Making Collaborative Improvement a Virtual Reality

Probably no feature of modern life has shrunk the world more than computer technology, and the Internet has altered things the most. Among other things, the Internet has led to previously unimaginable interactivity between users, regardless of location, and profoundly changed how people “participate” in trainings and access new skills.  Teachers and students no longer need to be in the same place or even in the same time zone to share a virtual classroom. All that’s required for distance learning, as it’s called, are the right equipment, access to the Internet, and willing participants.
 
These elements converged last year when the Institute for Healthcare Improvement (IHI) launched its first-ever virtual improvement project. Funded with the help of a $450,000 grant from the Alfred P. Sloan Foundation, the Sloan/IHI Virtual Breakthrough Series Collaborative to Improve Access to Primary Care is based on the IHI Breakthrough Series learning model that, since 1995, has enabled more than 1,000 health care organizations to improve health care quality while maintaining or reducing costs.
 
The six- to 15-month Breakthrough Series Collaboratives focus on topics ranging from Asthma Care to Reducing Delays and Wait Times, and in many instances the phone, email, online discussion groups, and Extranet postings are all integral to the learning process. However, the Breakthrough Series model has also relied upon periodic face-to-face training sessions. Replacing them with remote-site sessions conducted via the Internet was a natural evolution. “We wanted to test a next-generation design for collaborative education,” says Barbara Boushon, RN, Collaborative Director for the IHI/Sloan Virtual Breakthrough Series Collaborative to Improve Access in Primary Care.
 
Virtual Collaboratives have the potential to increase the reach of the Breakthrough Series approach to improvement by significantly lowering costs. Organizations enrolling in face-to-face Collaboratives typically pay $30,000 to $60,000 for a team of three individuals to participate, covering tuition, travel, accommodations, and related expenses. Most of the costs for IHI’s virtual Collaborative pilot project are underwritten by grant funding, but in the future online training is expected to slash participant costs by half. “That means we can bring collaborative learning to a much wider audience,” says Boushon.
 
Planning for the virtual Collaborative began in January 2004. After choosing a well-tested topic — better primary care access — and consulting with outside experts in adult distance learning, an IHI planning group evaluated vendors for the web-conferencing software required for online seminars. They decided on WebEx, whose training platform provides integrated telephony, including voice-over-Internet and video support. Six weeks before the first training session on June 15, 2004, the team members of the 19 organizations selected for the new-style Collaborative participated in explanatory phone calls with IHI in which they learned about each other, the technology that would connect them, the project infrastructure, and its measures.
 
Because participants ranged across 18 US cities and four time zones, sessions ran from 11 AM to 5 PM EST. Using a high-speed Internet connection, students phoned in at the arranged time to begin the session — presented in PowerPoint slides — right on their computer screens. Since the program does not include video-conferencing, participants could not see one another, but technology such as on-screen whiteboards allowed them to share ideas, and breakout sessions allowed them to convene in smaller discussion groups. A chat window along one side of the screen allowed participants to make comments or ask questions, and emoticons helped convey meaning and tone.
 
One of the biggest challenges for facilitators was to manage the flow of communication, which can become chaotic with dozens of people interacting online. “We had rules for when and how people could contribute — to ask questions, participants needed to raise a little ‘hand’ next to their names on the screen — and instructors had a lot of control over the traffic,” notes Boushon. “The chat box function let us respond individually so we didn’t need to interrupt the lesson if the answer didn’t benefit everyone,” she says, “and if things started to get too hectic, we could mute some individuals or even mute everyone.”
 
As with the Breakthrough Series model built around face-to-face training, the days-long virtual meetings were separated by months-long Action Periods, during which participants took what they learned back to their organizations. During these practical application periods, Collaborative staff provided coaching phone calls, online discussion, and other supportive services, while fellow-learners shared advice and encouragement via email and a dedicated Extranet site for well-worded protocols or other useful postings.
 
After the first virtual session, feedback from participants led to some modifications in the second and third sessions held in September 2004 and March 2005. The initial format of three five-hour sessions was reformulated into two six-hour sessions, with longer breaks and more interaction among participants and between participants and faculty. On June 16, 2005, graduates of the course will present what they’ve learned about improving primary care access in an online Congress. The goal is to provide those interested in reducing waiting times for medical appointments and improving efficiency to see how theories are put into practice.
 
Virtual Collaboratives are still a work in progress for IHI, but early responses to the project have been positive. More than 80 percent of participants rated their satisfaction with the course as very good or excellent. Monica Russo is Director of Operations for PracticePartners, which manages the office practices of 94 physicians affiliated with Maine Medical Center in Portland. She was a participant in the Breakthrough Series Collaborative on Improving Primary Care Access several years ago, when Learning Sessions were face-to-face. Still, the chance to participate in a Collaborative virtually with a team from an office that had fallen short of their efficiency goals was irresistible, especially given the very low cost. “The Collaborative helped our team so much the first time, I knew it would help this team, too.” And it has, says Russo. “We’re doing much better at scheduling appointments in a timely way.”
 
Comparing the two experiences, Russo says she prefers the virtual Collaborative for its cost-cutting. However, she’s concerned that collegial bonds are not as easy to form online as in person. “I’m still in touch with people I met in the first Collaborative. I’m not sure that’s going to happen this time.” She also warns that self-discipline and commitment are especially critical in virtual settings: “You don’t feel as much obligation to work hard when you don’t have to face the instructors.” Nonetheless, Russo says she would recommend virtual training for its efficiency.
 
Ann Gilbertson, RN, Patient Care Manager for the Marshfield Clinic in Rice Lake, Wisconsin, says that providing same-day appointments has been one of the clinic’s biggest problems for decades. Despite previous efforts to improve, “it always shows up on patient satisfaction surveys,” says Gilbertson. “It’s been a real struggle, but I feel that the virtual Collaborative provided the direction and resources we need to achieve that goal.”
 
Like Russo, Gilbertson most valued the opportunity to learn while staying put. “It’s difficult to travel and be completely away from the office.”
 
The long-range future of virtual Collaboratives is still under discussion, but the immediate future is clear. On April 28, 2005, IHI will sponsor an online seminar called “The Virtual Frontier” to give other training organizations a chance to learn from IHI’s experiment.
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