of resources can be received by your team.

Step # 11: Fundraising

Describe your projected fundraising efforts, including the targeting of new donors and the planning of fundraising events. You should also be clear about who will supervise fundraising volunteers and what other foundations or organizations may be contributing to your project.

Step #12: Define Project Roles and Responsibilities

Define the general roles and responsibilities of those who will be involved in the project, including the project sponsor, Steering Committee Chair and members, the team leader, fundraisers and project volunteers.

Step #13: Communications Planning

You must be vigilant about letting the right people know what is happening at the right time. Decide who will take responsibility for items such as e-mails to team members, reports to management and the board, updates to community partners, communications within your twin organization, and donor appreciation. You must also designate someone to deal with the media.

Step # 14: Anticipate Risks Involved

A degree of risk accompanies all projects. Risk identification must therefore be conducted by project managers, members of the project team and stakeholders. When identifying potential risks, be sure to rate their likelihood of occurring, and identify what you would do to address them.

5. Phase 1 Checklist

1. Develop a Vision Statement
2. Recruit Volunteers
3. Seek out Expertise
4. Match Volunteer Jobs to Skills
5. Get Support From Your Organization
6. Review Legal Issues
7. Make a Presentation to Your Board of Directors
8. Choose a Steering Committee
9. Make a Project Plan
10. Assess Your Project Readiness

Phase 2: Partnership

1. Finding a Twinning Partner

The most obvious place to look for a twinning partner is through a pre-existing connection with an individual or organization involved in hospice palliative care twinning. If you have no such connection, you may wish to contact the following sources...

• The Hospice Information Bulletin is an international electronic newsletter published every two months. You can advertise for a "Hospice Twin" at http://www.helpthehospices.org.uk
• The International Network for Cancer Treatment and Research (INCTR) is involved in groundwork, education, and development of training centres for palliative care in developing countries. The International Network for Cancer Treatment and Research INCTR's relationships with new programs could provide a great foundation for a twinning project. http://www.inctr.org
• The International Association for Hospice and Palliative Care (IAHPC) has a twinning and hosting application form. http://www.hospicecare.com forms/twin_form.htm
• The Foundation for Hospice in Sub-Saharan Africa has an application for partnership form and a toolkit to help organizations get started. http://www.fhssa.org/i4apages/Indexcfm?pageid=3296

Prepare a Letter of Interest

Select potential twin organizations and prepare a Letter of Interest (see Appendix C) to let them know that you are interested in a twinning partnership. In your Letter of Interest you should outline your organization's history and services, as well as its proposed twinning mission, vision and goals.

Since this is also an opportunity for your prospective twins to consider the merits of your organization, you may wish to send each of them a copy of your Readiness Assessment (See page 14) along with your Letter of Interest.

It is important at this stage to refrain from making any firm commitments. Determine what the next steps should be if both parties are interested.

Make a Preliminary Visit

Communication by letter, e-mail, or telephone can get the ball rolling but there is nothing like a personal meeting to establish familiarity, confidence and trust. An initial visit to the site allows you to meet key personnel, compare goals, assess the situation, and discover the "spirit" of your prospective twinning partner. It is important that you and your prospective partner agree before-hand what each of you would like to gain from your site visit.

Find the Best Fit

It is only natural to have big dreams for your project, but you should temper your expectations with practical thinking about the challenges you will encounter on the ground and how you will deal with them.

Making Your Decision

It is important that your group reach consensus on your choice of twin. Discuss the options until agreement is reached. Once you have made your choice, contact your prospective twin to let them know that you are ready to enter into a twinning partnership. If you choose not to twin with a particular organization, you may wish to inform the organization of your decision and the rationale behind it in a sensitive and respectful way.

Balance Interests, Concerns and Expectations

All of those committed to the project will have their own interests, concerns and expectations. Be prepared for differences in perspectives, both within your group and between organizations. There will likely be differences in opinion with respect to project definition, individual responsibilities, priorities for action, and how project control is shared. In order to avoid competing personal agendas, ensure that spokespersons for both twinning partners impartially represent the interests of their entire organizations.

Focus on Partner Needs

Your twinning partner is the expert on its own situation. Carefully consider your partner's concerns and its system for addressing palliative care needs. Make sure you fully understand your partner's perspective before offering suggestions for improving hospice palliative care.

2. Defining Your Partnership

A Friendship Agreement (see Appendix D) defines the spirit of your partnership and formalizes your relationship. It is co-written and signed by representatives of both organizations and includes project goals and methods, which should be reviewed annually by both partners to see if adjustments are required.

Request a Needs Assessment from Your Twin

Your twin should perform a Needs Assessment (see Appendix E) to determine which services, materials and resources are already in place for parents and families, and which need to be provided in order to enhance hospice palliative care in the community. This assessment should include: an overview of current infrastructure, skills, knowledge and training; educational materials, supplies and equipment; and community support, networking and partnerships.

By examining your twin's current situation you will find their strengths and discover services already provided. Ask your twin what its program would look like if it could acquire resources needed to address a broader range of palliative care needs.

Setting Project Goals

Project goals are determined by the difference between what is in place and what is needed. Be sure to create a list of steps to meet specific goals, and then define who will take responsibility for each step. Compare these goals with the goals laid out in your Project Plan.

In defining your project goals you should establish a balance between immediate needs (such as treatments that contribute directly to patient comfort) and long-term needs (such as dedicated infrastructure to house patients). There is no "correct" balance. Your ultimate goals will depend on your collective capacities and priorities.

Obtain Board Approval

Provide each member of your board of directors with a copy of your Project Plan well in advance of your project approval meeting. Your presentation could be accompanied by a slide show or other visuals that demonstrate real people with genuine needs. Be patient if you meet with skepticism; the board is simply doing its job when it asks tough questions and demands satisfactory answers.

While the board's questions will be addressed in your Project Plan, you should be prepared to respond to queries on specific details and eventualities. Questions from the board are a great opportunity to uncover areas where you need to do further planning.

3. Signing an Agency Agreement

Support from your board, together with your written Friendship Agreement, is the springboard for your Agency Agreement (See Appendix F).

An Agency Agreement is a legal requirement if you are a registered non-profit society incorporated under the Society's Act. The Agency Agreement covers financial and service goals, explains why these goals are attainable, and presents a plan for reaching them. By completing the Agency Agreement you ensure that donations to your project are tax deductible.

4. Acting with Sustainability in Mind

Project sustainability demands that you be realistic about budget allocations. It is better to provide a modest sum that is reliable than to aim too high and not follow through. Plan a safety net right from the beginning. Make sure that you have three months of payments in the bank before you begin in order to avoid gaps in regular funding.

Under the terms of the Agency Agreement, you and your twin must determine how money will be spent. Your budget should address all possible expenses, including the costs of handling the funds (i.e., currency conversion, bank transfer and administrative fees).

Allow for Additional Costs

Be sure to allow for additional project costs, which may include: on-site contractors to set up communication systems; communications equipment such as computers, telephones, or cameras; shipping; travel for on-site visits; the costs of meetings (including room rentals, refreshments, and travel costs for presentations); and potential honorariums for people who have made outstanding contributions.

Division of Funds

A general rule of thumb for most projects is that 80 percent of funding goes directly to support operations within the twin organization. The remaining 20 percent, if required, will be allocated to administrative and communication support. Financial agreements should be developed jointly with the twin organization and signed by authorized persons. Any deviation from the agreement must be made in writing and agreed to by both parties.

When you have reached consensus on your Agency Agreement, ensure that authorized representatives sign the agreement and that copies are retained by each partner.

