The National Health Forum (NHF), a nationwide popular movement in El Salvador, played a central role in the development of the National Public Health System from 2009 to 2018 (León et al., 2020). It is part of a global movement that aims to build coalitions and networks. The People’s Health Movement (PHM) brought together grassroots health activists, civil society organizations and academic institutions from around the world to address the social, environmental, and economic determinants of health (Kapilashrami et al., 2016).

The NHF provides a strong example of community participation and exemplifies a social movement with fully achieved goals. Formally created in 2010, the NHF had three fundamental goals that were met via social movement actions:

1. to build people’s power and strengthen the organizational fabric
2. to stand against the idea that previous governments held of privatizing health care
3. to stimulate and promote effective social participation in health

The NHF developed three community participation strategies that played a role in strengthening El Salvador’s national public health system. These strategies are: (1) building capacity among local community leaders to become effective decision-makers at all levels of the health-care system, (2) responding to and prioritizing the needs identified by the community for the sector-specific working groups, and (3) advocating for policies based on human rights.

“The NHF was born with high participation of different social movements, all united in the same direction. There were a series of problems, as they wanted to privatize health care […] The NHF was created when the health reform came into being. We, the NHF, are part of the reform” – NHF member

The Alzheimer’s Association (Alzheimer's Association | Alzheimer's Disease & Dementia Help) was founded in 1980 by a group of family care providers and individuals who supported the need for an organization dedicated to support the needs of caregivers facing Alzheimer’s and to advance knowledge through research. As early activists for the Alzheimer’s movement, they sought to break down the silence of Alzheimer’s and learn more about the disease, including prevention, treatment and a cure.

Through a people-led approach, the association reaches millions of people globally through a multi-pronged approach grounded in individual and collective action. Advocacy to give all persons living with Alzheimer’s access to the support services they need includes strategies such as launching awareness campaigns and grassroots campaigns to impact legislation.

With multiple chapters throughout North America and globally, the Alzheimer’s Association includes a network of advocates and allies. These include other Alzheimer’s organizations, universities engaged in research, corporations and pharmaceuticals. As an example of a civil society organization, the Alzheimer’s Association is a community-based non-profit organization that has protected and advocated for the needs and interests of persons and families living with Alzheimer’s for over 40 years.

The Campus Kitchens Project (CKP) is an example of a successful scaled-up change initiative. Founded in 2001 as a branch of a community kitchen initiative that targeted food insecurity in Washington, D.C., United States, this non-profit is the first and largest student-led social movement taking on the crisis of food waste and hunger in the United States (Larson et al., 2017). More than 30,000 students in 63 universities, colleges and high schools are now repurposing unwanted or surplus food to provide meals to people who have food insecurity.

Working in leadership teams, student leaders and volunteers on campuses receive education, training and coaching over a period of several months to help empower people, families and communities on topics including:

• food insecurity
• improving social and nutritional health by increasing food knowledge and helping others developing cooking skills

The Campus Kitchen Project also establishes community partnerships with existing local organizations that provide services and food to individuals already challenged with food insecurity, such as senior housing facilities, youth outreach groups and churches. Local leadership teams also partner with dining services that operate large foodservice kitchens and dining halls and engage student groups and faculty advisors.

Student teams carry out different functions. While some teams focus on improving the way that homeless shelters prepare and deliver meals, other teams host communal dinners, partner with senior centers, or improve transportation to improve access to food.

“Instead of more branch offices or trying to provide all the services in-house, we find universities and students to partner with who already have the necessary resources on campus and want to do this kind of community impact work.  Turning our nation’s institutions of higher education into hubs for replication and ongoing innovation could be the superhighway to scaling up for any nonprofit.” - Laura Toscano, Director, The Campus Kitchens Project

RNAO’s Best Practice Spotlight Organization® (BPSO®) program itself was scaled up, scaled out and scaled deep – on the national level – when RNAO and the Canadian Patient Safety Institute (CPSI) entered into a formal partnership on a pan-Canadian falls prevention initiative campaign in 2007, with a focus on long-term care (LTC) (McConnell et al., 2018).

This collaboration involved the implementation of best practices, capacity building at the micro and meso levels with individuals and organizations, and engagement with national partners. The work was informed by the first and second editions of RNAO’s best practice guideline (BPG) Prevention of Falls and Fall Injuries in the Older Adult and CPSI’s program Safer Healthcare Now! on falls prevention as a critical patient safety issue Reducing Falls and Injuries from Falls.

