Background/Rationale:
Homecare organizations face increasing challenges engaging staff in the context of post-pandemic hybrid work, where reliance on digital tools has reduced in-person interaction and contributed to isolation, burnout, and moral distress. These challenges are amplified in large, geographically dispersed organizations such as Bayshore Healthcare, a national Best Practice...
Non-traumatic lower-limb amputations remain a significant and preventable health concern in Northeastern Ontario, with Indigenous populations disproportionately impacted by diabetes, peripheral vascular disease, and barriers to equitable healthcare access. In response, the Maamwesying Ontario Health Team (MOHT) and Health Sciences North, implemented a comprehensive Lower Limb Preservation...
Responsive behaviours associated with dementia are complex personal expressions of unmet need. In long-term care, these behaviours can contribute to staff distress, fragmented communication, inconsistent care planning, and avoidable reliance on pharmacological interventions. The RNAO “Delirium, Dementia, and Depression in Older Adults” Best Practice Guideline emphasizes person- and family...
This presentation speaks directly to Academic BPSOs by examining how implementation efforts translate into measurable outcomes across curriculum, faculty development, student learning, and academic–practice partnerships. It reflects a range of academic leadership and implementation perspectives within undergraduate nursing education programs in Ontario.
While the impact of BPSO designation...
Rationale: In resource-limited rural areas, fragmented care transitions isolate patients. As a community hospital anchor, advancing RNAO Best Practice Guidelines (BPGs) depends on inclusive collaboration among interdisciplinary staff, patients, families, and cross-sector care partners.
Purpose: This project aimed to conduct comprehensive gap analyses of people-centred care,...
Bed and chair alarms have traditionally been used in long-term care to reduce falls risk; however, evidence supporting their effectiveness is limited, and alarms may negatively impact resident dignity, autonomy, and quality of life. Building on existing implementation of the RNAO Preventing Falls and Reducing Injury from Falls Best Practice Guideline, Faith Manor undertook a quality...
St. Peter’s is a 221-bed long-term care (LTC) home in Hamilton, Ontario, operated by Thrive Group. As a not-for-profit organization, it is guided by a philosophy that living well is enhanced through research, evidence-informed practice, and an integrated model of care tailored to individuals with unique needs. Despite this approach, gaps in communication between hospitals and LTC home were...
Background Rational
Our team began implementing Transitions, at which time we identified a number of gaps within multiple areas related to transitions in care. As a team we worked together to review our admission process, hospital transfers and external appointments to determine where specific gaps were presented.
Our goal was to collaborate with our residents/families to develop tools to...
Background/Rationale
Nipissing University’s RPN-to-BScN distance nursing students possess clinical experience across various settings. Online nursing programs serve students in a common geographic region, providing access to undergraduate education and allowing learners to interact with course materials independently. Nevertheless, faculty members’ engagement, expertise, and competence...
Most BPSO organizations operate within institutional structures that were also the context in which evidence-based practice frameworks were developed. The Sioux Lookout First Nations Health Authority (SLFNHA) operates uniquely by providing community-based care with 17 sites and 8 community health hubs, across 33 First Nation communities in Ontario's Sioux Lookout region. SLFNHA is governed by...
Background:
Humber Meadows is a 320-bed long-term care home in Toronto and the first home to open as a pre-designated Best Practice Spotlight Organization (BPSO) while simultaneously implementing clinical pathways. Guided by person- and family-centred care, palliative care, and pain management best practice guidelines, they sought to build a strong evidence-based culture while addressing the...
Background:
Scarborough Health Network (SHN), a Best Practice Spotlight Organization (BPSO®) for over 11 years in partnership with the Registered Nurses’ Association of Ontario (RNAO), is committed to high-quality, patient-centred, evidence-informed care. This initiative aimed to strengthen internal capacity to grow BPSO Champions and actively advance RNAO Best Practice Guideline (BPG)...
The City of Ottawa Long-term Care Services operates four Long-Term Care homes. In 2025, they identified pressure injury prevention and wound management as priorities after wound indicators remained elevated. In November 2025, a Skin Wellness Associate Nurse (SWAN)-supported approach was introduced across four long-term care homes to strengthen staff knowledge, assessment, prevention,...
