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					Learning Management Systems
        INL 880: Capstone Project
       Professor Margaret McCoey
               Spring 2008

                                    Team members:
                                     Wayne Collier
                                    Shawn Hopkins
                                        Rich Scully
                                                    Table of Contents
1.  Executive Summary ................................................................................................................ 4
2.  Learning Management Systems (LMS) Background ............................................................. 6
  a. Why is an LMS necessary? ......................................................................................... 6
  b. What is an LMS? ............................................................................................................ 7
  c. Global Components ....................................................................................................... 8
    i) Modes of Delivery ........................................................................................................... 8
    ii) Features .......................................................................................................................... 8
    iii)   Technical Specifications ............................................................................................. 8
    iv)    Component Summary .................................................................................................. 9
  d. Business Concerns ....................................................................................................... 10
    i) Financial Costs (Resources?) ....................................................................................... 10
    ii) Operational Benefits (formerly Organizational mandate versus organization desire- Wayne) ............... 10
3. History of LMS (Wayne) (starts with old ―1b. Origin/ Purpose (Wayne)‖) ..................................... 13
4. LMS in Healthcare Industry.................................................................................................. 20
  a. LMS Healthcare Components ................................................................................... 20
  b. Healthcare Historical Case Studies.......................................................................... 22
  c. Recent Healthcare Case Studies ............................................................................... 27
5. LMS Healthcare Business Cases .......................................................................................... 30
  a. Case 1: Visiting Angels Home Care Agency ........................................................ 30
    i) About ............................................................................................................................. 30
  b. Case 2: Complete Healthcare Resources ................................................................ 33
    i) About ............................................................................................................................. 33
    ii) Business Case Summary ............................................................................................... 34
    iii)   Network Topology ..................................................................................................... 35
    iv)    Requirements............................................................................................................. 36
    v) Solution Selection Methodologies ................................................................................. 39
    vi)    Solution Alternatives ................................................................................................. 42
    vii)   Final Selection .......................................................................................................... 43
6. Lessons Learned.................................................................................................................... 44
7. Future Outlook/ Next Steps .................................................................................................. 45
8. References ............................................................................................................................. 46
9. APPENDIX ........................................................................................................................... 49
  a. National Standards of Home Health Aide training program. ............................ 49

Revision History

Date       Name    Summary
4/2/08     Shawn   Reorganized sections, applied new outline format to entire document,
                   started writing opening section, inserted Executive Summary, created
                   Table of Contents

1. Executive Summary

   The proposed project is to present an overview of Learning Management Systems while

providing a breakdown of their core technical components and business purposes. This project

will examine the best practices for an LMS through a review of case studies in various fields and

industries. The LMS should support and manage training and certification of existing and newly

hired employees or contract laborers. The core functionality of an LMS is to catalog, present and

make training accessible to an organization. It should provide basic reporting capabilities about

learners, curricula, and utilization. The differences that set one LMS apart from another are

complimentary, value-adding functionalities, such as:

              Self-registration for courses,

              Training workflow (notification, approval, assessment, evaluation),

              Variety and flexibility of formats or presentation (e.g. Computer-Based Training

               (CBT), self-paced materials, readings, examples, exercises),

              Collaborative learning (online classes, discussion boards, white boards),

              Course and/or content management

   Case studies and other aspects of training and LMS will be reviewed. Turnover costs include

expensive replacement training. Retention, training and employee engagement programs are all

integral components of talent management challenges. Performance management is the most

popular issue currently as 56% of organizations perform annual reviews. Of that percentage,

65% use manual or homegrown systems. As technology grows in this area, performance

management will help to make performance management a continuous process rather than a

point-in-time exercise.

2. Learning Management Systems (LMS) Background

   a. Why is an LMS necessary?

       Companies in the world today strive for operational efficiency and business continuity.

Everyone wants to figure out the cheapest way to bring the best, most desired product to market.

However, in order to meet these demands, business processes must be defined, developed and

shared across the organization. With the worldwide market, global enterprises and international

competition, companies find it difficult to train, share information, and assess the skills of all

their employees. A skilled workforce is best suited to deliver the most refined business

practices. Learning Management Systems support the training needs of larger organizations.

   b. What is an LMS?

