March 2017
Issue Map
The Public Manager

A Healthy Approach to Training

Friday, March 10, 2017

Jim Warner builds just-in-time learning for thousands of VHA employees.

Jim Warner, chief learning officer at the Veterans Health Administration (VHA), says the most powerful and rewarding aspect of his career is to work with midcareer professionals who are developing themselves by advancing their professional knowledge. At VHA, this means providing educational opportunities for a large, diverse, and distributed workforce.

The healthcare professionals at VHA care for veterans who served from World War II to the ongoing fights against terror around the globe. They are motivated to learn new skills and hone their existing ones. Their industry is evolving with new knowledge and techniques almost daily, and they want to stay ahead of it.

Here, Warner explains what it takes to facilitate nimble learning on such a massive scale. He discusses the importance of engaging learning communities and the role new training technologies play at VHA.

Tell us about the scope of training at VHA.

VHA is the nation's largest integrated healthcare system. It has more than 1,700 sites of care with and serves almost 9 million veterans every year. There are more than 300,000 employees in the system, so it's 300,000 employees at 1,700 sites taking care of 9 million veterans.

The size obviously makes training difficult. What are some of the unique challenges you face?

The system is large, so we have to touch on everything, from administration to any medical specialty you can imagine. Scope and scale are real challenges. The healthcare industry is constantly evolving. There's always something new to know. There are always changes in medicine, changes in practices, and changes in treatments.

So how do you stay ahead of that curve?

It's less about staying ahead of the curve and more like riding the wave. Fortunately, healthcare workers are lifelong learners by nature. We have a lot of individuals who are organized as a group to hone their own proficiencies. Whether that's emergency room nurses or medical doctors of a particular clinical specialty, there is a community of practice with a common standard of work. VHA's role as a learning organization is to help the subject matter experts identify their best practices and make sure that they're shared widely with all the members of the community.

How do you go about accomplishing that goal in an organization of this size?

We support the learning communities. We use the ADDIE process. Assess what needs to be done, design and develop a program, and implement it. Then, evaluate your achievement and start over to further remedy as needed.

For example, VHA was challenged by a wide divergence in the processes by which we scheduled appointments for the 9 million veterans we care for. A couple of years ago, VHA made a concerted effort as an organization to define how we wanted that community to perform this work to common performance standards. We had to identify members of that community and their roles in their teams. The experts defined roles and tasks for the work. Our trainers developed training support packages around the tasks for each of those roles, and experts implemented the program.

Just as important, we had to design the system so community members could continue to evaluate their work and improve. Is there another task or another skill that a member of this team needs to gain proficiency on? Is there a new way of doing this that we need to train everyone in our team on? That's the virtuous cycle of evaluating your performance and modifying procedures to train each and every member of the team.

In the past, there was an idea that you had to get an education and then perform what you learned in the "real world." Now training has shifted to just-in-time, just-in-place learning and performance support. How has this shift affected VHA?

I think this is just a change in cycle time. You used to learn things in school and then practice those things for 20 years. Now you're taught things in school, and you practice them for two or three or five years before something better, something newer comes along. Our employees are not only looking for the new and better ways, but now they also create and share them in the workplace.

There is innovation and rapid change on all fronts, not just in healthcare, but in everything that we do. So we have to have support tools in place that enable employees to respond to changes and generate solutions that improve performance. What's more, we have to capture that and disseminate it to the rest of the employees. Knowledge sharing is key.

There's a dual goodness to learning at "point-of-need." If you think back to the lessons that were most powerful to you, the things that you learned best, it might have been something that you made a big mistake on. That made a big impression on you, so you never made that mistake again. Or, perhaps it was something that you learned just at the point of time and place where you needed it.

We can now create circumstances to make mistakes with full learning impact in a safe environment. And we have new ways to give you exactly what information or skill you need, exactly when you need it. That's powerful. Retention increases, understanding surges, and productivity derived from that learning delivery improves. A lot of the learning science right now is figuring out how to have just what you need where and when you need it. And there are a lot of new technologies that provide options.

What kind of technological tools are you using, and how have they changed the way that VHA is delivering training?