5. Phase 2 Checklist

1. Contact Twinning Resources
2. Prepare a Letter of Interest
3. Make a Preliminary Site Visit(s)
4. Choose Your Partner
5. Sing a Friendship Agreement
6. Request a Needs Assessment from your Twin
7. Examine Income Tax Implications of Your Project
8. Set Project Goals
9. Obtain Board Approval
10. Sign an Agency Agreement

Phase 3: Implementation

1. Financial Management and Accountability

Managing Donations

When you wrote your Agency Agreement, you and your twin agreed on how donations would be spent. You outlined a budget and how to be accountable. At the implementation stage you must now clarify the accountability requirements of both organizations with a view to determining who will manage donations, what kind of record keeping is acceptable, how money will be sent and received, and who will make sure that funds are spent as designated.

A twinning project must balance faith and goodwill with realism. Mismanagement and diversion of funds are potential concerns. While effective, trusting relation-ships will evolve during the course of the project, both partners must agree at the outset that everyone handling project money will be accountable.

One of your first project priorities is to appoint a person or group to handle your project's finances. The group, which may form the core of your Fundraising Committee, will be required to establish a project account and billing number. As the project gets underway, this group will be responsible for receiving donations in the form of cash, post-dated cheque or credit card, managing and accounting for deposits and withdrawals, and setting up a system for issuing tax refundable receipts to donors.

Fundraising communication within your own organization can be done through an e-mail distribution list. Donors should receive biannual updates informing them of how their donations are being spent.

Transferring Money to Your Twin

It is a good idea to send funding installments to your twin four times a year rather than every month. This will cut down on banking fees and administrative time for both you and your project partner.

For small projects, the most efficient way to transfer funds is to open a bank account and give your partner a bank card for money withdrawal in the project country. This method is inexpensive and easy.

Managing Hospice Staff Donations

The best way to ensure a consistent stream of funding is to ask hospice staff donors to commit to automatic withdrawals from their pay twice a month. Remember: a little goes a long way. Even $10.00 from each pay cheque can make a big difference. This method of fundraising will form the backbone of your project.

Managing Other Donations

Monthly donations from the community also provide reliable, ongoing support. First, determine how many donors it will take to meet your monthly financial goal, then distribute a Twinning Project Pledge Form (See Appendix G) to your donors. You should also create opportunities for people to make "one-time" or annual donations.

2. Fundraising

The Project Steering Committee must decide what kind of fundraising is acceptable. A Steering Committee member should therefore be assigned to the Fundraising Committee, ideally as Committee Chair.

Communicating Your Fundraising Needs

You will likely have lots of people volunteering goods and services. Effective coordination of these resources is crucial to project success. Communication and coordination go hand in hand. Keep everyone in the loop. Make a habit of consulting regularly with your communications or public relations officer, fundraising officer, board members, executive director and volunteer manager.

Fundraising Special Events: Explore Your Options

One-time events are a great way to raise money for your project. Examples include: a launch party with dinner music and a slide show; an auction of souvenirs collected during your initial site visit; or an audio-visual night at which you show pictures and tell stories about people who are contributing to your project.

You should also connect with your friends and business networks. Look for established businesses that might be willing to contribute to your special event.

3. Planning visits and exchanges

Pre-visit Preparation

At the heart of twinning is meeting people and building credibility, friendship and trust. For this reason, yearly visits or exchanges should be part of your annual planning process.

Explore resource and material needs as thoroughly as possible before your site visit. Also, when deciding who to send on your visit, consider what professional service needs your hosts would like to see addressed. If your host wants training or education for nurses, send a nurse. If your host wants help with administration, send an administrator.

Prior to your arrival, agree with your host partner on the number of people who will visit. You should also be very sensitive to the rights of patients and families. For this reason, you should discuss with your partner beforehand what kind of direct contact with patients and families will be permitted.

4. Keeping Communication at the Forefront

Consider Intercultural Communication Training

Pre-visit intercultural communication training will ease the transition to your host community by helping you to explore the significance of intercultural power dynamics. Look for training in your town or city that covers areas such as culture, race, ethnicity, stereotypes, generalizations, values, expectations and assumptions.

Connecting on a Personal Level

If you want to connect on a personal level, you must do some advance preparation. Find out ahead of time what small gifts would be appreciated. Bring photos of your family and your place of work. Connecting mother to mother, social worker to social worker, and person to person helps bridge cultural gaps and language barriers.

Be Aware of Your Impact

Your visit will affect individuals and organizations across the entire host community. You should therefore consult regularly with your twin to gain a good understanding of this impact and what you can do to accentuate the positive and minimize any unintended negative consequences of your visit.

Focus on Respect and Mutual Understanding

The first priority of your visit is to learn about your twin's world. Find out everything you can about your twin's operation. Focus on respect and mutual understanding. Be aware of any urge to teach a "better" way. Maintaining an attitude of curiosity and openness will help you to build friendships.

Adjusting to Your New Surroundings

Even when you are well prepared, the impact of arriving in a new country and meeting new people can be overwhelming. You may find that it takes a while to adjust to these environmental changes.

Allow two or three days to adapt to the time zone, culture, climate, and new medications, if applicable. Fatigue alone can make it hard to adjust. Recognize that you need time to familiarize yourself with the community and its culture. Be flexible and patient. Listening is the most important part of your visit.

Addressing Team Challenges

You may find the sudden intimacy of traveling and living with colleagues to be a little uncomfortable. It is normal for travelers to want some time and space to themselves. Attend to your own needs by allowing for time alone, recording your thoughts and feelings in a journal, and allowing for retreat into books or music.

Your traveling team should debrief once a day. Keep discussion open and honest. Ask your team members how things are going, if they need anything from you, or if you could be doing anything to help make their experience better. Be sure to communicate your own needs.

Beware of Mission Drift

The people you meet will touch your hearts and you may be struck by the unfairness of their situation. In the face of overwhelming need, it will be tempting to offer help above and beyond the prescribed project guidelines. While this experience is common, seasoned twinning volunteers will tell you that even the most determined people are usually unable to follow through on promises once they get home. Taking on additional responsibilities may also detract from the project's main goals. That is why it is a good idea to keep commitments within the formal context of the visit, respecting official lines of communication and authority.

Ask Your Twin for Feedback

If annual visits are part of your project plan, you can achieve maximum benefit from these visits by asking for and giving honest feedback. Remember that the potential for miscommunication and misunderstanding is normal in all human relationships. By inviting discussion, you can address small problems before they develop into bigger ones.

Contact the project leader within your twin organization and ask him or her to send an evaluation or communicate directly with you via phone or e-mail. Once you have received your twin's feedback, ask your twin to make recommendations for your next visit. Carefully consider your twin's feedback and recommendations before making your own recommendations for the next visiting project team.

Post-trip Debriefing

Debrief team members as soon as you get home. Discuss the highlights of the trip and bring up any issues of contention or concern among team members (i.e., adequate preparation, support, satisfactory level of participation, sense of project ownership or accomplishment). Only after this debriefing should you make collaborative decisions on what follow-up action should be taken.

Write a Trip Report

A written trip report should describe trip success and barriers, benefits for the two organizations, lessons learned, and recommendations for resolving outstanding issues. Make sure your trip report captures the human side of your visit. You can convey the spirit and grace of the people you visited through stories and photos that paint a vivid portrait of project reality for stakeholders back home.

Your supporters will appreciate your work and they will feel more connected to the project. This connection is what keeps the project alive and exciting for all!

