Getting the Best Results from the RNAO Falls Prevention Best Practice Guideline: Implementation Stra

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Getting the Best Results from the RNAO Falls
Prevention Best Practice Guideline
Implementation Strategies that Work!

• Edmonton III Conference
• Tuesday February 26, 2008
• Irmajean Bajnok, RN, MScN, PhD
• Director, RNAO International Affairs and Best
  Practice Guidelines Programs

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Presentation Outline

• Quick Background
• Best Practice Guidelines Program
• Mandate
• Guideline Development Process
• Implementation and Sustainability
• Overview
• Models and Processes
• Individual influencers
• Organizational facilitation
• System as a Target

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Nursing Best Practice Guidelines Program

• RNAO launched the Nursing Best Practice
  Guidelines (BPG) Program in November 1999 with
  funding from the Government of Ontario.

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Nursing Best Practice Guideline Program Mandate
To develop, pilot implement, evaluate,
disseminate and support the use of evidence based
clinical and Health Work Environment (HWE)
nursing best practice guidelines.
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What are Best Practice Guidelines (BPG)?

• Systematically developed statements based on best
  available evidence to assist practitioners in
  making the best clinical decisions for patients
  (adapted from Field Lohr, 1990)

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Goals for Clinical Best Practice Program

• Improve patient care, reduce unexplained
  variation in care practices and care costs by
• Transferring, research evidence into clinical
  practice.
• Supporting knowledge-based clinical decisions and
  evidence-based nursing practice.
• Stopping clinical interventions that have little
  effect or cause harm.
• Identifying clinical practice gaps in nursing and
  encouraging research.

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Goals for HWE Best Practice Program

• To create practice settings that maximize the
  health and well being of nurses, quality patient
  outcomes and organizational and system
  performance by

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BPG Guideline Development Methodology

• Topic expert panel selection
• Scope definition
• Evidence review
• Development of
• recommendations evaluation indicators
• External stakeholder
• review
• Pilot Testing
• Revision
• Publication, dissemination and uptake
  facilitation.

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BPG Topic Areas

• Abuse
• Adolescence
• Asthma
• Breastfeeding
• Client Centred Care
• Chronic Obstructive
• Pulmonary Diseased (COPD)
• Cognitive Impairment
• Continence
• Constipation
• Crisis
• Diabetes

• Falls Prevention
• Family
• Healthy Work Environments
• Hypertension
• Intravenous Therapy
• Obesity
• Oral Health
• Pain
• Postpartum Depression
• Skin and Wound
• Smoking Cessation
• Stroke
• Therapeutic Relationship

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• Healthy Work Environment BPGs
• Collaborative Practice Among Nursing Teams
• Developing and Sustaining Effective Staffing and
  Workload Practices
• Developing and Sustaining Nursing Leadership
• Embracing Cultural Diversity in Health Care
  Developing Cultural Competence
• Professionalism in Nursing
• Workplace Health, Safety and Well-being of the
  Nurse

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Link Between Healthy Work Environment BPGs
Clinical BPGs

• Enable a positive response to the growing
  understanding of the relationships between
  nurses work environments and patient outcomes,
  organizational and system performance.
• Facilitate retention and recruitment of nurses
  during a time of nursing shortages.

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Implementation and Sustainability

• Overview
• Models and Processes
• Individual influencers
• Organizational facilitation
• System as a target

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Active Implementation Strategies

• Training and support of local opinion leaders
• Face to face visits (outreach visits or academic
  detailing)
• Guideline reminder systems
• Training and support for audit and feedback
• Integration into re-certification or licensing
  exam
• Admin strategies design of forms

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Implementation Enablers

• Support Financial, ideas, information
• Collaboration Education sessions with allied
  staff
• BPG Champions Positive early experiences
• Leadership
• Administration involvement buy-in from
  management, steering committees
• Clinical Resource Nurse Dedicated role,
  availability
• Education Tools, sessions, paid time
• Congruence with current practice, beliefs and
  values

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Implementation Barriers

• Attitudes we do it already
• Workload Interferes with education sessions
• Lack of continuity Limited time with patients
• Limited resources staff education, purchase of
  equipment
• Organizational constraints use of agency nurses,
  staff changes
• Lack of practice supports e.g., documentation
  systems not changed to prompt recording of
  intervention.

