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Transforming Nursing Through

Knowledge: An Overview Of the IABPG Centre, RNAO

November 1, 2016

PHO Grand Rounds Dr. Irmajean Bajnok, Director, International Affairs and Best Practice Guideline (IABPG) Centre, RNAO

Dr. Michelle Rey, Associate Director, Guideline Development, IABPG Centre, RNAO

Ms. Heather McConnell, Associate Director, Guideline Implementation, IABPG Centre, RNAO

Dr. Yaw Owusu, Associate Director, Research and Evaluation, IABPG Centre, RNAO

1

Presentation Outline

• Introduction of the Registered Nurses' Association of Ontario

• Overview of the Best Practice Guidelines (BPG) Program

• BPG Development

• BPG Implementation

• Best Practice Spotlight Organization Designation (BPSO®)

• Research and Evaluation

• NQuIRE ® • Opportunity for questions and discussion

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3

RNAO is the professional association of Registered Nurses, Nurse Practitioners and

nursing students in Ontario, Canada

The strong, credible voice leading the nursing profession to influence and promote healthy public policy, and clinical excellence

The Best Practice Guidelines is a signature program of RNAO

Professional association of Registered Nurses, Nurse Practitioners and nursing students in Ontario, Canada

RNAO ENDs Engage with RNs and nursing

students to stimulate membership

Advance the role and image of nurses

Speak out on emerging issues

Influence healthy public policy

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2

3

4

4

RNAO Best Practice Guideline Program

Funded by the Ontario, Canada Ministry of

Health and Long-term Care since 1999 to:

Develop, disseminate, and actively

support the uptake of evidence-based

clinical & healthy work environment best

practice guidelines and to evaluate their

impact in patient/organizational and health

system outcomes. 5

6 RNAO Best Practice Guideline Program

Overall Model of the Best Practices Guideline Program

Goals of the BPG Program

Improve health care

• Reduce the variation in care

• Transfer research evidence into practice

• Convey the knowledge base of nursing

• Assist with clinical decision making

• Identify gaps in research

• Stop interventions that have little effect or cause harm

• Reduce cost

7

Our VISION:

To Transform Nursing Through Knowledge

Locally, Nationally and Internationally!

8

9 RNAO Best Practice Guideline Program

Best Practice Guidelines are

They must be credible:

AGREE II Standards

Visit: http://www.agreetrust.org/resource-centre/agree-ii/

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AGREE II Appraisal of Guidelines for REsearch & Evaluation II

• Developed to address the issue of variability in guideline

quality.

• Purpose:

1. assess the quality of guidelines;

2. provide a methodological strategy for the

development of guidelines; and

3. inform what information and how information ought to

be reported in guidelines.

11

Brouwers M, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, Fervers B, Graham ID, Grimshaw J, Hanna S,

Littlejohns P, Makarski J, Zitzelsberger L for the AGREE Next Steps Consortium. AGREE II: Advancing guideline development,

reporting and evaluation in healthcare. Can Med Assoc J. 2010. Available online July 5, 2010. doi:10.1503/cmaj.090449

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Nursing Best Practice Guidelines is a signature

program of the RNAO

Clinical Guideline Recommendation Types

Practice

Recommendations

Education

Recommendations

Organization

& Policy

Recommendations

What the professional needs to do

What the professional needs to know

What the Organization needs to create an Evidence Based Culture

13

42 Clinical

Best

Practice

Guidelines ** in development

• Facilitating Client Centred Learning

• Person- and Family-Centred Care

• Establishing Therapeutic Relationships

• Supporting and Strengthening Families through expected and unexpected life events

