Increasing Training Compliance Rates at Children's Hospitals with e-Learning: Case Studies

In the health care arena, educational initiatives can generate a large amount of work for organizational leaders and employees alike. Though e-Learning plays a much bigger role in health care provider training than ever before, incorporating it into the educational process takes time, thought, and practice. Just implementing e-Learning in an organization is not enough. Initiatives must be communicated to learners, blended learning programs must be employed in certain instances, and education must be customized for each audience.

In this article, I will present five children’s hospitals and the ways in which they used CHEX Knowledge Exchange (CHEX) to improve educational compliance. These children’s hospitals must thoroughly train their employees on subjects specific to health care and to pediatrics. As you will see, these organizations must comply with requirements set by many regulations and governing bodies, and e-Learning has been the key to success in this effort. Failure to comply with health care and pediatric industry standards can lead to serious consequences including fines to the hospital, and loss of professional licensures and organization accreditation.

CHEX is a unique organization that brings these hospital educators together at regular meetings in order to network, learn from each other, and share best practices. (See Sidebar, “CHEX Knowledge Exchange Background”.) The consortium model upon which CHEX was built has proven to be most effective. Through CHEX, hospital educators have access to a catalog of nearly 100 online courses that were developed specifically for pediatric organizations, and they are able to participate in a variety of education-related projects. In addition, they can take advantage of robust reporting features to accommodate their compliance needs.

Technology and Learner Acceptance

CHEX developers use Macromedia Homesite and Adobe publishing products to create courses. Only a minimal amount of Flash technology, sound and streaming video appears in these courses because the majority of hospital computers do not have the technology to support these features. CHEX also provides its participating hospitals with a course authoring tool to allow them to create courses specific to their local requirements.

CHEX contracts with a leader in the e-Learning industry to provide participating hospitals with a common LMS. This arrangement makes it possible to benchmark and compare best practices with other children’s hospitals outside the CHEX consortium. The LMS offers a wide variety of functionalities and is flexible enough to meet the distinct learning needs of 24 different organizations.

Ensuring learner buy-in to this technology has been a challenge for some hospitals. The most successful organizations have found that to be most effective, e-Learning needs to be incorporated into daily learning activities. It is also essential to have executive-level champions filter this culture shift from the top down. Supervisors need to actively and routinely encourage their employees to take their professional development into their own hands and be responsible for their own learning and development. Many learners find this easy to do because e-Learning allows them to take courses when and where it is personally convenient. Additionally, some are relieved by the fact that they may never again be required to sit through lengthy instructor-led classes for certain topics.

Nurses and other staff take online courses in computer labs at their hospitals, on their home PCs, in hospital lounges — just about anywhere they can access the Internet. This is particularly important for nurses who, because of the current shortage in their profession, cannot take time away from patient care for classroom training.

Overall, technology is rapidly becoming ingrained in the health care industry. Staff members who have not grown up with technology are quickly realizing it is essential to possess the skills needed to use it. Most of the CHEX hospitals offer basic computer skills training to increase the comfort levels of those not as familiar with the technology.

Types of Mandatory Health Care Education

All hospitals are regulated by a wide variety of governmental and accrediting agencies. For hospitals to receive certain types of accreditation and to be compliant with industry standards, employees must receive training in particular areas and be able to demonstrate their knowledge. CHEX hospitals are using the LMS to increase and track the number of employees who have completed this required training. Most organizations strive for a training compliance rate of 95 to 100 percent (the number of employees who completed training divided by the total number of employees).

Health care regulatory agencies can be compared to other industry-specific organizations that impose certain guidelines and standards as a condition of doing business, or being certified or approved to provide certain products or services. For example, certain businesses comply with ISO 9000 technology standards, just as food companies must meet important U.S. Department of Agriculture (USDA) regulations. The following regulatory bodies and standards are some of the health care industry’s equivalent to these industry standards.

Government-mandated regulations, such as the Health Insurance Portability and Accountability Act (HIPAA) protect the privacy of patient health information. HIPAA was a huge initiative that cost the health care industry more than $40 billion in training to achieve compliance with these new privacy standards. These standards affected not only hospitals, but insurance companies, health care related businesses, dentists, pharmacies and other providers. HIPAA even affected the way businesses manage their employee benefits.

HIPAA compliance is achieved by following a specific prescription, including assigning a privacy officer for your organization and training employees how to handle and communicate certain types of patient data. By the time exact HIPAA requirements were identified and published, the industry had created numerous national conferences on the topic, training manuals, audio conferences and many other training opportunities to aid organizations in achieving compliance by April 2003. Violations of this important standard can lead to costly fines, even jail time.

