Disability and Rehabilitation

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/idre20

Identifying clinicians’ priorities for the

implementation of best practices in cognitive
rehabilitation post-acquired brain injury

Valérie Poulin, Alexandra Jean, Marie-Ève Lamontagne, Marc-André Pellerin,

Anabelle Viau-Guay & Marie-Christine Ouellet

To cite this article: Valérie Poulin, Alexandra Jean, Marie-Ève Lamontagne, Marc-André Pellerin,
Anabelle Viau-Guay & Marie-Christine Ouellet (2021) Identifying clinicians’ priorities for the
implementation of best practices in cognitive rehabilitation post-acquired brain injury, Disability and
Rehabilitation, 43:20, 2952-2962, DOI: 10.1080/09638288.2020.1721574

To link to this article: https://doi.org/10.1080/09638288.2020.1721574

Published online: 11 Feb 2020.

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DISABILITY AND REHABILITATION
2021, VOL. 43, NO. 20, 2952–2962
https://doi.org/10.1080/09638288.2020.1721574

REHABILITATION IN PRACTICE

Identifying clinicians’ priorities for the implementation of best practices in

cognitive rehabilitation post-acquired brain injury
Vale
rie Poulina,b, Alexandra Jeana, Marie-Eve Lamontagneb,c , Marc-Andr
e Pellerinb,c,d, Anabelle Viau-Guayd,e
and Marie-Christine Ouelletb,f
a
Department of Occupational Therapy, Universit
e du Qu
ebec a Trois-Rivieres, Trois-Rivieres, Canada; bCentre for Interdisciplinary Research in
Rehabilitation and Social Integration (CIRRIS), Centre Int
egr
e Universitaire de Sant
e et de Services Sociaux de la Capitale-Nationale (CIUSSS-CN),
Institut de R
eadaptation en D
eficience Physique de Qu
ebec (IRDPQ), Qu
ebec, Canada; cDepartment of Rehabilitation, Universit
e Laval, Qu
ebec,
Canada; dFaculty of Education Sciences, Universit
e Laval, Qu
ebec, Canada; eCentre de Recherche et d’intervention sur la R
eussite Scolaire,
Universit
e Laval, Qu
ebec, Canada; fSchool of Psychology, Universit
e Laval, Qu
ebec, Canada

ABSTRACT ARTICLE HISTORY

Purpose: To identify clinicians’ perceptions of current levels of implementation of cognitive rehabilitation Received 18 June 2019
best practices, as well as individual and consensual group priorities for implementing cognitive rehabilita- Revised 20 December 2019
tion interventions as part of a multi-site integrated knowledge translation initiative. Accepted 22 January 2020
Method: A two-step consensus-building methodology was used, that is the Technique for Research of
KEYWORDS
Information by Animation of a Group of Experts (TRIAGE), including a cross-sectional electronic survey Best practices; cognitive
followed by consensual in-person group discussions to identify implementation priorities from a list of rehabilitation; priority
evidence-based practices for cognitive rehabilitation following traumatic brain injury and stroke. Thirty- setting; implementation;
eight professionals from three rehabilitation teams (n ¼ 9, 13 and 16) participated, including neuropsy- acquired brain injury
chologists, occupational therapists, speech-language pathologists, educators, clinical coordinators and pro-
gram managers. Descriptive statistics were used to document the perceived levels of implementation as
well as individual and consensual group priorities.
Results: Most of the best practices (81–100%) were perceived as at least partially implemented by a min-
imum of 50% of the participants but only 20–25% of the practices were considered fully implemented.
Findings suggest that current practices are mostly consistent with general cognitive rehabilitation princi-
ples suggested in guidelines but that further efforts are needed to support the application of specific
cognitive rehabilitation strategies and interventions. Executive function and self-awareness retraining, as
well as interventions promoting the generalization of skills, were among the highest implementation pri-
orities. Consensual in-person group discussions, included as part of the TRIAGE process, also helped to
define and operationalize these best practices into more specific intervention components according to
the teams’ needs and priorities.
Conclusions: TRIAGE consensus-building methodology can be used to engage stakeholders and support
clinicians’ decision-making regarding the identification of implementation priorities in cognitive rehabilita-
tion post-ABI in order to tailor the implementation process to local needs.

ä IMPLICATIONS FOR REHABILITATION

 The Technique for Research of Information by Animation of a Group of Experts (TRIAGE) can be used
to support clinicians’ decision-making regarding the identification of implementation priorities in cog-
nitive rehabilitation post-ABI.
 The combination of individual consultations followed by consensual in-person group discussions, as
part of the TRIAGE process, may help clinicians in defining and operationalizing best practices into
more specific intervention components to implement.
 Effective implementation strategies are needed to support the use of specific cognitive rehabilitation
interventions in prioritized areas, such as executive function and self-awareness retraining, as well as
generalization of skills.
 Some differences in clinicians’ perceived priorities point up the importance of tailoring implementa-
tion to local needs and contexts from the early stages in the process.

Introduction
Cognitive function disorders are among the most common and
disabling long-term sequelae of acquired brain injury (ABI) such
as traumatic brain injury (TBI) and stroke [1–3]. Cognitive deficits
affect participation in rehabilitation [4] and increase the risk of
functional dependence [1,2] and poor social participation [5–7].
Detection and effective treatment of these disorders are there-
fore critical.

CONTACT Val
erie Poulin valerie.poulin@uqtr.ca Department of Occupational Therapy, Universit
e du Qu
ebec a Trois-Rivieres, 3351 Boul. des Forges, P.O. Box
500, Trois-Rivieres G9A 5H7, Canada
ß 2020 Informa UK Limited, trading as Taylor & Francis Group

