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Joe McCannon is IHI faculty and co-founder of the Billions Institute. Pedro Delgado is Vice President at IHI. Pierre Barker, MD, is Chief Scientific Officer at IHI.
From the early days of the COVID-19 pandemic, we have observed remarkable, global cooperation as health care providers scramble to address new challenges. Leaping to one another’s aid, clinicians have deepened relationships and formed new connections, in the process solving thorny problems with extraordinary speed. From Madrid to Bergamo, Belfast to New York, and Hong Kong to Cape Town, they have sought and received help from peers around the world to answer a steady stream of hard questions: Is this symptom complex a sign of COVID-19? How do we treat those made sick by the virus? How do we secure protective equipment? How do we test community members? How do we distribute vaccines?
These largely spontaneous and deeply collegial collaborations have inspired us. After more than thirty years of study on how health systems can learn and improve as fast as possible, the Institute for Healthcare Improvement (IHI), its faculty, and its partners have begun to reexamine what we know about learning networks, asking what is durable from our prior experience and what is new.
To help health care leaders better manage the current crisis — and to accelerate efforts to advance better care worldwide — below are some promising findings about learning networks that work.
- Don’t disrupt human nature. Human beings instinctively understand how to combine and cooperate; it is essential to who we are. When collaborations like those described above organically emerge, the best managers don’t get in their way or seek to control them. Instead, they celebrate these networks and try to put wind in their sails. They ask, how can we supply the resources and tools these networks need to accelerate their good work?
- Leverage existing collaborations and networks. Trust is key to forming relationships and networks. If providers already have professional associations and gathering places, it is better to use those than to create new networks. For instance, the international, multidisciplinary network of researchers that discovered the link between COVID-19 and loss of smell had its roots in pre-existing relationships. Importantly, however, network managers must also ensure that existing associations don’t become exclusive; representation and diversity vastly enhance a network’s effectiveness.
- Establish a shared goal that centers equity.Without a clear objective, a learning network loses energy. A shared goal creates urgency for change and encourages practitioners to exchange ideas and solutions to hard challenges. The cities, states, and countries that have been most successful in their vaccine rollout efforts have clear weekly goals and they apportion them across the different settings (e.g., hospitals, pharmacies, stadium sites) where vaccines are being delivered. They also publicly track whether distribution prioritizes communities of color and other historically neglected groups.
- Limit fear. Becky Margiotta, co-founder of the Billions Institute, says that the best learning networks “make it safe for adults to learn in public.” Leaders must do everything possible to make it comfortable for participants to share problems — without fear of embarrassment or reprisal — in order to accelerate the pace at which problems get solved. Smart networks praise members who ask questions. They also root out jargon that intimidates those seeking to join the group.
- Link to the community and focus on equity. To improve outcomes, effective learning groups tend closely to the hopes, obstacles, and worries of those they seek to serve. This means opening their networks to more representative membership and deeply understanding systemic imbalances. It also means more regularly asking community members what they require. In addressing a challenge like vaccine hesitancy, for instance, the learning network needs to understand sources of concern (e.g., historical racism in clinical trial designs, provision of medicines to communities of color), working closely with community leaders and trusted providers to design equitable vaccine coverage and improve communication.
- Manage knowledge deliberately. Even in an emergency like the pandemic, when health care providers proactively seek out colleagues for solutions to new challenges, there is a benefit to introducing a deliberate, systematic approach to knowledge management. Otherwise, providers miss out on innovations and lose time. Learning network moderators with mastery of relevant subject matter should scan the group’s questions and ideas as well as emergent evidence, distilling it into actionable insight and connecting colleagues to useful information. NHS Nightingale Hospital London, a temporary facility built to manage pandemic demands, formalized this approach by creating Bedside Learning Coordinators to harvest and share new ideas with their colleagues each day.
- Look outside. Many of us believe that success means finding solutions ourselves, within the walls of our own organizations. In fact, organizations that thrive continuously look outside, regularly studying breakthroughs in different settings and countries. For example, Newcastle’s very rapid COVID vaccination program (vaccinating at a rate of 2,500 people every 6 hours) learned from military approaches in designing its operations.
- Eliminate obstacles. Effective learning network leaders identify regulations and policies that impede the progress of their members, and then take responsibility for working with government leaders and other influential stakeholders to remove those obstacles. These are “gifts” to those working mightily at the front lines of care, accelerating their urgent efforts.
- Apply many methods.Learning networks take many different forms, from email listservs to structured Breakthrough Series Collaboratives to “fishbowls” (where pilot sites enable others to observe and study their work in real time). The fastest learning organizations often use multiple methods in parallel to hasten the spread of new knowledge.
- Unleash experimentation. Learning networks benefit when members view themselves as active experimenters, not passive recipients of guidelines and information. Just as anyone in the network can ask a question, everyone is expected to regularly test and adapt new innovations, sharing what they learn with the larger group (“all teach, all learn”). The rate of testing is an important indicator of network health.