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Generally Effective Change Strategies

• Educational Outreach Visits
• Reminders
• Interactive Educational Meetings
• Multifaceted with 2 or more of Audit Feedback,
  Reminders, Local Consensus Processes, Marketing

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Sometimes Effective Change Strategies

• Audit Feedback
• Local Opinion Leaders
• Local Consensus Processes
• Patient Mediated Interventions

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Little or No Effect Change Strategies

• Educational Materials
• Didactic Educational Meetings

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Implementation and Sustainability

• Overview
• Models and Processes
• Individual influencers
• Organizational facilitation
• System as target

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Rogers Innovation-Adoption Process

• Knowledge stage
• Persuasion stage
• Decision stage
• Implementation stage
• Confirmation stage

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The PARIHS Framework

• Promoting Action on Research
• Implementation in Health Services
• Developed as a conceptual framework in 1998

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PARIHS Framework for Research Implementation
Kitson, et al., 1998, QSHC)
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RNAO Guideline Implementation Model
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Implementation Tool Kit

• A planned change process
• All aspects from selection and assessment of the
  change to evaluation
• Provides cases and examples of change applied to
  a clinical situation
• Includes specific information on stakeholders and
  environmental assessment
• Outlines implementation strategies
• Based on results of comprehensive reviews
• Moves the implementer to action
• Incorporates evaluation

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Evaluation of Tool Kit UsefulnessDobbins,
Davies, Danseco,Edwards, Virani, 2005

• Highly useful 85
• What was most useful
• Stakeholder Assessment and Analysis
• Organizational Readiness
• Planning Implementation Strategies

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Quality Improvement Processes

• Needs based
• Goal target driven
• Examine processes
• Plan, Do, Study, and Act
• Share and learna learning knowledge based
  culture
• Standardize, redesign, engage, build in success

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Implementation and Sustainability

• Overview
• Models and Processes
• Individual influencers
• Organizational facilitation
• System Level
• Goal Maximize enablers and overcome barriers
• Support nurses as knowledge professionals

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• Personal/Individual nurse factors
• Attitude toward research and research
  utilization or toward the specific evidence,
  belief suspension, number of inservices, trust in
  the knowledge source

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Individual Level

• Raising awareness, engagement
• Self-reflection/ assessment
• Developing capacity through professional
  development
• Motivating action (acknowledgement and
  recognition)
• Providing cues/reminders
• Supporting behaviours
• Tools and Resources

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From our Experience

• Developing Individual Capacity
• Nursing Best Practice Champions Network
• Advanced Clinical Practice Fellowships
• Conferences
• Residential Institutes
• Relevant Practice Tools

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Best Practice Champions Network

• Purpose of
• Best Practice Champions
• To disseminate evidence
• To assist with knowledge transfer
• To promote the uptake of best practices
• To share resources
• To take knowledge to the action level at point of
  care

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Best Practice Champions Network

• Over 1600 Champions over 400 in long term care
• Over 400 Organizations
• Formal informal networking, sharing
• Website
• Monthly learning teleconference sessions
• Open houses for local champions show and learn
• Symposiums
• Newsletters

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The Nature of Nursing Practice..
HEALTH CARE SYSTEM

Most implementation strategies based on research
related to physicians in practice Nursing is
different, therefore individual strategies, while
useful, are not enough
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Implementation and Sustainability

• Models and Processes
• Individual influencers
• Organizational facilitation
• System Level
• Goal Maximize enablers and overcome barriers
• Support nurses as knowledge professionals

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Implementation for the Long Term No piece of
cake (J. Ritchie, 2007)

• Real challenge is transforming the work
  patterns of behaviours that have developed around
  the work.
• Improving patient safety is primarily a cultural
  change, not a technical change.
• (Ross Baker, 2005)

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Organizational Level

• Developing a project plan
• Allocating resources
• Using change management principles
• Enacting transformational leadership, team work,
  etc.
• Using Quality Improvement Principles