• Transitions in Care

• Digital Health

Foundational

• Breastfeeding Best Practice guidelines for Nurses

• Interventions for Postpartum Depression**

• Primary Prevention of Childhood Obesity

• Promoting Asthma Control in Children

• Enhancing Healthy Adolescent Development

• Women Abuse: Screening, Identification and Initial Response

• Promoting Safe Sleep in Infants

Women and Children

• Engaging Clients Who Use Substances

• Integrating Smoking Cessation into Daily Practice

• Supporting Clients on Methadone Maintenance Therapy

• Assessment and Care of Adults at Risk for Suicidal Ideation and Behaviour

• Crisis Intervention

Addictions and Mental

Health

14

42 Clinical

Best

Practice

Guidelines

• Risk Assessment and Prevention of Pressure Ulcers

• Assessment and Management of Pressure Injuries for the Interprofessional Team

• Assessment and Management of Venous Leg Ulcers

• Assessment and Device Selection for Vascular Access

• Care and Maintenance to Reduce Vascular Access Complications

• End-of Life Care During the Last Days and Hours

• Assessment and Management of Pain

• Oral Health: Nursing Assessment and Intervention

• Promoting Safety: Alternative Approaches to the Use of Restraints

Clinical Management

•Promoting Continence Using Prompted Voiding

• Prevention of Constipation in the Older Adult Population

• Prevention of Falls and Fall Injuries in the Older Adult

• Elder Abuse

•Delirium, Dementia and Depression in Older Adults: Assessment and Care

Older Persons

•Ostomy Care and Management

•Strategies to Support Self-Management in Chronic Conditions with Clients

•Decision Support for Adults Living with Chronic Kidney Disease

•Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with COPD

•Nursing Management of Hypertension

•Subcutaneous Administration of Insulin in Adults with Type 2 Diabetes

•Reducing Foot Complications for People with Diabetes

•Assessment & Management of Foot Ulcers for People with Diabetes

•Stroke Assessment Across the Continuum of Care

•Adult Asthma Care: Promoting Control of Asthma

Chronic Diseases

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Individual/Team

Recommendations

Education

Recommendations

Organization

& Policy

Recommendations

HWE Guideline Recommendations

What the

Nurse/Team

needs to do What the

Nurse/Team

needs to know

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System and Healthy Work Environment BPGs 1. Intra-professional Collaborative

Practice among Nurses, 2nd edition

NEW

2. Developing and Sustaining Effective

Staffing and Workload Practices *

3. Developing and Sustaining

Interprofessional Health Care:

Optimizing patients/clients,

organizational, and system outcomes

4. Developing and Sustaining Nursing

Leadership, 2nd edition

5. Embracing Cultural Diversity in Health

Care: Developing Cultural Competence

6. Managing and Mitigating Conflict in

Health-care Teams

7. Preventing and Managing Violence in

the Workplace

8. Preventing and Mitigating Nurse Fatigue

in Health Care

9. Professionalism in Nursing

10.Workplace Health, Safety and Well-being

of the Nurse Guideline

Education Focus

1. Practice Education in Nursing, NEW

* In development 17

6 steps for BPG Development

18

Development of an RNAO Guideline Involves

• Leadership by nurse researchers in defining

research questions, and conducting systematic

reviews

• A project coordinator

• A health librarian

• Critical Review by an Expert Panel

• Stakeholder Reviewers

• Editor & Publisher

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BPG development involves 6 steps

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1. RNAO selects a topic

– Revision of older BPGs (5-year cycle)

– New BPGs

• Submissions from members and external

stakeholders (e.g. LGBTQ)

• Policy/government influences (e.g. Elder abuse &

Obesity)

• Literature search for trends and practice concerns

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2. A panel of experts • Panel members:

– experts in the topic area

– represent different healthcare sectors (LTC, hospital, etc.)

– represent different backgrounds (clinical, academia/research,

policy, and people with lived experience

– different geographic areas within Ontario, Canada, International

– Multidisciplinary (nurses (>50%), physicians, etc.)

– Two co-chairs (one is a nurse researcher)

• Review purpose, scope and research questions

• Research questions:

• 2 Practice (nursing process AP,IE)

• Provider education and training

• Organizational support

3. Systematic Review

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3. The Nursing Research Associates

(NRA) conduct the systematic review

Narrative Summaries

Data Extraction

Quality Appraisal

Relevance Review

Title and Abstract Screen

Literature Search

Recommendation statements

Research

Questions (4)

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Rigorous Methodology of BPG

Development

Draft guideline

Refine Recommendations

In-person discussion

Draft Recommendations

Narrative Summaries

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26

Publication Editorial review

Stakeholder review

5. BPG drafts undergo an extensive

review process prior to publication

5. Stakeholder Review

• List of stakeholders:

