Supporting Best Practice Guideline initiatives at the local unit level

Supporting Best Practice Guideline Initiatives At The Local Unit Level Manager’s Information Booklet Nursing Practice and Education 2020/21 Supporting Best Practice Guideline Initiatives at the Local Unit Level

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Table of Contents

Introduction .............................................................................................................. 2 Best Practice Guideline Funding Process ................................................................ 3 Identifying a BPG Nurse Champion ......................................................................... 5 Identifying a Unit Mentor .......................................................................................... 5 Roles & Responsibilities ........................................................................................... 6 St. Michael’s Hospital Best Practice Spotlight Organization Team Contact Information ............................................................................................................... 9 Quality Improvement & Change Management Resources ....................................... 9 Appendices ............................................................................................................ 10 References ............................................................................................................. 17

Supporting Best Guidelines Initiatives at the Local Unit Level

Introduction This booklet is an information resource for Clinical Leader Managers (CLMs) who are dedicated to providing support and leadership at the local unit level for building evidence based nursing practice through the implementation, evaluation, spread and sustainability of Best Practice Guidelines (BPGs). The booklet provides background and overview regarding St. Michael’s Hospital Best Practice Spotlight Organization designation and the Registered Nurses’ Association of Ontario (RNAO) BPGs. It also provides information on the backfill funding process, identifying a BPG Nurse Champion and Unit Mentor and, roles and responsibilities of the CLM, the BPG Nurse Champion, and the Unit and Nursing Professional Practice Mentors.

Best Practice Spotlight Organization BPSO refers to Best Practice Spotlight Organization, the designation awarded by the RNAO upon successful implementation, evaluation and knowledge translation of established BPGs. The association created its BPG program to provide nurses and healthcare teams with the most up-to-date, comprehensive, best evidence based patient-care and healthy work environment recommendations. RNAO BPG’s are recognized provincially, nationally and internationally (RNAO, 2012).

St. Michael’s Hospital launched its three-year BPSO candidacy journey during Nursing Week 2009 and achieved designation in spring 2012. The hospital joins hundreds of national and international healthcare organizations and academic settings who have achieved BPSO designation.

St. Michael’s is committed to maintaining our BPSO designation by actively engaging staff nurses to take the lead in contributing to the hospital’s evidence based nursing culture. Backfill funding opportunities provide BPG Nurse Champions at the local unit level dedicated time to engage in quality improvement, develop leadership skills and build capacity while facilitating practice improvements and sustaining changes that enhance quality patient care.

Best Practice Guidelines RNAO BPGs are comprehensive evidence based documents that provide tools, resources and recommendations relevant to a specific topic. Clinical BPGs have been developed for older persons, adults, adolescents and children and are focused on health promotion, disease prevention and curative topics. Healthy Work Environment (HWE) BPGs have been developed for topics relevant to supporting healthy work environments for nurses and healthcare teams (RNAO, 2012).

BPGs are implemented based on the specific needs of the organization, practice setting and/or patient/family population. The implementation of a BPG should address one or more of the following objectives (RNAO, 2012): Supporting Best Practice Guideline Initiatives at the Local Unit Level

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To deliver effective care based on current evidence To resolve a concern in the clinical setting (e.g. improved pain management) To achieve excellence in care delivery by meeting or exceeding quality assurance standards To introduce an innovation (e.g. a new test or treatment) To eliminate use of interventions not recognized as best practice To create healthy work environments that enable clinical excellence

When identifying a BPG and recommendations to implement, evaluate and sustain, the CLM/ team should consider the following:  Needs of the local unit identified by staff surveys and/or other forums  Patient and family surveys and/or other forums  Current local and corporate priorities including but not limited to, Unity Health Toronto Corporate Strategic Plan, Unity Health Toronto Quality Improvement Plan (QIP) and Senior Friendly Hospital Strategy.

Best Practice Guideline Funding Process Backfill Funding When funding is available, backfill opportunities may be available for CLMs to identity a staff nurse to step away from direct patient care for a select number of days to enter into a temporary leadership role of BPG Nurse Champion. The BPG Nurse Champion leads local unit implementation, evaluation, spread and sustainability of RNAO BPGs. This may include:  Implementing a new BPG  Evaluating the impact of a previously implemented BPG  Sustaining a previously implemented BPG  Spreading a previously implemented BPG in a local unit to another unit within the same department/program Backfill funding can only be utilized to replace a staff nurse (BPG Nurse Champion) in direct patient care with another staff nurse, allowing them dedicated time to work on a BPG initiative. Funding cannot be used for other purposes.