       LMS is intended to integrate, organize and standardize learning across an organization. It

uses educational programs to distribute, manage and assess knowledge across departments and

geographies in an efficient, fast and low-cost manner. LMS enhances education‘s connection to

operational efficiency and organizational success. It needs to be a real-time, knowledge-sharing

system to coordinate business activities across the enterprise. It can even be extended to the

supply chain (via enterprise portals, applications or EDI). LMS adoption rates are growing and

offer a quick return on investment [mention in case studies]. LMS have also become a symbol of

corporate accountability. [Find/cite supporting info for last 3]

   c. Global Components

       i)      Modes of Delivery

       LMS can be categorized into three primary modes of delivery: self-paced, scheduled

classes, and group learning. Self-paced training includes Web-based seminars and classes, as

well as downloadable materials, such as slides, computer-based training (CBT), video content,

etc. Scheduled classes are delivered live by an instructor in physical classroom settings or

online. Group learning is typically free-formed online chats or discussions used to extend or

enhance the two other LMS modes.

       ii)     Features

       Several features support the operational effectiveness of a Learning Management System.

First, it should be robust enough to meet the varied needs of learners, administrators, content

builders and instructors at the same time. It should support automated and personalized services,

such as self-paced and role-specific learning or notifications. The access, delivery and

presentation of material must be easy-to-use and intuitive, often integrating workflow


       iii)    Technical Specifications

       The LMS technological infrastructure needs to be scalable to meet future growth, in

volume of instruction and size of student body. It must support content from different sources

and multiple vendors‘ hardware/software solutions. It should be based on open industry

standards for Web deployments (XML, SOAP or AQ) and support major learning standards

(AICC, SCORM, IMS and IEEE). It should be stable enough to handle large numbers of users

performing varied tasks at any given time. The system should also offer the security to

selectively limit and control access to online content, resources and back-end functions, both

internally and externally, for its diverse user community.

       iv)     Component Summary

       In summary, a LMS should support the following features:

       •       Availability

       •       Usability

       •       Scalability

       •       Interoperability

       •       Stability

       •       Security

   d. Business Concerns

       i)      Financial Costs (Resources?)

       From a financial and budgeting perspective, most Learning Management Systems follow

traditional Licensing models. The software can be purchased and maintained internally. A

Company could buy software, but contract with a third party to house and manage it, and users

access the system remotely over Internet. A Company could also buy software and integrate it

into its own data platform, (but maintenance and upgrades could be managed by vendor or

another third party). Finally, a Company could ―lease space‖ from the vendor data site to share

access to operating system.

       ii)     Operational Benefits (formerly Organizational mandate versus organization desire- Wayne)

       Characteristics can range from the many applications in use, but all have many of the

same ideas and feature behind them. Managing users, roles, courses, instructors and generating

reports are a key element shared by almost all LMSs applications. Course calendars, messaging

and notification functionality, testing, scores and transcripts, roster processing and web-based

course delivery are all attributes of LMSs no matter what capacity they‘re being used at.

Characteristics targeted more for learning in the enterprise include auto-enrollment, which allows

managers to track employees on a learning and career path suited to their profession that is

sought after by the enterprise. These courses are then tied into performance tracking and

management systems API‘s that can be reviewed by upper-management for employee

assessment for pay raises and job placement. From these assessments, skill-gaps for individual

employees or entire departments can be utilized to see strengths and weaknesses that need to be

cultivated, disseminated or possibly outsourced. Learners can also be grouped through

performance tracking by demographic sectors, business size or product line (2). This can also

allow for employees to attain more than one job title as needed based on education background

and experience.

       Trying to disseminate data for knowledge to many people effectively is a main goal of

many organizations met by LMS. Gaining instantaneous feedback through testing and giving the

ability to managers instantly approve training presents an enterprise and its employees a stronger

opportunity to meet the learning requirements of any realm of business. This methodology also

counteracts the strict training requirements of many regulatory bodies that encompass many

work fields. Not only technical skills can be taught through LMS, but also ―soft skills‖ such as

human relations and benefits, which is attractive and beneficial to any company.

       When choosing a particular LMS a company should focus on whether the chosen

software has the 15%-20% that they truly need. All LMSs have many add-ons and features that

a business will never use. Creating a use case to fit the business process must be the initial act of

determining which software best suits the needs of the company. It must meet every need that is

devised in the process such as actually producing the learning required, generating useful reports,

meeting tracking requirements and handling diverse categories of content. Knowing the business

and legal regulations of specific certification programs and managing access security within the

course catalog is important. Many individual questions must be answered on a business to

business basis to come to a complete solution for particular needs. LMSs are suggested for

companies with more than five-hundred employees to actually be effective and to justify the cost

of housing one. If the need to train customers, partners or reseller are in order, than the need for

an LMS is multiplied. There is a $580 million market for LMSs and big companies such as

Oracle, Peoplesoft, SAP and WebEx all have solutions (9).

3. History of LMS (Wayne) (starts with old “1b. Origin/ Purpose (Wayne)”)

       The main purpose and business driver for a company buying and maintaining an LMS is

to manage training administration. The system is based on the principle that the tracking,

reporting and interactive anytime\anyplace functionality of the tool for end-users will increase

ROI by augmenting personnel knowledge and therefore bolster overall quality production.

Educational gains among staff have numerous benefits. A patient will be diagnosed more

accurately and quickly than by an untrained healthcare employee. This causes an increase of

patient turnaround, which increases the overall income of the healthcare provider. Theoretically,

it should also decrease lawsuits brought on a business by misdiagnosing a patient and enhance

the overall reputation of the company. LMSs also play a major part in keeping the morale of the

employee raised by maintaining their training as adequate and current in the field, making them

more marketable. A reciprocal feedback occurs which retains the provider‘s workforce

turnaround to a minimum since employees will be more likely to reside in a company that

encourages active learning.

       Essential benefits that can be gained from an LMS implementation include an

anywhere\anytime learning format that employees can utilize to fit their schedule. Training can

be accessed from home or at the workplace making the task of continued education a more

convenient method for advancement and business edge for both learner and company. The need

for scheduling personnel can be reduced through automated formats driven by software that is

pre-configured by managers to meet the learners‘ needs. Another benefit of LMSs is that access

is granted to up to date information at any given time. The advantage of not having to physically

attend trainings is very beneficial for large corporations that would need to juggle trainers,

people, ample sized conference rooms and designated training centers and the money that would

be need to support these services. Being centrally managed, LMSs are able to be updated by a

trainer at any time with internet access or central server access to reduce the time to drastically

disseminate information to many people. Information can be sorted for easier access and making

a cleaner web experience for the end-user for quick access to pertinent data. Comprehensive

information libraries, course evaluations, program content surveys, file exchanges and discussion

groups can easily be organized in web layout format. Experts in the field of healthcare can be

available for users through web-based trainings. Barring storage capacity limitations, many files

can be made available in any file format including: movies, PDF, Word, HTML, PowerPoint

slides, text files and any other compatible file formats available within modern browsers.

       An LMS also allows an employer to track the progress an employee is making within the

company and can be cause for pay raises or decreases depending on the case. In this respect, the

LMS is monitoring the quality and knowledge of its workforce and allowing for relevant

countermeasures to take place which can be leveraged as an argument that money is being spent

wisely. It can also guide a career path for an employee by choosing the education most adept to

a certain person‘s talents and desires. An LMS for an employer is a high-level planning and

management solution for strategic learning in an organization. The system replaces disjointed

training programs with a unified means of competency assessment. Certification management is

imperative in the healthcare industry, and it is important to attain the most streamlined and

strategic goal-aligning process available through learning initiatives. The main purpose is to

manage learners by tracking their development and performance via diverse types of training

activities. LMSs can also be fed into human relations and enterprise resource planning (ERP)

systems for a complete business advantage across many different departments.

       As discussed earlier, CMSs became LMSs after the increase of popularity of the internet.