Reciprocating the Visit

If you decide to host a group from your twin organization, agree on learning goals for the trip and determine what your visitors will be doing with their time. Answer your twin's questions about your culture and develop a hosting plan that responds to your visiting group's needs and interests.

Once your twinning visitors have arrived in Canada, give them an opportunity to rest and adjust to their new environment. Show them highlights of the area in which you live and open conversations about cultural issues. Help them to connect personally.

You may find that there is a different cultural expectation of the roles of "guest" and "host" among your visiting partners. In more individualistic cultures there may be an expectation that guests would like time to explore by themselves. In socially oriented cultures a guest may expect to be accompanied for the entire visit. Be sure to clarify your twinning visitors' preferences.

Staying In Touch with Your Twinning Partner

Keeping in regular contact with your twinning partner can be a challenge. Consider your partner's access to technology (computer e-mail, fax, and phone). You may wish to use project start-up funds to buy communication products and services. If technology permits, consider using free voice and video internet services for inter-professional consultation.

Attend To Your Public Image

A good public image is vital to your project. You should therefore convey your communication priorities very clearly to the people within your organization who are charged with promotion, publicity, fundraising and volunteer management. Listen to what these people have to say about your project priorities and agree on a strategy for implementing them.

5. Phase 3 Checklist

1. Address Financial Accountability
2. Assign a Group to Manage Finances
3. Familiarize Yourself With Banking Rules/Regulations
4. Distribute Pledge Forms to Donors
5. Organize Fundraising Events
6. Pre-visit Preparation (Focus on Partner Needs, Expectations)
7. The Visit (Be Patient; Stay Focused on Project Goals)
8. Request Twin Feedback
9. Conduct Post-trip Debrief
10. Write Trip Report

Phase 4: Completion

1. Progress Review

The first step in the Completion Phase of your twinning project is to undertake a Progress Review (see Appendix H), which satisfies your commitment to transparency and accountability and enables you to record each project milestone.

The Progress Review also helps you update your plan of action for going forward. Make sure this revised plan of action is in line with the original agreements made with your board and donors and that it complies with your provincial Societies Act and Canada Customs and Revenue Agency guidelines. Your revised plan of action should be clearly outlined in writing and agreed to by both project partners.

2. Project Report

The second step in your Completion Phase is to prepare a Project Report summarizing project objectives, actions, changes, impacts, fundraising and spending.

3. Project and Partnership Evaluation

Once you have completed your Project Report, you are ready to do your Project and partnership Evaluation (see Appendix I). The following section outlines key questions posed in this evaluation.

Project and Partnership Evaluation Key Questions

1. How has the partnership been beneficial?
2. Is your project a success?
3. Have the achievements been worthwhile?
4. What did you learn that could help future projects?

3.1. How Has the Partnership Been Beneficial?

Refer to your Progress Review and the Project Report for information on this question. You will want to interview the project team, staff and board members from each twinning partner to assess personal, professional and organizational benefits.

Your twinning project should have resulted in personal or professional benefits (i.e., learning new skills, methods, or knowledge) in one or more of the following areas:

• care, treatment or support strategies;
• legal, ethical and human rights initiatives;
• a formal network that has been strengthened and developed;
• policy development and advocacy;
• strengthened communication, fundraising, and management skills;
• community-based research; and
• development of the board of directors.

Your twinning project should have resulted in one or more of the following organizational benefits:

• increased capacity building;
• identification of best hospice palliative care practices;
• increased program effectiveness;
• broadened horizons;
• enhanced relationship building;
• organizational solidarity and progress; and
• contribution to the global hospice palliative care movement.

3.2. Is Your Project a Success?

To determine if your project is a success, you will need to revisit your Friendship and Agency Agreements (Appendix D and Appendix F), as well as your Progress Review and Project Report. Project participants should be interviewed to gather observations and evaluations.

Each partner should assess the project independently before comparing notes. It is important to know if both partners agree on whether or not the project was successful. If you both agree, do you agree for the same or different reasons? Is there consensus on which achievements, processes, structures or events were most effective in advancing project goals?

3.3. Have the Achievements Been Worthwhile?

It is important that both partners reach consensus on whether or not the overall project achievements were worth the efforts expended. Review your project outcomes in light of each partner's mandate and activity areas. Refer to the Friendship Agreement. You may also want to interview staff and board members from each twinning partner. Evaluate whether your partnership has served the vision and goals of each partner as well as your partnership mission.

You must also determine whether there was enough support and enough resources to sustain the partnership and meet the Project Plan. Were both organizations fully engaged in the partnership? Did both partners feel they were seen as equals? Was input from both partners given equal weight?

3.4. What Did You Learn That Could Affect Future Projects?

Look at your Progress Review and Project Report, as well as information from your Project and Partnership Evaluation, to assess what was learned. It is important to identify barriers and challenges, and find strategies that can be used to avoid mistakes in future partnership projects. You will also need to determine who might benefit from the personal, professional and organizational knowledge gained from the project. Think about how you might share lessons learned with other staff members, board members, and local and national community partners.

4. Planning for the Future

You must now decide whether the partnership will continue and, if so, in what way. Your options include: continuing with the present level of commitment, expanding your commitment, adding other partners to increase project effectiveness, or ending the relationship.

Wrap-up

Make sure that all donations have been accounted for and that all fund transfers have been completed. Then sign off on bank accounts, internet accounts, and audit records and make sure there are no outstanding bills or charges.

Contact everyone on your list of major stakeholders and debrief them on the project. Follow up with a written thank you note acknowledging their support and participation. Any relationship issues between your team, your partner's team, or your organizations should be resolved. Acknowledgement and appreciation should always be formally expressed.

5. Phase 4 Checklist

1. Undertake Progress Review
2. Prepare Project Report
3. Complete Project and Partnership Evaluation
4. Detail Project Benefits
5. Detail Project Successes
6. Have Achievements Been Worthwhile?
7. Detail Personal, Professional and Organizational Benefits
8. Make Your Partnership Decision
9. Plan for the Future
10. Wrap-up

Conclusion

A Practical Took Kit for Your Organization

This "How-To" Guide to Hospice Palliative Care Twinning Projects is intended to serve as a practical tool kit for your organization as you undertake and develop  your hospice palliative care twinning project with a partner health care organization in a developing country.

The guide's four-phase approach to preparation, partnership, implementation and project completion offers step-by-step support to all those involved in your initiative from hospice palliative care professionals to project volunteers, supporters and stakeholders.

This practical approach is accompanied by a comprehensive overview of guiding principles for twinning which will assist you in developing and implementing a highly successful twinning project. These principles include: patience and flexibility, sensitivity and respect, sustainability, reciprocity, well-managed funding, appropriate assistance, and a commitment to effective communication.

It is hoped that the application of the guide's four-phase approach and guiding principles will help you and your partner organization in your collective efforts to enhance hospice palliative care delivery and make a real difference for individuals and families in your project community.

Good luck!

Appendix A -Twinning Project Guiding Principles - A Personal Perspective

Dr. David Falk, from Hold Me Africa, shares some guiding principles.