Over the last decade, there has been growing interest in and
research into the management of cognitive disorders post-ABI,
and recent best practice guidelines include recommendations spe-
cific to cognitive rehabilitation [8,9]. Cognitive rehabilitation has
been defined as a “systematic, functionally-oriented service of
therapeutic activities derived from the assessment and under-
standing of the patient’s brain-behavioural deficits”
[10, p.1596–1597] which aims to improve dysfunctional cognitive
processes and everyday functioning [11]. Different approaches
have been suggested [10,12–14]. Some are oriented toward bot-
tom-up retraining of specific cognitive processes, such as retrain-
ing attention and working memory with computer-based tasks,
while others involve top-down training using compensatory strat-
egies, such as training in the use of metacognitive problem-solv-
ing strategies or external aids to improve everyday activities
compromised by cognitive impairments (e.g., memory, planning)
[10,12–14]. According to best practice guidelines, cognitive
rehabilitation should be personalized and designed to achieve
changes that improve functioning in meaningful areas of life
deemed important to the patient [8,9].
While clinicians are encouraged to implement the recommen-
dations in these guidelines, previous studies have suggested there
are gaps between best and actual practices in cognitive rehabilita-
tion post-ABI [15–19]. Findings from Canadian and Australian sur-
veys concerning stroke rehabilitation practices suggested a low
prevalence of the use of interventions that address specific cogni-
tive functions, such as those aimed at enhancing problem-solving
strategies or employing computer programs designed to retrain
executive processes [16,17]. Similarly, a qualitative study of health-
care providers in the United Kingdom reported perceived gaps in
care for patients with cognitive and memory deficits [18]. In the
context of TBI care, a recent Australian survey [19] indicated that
while many reported practices appeared at least partly consistent
with cognitive rehabilitation guidelines, other interventions were
applied less often, including retraining attention and training
carers. The rapidly growing body of published research in this
area, coupled with insufficient efforts to translate this evidence to
frontline clinicians, may explain some of these gaps. In addition,
the complexity of cognitive rehabilitation can make it particularly
challenging to put the evidence into practice [15]. Indeed, many
implementation theories and frameworks, such as the
Consolidated Framework for Implementation Research [20], sug-
gest that the complexity of an intervention can pose additional
challenges to its implementation. More specifically, cognitive
rehabilitation involves complex interventions that clinicians must
select and adapt according to the individual’s cognitive and com-
munication profile [15]. Furthermore, team members from various
disciplines need to collaborate with the individual and family to
deliver interventions consistently and promote the generalization
of skills to everyday life. To address these challenges, further
efforts to implement recommendations in the guidelines specific
to cognitive rehabilitation post-ABI are needed in this area where
“translation to frontline clinicians has been weak” [15, p.275]. As
part of an international workshop, an expert panel of clinicians
and researchers concluded that cognitive rehabilitation was one
of the top three high-priority areas to implement in TBI care [15].
An integrated knowledge translation (iKT) approach, where
researchers and ends users collaborate to identify and implement
relevant research recommendations [21,22], may hold promise for
fostering the implementation of guidelines in cognitive rehabilita-
tion. Gagliardi et al. posited that iKT might “enhance researcher
understanding of the research user context and needs, thereby
enhancing the relevance of the generated research, and
IDENTIFYING IMPLEMENTATION PRIORITIES 2953
increasing research user understanding of the research process,
awareness of the research, and appreciation for how and when it
can be applied.” [23, p.105]. Also, as suggested by the
Knowledge-to-Action framework [24], engaging clinicians in iden-
tifying their knowledge needs and priority issues, as a first step in
this process, could increase the relevance of the research for the
local context and, potentially, the success of the implementa-
tion [25,26].
While there may be various ways to involve rehabilitation
teams in assessing needs and prioritizing which evidence-based
practices to implement [27], recent studies have highlighted the
importance of group discussions to compare points of views,
resolve differences in perceptions and build a common vision
among team members [28–30]. This may be particularly important
when the practices to implement are complex and involve inter--
professional collaboration, as is the case with cognitive rehabilita-
tion interventions [15,31,32]. Moreover, given the potential
challenges and efforts in implementing cognitive rehabilitation
interventions, priorities for implementation should be carefully
identified [15], based on rehabilitation teams’ perceived needs,
resources, and environmental context [26], in addition to the level
of evidence. Conversely, trying to implement these complex inter-
ventions without considering stakeholders’ perceptions of these
practices, including their perceived level of implementation and
importance [26], could potentially result in less adoption of
desired practices [33,34]. It is thus important to seek a greater
understanding of the perceptions and priorities of clinicians from
various disciplines, using well-defined approaches [35], in order to
inform future knowledge translation initiatives for implementing
cognitive rehabilitation best practices post-ABI.
Therefore, the general objective of this study, which is the first
step in a multi-site integrated knowledge translation (iKT) initia-
tive, was to document clinicians’ priorities for the implementation
of best practices in cognitive rehabilitation post-ABI. More
specifically, the study aimed to identify (1) perceived level of
implementation of evidence-based practices in cognitive rehabili-
tation post-ABI, and to determine (2) individual preferences as
well as (3) consensual group preferences for implementing cogni-
tive rehabilitation interventions.
Methods
Design
This study used TRIAGE, a two-step consensus-building method-
ology [36–38], consisting of a cross-sectional electronic survey fol-
lowed by group discussions. The TRIAGE process was executed
independently with three separate interdisciplinary teams provid-
ing inpatient and outpatient services post-ABI in two rehabilitation
centers in the province of Que
bec, Canada. The study protocol was
approved by the university at which the research was conducted
(#CER-16-227-07.11) and by the research ethics committee of the
rehabilitation centers where the participants were recruited (#EMP-
2016-523).
Participants
Of the three interdisciplinary teams involved in this study
(referred to as teams 1, 2 and 3 in the following text), two worked
at the same rehabilitation center serving the population from
three sociodemographic regions. One team (team 1) provided
stroke rehabilitation services while the other (team 2) had expert-
