Evaluate outcomes

Spectrum Health Care (Spectrum), an RNAO Best Practice Spotlight Organization® (BPSO®), is a home health organization with more than 200 nursing staff across three locations in the province of Ontario, Canada.

Spectrum chose to implement the 2015 Person- and Family-Centred Care (PFCC) Best Practice Guideline (BPG) to enhance person- and family-centred care and to reduce complaints regarding care. Members of the senior leadership team at Spectrum Health Care led implementation together with Spectrum’s Patient and Family Advisory Council.  

To support the practice change, Spectrum used the following implementation interventions:

• Conducting a gap analysis to determine the knowledge/practice gap;
• Holding education sessions for staff on person- and family-centred care best practices;
• Revising their care processes to include review of care plans with the person and/or members of their family
• Surveying staff members on their attitudes about person- and family-centred care via surveys
• Developing staff education on communication strategies to support the assessment of a person’s care needs and care plans.

After implementing these interventions, Spectrum assessed the number of complaints received from persons receiving care per 1,000 care visits and compared that to their baseline. 

They found a decrease of 42 per cent of complaints from persons received over an 18-month time period at one of the sites that was implementing the PFCC BPG at Spectrum Health Care. 

At another site, an 80 per cent reduction in complaints was found following the staff education intervention.    

Data analyses overall indicated that the implementation of the PFCC BPG was highly successful in reducing persons' complaints regarding care.

Read more about Spectrum Health care’s results of implementing the PFCC BPG here: Slide 2 (rnao.ca)

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.

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)