LTC illustration
Long-term care (LTC) homes across Ontario support staff to provide best practices in care.
RNAO/Nishant Bajaj
Using evidence to enhance resident care

Imagine you’ve applied to work at a long-term care (LTC) home and have been invited for an in-person interview. You enter the home – excited and nervous. As you enter the building, you see a big sign: Best Practice Spotlight Organization (BPSO). Do you smile knowing what this means and feel confident? Or do you become more nervous of the unknown? 

You’re greeted into a meeting room with the interviewers – the hiring manager, director of care and an unexpected panelist: a resident who lives in the home. The resident asks you about yourself and why you want to work in their home. This may come as a surprise to you, but the home – which is a BPSO – regularly enlists residents to join interviews. They do so because it’s a great way to fulfill their commitment to engage residents in meaningful roles that make them active partners in their care – a recommendation outlined in RNAO’s Person- and Family-Centred Care best practice guideline (BPG).

The home in this example is managed by UniversalCare Canada Inc., the first host* organization in RNAO’s BPSO LTC program, which was established in 2014. The program, supported by 14 expert LTC best practices implementation coaches (formerly known as LTC best practice co-ordinators), sets the gold standard for resident care in the province. LTC BPSOs are coached on how to improve the knowledge, skills and practices of dedicated staff in the sector. This includes support with the implementation of mandatory BPGs, such as the one noted above, and any other RNAO BPGs that are relevant to their organizational needs. 

According to Carol Holmes, RNAO’s retired LTC program manager, many homes didn’t initially join the BPSO program due to strained human and financial resources. Another challenge was that BPSO requirements were not specific enough for resident care. Instead, LTC homes engaged with one of RNAO’s LTC implementation coaches without a formal commitment to the BPSO program. Being responsive to the needs of staff and residents in LTC, RNAO CEO Dr. Doris Grinspun charged Holmes and Heather McConnell, then associate director for the International Affairs and Best Practice Guidelines (IABPG) Centre, to revise the general criteria of BPSOs to better support LTC homes. 

“We wanted to support (LTC homes) in their work to move forward with formal guideline implementation. We held meetings, got input and put together recommendations for creating a specific path for LTC homes to become BPSOs,” Holmes shares. “As experience shows, once we developed the program to meet their needs, homes came onboard.” 

Carol Holmes, former LTC program manager for RNAO, welcomes the first cohort of LTC-BPSOs during the launch of the program in 2014.

When the BPSO LTC program was first introduced almost 10 years ago, RNAO welcomed four organizations: Parkview Manor in Chesley, Vision Nursing Home in Sarnia, Hamilton’s St. Peter’s Residence at Chedoke, and homes in the Region of Peel. Revised resources, including RNAO’s LTC Best Practices Toolkit, webinars and monthly knowledge exchanges were launched to support homes in their quest to become a BPSO (typically a three-year process). This first cohort graduated at RNAO’s 2017 Annual General Meeting, with other cohorts graduating every year since. 

Braemar Retirement Centre receives BPSO designation at RNAO's AGM in June 2023.

Veronica George is a quality improvement RN and the BPSO lead at Braemar Retirement Centre in Wingham, one of the newest BPSO LTC designates to graduate in 2023. Braemar is home to approximately 50 residents and has seen “great success” implementing the falls prevention BPG, despite the COVID-19 pandemic. Staff members were eager to adopt RNAO’s recommendations related to falls prevention. “I didn’t receive a lot of push back because they knew it was for resident safety and care,” George says. 

Sue Sweeney, RNAO’s BPSO LTC program manager and Braemar’s LTC coach, notes the home’s impressive dedication to guideline implementation during the pandemic. “Their staff were so engaged about the work and improving the quality of care, so even when there were challenges with COVID, someone else would pick up the ball and keep it going,” she says. “They all had a shared goal to improve quality of care for their residents, families and staff.”

Braemar increased its safety interventions for residents and introduced RNAO’s recommended “falling stars” initiative to identify residents at high risk for falls. George and her team attach images of stars to resident equipment, such as wheelchairs and walkers, to draw attention to fall risks. They also have star-themed magnets above residents’ beds with transfer instructions to prevent falls. “This is an easy indicator for new staff coming onto the floor to identify residents in need of extra attention,” George says, highlighting the home’s very purposeful approach to maintaining the BPGs introduced in the home.

After implementing the Preventing Falls and Reducing Injury from Falls BPG, Braemar has seen a 75.2 per cent decrease in falls-related injuries and a 100 per cent improvement in falls risk screening. You can read more about the outcomes of Braemar’s BPSO work in the Evidence Booster** that was published in January 2022. 

Veronica George shows an example of one of the falling stars magnets used to identify residents at high risk of falls in the LTC home.

In addition to improving residents’ experiences and outcomes, George says BPG implementation has boosted staff morale by improving the practice, acceptance and energy levels within the home. It’s also motivating to know the management team and owners of the home support an evidence-based culture, she adds.

Becoming a BPSO has given staff “…confidence in themselves,” says Archie MacGowan, Braemar’s owner. “Joining BPSO has really raised our level of care.” 

