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Table 3 Description of spread process sites 1 and 2

From: Spreading and sustaining best practices for home care of older adults: a grounded theory study

Site 1 Site 2
Background Background
This accredited for-profit agency provides home care services in urban, rural, and remote communities throughout Ontario, Canada. There are ten geographically dispersed branch offices. The team includes nurses, rehabilitation therapists, and community support workers who deliver a broad range of services including chronic illness management, nutrition, physiotherapy, personal grooming and support, palliative care, and relief for caregivers. This accredited agency is a Community Care Access Centre (CCAC), 1 of 14 operating in Ontario, and funded by the Ministry of Health and Long-Term Care. CCACs provide a first point of contact for public access to government-funded home care, community services, and long-term care homes. This organization has five geographically dispersed branches. The CCAC’s care coordinators provide coordination services in home and hospital settings and include services related to older adults, palliative care, pediatric care, rural health care, and information and referral. CCACs provide funding to community agencies that deliver nursing, rehabilitation, and other services in the home.
Committing to change Committing to change
Site 1 became a Registered Nurses’ Association of Ontario Best Practice Spotlight Organization in 2009, some years before the start of the pain spread initiative. This involved a commitment to implement and evaluate four best practice guidelines over a 3-year period. The project lead, who was a manager, received a fellowship that enabled her to focus on developing leadership and skills related to chronic pain best practices. Her passion about this topic and guidelines in general led to discussions with senior leadership and a decision to pursue the implementation and spread of the pain assessment and management guideline. A steering committee composed of frontline staff, champions, managers, and the project lead was established to lead the process of developing and implementing a tool related to pain. Using the RNAO guideline on assessment and management of pain as a basis, a tool was developed to support the assessment and management of pain for home care clients. The three-page tool included a detailed assessment of pain characteristics and assessment findings, client goals, and resources. The tool also included a pain assessment and management flow sheet that addressed use of medications and alternative pain management strategies, client reports of impact of the intervention, and side effects of treatment. The steering committee held workshops with frontline staff and champions to present the tool and obtain feedback prior to its implementation. This preliminary feedback was used to make some minor revisions to the tool. Site 2 became a Registered Nurses’ Association of Ontario Best Practice Spotlight Organization in 2009. This involved a commitment to implement and evaluate best practice guidelines over a 3-year period.
A steering committee composed of care coordinators, a service manager, and a clinical expert was established to lead the process of developing and implementing a case management decision process for venous leg ulcers. Using the RNAO guideline on Assessment and Management of Venous Leg Ulcers, tools were developed to support the care coordination of service providers (nurses and others) who were providing care to clients with venous leg ulcers. These tools included a detailed care pathway to guide service provision in light of degree of leg ulcer healing, posters related to the wound care pathway, and laminated flip cards with detailed guidelines for implementing the new care pathway. An advanced practice consultant was hired to provide clinical expertise related to wound care and assist with staff education.
Implementing on a small scale Implementing on a small scale
Site 1 implemented the first version of the pain assessment and management tool in two of its ten branches, one in an urban location and one in a more rural location. The project lead and Clinical Nurse Educators (champions) conducted in-services for all nursing staff at these locations to learn about the pain tool. Weekly emails were sent to the staff that included reminders about the tool and clinical vignettes that gave actual examples of how the tool was implemented and positive impacts in selected client situations. The project lead provided informal one-to-one education for some frontline staff, both in the office and at joint home visits. At monthly team meetings, the project lead, managers and champions had informal discussions with the staff about the use of the tool. Site 2 implemented the first version of the venous leg ulcer tools in one branch in an urban area. The project lead and steering committee members conducted train-the-trainer sessions for champions related to this new tool. The project lead and other senior level staff provided informal one-on-one education sessions about the new tool with care coordinators.
Adapting locally Adapting locally
Formal and informal feedback about the tool was obtained from frontline staff and discussed at steering committee meetings throughout the early implementation phase. The project lead conducted some client visits on her own and identified challenges in using the tool in the actual client homes. In particular, the tool was lengthy for both clients and nurses to complete, and some clients expressed concern about the burden of completing this assessment. This ongoing feedback resulted in the steering committee and project lead making revisions to the tool including shortening it, simplifying the assessment and response items, and using check boxes instead of open-ended responses in other spread sites. Chart audits were completed by the Advance Practice Consultant during the early implementation, and results were shared with care coordinators.
The project lead also revised her educational strategies from early implementation sites to later ones, moving from more didactic sessions to discussions of real client scenarios in small groups. She encouraged nurses to describe results of using the pain tool, problem solve possible interventions together and then followed up on the results of those interventions. The project lead took on major responsibility for education and communication about the pain tool while implementation occurred at the first two sites. She regularly visited the sites, met with managers, nurses and champions, conducted joint visits with nurses and coached them on the use of the tool. However, in consultation with the steering committee and leaders, she recognized a need to increase the participation and responsibility of local nurse managers at the other eight sites to better facilitate spread. Thus, education and support was provided to local managers to better enable them to support the spread of the pain tool in their own branches. The project lead then followed up with managers regularly to discuss results of chart audits and other indicators of spread.  
Spreading internally Spreading internally
Over the next 6 months, the tool was spread to the other eight geographically dispersed branches. The tool was integrated into all client charts on new admission. The project lead and managers at the local branches provided in-service education for all the staff related to the tool. The staff were paid to attend these educational sessions. The local nursing managers dedicated time during at least two of the monthly team meetings to discuss the pain tool and engage the staff in discussions of their experiences and suggestions for change. Several newsletters included articles written about the tool by the project lead. The tool was often mentioned in weekly emails to the staff. A pain guideline package was created and posted on the portal website for the staff. Nurse managers had coaching sessions related to the tool with the staff in the office and in client homes. The tool was integrated into the employee orientation plan as well as the annual performance appraisal process. Components of the tool were integrated into the palliative and oncology care plans. Chart audits that included the pain assessment tool were completed by steering committee members and frontline staff. Results of these audits, such as extent of use of the tool, were shared with managers so they could share these at team meetings and address gaps in care with frontline staff. Stories were widely shared about the benefits of using the tool, such as actual changes in client pain and quality of life, and improved responses of family physicians when nurses shared the results of their pain assessments and ideas for managing client pain. Over a 2-month period, the new tools were spread to four geographically dispersed sites.
Steering committee members held question and answer sessions with staff members to obtain feedback and subsequently streamlined the case management pathway to make it simpler and easier to use. Leadership developed and monitored some key performance indicators through an electronic database and shared results with frontline staff at staff meetings.
Disseminating externally Disseminating externally
The pain tool and processes of spread were shared with a number of external agencies and at a number of events. For example, the tool was shared with the home care coordinator agency that contracted site 1 to provide care. The project lead and a manager presented the pain tool at an Ontario Palliative Care conference as well as at RNAO workshops and teleconferences. The project lead and one of the managers integrated content about the tool into a Comprehensive Advanced Palliative Care Education course offered in the community through hospice care consultation teams. The venous leg ulcer care pathway and processes of spread were shared with a number of external agencies and at some events. For example, the project lead met one-on-one with local family physicians and surgeons to describe the new pathway. Care coordinators working in hospital settings to facilitate the discharge process to home care shared the tool with the hospital-based Skin and Wound committee. The innovation was also shared with a regional best practice group including public health and hospital staff and at a variety of workshops such as the Ontario Association of Community Care Access Centre conference. A paper was published describing the new pathway and the processes used to implement and spread this innovation. Finally, the project lead was consulting with the Ontario Association of Community Care Access Centres, a provincial group representing all 14 CCACs, on the development of a consolidated wound care pathway that could be used across all CCACs.