– Suggestions from the panel

– Experts not available

– Leading organizations

– Open application online

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6. BPGs are published in hard copy & online

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Knowledge and Implementation Products

• A Patient Education Fact Sheet to guide

patients and help with health teaching related to

the BPG

• Nursing Order Sets which provide clear,

specific nursing interventions based on the

evidence & recommendations

• Structural indicators (generic to all BPGs),

and BPG specific process, & outcome

indicators to help direct monitoring and

evaluation that can be utilized to enter data into

RNAO’s data system-NQuIRE.

29

30 RNAO Best Practice Guideline Program

A Look at Knowledge Transfer and Guideline

Implementation

RNAO’s Framework for Guideline

Implementation

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RNAO Toolkit:

"Implementation of Clinical

Practice Guidelines (2nd

Edition)" is an evidence

based guide for a systematic

approach to BPG

implementation.

– Available for free

download www.RNAO.ca

– English and French 31

RNAO's BPG Implementation

Methodology – Individual Level

• Champion Network®

• ACPF

• Nursing Order Sets

• BPG APP

• RNAO Communities

• Professional Development

– Organizational Level

• Best Practice Spotlight

Organization® Designation

– System Level

• Implementation Projects

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RNAO Best Practice Champion Network

– RNAO has prepared thousands of Champions in a range of sectors, provincially, nationally and internationally:

• Best Practice Champions

• Long-Term Care

• Smoking Cessation

• eHealth

• Addictions and Mental Health

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A collective force that influences knowledge transfer

and uptake of best practice guidelines

33

• A knowledge translation tool to embed the

clinical Best Practice Guidelines within electronic

health information systems or paper-based

environments.

• Provides content for clinical decision support

logic to trigger interventions based on specific

parameters and generate alerts/reminders to

enhance patient/client/resident safety and aid

decision-making at the point of care.

• Coded to International Classification for Nursing

Practice (ICNP) Standardized Nursing

Language

• Accredited ICNP Research & Development

Centre

Nursing Order Sets

34

BPG APPS

• Through access to over 50 clinical

and healthy work environment

RNAO BPGs obtain

• Nursing knowledge where you are

• Nursing knowledge when you need it

• Nursing knowledge at the point of

care

• Launched at RNAO AGM, May 6,

2016

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RNAO Communities • This free professional

networking site has

been developed to

support networking,

communication and

sharing of resources

between nurses who

are implementing, or

interested in

implementing, clinical

or healthy work

environment

guidelines.

36

Professional Development

• Institute are generally

– 3-5 days long

– all inclusive

– focused on an integrated curriculum including theory, application and small group work

– targeted to participants to assist them lead implementation programs in specific topic areas

• Topic areas include:

RNAO’s signature approach to professional development for nurses and others to enable uptake of knowledge and skills in key areas

related to guideline implementation

• BPG implementation- foundational and advanced

• Healthy work environments • Mental health and addiction • Executive Leadership

• Primary care • Chronic disease prevention

and management • Wound care foundational and

advanced www.RNAO.ca/events

37

Professional Development

• Workshops

• One or two day workshops to develop knowledge

and skills in specific guideline content areas

• Webinars- Free of Charge

• Strategy to launch new/revised guidelines and

related implementation tools – marketed

nationally and internationally.

38

RNAO's BPG Implementation

Methodology

– Individual Level

• Champion Network®

• ACPF

• Nursing Order Sets

• BPG APPS

• RNAO Communities

• Professional Development

– Organizational Level

• Best Practice Spotlight Organization® Designation

– System Level

• Implementation Projects

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Organizational Implementation

Key Strategy

Best Practice Spotlight Organizations® (BPSO®)

Goal

To influence the uptake of best practice guidelines across all health care organizations, to enable practice excellence and positive client outcomes

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Best Practice Spotlight Organization®

• Application process and formal partnership with BPSO

• Specific requirements re:

– Systematic guideline implementation

– Infrastructure

– Reporting

– Knowledge exchange

– Sustainability planning

– Measuring outcomes through use of standard indicators

• Designated BPSO: sustained use, expansion, spread, and mentoring opportunities

41

Organizations partner with RNAO to implement multiple clinical

BPGs over a 3 Year period and attain the BPSO Designation

Types of BPSOs

Service BPSOs: focus on evidence based practice to impact client outcomes

Hospital, home care, public health, primary care

Tailored BPSOs for Long Term Care Settings

Academic BPSOs: focus on evidence based nursing education, to impact student learning, and client outcomes

42

Two Models of BPSO® BPSO Direct: Organization develops a contract directly

with RNAO to work for a 3 year period to become a BPSO

Designate, and as a Designate continues the relationship

with RNAO

BPSO Host: Organization (BPSO Host) develops a

contract with RNAO to oversee the BPSO Designation in

their jurisdiction. Will work with RNAO as they provide

support to enable organizations in their jurisdiction to apply

and work to become BPSO Designates, and as a designate

continues the relationship with the BPSO Host.

43

90 BPSOs Direct and 4 BPSO Hosts

representing over

500 Health-care and Academic

Organizations

In

Progress

Portugal

In

Progress

Malawi

In

Progress

Uruguay

In Progress

Chile as

BPSO Host

BPSO

HOST

44

Successes: • Thousands of nurses involved in

impacting the care and outcomes of

millions of clients

• Guidelines with greatest impact on

client outcomes – Falls, Client Centred Care, Pain, Stage IV Pressure

Ulcers, Smoking Cessation

• Guidelines with greatest impact on

practice – Falls, Pain, Breastfeeding, Client Centred Care,

Smoking Cessation

• Key sustainability strategies – Staff education, evidence-based policy dev., quality

improvement activities, integration of best practices

into doc. systems, orientation for new staff.

• Client outcomes and economic

results BPSO Survey 2014-2015 45

46

BPSOs Leading the Way to Quality

Care

Best Practice Guidelines

Implementation Science

Peer Support

Nursing Order Sets to guide assessment and

Intervention

NQuIRE for Measurement and Evaluation

A BPSO Host Model that enables world wide

spread

RNAO's BPG Implementation

Methodology

– Individual Level

• Champion Network®

• ACPF

• Nursing Order Sets

• BPG APPS

• RNAO Communities

• Professional Development

– Organizational Level

• Best Practice Spotlight Organization® Designation

– System Level

• Implementation Projects

47

Systems Level Strategies -

Provincial

Specific projects and initiatives at the provincial level that are based on

implementation of RNAO BPGs such as:

• Smoking Cessation BPG, Provincial Project;

• The Long-Term Care Best Practices Program across Ontario to

support implementation of BPGs in long-term care settings

• Mental Health and Addiction Initiative, is a Provincial Project and

includes a national initiative focused on developing a faculty

education resource to integrate mental health and addictions in the

undergraduate nursing curriculum in collaboration with CASN

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Systems Level Strategies - National

• Falls BPG – RNAO is the national lead for the Safer

Healthcare Now! Falls Prevention Intervention for the

Canadian Patient Safety Institute

• Peer Leader Project – Canada Health Infoway

• Digital Health BPG – Development of a guideline

focusing on the integration of digital health, in partnership

with Canada Health Infoway

•Collaborative call for Commissioned Research 2016-

2017 featuring RNAOs Person and Family Centred Care

and the Care Transitions BPGs with CPSI and other

collaborators

Specific projects and initiatives at the national level that are based on

implementation of RNAO BPGs include the:

49

50 RNAO Best Practice Guideline Program

A Look at Research and Evaluation - NQuIRE

Research and Evaluation

51

NURSING QUALITY INDICATORS FOR

REPORTING AND EVALUATION

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Vision of NQuIRE

• “To develop a robust data system for reporting,

monitoring and research that demonstrates how

evidence based nursing practice improves health

outcomes. As the data system expands, it will

impact practice, management and policy

decisions, education and health system

research.”