The National Collaborative on Falls Prevention in Long-Term Care, launched in 2008–2009, included staff from 32 LTC homes and an interprofessional expert panel. The goals of the collaborative:

1. to reduce the rate of falls in older adults by educating and training staff and patients about fall prevention
2. develop a forum for improvement teams
3. participate in a methodology on quality improvement initiatives using the Model for Improvement (Langley et al., 2009).

The collaboration was highly successful – process indicators showed decreased rates of falls in the LTC homes following implementation. However, it was determined that more time and support would be needed to scale the fall prevention initiative out and deep to in order to embed and sustain the practice changes. 

In 2010–2011, the collaborative expanded to a national campaign where the program was delivered virtually to more than 45 organizations from diverse health sectors using web-based technology. This enabled greater access to the program with impressive outcomes, and showed that technology could be used as a tool to scale the program up and out.

This was followed up by creation and delivery of a fall prevention learning series in 2011–2012 to strengthen the uptake and sustainability of best practices. The training integrated implementation science, change theory and quality improvement methodology. As with the other collaboration components, the outcomes of the learning series demonstrated improvements in practice changes and reductions in falls causing injury, and organizational policies to support and sustain the change. The continued use of evaluation to determine outcomes and impact as part of quality improvement and using ongoing audit and feedback demonstrated a change that was scaled deep. 

The collaboration helped embed principles of social action movement by its focus on a credible and important shared concern – preventing falls – where urgent change was needed. Momentum was used to support the continued engagement of fall prevention champions across sectors. Networks were used to share resources and expand collaborations across communities.          ​​​​​​

Although positioned as the “future leaders of health-care transformation and innovation,” junior doctors (or interns) in the United Kingdom actually receive very little training in leadership competencies at medical schools to prepare for this role (Carson-Steven et al., 2013). Instead, they learn in clinical environments that are frequently unreceptive to change and innovation informed by best practices.

To overcome these barriers and emerge as leaders, a group of junior doctors chose to independently learn how to innovate and champion evidence-based practice by applying social movement approaches including mobilizing for change. By participating in programs, such as the Institute for Healthcare Improvement’s “Open Schools,” they built capacity in social movement thinking and actions and used their knowledge, skills, networks and experiential learning to drive change in their clinical practice. 

The junior doctors applied social movement actions when they led a change initiative to implement the World Health Organization’s guidelines on the use of surgical safety checklists for patient safety. They co-created a supportive learning community to learn together and from one another and to overcome obstacles and resistance. As emerging leaders, they engaged in collective action, including organizing a “teach-in” to raise awareness about the urgent need for change and the implementation of best practices in surgical care as determined through evidence. And, each doctor committed to recruiting colleagues to strengthen the social movement and build momentum and a critical mass.

For more details, see The social movement drive: a role for junior doctors in healthcare reform - PubMed (nih.gov).

The Best Practice Guideline (BPG) Program has supported the leadership and influence of thousands of Registered Nurses’ Association of Ontario (RNAO) Best Practice (BP) Champions as change agents engaged in the implementation of evidence-based practice changes.

For example, at Clínica las Condes (CLC), a Latin American Best Practice Spotlight Organization® (BPSO®) in Santiago, Chile, BP Champions are committed volunteers consisting mostly of nurses and other health professionals. Their leadership is evident in the multiple activities they lead, including:

• reviewing guidelines and organizational policies
• motivating colleagues
• presenting guideline recommendations at clinical services meetings twice a year
• ensuring adherence to practice changes in their clinical units

(Serna Restrepo et al., 2018)  

Behavioural Supports Ontario (BSO) is a pre-designate Best Practice Spotlight Organization® (BPSO®) serving long-term care (LTC) homes in Hamilton, Haldimand-Norfolk, Brantford, Burlington and Niagara Regions. BSO aims to enhance care and services for older adults with dementia, complex neurological conditions and mental health challenges who present with responsive behaviours through comprehensive assessment and the development of strategies to optimize care for the resident. 

The Hamilton Niagara Haldimand Brant (HNHB) BSO team supports 86 LTC homes with more than 11,200 beds combined. Using transformational leadership and applying key characteristics from the Social Movement Action (SMA) Framework, the organization successfully shifted the culture of the organization to one that supports and sustains high quality and best practices by engaging and motivating staff.  Integral to the process was a strong core leadership team of interprofessional staff, intrinsic motivation and momentum.