As part of an organization-wide digital transformation initiative, William Osler Health System (Osler) introduced Social Drivers of Health (SDOH) documentation across clinical and administrative workflows. While SDOH information is essential for advancing equitable, people-centred care and informing population health planning, staff expressed uncertainty regarding the purpose and practical...
At Copernicus Lodge, our mission is to provide the highest quality of holistic, resident-focused care grounded in dignity, respect, compassion, and partnership. We selected the Person and Family Centred Care (PFCC) Best Practice Guideline to strengthen our commitment to placing residents and families at the centre of care. Baseline assessments identified opportunities to improve the admission...
Background: Errors in treatment are frequently reported through approaches that prioritize individual actions over system- level factors, contributing to fear of blame, limiting meaningful organizational improvement, and reducing opportunities for learning and prevention (Hibbert et al., 2025; Wawersik et al., 2023). At Niagara Region Public Health, error reporting relied on paper forms and...
Objective: Synergize evidence-based practices from the Pressure Injury (PI), eHealth, and Interprofessional Care Best Practice Guidelines (BPGs) to optimize skin assessments and wound documentation workflow at Scarborough Health Network (SHN). The target is ≥90% utilization by December 2026.
Background: Inconsistent skin assessments and documentation have contributed to gaps in data and...
BACKGROUND:
CAMH is Canada’s largest mental health teaching hospital and one of the world’s leading research centers in its field. In 2023, CAMH committed to partnering with the Registered Nurses Association of Ontario (RNAO) to become a Best Practice Spotlight Organization ® (BPSO®) through the implementation of five RNAO BPGs. As of 2026, CAMH achieved RNAO BPSO® designation, which...
Background/Rationale
Simcoe Muskoka District Health Unit’s (SMDHU) journey toward becoming a Best Practice Spotlight Organization (BPSO) emerged from responding to complex substance use and harm reduction program challenges within our region. Earlier work, including support for a Consumption and Treatment Services application, highlighted the importance of evidence based, compassionate...
Background: As a Best Practice Spotlight Organization (BPSO) comprised of five long-term care homes, Peel Long Term Care is strengthening its champions and care excellence by embedding emotion-based care and best practices into daily service delivery. By integrating the RNAO best practice guideline (BPG), person and family centred care with an emotion-based care approach, our organization is...
Background: Since its designation as a Best Practice Spotlight Organization (BPSO) in 2006, West Park Healthcare Centre (WPHC)-University Health Network (UHN) has remained steadfast in its commitment to evidence-informed practices. The implementation of Best Practice Guidelines (BPGs) at WP is grounded in social movement science, promoting knowledge acquisition and sustained practice change....
Background:
Sustained implementation of evidence-based practice (EBP) requires intentional strategies to build leadership and knowledge translation capacity among emerging healthcare professionals. Undergraduate nursing education represents a critical opportunity to develop early Best Practice Guideline (BPG) champions who can support the integration of evidence into practice. Structured...
Poster display board for Champion and Capacity building
Abstract:
Developing sustainable capacity for Best Practice Guideline (BPG) implementation requires more than identifying champions, it demands intentional strategies that prioritize engagement, accessibility, and organizational support. This presentation will outline a practical approach to building and mobilizing champions within a long-term care setting, with a focus on removing common...
William Osler Health System (Osler) and the Daphne Cockwell School of Nursing (DCSN), Toronto Metropolitan University, both Registered Nursing Association Ontario (RNAO) Best Practice Spotlight Organizations have initiated a People-Centred Care (PCC) Academic- Practice Partnership (APP), with integration across practice, education and research. This unique collaboration demonstrates the value...
Background
Health information technology is a driver improving care quality and efficiency (Chaudhry et al., 2006). In 2023, Southlake Health began implementing RNAO BPG Adopting eHealth Solutions, focusing on Computerized Provider Order Management (CPOM).
Purpose
To transition from hybrid order management to fully integrated, standardized electronic order management...
Background
The International Pressure Injury Prevalence Survey (IPIP) is a global benchmarking initiative to support pressure injury prevention and assessment efforts. WOHS sought to improve engagement when participation rates plateaued at 65% in 2023. This gap reflected challenges in frontline awareness, ownership and sustained engagement highlighting an opportunity for nursing...