ise in TBI rehabilitation. Both provided inpatient and outpatient
rehabilitation services in a university teaching rehabilitation center
2954 V. POULIN ET AL.
in a large urban area. The third team (team 3) provided inpatient
rehabilitation services post-ABI, including stroke and TBI, in a
healthcare center in a smaller urban area in a different sociode-
mographic region. These three rehabilitation teams serving vari-
ous populations with ABI from different sociodemographic
regions were selected in order to explore a variety of perspectives
and needs of clinicians working in different clinical contexts.
Clinicians from various disciplines delivering cognitive rehabili-
tation interventions, as well as clinical coordinators and program
managers, were invited to participate in the study. They were eli-
gible if they: (1) worked as a clinician in occupational therapy,
neuropsychology, special education, speech and language ther-
apy, or other relevant discipline suggested by the manager, or as
a clinical coordinator or manager in a rehabilitation program pro-
viding services post-ABI (including stroke or TBI); (2) spent at least
25% of their position’s time in the clinical program involved in
this study; (3) had worked in that program for the previous
6 months at the time of study recruitment; and (4) spoke French.
No exclusion criteria were applied.
Recruitment procedures
A meeting was held with the program manager from each team
to explain the study and identify potentially eligible participants.
With the manager’s agreement, the research team sent an email
to all potentially eligible team members to inform them about
the study’s aims and methods (electronic survey and
group meeting).
Data collection procedures
The TRIAGE data collection methods included (1) a preparation
phase to document individuals’ perspectives and priorities using
individual data collection methods, followed by (2) a production
phase using group discussions to clarify important concerns and
discuss the rationale for these priorities, in order to obtain a
team consensus.
In the present study, the preparation phase consisted of an
electronic survey to identify the perceived level of implementa-
tion of evidence-based practices in cognitive rehabilitation post-
ABI, and to determine individual priorities for implementing these
interventions. Then, in the production phase, team members par-
ticipated in a consensual face-to-face group discussion lasting
approximately 90 min. An animator guided the participants’ dis-
cussions with the aim of categorizing the list of priorities using a
visual aid, in order to reach consensus about one practice to
implement in each team. This consensus-building technique was
used in previous research in rehabilitation contexts to support
decision-making about important outcomes [28,39] or indicators
of quality and performance for rehabilitation services [29,40].
Measures
Sociodemographic and clinical variables
For both the preparation and production phases, participants’ socio-
demographic and clinical characteristics (e.g., education and clinical
experience) were collected using self-administered questionnaires.
Individuals’ perceptions of their current level of implementation
of cognitive rehabilitation practices and implementation priorities
(preparation phase)
An electronic survey designed with the Eval&Go platform (http://
www.evalandgo.com/) was used to document (1) individuals’
perceptions of their current level of implementation of evidence-
based cognitive rehabilitation practices, as well as (2) implementa-
tion priorities. The lists of practices were based on two recent
evidence-based guidelines for cognitive rehabilitation including:
(1) the Cognition module from the Canadian Stroke Best Practices
Recommendations [9] and (2) the Institut national d’excellence en
sante
et en services sociaux (INESSS) – Ontario Neurotrauma
Foundation (ONF) Clinical Practice Guideline for the Rehabilitation
of Adults with Moderate to Severe TBI [8]. These guidelines were
created by internationally recognized organizations using rigorous
methodologies and with input from ABI experts and local stake-
holders, including several participants from the province of
Quebec, Canada, where the present study was conducted.
Relevant recommendations concerning non-pharmacological inter-
ventions were identified by the first author (VP), who is a
researcher with expertise in cognitive rehabilitation post-ABI, and
validated by two other researchers (MCO and MEL) with research
expertise in psychology and iKT in the area of neurorehabilitation.
Three slightly different versions of the electronic questionnaire
were created, one for each team, with a list of 16 evidence-based
practices specific to stroke rehabilitation for team 1 [9], 16 practi-
ces specific to TBI rehabilitation for team 2 [8], and a combination
of 15 practices for cognitive rehabilitation post-ABI for team 3
[8,9]. The majority of the cognitive rehabilitation interventions
included in each list were very similar since many intervention
studies and systematic reviews in this area focused on combined
samples of patients with TBI or stroke [12]. There were only a few
practices specific to stroke (e.g., mirror therapy for unilateral
inattention) or TBI guidelines (e.g., cognitive behavior therapy for
reducing attentional deficits thought to be secondary to sleep-
wake disorders, anxiety or depression). For each practice in the
list, participants rated its current implementation level in their
team on a 3-point scale (fully implemented, partially imple-
mented, or not implemented at all). They could also indicate if
this practice was not applicable in their clinical context. In the
next section of the survey, they chose their top 5 priorities for evi-
dence-based practices to implement in their team, using the
same list. They ranked those five practices from 1 (their top prior-
ity) to 5 (fifth priority) according to perceived clinical relevance,
feasibility and implementation level. Participants could also add
comments to explain their perspective (see Appendix 1 for the
survey questions).
The development of these scales was based on a previous
electronic survey of perceived implementation gaps in TBI
rehabilitation [26]. To verify the clarity of the questions and
usability of the survey platform, the questionnaire was pretested
with two clinicians with clinical expertise similar to that of the
study participants. Following their feedback, minor changes were
made to improve the clarity of the wording of some best practice
recommendations and instructions regarding the ranking of
implementation priorities were added.
Participants in the study had 2 weeks to complete the survey
questionnaire, which took approximately 15 to 20 min. Two
reminders were sent, one and 2 weeks after the initial email.
Participants were invited to contact the research team if they
needed further information or clarifications about the practices.
Consensual group preferences for implementing cognitive
rehabilitation interventions post-ABI (production phase)
All practices selected by at least two team members in the elec-
tronic survey (individual preparation phase) were discussed during
the group meeting (production phase) in order to reach a consen-
sus on one practice to implement in each team. The discussions
 IDENTIFYING IMPLEMENTATION PRIORITIES 2955