The organization used RNAO’s BPSO model and gap (opportunity) analysis tools to identify and evaluate areas of improvement in process and practice in three fields of work during the implementation of three RNAO best practice guidelines (BPG) – Person and Family Centered Care, Identification and Assessment of Pain and the Management of Delirium, Dementia and Depression. The impact on personalized care and satisfaction with care are described in Figures 1 and 2.  

Figure 1: Percentage of residents and families participating in developing their personalized plan of care (assessments completed during referrals) 

Evaluation impact: There was a 50.3 per cent increase in residents’ and families’ participation in developing personalized care plans.  Data remained consistently above the HNHB average since January 2021.

Figure 2: Number of residents and families satisfied with their involvement in care and treatment planning

Evaluation impact: There was an 80 per cent increase in residents’ and families’ satisfaction with their involvement in the care and treatment plan at the five implementation sites. Survey results from the five implementation sites demonstrated that residents and families responded “always” and “usually” when asked if they were satisfied with their involvement in the care and treatment planning.

In addition to these outcomes, HNHB BSO has identified the following improvements via quantitative data: 

• increased number of screenings and assessments for pain completed
• improved consistency in the screening and assessments of delirium, dementia and depression for all clients
• improvement of more than 80 per cent in the number of residents and families satisfied with their involvement in care and treatment planning

Lessons learned

While implementing the BPGs, HNHB BSO discovered several effective strategies, including the following: 

• Engaging staff to agree on a common resident-centered goal by developing a “BSO High Five” program. This program recognizes front-line workers who have demonstrated a person-and family-centered approach to care and have motivated other staff to implement and sustain best practices.
• Applying transformational leadership that focused on staff and stakeholder involvement and engaging them throughout the assessment, planning, implementation and evaluation phases of BPG implementation.
• Developing a best practice steering committee that includes formal and informal leaders, staff, and stakeholders. Persons with lived experience are also engaged in the committee to ensure the incorporation of a global perspective into the planning process from the start.
• Ensuring best practices are on all meeting agendas to sustain momentum toward BPG implementation.
• Conducting process and education gap analyses to address areas of improvement as part of a quality improvement project. 
• Valuing staff-driven changes and improving synchronization between the project managers and the team to ensure cohesion, a common identity and a shared vision.
• Understanding the importance of going slow and growing the changes to ensure the alignment amongst all staff. This was crucial to the planning and evaluation phases and allowed for the realignment of strategies and approaches, if necessary, during the implementation of projects. 

Shared with permission from Hamilton Niagara Haldimand Brant (HNHB) Behavioural Supports Ontario (BSO)

A group of volunteers, staff and physicians from St. Joseph’s Healthcare Hamilton, an acute care facility in Hamilton, Ontario, Canada engaged in a social movement to address environmental issues, such as carbon emissions (Herechuk et al., 2010). The change agents formed a team of grassroots activists called the Environmental Vision and Action. They were intrinsically motivated as environmental stewards to make sure changes were made that aligned with environmental determinants of health. Through the support of the hospital’s senior leadership team, the hospital went “green” with environmentally-driven organizational changes, including the creation of a model for environmental excellence. For more details, see Achieving environmental excellence through a multidisciplinary grassroots movement - ScienceDirect 

In Barcelona, Spain, Vall d’Hebron Barcelona Hospital Campus, a Best Practice Spotlight Organization®(BPSO®) Nursing care | Vall d'Hebron Barcelona Hospital Campus (vallhebron.com), nurses and other staff became RNAO Best Practice Champions in several clinical areas including breastfeeding, ostomy and wound care. A ceremony was held to recognize the champions’ leadership and their commitment to using evidence-based guidelines to achieve excellence in clinical practice. Their intrinsic motivation is evidenced by their dedication to providing best practices and optimizing their patients’ health and well-being. For more information, watch the video BPSO Program: Excellence in Cares of Infirmary - YouTube 

RNAO supports making harm reduction services available for people who use substances as a means of saving lives, reducing stigma and building healthy communities. As part of this work, RNAO advocates for using evidence to inform policy in the area of supervised injection services.

When the only supervised injection services site in Canada faced threats of closure by the federal government, RNAO mobilized by engaging members’ support, the media and the public. As part of a coalition, RNAO and others advocated for and participated in a hearing before the Supreme Court of Canada.

As a result of the evidence on the benefits of harm reduction and public interventions advocating for the continued access to supervised injection services, the court ruled that the site should remain open. The victory led to the groundwork for additional supervised injection services to open in other provinces across Canada, including Ontario (Grinspun et al., 2018a).