Abstract
Background: Meighen Health Centre is a 168-bed long-term care home in Midtown Toronto committed to safe, person-centred transitions. While admission processes were well established, gaps in medication reconciliation created risks for omissions and inaccuracies, impacting resident safety and continuity of care.
Aim: To strengthen transitions in care by improving medication...
https://thrivegroup-my.sharepoint.com/:p:/g/personal/mkelter_thrivegroup_ca/IQAc649SibqcSp7903-b9NSiAWd04oUgrhpZP-gOT5PFuAc?e=nmKYFQ&nav=eyJzSWQiOjI1Nn0
Hôtel-Dieu Grace Healthcare (HDGH) is a 287-bed specialized post-acute care hospital providing comprehensive services, including mental health, addictions care, rehabilitation, complex medical care, palliative care, and community programs. As part of the inaugural Mental Health and Substance Use Best Practice Spotlight Organization® (BPSO®) specialty program, HDGH is committed to...
Background:
Transitions in Care and Services (TICAS), a Best Practice Guideline (BPG) developed by the Registered Nurses’ Association of Ontario (RNAO), provides evidence-based recommendations to support safe, equitable, and coordinated transitions across health systems. Grey Bruce Public Health implemented the guideline using a systematic and innovative approach and developed an evaluation...
Background / Rationale
Lower-limb complications are a significant concern among Community Health Centre (CHC) clients who experience chronic disease, homelessness, substance use, and barriers to accessing care. South Riverdale CHC recognized the need for an integrated, trauma-informed, low barrier, and team-based approach to support the early detection of lower-limb complications and...
Long-term care (LTC) homes are increasingly supporting residents with complex chronic illness, frailty, and end-of-life care needs. Recognizing opportunities to improve consistency, communication, and staff confidence in palliative and end-of-life care, our organization implemented the RNAO Best Practice Guideline (BPG) A Palliative Approach to Care in the Last 12 Months of Life. The...
Purpose- The purpose of this project was to implement the End-of-Life Best Practice Guideline in a rural acute care hospital where palliative care needs were often identified late in the disease trajectory, limiting timely support for patients and families. With a predominantly older adult population over the age of 65, this gap highlighted an urgent need for more proactive palliative care...
Background/Rationale
The Registered Nurses’ Association of Ontario Transitions in Care and Services (TICAS) Best Practice Guideline (BPG) provides evidence-informed recommendations to strengthen continuity, intersectoral coordination, and person-centred care across with service delivery. While TICAS is primarily implemented in clinical settings, public health organizations are...
Background: Transitions in care are critical points in the patient journey and can significantly impact safety, continuity, and overall patient experience. Individuals receiving care at home may experience uncertainty, repeated assessments, fragmented communication, and difficulty navigating services. S.R.T. MedStaff is a home healthcare organization that implemented the RNAO BPG...
Background
Older adults with complex care needs often face challenges navigating fragmented health and social services, resulting in unmet needs, caregiver burden, and inequitable access to care. Within a Toronto Family Practice Elder Care Program (ECP), providers identified gaps in awareness and coordination of community supports. Guided by the RNAO Person- and Family-Centred Care Best...
St. Joseph’s Health Care London is a multi-site organization with various specialized care areas. Care areas range from acute care, long-term care, forensic mental health, and tertiary mental health care.
The tertiary mental health care teams’ interface with clients that use substances that come from the community directly through the Assertive Community Treatment (ACT) teams. Recent...
Objective/Background: Transitioning into long-term care is a complex and often stressful experience for residents, care partners, and the staff supporting the move. Recognizing the need to enhance our move-in process, we aligned our approach with the RNAO BPG on Transitions in Care and Services and Resident- and Family-Centered Care.
Methods: Gap analyses were conducted to evaluate...
Villa Colombo Toronto, a Best Practice Spotlight Organization designated in 2022,expanded within the OHT(2024), has implemented a comprehensive, technology-enabled model to embed,adapt& sustain evidence-based practices across LTC. This initiative integrates clinical pathways derived from RNAO BPGs with advanced digital infrastructure to enhance quality, safety & person family-centred...