Dear Friends:
Remember that we come from a western perspective with more cultural assumptions than we think we have. This is a built-in bias. We have a need to be involved in "meaningful" things, but so often that need is our need, not our partners. Remember:

1. We are not the experts.
   So often we want to share what we have learned but we do it with an attitude that we know the answers. Our partners have lived in their community for many years and know many answers of attitudes, processes, community, and values which we do not even start to comprehend. They are the experts in their community; therefore we come with our story to share and interface with their story.
2. Our money can be a poison.
   So often the first thing that comes to mind is what we do not have. Our partner is no different. When asked how we can help, a list of things they would like comes before you - a building, more drugs, a salary, a trip, a computer, etc. We can come with our money, but it can spoil their growth. I have found that a small amount of money used wisely promotes more growth than a larger amount of money. Do not venture into financial assistance without your partner contributing at least ½ of the costs, either in cash or in kind. Nor should you expect your partner to give everything without you giving your half.
3. Look behind the "want" list.
   So often the real need is not in the first want list but in the reasons behind the "want" expressed. We have given laptop computers which have been of great assistance, but the real need is not so much the computer as the knowledge of how best to use the computer and what it can accomplish. The learning needed behind that computer is most valuable. Requests for vehicles are always present. The real need behind this request is usually improved transportation on roads which need repair, or money to use the existing public transportation, or the need to transport patients. Sometimes the "want" list item comes from what they perceive a hospice program looks like from TV but it is not based on knowledge of reality.
   
   Our "want" list comes with the need to "help". But help is so often defined as what I can give or do for you. Why do we "want" this? Examine your motives.
4. Watch your heart response.
   If you are to visit your partner's community, be aware that the needs you will see are astronomical and your heart will be torn. Let it be torn but do not bend to helping out of sympathy. This only promotes dependency and destroys mutual respect. Take much time to examine yourself to see that you do not act out of sympathy to ease your own conscience.
5. Empower people, not systems or things.
   Your partner knows the processes and the resources that are available in the local area. They need to have eyes to see these resources so they can harness them to good use, not ask you to provide these resources for them. You do not need to be recognized because you have helped twin a hospice. The people we empower get that recognition, we get their friendship.
6. Always have sustainability before you.
   This is not just sustainability from your perspective but what your partner can sustain. So often we worry that we will not be able to sustain our end of the partnership and so we lose sight of how well our partner is doing. Or we want to share all we have learned and experienced in our hospice program, and forget to check how well our partner is able to incorporate all this into their life, their program. Or we do not have time to hear their knowledge and their experiences. It is better to start small and slow than big and fast. It is better to learn from a small number of committed people who will stay for a number of years than to spread yourself to many.
7. Always start with the end in sight.
   Remember that friendship has boundaries. When you make a commitment, establish a mutual timeline with a well-defined endpoint and stick to it.
8. Don't just build buildings, build people, and build friendships, because these people will build a program or a community that will care for the dying. This is more important than spending resources on buildings alone, which can rob you of precious resources and time from the primary purpose - helping those who are dying.

Appendix B - Volunteer Application Form

Name:
Street Address:
E-mail:
Phone:
Emergency contact:

Relevant Skills:

Areas of interest:

• Fundraising
• Communication
• Finances
• Traveling

Character references:
Name and Contact Information:
Name and Contact Information:

I agree to follow the guidelines of the steering committee when volunteering my time.
I agree to focus my efforts on the goals and purposes of the twinning project.
I agree to refrain from creating "side projects" while working on the twinning project.

Signature:

Appendix C - Letter of Interest

(Name of your twin organization)

Dear:

(Name of your organization) is a palliative end-of-life care facility that has provided services to patients and families over the past (write out number) of years. Our vision is to (write out your vision). Our mission is to (write out your mission).

In keeping with our vision and mission statements our particular goal for this project is to (Fill in your goal).

We would like to know if your organization would be interested in twinning with us.

We are willing to make an initial (fill in the number) year commitment to assist your organization in meeting palliative end-of-life care needs of patients and families and to support staff in the delivery of care. The assistance will depend upon what your identified needs are and our ability to meet them. Assistance could take the form of direct funding or the provision of practical materials. We could also provide clinical practitioners to visit your organization to help provide care in a direct way.

At the same time, we can learn much from your organization that can be used in our own organization, such as how to be present for patients and families from different cultures, and how to use alternative or complementary medicine that is not well known to us. (Add other things that you would like to learn).

If you are interested in discussing the possibility of a twinning relationship, I would be very pleased to hear from you.

Sincerely,

Executive Director
(Insert the name of your organization)

Appendix D - Friendship Agreement

Between: (The name of your organization)

And: (The name of your twin's organization)

Our Goals:

Our Methods:

This agreement will be reviewed annually in order to assess our effectiveness as partners in hospice palliative care and to make any necessary changes to our goals and methods.

For:

Name and position/Date

Name and position/Date

For:

Name and position/Date

Name and position/Date

Appendix E - Needs Assessment

The purpose of this form is to help us to understand your situation.
Please discuss the following:

• Who is facing end-of-life care?
• What kind of resources (spiritual, social, mental, emotional, physical) do patients and families already have?
• What kind of spiritual, social, mental, emotional, and physical challenges do patients and families face?
• What community resources are already in place that might assist the dying and their families?
• List what is needed.
• From this list, what is the most important?
• What kind of training would be needed to put this in place?
• What kind of material resources would be needed to put this in place?

Appendix F - Agency Agreement

Your name:

Your twin's name:

Name of your Twinning Project:

Made in duplicate and to remain in effect for a period of (insert number of years) from the date of agreement, at which time it will be reviewed with the option to renew.

Between:

Name of your organization:

Address:
Hereinafter known as YO

And:
Name of your twin organization:

Address:
Hereinafter known as YTO

This agreement will commence on (insert date) and will remain in effect for (insert number of years), after which it will be reviewed with the option to renew.

Whereas YO, a registered non-profit Society incorporated under the Society's Act of (insert your province), and YTO, operating in (insert city and country of YTO), wish to enter into a twinning project for the purposes of providing care and support that adheres to the philosophy of hospice palliative care to YTO patients and their family members, and

Whereas the Canadian Income Tax Act requires that, as a registered charity, YO must direct and control the administration of its charitable activities, and

Whereas YO wishes to enter into an agreement with YTO to assist in the administration of the charitable activities of YO.

Therefore:
YO and YTO agree, to the mutual benefit of both parties, to collaborate and cooperate in the administration of charitable activities that meet the guidelines set out by the Canada Customs and Revenue Agency, the Society's Act of (insert your province), and the Constitution and Bylaws of YO, and that adhere to the philosophy of hospice palliative care as set out in the Canadian Hospice Palliative Care Association's "A Model to Guide Hospice Palliative Care" (March 2002), and YO agrees to generate charitable donations and distribute funds to YTO to facilitate the delivery of hospice palliative care to patients and family members under their care, and

YO and YTO will mutually agree, in writing, to any intended use of charitable funds directed from YO to YTO, prior to the release of funds. Use of funds may include, but will not be limited to, the following:

1. hiring professional staff who provide direct patient care;
2. purchase of medications for patients;
3. purchase of equipment and educational materials used to facilitate care; and
4. other special projects that are deemed acceptable by both parties.

YO and YTO will agree upon an annual budget at least one month prior to the date of the initial distribution of funds from YO to YTO, and thereafter at least two months prior to the first day of January each year, which is the first day of YTO's fiscal year, and YO will make regular payments of charitable funds to YTO at agreed upon intervals, and YTO will provide written quarterly progress reports to YO regarding the use of transferred charitable funds, and agrees to allow visiting representatives of YO to inspect the project on reasonable short notice.

Any deviation in the use of funds from that set out at the beginning of each fiscal year will be considered a "special project" and must be applied for in writing to YO.

