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Getting guidelines into practice

lessons learned as Best Practice Spotlight Organization host

Moreno-Casbas, Teresa RN, MSc, PhD, FEAN1; González-María, Esther RN, MSc, PhD1; Albornos-Muñoz, Laura BSc1; Grinspun, Doris RN, MSN, PhD, LLD(hon), Dr(hc), O.ONT2

Author Information
International Journal of Evidence-Based Healthcare: June 2019 - Volume 17 - Issue - p S15-S17
doi: 10.1097/XEB.0000000000000178
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Evidence-based practice is considered a methodological paradigm that should serve as a reference for the unification of criteria in clinical decision-making.

Best Practice Spotlight Organizations (BPSO) (BPSO in Spain are called ‘Centros Comprometidos con la Excelencia en Cuidados’) are healthcare and academic organizations selected by the Registered Nurses’ Association of Ontario (RNAO) through a request for proposals process to implement and evaluate the RNAO's Best Practice Guidelines (BPG). It is a dynamic partnership that focuses on making a positive impact on patient care though evidence-based practice.

The Nursing and Healthcare Research Unit (Investén-isciii) and the Spanish Centre for Evidence Based Nursing and Healthcare applied, in 2010, as a BPSO Host, to initiate the BPSO Program at national level. This program is demonstrated to have an impact on health structures, organizational concerns, process and patients’ outcomes.


The project aimed to influence the uptake of nursing BPGs across healthcare organizations, to enable practice excellence and positive client outcomes.


In 2011, the Host Organization published the first formal call for proposals to select healthcare settings in Spain to implement the RNAO's BPG, once they have been translated into Spanish. The implementation of BPG Toolkit1 guides the process.

The Spanish BPSO Program is based on four strategies:

  1. Translation of BPG into Spanish: Investén-isciii translated RNAO's BPGs for use in the Spanish context, in partnership with RNAO, establishing quality criteria for translation.
  2. Dissemination: On-line access to BPSO Program information, social media launches and informative sessions were means for drawing attention to opportunities of participation.
  3. Implementation and evaluation: The Spanish BPSO Host launched, in 2011, the first call for proposals through a competitive application process, selecting healthcare settings for implementing RNAO's BPG and evaluating the results2 (first cohort). This approach is nursing-led and multidisciplinary; multipronged in strategy; context specific; and involves a wide range of stakeholders. The toolkit: Implementation of BPG1 guides the process with cascade training, selection of recommendations to be implemented, a 3-year schedule of planned implementation activities, and monitoring by measuring process and outcome results for discharged patients 60 days a year. The Host Organization supports healthcare settings selected.
  4. Sustainability: Supporting the maintenance and scaling-up BPG implementation, creating a national BPSO network of becoming part of the international network.

Evaluation is one of the key pillars of the program. For this purpose, ‘Data Dictionaries’ have been developed to document and report on the Nursing Quality Indicators. RNAO's Nursing Quality Indicators for Reporting and Evaluation (NQuIRE) provides the evaluation mechanism and process to monitor BPG implementation by BPSO. To adapt evaluation to country requirements, the Spanish BPSO Host developed a specific database, CarEvID, to measure the structure, process and outcomes of BPG implementation in Spanish organizations. Together RNAO and the Spain BPSO Host have analyzed minimum data set applicability and established procedures to transfer data from the national nursing database CarEvID to the international platform NQuIRE.

All BPSO collect baseline data, from the month prior to their official beginning as BPSO candidates. Data are then collected on the last 5 days of every month, except for low-prevalent cases, such as ostomies, in which all patient cases are measured. Descriptive analysis of variables is analyzed by CarEvID and reported monthly to institutions.


For the first cohort, out of 33 organizations attending the call, eight healthcare settings caring for 1.3 million people, were selected. They are located in seven regions including hospitals and primary healthcare centers. Overall, the eight BPSO implemented 10 BPG, according to the needs at each institution. Among 26 available guidelines, the most selected BPG were Ostomy Care and Management, Prevention of Falls and Fall Injuries in the Older Adult, Breastfeeding, and Assessment and Management of Pain.

From 2012 to 2014, BPSO candidates engaged and trained health practitioners in implementing the selected guidelines; reviewing and updating protocols and procedures; monitoring and evaluating their utilization, and reporting data to Investén-isciii and RNAO. Upon successfully attaining all of the deliverables, they earned their BPSO Designation in 2015. Designated organizations continue to receive support from Investén-isciii and RNAO, and renew their designation every 2 years.

In late 2014, a second open call for BPSO candidates was published, in which 10 out of 60 organizations were selected to begin implementation during 2015. Considering both cohorts, 16 BPG are currently being implemented. Even if the characteristics of the new cohort organizations differ from the former, the feeling of leaders and champions remains encouraging.

Finally, in 2018, a third cohort joined the program – from 25 interested organizations eight new sites were selected, which will implement 15 BPGs.

At present, we have managed to involve 26 organizations representing 271 healthcare sites across Spain. Figure 1 shows the map of the 263 BPSOs currently implementing guidelines in Spain.

Figure 1:
Map of 26 healthcare settings included in the Spanish Best Practice Spotlight Organizations Program.

Nowadays, CarEvID includes more than 8000 falls prevention-related records, 3000 records of assessment and management of pain, 1500 breastfeeding-related records, 700 ostomy care-related records and 200 stroke assessment-related records. The impact of the program in Spain is observed in many areas:

  1. New organizational structures have been created or promoted that serve to embed evidence-based culture into the organization.
  2. More than 3200 nurses and other healthcare professionals have training in implementation, or specifically in each BPG's recommended interventions. Their training has resulted in harmonization of interventions, development or update of evidence-based protocols, promotion of patient education and evaluation of international BPSO indicators using an electronic platform.
  3. One of the most important results is the harmonization of records. As clinical records are established at a regional level, any change influences all healthcare organizations, thus suggesting a wide spread of BPG implementation in the future.
  4. Some of the major findings include the improvement of process and outcome indicators. The three most selected guidelines were falls prevention (11 BPSOs), ostomy care (nine BPSOs) and breastfeeding (nine BPSOs), whose results showed significant improvements when comparing baseline measures to the 3rd year postimplementation data.


Conflicts of interest

The authors certify that they have NO affiliations with or involvement in any organization or entity with any financial interest, or nonfinancial interest in the subject matter or materials discussed in this article.


1. Registered Nurses’ Association of Ontario. Toolkit: implementation of best practice guidelines. 2nd ed.Toronto: Registered Nurses’ Association of Ontario; 2012.
2. Ruzafa Martínez M, González María E, Moreno Casbas M, del Río Faes C, Albornos Muñoz L, Escandell García C. The Spanish best practice guidelines implementation project 2011–2016 [in Spanish]. Enf Clin 2011; 21:275–283.

Best Practice Spotlight Organizations; evidence implementation; evidence-based guidelines; Registered Nurses’ Association of Ontario

© 2019 Lippincott Williams & Wilkins, Inc.

A video commentary on implementation project titled: How do health professionals prioritise clinical areas for implementation of evidence into practice? The commentary is provided by Andrea Rochon RN, MNSc, Research Assistant, Queen's University, Ontario, Canada