were facilitated by a trained animator (VP), who had previous Table 1. Participants’ sociodemographic and clinical characteristics.
experience managing group discussions. During this phase, the Team 1 Team 2 Team 3
animator acted as a facilitator by creating a positive climate that (n ¼ 13) (n ¼ 16) (n ¼ 9)
fostered the productive exchange of ideas [36]. The animator also Gender (n, %)
summarized and highlighted key elements from the discussions Female 13 (100.0) 14 (87.5) 9 (100.0)
Male 2 (12.5)
while remaining neutral with regard to the participants’ choices. Age (n, %)
After explaining the objectives and procedures for this phase 20–29 1 (7.7) 2 (12.5) 3 (33.3)
(see Appendix 1), the animator read the list of practices. The 30–39 6 (46.2) 3 (18.8) 1 (11.1)
strength of the evidence supporting each recommendation (i.e., 40–49 2 (15.4) 9 (56.3) 3 (33.3)
50–59 3 (23.1) 2 (12.5) 1 (11.1)
level A, B or C) was also identified in a written summary given to
60–69 1 (7.7) 1 (11.1)
the participants. As necessary, the animator provided further clarifi- Discipline (n, %)
cations about the practices to ensure a common understanding. Occupational therapy 7 (53.8) 8 (50.0) 4 (44.4)
Each practice was transcribed on a card and placed on the wall of Speech therapy 2 (22.2)
Neuropsychology 5 (38.5) 8 (50.0) 1 (11.1)
the room, which was divided into six sections: Memory, Grouping,
Special education 1 (7.7) 1 (11.1)
Fridge, Veto, Garbage and Selection. At the beginning of the session, Nursing 1 (11.1)
all cards were placed in the Memory section. Over the course of the Education (n, %)
discussions, the animator invited the participants to move the College 1 (7.7) 1 (11.1)
cards to different sections of the wall, according to perceived prior- Bachelor 6 (46.2) 8 (50.0) 3 (33.3)
Master 3 (23.0) 2 (12.5) 5 (55.6)
ities and consensual decisions. Participants could combine, divide PhD 3 (23.0) 6 (37.5)
or modify practices (e.g., include additional ideas) in the Grouping Job title (n, %)
section. Rejected practices were placed in the Garbage section, Clinician 12 (92.3) 15 (93.8) 8 (88.9)
while practices concerning which participants disagreed or were Clinical coordinator 1 (7.7) 2 (12.5)
Manager 1 (7.7) 1 (6.3) 1 (11.1)
ambivalent were placed in the Fridge section to be discussed later. Rehabilitation setting (n, %)
The Veto section was used if participants could not reach a consen- Inpatient 9 (69.2) 12 (75.0) 9 (100.0)
sus about some practices, which would then be submitted to Outpatient 6 (46.2) 13 (81.3) 1 (11.1)
external experts. The best practices that had the closest fit with the Years of clinical experience (mean, SD)
Total 15.2 (9.2) 16.6 (8.5) 12.9 (8.3)
participants’ priorities were placed in the Selection section. One of Specific to ABI 10.1 (8.2) 11.3 (8.7) 12.1 (9.2)
these practices to implement was consensually chosen by the par- Confidence in abilities to manage cognitive deficits post-ABI (n, %)
ticipants as their final selection. This group data collection process Not at all confident
lasted about 2 h. At the end of the discussions, a picture of the vis- Slightly confident 3 (33.3)
Somewhat confident 6 (46.2) 8 (50.0) 4 (44.4)
ual set-up was taken to keep track of the decision-making process. Very confident 7 (53.8) 5 (31.2) 2 (22.2)
Extremely confident 3 (18.8)
While most participants completed both data collection phases, a few partici-
Data analyses
pated only in the electronic survey (i.e., one person in each team) or only in the
Descriptive statistics were used to describe the participants’ socio- consensual group discussions (i.e., one person in teams 1 and 3, and two in
demographic and clinical characteristics. For each team, the cur- team 2). This table shows the sociodemographic characteristics of every partici-
pant in the study. Some participants fit in more than one category.
rent level of implementation of cognitive rehabilitation practices
(objective 1) was estimated by calculating the proportions of
respondents who selected the various categories of levels of collection phases, a few participated only in the electronic survey
implementation for each practice in the list. Also, to address the (i.e., one person in each team) or only in the consensual group
second objective (individual priorities), the proportions of partici- discussions (i.e., one person in teams 1 and 3, and two in team 2).
pants who selected a given practice among their top five prior- The participation rates for the electronic survey were 100% for
ities, as well as the mean ranking (on a scale from 1 to 5, where 1 team 1, 88% for team 2, and 62% for team 3.
is the most important priority), were calculated for each priori- The vast majority of study participants were female, and they
tized practice. To describe consensual group preferences (object- worked as clinicians. Most participants from teams 1 and 2 were
ive 3), descriptive statistics were used to document the occupational therapists (50–54%) or neuropsychologists (39–50%)
frequencies of practices included in each section (Memory, while participants from the third team included a broader range
Grouping, Fridge, Veto, Garbage, and Selection) over the course of of clinical backgrounds including occupational therapy (44%),
the discussions. All group discussions were audiotaped and tran- speech-language pathology (22%), neuropsychology (11%), special
scribed in full. The key reasons for prioritizing the practices to education (11%), and nursing (11%). For teams 1 and 2, all poten-
implement were identified using qualitative content analysis tial participants from each discipline targeted for this study were
[41,42]. All the content was co-coded by two team members. involved in at least one of the data collection phases. While the
Findings from the qualitative analyses with respect to factors participation rates were lower for the third team, the sample
influencing decision-making processes for prioritizing best practi- (n ¼ 9) still appeared broadly representative of the larger group of
ces to implement are reported in more detail in another paper by clinicians approached for the study (n ¼ 13) in terms of the pro-
Poulin and colleagues (upcoming). portions of participants from each discipline (i.e., 4 of the 7 occu-
pational therapists, both of the speech-language pathologists, 1
of the 2 neuropsychologists, the educator, and the manager with
Results
a nursing background). The mean number of years of clinical
There were 38 participants in the study, with 13, 16 and 9 partici- experience specific to ABI was similar across all teams and ranged
pants, respectively, from teams 1, 2 and 3. Table 1 presents the from 10.1 to 12.1 years. Most participants reported that they spent
sociodemographic and clinical characteristics of the participants more than 75% of their position’s time providing ABI rehabilita-
from each team. While most participants completed both data tion services in the clinical program involved in the study, except
2956 V. POULIN ET AL.