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is an independent, not-for-profit organization that evaluates the quality and safety of more than 16,000 health care organizations in the United States. To earn and maintain accreditation, these health care organizations must undergo an extensive on-site review by a team of JCAHO professionals. For many hospitals, this means investing many months of preparation and staff training to ensure their organization obtains or keeps accreditation. Since its inception in 1951, JCAHO accreditation has become an industry standard in health care that most hospitals strive to achieve. It serves as a symbol of their quality patient care and dedication to performance improvement.

Other types of regulatory compliance include corporate-mandated training, such as safety regulations specific to each hospital or new employee orientation. Within the health care industry, licensed professionals (e.g. nurses, pharmacists, therapists, physicians, etc.) are also required to maintain their professional certifications and must annually take continuing education for credit.

CHEX success stories

Today, CHEX offers a range of online training courses to help its children’s hospital employees efficiently meet their annual education requirements while ensuring the hospital remains compliant with regulatory and accrediting standards. Here are five of these children’s hospitals and the successes seen and lessons learned since launching e-Learning with CHEX.

Government and industry-regulated compliance standards:

Children’s Medical Center of Dallas

Children’s Medical Center of Dallas (CMC) experienced some surprising results when it switched from a traditional training approach to one that incorporated e-Learning. In this case the challenge was HIPAA compliance. In a short period of time, hospital educators had to define what training was needed to comply with this new standard and develop a strategy to educate their employees. Educators decided online courses available through CHEX would be the most efficient option. (See Figure 1.)

Figure 1 CHEX courses on patient privacy regulations reduced training costs by 41 percent.

Although CMC had been using CHEX courses to support new employee training, the HIPAA training initiative was the first time online courses were used house-wide to meet a regulatory requirement. Previously, for example, CMC educators tackled required code-of-conduct annual education for all staff using traditional training methods. Employees were pre-enrolled for specific instructor-led classes on the topic. After attending an assigned two-hour session, each employee was required to sign an acknowledgement form. For such endeavors, more than 50 instructors in the organization were trained to support 100-plus sessions being held at the training site with each session targeting 40 employees.

Comparing CMC’s approach to its corporate code-of-conduct training to the experience with HIPAA, educators reported a 41 percent reduction in overall training costs by using the online courses. e-Learning completely eliminated costs associated with instructor-led training, time spent training the trainer, creating and attending courses, and commuting learners to the training site. It also greatly reduced the cost and time devoted to tracking compliance rates. Moreover, through successful marketing of the CHEX online courses and the importance of meeting the government’s deadline, CMC achieved a 98 percent compliance rate for its HIPAA training initiative.

“From an operational perspective, computer based training (CBT) for staff is invaluable,” said Donna Steen, R.N., director of ambulatory services at CMC. “It provides the employees the opportunity to access the system any time their workload permits. In addition, CBT also ensures all employees are presented with exactly the same material. In the ambulatory areas, compliance is great and the managers can receive immediate updates regarding completion of the course for all of their employees. It’s a real win-win situation for us!”

Several marketing efforts were employed by the education department to help them achieve such a high compliance rate. They sent emails to the hospital’s managers and directors notifying them of the HIPAA training initiative with information to pass along to their employees. They also posted fliers throughout the hospital to directly communicate what was expected and required of the learners to help the hospital achieve compliance. CMC also included links and directions to access the courses in the hospital’s “Daily Briefing” email to all staff to promote the initiative. To further encourage compliance, the education department made sure all managers received frequent exception reports to notify them of the non-compliant employees.

To provide HIPAA training to a constant flow of new employees, taking the course was required of all new employees within a certain time period. Over time, the education department realized that they were seeing significant delays in completion rates. To remedy this problem, they decided to set aside time for all new hires to spend in the computer lab during their first week of orientation to ensure the mandatory course was completed. This has increased the course completion rate considerably.

The success of HIPAA training has compelled CMC to expand e-Learning usage to meet other training needs. Currently, CMC makes more than 100 online CHEX courses available to staff.

Helping employees keep up with required professional education:

Miami Children’s Hospital

All nurses are required annually to take continuing education for credit. While the number of units and topics vary from state to state, all nursing professionals must fulfill annual continuing education units (CEU) to maintain their licensure. To aid employees with these professional requirements, Miami Children’s Hospital (MCH) began offering nurses online CEU options, providing a quick and easy method for nurses to obtain required credits for re-licensure. (See Figure 2.) In addition, all other licensed health care professionals, such as physical therapists, pharmacists and physicians, are also required to take continuing education for credit.

Figure 2 Miami Children’s Hospital offers online CEU options for nurses.

Online CEU offerings reduce the need for nurses to travel, or even leave the hospital unit, for training, ultimately giving nurses more quality time with patients. This educational service is a huge convenience for MCH nurses and it demonstrates the hospital’s dedication to employee satisfaction and retention. With the current nursing shortage, it is more important than ever to provide benefits to nurses to increase their job satisfaction. This is a benefit that the education department heavily promotes to their learners through various communication channels.

