Case studies
Social Movement Action Framework
Scaling up, scaling out and scaling deep a fall prevention initiative
A joint fall prevention program by RNAO and the Canadian Patient Safety Institute (CPSI) that was scaled up, scaled out and scaled deep.
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:
- to reduce the rate of falls in older adults by educating and training staff and patients about fall prevention
- develop a forum for improvement teams
- 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.
Building capacity in change agents for health innovation and transformation
United Kingdom junior doctors increased their capacity as change agents after mobilizing and implementing the WHO surgical checklist.
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 Alabama Comprehensive Cancer Control Coalition
A coalition of community partners who took action and created change for cancer prevention and promotion.
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.
Knowledge-to-Action Framework
Identifying the problem at Cardioinfantil Foundation of Cardiology Institute (FCI-IC) to achieve excellence in care
Cardioinfantil Foundation of Cardiology Institute is an acute care facility with a goal of achieving excellence in care in the prioritized areas of fall prevention and wound care.
Cardioinfantil Foundation of Cardiology Institute (FCI-IC) is a 340-bed hospital in Bogotá, Colombia. Recognizing that the use of best practice guidelines (BPG) for nursing care was uncommon in Colombia, they joined RNAO’s Best Practice Spotlight Organization® (BPSO®) program with the goal of achieving excellence in care.
FCI-IC had 10 years of evaluation data that revealed problems in specific clinical areas such as fall prevention and wound care. They conducted a baseline diagnostic evaluation to identify the highest priority problems to tackle and to select the most appropriate guidelines and best practice recommendations. As part of this, they surveyed their key partners in the change to learn more about their use of assessment tools, the status of electronic medical records, routine clinical practices such as the use of bed rails, and prevalence data.
This assessment process led to them selecting three RNAO BPGs as knowledge tools: Prevention of Falls and Fall Injuries in the Older Adult, Risk Assessment and Prevention of Pressure Ulcers, and Assessment and Management of Foot Ulcers for People with Diabetes.
Conducting gap analyses to successfully implement new clinical practices at Tilbury Manor
Tilbury Manor, a long-term care home, chose to focus on provincially-mandated “required programs” when seeking to improve resident care using a gap analysis.
Tilbury Manor, a 75-resident long-term care home in Tilbury chose to focus on provincially-mandated “required programs” (fall prevention, skin and wound care, continence care, bowel management and pain management) when seeking to improve resident care.
They conducted a gap analysis to compare their current practices with the best practices outlined in related RNAO best practice guidelines. Their analysis included an assessment of clinical practices, policies and documentation systems. The results of the gap analysis helped them create specific action plans.
Tilbury Manor then formed project teams led by nurses and supported by a team of champions. These teams proceeded to educate staff, implement new clinical practices, conduct care reviews and conduct audits.
Multiple positive outcomes were reported as a result of implementing these best practices including reductions in reports of pain, less use of restraints, and less falls, pressure ulcers and urinary tract infections.
Adapting the Person- and Family-Centred Care best practice guideline to local context at Sioux Lookout Meno Ya Win Health Centre
Sioux Lookout Meno Ya Win Health Centre (SLMHC) is a pre-designate Best Practice Spotlight Organization® (BPSO®) in Sioux Lookout, a town in Northwestern Ontario. The service area is remote, isolated and encompasses 385,000 square kilometres, with a population that is 85 per cent First Nations. Learn more how this site adapted guidelines to their local context in this case study.
Sioux Lookout Meno Ya Win Health Centre (SLMHC) is a pre-designate Best Practice Spotlight Organization® (BPSO®) in Sioux Lookout, a town in Northwestern Ontario. SLMHC is a hub for inpatient and outpatient hospital services, providing services to including Sioux Lookout and 28 northern communities. The service area is remote, isolated and encompasses 385,000 square kilometres, with a population that is 85 per cent First Nations.
As part of its pre-designation process, the SLMHC change team implemented the Person- and Family- Centred Care (PFCC) best practice guideline (BPG). During implementation, the SLMHC change team worked to adapt the PFCC BPG to the local context of their organization in order to best serve the needs of the population in the surrounding areas as well as in other remote communities.
The SLMCH local context posed unique challenges. Among these:
- Standard guidance on privacy did not always apply to members of the First Nations communities served. Some members wished to have their health information shared with their chief and community.
- Some people must travel as far as 400 or 500 kilometers to return home after discharge from SLMHC. Thus, it was essential to arrange appropriate care transitions and make sure people being discharged would not lose personal belongings.
The SLMHC change team adapted the PFCC BPG to the local context by:
SLMHC Patient Oriented Discharge Summary. Shared with permission.
- placing names on the doors of the hospital rooms of some individuals, so their community members could stop by and visit.
- creating a Patient Oriented Discharge Summary (PODS) that included the following options to indicate the person’s preferences regarding sharing their health information:
- I agree to my health information being shared with________
- I do not agree with my health information being disclosed to people in my community (for example, band or council)
- creating a detailed staff checklist within the PODS to ensure safe care transitions (by, for example, faxing the completed form to an external Indigenous Transition Navigator, or listing personal items collected from the room).
- working with an Indigenous Transitions Facilitator, whose roles include conducting follow-up phone calls with the person, patient rounding, and coordinating safe transitions.
After successfully creating a tailored PODS that meets the need of the population they serve, SLMHC has been able to better support person- and family-centred care principles within the organization.
Shared with permission by Sioux Lookout Meno Ya Win Health Centre
Engaging Persons with Lived Experiences
Holland Bloorview Kids Rehabilitation Hospital: Co-designing change through the active engagement of persons with lived experience
A case study from Holland Bloorview Kids Rehabilitation Hospital focused on engaging persons with lived experience in a change process.
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.
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.
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.
Engaging Patient Family Advisors to advance guideline implementation at Scarborough Health Network
A case study about the integration of patient family advisors at Scarborough Health Network to enhance community engagement and health equity.
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
Co-designing change through the active engagement of persons with lived experience - Holland Bloorview Kids Rehabilitation Hospital
Case study - Holland Bloorview
Holland Bloorview Kids Rehabilitation Hospital (Holland Bloorview) is a designated Best Practice Spotlight Organization® (BPSO®) in Toronto, 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.
These family leaders are families and caregivers who have received services at Holland Bloorview and have lived experiences of paediatric disability. Their roles include mentoring other families, acting as advisors to committees and working groups, and co-teaching workshops to students and other families.
One example of a successful implementation co-design within Holland Broadview is the ENFit™ Working Group. This interprofessional team works on the adoption of a new type of connection on products used for enteral feeding – or 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. This in turn decreases harm to children and youth who require enteral feeding.
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, the potential impacts on persons and families were emphasized. The working group engaged the family member by:
- co-creating the implementation plan
- involving them in a failure mode and effects analysis highlighting 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
Shared with permission from Holland Bloorview
