Delivering Blended Learning into Europe's Largest Organization: How the ADL Initiative Has Helped Tackle Healthcare Associated Infections in the NHS Free

According to figures released by the British National Audit Office for 2004, one in nine patients in the United Kingdom will acquire an infection during their healthcare treatment, directly resulting in 5,000 deaths, contributing to a further 15,000 mortalities, and resulting in over 100,000 healthcare associated infections (HCAI). These infections clearly have a major impact on the availability of beds and the length of waiting lists, because infected patients have to spend, on average, an extra 11 days in hospital. Furthermore, infected patients cost around three times more to treat than uninfected patients, costing an estimated £1 billion (approximately $2 billion) to the health service every year. With improved hand hygiene and environmental cleanliness, it has been estimated that around 15–30% of HCAIs could be avoided.

In October 2005, theNational Infection Control Training Program was launched to address staff training across the service in an effort to reduce the number of HCAIs. Since then, the Core Learning Unit of the National Health Service (NHS) has been responsible for the rollout of the program, targeting all NHS employees.

The program aims to support busy hospital staff by providing both e-learning materials that learners can access independently and face-to-face materials that can be cascaded throughout the organization by a broad range of trainers. It was developed on behalf of the service by an expert reference group from the service and education supported by Infection Control Experts at the Richard Wells Research Centre (at Thames Valley University in London) in conjunction with technology-enabled education company Intuition. From the outset, the project team adopted a standards-based approach to e-learning content development, with SCORM 1.2 conformance being written into the project specification. This case study demonstrates how a SCORM approach has aided both the development and delivery of the program at a number of key points in the project cycle, ultimately ensuring that Infection Control Training is available to the widest possible audience, without barriers.

The health service in the United Kingdom is a geographically dispersed and decentralized organization with executive powers residing in various regional authorities. It is the largest employer in Europe, with 1.3 million staff. The NHS has recently restructured from 28 to 10 Strategic Health Authorities (SHAs), each with responsibility for coordinating the strategies of the healthcare trusts within their regions. The different trust types are: Acute Trusts (hospitals), Ambulance Trusts, Care Trusts, Mental Health Trusts, and Primary Care Trusts.

Making the content available to all NHS employees in these different trust types was a daunting challenge for the program from the outset. Adding to the challenge is the range and diversity of the employee roles within the service—ranging from clinical staff who are IT literate and have access to IT resources but are typically time-poor, to nonclinical staff who traditionally have not been afforded learning opportunities and will often encounter barriers in terms of both skills and access to IT equipment.

High quality evidence-based learning resources were developed with the aim of providing a centrally-validated suite of courseware delivering underpinning knowledge in the principles of infection control and prevention. These resources are distributed freely across the NHS as a toolset available to both Infection Control teams and standard Training Units. The materials are designed to be relevant to all levels of staff within the NHS, from cleaners, porters, technicians, and receptionists, to nurses, doctors, managers, and chief executives. Two versions of the program have been developed (an e-learning version and an instructor-led version), and each of these has been further split to suit both clinical and nonclinical staff.

Initial plans for technical delivery centered on an NHS-wide Learning Management System which was, at that time, in the process of procurement. The project team was able to confirm that the future platform would support SCORM 1.2 content, which gave confidence to proceed with content development with minimal interoperability or compatibility concerns. However, due to organization change, the LMS procurement was cancelled, and by the time the Infection Control courses were ready for release, the plans for a centralized delivery system had been withdrawn. At this early stage, the SCORM conformant approach began to pay off; since the content had been developed using a standards-based approach, it was possible at short notice to swap in Intuition's own LMS as a Web-hosted service.

Intuition has been a SCORM adopter since 2002 and has benefited significantly over the years from implementing a common technical delivery standard across all projects. In some cases, the main benefits have been realized through reuse of its own SCORM 1.2 platform, in others through the efficient development of content for delivery on client platforms that utilize the same standard. For the NHS project, this meant that the project team could continue to concentrate on the quality, usability, and interactivity of the content rather than be sidetracked into technical development challenges. With just a small amount of rebranding and customization, Intuition's LMS became the delivery mechanism for the Infection Control Training Program.