Learning content management systems (LCMS) are systems that provide tools to deliver and

manage instructor-led synchronous and asynchronous online training based on learning object

methodology (6). LCMSs utilize the authoring and reuse of content through mutated learning

objects (MLO). This is also accomplished through virtual spaces for interaction with the teacher

or other students through discussion forums and same time\different place chat rooms. The term

LMS is often misused to also mean CMS or LCMS. An LCMS is actually a further expansion of

an LMS, such as object-oriented programming is an expansion of basic C programming. It

reuses sections of learning content so as to not reinvent the wheel every instance a curriculum

must be formulated and presented to learners. It solves the business problem of creating just

enough content just in time to meet specific and individual needs at a certain time. Instructional

designers can create the learning objects for course developers throughout an organization

eliminating the double effort while permitting swift assembly of content. The term ―Computer

Learning Content Information Management System‖ (CLCIMS) has been formed to create a

standardized means of referencing a learning system based on advanced learning technology for

any virtual learning environment (7).

       Content Management Systems (CMS) are online front-ends that are designed to sustain

remote classroom learning. They can be employed to place course materials online such as

syllabi, schedules, specific lessons, readings, lecture slides, etc. CMSs are easy to setup and

deploy, and approximately 70% of universities‘ instructors have utilized CMSs for course

content (8). Resembling LMSs, CMSs can also track a student‘s advancement through online

exams and even sometimes feature online grade books where students can see how they fare in a

particular class. Popular CMSs include Blackboard, WebCT and Moodle. CMSs can host

discussion boards which utilize the different time\different place tactic of learning acting almost

as a blogging site for learning. CMSs differ from LMSs by the fact that LMSs are software that

acts as electronic registrars by executing enrollment tasks and monitoring a students learning and

career tract, whereas CMSs are the actual web medium for delivering that content. They seem to

be very similar, both allow for enrollment, communication, performance tracking and

disseminating learning materials, but they are designed for two separate instances. If one system

is employed when the other was intended, problems in the execution of applying the software for

the business need will occur.

       (old start of “History” section) Learning management   systems (LMS) consist of software tools

devised for managing learning from remote locations outside of a classroom. They differ from

simple learning records management systems in that they offer much more functionality to the

end-user. Students can self-register for learning modules, follow an instructor devised training

workflow, attain notifications of further requirements for training, gain manager approvals,

attend collaborative learning environments online, in addition to many other features. One of the

most alluring features from a manager‘s perspective is an integrated performance management

system, which allows the opportunity for period-based appraisals, competency management,

skills-gap analysis, succession planning and 360 degree reviews (1). LMSs are usually web-

based to facilitate anytime\anyplace learning which aids in convenience while following

compliance training business guidelines. A system in place that covers everything from

recruitment to retirement, and all employee skill growth in between, is a beneficial asset to any


       Starting out as content management systems (CMS), hypertext navigation software did

not have a significant impact on learning until the 1980‘s when the Owl Corporation developed a

DOS commercial course authoring package called GUIDE (3). There were other software

packages that existed before OWL, but none were available off the shelf. Plato was a project

developed by the University of Illinois and a variety of corporate and military training

applications existed, albeit small in stature compared to today‘s LMSs. They usually focused on

a much smaller educational need and didn‘t encompass many, if not all, of the feature included in

today‘s software packages. Plato was ported to DOS and became Tencore, but quickly lost

attention due to a slow adoption of Windows. Other upstart companies such as Asymetrix

Corporation, Quest, Multimedia ToolBook and Course Builder were gaining popularity and

vying for market share. LMS software grew into complete computer courses starting with

hypertext utilities and then added hypermedia authoring features in the early 1990‘s (3). All the

aforementioned packages were established up until 1999, but almost none were employed by


       Most CMSs were designed for floppy disk or CD-ROM and peaked in popularity in

around the mid-1990‘s. The increase in use from the early 80‘s to approximately 1995 was

finally sequestered due to the popularity of HTML authoring and editing software packages as

the internet was beginning to explode. Corporate training and universities began to remove itself

from physical CMSs software through books and disks since web-based, real-time tools were

being created that were vastly more efficient and convenient (4). As the 20th century began,

most video training and CMS CD-ROM packages declined because the web was such a driving

force at bringing training to end users at such a fast pace. Companies were not making much

money on book and disk sales also and many DOS versions of software were never ported over

to Windows once NT came along. Macintosh‘s CMS software almost completely disappeared

after the fall of their market share during this time. There have been four main periods of LMS

over the last 10 years. It was first designed as a back-office training administration system, then

as an e-learning platform, then as an enterprise-wide corporate learning application and now

emerging as talent management platforms (9).