53

What is NQuIRE®

• Nursing Quality Indicators for Reporting and Evaluation®

– Launched August 2012 (90% of BPSOs participating)

• A data system of quality indicators derived from the

practice recommendations within RNAO’s BPGs

– Collects, analyzes and reports comparative data

(quarterly) on indicators reflecting the structure,

process and outcomes of care arising from BPG

implementation

• Utilized by Best Practice Spotlight Organizations®

(BPSO®)

• International Advisory Council

54

NQuIRE: uses web-based user interface and database storage system

• NQuIRE reports

NQuIRE

storage

55

What does NQuIRE measure?

• 6 structural indicators across all BPGs: nursing

intensity, skill mix, absenteeism, turnover,

educational preparation, and model of care

delivery

• 4 to 8 process and outcome quality indicators based

on the practice recommendations in our BPGs

– Nursing-sensitive indicators unique to each BPG

• Measured nationally and internationally across

different health sectors

• Collected monthly within BPSO organizations 56

Some NQuIRE indicators • Falls prevention

• Pressure ulcer prevention

• Stroke assessment

• Pain management

• Breastfeeding

• Foot ulcers

• Ostomy care

• Client centred care

• Self-management

• Foot complications

• Stage I to IV pressure ulcers

• Hypertension

• Delirium, dementia & depression

screening

• Smoking cessation

• Continence

• Constipation

• Oral health

• Chronic obstructive pulmonary

disease

• Supporting & strengthening families

Access to Data Dictionaries that provide standardized

indictors for ALL BPSOs to help with comparisons 57

NQuIRE Participation: Key

Activities

• Data agreement

• BPSO Lead account registration

• Organization profile

• Indicator selection

1. BPSO Enrollment

• Implementation Site USER account registration

• Site profile

• Indicator selection

2. Implementation

Site Registration

• Baseline data

• Monthly data

• Quarterly submissions

3. Data Submission

• Internal comparative data

• BPSO peer group comparative data

4. Reports

58

Collaboration with BPSOs in all sectors

NQuIRE®

Primary Care

Public Health

Home Care

Long- term Care

Hospital Care

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Think of the Bird as BPSO carrying the NQuIRE indicators

• BPSOs & NQuIRE taken off

• Tremendous global impact and proudly your BPSO is part of this new frontier for nursing

• Your contribution

– Provide reliable data

– Engage in indicator validation process

– Feedback on data dictionaries

– BPSO reports

– BPSO Dashboard

– NQ website enhancements

– NQ excel import template

NQuIRE®

BPSOs

RNAO’s BPG Program

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*all reports are interactive and customizable

1. Single indicator reports:

– Single indicator trend report

– Indicator comparisons across the organization

2. Indicator overlay reports:

– Comparing one indicator to another within one

Site in the organization

3. Immediate future

– Investigate degrees of associations between

indicators

Types of NQuIRE Reports*

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Types of reports – single indicator

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Types of reports - indicator overlay

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Annotation feature for NQuIRE reports

BPSOs now have the ability to:

- Select from a drop-down list or select ‘other’

- Have annotations appear on their graph

- Provide notes which will appear at the bottom of tables

- Capture additional details which will provide context for their data

64

BPSO Dashboard

• Customizable BPSO Dashboards

• Launched December 1st, 2015

• Easily share data within your organization

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Membership

• 132 individual members

• 45 organizational members

• RNAO - Guidelines International Network Membership

Research and Network and

Capacity Building Activity

• 235 research studies/projects

• 371 publications

• Over 20 decision maker researcher sessions and educational events

Annual General Meeting

• NBPRC hosted its third AGM (March 9, 2016)

Nursing Best Practice Research Centre

Centre de recherche sur les pratiques

exemplaires en soins infirmiers

Annual Report 2013-2014

Nursing Best Practice Research Centre

Advancing care through knowledge

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• RNAO BPGs translated into 8 different languages

• BPGs freely accessible on the web site, and used globally

• BPGs Impacting care in nations all around the world through internationally recognized BPSO Designation spanning Canada and in 10 countries

• NQuIRE and Nursing Order sets gaining international attention and acclaim

• RNAO Recognized as an ICNP Research & Development Centre

RNAO's International Reach Through

BPG Program

Questions

&

Discussion

68