• Defining scope of practice/environmental
  improvement
• Environmental Readiness
• Healthy Work Environment
• Assigning project manager/leader
• Developing capacity

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From our Experience

• Best Practice Spotlight Organizations
• Education Resource Integration of Best Practice
  Guidelines
• Toolkit Implementation of Clinical Practice
  Guidelines
• Healthy Work Environment Guidelines
• Centre for Professional Nursing Excellence

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Best Practice Spotlight Organizations (BPSO)

• 9 designated BPSOs
• Hôpital Charles LeMoyne, Greenfield
• Park, Quebec
• Hôpital régional de Sudbury Regional
• Hospital, Sudbury
• McGill University Health Centre,
• Montreal, Quebec
• Niagara Health System, St. Catharines
• Royal Victoria Hospital, Barrie
• Saint Elizabeth Health Care, Markham
• University Health Network, Toronto
• VON Canada, Ottawa
• West Park Healthcare Centre, Toronto

• 12 BPSO candidates
• Cambridge Memorial Hospital
• Chatham-Kent Health Alliance
• Community Care Access Centre HNHB
• Extendicare York
• Hamilton Health Sciences
• The Hospital for Sick Children
• Hotel-Dieu Grace Hospital
• London Health Sciences Centre
• Niagara Region Public Health Department
• The Ottawa Hospital
• St. Joseph's Health Care, London
• St. Joseph's Health Care, Hamilton

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Best Practice Spotlight Organizations (BPSO)

• 3 Year Partnership
• Multiple BPG Implementation Evaluation of
  impact on clinical/patient, system, nurse
  outcomes
• Process of certification and designation as BPSO

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Best Practice Spotlight Organizations (BPSO)

• BPSOs Have a research commitment
• Out of 13 studies this year, 2 are focusing on
  Falls and Falls Prevention
• Estimating the Cost of Injurious Falls in an
  Acute Care Hospital
• Implementation and Evaluation of RNAO Prevention
  of Falls and Fall Injuries in the Older Adult
  Best Practice Guideline in Three Acute Care
  Ontario Hospitals A Case Study

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Organizational Change Processes

• Standardization
• Change Work Design
• Make it Impossible to Fail
• Engage the Client, staff, family

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Organizational Change Processes

• Standardization
• Routine practices
• Assess all residents fall risk on admission
• Communicate the results of the falls risk
  assessment to the healthcare team and the
  resident and family
• Develop an individualized resident care plan and
  interventions based on the risk assessment.
• Evaluate all residents who are taking more than
  five medications
• Investigate each fall or near fall to identify
  contributing factors and to prevent
  re-occurrence.

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Organizational Change Processes

• Change Work Design
• Develop a corporate policy and procedure for
  falls prevention/reduction and management that
  includes roles and responsibilities of each
  healthcare provider.
• Develop approaches for regular resident safety
  checks.
• Create an environment that supports interventions
  for fall prevention.
• Provide access to supplies and equipment for
  preventing falls and/or signalling high-risk
  situations, to the multidisciplinary team
• Time with residents

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Organizational Change Processes

• Make it harder to fail than succeed
• Clearly identify all residents assessed as at
  risk for falls
• Empower staff
• Learning culture,
• Maxi learning mini time
• Wired for knowledge
• Tailor tools to sector and staff

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Organizational Change Processes

• Engage the Client, staff, family
• Teaching
• Educate all staff on the prevention of falls and
  fall injuries
• Patient teaching
• Implement strength, balance and coordination
  training to increase residents physical
  fitness/strength.
• Educate all residents and families of residents
  who have been assessed as at risk for falling
  regarding their risk status
• Involve the family
• Patient education fact sheets

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Implementation and Sustainability

• Models and Processes
• Individual influencers
• Organizational facilitation
• System Level
• Goal Maximize enablers and overcome barriers

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System Level

• Raising awareness and influencing agendas
• Enacting system change principles developing
  clear policy change recommendations, sufficient
  evidence, coalition partners, advocacy framework
• Targeting professional regulatory bodies,
  existing task forces and advisory groups,
  government, and other civil society organizations
• Informing, engaging and supporting public action.

