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).

In Alabama, United States, a public health community coalition targeting breast and cervical cancer prevention engaged in grassroots advocacy to influence policy and legislation for smoke-free spaces (Wynn et al., 2011).

This coalition was made up of local stakeholders, including an interdisciplinary committee of government officials, faith-based organizations, academics, researchers and volunteers. Their collective efforts were effective in part because the people involved were receptive to change. 

There was a strong impetus for change caused by these concurrent factors:

• data showing an unequal burden of cancers among Black Americans due in part to higher rates of tobacco use and second-hand smoke exposure.
• recognition that the risk of cancers could be lowered by: implementing evidence-informed strategies; increasing public awareness and advocacy; and promoting healthy public policy.  
• the coalition’s commitment to creating social change by improving the health and well-being of the community to achieve positive health outcomes.
• public support for the establishment of legislated smoke-free areas, evident from the results of local and national Gallup polls.
• an understanding of the powerful impact of social movement actions to create change.

This receptivity to change led the coalition to engage in social movement actions. They became empowered by learning strategies to lead change; they realized the power of their collective voices and mobilized actions. They felt their actions were timely and needed due to the data indicating rising cancer levels amongst Black Americans. They were committed to taking action to address and rectify health inequities.                

Sandy Lake Health Authority is a designate, Indigenous-focused Best Practice Spotlight Organization® (BPSO®) that manages health programs in Sandy Lake First Nation. Sandy Lake is a fly-in remote First Nation community in Northwestern Ontario. The community is located 600 km northwest of Thunder Bay, Ontario and 450 km northeast of Winnipeg, Manitoba (Sandy Lake First Nation, 2023).  

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                                                  Sandy Lake First Nation Logo and nursing station [Shared with permission by Sandy Lake First Nation Health Authority]

Sandy Lake Health Authority has been implementing various best practice guidelines (BPG) from the Registered Nurses’ Association of Ontario (RNAO) since the beginning of its designation in 2021. These implemented BPGs have included: Assessment and Interventions for Perinatal Depression, Person- and Family-Centred Care, and Promoting Smoking Reduction and Cessation with Indigenous Peoples of Reproductive Age and their Communities.

The change team at Sandy Lake has been building public visibility and promoting best practices within its community by:

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Posters created by the Sandy Lake team to promote events and build public visibility of BPSO;  [Shared with permission by Sandy Lake First Nation Health Authority]

• promoting BPSO and best practice initiatives such on the local community radio show, announcements on internal media page, word-of mouth, and on-going conversations with health care providers,
• holding several events (e.g., mental health support for prenatal clients, health fairs) to support community wellness and engagement as allowed by pandemic restrictions,
• creating eye-catching posters to promote the events,
• using a closed Facebook page and messenger to communicate with prenatal clients, and
• displaying BPSO logo on Facebook, posters and other materials.

As a result of their collective action, Sandy Lake First Nation Authority has been able to build public visibility, meaning and awareness of their best practice initiatives within their community and region. As an inaugural member of the Indigenous-focused BPSO program, Sandy Lake First Nation has also leveraged provincial and international networks to share their community approaches to promoting prenatal health and wellness with others.

Perley Health is a designate Long-Term Care Best Practice Spotlight Organization® (BPSO®) which demonstrates a strong commitment to providing evidence-based care. During the pandemic, the team identified skin and wound infection as a clinical concern among their residents. Consistent with the literature, residents at Perley Health experiencing comorbid medical conditions such as frailty, diabetes, and arterial and venous insufficiency were at increased risk for chronic wound infections [1]. Chronic wounds are a prime environment for bacteria, including biofilm, making wound infection a common problem [2] [3]. Managing biofilm, which can affect wound healing by creating chronic inflammation or infection [3], becomes crucial as up to 80 per cent of infections are caused by this type of bacteria [4] [5].

To adopt and integrate best practices, the team at Perley Health decided to implement the Assessment and Management of Pressure Injuries for the Interprofessional Team best practice guideline (BPG). To support a systematic approach to change, four of the action cycle phases of the Knowledge-to-Action Framework, from the Leading Change Toolkit [6] are highlighted below.