         LMSs stem from a variety of development platforms ranging mostly from Java EE and

Microsoft .NET. Most likely they‘re using a stout backend database such as Oracle or SQL

Server to handle the extensive amount of data and cross relationships. Most LMSs are

proprietary and do not allow viewing to the source code as well as employing software licenses.

However, open source software does exist such as: Moodle, Fle3, Claroline and ATudor to name

a few. In a university educational setting they are used as virtual learning environments

formulated by instructors to administer course content and coordinate information exchange to

students for courses that last weeks or months, all without having to ever meet face to face.

Corporate applications may be less extensive on a one-off basis to learners with possibly only

one or several online sessions designed for certification paths or extended program development.

Most LMSs are intended for large, enterprise sized companies with many custom features which

make it harder for disparate systems to become compatible with one another. Costs for in-house

LMSs, after flexibility, compatibility and two or three headcounts to maintain and monitor the

system, can exceed $150,000 (5). Application service providers (ASP) are utilized as third-party

software outsourcing for LMS solutions due to high in-house costs.

4. LMS in Healthcare Industry

   a. LMS Healthcare Components

       One of the foremost challenges of training and learning management in healthcare is the

wide range of professionals employed within the industry. Many training modules can be

distributed across all types of jobs, such as HIPAA privacy and security, safety, patient

interaction skills, and disaster response. However, job specific training can vary from doctors to

nurses to other staff, as well as for the type of facility or medical specialty. The complexity and

number of different training modules increases the difficulty of bringing them together in a

single LMS. The Pennsylvania Department of Health includes the following professions among

a list of potential users for its statewide LMS:

      Emergency Medicine and Nursing professionals

      Critical Care/Trauma services

      EMT professionals

      Administration professionals

      Security

      Behavioral Health specialists

      Critical Care/Trauma services

      Laboratory professionals

       Hospitals and other healthcare facilities often operate everyday and around the clock.

The LMS needs to be available whenever users find time for training activities. Online and self-

paced training courses also help reduce the amount of time personnel needs to be scheduled to

attend training sessions. Collaboration tools must support and enhance asynchronous

communication since users will accessing the system morning, day and night. Finally, a variety

of presentation modes are required to reach intended audiences and present training materials.

These formats include movies, text, PDF, PowerPoint, audio files, etc.

       [LMS reports to support disaster/emergency healthcare preparedness] -


   b. Healthcare Historical Case Studies

       Medical training is an enormous challenge for many healthcare providers being that the

knowledge in the field is so vast, that managing them seems near impossible. Hundreds of

specializations exist that medical staffs need to be specifically trained in. The American Board

of Emergency Medicine, the Certificate of Eligibility for Specialist Registration, the American

Nurses Credentialing Center, the Postgraduate Medical Education and Training Board and many

other medical training institutions supply current knowledge to healthcare professionals in their

given fields. There are basic business divisions within healthcare organizations such as human

relations, IT and legal departments that require certification. Managing training across

environmental health professionals, first responders, mental health professionals and office

workers can be a daunting task. Government mandates medical training, although time-

consuming and expensive, be delivered promptly and efficiently as part of a healthcare

provider‘s expense. Recently, outside legal pressures have pressed the issue for continuous

medical training adding to a patient‘s overall medical experience and quality of care.

       Integrating disparate learning systems through non-standard methods is a test for any two

companies. The University of Pennsylvania and CE Medicus aggregated their Continuing

Medical Education (CME) content catalog through a unified search engine by using online web

technologies. Through a seamless integration between two disparate LMS databases and web

front-ends combining two LMS systems, they developed one system with a single login that has

access to both systems using integrated and proprietary API‘s. Now, instead of costly upgrades

to different servers, databases and software; they are able to increase ROI, compatibility, uptime

and convenience through the system fusion.