As an organization, we have learned that building and sustaining a Best Practice Spotlight Organization (BPSO) requires more than education it requires a culture that supports learning, mentorship, and shared ownership. This presentation highlights how Labdara Lithuanian Nursing Home (Labdara) has strengthened its BPSO capacity through staff engagement, leadership support, and champion...
Background/Rationale: Downsview Long-Term Care Centre is a for-profit, 252-bed multicultural home in North York, managed by Gem Health Care Group since 2012 and part of the North West Ontario Health Team. Newly admitted residents have consistently contributed to fall incidents. To ensure accurate measurement despite fluctuations in census and admissions, we monitor the fall rate per 1,000...
Project Overview
The Legacy Project is a person-centered storytelling initiative for residents in long-term care. Residents create meaningful keepsakes using stories, letters, poems, reflections, and photographs that celebrate their lives and memories.
Purpose
To honor residents’ lives, strengthen relationships with families and staff, and support emotional well-being through meaningful...
Pressure injury prevention (PIP) and wound care management is a priority for the 250-bed multi-site complex-continuing care and rehabilitation hospital. Understanding the current wound care landscape is crucial as the Interprofessional Practice and Education (IPPE) team revitalizes its wound care program.
Aim
To leverage wound care metrics related to prevalence, incidence, and...
Background
Behavioural Supports Ontario (BSO) was established in 2012 to enhance coordination and leverage existing resources across the continuum of care for older adults experiencing responsive behaviours associated with cognitive impairment. All long-term care homes (LTCHs) in Ontario have access to specialized behavioural support services through embedded or mobile BSO teams. BSO...
Background: The RNAO People-Centred Care (PCC) Best Practice Guideline (BPG) provides a strong foundation for advancing PCC across healthcare sectors. However, many organizations face challenges translating these principles into consistent, measurable practice. At VHA Home HealthCare, a comprehensive gap analysis highlighted the need for a more practical and accountable approach to...
Background: Self-management of COPD has been associated with improved quality of life and decreased hospitalization. My Lung Health Coach is a virtual self-management program delivered by a Certified Respiratory Educator at the Lung Health Foundation. Prior work involved co-designing and implementing of an Epic-integrated Care Companion application to support virtual care delivery and digital...
Abuse and neglect in long-term care (LTC) remain critical concern that impacts resident safety, dignity, and quality of life. At Burton Manor LTC, strengthening frontline staff knowledge and fostering a culture of person-centered care have been key priorities in addressing these challenges. PANDA is an education initiative that help staff recognize,
prevent, identify, and respond to abuse...
Background:
Humber Meadows is a 320-bed long-term care home in North York and the first home to open as a pre-designated Best Practice Spotlight Organization (BPSO) while simultaneously implementing clinical pathways. Recognizing the complexity of opening a new home while embedding evidence-based practice, Humber Meadows leveraged strategic partnerships to strengthen person- and...
This poster highlights Confederation College’s Practical Nursing (PN) program’s ongoing journey to integrate safe transitions in care and Indigenous Learning Outcomes (ILOs) throughout its curriculum. Guided by Graham’s (2006) Knowledge to Action (KTA) Framework and Grinspun’s (2020; 2022) Social Movement Action (SMA) Framework, this work reflects a deliberate effort to create a responsive...
Background
Maintaining patient and staff safety while supporting least restraint care remains a priority in acute care settings, particularly for patients with cognitive, behavioural, or mobility-related risks. Variability in observation and least restraint practices across inpatient units identified opportunities to improve consistency. Evidence supports structured observation...
Moving from organizational readiness to sustained impact, Long-Term Care homes must solve the critical challenge of "champion fatigue". Our Best Practice Spotlight Organization (BPSO) recognized that clinical guidelines succeed only when front-line staff leading them are energized, resilient, and aligned with their roles. True clinical sustainability requires a shift from passive...
Completing a gap analysis while implementing a Best Practice Guideline (BPG) is an opportunity to recognize what an organization is doing well and identify areas for improvement. The first step in the Knowledge-to-Action framework is to clearly define the problem and the gap. To ensure these gaps reflect real practice, engaging direct care clinicians is essential.
Traditional group...
Background/Rationale:
Across our five hospital sites, annual rental air surface costs exceeded $1.2 million, yet hospital-acquired pressure injury (HAPI) rates remained unchanged. Despite organization-wide implementation of gel surfaces in 2022, rental utilization remained high. Key contributing factors included limited staff knowledge of surface indications, functions, and costs,...
Background
Markhaven Home for Seniors is a 96-bed, not-for-profit long-term care home in Markham, Ontario. In 2017, Markhaven entered a three-year partnership with RNAO as a Best Practice Spotlight Organization (BPSO) and achieved designation status in 2020. While many individuals have contributed to shaping the program’s vision and execution, maintaining continuity in BPSO leadership has...
Background:
Safe and competent management of central venous access devices (CVADs) is essential to preventing complications such as central line–associated bloodstream infections. An environmental scan within the Pediatric Intensive Care Unit (PICU) at CHEO identified gaps in standardized education, hands-on practice, and formal competency validation for CVAD care, revealing misalignment with...
Background
Oral health is a critical component of patient safety and overall health, yet it is often overlooked in daily care, particularly among patients dependent on clinicians for oral hygiene. A baseline gap analysis in a complex continuing care organization identified inconsistent oral health documentation, lack of a standardized assessment tool, and limited staff knowledge and...
. Rationale
Successful implementation of evidence-based practices requires a culture of collaborative leadership, stakeholder engagement and comprehensive opportunity analysis. To launch the Best Practice Spotlight Organization (BPSO) initiative, leadership sought an inclusive strategy to assess baseline practices across transitions in care, pressure injury prevention, and people-centered...
Background
Home care is increasingly a setting where nurses provide complex, high-acuity care that was traditionally delivered in hospitals. Ontario’s expansion of home care is moving more complex patients into the community, making nurse confidence, competence, and clear escalation pathways critical to safe care at home. In collaboration with our integrated care programs, Spectrum Health...
Background:
Older adults with dementia residing in long term care homes (LTCHs) often exhibit behavioural and psychological symptoms of dementia (BPSD) such as agitation and wandering. Antipsychotics are often used to manage these behaviours; when prescribed without a diagnosis of psychosis, this constitutes inappropriate use and is linked to risks such as falls and death. The rate of...
Background
Orientation processes for new hires at VHA Home HealthCare were fragmented and inconsistent. This led to an overwhelming onboarding experience, unclear expectations, challenges in identifying roles and responsibilities, and lack of confidence when using digital health technologies to support care.
Aim
To design and implement a standardized, organization-wide orientation...
Background:
Transfer of Accountability/Transfer of Information (TOA/TOI) is the exchange of patient information, responsibility, and accountability between healthcare providers during care transitions. Communication failures are well documented as sources of preventable harm, underscoring the need for standardized, high-quality TOA. In 2025, patient safety incidents identified local practice...
The Top Banana Award is a monthly quality‑improvement recognition program designed to celebrate excellence, reinforce best practices, and sustain a culture of safety within the long‑term care home. At its core, the award highlights the villa that demonstrates the strongest performance in key clinical areas—most notably fall prevention, but also infection control, wound care, and compliance...
Background
In December 2024, Kingston Health Sciences Centre (KHSC) transitioned from paper-based documentation to the Cerner Health Information System (HIS). Following implementation, variability emerged in the delivery of Transfer of Accountability and Information (TOA/I) during patient handovers. Communication failures during transitions of care are a recognized contributor to patient...
The learning objective for this gap was to establish the baseline data for our home as most of the work for a transition is done prior to admission of the resident.
Once baseline data was determined key areas of improvement were identified as communication, education and documentation.
• 1 Communication
• Improve communication with residents and families prior to admission using phone...
Preparing for Accreditation Canada’s Qmentum Global™ onsite survey while pursuing BPSO designation provided North Shore Health Network (NSHN) with an opportunity to align quality improvement priorities and accelerate evidence-informed practice change. Rather than treating accreditation and BPSO work as separate initiatives, an interprofessional team of leaders, clinical staff, allied health...