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Identify the problem 

Perley Health’s wound care protocol was audited and the following gaps were identified based on current evidence:

• Aseptic wound cleansing technic could be improved, as nonsterile gauze was used for wound cleansing.
• Wound cleaning solution was not effective to manage microbial load in chronic wounds
• Baseline wound infection data were collected on the number of infected wounds within the organization each month over three years and is ongoing

Adapt to local context

The project was supported by key formal and informal leaders within the organization including the Nurse Specialized in Wounds, Ostomy and continence (NSWOC), the Director of Clinical Practice, a team of wound care champions, the IPAC team and material management. Staff was motivated to improve resident outcomes by lowering infection rates which facilitated the project but many continued to use old supplies so as to not waste material. Providing the rationale for the change and associated best practices improved knowledge uptake, as did removing old supplies to cut down on confusion. Barriers the team encountered included staff turnover and educating new team members.

Select, tailor, implement interventions

The interventions listed below were selected, tailored and implemented based on the evidence that was adapted to the local context. They were purposely chosen to support the clinical teams’ needs on busy units and to creatively overcome staffing challenges. Interventions included:

• use of a wound cleanser containing an antimicrobial
• use of sterile equipment for wound care, including sterile gauze
• creation of a wound-cleansing protocol was created to reflect best practice
• updating and approval of a policy by the Risk Assessment and Prevention of Pressure Ulcers team in collaboration with the director of clinical practice

Perley Health also created and delivered education in two formats designed to be accessible to front-line staff:

• Just-in-Time education was provided on every unit, on every shift, to registered staff by the NSWOC on all shift sets, over a one-month period. Wound care champions were available on each shift to aid in learning and answer additional questions to support the team’s needs.
• A continuing education online learning module was created and uploaded onto Perley Health’s Surge learning platform. Training is included in new hire onboarding and mandatory for yearly education.
  
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 An RPN demonstrating how to cleanse a wound using wound cleanser at Perley Health

Evaluate outcomes

Evaluation indicators were selected to determine the impact of the implementation interventions when compared to baseline data, including the rate of wound and skin infections per 1,000 days.  A 50 per cent reduction in wound infections was identified following the implementation of the identified change strategies and education above. 

This graph represents four years of data collection on wound infections at Perley Health. Three years of baseline data and one year of post-implementation data are highlighted in red.

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References

1. Azevedo, M., Lisboa, C., & Rodrigues, A. (2020). Chronic wounds and novel therapeutic approaches. British Journal of Community Nursing, 25 (12), S26-s32.
2. Landis, S.J. (2008). Chronic Wound Infection and Antimicrobial Use. Advances in Skin & Wound Care, 21 (11), p 531-540.
3. Registered Nurses’ Association of Ontario (2016). Clinical best practice guidelines: Assessment and management of pressure injuries for the interprofessional team (3rd ed.). Registered Nurses’ Association of Ontario: Toronto, ON.
4. Jamal, M., Ahmad, W., Andleeb, S., Jalil, F., Imran, M., Nawaz. M., Hussain, T., Ali, M., Rafiq, M., & Kamil, M.A. (2018). Bacterial biofilm and associated infections. J Chin Med Assoc. 81(1): 7-11.
5. Murphy, C., Atkin, L., Swanson, T., Tachi, M., Tan, Y.K., De Ceniga, M.V., Weir, D., Wolcott, R., Ĉernohorská, J., Ciprandi, G., Dissemond, J., James, G.A., Hurlow, J., Lázaro MartÍnez, J.L., Mrozikiewicz-Rakowska, B., & Wilson, P. (2020). Defying hard-to-heal wounds with an early antibiofilm intervention strategy: wound hygiene. J Wound Care, (Sup3b):S1-S26.
6. Registered Nurses’ Association of Ontario (2022). Leading change toolkit: Knowledge-to-action framework. https://rnao.ca/leading-change-toolkit Registered Nurses’ Association of Ontario: Toronto, ON.

Holland Bloorview Kids Rehabilitation Hospital (hereafter referred to as Holland Bloorview) is a designated Best Practice Spotlight Organization® (BPSO®) in Toronto, Ontario, Canada.  Holland Bloorview has an award-winning Family Leadership Program (FLP), through which family leaders partner with the organization and the Bloorview Research Institute to co-design, shape, and improve services, programs, and policies. Family leaders are families and caregivers who have received services at Holland Bloorview, and have lived experiences of paediatric disability. Family leaders’ roles include being a mentor to other families, an advisor to committees and working groups, and faculty who co-teach workshops to students and other families. 

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 Family Leader Roles at Holland Bloorview. Photo provided with permission by Holland Bloorview Kids Rehabilitation Hospital.

The ENFit™ Working Group is an example of a successful implementation co-design process within Holland Bloorview. The ENFit™ Working Group is an interprofessional team working on the adoption of a new type of connection on products used for enteral feeding  [feeding directly through the stomach or intestine via a tube]. By introducing the ENFit™ system, a best practice safety standard, the working group plans to reduce the risk of disconnecting the feeding tube from other medical tubes, and thus decrease harm to children and youth who require enteral feeding.

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Family Partnering with the EnFit Working Group. Photo provided with permission by Holland Bloorview Kids Rehabilitation Hospital. 

The working group invited a family member and leader whose son had received services at Holland Bloorview. This family member had significant lived experience with enteral feeding management, enteral medication administration, and other complexities associated with enteral products. During the meetings, great attention was given to the potential impacts on persons and families. The group engaged the family member by:

• co-creating the implementation plan
• involving them in a failure mode affects analysis, which highlighted the impact of the feeding tube supplies on transitions to home, school, and other care settings
• working with the family member to advocate for safe transitions within the provincial pediatric system, which led to the development of the Ontario Pediatric ENFit™ Group

To learn more about Holland Bloorview’s experience in partnering with families in a co-design process, watch their 38-minute webinar: The Power of Family Partnerships.

Scarborough Health Network (SHN) (Home - Scarborough Health Network (shn.ca) is an organization pursuing Best Practice Spotlight Organization® (BPSO®) designation in Scarborough, Ontario, Canada. Patient Family Advisors (PFAs) are a vital part of SHN’s philosophy of care, representing the diverse community SHN serves. A key element of the PFA role is sharing lived experiences with SHN staff and the Scarborough community.

SHN has demonstrated commitment to the role of PFAs within their organization by creating a new department for health equity, patient and community engagement (HEPCE). This department focuses on:

• recruiting, onboarding, managing, recognizing and retaining PFAs
• educating staff on best practices related to engaging with PFAs

During recruitment and onboarding, the HEPCE and current PFAs educate potential PFAs about the role’s scope and expectations. All PFAs are also provided with information on how to share their patient or caregiver story with their audience.  

PFAs have played an important role in SHN’s BPSO committee. Indeed, one PFA has been integral to the process of recruiting and engaging champions at SHN throughout the COVID-19 pandemic’s health human resources (HHR) crisis. Their role has included participating in champions’ virtual drop-in sessions (2020-2021) and in-person roadshows (2022).

Champion roadshows are events during, which SHN practice leaders and PFAs promote the BPSO program, share best practice guidelines and recruit champions around the organization, without asking busy staff members to leave their units.

The PFA also supported the recruitment and engagement of champions by:

• collaborating with other champions and working group members to plan champions’ drop-in sessions and roadshows
• working alongside the team to plan safe spaces for staff and PFAs to share their stories
• sharing stories of positive experiences with staff members in relation to the impact of best practices (for example, RNAO’s Person and Family Centred-Care best practice guideline) on their experience

Staff members have reported being motivated to become best practice champions after attending a champion’s roadshow. SHN has also consistently gained champions during the HHR crisis and maintains at least 15 per cent of nursing staff as best practice champions.

The PFA’s role was vital to demonstrating the lasting impact of best practices. They have expressed feeling empowered by their role in BPSO work, expressing that the work helped them find their voice and become part of the movement to promote and implement best practices.  

Overall, PFAs play an essential – and dual – role in supporting the implementation of best practices at SHN. In line with person- and family-centred care, PFAs assume an outward-facing role in shaping the implementation of best practices and SHN’s values. In addition, they also act in an inward-facing role to support the bolstering of champions.

To learn more about the PFA role at SHN, please visit the following link: Patient Family Advisors.

Shared with permission by Scarborough Health Network