for two participants in team 1 and one in team 3, who spent
between 25 and 75% of their time. Concerning the clinicians’ per-
ceived self-efficacy for managing cognitive deficits post-ABI, a
majority of participants from team 1 (54%), half of team 2 (50%)
but only 22% of participants from team 3 reported being very or
extremely confident in their abilities to treat patients with cogni-
tive deficits post-ABI.
Current implementation levels of best practices (objective 1)
Tables 2–4 detail the perceived implementation levels of each
best practice, as well as implementation priorities for each team.
Overall, most of the best practices (81–100%) were perceived as
at least partially implemented by at least 50% of the participants
but only 20–25% of the practices were considered fully
implemented.
Specifically, in team 1 (see Table 2), the perceived implementa-
tion levels suggest that four of the 16 best practices were per-
ceived as fully implemented by at least 50% of the participants.
These included cognitive rehabilitation services based on patient-
centered goals (83%); referral to and management by mental
health professionals as needed (58%); personalized evidence-
based interventions to facilitate resumption of desired activities
(50%); and interventions adapted to the patient’s cognitive and
communication profile (50%). Interventions perceived as not
implemented by a majority of participants were computer-based
working memory and attention training (75 and 58%, respect-
ively), as well as mirror therapy for unilateral inattention (75%).
The remaining nine practices were considered as partially imple-
mented by a majority of participants.
In teams 2 and 3 (see Tables 3 and 4), all practices were per-
ceived as fully or partially implemented by at least 50% of the
participants. The practices showing the highest levels of imple-
mentation by team 2 consisted of personalized life skills training,
and interventions fostering patient involvement and effort dur-
ing inpatient rehabilitation, with 64 and 86% of participants,
respectively, considering these practices as fully implemented. In
team 3, personalized evidence-based interventions to facilitate
resumption of desired activities, and interventions adapted to
the patient’s cognitive and communication profile were also per-
ceived as fully implemented by a large proportion of team mem-
bers (62.5%).
Individual priorities identified in the electronic survey
(objective 2)
The individual priorities for implementation of cognitive rehabili-
tation best practices are also shown in Tables 2–4. In team 1 (see
Table 2), three practices were identified as high priority by at least
50% of participants: metacognitive strategy training for executive
functions (70%), internal compensatory strategies for memory
(50%), and interventions adapted to the patient’s cognitive and
communication profile (50%).
Similarly, in team 2 (see Table 3), the practices most frequently
identified among participants’ top five priorities also addressed
executive function and memory rehabilitation, that is, metacogni-
tive strategy training for executive functions (67%), internal and
external compensatory strategies for memory (58 and 50%,
respectively), and strategies to promote learning for patients with
memory impairments (50%).
In team 3 (see Table 4), individual priorities also involved
memory and executive functions (67 and 50%, respectively).
Participants also rated as a high priority implementing cognitive