YO may, at any time, withhold payment of charitable funds if documentation and progress reports are deemed unsatisfactory by YO, or if it is felt that the actions of YTO are in direct contravention of Canada Customs and Revenue Agency guidelines, and/or the Society's Act of (insert your province), and/or the Constitution and Bylaws of YO.

For audit purposes, both parties will keep accurate accounts of all receipts and expenditures of funds designated by donors for the Twinning Project in a separate general ledger account within their respective accounting systems.

Agreed to this day of , 200
On Behalf of the YO - YTO Hospice Palliative Care Twinning Project:

For YO:

Witness/Name and position

Witness/Name and position

For YTO:

Witness/Name and position

Witness/Name and position

Appendix G - Twinning Project Pledge Form

Name of Your Organization:
Address:
Phone:
Email:
Name of Project:
Project donor details:

Name:
Address:
Phone:
Email:

I wish to become a partner with (Your Organization's Name) in supporting hospice palliative care work in (Country) through the (Name of your twin organization).

1. I am willing to make a monthly donation in the amount of:
   • $10 per mo.
   • $20 per mo.
   • $50 per mo.
   • $100 per mo.
   • Other
   • Or with post-dated cheques.
2. I am willing to give a one-time gift of to help with special projects at your organization's name.

   Credit card information

   Card type:

   Card number:
   Expiry:

   Name on credit card (please print):

   Signature:

   Cheques to be made payable to Your Organization's Name

Appendix H - Progress Review

Date:

We have completed the following steps:

Our next steps will be:

Appendix I - Project and Partnership Evaluation

(The information in this Evaluation has been adapted from material taken from the Interagency Coalition on AIDS and Development's twinning manual).

Effectiveness of the Project

How has the twinning project affected team members' learning new skills, methods, or knowledge in one or more of the following categories?

• Care, treatment or support strategies
• Legal, ethical and human rights initiatives
• Developing and strengthening a formal network
• Policy development and advocacy
• Strengthening communication skills
• Strengthening fundraising skills
• Strengthening management skills (change, time, or project management, strategic planning)
• Community-based research
• Board of directors development
• Training and technical assistance on how to use research to improve and assess service delivery

Extent to Which you met Your Goals

• Number of participants
• Amount of materials developed
• Amount of materials distributed
• Number of workshops delivered
• Number of patients and families served

Project Impact

• Behaviour change
• Knowledge change
• Attitude change
• Policy change
• Practice change
• Change outside the twinning project

Vision and Mission

• The twinning project has advanced each twinning partner's own organizational mandates.
• The achievements of the twinning project directly relate to the intended purpose of the partnership.
• Partners have enhanced understanding of their respective priorities and perspectives.

Effectiveness of the Partnership

How has the twinning project affected the following?

• Capacity building
• Identification of best hospice palliative care practices
• Increased program effectiveness
• Broadening horizons
• Relationship building
• Solidarity
• Building a global movement

Value of the Partnership

• Level of support and resources to sustain the partnership and to meet the needs of your project plan.
• Extent that both organizations have engaged in the partnership.
• Equality.
• Equal weight given to input from both parties.

Success of the Project

• Partners have achieved planned activities with designated resources (time, funding, materials and staff).
• Both partners felt there was an equitable level of control over and responsibility for the project.
• Both twinning partners felt that their input was valued and incorporated into the project

Both partners perceive positive working relationships.

Lessons Learned

• Identify barriers and challenges.
• Identify strategies to avoid or address problems, should project continue.

Future Plan

• Describe how you will end the project.
• Make recommendations for the future.

Web references

1. Sample Completed Project Plan

Victoria Hospice Society
Pilot Project Plan
Project#:

Author: Steering Committee
Creation Date: November 26, 2007
Last Updated: February 15, 2008
Version: Final copy

Definition of Twinning
Twinning is a professional and social collaboration between organizations in different countries to achieve mutual benefits through combined efforts and a common vision.

Victoria Hospice Twinning Vision
To achieve quality end of life care for all through shared resources, knowledge and expertise.

Note: The term "volunteers" in this document refers to project volunteers who might be Victoria Hospice paid and unpaid staff or others associated with this project.

Purpose

This pilot project will explore the mutual benefits to be achieved through the transfer and exchange of knowledge and expertise in end of life/palliative care between Victoria Hospice volunteers and an organization in another country.

The project adheres to Victoria Hospice's Vision: "Quality End of Life Care for All". It is further reflected in our Mission Statement: "To enhance the quality of life for those facing advanced illness, death, and bereavement through skilled and compassionate care, education, research and advocacy." There are no national boundaries to these guiding principles. The skills that have been well honed within Victoria Hospice to meet the needs of our local community can help meet similar needs in palliative care centres in other parts of the world. And at the same time there are mutual benefits. There is an exchange of information and methodologies for dealing with physical, psychological, and spiritual issues surrounding palliative end of life care.

Victoria Hospice can benefit considerably by learning about alternative practices in end of life care and increase our understanding of different cultural overlays to the palliative end of life process while deepening our commitment to this important work.

Background

Palliative/ end of life care in many countries is almost non-existent. This results in unbearable suffering for patients who don't have access to adequate care, medicines and equipment (see New York Times article - In India, a Quest to Ease the Pain of the Dying, September 11, 2007).

There is a long history of Victoria Hospice staff travelling to other countries to provide their expertise and experience in palliative/end of life care without formal support from our organization.

Victoria Hospice has shown peripheral support by providing material such as our text book, Medical Care of the Dying, but the opportunity to "twin" with an organization in a developing country that has similar goals for those needing palliative/end of life care is an idea that has been part of Victoria Hospice for some time.

We would not be the first hospice organization to "twin" with another palliative care centre in another part of the world. Nanaimo Hospice initiated a twinning project approximately 2 years ago with a palliative care program in Bhaktapur, a town located within the Kathmandu region of Nepal. Currently, this project has resulted in Bhaktapur Cancer Hospital receiving financial, practical, and human resources such as medication and staff training to support the ongoing advancement and sustainability of their palliative care program.

The Nanaimo-Bhaktapur project is driven by volunteer efforts and financially sustained through several fundraising activities within the Nanaimo community. Notably, the staff of Nanaimo Hospice and the palliative care community generously contribute money to support ongoing initiatives of the project. With a commitment of providing a minimum of approximately $400 per month raised by volunteers, the twin organization has been able to hire two full time nurses and a nurse's aide, and purchase critically needed medication.

Nanaimo Hospice is prepared to support our endeavour by sharing written materials, practical experience and knowledge to help guide us.

Within Victoria Hospice an informal voluntary twinning steering committee has been formed consisting of a dedicated core group of six members, with sponsorship and oversight by the Executive Director to explore the viability and feasibility of creating a pilot project to twin with another palliative care organization elsewhere in the world. Other Victoria Hospice staff have expressed interest in the project and are wanting to support and contribute in various ways. Several members of the committee have prior international experience.

Recommendation

The Steering Committee is recommending to the management committee and the Society Board that Victoria Hospice support this proposal as it is described herein. The selection of the twin organization will be based on the criteria and by an on-site assessment of possible locations by Dr. Fraser Black who will be in India and Nepal on medical business not associated with Victoria Hospice nor paid by this organization.

Project Goals

1. To increase the knowledge and expertise of those involved in palliative end of life care within both organizations.
2. To develop cultural sensitivity to patients from different backgrounds.
3. To deepen the commitment to our vision of "Quality end of life for all".
4. To live our values within another context that deepens their meaning.
5. To learn alternative methods for being present with patients and families.
6. To create opportunities for generosity to take place.

