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"Unidad de Investigación en Cuidados y Servicios de Salud (Investén-isciii), Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Investigación en Cuidados y Servicios de Salud (Investén-isciii), Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Registered Nurses’ Association of Ontario (RNAO), Toronto, Ontario, Canada" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Implantación de Guías de Buenas Prácticas en España a través del Programa de Centros Comprometidos con la Excelencia en Cuidados®" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The gap between evidence and practice is a fixed result in research.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Studies show that approximately 30%–40% of patients do not receive care according to scientific evidence and that 20%–25% receive unnecessary or potentially harmful healthcare.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The implementation of Best Practice Guidelines (BPG) helps to improve clinical practice and decrease clinical variability.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Having evidence available is insufficient for transplanting such guidelines.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> They have to be implemented in daily clinical practice, which is understood to be <span class="elsevierStyleItalic">the use of the strategies to adopt and integrate evidence-based health interventions and changes in patterns of practice in specific clinical settings.</span><a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Knowing which elements intervene and facilitate implementing scientific evidence in practice and recognising result efficacy are necessary. However, research in such implementation is lacking in descriptions of the strategies developed and the theoretical approach used is imprecise.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This limits the application of the elements that lead to the best results.</p><p id="par0020" class="elsevierStylePara elsevierViewall">To base practice on evidence effectively, we need to work on the activities related to the interventions and on the implementation process.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Consequently, established an implementation method, accompanied by a thorough assessment, is essential.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Best Practice Spotlight Organizations®</span><p id="par0025" class="elsevierStylePara elsevierViewall">In Canada, the Registered Nurses’ Association of Ontario (RNAO) initiated the government-funded nursing Best Practice Guideline programme in 1999 with the objective of developing, disseminating, piloting and assessing healthcare-oriented clinical practice guidelines.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> To date, they have released 56 BPG. In 2003 the Best Practice Spotlight Organizations® (BPSO®) programme was rolled in Canada as part of the Nursing Best Practice Guideline Programme. Its goal is encouraging, facilitating and supporting the implementation, assessment and maintenance of good care practices, in all nursing practice settings, with the final goal of improving healthcare attention. The RNAO has developed 2 evidence-based methodological guidelines for setting up BPG in clinical<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and academic settings,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> in which the BPSO® programme is supported.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The BPSO® are healthcare and academic institutions chosen in a competitive process; the centres present their proposals for implementing and assessing the RNAO BPG during the 3 years in which they are considered candidates. Afterwards, they maintain the implementation and assessment, with new agreements, but as designated BPSO®. The programme has extended internationally to 14 countries, with a total of 135 BPSO®, including more than 500 healthcare and academic institutions.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">The BPSO Host Model</span><p id="par0035" class="elsevierStylePara elsevierViewall">The RNAO has signed agreements to set up the BPSO Host model with organisations that coordinate the BPSO® programme in the region or country where they are located, maintaining the principles established faithfully. The BPSO Host is responsible for all aspects of the programme, from selecting BPSO® candidates and following them up by periodic meetings, up to preparing progress reports for the RNAO, acting as the liaison between the RNAO and the BPSO® of the specific region or country. The RNAO holds periodic meetings with the BPSO Hosts and advises them on dissemination, application, sustainability and assessment. Likewise, the RNAO provides support, through professional development and access to all its resources (such as report prototypes, their network of «champions» of best practices, training for «champions», methodological manuals and the BPG app, among others). It takes 3 years for the organisations to be designated as Hosts.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In Spain, the Health Research Unit for Care and Services (<span class="elsevierStyleItalic">Unidad de Investigación en Cuidados y Servicios de Salud</span>) at the Carlos III Health Institute, in collaboration with the Spanish Centre for Evidence-Based Health Care), signed a collaboration agreement with the RNAO, in 2010. The agreement designated the Health Research Unit at the Carlos III Health Institute as the coordinating centre for the programme in Spain (the BPSO Host). The objective was to set up the RNAO’s programme of BPG implementation based on the same principles as the Canadian BPSO® programme; the Spanish programme was called Centres Committed to Excellence in Care® (<span class="elsevierStyleItalic">Centros Comprometidos con la Excelencia en Cuidados</span>®) (CCEC®).</p><p id="par0045" class="elsevierStylePara elsevierViewall">The BPSO Host model is based on 4 strategies<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>: 1) translating the RNAO BPG and their updates; 2) disseminating these BPG; 3) implementing the BPG and assessing their results in the CCEC® (called BPSO® interchangeably in this article) chosen after the competitive process convoked every 3 years, and 4) developing mechanisms to sustain and continue the programme, when the designated or candidate BPSO® renew the agreement with additional objectives (implementing new BPG, expanding those already implemented or mentoring other centres in their sphere of influence). All the procedures developed are coordinated based on the international BPSO® programme.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Expansion to the autonomous community level began in 2018 with the roll out of regional BPSO Hosts coordinated by the national Host, based on a cascading expansion model. The first 3 regional BPSO Hosts were the Health Ministry in the <span class="elsevierStyleItalic">Principado de Asturias</span> (Principality of Asturias), and the Healthcare Services in the <span class="elsevierStyleItalic">Illes Balears</span> (Balearic Islands) and in <span class="elsevierStyleItalic">Osakidetza</span> (the Basque Country). In 2019 the Council of Health and Families for the <span class="elsevierStyleItalic">Junta de Andalucía</span> (the regional government of Andalusia) and the Health Service in the Canary Islands were incorporated as BPSO Hosts.</p><p id="par0055" class="elsevierStylePara elsevierViewall">This structure has made it possible to create a national network of CCEC® that promotes the use of practices based on the best results in care research and that forms part of the international network of BPSO®. The regional Host model also enables us to increase the reach of the programme and provide sustainability mechanisms.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">BPSO® methodology</span><p id="par0060" class="elsevierStylePara elsevierViewall">There are numerous knowledge transfer models in the nursing discipline. Examples are Rogers’<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Theory of Innovation Dissemination, the model for Promoting Action on Research Implementation in Health Services: PARISH framework,<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> the model for individual factors of research utilisation<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and the Knowledge to Action Model.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> These models are applied to develop interventions for knowledge transfer, to identify appropriate variables, measures and results, and to guide assessment of the knowledge transfer process.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The model established in the RNAO BPG implementation method is that of the Knowledge to Action (Framework of Knowledge for Action), as an adaptation of the Knowledge Translation in Health Care: Moving from Evidence to Practice.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> To adapt it, more than 30 action planning theories were reviewed, identifying the common elements. It is normally used in health settings, it is intuitive and easy to understand; it includes the most relevant elements for implementation<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and for being extended in the system.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Non-lineal and iterative, it takes the process of creating knowledge and the action cycle into consideration. In that process, it tackles identifying evidence and synthesising it in tools and knowledge products. In the action cycle, it is focused on applying knowledge in the area of the practices, including 6 stages, based on a synthesis of theories of systematic change process that occurs in healthcare-related systems and groups.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">In the BPSO® programme, common procedures associated with each of the action cycle stages are established. The BPSO Host forms, supports, mentors and audits the development throughout each of the stages.</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Stage 1. Identifying the problem and forming selected CCEC®</span><p id="par0075" class="elsevierStylePara elsevierViewall">Clinicians and managers define the problem and examine the BPG that can help to resolve it. In the programme, the institutions identify their needs and choose the RNAO BPG to implement when they send their candidate application in the CCEC® selection process. Before that, the gaps between practice and evidence are analysed on the basis of the degree of complying with the BPG recommendations. This initial stage determines what the implementation process will be like, its potential for reaching quality improvements and the degree to which it will contribute to solving the problem identified.</p><p id="par0080" class="elsevierStylePara elsevierViewall">The coordinating group for the implementation (including the leader and the managers for the guidelines to be implemented) has to be identified in the candidate application sent in the CCEC® process; it is essential for it to be lead by nursing staff. Once the institutions have been chosen as CCEC® candidates and set up as cohorts, training in cascade form is established: the leader and managers complete the «Institute of Methodology for RNAO BPG Implementation» to learn about this method and about the international BPSO® programme. In the next stage, they form implementation groups in their institutions. The cascade model is standardised so that all the international BPSO® receive the same training, with the same methodology and materials.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Stage 2. Adapting to the local context</span><p id="par0085" class="elsevierStylePara elsevierViewall">This is the key stage for effective knowledge transfer. It is based on an analysis of the context so that the recommendations can be adapted. This includes an in-depth examination of the choice of all the BPG recommendations to be implemented, so the adaptations needed can be made; the interested parties, their support and the associated roles have to be analysed as well.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> With the results, the professionals become involved in the work groups so they contribute to implementation planning. This increases the probability that the BPG respond to the needs of the institution and will be adapted to its context.</p><p id="par0090" class="elsevierStylePara elsevierViewall">The «champion» is an essential part of the programme. This individual is the one most involved, who has been trained in implementation methodology and identifies all the needs in the implementation process, participating in diagnosing the situation and designing and executing the strategies needed for developing the implementation. The champion supports elements in the process,<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> in addition to applying the recommendations.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Stage 3. Assessing facilitating aspects and barriers</span><p id="par0095" class="elsevierStylePara elsevierViewall">This stage consists of analysing the possible factors that facilitate and partially or totally prevent the use of the BPG in a specific context and ascertaining the possible impact on the various interested parties. The barriers and the facilitating aspects are classified according to the organisational context, recipients, evidence and resources.<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,10,20</span></a> This analysis has to be documented, given that its results provide the information for the next stage.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Stage 4. Adapting and implementing the interventions</span><p id="par0100" class="elsevierStylePara elsevierViewall">Before beginning to implement, the action plan must be defined. This plan will cover the development of implementation strategies that take into consideration the interested parties, the barriers and the facilitating aspects. The BPG recommendations should be adapted to the environment in which they are to be applied and should contain the revision or creation of evidence-based protocols adapted to the context as a major activity.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Evidence shows that planning the strategies and using them in combined form helps to promote effective changes in practices.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Among the most common interventions is training, which should be interactive and combined with other activities. The evidence indicates that isolated, passive training is unlikely to produce changes, and that printed training materials have only a small positive effect on professional practice.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Auditing and feedback impact the practice of health professionals; they are effective when they are concentrated, personalised and long term.<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> Local opinion leaders can affect practice, although the effect on patient results is unclear.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Patient-mediated interventions may be effective as part of a multifaceted strategy.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Adaptation and implementation of the activities have to be documented and specified in the action plan. This will ensure its updating and assessment during the entire process.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Stage 5. Monitoring and assessing results</span><p id="par0115" class="elsevierStylePara elsevierViewall">This stage includes assessing BPG use, verifying the fulfilment of the recommendations or the changes in knowledge or attitudes, and evaluating the impact of the implementation, using a method established in the international programme. All of the BPSO® should include a plan for assessing them. The assessment identifies the managers and the evaluation teams, and includes the objectives to be reached by the implementation, the target population, the environment for application, the chronology of measurement, the analysis and the feedback. The indicators established in the BPSO® programme to assess knowledge use and impact on the patients, professionals and system are based on the Donabedian framework<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>: structure, process and outcome. The structure indicators provide information about institution characteristics, population to which services are given, workload and time considerations. The process indicators de process make it possible to monitor the quality of patient attention. The third indicators examine the effect of using the evidence on the health outcomes. Each RNAO BPG includes a section with suggestions for indicators to be used; nevertheless, which ones are evaluated by the BPSO® in each BPG and how they are measured are defined in the international programme.</p><p id="par0120" class="elsevierStylePara elsevierViewall">In the BPSO®, the scope of application is defined to be the level of the units that implement the recommendations. Assessment is monthly during the first 3 years of implementation; the selection is non-probabilistic, evaluating all the hospital discharges or hospital and primary care visits performed in 5 days a month. There may be exceptions, such as with BPG that concern non-prevalent health problems in which the entire population seen is assessed, or the random selection of a sample from the population in a few specific, predefined situations.</p><p id="par0125" class="elsevierStylePara elsevierViewall">As for monitoring, there is an online data gathering tool, with personalised access, whose data forms correspond to the programme-established indicators. The database for the international programme is called Nursing Quality Indicators for Reporting and Evaluation (NQuIRE®).<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> In the BPSO® environment, Spain has a mirror platform called Care Evaluation Indicators (CarEvID®), which contains specific indicators for the regional and national Host environments as well. These platforms make it possible to produce feedback reports automatically.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Stage 6. Sustainability</span><p id="par0130" class="elsevierStylePara elsevierViewall">This stage concentrates on maintaining the change produced in the practice. The RNAO recommends following the United Kingdom’s National Health Service sustainability model, which considers factors relating to staff, process and institution.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> The BPSO® need to identify sustainability elements from early stages of the implementation so that the implementation of the evidence has taken hold and is maintained by the end of the period. A formal requirement is that, in the semester before the end of the 3 years of candidacy, or every 2 years in the case of designated BPSO®, the centre sets up a sustainability plan in which how it is going to continue to maintain the BPG implemented is indicated and new objectives for the following agreement period are proposed.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Lastly, in each of these stages the elements that promote implementation effectiveness are incorporated. Examples are the competitive participation to be selected as a BPSO® candidate, the selection of the appropriate BPG by the BPSO®, leadership by nurses with a multidisciplinary focus, process planning based on non-vertical work structures that have the support of the institution, simultaneous use of multiple strategies, continuous assessment and outcome feedback. All of this, will be mentored and supported by the BPSO Host.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Ethical considerations</span><p id="par0140" class="elsevierStylePara elsevierViewall">The institutions and the professionals that participate sign an agreement of confidentiality and commitment to the BPSO® programme with its ethical rules, respecting the current applicable national and international legislation for research, as well as the Declaration of Helsinki. The databases used in the assessment are coded and contain no personal information personal, so identifying the participants is impossible.</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results. Centres Committed to Excellence in Care® Programme</span><p id="par0145" class="elsevierStylePara elsevierViewall">In the first CCEC® cohort (2012–2014), 8 institutions were selected from the 33 proposals presented; these institutions were designated as BPSO® in 2015, after the 3 years of candidacy, as the objectives proposed were achieved. In the second cohort (2015–2017), 11 institutions were selected from 60 proposals, receiving their BPSO® designation in 2019. The implementation of the 8 institutions of the third cohort, selected from 25 proposals, began in 2018; their candidate period will end in December 2020, coinciding with the selection of the next cohort.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Currently, the programme in Spain includes 27 institutions, representing 271 centres. The institutions vary considerably; there are health areas, integrated organisations, consortia with or without university teaching universities, hospitals and primary care centres (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In the total group of Spanish BPSO®, there have been 20 clinical BPG implemented, to which a few BPG for healthy work environments have been added (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">The programme has affected multiple elements. Multidisciplinary organisational structures have been created, meeting periodically to plan and approach BPG implementation. Professional development efforts for healthcare and non-healthcare professionals, degree students and residents has been notable, including both implementation methodology and specific clinical training in the BPG. There are new or updated protocols and procedures to make applying the recommendations selected systematic and improve documentation. This has meant including and adapting the records in the computer applications and, consequently, training the professionals. Holding workshops and developing patient-focused educational materials are other aspects worthy of mention. Structural improvements have been analysed and carried out and specific new consultations have been set up. Implementing work environment BPG strengthens leadership, teamwork and assessment of clinical variability; in addition, these features serve as a support to promote the implementation of clinical BPG. The scientific impact achieved by the professionals can be seen in the publications, doctoral theses, projects for obtaining a Master, multicentre research projects, attendance at scientific and outreach events and so on. Another highly interesting aspect is the fact that new external alliances with other healthcare centres, patient associations, support groups and organisms in different administrations have been made; this is one of the most important results achieved for sustainability and the establishment of a network of centres collaboratively share, develop and disseminate the implementation of best practices.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> It also makes it possible to develop communities of practice in specific clinical topics.</p><p id="par0160" class="elsevierStylePara elsevierViewall">As for the impact on care, nursing staff valuations and the use of care plans have grown after 3 years of implementation. Health outcomes have also improved: falls have decreased and the injuries derived from them are less serious, peristomal skin complications have been reduced, exclusive breastfeeding has grown, among other favourable results. The difficulties and barriers to implementing the BPG and to maintaining sustainability in the context of the Spanish Health system have also been analysed, allowing future improvement actions. These results are presented in the current monograph.</p><p id="par0165" class="elsevierStylePara elsevierViewall">Because of its impact, the programme was chosen by the European region of the World Health Organisation as a best practice in its «Compendium of Best Practices for Transforming Health Services».<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">The structure and organisation of the programme have evolved, maintaining the implementation method but widening its reach, which includes the regional Host model. Nine centres selected in the first call of the regional BPSO Hosts in Asturias, the Balearic Islands and the Basque Country were incorporated in 2019 (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). That same year, the invitation to choose centres in the regional Andalusia and Canary Islands Hosts was published.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Implications of the programme for clinical practice and research</span><p id="par0175" class="elsevierStylePara elsevierViewall">The BPSO® initiative has great potential to enrich professional evidence-based practice and increase collaborative work in networks. It also impacts results in patient health and improves the quality of care given. The RNAO’s experience and follow-up of an evidence-based method has promoted effective application of knowledge, following a standardisation of criteria and processes that has permitted institutions of widely differing characteristics to apply the knowledge individually or in an integrated form, collaborating significantly.</p><p id="par0180" class="elsevierStylePara elsevierViewall">Using theories, models or frameworks can help those involved in such implementation, contributing with demonstrated knowledge about how and why implementation is successful.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> However, it should be remembered that any attempt to systematise the process has to be approached by creating opportunities to contextualise it in the local culture. The Knowledge to Action Model<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> has been adapted to develop the programme and it can be applied in institutions having extremely varied characteristics; in fact, all the BPSO® have designed their context-adapted strategies based on the evidence. In a context different from implementing BPG in BPSO®, Haines & Waldron<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> indicate how to carry out the transfer of knowledge to prevent falls using the Knowledge to Action framework, after analysing the outcomes of clinical trials that assess the effectiveness of programmes for preventing falls with individual and multifactor activities. They point out the need to apply in practice only elements based on a strict method.</p><p id="par0185" class="elsevierStylePara elsevierViewall">Implementation studies vary in goals, quality and patient outcomes. The results of the programme in Spain are consistent with studies from other countries after the implementation of RNAO BPG in BPSO®. Significant improvements were found after applying the BPG in the majority of the indicators on asthma, diabetic foot care and venous ulcer care,<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> and there was a decrease in pressure ulcers, falls from hospitalised elderly and pain self-reported as severe or moderate.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">According to Lynch et al.,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> theoretical focuses to assess and interpret the findings of an implementation process tend to be applied retrospectively, with the limitation of not being able to design a planned process in which the strategies developed are informed by the evolution of the implementation and might be more successful. A strength of the BPSO® programme is that it is supported by an evidence-based theoretical model and it is applied in a planned fashion harmonised throughout the entire structure.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions and future development lines</span><p id="par0195" class="elsevierStylePara elsevierViewall">The growing number of BPSO® centres in Spain and the increase in the years of implementing the different BPG will make it possible to ascertain the effectiveness of the programme. Likewise, these factors will permit in-depth examination of strategies that promote applying evidence in practice, their sustainability and their expansion (the last, an area of knowledge that is still scanty and evolving.</p><p id="par0200" class="elsevierStylePara elsevierViewall">Various future lines of work have been proposed. On the one hand, we need to know which interventions derived from each BPG are associated with outcome effectiveness, and what the minimum set of activities to reach these outcomes is. Likewise, we need to delve into the knowledge on the specific characteristics of the context and on the necessary time for promoting achievement of the best results expected. Finally, the great challenge is performing a cost-effectiveness analysis as one of the key elements for the decision-makers at institution and health system levels.</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Funding</span><p id="par0205" class="elsevierStylePara elsevierViewall">The programme for implementing BPG in CCEC® is partially funded by the <span class="elsevierStyleGrantSponsor" id="gs0005">Spanish Centre for Evidence-Based Care: Centre of Excellence at the Joanna Briggs Institute</span>. It has also received funding through the <span class="elsevierStyleGrantSponsor" id="gs0010">Healthcare Research Fund</span> (Spanish: <span class="elsevierStyleItalic">Fondo de Investigación Sanitaria [FIS]</span>): file numbers <span class="elsevierStyleGrantNumber" refid="gs0010">PI12/01603</span> and <span class="elsevierStyleGrantNumber" refid="gs0010">PI16CIII00032</span>.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1352242" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1243540" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1352241" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1243539" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Best Practice Spotlight Organizations®" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "The BPSO Host Model" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "BPSO® methodology" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Stage 1. Identifying the problem and forming selected CCEC®" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Stage 2. Adapting to the local context" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Stage 3. Assessing facilitating aspects and barriers" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Stage 4. Adapting and implementing the interventions" ] 4 => array:2 [ "identificador" => "sec0045" "titulo" => "Stage 5. Monitoring and assessing results" ] 5 => array:2 [ "identificador" => "sec0050" "titulo" => "Stage 6. Sustainability" ] 6 => array:2 [ "identificador" => "sec0055" "titulo" => "Ethical considerations" ] ] ] 8 => array:2 [ "identificador" => "sec0060" "titulo" => "Results. Centres Committed to Excellence in Care® Programme" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Implications of the programme for clinical practice and research" ] 10 => array:2 [ "identificador" => "sec0070" "titulo" => "Conclusions and future development lines" ] 11 => array:2 [ "identificador" => "sec0075" "titulo" => "Funding" ] 12 => array:2 [ "identificador" => "xack468733" "titulo" => "Acknowledgements" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-08-08" "fechaAceptado" => "2019-09-25" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1243540" "palabras" => array:4 [ 0 => "Implementation" 1 => "Best Practice Guidelines" 2 => "Best Practice Spotlight Organization®" 3 => "Evidence-based practice" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1243539" "palabras" => array:4 [ 0 => "Implantación" 1 => "Guías de Buenas Prácticas" 2 => "Centros Comprometidos con Excelencia en Cuidados®" 3 => "Práctica basada en la evidencia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">The implementation of Best Practice Guidelines is effective in improving clinical practice and reducing clinical variability. The Best Practice Guidelines of the Ontario Nurses Association have been implemented in Spain since 2012 following the principles of the Canadian programme of the Best Practice Spotlight Organisations®. The Nursing and Healthcare Research Unit (Investén-isciii) coordinates this programme in Spain, having been nominated BPSO host by the Ontario Nurses Association.</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Four strategies were followed. Translation of the Best Practice Guidelines, dissemination of same and of the programme, implementation of the Best Practice Guidelines and assessment of the results in competitively selected centres and, finally, the development of sustainability mechanisms.</p><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Implementation is based on the theoretical Knowledge to Action model, which establishes a cycle of six phases. Identification of the problem and training of selected BPSO®; adaptation to the local context; assessment of facilitators and barriers; adaptation and implementation of interventions; monitoring and evaluation of results and sustainability. Each of these phases incorporate evidence-based elements that promote the effectiveness of implementation, such as the competitive selection of candidates to participate in the programme, selection by the institution of the guidelines to be implemented, leadership by nurses with a multi-professional approach, planning of the process from work structures that are non-vertical but with the support of the institution, the simultaneous use of multiple strategies, ongoing assessment and feedback of results. All of which is mentored and supported by the BPSO Host.</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">There are currently 27 institutions in Spain of different characteristics that implement a total of 20 clinical guidelines. The scope and structure of the programme has recently been extended with regional BPSO Host coordinating centres, which has brought the number of institutions to 36 and the number of implemented clinical guidelines to 22.</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">The programme has had a positive impact on organisations and the system, on care processes and on patient health. This is evidenced by enriched evidence-based professional practice, the promotion of collaborative networking and by improved patient health outcomes and the quality of care provided.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">La aplicación de Guías de Buenas Prácticas es efectiva en la mejora de la práctica clínica y en la disminución de la variabilidad clínica. En España se implantan desde 2012 las Guías de Buenas Prácticas de la Asociación de Enfermeras de Ontario a través del Programa de Centros Comprometidos con la Excelencia en Cuidados, siguiendo los principios del programa canadiense <span class="elsevierStyleItalic">Best Practice Spotlight Organizations</span>®. La Unidad de Investigación en Cuidados y Servicios de Salud (Investén-isciii) coordina dicho programa en España, tras ser nombrada BPSO Host por la Asociación de Enfermeras de Ontario.</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Se han seguido cuatro estrategias. Traducción de las Guías de Buenas Prácticas, difusión de las mismas y del programa, implantación de las GuÍas de Buenas Prácticas y evaluación de los resultados en centros seleccionados de forma competitiva, y, finalmente, desarrollo de mecanismos de sostenibilidad.</p><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La implantación se apoya en el modelo teórico <span class="elsevierStyleItalic">Knowledge to Action</span>, que establece un ciclo de seis fases. Identificación del problema y formación a CCEC® seleccionados; adaptación al contexto local; evaluación de los facilitadores y barreras; adaptación e implantación de las intervenciones; monitorización y evaluación de resultados y sostenibilidad. En cada una de estas fases se incorporan aquellos elementos basados en la evidencia que favorecen la efectividad de la implantación, como son la concurrencia competitiva para ser seleccionado candidato a participar en el programa, la selección por la institución de las Guías a implantar, el liderazgo por enfermeras con un enfoque multiprofesional, la planificación del proceso a partir de estructuras de trabajo no verticales pero con apoyo de la institución, el uso de múltiples estrategias de forma simultánea, la evaluación continuada y la retroalimentación de resultados. Todo ello tutorizado y apoyado desde el BPSO Host.</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Actualmente en España hay 27 instituciones de diferentes características que implantan en total 20 guías clínicas. Recientemente se ha ampliado el alcance y estructura del programa con centros coordinadores BPSO Host regionales, lo que ha ampliado el número de instituciones a 36 y el número de Guías clínica implantadas a 22.</p><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">El programa ha tenido un impacto positivo a nivel de las organizaciones y el sistema, en los procesos de cuidados y en la salud de los pacientes. Se observa en el enriquecimiento de la práctica profesional basada en la evidencia, el fomento del trabajo colaborativo en red, así como en la mejora en los resultados en salud de los pacientes y en la calidad de los cuidados prestados.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: González-María E, Moreno-Casbas MT, Albornos-Muñoz L, Grinspun D, Grupo de Trabajo del Programa de implantación de buenas prácticasen Centros Comprometidos con la Excelencia en Cuidados®. Implantación de Guías de Buenas Prácticas en España a través del Programa de Centros Comprometidos con la Excelencia en Cuidados®. Enferm Clin. 2020;30:136–144.</p>" ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">RNAO: Registered Nurses’ Association of Ontario.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Centre \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Cohort \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Number of beds or population<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Champions \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vall d'Hebron University Teaching Hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="9" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,251 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">847 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Rafael Méndez de Lorca Hospital & the \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">287 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">158 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">University of Murcia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Integrated Healthcare Management for Albacete<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">736 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">133 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Medina del Campo Hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">119 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ponferrada II Health Centre (Primary Care, Integrated Healthcare Management for the Bierzo region)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">23,150<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Doctor José Molina Orosa Hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">292 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">75 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">San Carlos Clinical Hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">860 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">285 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Specialised Care Management. Torrelavega-Reinosa Health Areas. Sierrallana & Tres Mares Hospitals \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">301 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">144 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Donostialdea Integrated Healthcare Organisation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="11" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">715,000<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">190 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Navarra Hospital Complex \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,086 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">110 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Health Area for Menoría: Mateu Orfila Hospital & Primary Care Health Centres \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">95,000<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">81 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Arnau de Vilanova-Santa María University Teaching Hospital Consortium & the Faculty of Lleida \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">692 (463 + 229) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">205 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Puerto Real University Teaching Hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">304 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">120 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Virgen de las Nieves University Teaching Hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,853 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">280 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">San Cecilio University Teaching Hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">752 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Debabarrena Integrated Healthcare Organisation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76,000<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">76 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">José María Llanos Health Centre \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9,000<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Integrated Healthcare Management for Alcázar de San Juan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">130,699<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">99 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Valle del Nalón Hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">223 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Integrated Management Structure for Lugo, Cervo & Monforte de Lemos \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="8" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a></td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">333,511<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">94 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Integrated Healthcare Organisation Araba \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">340,000<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">161 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Santa Lucía General University Teaching Hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">644 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">109 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Integrated Healthcare Management for La Coruña \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">547,328<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">36 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Guadarrama Hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">144 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Germans Trias i Pujol University Teaching Hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">502 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">86 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Alcorcón Foundation University Teaching Hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">400 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">116 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Málaga Regional University Teaching Hospital \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1,076 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">64 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2321232.