Table 2. Perceived implementation levels and priorities identified by participants from team 1.
Implementation levels (n ¼ 12) Individual priorities (n ¼ 10)
Fully Partially Not Mean rank Group decision-
Cognitive rehabilitation best practices (%) (%) (%) (SD) (%) making (n ¼ 12)
1.1 Metacognitive strategy training for executive functions 0.0 58.3 41.7 3.1 (2.0) 70.0 Preselected and
Final selection
1.2. Internal compensatory strategies for memory 0.0 58.3 41.7 3.0 (1.0) 50.0 Grouped with 1.5
and Preselected
1.3. Goals and interventions adapted to the patient’s cognitive and 50.0 41.7 8.3 2.2 (1.8) 50.0 Preselected
communication profile
1.4. Additional support to foster the engagement in rehabilitation of 25.0 66.7 8.3 3.0 (4.1) 40.0 Preselected
patients with communication and cognitive issues (e.g., family
involvement)
1.5. External compensatory strategies for memory 16.7 83.3 0.0 4.3 (1.5) 40.0 Grouping with 1.2
and Preselected
1.6. Remedial-based strategies for visual perceptual deficits 8.3 83.3 8.3 3.8 (1.3) 40.0 Garbage
(e.g., prisms)
1.7. Strategies for visual neglect (e.g., visual scanning, cueing, imagery) 0.0 83.3 16.7 2.8 (1.7) 40.0 Garbage
1.8. Personalized evidence-based interventions to facilitate resumption 50.0 50.0 0.0 3.0 (1.7) 30.0 Preselected
of desired activities and participation
1.9. Strategies for apraxia (e.g., errorless learning, gesture training, 0.0 75.0 25.0 3.3 (0.6) 30.0 Garbage
graded strategy training)
1.10. Referral to and management by mental health professionals for 58.3 41.7 0.0 1.3 (0.6) 30.0 Garbage
patients with evidence of changes in mood or other
behavioral changes
1.11. Cognitive rehabilitation services based on patient-centered goals 83.3 16.7 0.0 3.0 (1.4) 20.0 Garbage
1.12. Focus on education and support for caregivers of patients with 25.0 58.3 0.0 2.0 (1.4) 20.0 Garbage
†
more severe deficits (e.g., moderate dementia)
1.13. Computer-based working memory training 0.0 25.0 75.0 4.0 (0) 20.0 Garbage
1.14. Mirror therapy for unilateral inattention 0.0 25.0 75.0 3.0 (0.0) 10.0
1.15. Aerobic exercise for treatment of cognitive impairments 33.3 41.7 25.0 3.0 (0.0) 10.0
1.16. Computerized skill training for attention† 0.0 25.0 58.3 0.0 0.0
Two participants did not complete the second part of the electronic survey on individual priorities. Mean rank on a 5 point-scale, with 1 being the highest
priority and 5 the lowest. Percentage of participants who selected this practice among their top 5 priorities. †Some participants answered “not applicable” for
the current implementation level of these practices.
 IDENTIFYING IMPLEMENTATION PRIORITIES 2957

Table 3. Perceived implementation levels and priorities identified by participants from team 2.
Implementation levels (n ¼ 14) Individual priorities (n ¼ 12)
Fully Partially Not Mean rank Group decision-
Cognitive rehabilitation best practices (%) (%) (%) (SD) (%) making (n ¼ 15)
2.1. Metacognitive strategy training for executive functions 7.1 64.3 21.4 3.4 (1.4) 66.7 Preselected and
Final selection
2.2. Internal compensatory strategies for memory 14.3 78.6 7.1 2.9 (1.5) 58.3 Garbage
2.3. External compensatory strategies for memory 21.4 64.3 14.3 3.0 (1.3) 50.0 Fridge, then Garbage
2.4. Strategies to promote learning for patients with memory 14.3 64.3 21.4 3.2 (1.6) 50.0 Preselected
impairments
2.5. Inpatient rehabilitation interventions targeting advanced 21.4 78.6 0.0 3.6 (1.5) 41.7 Garbage
cognitive functions
2.6. Metacognitive strategy training using functional activities for 21.4 71.4 7.1 3.2 (1.6) 41.7 Preselected
patients with mild to moderate attention deficits
2.7. Strategies for the monitoring of performance and feedback in 28.6 64.3 7.1 2.6 (1.7) 41.7 Fridge, then Garbage
patients with impaired self-awareness
2.8. Personalized life skills training protocol 64.3 28.6 7.1 2.5 (1.7) 33.3 Garbage
2.9. Functionally-oriented cognitive rehabilitation 50.0 50.0 0.0 2.8 (1.7) 33.3 Garbage
2.10. Cognitive behavior therapy to improve attentional functioning 35. 7 42.9 21.4 3.3 (0.6) 25.0 Garbage
2.11. Inpatient rehabilitation interventions fostering patient 85.7 14.3 0.0 2.3 (2.3) 25.0 Garbage
involvement and effort
2.12. Interventions promoting the generalization of skills (e.g., using 50.0 50.0 0.0 3.5 (0.7) 16.7 Garbage
meaningful activities, ecological environment)
2.13. Training in dual-tasking 14.3 57.1 28.6 2.0 (1.4) 16.7 Preselected
2.14. Strategies to analyze and synthesize information 0.0 57.1 42.9 0.0
2.15. Retraining strategies for visual neglect 7.1 78.6 14.3 0.0
2.16. Structured and distraction-free environment† 35.7 50.0 0.0 0.0
Two participants did not complete the second part of the electronic survey on individual priorities. Mean rank on a 5 point-scale, 1 being the highest priority
and 5 the lowest. Percentage of participants who selected this practice among their top 5 priorities. †Some participants answered “not applicable” for the cur-
rent implementation level of this practice.