Scope

A three year contractual agreement will be established between Victoria Hospice Society and a health care organization in another country. The Victoria Hospice twinning steering committee will, through its approved budget, offer time-limited financial resources, equipment, educational material and expertise to our partner based on their requests. The agreement will include a mutually agreed upon cancellation clause in the formal agreement and the project will be evaluated by both parties at agreed upon intervals with a final evaluation, after the contract period has expired (see Sample Agency Agreement).

The project primarily relies upon volunteers to design, organize, manage and support the project with assistance from Victoria Hospice for monitoring finances. Based on established criteria, we will collaborate with a health care organization in another country interested in expanding their resources and open to receiving support and expertise for the delivery of palliative and end-of-life care in their community.

VHS will not finance time off work, travel or other expenses incurred for VHS personnel. These costs and others will be covered by fundraising or by grant applications to national and international organizations.

Nanaimo Hospice realized that a visit to their twin organization was essential to develop relationships, assess first hand conditions and to provide a focus on activities, and to provide hands-on help. $4000 was established as a travel fund which allowed staff to travel to the site.

Benefits

1. Learning different ways of dealing with pain and suffering.
2. Learning about the dying process in different cultures.
3. Learning alternative and complementary approaches to the relieving of suffering.
4. Enhancing Victoria Hospice's image in the community, serve to develop new partnerships with community members and inspire different sectors of donors in the community.
5. Extending work related experience for staff.
6. Furthering our commitment to our values of Respect, Compassion, Integrity, Commitment, Collaboration, and Excellence into practical action oriented ways.
7. Drawing on resources and skills of former VHS employees interested in channeling time and energy towards this project and initiative.
8. Renewing energy, experience and passion in staff by being part of a broader purpose.
9. Helping to bring attention to the need for access to palliative care for every citizen of the world.
10. Sharing experiences to further develop educational/ teaching resources for Victoria Hospice and the twin organization.

Criteria for Selection of Twin Organization

To Ensure Successful Twinning the Following Criteria has Been Developed:

1. A palliative/end of life organization in a developing country that has expressed an interest in being a twinned for the purpose of enhancing palliative care.
2. The potential twinned organization has similar goals and objectives to Victoria Hospice.
3. There are individuals or groups willing to champion the project in both organizations.
4. Working knowledge of English is necessary as VHS lacks the ability to correspond in other languages.
5. Stable political climate to help safeguard the viability of the project over its lifetime.
6. Previous contact and work with the organization by VHS staff or people known to VHS.
7. An ability to identify mutual learning and knowledge transfer opportunities that will further enhance each organization.

Major Deliverables

1. Creation of a twinning project steering committee.
2. Identified project sponsor (Victoria Hospice Executive Director) who will report activities to the Board and the management committee.
3. Criteria for selecting an organization.
4. Established scope, activities, deliverables, risks and issues related to services offered to meet the partnering organization's needs.
5. Respective responsibilities in achieving the project's goals.
6. Contract between both parties that identify individual organization and mutual requirements.
7. Friendship Agreement.
8. Fundraising processes.
9. Communication links with all stakeholders.
10. Evaluation process for the project.
11. Financial and time commitments of Victoria Hospice and partner organization.

Stakeholders

• Victoria Hospice Society Board of Directors
• Victoria Hospice Foundation Board of Directors
• Wayne Peterson, VHS Executive Director & Project Sponsor
• Victoria Hospice paid and unpaid staff (volunteers)
• Interested former staff (e.g. retired) and community partner staff (e.g., HCCN)
• Twin organization
• Potential donors from the community
• International Association of Hospice Palliative Care

Driver Constraints

1. Potential limited resources: people and time
2. Potential lack of understanding and support by stakeholders
3. Communication challenges within VHS, between members of the steering committee, staff or between VHS and the twinning organization in the developing country.

Milestones

The high-level project milestones are:

Milestone	Target Date/ Completion Date	Responsible Party
Establish Steering committee	December 2007	Dr. Fraser Black -Advisor Susan/Marjorie/ Lorea/Wayne/ Lucie/Caelin/
Complete Project Charter	January 2008	Steering Committee
Establish reporting mechanism to management	January	Wayne
Criteria for selecting twinned organization	January	Steering Committee
Present Project Charter to VHS management and Board for approval	February	Wayne
Finalize 2008/9 Twining Project Budget	March	Wayne
Choose twin organization	March	Steering Committee/Fraser
Sign Friendship Agreement	May	Board President & Exe. Director
Completion of detailed needs assessment of Twin	June	Steering Committee
Develop Business Plan including fundraising strategy	July	Steering Committee
Sign Agency agreement	July	ED and Twin Org. rep.
Approval of Business Plan by VHS Board	September	Wayne
Begin fundraising efforts	September	All
Begin transfer of resources to twin organization	Fall 2008	Project Manager
Evaluation of project	Spring/Summer 2009	Steering Committee
Recommendations to Board for involvement beyond contracted period.	February 2011	Steering Committee

Funding

Within its 2007 budget Victoria Hospice provided $5000 to help structure and support the development of creating a pilot process with the understanding that once the project plan was completed it would require approval from management committee and the Board.

It is proposed that Victoria Hospice will match donations up to $400 per month over a three-year pilot period once agreements have been signed with the "twinned" organization. The maximum contribution by Victoria Hospice will be $4800 a year for 3 years. A yearly review will be conducted and a final review will be carried out after the three-year period to assess the results.

Funds will be sent to the twin organization on a quarterly basis with a monitoring process of funds in place.

Fund Raising

• The Victoria Hospice Twinning Steering Committee will work with the Victoria Hospice and Palliative Care Foundation to ensure that the twinning project will secure funding in ways and from sources that will not jeopardize funding for existing VHS activities.
• It is expected that financial contributions will originate from voluntary monthly donations using post-dated cheques.
• And from efforts such as dinners, silent auctions, car washes, teas, presentation of slide shows of "Twin Partner" organization and country.
• VHS finance department will manage contributions relating to the twinning project to ensure financial integrity and accountability.
• Fund raising projects will be delegated to and carried out by volunteers.
• Fundraising projects will be overseen by the steering committee.
• Donations from the public interested in supporting Victoria Hospice's desire to teach and learn more about palliative end of life care services through this form of partnership.
• Grants from Educational, Charitable or Health care clinics or organizations,
• Joint ventures with established organizations, e.g. that already have a high profile in the community.

Use of Funds

Eighty percent (80%) of the 2008 funds raised will be used to directly support operations in the twin organization.

The remaining twenty percent (20%), if required, will be allocated to administrative and communication support by Victoria Hospice and if funds permit, supplementary travel costs to the site by volunteers to directly help the twin organization, establish stronger partnership ties and assess progress.

Because of limited funds it is expected that the budget will accommodate 2 or 3 individuals who will do at least one on-site visit for the purposes described above. All others interested in visiting the twin organization will be responsible for their own travel and associated costs.

Financial agreements will be developed jointly with the twin organization and signed by authorized persons. Any deviation from the agreement must be made in writing and agreed to by both parties.

For the Twin Organization Funds Might be Used to:

• Purchase and deliver medical supplies and other related materials
• Hire local staff
• Train local staff
• Pay travel costs for staff from the twin organization to train at VHS
• Support special or unexpected projects
• Meet other identified needs
• Funds to support travel of staff member(s) to appropriate centers in their own region for training

For Victoria Hospice Staff and Volunteers Funds Might be Used to:

• Develop or co-develop curriculum development/educational materials with the twinned organization.
• Provide cultural sensitivity training and other educational materials to support palliative care in the twin country. Cross-cultural training through the Center for Intercultural Communication at UBC, a minimum of $250.00 per person plus possible travel expenses to Vancouver or offer the training to interested staff member at Victoria Hospice by having a trainer come here.
• Supplement travel costs to support palliative care in twinning organization country for a designated limited period. Staff would work under a pre-arranged budget, mutually agreed upon by both organizations.
• Educate steering committee members on the legalities and intricacies of handling and receiving donations and goods and how to safely and efficiently manage donations, money transfers, visa forms, etc.
• Victoria Hospice staff/volunteers would work as volunteers at the twinning organization without pay from either Victoria Hospice or the twinned organization.

Other Costs

Contractors

Contractors are not required as part of this pilot project.

Equipment

A reputable computer company will likely be needed to provide technical equipment, installation and servicing of equipment in twinning country.

It may be necessary to purchase equipment to assist with communication on a one-time basis, such as computer, fax machine, telephone service for the twin organization. Also a one time purchase of a digital camera to transfer picture information back to Victoria Hospice twin for viewing of project changes and ongoing communication. The approximate cost for this one time expenditure: $1000.

Communications

Telephone calls through a system, which is traceable, printable and will allow for accountability for expenses. Estimates - $200.00 per year.

Shipping

Shipping companies will be needed to ship equipment and supplies.

Future Travel Requirements

On-site visits to be decided upon by mutual agreement between VHS, the steering committee, and twinning organization and the budget available to support travel.

Future Meetings

1. Non-paid bi-weekly meetings once project is underway. As the project progresses meetings may be held to discuss, or present special reports from staff members who have been working with the twin project committee members in some way or have traveled to twin country and want to present a report.
2. Meetings may also involve using larger rooms for presentations to allow for larger groups to attend. Fees not likely to be involved.
3. Catering expenses may be involved for a special presentation of the "Twinning project" or for fundraising, but not anticipated for regular meetings. If catering was used possible budgeting could be approximately $500.00 or less for the year.

Other Possible Future Expenses

Honorariums for outstanding support from person(s) supporting project, without salary. $500.00 maximum per year.

Roles and Responsibilities

The following descriptions define the general roles and responsibilities of the resources to support this project.

1. Role: Sponsor

Responsibilities

• Executive Director of Victoria Hospice
• To ensure that the project is being executed as designed and within the parameters set by the management committee and the Board
• Reports on progress to the Board
• Provides updates to the management committee
• Facilitates/resolves issues that arise within the steering committee

2. Role: Steering Committee

Responsibilities

• Plans and controls all project activities.
• Provides expert advice to the Project Manager (and Team Leaders).
• Identifies resources.

3. Role: Project Manager

Responsibilities

• Coordinates the delivery of materials
• Acquires resources.
• Completes the assigned tasks at the scheduled time as indicated in the project plan.
• Communicates status and project information to sponsor, committees, and project stakeholders on a regular basis as agreed.
• Ensures all project tasks and deliverables conform to quality management standards where they exist and are appropriate to the project.

4. Role: Team Leaders

Responsibilities

• Responsible for delivery of products within sub-project or component.
• Identifies resource requirements
• Completes the assigned tasks at the scheduled time as indicated in the project plan
• Manages issues, decisions, changes, and problems to resolution at the sub-project level
• Collects status from team and communicates to project manager on a regular basis as agreed
• Participates in management of project.

Project Control

1. The Project Manager will provide a status report after each meeting of the steering committee, or after any significant event or occurrence affecting the twinning project.
2. Communication regarding the twin organization will be via email, phone calls, or face-to-face meetings. Information will be shared either promptly with other committee members or staff via email if urgent or weekly, if non urgent at the steering committee meetings. The idea and spirit of communication, is that all staff members will be kept up to date on any significant progress or communication regarding the project.
3. All agreements and communication with the twin organization will be created, documented in written form, complete with date and time of communication.
4. All agreements with the twin organization will be created in written legal form, following the VHS Constitution and by-laws and made in duplicate, following the policy of the Canadian Income Tax Act, adhering to guidelines of the Canada Revenue Agency, Societies Act of B.C. as well as the spirit and philosophy of the Hospice Palliative Care Association and the Victoria Hospice Society.
5. Regular communication will be initiated and facilitated by the members of the Victoria Hospice Steering Committee and the twin, before, during and after formal mutual agreements have been created and signed by both parties. It will be decided by the steering committee who will be communicating with whom and what will be communicated to the twin with the idea of moving forward with clear, organized, friendly communications.
6. Known barriers to communication will be discussed with the twinning organization, before twinning agreements are signed and will also be taken into account during communications with any of the twin organization staff members.
7. If communication becomes difficult with any committee or staff member for any reason, the issue is to be brought to the VHS Sponsor to ensure that there is resolution. The spirit or tone of communication is one of caring, clarity, support and friendship.
8. Cultural barriers will be identified and discussed as they arise, in the spirit of friendship and mutual learning by both parties.
9. Meeting dates will be promptly emailed to committee members and staff.
10. Any Victoria Hospice staff that wish to take time off from their work at Victoria Hospice must do so in accordance to the organization's vacation policies.
11. Staff that have travelbled to the twin organization for work exchange will be required to give a report or presentation to the Steering Committee with invitations to management and board members. The report will be given within one month of returning from the work exchange project.
12. Written documentation of the results of the trip will also be required. The written report will be distributed to committee members, management committee and VHS board members as well as the twin organization. Pictures will be useful for explanation and informing all people who are supporting the Twinning project.
13. Communication to the public and media regarding the VHS Twinning project proposal will be facilitated by Victoria Hospice's communication coordinator or by an appointed committee member, with information first screened by the VHS sponsor.

Risk Assessment

Potential risks include loss of money, time, and health, misunderstandings between cultural groups, and unknown risks due to political strife or natural disaster.

1. Loss of substantial amount of money
2. Loss of time
3. Loss of health
4. Misunderstandings between cultural groups
5. Change of commitment from either party
6. Unknown risks due to political strife or natural disaster
7. Unpredictability of funding

Risk Assessment

Number	Risk Event or Assumption	Impact if Occurs (L,M,H)	Likelihood of Occurrence (L,M,H)	Mitigation Plan
1.	Loss of substantial money	High	Low	Careful assessment of accountability beforehand. Ongoing assessment
2.	Loss of time	High	Medium	Ongoing assessment of the plan
3.	Loss of health	High	Low	Continual assessment of health concerns
4.	Misunderstanding between cultural groups	High	High	Clear and sensitive communication between partners. Communication plan to deal with conflict
5.	Change of commitment from either party	High	Low to Medium	Readiness assessment Frequent communication, support and assessment of concerns as they arise
6.	Unknown risks due to political strife or natural disaster	Medium to High	Medium to High	Be alert to potential problems. Impact would depend on extent of problem. Exercise safe judgment
7.	Unpredictability of funding	High	Low	High interest and Nanaimo model demonstrates continued support and interest

Project Review and Completion Criteria

The Project Will be Deemed Successful if:

• All parties are satisfied with the interaction
• The mutually agreed upon objectives and goals were met
• We learned something of value that can be applied in both locations
• Priority tasks are completed
• The project evaluation is positive
• All donated resources have been accounted for
• Both parties are satisfied that the contract has been fulfilled
• The project will be deemed complete when:
• The contract period has ended, or
• Withdrawal from the project as allowed within the contract

The project will be deemed complete when:

• The contract period has ended, or
• Withdrawal from the project as allowed within the contract

2. Sample Letter of Interest

January 28, 2008

Greetings from Victoria Hospice:

Victoria Hospice is a secular, not-for-profit palliative end-of-life community based program of care situated in Victoria, British Columbia, Canada. Our mission, "To enhance the quality of life for those facing advanced illness, death and bereavement through skilled and compassionate care, education, research and advocacy" has guided us over the past twenty-seven years in providing services to patients and their families.