- Respond fast (hotlines, not libraries). Health systems should develop learning networks that directly respond to urgent challenges today. If a person comes to the learning community once and doesn’t get timely answers, they are unlikely to return, contribute ideas, or refer others. In pursuit of fast, helpful responses, 24-hour hotlines that practitioners can call with pressing questions are more productive and time-efficient than extensive libraries of information. They allow interpersonal exchanges about the practical how-to details of implementation, which are especially important when dealing with the novel challenges presented by the pandemic. “Our most effective knowledge management tool,” says expert Nancy Dixon, “is conversation.”
- Face into data (bright spotting). The best pandemic learning networks face into data every day, studying promising trends (“bright spots”) and worrying patterns with equal curiosity, using them as a springboard to deeper investigation in the field. Given the travel limitations introduced by the pandemic, in-person site visits might need to be virtual; the virtual clinic networks developed by our partners at Project ECHO provide a world-class blueprint for this.
While these characteristics represent some of our learning thus far, the field continues to quickly evolve with new advances in technology and a new wave of social movements. Some questions we’re exploring now include the following:
- Which learning approaches are best in emergencies? How do incident command systems and “swarm intelligence” methods, for example, address the work of knowledge management?
- Do learning networks have shelf lives? Is it okay for them peter out when they’ve served their purpose?
- How do learning networks show enough value to attract busy practitioners? What form should they take to best serve those who feel exhausted and overwhelmed by their workload?
- How can learning networks advance equity? How do they perpetuate the status quo?
- How do learning networks and social media amplify one another? How do they work at cross purposes?
We invite you to join us in this conversation to share your best ideas on accelerating learning!
The collection of articles, papers, and books listed below represents some of our writing and reading on the topic to date.
Articles and Papers:
- Perla R, Provost L, Onie R, Parry G. To reach our Covid-19 vaccine goals, don’t let a dose go to waste. US News and World Report. January 27, 2021.
- Shand J, Allwood D, Lee N, et al. Systematically capturing and acting on insights from front-line staff: The “Bedside Learning Coordinator.” BMJ Quality & Safety. February 5, 2021.
- Jones S. Why aren’t more health-care workers getting vaccinated. New York (Intelligencer). February 4, 2021.
- Bohmer R, Shand J, Allwood D, Wragg A, Mountford J. Learning systems: Managing uncertainty in the new normal of Covid-19. NEJM Catalyst Innovations in Care Delivery. 2020;10.1056/CAT.20.0318.
- Berwick D. Choices for the “new normal.” Journal of the American Medical Association. 2020 May;323(21):2125-2126.
- The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement.IHI Innovation Series white paper. Boston: Institute for Healthcare Improvement; 2003.
- Planning for Scale: A Guide for Designing Large-Scale Improvement Initiatives. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2008.
- The Power of Learning Networks. James M. Anderson Center for Health Systems Excellence (Cincinnati Children’s Hospital).
- McCannon J, Margiotta B. Inside the command center. Stanford Social Innovation Review. January 21, 2015.
- McCannon J, Massoud R, Alyesh A. Many ways to many. Stanford Social Innovation Review. October 20, 2016.
- Marcus L, McNulty E, Dorn B, Goralnick E. Crisis Meta-Leadership Lessons from the Boston Marathon Bombing Response: The Ingenuity of Swarm Intelligence. National Leadership Preparedness Institute; 2014.
- McCannon J, Han H. A guide to managing a volunteer workforce. Harvard Business Review. March 2, 2016.
- Institute of Medicine. The Learning Healthcare System: Workshop Summary. Washington, DC: The National Academies Press; 2007.
- Webster PD, Deka S, Ismail A, Stern AF, Barker PM. Using a multicountry learning network to harvest and rapidly spread implementation knowledge across programs aimed to reduce mother-to-child transmission of HIV and improve nutrition: Perspectives and lessons learned for similar large-scale initiatives. Journal of the International Association of Providers of AIDS Care. January 2019.
- Onie R, Lavizzo-Morey R, Lee T, Marks J, Perla R. Integrating social needs into health care: A twenty-year case study of adaptation and diffusion. Health Affairs. February 2018.
- Sodzi-Tettey S, Twum-Danso NAY, Mobisson-Etuk N, Macy LH, Roessner J, Barker PM. Lessons Learned from Ghana’s Project Fives Alive! A Practical Guide for Designing and Executing Large-Scale Improvement Initiatives. Cambridge, MA: Institute for Healthcare Improvement; 2015.
- McCannon CJ, Perla RJ. Learning networks for sustainable, large-scale improvement. Joint Commission Journal on Quality and Patient Safety. 2009 May;35(5):286-291.
- Berwick DM. Lessons from developing nations on improving health care. British Medical Journal. 2004 May 8;328(7448):1124-1129.
- Berwick DM. A learning world for the global fund. British Medical Journal. 2002;325(7355):55-56.
- Dixon N. Common Knowledge.
- Nonaka I. The Knowledge-Creating Company.
- Solnit R. A Paradise Built in Hell.
- Rogers E. Diffusion of Innovations.
- Argyris C. Knowledge for Action.
- Friere P. Pedagogy of the Oppressed.
- Weick K. Making Sense of the Organization.
- Senge P. The Fifth Discipline.
- Heimans J, Timms H. New Power.