“The nursing staff has really appreciated the flexibility and opportunity that is offered through CHEX CEUs online,” said Jackie Gonzalez, ARNP, MSN, CNAA, Vice President and Chief Nursing Officer at MCH. “It is part of MCH’s commitment to our employees to be the employer of choice for pediatric nurses.”

Educators attribute the success of the program to the direct support of upper level managers, like Gonzalez, who embraced this educational initiative and made it an organizational priority. Administrative support was instrumental in achieving buy-in from all disciplines and communicating the benefit to all MCH employees. With the overwhelming response from nurses about the CEU offerings, educators are now working with additional hospital departments to put continuing education online for other health care providers, such as physicians, physical therapists, social workers and others.

Tackling new employee orientation at three children’s hospitals:

Children’s Hospitals and Clinics, Minneapolis-St. Paul

For health care organizations like Children’s Hospitals and Clinics (CHC) in Minneapolis-St. Paul, making the move to e-Learning for mandatory training very quickly made a tremendous impact on educational compliance rates. Less than a year ago, all hospital employees were oriented to the organization by reading a 30-page manual that outlined safety procedures and other standards of conduct specific to the hospital.

With the self-learning process involved with the hard copy manual, the hospital achieved a marginal result — a 50 percent compliance rate. In addition, educators feared that many of the compliant employees were not actually reading the entire novel-like manual. Not satisfied with the compliance rate or the process, the hospital educators decided to pursue e-Learning and prompted the organization to participate in the educational consortium. Through CHEX, the hospital joined other peer children’s hospitals in utilizing a common LMS, standardized pediatric content, tools to author hospital- specific online courses and networking opportunities. With these new resources, CHC educators had high hopes for improving the employee orientation experience and the training compliance rate.

They were not disappointed. (See Figure 3.) Within a month of replacing the new employee orientation book with an online course, the compliance rate increased dramatically from 50 to 95 percent. A few months prior to the safety initiative, CHC’s HIPAA training initiative was introduced, so learners were already familiar with CHEX courses. The education department communicated the importance of completing the safety course through the hospital’s weekly newsletter, their Intranet and brochures that were distributed to all employees through their managers.

Figure 3 The Children’s Hospitals and
Clinics in Minneapolis nearly
doubled their compliance rate
in the first year with CHEX.

Educators were excited that the training was well received and tracking compliance had never been easier. “CHEX has brought efficiency and effectiveness to our corporate compliance program,” said Karen Huggett, corporate compliance officer at CHC. “With online training, we are more confident that everyone is actually reading and learning the necessary information to retain our ethical business practice.”

With the publicized success of new employee orientation, many other hospital departments are dipping their toes into e-Learning. Currently, 12 satellite hospital-owned clinics outside of the main campus, consisting of 750 clinical and non-clinical staff members, are making use of an online curriculum. Plus, educators will soon be providing annual online training for several hospital departments.

Although there has been an overwhelmingly positive response to this new educational method, educators realize that some challenges still must be overcome. They quickly discovered that it was a challenge to get their workforce of over 4,000 employees to change from a paper sign-off to a computer-based training program. Whereas some people were very receptive to the idea, others had issues with navigation, access and ease of use. To deal with some of these issues, the education department made the training available from kiosks located throughout the hospital for those employees who did not have ready access to a computer. Ultimately, there were still some individuals that needed a paper based system, and the administrator would manually enter their training completion date.

Overall, educators are encouraged by the results achieved to date, and they plan to expand the available content beyond compliance training and into the clinical areas.

Children’s Mercy Hospitals and Clinics, Kansas City

With new locations and facility expansions to meet an increasing demand for pediatric health care services, Children’s Mercy Hospitals and Clinics (CMH) has also made significant additions to its workforce. With this growth came the challenge of effectively training new employees and keeping up with continuing education for all staff members. Dealing with a variety of educational needs in multiple locations, educators at CMH decided that e-Learning would be the quickest, most effective way to provide training and tracking.

Targeting the new employee training issue, educators at CMH developed an orientation program in summer 2003 for new employees who had recently graduated from nursing school. The three month program made use of online courses whenever possible. For instance, on a designated “skills day” which encompassed patient care skills and computer orientation, each nurse completed a related online clinical course on the CHEX system. Later in the orientation program, nurses completed the HIPAA courses to comply with their mandatory training requirement. In about two weeks, 95 new nurses completed the program. Prior to moving training online, HIPAA education was conducted through a video. The education department is quickly phasing this method out of their training program to focus on the online courses, which is less time consuming and more flexible for the learners’ busy schedules.

In addition to the orientation program, educators have moved toward e-Learning for annual mandatory training for all staff. In the past, this type of training was provided during a “safety education fair” in which employees would gather in a common area and travel in small groups to a number of “stations” to listen to speakers discussing safety and various compliance issues, such as JCAHO and HIPAA. This was a resource and time-intensive process for all involved as the safety fairs were held several times each year.