       CMEOHIO.com is another example of bringing different training systems together for

convenience and cost savings. Medical practitioners needed seven different account

management centers. Now these are integrated into one central portal connecting all of Ohio‘s

medical affiliates. They utilize one web portal that has all databases connected at the back-end

through MedBiquitous Standards and proprietary API‘s. They share content and view real-time

reports from all seven educational databases, while still maintaining the independence of each.

       Many healthcare case studies I‘ve reviewed that implement an LMS into their

organization are challenged by five major standards that must be utilized. The Sharable Content

Object Reference Model (SCORM) is a suite of standards for web learning that enables

interoperability of content with many different LMSs. It implements a staged approach to

learning that aggregates units of digital instruction called ―learning objects‖. They are self-

contained and may be reused again, much like object-oriented programming. Utilizing this

method enables developers can reuse older code in order to lay the foundation for a similar

learning module. Learning object metadata provides descriptive information about learning

objects. This allows students and developers find proper instruction through different parts of

the learning curriculum or code, depending on who is looking at the data. Content packaging

provides a clean and interoperable method of importing and exporting data between different

LMSs. Run time environment presents course content and tracking their progress as they

continue through their courses. Finally, sequencing and navigation is the standard for

establishing a learner‘s path through course content so it can be molded to the student‘s

individual needs of education.

       California State University was motivated by the need for expansion and the willingness

to augment to ability to provide online course tools for faculty and students. They executed a

project to select and implement an LMS for their enterprise. They formed a committee, decided

upon business needs, literature and course content to be posted, reviewed LMS vendors and

developed pass\fail and best fit rubrics for deciding and finally produced a committee report with

a solution in mind. CSU had supported WebCT for six years and had upgraded many times. The

original structure of the older CMS solution has remained and the life of the system was waning.

WebCT only provided limited functionality for the needs of the growing university with more

tech-savvy learners able to access broadband speed internet and the willingness to upgrade

brought them to their eventual plan to change and RFP. The chance to implement for effective

and efficient LMS functionality was the main proponent for upgrade. It now leverages ease of

use, supports the national standards, improves upon assessment capabilities and supports more

effective learning strategies.

       A sixteen person committee was formed including co-chairs, a manager of the

Technology and Learning Program, professors and the manager of Distributed Learning

Technologies. They devised a method for considering the outlooks of other universities

including their students, faculties, advisory groups, committees and technical support personnel.

They felt it vital to collect a shared vision of the needs of the enterprise and what an LMS would

provide for their individual needs at CSU. Through this initial study they were able to formulate

many ideas and gain a broader perspective of the problem to be dealt with, at the same time

adding real-world experience and research into their first phase of the upgrade project. They

then developed a pass\fail rubric based on their previous findings for a way to rate the potential

vendors they would examine. It included user and supportability requirements such as:

accessibility, availability, compatibility with campus technology standards, track record, support,

etc. If a product didn't meet these requirements, it was eliminated from further consideration.

       The committee then conferred with the Gartner Group to collect advice and as a source to

bounce the findings they had gathered off of. They immediately eliminated open source

solutions from the group of vendors as they, and Gartner, concluded that none of the options

were viable considering labor requirements, enterprise-wide integration, cost and track record

(12). From the pass\fail assessment, they narrowed it down to ―BlackBoard Academic Suite‖

and ―WebCT Vista Campus Enterprise Edition‖, and they were the only application suites to

continue to the second phase of their decision progression. They began with five main

categories: teaching and learning, academic program assessment, support and sustainability,

enterprise integration, and institutional partnership (12). CSU then developed a best-fit rubric to

use for asking vendors certain questions to realize if their products had the solutions they most

needed through a detailed question-set.   This second rubric was comprised from two days of

discussions and presentations with Blackboard and WebCT present, along with the campus

population. The presentations were focused on recording ideas rather than trying to rate the two

remaining vendors‘ products. That was to be withheld for the resulting rubric that was created.

The discussion groups and information gathering sessions also yielded an LMS strategic review

report where areas of distinction were emphasized. A major focus was also how easily the

students and faculty could transition from the current WebCT implementation from the last six

years to a new solution. Technical migration aspects were also discussed as key deciding points.

