1. How implementation science helped us change practices
How implementation science helped us change practices. The IRGLM’s experience with the Spinal Cord Injury Knowledge Mobilization Network  
Marie-Thérèse Laramée, Caroline Joly,
Isabelle Robidoux, Violette Jeune,
Sonia Côté, Saagar Walia
My name is Marie-Therese Laramee and I work here in Montreal at the CIUSSS Centre sud - Institut de réadaptation Gingras Lindsay ‘s site.
I would like to acknowledge the work of my colleagues Caroline Joly, Isabelle Robidoux, Violette Jeune, Sonia Côté, Saagar Walia

2. Background What is Spinal Cord Injury
Knowledge Mobilization network (SCI KMN)
Community of practice formed in 2011 comprised of seven Canadian rehabilitation centres across 4 provinces.
The goal of the SCI KMN
To adopt and utilize the best available practices in spinal cord injury care to improve outcomes.
To guide its work with evidence-informed implementation methodology adapted from the National Implementation Research Network (NIRN) frameworks
The SCI KMN, formed in January 2011, is a spinal cord injury (SCI) rehabilitation community of practice funded by, and in collaborative partnership with, the Rick Hansen Institute (RHI), the Ontario Neurotrauma Foundation (ONF) and the Alberta Paraplegic Foundation (APF). It is comprised of 7 rehabilitation hospitals across 4 provinces in Canada, with a mission to improve health outcomes for persons with SCI with demonstrated economic impact through implementation science leading to innovations in clinical practice.
The goal of the KMN is to adopt and utilize best practices to improve outcome.
It is well known that a successful and sustainable implementation of a new practice is ensure by being based on implementation science.
The SCI KMN established a partnership with the National Implementation Research Network (NIRN), an implementation science group whose theoretical frameworks and practical tools were designed for Best Practice implementation (BPI). Using implementation science, the SCI KMN community of practice systematically implemented best practices in Pressure Ulcer and pain assessment and management . The concept of adaptation and contextualization is imperative to the dynamic process of BPI. As such, the SCI KMN adapted the NIRN Active Implementation Frameworks and tools to meet the unique, evolving, and immediate needs of the network towards implementing best practices into active service in SCI healthcare, nationally.

3. Objectives Today’s presentation will describe:
adapted NIRN’s integrated frameworks that guided our work
level of completion of the two pressure ulcer prevention and two pain management practices
impact on the clinicians and patients
main facilitators and barriers to implementation that were encountered.

4. Methods
Review evidence and reach consensus on the best practices to be implemented
The best practices selected are recommendations from clinical practice guidelines.
»The first thing that we have done was to review the evidence and reac

5. Our best practices PRESSURE ULCER PAIN
Conduct comprehensive, systematic and consistent assessment of risk factors in individuals with SCI
Provide structured education and provision of specific information.
PAIN
Use an interdisciplinary approach to assessment of pain and treatment planning.
Address the person’s concerns and expectations when agreeing which treatments to use by discussing for example coping strategies for pain and for possible adverse effects of treatment.
There are the practices chosen as described in the SCI Practice guidelines

6. Adapted NIRN frameworks
Practice, program and systems change through…
Multi-dimensional, Fully integrated
Implementation Teams
Implementation Drivers
Implementation Stages
Improvement Cycles
How did we implement the practices?
With the implementation science of NIRN’s adapted frameworks.

7. SCIKMN adapted Framework 1 : Teams
Implementation Teams and Organizational Structure for Networks of Implementation Teams

8. SCIKMN adapted Framework 2: Stages
Guidance using activities through four stages of implementation

9. SCIKMN adapted Framework 3: Drivers
Assessment and analysis of implementation drivers

10. SCIKMN adapted Framework 4: Cycles
PLAN
Explore and
prepare DO
Engage as
planned
STUDY
Evaluate
effectiveness
ACT
Learn and
improve
This is exactly what I did for this presentation . I analyse the collected data to address any improvement cycles that might be necessary
Evaluation and Analysis of data collected to inform

11. SCIPUS at admission What has our improvement cycle analysis tell us:
Our Risk factors tool completed by nursing staff at admission:
From not having one in 2011, we are at more than 90% completion rates year after year. We are still working at having it completed within 72 hours of admission which has improved since our last analysis as shown by the 2015 data.

12. Education program
As we thought that this practice was well installed and it is, this improvement cycles will need a more thorough analysis.
We see that our attendance to group sessions tend to decrease each year. Few pistes de reflexion:
We have had more incomplete lesions (79%) for whom attendance to group sessions is less appropriate.
The lenght of stay has decreased and we give the group sessions every 6 weeks. Before, this was correct. With the lenght of stay decreasing, we will have to look at this carefully

13. Interprofessional team risk assessment
We have worked on this a lot. We were doing quite poorly with a lot of incomplete interdisciplinary assessment.
We have installed a new interdisciplinary discussion

14. Pain assessment at admission
Our cycle has made it possible to improve the level of completion of the ISCI pain data set. Where we can see that our fully completed tool percentage has improved
This is one of the disadvantage of inter professional tools. If one clinician does not fill its section, it is considered incomplete.

15. Concerns and expectations
Same as the previous slide

16. Incidence of pressure ulcers
Outcomes now
Even if the percentage of our retropective PU is underrated we have passed from 11-12% incidence of PU developed during rehab at a mean of 7% and this year after year. We even had one year with a percentage

17. Incidence of pain
The incidence of pain has to be looked at carefully since our retrospective group might not have been as

18. FACILITATORS OBSTACLES
Multi level support by the organization
Presence of dedicated coordinators
Time allocated by managers
Limited burden on clinicians
Interactions between
The limits of the tool
Individual characteristics (resistance to change, individual knowledge, lack of motivation…)
Tool characteristics (validity, reliability, value for clinicians…)
Perception of added value
Individual factors of the patients
Challenge of having interdisciplinary best practices 
Possibility of adapting the best practice
Budget cutback and health network changes
Presence of a culture on interdisciplinarity
Staff turnover
Financial support
Support from the SCI KMN central structure
Implementation science and frameworks to guide the implementation

19. In summary
SCIKMN has enabled the IRGLM’s team to develop implementation science capacity;
• Four BPs have been successfully implemented since 2011.
• PDSA cycles have allowed the teams to revisit the practices and improve the level of completion.
IRGLM scaled this capacity to allow a better standardization of practices within the Montréal continuum of care following SCI
Start of another multi-site implementation initiative for the use of electrical stimulation... Combined with standard wound care interventions with one rehabilitation centre and one acute hospital in the Montréal region.

20. Acknowledgements The patients involved in this project
The clinicians of the SCI Program of IRGLM
SCI KMN and the sponsors:
Rick Hansen Institute
Ontario Neuro Foundation
Contact: