Best Practices


Quality of care is one of the four pillars of our 2021–2026 Strategic Plan. It states that, “We will deliver the highest quality care to achieve the best possible outcomes for our patients and their families.”

Within this pillar we: employ best practices to promote safe care and optimize outcomes; and expand the use of evidence-based practices and measurable outcomes to drive continuous quality improvement.

This is a natural fit with RNAO’s Best Practice Spotlight Organization (BPSO) program, which is ‘targeted to support the uptake and sustainability of best practice guidelines (BPG) to optimize outcomes.’


Staff were supported to present the RVH “Up for Meals” falls prevention and reduction initiative as part of the Best Practice Spotlight Organization (BPSO) conference held in Toronto in September 2023. This is one of many ‘best practices’ that our BPSO champions have implemented at RVH. 

BP Falls poster  


RVH Patient Safety 2022 (PDF) 

RVH receives funding to help implement best practices (PDF) 

RVH proposal team

RVH’s team of nurses responded to the RNAO’s RFP in late 2014. The RVH proposal team includes Jessica Gilbert, Clinical Manager of the Acute Care Unit; Christene Ferguson, Vice-President of Patient Care Services; Janice Verch-Whittington, Clinical Manager of the Nephrology Program; Charlene Hanniman, Clinical Manager of Complex Continuing Care; Kim Dick, Clinical Manager of Emergency/Ambulatory Care; Jennifer Valiquette, Manager of the Regional Assault Care Program; Rhonda Normandeau, Clinical Manager of the Operating Room/Oncology/CSS; and Kelly Hebert, Infection Control Coordinator (not pictured).


In 2015, RVH responded to a request for proposal to obtain funding from the Registered Nurses Association of Ontario (RNAO). The funds would be used to implement five of RNAO’s best practices over the following three years.

The guidelines that RVH would implement included:

  • Person & Family Centred Care BPSO NODD Video (RVH staff)
  • Screening for Delirium
  • Decision Support for Adults Living with Chronic Kidney Disease
  • Women Abuse: Screening and Initial Response
  • Assessment and Management of Pain

BPSO Update – October 2017 (PDF) 

The successful implementation of those best practice guidelines (BPGs) would lead to RVH’s BPSO designation in 2018.

 staff imagestaff


The most important element of our success was our staff. More than 50 frontline nurses and allied healthcare staff supported the implementation of BPGs and evidence-based practice across the organization, most as Best Practice Champions and many on the advanced team for each best practice that was to be implemented.

RVH holds an annual BPSO retreat day during Nursing Week with guest speakers, patient stories and updates on our BPG implementation.

Grace SuvaJulie Langlois 

Left, Grace Suva, our BPSO Coach from RNAO 2016; & right, 2018, Julie Langlois, Accreditation Canada 2017

Best Practice Champions 2016 Meg Soper Nursing Week BPSO Retreat Day 2019

Left, Best Practice Champions 2016; middle, Meg Soper, 2019; and right, Nursing Week BPSO Retreat Day 2019


RVH received BPSO designation for 2022–2024 for best practice activities that included:

  • establishment of Best Practice Champion Working Groups and a Best Practice Leadership team that meet regularly
  • collaboration and co-creation of initiatives with our Patient and Family Advisory Council (PFAC)
  • implementation of the Preventing Falls and Reducing Injury from Falls BPG – led by the RVH Physiotherapy team-see Sept 1, 2022 staff communique & June 23 & 28, 2022
  • implementation of an “Up for Meals” initiative on the Complex Continuing Care unit to increase functional mobility for appropriate patients and reduce falls
  • implementation of the Adopting eHealth Solutions BPG/using nurse Champions as EPIC (electronic health information system) Super Users.

End PJ paralysis group Up For Meals poster RVH Physio team

 Left, “Up for Meals” initiative in Complex Continuing Care; middle, Up for Meals Initiative poster; right, RVH Physio team


EPIC poster

Implementing EPIC poster


Press release: Renfrew Victoria Hospital awarded two-year BPSO® designation