Table 4. Perceived implementation levels and individual priorities identified by participants from team 3.
Implementation levels (n ¼ 8) Individual priorities (n ¼ 6)
Fully Partially Not Mean rank
Cognitive rehabilitation best practices (%) (%) (%) (SD) (%) Group decision-making (n ¼ 8)
3.1. Personalized life skills training protocol 37.5 50.0 12.5 2.2 (0.8) 83.3 Grouped with 3.6, then
Preselected
3.2. Strategies to promote learning for patients with memory 0.0 87.5 12.5 3.5 (1.3) 66.7 Fridge, then Garbage
impairments
3.3. Metacognitive strategy training for executive functions† 25.0 25.0 37.5 2.7 (1.5) 50.0 Grouped with 3.1 and 3.6, then
separated from this grouping
and put in Fridge,
then Garbage
3.4. Functionally-oriented cognitive rehabilitation† 37.5 50.0 0.0 1.3 (0.6) 50.0 Garbage
3.5. Additional support to foster the engagement in 35.7 50.0 12.5 2.5 (2.1) 33.3 Garbage
rehabilitation of patients with communication and cognitive
issues (e.g., family involvement)
3.6. Personalized evidence-based interventions to facilitate 62.5 25.0 12.5 3.5 (0.7) 33.3 Grouped with 3.1, then
resumption of desired activities and participation Preselected
3.7. Strategies for the monitoring of performance and feedback 12.5 62.5 12.5 5.0 (0.0) 33.3 Preselected
in patients with impaired self-awareness†
3.8. Intervention promoting the generalization of skills (e.g., 25.0 50.0 12.5 4.5 (0.7) 33.3 Preselected and Final selection
using meaningful activities, ecological environment)†
3.9. Retraining strategies for visual neglect† 25.0 62.5 0.0 4.5 (0.7) 33.3 Preselected, then Garbage
3.10. Cognitive rehabilitation services based on patient- 50.0 50.0 0.0 1 (0.0) 16.7
centered goals
3.11. Goals and interventions adapted to the patient’s cognitive 62.5 37.5 0.0 2 (0.0) 16.7
and communication profile
3.12. Metacognitive strategy training using functional activities 12.5 62.5 25.0 2.0 (0.0) 16.7
for patients with mild to moderate attentiondeficits
3.13. Internal compensatory strategies for memory 25.0 50.0 25.0 3.0 (0.0) 16.7
3.14. External compensatory strategies for memory † 37.5 50.0 0.0 5.0 (0.0) 16.7
3.15. Training in dual-tasking 25.0 50.0 25.0 0.0
Two participants did not complete the second part of the electronic survey on individual priorities. Mean rank on a 5 point-scale, 1 being the highest priority
and 5 the lowest. Percentage of participants who selected this practice among their top 5 priorities. †Some participants answered “not applicable” for the cur-
rent implementation level of these practices.

rehabilitation practices that are functionally oriented (50%) and training for attention in team 1; strategies to analyze and synthe-
involve personalized life skills training (83%). size information, retraining strategies for visual neglect as well as
Finally, it is noteworthy that some practices were not priori- structured and distraction-free environment in team 2; and train-
tized by any of the participants including: computerized skills ing in dual-tasking in team 3.
2958 V. POULIN ET AL.
Group priorities (objective 3)
The practices prioritized by at least two participants in the individ-
ual preparation phase (electronic survey) were included for the
consensual group discussions during which each team selected
one practice to implement (also see Tables 2–4).
Team 1
Among the 13 best practices discussed by team 1 (see practices
1.1–1.13 in Table 2), seven were initially rejected in the Garbage
section because they did not fit with the interdisciplinary team
members’ common priorities for changes [i.e., cognitive rehabilita-
tion services based on patient-centered goals (1.11), strategies for
apraxia (1.9), strategies for visual perceptual deficits and visual
neglect (1.6 and 1.7), referral to and management by mental
health professionals for patients with evidence of changes in
mood (1.10)], because they had low perceived evidence of effi-
cacy [i.e., computer-based working memory training (1.13)], or
because they did not address their clients’ common needs [i.e.,
education and support for caregivers of patients with demen-
tia (1.12)].
Two practices related to memory rehabilitation (1.2 and 1.5)
were combined in the Grouping section and preselected.
Practices to foster the engagement in rehabilitation of patients
with communication and cognitive issues (1.4), as well as inter-
ventions involving strategy training for executive functions (1.1)
were also preselected by consensus. Clinicians mentioned that
these practices had the potential to mobilize several disciplines
including occupational therapists, neuropsychologists and educa-
tors and to address important patient needs, and might result in
positive rehabilitation outcomes. Participants also identified two
practices that they considered key principles underlying cognitive
rehabilitation: interventions adapted to patients’ cognitive and
communication profiles (1.3), and personalized evidence-based
functional interventions (1.8). They said it would be helpful to
consider these general overarching principles as they implement
other cognitive rehabilitation practices. Finally, among the
selected practices, participants consensually prioritized strategy
training for executive functions (1.1). Specifically, one team mem-
ber—a neuropsychologist—suggested focusing on strategies to
improve patients’ self-awareness and monitoring of performance,
such as the use of feedback, since it was a significant issue influ-
encing patient engagement in rehabilitation and a significant pro-
portion of their clients might benefit from these interventions.
Other team members with various clinical backgrounds (occupa-
tional therapy, neuropsychology, special education) supported
this suggestion. They thought that implementing this practice, as
compared to others from the list, was more likely to fit with their
current work organization and available resources. They also
reported that they were familiar with some aspects of this prac-
tice (suggesting some capacity to implement it), and that its
implementation might foster intervention consistency across vari-
ous disciplines.
Team 2
Thirteen best practices were retained for the group discussion in
team 2 (see practices 2.1–2.13 in Table 3). Three of these were ini-
tially rejected in the Garbage section because they were per-
ceived as general principles for cognitive rehabilitation that would
be difficult to operationalize and implement: inpatient rehabilita-
tion interventions targeting advanced cognitive functions (2.5)
and fostering patient involvement and effort (2.11), as well as per-
sonalized life skills training protocol (2.8). Participants grouped
two other practices that were also considered general principles
underlying cognitive rehabilitation interventions: functionally-ori-
ented cognitive rehabilitation (2.9) and interventions promoting
the generalization of skills (2.12). After further discussion, these
practices were rejected in the Garbage section. Two additional
practices were also put in the Garbage section because they were
specific to one discipline, that is, cognitive behavior therapy
(2.10), or only applicable to a minority of patients with moderate
to severe brain injury, that is, internal compensatory strategies for
memory (2.2), and as such did not fit with perceived priorities.
Next, team members discussed the use of external memory
strategies (2.3) and strategies for the monitoring of performance
(2.7). These practices were placed in the Fridge section since they
were already being successfully used with some clients and were
not perceived as high priority areas for improving practices.
In total, four practices were preselected by the team among
their top priorities: metacognitive strategy training for patients
with mild to moderate attention deficits (2.6), training in dual
tasking (2.13), strategies to promote learning for patients with
memory impairments (2.4), and metacognitive strategy training
for executive functions (2.1). Team 2 finally prioritized this last
practice (2.1) after asking for everyone’s preferences. More specif-
ically, some clinicians suggested implementing Goal Management
Training [43] as an evidence-based intervention for executive
function training. This intervention was already known and par-
tially implemented by some neuropsychologists in the team. They
believed this practice could be improved and shared with other
team members.
Team 3
In team 3, participants initially discussed nine best practices (see
practices 3.1–3.9 in Table 4). Two of these practices involving
functionally-oriented cognitive rehabilitation (3.4) and strategies
to foster the engagement in rehabilitation of patients with com-
munication and cognitive issues (3.5) were rejected in the
Garbage section because they were perceived as already imple-
mented by the team and, as such, did not fit with their priorities.
Next, two practices were set aside in the Fridge section
because of a lack of consensus between team members: strat-
egies to promote learning for patients with memory impairments
(3.2) and metacognitive strategy training for executive functions
(3.3). Despite their potential evidence of efficacy (3.3), some par-
ticipants observed that these last two practices did not fit with
their inpatient rehabilitation context (3.2 and 3.3) or with the
functionally-oriented approach valued by the team (3.3).
Participants preselected five practices that fit with their prior-
ities and context. Practices 3.1 (personalized life skills training
protocol) and 3.6 (personalized evidence-based functional inter-
ventions) were merged and preselected since they appeared as
general principles to be applied in everyday practice. Practices 3.7
involving the monitoring of performance and feedback, 3.8 the
generalization of skills, and 3.9 strategies for visual neglect were
also selected because they fit with clients’ needs and were likely
to influence rehabilitation and functional outcomes. After further
discussion, practice 3.9 concerning visual neglect was put in the
Garbage section because the participants were relatively confident
about and satisfied with its current level of implementation.
Finally, to guide their final decision, participants asked the
researchers about the other teams’ choices. Since a similar prac-
tice involving the monitoring of performance and feedback (3.7)
had been chosen by team 1, they prioritized the other practice
concerning the generalization of skills (3.8) in order to get specific
support to implement it in their team but they also expressed a
desire to access the other learning tools developed for team 1 at