At this point in our development we are interested in looking into "twinning" or collaborating with another organization in a different geographic location to provide mutual benefits through combined efforts.

Our proposal to twin with another organization still needs approval from our board of directors but we are interested in knowing at this time if your organization is likewise interested and would like to work in partnership with us.

Our particular goal for this project is to establish a strong working relationship with another palliative end of life care organization. Together we can further our skills, gain insights into each other's practices and increase the benefits to our respective communities through the transfer of knowledge.

We will be proposing an initial three-year commitment to support the delivery of care with another organization that is meeting palliative end of life care needs of patients and families. As well, Victoria Hospice might be able to offer specific assistance depending on the identified needs of the organization that we twin with. Assistance might be in various forms such as direct funding, shared educational materials or equipment.

At the same time we would hope to learn much from the other organization that would improve the care that is offered through Victoria Hospice. Apart from what we might learn in the area of palliative care, we also want to reach out and build a network of friends.

Dr. Fraser Black, Medical Director for Victoria Hospice, will be visiting in your area over the next two weeks. If you are interested in twinning with us he will be pleased to talk to you on our behalf while he is there. Please let us know by email as soon as possible so we can contact him. When he returns he will meet with our twinning steering committee and share your thoughts and comments with us. Victoria Hospice only has the capacity to twin with one organization at this time but we hope to be able to make this commitment as soon as possible.

We look forward to hearing from you.

Sincerely,

Wayne Peterson
Executive Director
Wayne.Peterson@viha.ca

3. Sample Friendship Agreement

Friendship Agreement

Between: Nanaimo Community Hospice Society (NCHS)

And: Bhaktapur Cancer Care Centre, Palliative Care Program (BPCP)

Our Goals:

1. To develop a mutually supportive and encouraging relationship between NCHS and BPCP.
2. To share resources and learn from each other's experiences and cultures.

Our Methods:

1. NCHS agrees to fundraise for BPCP with the aim of providing a modest but reliable monthly income to support the care and comfort of palliative patients and their families being served by BPCP. This could include salaries for staff involved directly in the delivery of patient care. Any extra funds received will be used for projects or purchases to be decided by a special task group appointed by the Board of NCHS and BPCP.
2. BPCP agrees to report through documentation and feedback as outlined by the attached Agency Agreement.
3. NCHS will initiate and facilitate regular communication via email between NCHS and BPCP, and will facilitate communication between BPCP and other professional care partners involved in the delivery of local hospice palliative care programs within the area served by NCHS. This may include medical consultation between nurses and doctors (who would act as hospice volunteers when participating in this venture), the exchange of ideas with NCHS staff related to volunteer programs and grief and bereavement programs, as well as the exchange of stories and pictures.
4. NCHS will facilitate an exchange of staff work experience between our respective hospice palliative care programs. This agreement will be reviewed annually in order to assess our effectiveness as partners in hospice palliative care and to make any necessary changes to our goals and methods.

For Nanaimo Community Hospice:

Dave Sherstone, Board Chair / Date

Wendy Pratt, Executive Director / Date

For Bhaktapur Hospital Palliative Care Program:

Mr. Deewakr Raj Karnicar, Board Chair / Date

4. Sample Agency Agreement

Agency Agreement:
Nanaimo/Bhaktapur Hospice Palliative Care Twinning Project

Made in duplicate and to remain in effect for a period of three years from the date of agreement, at which time it will be reviewed with the option to renew.

Between: Nanaimo Community Hospice Society
1729 Boundary Avenue, Nanaimo, B.C.
(hereinafter referred to as "NCHS")

And: Bhaktapur Cancer Care Hospital Palliative Care Program
Box 6, Bhaktapur, Nepal
(hereinafter referred to as "BPCP")

This agreement will remain in effect for a 3 year period, commencing , 200_ at which time it will be reviewed with the option to renew.

Whereas NCHS, a registered non-profit Society incorporated under the Society's Act of British Columbia, and BPCP, operating in Bhaktapur, Nepal, wish to enter into a twinning project for the purposes of providing care and support, that adheres to the philosophy of hospice palliative care, to BPCP patients and their family members, and

Whereas the Canadian Income Tax Act requires that, as a registered charity, NCHS must direct and control the administration of its charitable activities, and

Whereas, NCHS wishes to enter into an agreement with BPCP to assist in the administration of the charitable activities of NCHS.

Therefore:

NCHS and BPCP agree, to the mutual benefit of both parties, to collaborate and cooperate in the administration of charitable activities that meet the guidelines set out by Canada Revenue Agency, the Society's Act of B.C., and the Constitution and Bylaws of NCHS and that adhere to the philosophy of hospice palliative care as set out in the Canadian Hospice Palliative Care Association's "A Model to Guide Hospice Palliative Care" (March 2002), and

NCHS agrees to generate charitable donations and distribute funds to BPCP to facilitate the delivery of hospice palliative care to patients and family members under their care, and

BPCP and NCHS will mutually agree, in writing, to any intended use of charitable funds directed from NCHS to BPCP, prior to the release of funds. Use of funds may include, but will not be limited to, the following:

1. hiring professional staff who provide direct patient care
2. purchase of medications for patients
3. purchase of equipment and educational materials used to facilitate care
4. other special project that are deemed acceptable by both parties

BPCP and NCHS will agree upon an annual budget at least one month prior to the date of the initial distribution of funds from NCHS to BPCP, and thereafter at least two months prior to the first day of January each year, which is the first day of NCHS's fiscal year, and NCHS will make regular payments of charitable funds to BPCP at agreed upon intervals, and

BPCP will provide written quarterly progress reports to NCHS regarding the use of transferred charitable funds, and agrees to allow visiting representatives of NCHS to inspect the project on reasonable short notice.

Any deviation in the use of funds from that set out at the beginning of each fiscal year will be considered a "special project" and must be applied for in writing to NCHS.

NCHS may, at any time, withhold payment of charitable funds if documentation and progress reports are deemed unsatisfactory by NCHS, or if it is felt that the actions of BPCP are in direct contravention of Canada Revenue Agency guidelines, and/or the Society's Act of B.C., and/or the Constitution and Bylaws of NCHS.

Both parties will keep accurate accounts of all receipts and expenditures of funds designated by donors for the Twinning Project in a separate general ledger account within their respective accounting systems, for audit purposes

Agreed to this day of , 2006

On Behalf of the Nanaimo - Bhaktapur Hospice Palliative Care Twinning Project

For NCHS:

Witness Dave Sherstone, President

Witness Wendy Pratt, Executive Director

For BCPC:

Witness Mr. Deewakar Raj Karnicar / Chairman

Witness Dr. R.P. Baral / Medic

5. Sample Priority List

Sample Priority List

S.N.	Particulars	Qty.	Unit Cost(US$)	Total	Cost Remarks
1.	Nursing Staff	2	150/month	150/month
2.	Support Staff	1	70/month	70/month
3.	Computer	1	650	650
4.	Printer	1	250	250
5.	Computer Table	1	85	85
6.	Water Beds	2	50	100	Duckback Indian
7.	Suction Machine	1	450	450	Surgix Indian
8.	Oxford test book of Palliative care (Latest edition)