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From our Experience

• Policy Recommendations
• New roles Long Term Care Best Practice
  Coordinators
• Media Relations
• Engaging the public (e.g., Public Seminars, BPG
  Vignettes, Health Education Fact Sheets)
• Linking with major public health policy
  initiatives (e.g., diabetes)
• Patient Safety Initiative
• Falls Collaborative
• HWE Quality Work life/Quality Care
• Nursing Best Practice Research Unit

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Long Term Care Best Practice Coordinators

• Most of 700 long term care homes are aware of the
  initiative.
• In each region, homes implementing one or more
  RNAO BPGs engaging in other evidence based and
  BPG work.
• Frequently implemented BPGs include
  prevention/management of pressure ulcers, falls
  prevention, management of incontinence/constipatio
  n, delirium/dementia/depression and pain
  management. (note all areas are related to falls)

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Falls Implementation Resources
Available at www.RNAO.org/bestpractices
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Implementation Strategies Research Outcomes

• NBPRU
• VISION
• MANDATE
• MEMBERSHIP
• Call for research projects with CNF

www.npbru.ca
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National Collaborative on Falls in Long-Term Care

• Taking Action Safer Health Care Now! and RNAO
  have partnered to lead a National Breakthrough
  Series Collaborative to reduce falls and injury
  from falls in long-term care facilities across
  Canada by 40

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The Breakthrough Series Collaborative Model
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Sustainability

• Definition
• Continued use of an idea (Anderson 2004)
• Needs to be planned
• Built on implementation activities
• Referencing work of Davies, Edwards, Ploeg,
  Virani, Skelly and Dobbins, 2006

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The Evidence

• Little research on long-term impact.
• The word sustainability found in 2 of 1000
  sources screened for a systematic review of the
  diffusion of innovations in health care
  organizations (Greenhalgh, 2004)
• A kind of bottom line
• many innovations are important only if they
  continue to be used (Rogers, 2003)

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Sustainability Continued use of Best Practices

• There needs to be a clarity and linkages
  (connections) to the organizational vision.
• Needs to be addressed right from the onset
• Change needs to be built into the organizational
  infrastructure
• organizational policies, performance management
  systems, frameworks, quality management
  initiatives, etc.

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Sustainability

• Need to protect the change from knowledge decay
• e.g. through staff turnover, forgetting,
  replacement, etc.
• Practice change should never be imbedded in one
  person or group.
• Protective factors knowledge refreshers,
  continual use, positive feedback, reminder
  systems.
• How else can you sustain best practices in your
  organization?

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Results of Sustained Use of Research Evidence in
Nursing SURE study

• After 3 years 60 of organizations demonstrated
  sustained use of RNAO guidelines
• Most had expanded use of guidelines through more
  guidelines, more partners, interprofessional
  involvement, integration of guidelines

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SURE Results Facilitators of Sustainability

• Leadership, leadership by champions,
  administrative support,
• Ongoing staff education
• Integration into policies and procedures
• Staff engagement and ownership
• Synergy with partners
• Multidisciplinary involvement

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SURE Results Barriers to Sustainability

• Changes in staffing and organizational structure
• Lack of sustained leadership by champions,
• Workload
• Limited ongoing education
• Lack of follow-up and feedback
• Staff resistance
• Limited management commitment or support
• Lack of integration in policies and procedures

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Conclusion

• Best Practice guidelines related to falls
  prevention are clear about what works in practice
  and more and more clinical evidence is available
  daily
• The challenge now is to use this information to
  change practice through standardization, work
  design, creating success and engagement
• This type of care truly has to be recognized as
  quality of life and cost effective health care

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This I Know for Sure!

• Nurses and nursing personnel have to embrace
  prevention of falls as their scope of practice
  and make it happen, not just one day or one week
  or one year but ALL the time!!
• Only then will be have solid, sustained
  implementation of Falls Prevention, injury from
  falls Best Practices for all Canadians

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• Thank you!
• Questions and Discussion