As a BPSO LTC host, UniversalCare has standardized its approach to BPG implementation with tools and resources to ensure staff across its 10 homes feel supported and empowered to enact change. RN Sara Ryan, the organization’s director of clinical services and BPSO host coach, is no stranger to implementing BPGs. Before taking on her current role, she worked at Chatham-Kent’s Tilbury Manor, a BPSO designate that is now managed by UniversalCare. Using her knowledge of conducting gap analyses, developing action plans and improving the leadership within interprofessional teams, Ryan supports UniversalCare’s homes as they apply BPGs that meet legislative requirements. 

Sara Ryan

Ryan also understands the importance of recognizing each home has specific needs. “Because our homes have implemented the Person- and Family-Centred Care BPG, they’ve come up with innovative ways of making their specific organizations more resident- and family-centred,” she says. Whether that’s having family members join committees or hosting events for residents, evidence-based care is like a tiny seed that we’ve planted and then we watch it grow, Ryan notes. BPSO work has fostered more enthusiasm and initiative in staff to continuously think about what else they can do to enhance resident care, she adds.

Mackenzie Health in Richmond Hill, which is also managed by UniversalCare, graduated as a BPSO LTC in 2023. NP Clara Nisan, its director of clinical care services and BPSO lead, says implementing RNAO BPGs gave the home “focus and structure,” boosting staff confidence in the care being provided. Mackenzie Health has about 60 champions in different areas (e.g., assessment and pain management, palliative approaches to care, and end-of-life care), and Nisan says she is proud of their interprofessional team’s relationship: “Everyone is on the same page…and understands (the care and processes are) evidence-based.” 

Clara Nisan

Nisan says graduating as a BPSO LTC “is a huge achievement,” and she commends RNAO’s LTC implementation coaches for their ongoing support. This dedicated team of experienced leaders in LTC welcome pre-designates annually, and ensure the program’s resources and supports meet homes’ needs to set them up for success. 

“I’ve seen significant changes in organizations that utilize BPGs, and staff feel empowered knowing they’re doing the right thing,” says Sweeney. “I often tell homes, BPGs aren’t an add on; they’re a tool to enhance the work you’re already doing. I find homes have much more success when BPGs become part of their everyday culture.”

At Braemar, George says their BPSO designation certificate is hung at the home’s entrance, right beside their popular fish tank. When residents and their families are looking at the fish, they’ll see the plaque too. It’s a symbol of the home’s dedication to resident-centred care. “Being designated is a great achievement that is beyond words,” says George. 

Braemar's certificate of BPSO designation hangs on the wall beside its fish tank for its residents and visitors to see.

“It’s a great feeling to go through the three years, implement so much, be recognized for what we did and see that residents are happy.”

A call for proposals for the next cohort closed Dec. 4, 2023, and selected BPSOs can expect to graduate in 2027 if they fulfill all the requirements.

RNAO releases a request for proposals annually.

*BPSO hosts run the program in their respective countries, regions or specialty areas using RNAO’s methodologies and materials. They report their progress to RNAO and receive continuous coaching.

**Evidence Boosters are published on an ongoing basis by RNAO’s research unit. Find out more about the unit’s monitoring and evaluation work online.  

The pathway to simpler BPG implementation and evaluation 

How do long-term care (LTC) homes improve the quality of care they deliver, embed evidence-based practices into electronic medical records and ensure legislative and regulatory compliance? 

They use RNAO Clinical Pathways. 

Approximately one-third of Ontario’s more than 600 LTC homes have already implemented RNAO Clinical Pathways, including Braemar Retirement Centre and UniversalCare Canada. And “there are many more in the queue that want to gain access to these evidence-based resources,” says Rita Wilson, eHealth program manager for RNAO and the staff lead for the program, which is delivered in partnership with PointClickCare, a global leader in electronic medical record systems for senior care. 

RNAO Clinical Pathways are based on BPG recommendations and “this means every home that adopts this tool is providing evidence-based, resident-centred care in accordance with the Fixing Long-Term Care Act,” says Wilson proudly. “These homes are improving the health outcomes of their residents.”

During RNAO’s annual Queen’s Park Day in March 2023, then minister of LTC Paul Calandra said: “Critical to strengthening our long-term care system is ensuring nurses have quick and convenient access to up-to-date sector-based practices.” Calandra announced the government’s intention to extend funding of the program, with the aim of building future success stories, similar to the ones featured in the Summer-Fall 2022 issue of RNJ

In September, during a stop at RNAO’s 18th annual BPSO Symposium, the current minister of LTC – Stan Cho – reiterated the government’s support for the program: “As we move forward with record spending…we need to make sure we are consulting with the experts to make sure the resources (spending) goes to the right place,” he said. “The Clinical Pathways program is a great example (of good spending). I’m going to be travelling the world and…I’m going to say proudly: ‘Look at this program we have here in Ontario.’” 

As a former director of care and administrator at an Ontario LTC home, Janet Chee, who is now RNAO’s associate director for the LTC Best Practices Program, says she wouldn’t think twice about implementing RNAO Clinical Pathways. 

“Regardless of whether you’re a brand-new grad or a really experienced nurse, RNAO Clinical Pathways can help improve care for residents,” Chee says. This is especially true right now because nurses are “feeling burnt out and overwhelmed with new legislation, policies and a growing body of evidence. Clinical pathways help them to standardize their practice in a consistent way so that regardless of the situation, the unit or the organization, they’re implementing evidence-based practice.” 

Learn more about RNAO Clinical Pathways on RNAO’s website

Shaila Aranha is one of the many LTC best practices implementation coaches who shows support for homes in person and online.
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