Clinical professionals see more change than any other profession. There are new techniques, papers, and research coming out every day. When clinical practitioners are about to go in and perform a procedure, provide a service, or offer advice to a patient, they'll pull out a phone or an iPad to check a medical database to see if any new information arrived today, this week, or since the last time that they faced this particular challenge. They know that they went to school for this and were trained for this. They studied this perhaps as recently as a week ago. But they check for new information because there might be some new practice or tool for addressing the issue or diagnosis. They are constantly learning.

New technologies provide mobile, modular learning options, searchable knowledge systems, and tailorable content for social sharing. As individuals see their work evolving in front of them, they have the tools to prepare themselves and to share or consult with others. VHA has to offer the best possible learning options to ensure our clinicians are able to provide the best possible care.

Can you tell me a little bit about your work with virtual and augmented reality? Why are those options useful in your field?

Virtual and augmented realities are maturing and have great potential. Training is a learning module that's designed to solve a challenge that professionals face in the course of their daily work, whether that's how to fill out a form, how to talk to a colleague, or how to report an incident. Basically, whatever tasks you're facing. Training is really just a vehicle to help professionals to be more effective and efficient in their daily responsibilities.


Virtual and augmented reality options allow us to create scenarios so that VHA employees can rehearse a particular task with high fidelity and a high standard of execution. This way, they can receive feedback and improve before they move forward into the workplace and actually have to, for example, counsel an employee or perform a clinical task. We judge the technology by its impact on the learners.

The technology is already here to create 3D scenarios. The equivalent of the Star Trek hologram is perfectly doable today. We have to figure out how to create high-fidelity practice opportunities that are integral to their workspaces, where employees sharpen essential skills and become flawless in performing essential tasks.

We have simulations where a clinician can perform a procedure or practice a task with extraordinary realism. We have mannequins with blood pressure and eye dilation. They make noise, talk, or complain of pain. They are controllable by a subject matter expert who can establish a very high-standard, high-fidelity practice opportunity for other clinicians. Clinical and administrative professionals can hone their skills and then deliver that high standard of care when they interact with veterans.

How have new technologies changed the architecture of training? And how can you tell what will be a useful technology and what might be tech for tech's sake?

If technology doesn't improve performance in the workforce, it's not useful. Does this new tool create more skill or knowledge to enable employees to do good work? If it doesn't, then it needs to be jettisoned. We can track what tools our employees use. Last year, we had hits on 180 million knowledge objects, including 4 million minutes of instructional video content. From that, we can adjust our efforts to support the employee needs as expressed by their demand.

New technologies are enabling us to capture knowledge more easily. Frequently, the tools people are using in their day-to-day activities are also knowledge tools. This means that as they are working, they're capturing knowledge and experience and sharing.

Technology also gives us the ability to make learning more modular. More learning will be smaller—15 minutes, 10 ­minutes, 5 minutes—instead of the one-hour block. This compartmentalization will help us develop learning programs that are just in time and just at the point of need.

What advice can you offer to agencies that want to adopt this type of on-demand training?

I would start by spending more time on needs assessment. The most important aspect of the entire training cycle is understanding employee need. To understand that, you have to be connected to the HR community, you have to understand succession planning, and you need to identify the greatest skill gaps. For instance, you can look at succession planning, and it will tell you where the greatest organizational needs are. It will help you build a learning strategy for your organization.

The second piece really goes to the structure of communities of learning within your organization. Almost every organization has natural learning communities. They are made up of the employees who come to work and want to improve themselves both personally and professionally. You have to ask yourself, "What have I done to support each of these individuals? What have I done to establish the infrastructure and the support tools necessary to capture the knowledge that's being created within their community, so that they can find answers to questions not just within their community, but across their communities?"

When you have the learning management and the knowledge management systems aligned in a way that they are moving toward enabling continuous learning on the job, that's where you find success.

You are a West Point and Harvard Business School grad and a retired army general. Why did you decide to apply your talents at the VA?

I entered service at an early age. I owe my personal and professional development to those with whom I served. I owed my life on several occasions to comrades of courage. In short, I owe them a debt I can never really repay. But I am going to do the best I can.

About the Author

Roxy Torres is a former senior manager at ATD, where she ran the FIRE, sales enablement, and government content areas. For the Sales Enablement Community, Roxy spearheaded the 2015 update of the ATD World-Class Sales Competency Model. Prior to joining ATD, Roxy held various roles in business development and sales enablement at CEB (now Gartner).

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