When educators first introduced the safety training via e-Learning, they received some push-back from learners who were not technologically savvy. The educators were challenged to prove the benefits of online learning to a large group of employees who were used to passively sitting in a classroom to complete required training. To address this concern, the educators offered basic computer skills training. The education department also provided a staffed, open computer lab for a few days prior to the first online training deadline to assist new users. Finally, the educators opted to slowly phase out the live safety fair to allow ample time for employees to get comfortable with online learning.

“Within the last two years, CHEX has had a significant impact on learning and has become part of the culture at Children’s Mercy,” said Teresa Shepherd, director of education at CMH. “Our busy staff appreciates the flexibility of being able to learn when they are ready, at a time and place convenient for them.”

In addition to the new-nurse orientation and the annual mandatory training, educators have found e-Learning to be effective for other initiatives. For instance, more than 800 nurses and other health care professionals completed an online course within two weeks in preparation for a hospital-wide survey by JCAHO. (See Figure 4.) It was such an effective tactic, the educators plan to again use an online course as a refresher before the next JCAHO hospital survey in 2005.

Figure 4 This online course helped more than 800 health care professionals to prepare for a hospital-wide survey.

The educators at CMH have also found that making a variety of online courses available to hospital staff members to use for self-directed learning can be very beneficial. They have made the full CHEX course library, which consists of nearly 100 courses, available to all learners. Whenever an employee needs to brush up on a topic or wants to enhance his or her own knowledge, he or she can access a CHEX course whenever and wherever a PC and the Internet is available.

e-Learning is quickly becoming a more feasible alternative to classroom training for the CMH staff members who work at nine locations throughout the Kansas City region. In the beginning of 2004, educators found that learners were coming to them and asking for online training and they feel that is a real sign of success.

The Children’s Hospital,Denver

For more than six years, all nurses new to The Children’s Hospital in Denver (TCH) went through four, eight-hour days of classroom instruction once they were hired. In addition to that, all new employees who were recent nursing school graduates, and nurses new to pediatrics, were required to attend three additional days of classroom training. However, after implementing CHEX in 2003, the educators decided it was time for a change.

In January 2004, they completely revamped their nursing orientation program to incorporate e-Learning. In doing so, the educators have effectively reduced the classroom instruction time by 12 hours for all newly-hired nurses and reduced new-nurse training for recent nursing school graduates by an additional two hours. (See Figure 5.) Before, new-nurse orientation consisted of all classroom training. It was transformed into a blended learning format by eliminating some of the classroom time and including more online courses.

Figure 5 The Denver use of CHEX
courses significantly reduced
classroom instruction time required.

The new blended learning approach to orientation allows instructors to use classroom time for more interactive case studies and scenarios as the foundational content is provided online. The education department is currently in the process of tracking overall training time by having learners log their time spent completing online courses. However, through informal learner surveys they have ascertained that there has already been at least a 30-50 percent reduction in training time overall.

As a part of orientation, TCH is using 14 CHEX-built courses and two internally created courses. With these resources, educators have created three curricula for learners that must be completed within 30 days. The number and type of curricula that are assigned to learners is based on their specialty and experience level. Overall, employees have been very pleased with the program, especially as it allows them more time for direct hands-on learning in their department. TCH ensures learner satisfaction and understanding of the online system by providing user guides with specific log-in instructions. (See Figure 6.)

Figure 6 User guides with specific log-in instructions improve learner satisfaction and understanding of the online system.

“It is our hope that by incorporating CHEX modules into our orientation programs, we will increase participant satisfaction while maintaining a quality program,” said Cindy San Miguel, clinical nurse specialist, nursing education.

Conclusion

Like many other health care organizations today, the pediatric hospitals described in these case studies have merely scratched the surface of e-Learning and they are willing to delve deeper. Though e-Learning technology may be a little slower arriving in the health care industry, these pediatric organizations are already seeing great benefits in a short amount of time. As the educators continue to find new and exciting ways to use e-Learning, alone or in a blended learning approach, they are helping to transform their individual facilities into true learning organizations.

While each of these pediatric organizations tackled challenges relating to different types of training (e.g., governmental/ regulatory, professional and organization- specific), there are common lessons learned that can be applied to any organization pursuing e-Learning. For instance, getting buy-in and support regarding e-Learning from both organizational leaders and learners is invaluable. It can make or break the program. In addition, it is important to realize that the use of e-Learning will require a culture shift and you must plan up front how to make it happen and how you will support learners in the time of transition. Finally, finding a way to network with peer organizations, as all of these hospitals have done through CHEX, offers educators easy access to best practices and a wealth of ideas to explore.

Comments

Login or subscribe to comment