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Population of reference in healthcare centres or in integrated health areas.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Institution whose structure has been modified after starting as a CCEC<span class="elsevierStyleItalic">®</span> (<span class="elsevierStyleItalic">Centro Comprometido con la Excelencia en Cuidados®</span>).</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Institutions in the 3 cohorts of Centres Committed to Excellence in Care<span class="elsevierStyleItalic">®</span> (CCEC<span class="elsevierStyleItalic">®</span>) and number of champions.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">BPSO®: Best Practice Spotlight Organizations®; RNAO: Registered Nurses’ Association of Ontario.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">RNAO BPG implemented \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Spanish BPSO® Institutions that have implemented RNAO BPG \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ostomy care and management \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Breastfeeding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preventing falls and reducing lesions caused by falls. Fourth edition \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pain assessment and management \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assessment and selection of vascular access devices. Care and maintenance of vascular accesses to reduce complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Risk assessment and prevention of pressure ulcers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Guidelines for healthy work environments \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Continuous care assessment of ictus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reducing foot complications in individuals with diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assessment and management of pressure ulcers by multidisciplinary teams \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Care focused on the person and the family \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Integrating tobacco-related interventions in daily practice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary prevention of child obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assessment and care of adults at risk of ideation and suicidal behaviour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assessment and management of diabetic foot ulcers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Care and support for families faced with unexpected and foreseeable circumstances \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Management of incontinence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Administering subcutaneous insulin in adults with type 2 diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nursing care for dyspnea: the sixth vital sign in individuals with COPD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Promoting healthy development in adolescents \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2321231.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">RNAO Best Practice Guidelines (BPG) implemented in Spain and number of BPSO® institutions that implemented them.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">BPSO®: Best Practice Spotlight Organizations®; RNAO: Registered Nurses’ Association of Ontario.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">RNAO BPG implemented \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Institutions that have implemented RNAO BPG \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assessment and selection of vascular access devices \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Breastfeeding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preventing falls and reducing lesions caused by falls. Fourth edition \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Guidelines for healthy work settings \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ostomy care and management \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Promoting safety: alternatives to the use of restraints \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assessment and management of pressure ulcers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pain assessment and management \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Care focused on the person and the family \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Crisis interventions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Primary prevention of child obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Assessment and care of adults at risk of ideation and suicidal behaviour \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2321233.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">RNAO Best Practice Guidelines (BPG) implemented and number of BPSO® institutions coordinated by the regional BPSO Hosts that implement them.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:30 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "From best evidence to best practice: effective implementation of change in patient care" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. 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Special Article
The implementation of Best Practice Guidelines in Spain through the Programme of the Best Practice Spotlight Organizations®
Implantación de Guías de Buenas Prácticas en España a través del Programa de Centros Comprometidos con la Excelencia en Cuidados®
Esther González-Maríaa, María Teresa Moreno-Casbasa,
, Laura Albornos-Muñozb, Doris Grinspunc, Grupo de Trabajo del Programa de implantación de buenas prácticas en Centros Comprometidos con la Excelencia en Cuidados®
Autor para correspondencia
a Unidad de Investigación en Cuidados y Servicios de Salud (Investén-isciii), Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable (CIBERFES), Instituto de Salud Carlos III, Madrid, Spain
b Unidad de Investigación en Cuidados y Servicios de Salud (Investén-isciii), Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Instituto de Salud Carlos III, Madrid, Spain
c Registered Nurses’ Association of Ontario (RNAO), Toronto, Ontario, Canada