the end of the study. Also, according to participants, this practice
(3.8) fit well with current initiatives, values and priorities in their
setting, as well as with clients’ needs, and had the potential to
mobilize several disciplines.
Discussion
Using the TRIAGE methodology [36–38], this study provided fur-
ther insight into the identification of clinicians’ priorities regarding
the implementation of best practices in cognitive rehabilitation
post-ABI. For two of the three teams involved, the consensual
group decisions confirmed individual preferences for implement-
ing evidence-based executive function interventions. The in-per-
son group discussions also allowed clinicians to further define
and operationalize these practices into more specific interventions
and components, such as Goal Management Training [43] or prin-
ciples for self-awareness training and feedback. For the third
team, the sharing of perspectives during the group discussions
may have played a particularly important role in prioritizing the
practice of generalizing skills, which was not among the highest
individual priorities but ultimately appeared to have the closest fit
with the team’s values and inpatient clinical context. Interestingly,
current evidence concerning the generalization of skills post-ABI
tends to support the use of various intervention principles identi-
fied as important individual priorities during the preparation
phase, such as personalized and functionally-oriented cognitive
rehabilitation, family involvement and metacognitive strategy
training for executive functions [44]. In short, these results sup-
port the feasibility and value of the TRIAGE structured, interactive
approach for engaging rehabilitation professionals in priority set-
ting for best practices implementation, using not only quantitative
methods (e.g., surveys) but also in-person meetings that allow for
explanations of topics and clarification of important issues for
implementation [28–30]. Moreover, when using TRIAGE as part of
an implementation process, rehabilitation professionals may find
it useful to keep track of the key reasons for prioritizing some
and excluding other practices.
In this study, the perceived level of implementation of cogni-
tive rehabilitation best practices was one of the criteria consid-
ered during priority setting. Encouragingly, most practices
appeared to be at least partially implemented, as indicated by the
participants’ ratings. Higher levels of implementation tended to
be reported for functionally oriented cognitive rehabilitation inter-
ventions, as compared to retraining specific cognitive functions.
This may suggest that clinicians’ practices are more consistent
with guidelines for the implementation of general principles of
cognitive rehabilitation, such as patient-centered functional goals,
but that further efforts and resources are needed to implement
specific cognitive retraining interventions. It is also noteworthy
that all the practices prioritized during the individual and group
data collection phases were already partially implemented by a
majority of team members. This suggests that, in a context of
competing priorities, participants preferred to make additional
efforts to implement practices that had already been successfully
pretested by some clinicians in order to apply them more system-
atically and consistently across their team. The fact that these
interventions had been previously introduced and pretested
through internally driven initiatives (as opposed to an external
source) may also have been perceived as a relative advantage of
these practices that was likely to influence the success of imple-
mentation [20].
Interventions involving executive functions and self-awareness
were among the highest priorities for all the teams, according to
IDENTIFYING IMPLEMENTATION PRIORITIES 2959
both individual and group data. Clinicians from all three teams
also identified interventions that promote learning and memory
rehabilitation among their priorities, although these practices
were not retained in their final choice. In a recent Australian sur-
vey [19] of occupational therapists, neuropsychologists and
speech-language pathologists providing TBI rehabilitation, mem-
ory rehabilitation was also recognized as an important focus of
current practices but executive functioning was identified as the
most challenging area of cognitive rehabilitation, particularly
when limited self-awareness affects patient engagement in
rehabilitation. This is also consistent with findings from another
Australian survey of multidisciplinary TBI rehabilitation professio-
nals [31], where one of the favorite topics for professional devel-
opment was insight or self-awareness (66%). Pagan and
colleagues noted that clinicians’ preferences for practice improve-
ment and skill development corresponded to patient-related
issues most commonly perceived as barriers to TBI rehabilitation
[31], such as self-awareness, which is recognized as an important
factor influencing the delivery of cognitive rehabilitation [3,45].
While there were many similarities between the teams’ prior-
ities, the results also point out some differences. Participants from
team 3 focused on more general principles of cognitive rehabilita-
tion that promote the generalization of skills, as compared to the
other teams, which selected interventions addressing specific cog-
nitive functions. These differences in perceived priorities empha-
size the importance of tailoring implementation to local needs
and contexts from the early stages in the process [26]. In the pre-
sent study, the third team appeared to differ from the other two
on several characteristics, such as the variety and proportion of
healthcare disciplines represented (e.g., participation of speech-
language pathologists but only one neuropsychologist), type of
client treated (i.e., inpatient ABI rehabilitation including both
stroke and TBI) and possibly less confidence in their abilities to
provide specific cognitive rehabilitation interventions (e.g., meta-
cognitive strategy training), as suggested by the clinicians’ ratings.
The potential influence of clinicians’ perceived self-efficacy on pri-
ority setting for implementing best practices warrants further
exploration, especially since professional confidence was related
to the frequency of delivery of neurorehabilitation interventions
in a previous study [46]. It would also be interesting to learn
more about clinicians’ perceptions regarding some practices that
were not prioritized at all during the survey (e.g., computerized
skills training for attention in team 1; strategies to analyze and
synthesize information in team 2; and training in dual tasking in
team 3). Since these practices were not included in the group dis-
cussions, it was not possible to draw any conclusions from the
present study to explain these choices.
There is also a need to better understand the process for how
practices are chosen within and between professions, and to
examine the leadership of healthcare professionals from various
disciplines during the process of prioritizing practices for imple-
mentation. For example, in the present study, team 2 prioritized
Goal Management Training [43], an executive function training
program that had been previously tested and partially imple-
mented by some neuropsychologists in the team. Analyses of the
roles, influences and dynamics between professionals during pri-
ority setting would enhance understanding of the decision-mak-
ing processes related to best practices implementation in a
context of inter-professional collaboration.
Findings from the present study reflect the perspectives of
clinicians from three ABI rehabilitation programs but might not
be generalizable to other settings. Nevertheless, the successful
application of the TRIAGE process in this study suggests that this
2960 V. POULIN ET AL.
method might be used for similar purposes in other programs
providing cognitive rehabilitation services. It should be noted that
the quality of the data obtained using the TRIAGE process may
vary according to the participants’ and animator’s expertise. In
this study, the animator received guidance and training from an
expert researcher (MEL) with extensive experience using TRIAGE
methodology. In addition, a relatively high proportion of poten-
tially eligible clinicians from each team engaged in the individual
and group data collection. The disciplines involved in this know-
ledge translation initiative were identified through consultation
with local managers in order to select clinicians who were more
likely to utilize cognitive rehabilitation interventions. Depending
on the local clinical and organizational contexts, it was not feas-
ible to include all disciplines potentially involved in cognitive
rehabilitation (e.g., physical therapists, nurses, rehabilitation assis-
tants). Different perspectives and priorities might have been iden-
tified if additional disciplines had been included. Also, it would
have been relevant to involve some patients and family members
in the TRIAGE process in order to consider their preferences and
perceived priority needs. Finally, the levels of implementation and
individual priorities regarding cognitive rehabilitation interven-
tions reported in this study should be interpreted with caution
since they are based on self-report measures. These results may
have been influenced by the degree of understanding of each of
the best practices, by some clinicians’ lack of knowledge of the
actual practices used, or by a potential desirability bias. It would
also have been recommended to include a fidelity measure and
to triangulate the findings with other data sources, such as
chart audits.
Conclusions
Using the structured, interactive TRIAGE consensus-building meth-
odology, this study documented clinicians’ perceived level of
implementation of evidence-based practices in cognitive rehabili-
tation post-ABI, as well as individual and consensual group prefer-
ences for implementing cognitive rehabilitation interventions. The
perceptions of the clinical teams suggest that current practices
are mostly consistent with recommendations in the guidelines for
the implementation of general cognitive rehabilitation principles.
Further implementation efforts may be needed to support the
application of specific cognitive rehabilitation strategies and inter-
ventions, such as executive function and self-awareness retraining,
as well as interventions promoting the generalization of skills,
which were among the highest implementation priorities. The
knowledge gained through this consensual process may also help
with planning and tailoring the implementation strategies in a
way that is likely to increase clinicians’ engagement and mutual
collaboration in the next phases of the implementation process
[26]. Ultimately, it would be interesting to explore the extent to
which clinicians’ engagement in this process has fostered the
adoption of the targeted interventions.
Acknowledgments
We thank our research participants for the time and energy they
devoted to this study.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Funding
This study was carried out with financial support from the Fonds
de recherche du Qu
ebec – Soci
ete
et Culture.
ORCID
Marie-Eve Lamontagne http://orcid.org/0000-0002-3301-7429
Anabelle Viau-Guay http://orcid.org/0000-0001-6725-090X
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2962 V. POULIN ET AL.
Appendix 1
Survey questions
1. Perceived levels of implementation of cognitive rehabilita-
tion practices
1.1. This question is about the current level of implementation in
your clinical setting of each of the practices listed below. You
must indicate how well each practice is currently being imple-
mented by yourself or other members of your team using the
following scale:
 Not implemented at all: This practice is not used and no
steps have been taken to implement it;
 Partially implemented: Some steps or activities related to
the implementation of this practice have been started,
but improvements could be made;
 Fully implemented: All the steps or activities relevant to
this practice are being correctly carried out by the peo-
ple concerned;
 Not applicable: This practice is not relevant or applicable
to our clinical program.
2. Individual priorities for implementing cognitive rehabilitation
interventions
2.1. In the next section, you are asked to prioritize practices that
you think are relevant to implement or improve in your program
from the following list of evidence-based best practices. You
must choose 5 priority practices to implement or improve and
rank them from 1 to 5, where 1 represents the highest priority
practice to implement. When doing so, criteria to consider could
include the clinical relevance for your patients, implementation
feasibility, and the current level of implementation by
your team.
2.2. For each practice, please indicate the reasons for your choice.
Guidelines for the consensual group meeting
1. Objectives of the multi-site integrated knowledge transla-
tion initiative
2. Objectives of the consensual group meeting as part of the
TRIAGE process
3. Overview of the procedures for the consensual
group meeting:
a. Using the visual aid to sort the practices
 Defining the six categories: Memory, Grouping,
Fridge, Veto, Garbage and Selection
b. Examples of criteria that could be considered when sort-
ing the practices: clinical relevance, feasibility, current
implementation level, level of evidence supporting the
best practice recommendations (identified using a scale
from A to C), as well as other relevant criteria identified
by the team
c. Reading the best practices
 As necessary, clarifying the practices to ensure a
common understanding
d. Inviting participants to share their opinion on the practi-
ces to be selected or discarded, as well as the reasons
for their choices and preferences