Scheduling a BPG Nurse Champion: Guidelines BPG Nurse Champions must be scheduled to work on a local unit BPG initiative for a minimum of 4 hours and a maximum of 11.25 hours per scheduled day. The BPG Nurse Champion released from direct patient care to work on their BPG initiative for less than 4 hours will not receive backfill funding for those hours. BPG Nurse Champions should not be working on a BPG initiative during unpaid hours (outside of scheduled BPG initiative days). A staff nurse in a BPG Nurse Champion role should not be scheduled to Supporting Best Practice Guideline Initiatives at the Local Unit Level

work on a BPG initiative on top of working full-time hours. The total number of days dedicated for the BPG Nurse Champion to work on their BPG initiative is dependent on the total amount of funding that was requested by the CLM and approved by Nursing Professional Practice. With the exception of the scheduled Communities of Practice, Nursing Professional Practice will not decide when the BPG Nurse Champion will be scheduled to work on their BPG initiative. The CLM and BPG Nurse Champion will choose dates that meet the needs of the local unit, the BPG Nurse Champion’s schedule and the scope of BPG initiative.

When scheduling the BPG Nurse Champion to work on their BPG initiative consider the following: 

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Schedule the BPG Nurse Champion to work on their BPG initiative once a week or every other week for either 7.5 hours or 11.25 hours, depending on the total amount of funding approved. BPG Nurse Champions may prefer to be scheduled 11.25 hours if 11.25 hour days are their normal work day. Discuss this with the BPG Nurse Champion Schedule the BPG Nurse Champion to work on their BPG initiative on the same day that key stakeholder groups are scheduled to meet or are available (e.g. unit based councils, staff meetings) to allow the BPG Nurse Champion the opportunity to engage with these groups as needed Schedule the BPG Nurse Champion to work on their BPG initiative immediately following the scheduled Communities’ of Practice to allow the BPG Nurse Champion to apply learnings in a timely manner

Receiving Funding A five step funding process has been established to support the application and reimbursement of backfill funding from Nursing Professional Practice to local units.

1. CLMs will submit a BPG Funding Proposal (Appendix A) to Nursing Professional Practice by an established deadline 2. Approvals will be communicated by Nursing Professional Practice to CLMs after the BPG Funding Proposal has been reviewed 3. CLMs will be requested to submit a preliminary midterm RN/BPG Champion Timesheet (Appendix B) to Nursing Professional Practice by an established deadline 4. CLMs will be requested to complete the bottom half of the approved BPG Funding Proposal and submit a final RN/BPG Champion Timesheet to Nursing Professional Practice by an established deadline 5. Prior to the end of fiscal year, Nursing Professional Practice will reimburse the local unit cost center identified on the BPG Funding Proposal in the amount of eligible hours listed on the RN/BPG Champion Timesheet Note: If at any time a CLM determines that they will not utilize the total amount of funds approved, please inform Nursing Professional Practice immediately, through Marta Sliz Supporting Best Practice Guideline Initiatives at the Local Unit Level

(marta.sliz@unityhealth.to), to allow the reallocation of funds to another area that has identified a need.

Identifying a BPG Nurse Champion A BPG Nurse Champion is selected to lead, facilitate and inspire the BPG implementation and evaluation process. A BPG Nurse Champion must be a registered nurse (RN) employed on a full time or part time basis. When identifying a local unit BPG Nurse Champion, consider the following:  Does the individual demonstrate initiative and commitment to best practices in their current role?  Is the individual passionate about the topic, patient population and the potential outcomes that can be achieved?  Does the individual have the ability to lead, coordinate and facilitate an initiative/project?  Does the individual role model positive clinical leadership?

A CLM may choose to use a formal application process to recruit a nurse to be a BPG Nurse Champion in their local unit. The ‘Call’ for Best Practice (BPG) Nurse Champion Applications template can be modified to meet the needs of the local unit (Appendix D).

Depending on restrictions and guidelines due to Covid-19 the 2020/2021 BPG Communities of Practice may be held virtually. The CLM is asked to ensure that their selected BPG Nurse Champion will have access to the following for the duration of their BPG initiative: 1. Computer with a video camera 2. Computer microphone or a phone 3. Zoom accessibility on the designated computer 4. A quiet location to participate in virtual BPG CoPs using Zoom technology BPG Nurse Champions need to be comfortable using technology ((e.g. participating and presenting using Zoom, comfort sharing screen during Zoom meeting).

