Baycrest Health Sciences enhanced pressure injury prevention through structured, team-based integration of RNAO guidelines, supported by the Advanced Clinical Practice Fellowship (ACPF). Using frameworks such as Leading Change, Social Movement Action, and Knowledge-to-Action, the organization conducted gap analyses, engaged stakeholders, updated policies and training, and developed educational resources.
Key achievements included:
- Culture of Continuous Improvement: Increased frontline engagement and sustainability through ACPF activities.
- Staff Capacity Building: Trained 51 nurses and 8 new hires, developed presentations, communication tools, and gamified learning.
- Strengthened Quality Improvement: Aligned documentation and practices with updated guidelines, using unit-specific data to target interventions.
- Knowledge Translation: Expanded Pressure Injury Champions, promoted BPSO certification, and provided accessible educational materials.
- Sustainability: Embedded best practices into ongoing education and organizational culture.
Overall, the initiative demonstrates Baycrest’s commitment to evidence-informed practice, interprofessional collaboration, and continuous improvement in outcomes for older adults.
Submission for Day 3: Evaluation, Outcomes & Impact of BPSO and BPG implementation
Introduction:
With the release of RNAO’s Pressure Injury Prevention and Management: Risk Assessment, Prevention, and Treatment (4th edition) in 2024, Baycrest Hospital undertook a comprehensive review of the updated guideline to ensure organizational alignment and integration into our existing clinical practices.. As part of this process, we evaluated our current Pressure Injury Championship Program and annual quality improvement priorities to sustain a strong knowledge-to-action translation of the guideline’s evidenced based recommendations. This review supports Baycrest’s commitment to delivering high-quality, person-centered care for older adults, while maintaining alignment with Best Practice Spotlight Organization (BPSO) standards and advancing a culture of continuous quality improvement.
Methodology
To support implementation of the updated RNAO Pressure Injury Prevention and Management guideline, Baycrest Hospital initiated structured interdisciplinary review process was initiated. An interprofessional team conducted a gap analysis, comparing existing organizational practices against the updated recommendations to identify opportunities for enhancement. Feedback was gathered from the clinical management team, Pressure Injury Best Practice champions, frontline staff, and quality improvement leads through a variety of forums such as team huddles, multiple different means. Data from audits and patient outcomes were analyzed to identify areas needing change. The revised practices were then incorporated into a twice/year pressure injury champions educational program. We ensure direct practice tips by having 1 on 1 staff hands-on support in assessment, use of clinical tools, and documentation processes. Ongoing monitoring and evaluation were also reviewed to ensure sustainability and continuous improvement.
Result:
By embracing the Leading Change Framework, Social Movement Action Framework, and Knowledge-to-Action Framework, Baycrest continues to thrive through fostered a culture of continuous improvement, frontline engagement, and sustainable practice change. Our Pressure Injury Championship program is a prime example of how these frameworks guided the organization in mobilizing changes, aligning strategic priorities, and translating evidence into action, resulting in enhanced clinical outcomes and strengthened staff capacity across the organization.
Conclusion
Through its long-standing partnership with RNAO and commitment to evidence-based practice, Baycrest has demonstrated sustained success as a Best Practice Spotlight (BPSO®). The integration of the Leading Change Framework, Social Movement Action Framework, and Knowledge-to-Action Framework has been instrumental in driving meaningful and lasting improvements in care. By fostering a culture of collaboration, innovation, and continuous learning, Baycrest continues to enhance health outcomes and lead system-wide change in clinical excellence.
| Attachment | Size |
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| BPSO GLOBAL SUMMIT Sept 2025VRM1.pdf (958.22 KB) | 958.22 KB |