The training program meets the recent requirements announced by the British Government's Health Act 2006, which includes a Code of Practice for the Prevention and Control of Healthcare Associated Infection. The Code of Practice requires every NHS body to ensure that mechanisms are in place to provide prevention and control of infection in induction programs for new staff and ongoing training programs for all existing staff. The code provides a legal basis for infection control practice accountability and, as part of this, stipulates that there must be a record of Infection Control training for each staff member. SCORM-based training records are available to infection control teams and training administrators through the reporting functionality of the learning management system. This provides auditable evidence of uptake for individual Trusts. The Code of Practice, which came into effect on October 1, 2006, is already a key area for self assessments submitted by all providers of healthcare to the industry regulator, the Healthcare Commission.

Although the infection control training is available in both e-learning and instructor-led formats, the e-learning has proven more popular for a number of reasons, summarized as follows:

• Staff can access individual modules in their own time and from any place. Users can even progress toward certification in 5–10 minute study sessions, with automatic tracking of their progress as they use the system

• The e-learning results in less “down time” while whole sections of staff undertake training to the same timetable

• All training records are available in a centralized national system—the qualification can therefore move with staff as they move between NHS organizations

• Content modules can be mixed and matched according to local need, since the content has been developed using a Reusable Learning Object (RLO) model (again based on the SCORM standard)

Compounding the challenge of rolling out the content to such a huge dispersed audience was the additional technical challenge resulting from a number of the service's SHAs/Trusts that had already invested in their own Learning Management Systems. When consulted, these SHAs/Trusts expressed a strong preference to continue to use their own systems rather than having to adopt a new national system to deliver e-learning content. Again, SCORM conformance delivered a solution to this challenge since all of the LMSs in use were SCORM 1.2-based and therefore were compatible with the existing content. Furthermore, to meet national and local requirements concurrently, a standards-based login was developed to offer learners the ability to launch and track their learning either from the national system (hosted by Intuition at www.infectioncontrol.nhs.uk), or from whichever learning management system is in use at their local Trust/SHA. Tracking of learner progress occurs concurrently on the national and whichever local system is in use, thereby meeting the requirements for both local and national uptake data. This maximizes the investment made by Trusts/SHAs in their own delivery platforms and enables them to leverage work put into those systems.

In September 2006, the Core Learning Unit and Intuition piloted a solution with South East Devon Primary Care Trust to tackle the problems of accessibility to IT hardware and poor computer literacy through the use of tablet PCs. The program is available on A4-sized tablet PCs running offline, meaning that it is truly accessible at any place and at any time. Tablet PCs help the program reach the widest possible audience and offer a state-of-the-art e-learning experience that is cost effective, easy to use, and highly intuitive. The digitized pen removes the need for any pre-existing keyboard skills and offers a fun, user-friendly platform from which to learn. The ADL initiative has again facilitated this delivery option since Intuition was quickly able to produce an offline player utilizing the SCORM 1.2 standards.

Paul Norrish, project manager, education, training and development at South East Devon PCT, commented that “The tablets PCs have been received remarkably well by our staff, who find them extremely simple to use. The portable nature of the device also means that they have much more flexibility to complete their training, and this is a hugely important factor for support staff who may not necessarily have a permanent day-to-day presence on site.”

The project team is also investigating the use of the content on Blackberry devices, potentially allowing more experienced clinicians to opt-out of annual training if they take a short refresher and can prove their continued mastery of the topics. A SCORM player has been developed for the Blackberry to facilitate this, which synchronises tracking results with the national system via Blackberry services.

The National Infection Control Training Program continues to grow at a rapid rate within the NHS—there are now almost 20,000 users registered on the system. The project team recognises that this successful rollout has been facilitated greatly through the use of the SCORM 1.2 standard. International interest in the training programme is also strong, with a Chinese Mandarin version already in production with the backing of the Chinese Ministry of Health, a Scandinavian version in the pipeline, and pilots are beginning in areas of Australia.

The authors thank the NHS Core Learning Unit and The Richard Wells Research Department at Thames Valley University.