Identifying a Unit Mentor Unit mentor candidate qualifications:  Understands the nursing/patient care goals at the local unit level  Has/acquires knowledge of the BPG to be implemented  Has practical experience in implementing a BPG using quality improvement methodologies  Has time and availability to mentor the BPG Nurse Champion throughout the duration of the BPG initiative

Supporting Best Practice Guideline Initiatives at the Local Unit Level

A Unit Mentor may be a CLM, Clinical Nurse Educator, Resource Nurse, Clinical Nurse Specialist, Nurse Practitioner, a previous BPG Nurse Champion or a clinician in any role who meets the above criteria.

Roles & Responsibilities Clinical Leader Manager Acts as the Clinical Leader and provides leadership at the local unit level for improving the quality of patient care by:  Developing a BPG Funding Proposal with input from staff and submitting to Nursing Professional Practice by an established deadline  Identifying a BPG Nurse Champion and a Unit Mentor to support the BPG Nurse Champion  Providing leadership and support to local staff, BPG Nurse Champion and Unit Mentor  Establishing regular communication with the BPG Nurse Champion to provide support, feedback and receive updates on initiative progress  Coordinating BPG Nurse Champion to participate in capacity building activities including scheduled BPG Communities of Practice and Nursing Week BPG Sustainability Poster Gallery Walk Event (dates will be provided each year)  Scheduling protected time for the BPG Nurse Champion to attend BPG Communities of Practice and to work on their BPG initiative following the scheduling guidelines outlined above  Assisting and supporting the BPG Nurse Champion to communicate the need, goal, initiative progress and engage staff on the local unit (e.g. providing updates at staff meetings, team building/skill days, bulletin boards, email, posters, flyers) BPG Nurse Champion Collaborates with CLM, Unit Mentor and Nursing Professional Practice Mentor to design/refine, implement and evaluate BPG at local unit level by:  Attending and contributing to BPG Communities of Practice  Utilizing leadership attributes at the local level to drive implementation and evaluation  Providing regular timely information to CLM on BPG initiative progress  Identifying challenges and offering strategies to overcome  Engaging unit colleagues to gain support for BPG implementation and evaluation plan and priorities  Monitoring change and communicating progress to CLM and colleagues using multi-model communication strategies (e.g. one on one meetings, staff meetings, bulletin boards, email, posters)  Developing a sustainability plan with input from CLM, Unit Mentor, colleagues, Nursing Professional Practice Mentor

Supporting Best Practice Guideline Initiatives at the Local Unit Level

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Actively approaching CLM, Unit Mentor and/or Nursing Professional Practice Mentor when assistance is required Preparing a PowerPoint presentation using the template provided by Nursing Professional Practice to share initiative progress at BPG Communities of Practice (date will be provided) Working with CLM to complete the bottom half of BPG Funding Proposal Template to submit to Nursing Professional Practice (date will be provided) Tracking scheduled BPG initiative days/hours using the RN/BPG Champion Timesheet provided and submit to Nursing Professional Practice when requested (date will be provided) Developing a poster to display during Nursing Week’s BPG Sustainability Gallery Walk event (date will be provided) Notifying Marta Sliz in advance if, for any reason, the BPG Nurse Champion is unable to attend a Communities of Practice

Unit Mentor Act as a facilitator and supporter throughout BPG implementation at the local unit level by:  Supporting and championing the BPG initiative at the local unit level  Assisting the BPG Nurse Champion with elements of team building, initiative/project management and change progress  Guiding, coaching and supporting the BPG Nurse Champion to implement their BPG initiative at the local level  Facilitating communication and problem solving between BPG Nurse Champion, CLM and Nursing Professional Practice Mentor regarding any issues that may arise with the initiative  Scheduling routine ‘check-in’ meetings with BPG Nurse Champion to provide support, feedback and receive updates on initiative progress  Assisting and supporting the BPG Nurse Champion to communicate the need, goal and progress through staff engagement (e.g. standing item on staff meeting agenda, team building/skill days, bulletin boards, email, posters, flyers)  Providing assistance, if needed, to the BPG Nurse Champion in preparing a PowerPoint presentation using the template provided from Nursing Professional Practice to share initiative progress at BPG Communities of Practice (date will be provided)  Providing assistance, if needed, to the BPG Nurse Champion in preparing a poster to display during Nursing Week’s BPG Sustainability Gallery Walk event (date will be provided) Nursing Professional Practice Mentor Act as a facilitator to BPG Nurse Champion throughout BPG implementation by:  Providing mentorship to BPG Nurse Champion through BPG Communities of Practice and scheduled one on one meetings as needed  Sharing knowledge and expertise in developing, planning, implementing and evaluating a BPG initiative Supporting Best Practice Guideline Initiatives at the Local Unit Level

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Providing support, guidance and coaching to BPG Nurse Champion and when requested, to CLM and Unit Mentor Providing assistance, if needed, to BPG Nurse Champion in preparing a PowerPoint presentation using the template provided from Nursing Professional Practice to share initiative progress at BPG Communities of Practice Providing assistance, if needed, to the BPG Nurse Champion in preparing a poster to display during Nursing Week’s BPG Sustainability Gallery Walk event

Supporting Best Practice Guideline Initiatives at the Local Unit Level

St. Michael’s Hospital Best Practice Spotlight Organization Team Contact Information Murray Krock Director, Nursing Practice and Education E: murray.krock@unityhealth.to T: 416-864-6060 ext.45514 Susan Beswick Evidence Based Practice Nursing Manager, Professional Practice E: susan.beswick@unityhealth.to T: 416-864-6060 ext. 43831 Marta Sliz Administrative Coordinator, Professional Practice E: marta.sliz@unityhealth.to T: 416-864-6060 ext. 44171

Quality Improvement & Change Management Resources 1. Jeffs, L., Indar, A., Harvey, B., McShane, J., Bookey-Bassett, S., Flintoft, V., & Maione, M. (2016). Enabling Role of Manager in Engaging Clinicians and Staff in Quality Improvement: Being Present and Flexible. Journal of nursing care quality.

2. Kotter, J. P. (1995). Leading change: Why transformation efforts fail. http://www.gsbcolorado.org/uploads/general/PreSessionReadingLeadingChange -John_Kotter.pdf 3. Health Quality Ontario [HQO]. (2012). Quality Improvement Guide http://www.hqontario.ca/portals/0/documents/qi/qi-quality-improve-guide-2012en.pdf 4. Registered Nurses’ Association of Ontario [RNAO]. (2012). Toolkit: Implementation of Best Practice Guidelines (Second Edition) http://rnao.ca/sites/rnao-ca/files/RNAO_ToolKit_2012_rev4_FA.pdf

Supporting Best Practice Guideline Initiatives at the Local Unit Level

Appendices A. 2020/21 Best Practice Guideline (BPG) Funding Proposal Template B. RN/BPG Champion Timesheet C. 2020/21 Best Practice Guideline (BPG) Communities of Practice Schedule D. ‘Call’ for Best Practice Guideline (BPG) Nurse Champion Applications

Supporting Best Practice Guideline Initiatives at the Local Unit Level

Appendix A

2020-21 Best Practice Guideline (BPG) Funding Proposal Template Please complete and send to Marta Sliz marta.sliz@unityhealth.to by September 11th. You will receive notification of approval from Nursing Professional Practice by September 30th. Backfill hours must be documented on the RN/BPG Champion Timesheet provided below and funding must be utilized between October 15th – March 31st 2021. Please complete the bottom half of this form and send it to Marta Sliz along with the RN/BPG Champion Timesheet no later than February 26th 2021 to receive your funding.

1. Funding Request Date 2.

Name of Clinical Department/Area

3.

Name of Clinical Leader/Manager

4.

Name of BPG Nurse Champion

5.

Name of Unit Mentor

6.

Title of BPG Initiative

7.

Title of RNAO BPG (click here to access RNAO BPGs on the SMH intranet)

8.

List RNAO BPG Recommendations Informing/Align with BPG Initiative (refer to BPG for list of recommendations)

9.

Describe BPG Nurse Champion Activities

10. Process and/or Outcome Indicators (identify metrics that will be collected to measure the impact of the initiative on nursing practice and patient care. Example of a process indicator: Clinical documentation compliance of the Falls Prevention SIMPLE tool; Example of an outcome indicator: Number of patient falls)

Supporting Best Guidelines Initiatives at the Local Unit Level

Appendix A 11. Expected Start and Completion Dates (months) 12. BPG Nurse Champion Pay Rate (per hour do not include benefits) 13. Number of BPG Nurse Champion Backfill Hours Required to Complete Initiative 14. Amount of Funding Approved ($)

To Be Completed By Nursing Professional Practice Upon Approval

15. Clinical Department/Area Cost Center Number (to be reimbursed by Nursing Professional Practice) Please complete the bottom half of this form and the RN/BPG Nurse Champion Timesheet below and send it to Marta Sliz marta.sliz@unityhealth.to by February 26th 2021 to receive your backfill funding. Please forecast any hours that will be utilized beyond February 26 th until March 31, 2021.

16. Total Number of Backfill Hours Utilized from October 15th until March 31st 2021 (please ensure the RN/BPG Champion Timesheet is accurate) 17. Initiative Deliverables (up until February 26th 2020) 18. List Initiative Outcomes (as Per Question 10) 19. List Sustainability Strategies 20. Reference and Attach Materials Developed (e.g., nurse and/or patient education materials, nursing practice tools)

Supporting Best Guidelines Initiatives at the Local Unit Level

Appendix B

RN/BPG Champion Timesheet Name of Clinical Department/Area Name of Clinical Leader/Manager Name of BPG Nurse Champion Title of BPG Initiative *Reminder: BPG Nurse Champions must be scheduled to work on a local unit BPG initiative for a minimum of 4 hours and a maximum of 11.25 hours per scheduled day. The BPG Nurse Champion released from direct patient care to work on their BPG initiative for less than 4 hours will not receive backfill funding for those hours.

Date of Activity

Supporting Best Guidelines Initiatives at the Local Unit Level

Description of Activity

Time (specify hours/minutes)

Appendix C

2020/21 Best Practice Guideline Communities of Practice Schedule Date October 15, 2020

Time 0800-1200

October 29,2020 0800-1200 November 12, 2020

0800-1200

December 10, 2020

0800-1200

January 14, 2021 0800-1200 February 11, 2021

0800-1200

March 11, 2021 0800-1200

Agenda Items Introduction to BPSO, Quality Improvement, Model for Improvement, PDSA Utilizing Process Mapping to Promote Change Update from Champions Survey Methods Literature Reviews and Compiling Results Update from Champions Developing and Delivering Education to Support Change Sustainability in QI Update from Champions Change Management: How to Minimize Resistance to Change and Maximize Update that is Sustainable PowerPoint and Poster Templates Update from Champions How to display data graphically and create graphs Champion Presentations Champion Presentations How to develop a Poster Presentation Update from Champions

Supporting Best Guidelines Initiatives at the Local Unit Level

Appendix D

‘Call’ for Best Practice Guideline (BPG) Nurse Champion Applications Nurses deliver knowledgeable care through best practice guidelines

The role of BPG Nurse Champion is to lead, facilitate and inspire the implementation of evidence based best practices in their local unit.

This is an exciting opportunity for nurses to put evidence based practice in action, engage in continuous learning, expand leadership skills & further their professional development through the application of BPGs.

Eligibility  Employed as a registered nurse on a full time or part time basis at St. Michael’s  Passionate about a BPG, patient population and the potential outcomes that can be achieved  Demonstrates initiative and commitment to best practices in their current role  Has the ability to lead, coordinate and facilitate an initiative/project  Role models positive clinical leadership This opportunity supports St. Michael’s Hospital Best Practice Spotlight Organization (BPSO) designation and the hospital’s corporate strategic directions focusing on quality, integration and innovation.

Start Date: October 15th 2020 Length (months): October – March 2021 Total Number of Days: TBD Interested in becoming a BPG Nurse Champion?  Speak to your Clinical Leader Manager [insert name and contact information here]

Appendix D

BPG Nurse Champion Application Form Applications are due: [insert date here]

Date of Application: ______________________________________ Applicant’s Name: _______________________________________ Highest Level of Education Attained: Diploma____ BScN ____ MN or MScN____ Other____ Numbers of Years at St. Michael’s Hospital: _________________ Full-Time: ________Part-Time: ________ Please List: Contributions to St. Michael’s Hospital (i.e. unit based council, nursing rounds, nursing council, function as preceptor for new graduate nurses or nursing students)

Please include the following with your application:  Name and a brief description of why your interested in becoming a BPG Nurse Champion  Brief description of any relevant previous experience and/or education  Current Curriculum Vitae Please submit your completed application to your Clinical Leader Manager [insert name and location] Please Note: All candidates will be advised by email within [insert time frame here] of the application closing.

References Registered Nurses’ Association of Ontario [RNAO]. (2012). Toolkit: Implementation of Best Practice Guidelines (Second Edition). Toronto, ON: Registered Nurses’ Association of Ontario. Retrieved August 11, 2017, from http://rnao.ca/sites/rnaoca/files/RNAO_ToolKit_2012_rev4_FA.pdf

Supporting Best Guidelines Initiatives at the Local Unit Level