CSU eventually narrowed it down to WebCT Vista Enterprise Edition and have been pleased

with the product since 2005.

   c. Recent Healthcare Case Studies

       Since the onset of HIPAA mandates in 1996 much demand has been brought about by

training healthcare professionals to deal with the privacy of its patients. The transference and

treatment of patient records has gained much more scrutiny and all healthcare professionals had a

deadline of April 13, 2003 to become learned in the ways of these new mandates (10). The

Military Health System known as TriCare, has 131,000 staff globally and needed a systematic

approach at training. They provide healthcare to 1.5 million active-duty service members, 1.4

million reservists and their beneficiary population is almost 10 million (11). The vast and

staggering number of medical records makes it that much more important that TriCare ensure

that staff are properly educated in the correct and legal manner of HIPAA protocol.

       TriCare realized several advantages of an LMS implementation when researching

different vendors through a government RFP in which they could stay current with rule changes

and provide compliance to regulators. Their LMS solution, Plateau, alerts employees by email

when deadlines draw near and automatically updates their HIPAA training requirements on the

fly. If an employee moves to a different facility, their training records are transferred

accordingly. If HIPAA rules change then adjustments are made to the respective employees‘

training modules which then generate updated alerts and deadlines. Plateau offers a central

repository for all training records with an audit trail for managers to provide to regulators. These

reports can be generated system-wide or only at certain facilities where needed adding

customization and flexibility to stringent laws and needed compliance. These reports are

provided to such departments as the DoD and the Department of Health and Human Services

Office of Civil Rights.

       Bristol-Myers Squib sought out Total Learning Concepts (TLC), who is a provider of

custom training materials for the pharmaceutical industry, to train sales representatives. TLC‘s

products have been used to train healthcare professionals, which in turn have been used to launch

over ninety pharmaceutical products globally (13). TLC began as a CMS with no internet

presence in the late-1990s. Their main sources of income was print, workshop and CD-based

courseware, but have since branched out to the web with the help of a company named Illumina

Interactive since 1999. The internet was the next logical evolution for presenting instructional

substance to a global company, such as Bristol-Myers Squib‘s eLearning initiative for product

representatives to launch new products. Their initiative was to not only to offer courses online,

but to build a cost-effective LMS for its pharmaceutical clients. The training solution would not

work for all their customers as did the system with only one client utilizing the system. A

scheme that could manage enormous amounts of data in a user-friendly manner was needed. It

also needed to be intuitive and valuable for the content creators and flexible for unforeseeable

needs in the future.

       A two stage conversion tool was created beginning with Microsoft Word files which then

dynamically translated data into XML. Current employees were already versed in Word and felt

comfortable using the existing tool, with conversions happening silently in the background.

Another conversion tools was created to translate the XML files into comprehensive eLearning

courses that would be used over the web or through CDs. This allowed the content creators to

write using a standard without having to create HTML templates, saving much effort, time and

money in the long run. The conversion tool can accept content from multiple sources and

enabled reviewers and editors to use standard tools for preparation and evaluation. Money was

also saved by reducing courseware development projects and expensive licensing for web

software. The content could then be reused to different output formats getting the most return on

investment from course creation.

       Bristol-Myers Squibb also employed Illumina Interactive by meeting the different needs

of their clients. Most had enterprise LMSs while others had no IT infrastructure at all, and others

still simply needed a way for employees to gain access to the content without having to be

caught up in red tape within their own organization. To solve these individualized challenges, a

custom LMS was created along with a middleware piece that allowed any course content to

communicate with any third-party LMS such as SABA, Docent and several others, while

keeping the integrity of the original courseware intact (13). This solution offers a simple system

that integrates with individual customer needs without needing the overhead of installing and

maintaining an enterprise-wide application. This solution meets the needs of providing tracking

of progress and reporting in addition to custom security levels which can also be self

administered if appropriate within an organization. Clients with an existing LMS can simply

port the courses with the standardized middleware layer. Custom database interaction can be

engaged that deploys the courseware to a client‘s system when the time suits the user

5. LMS Healthcare Business Cases

   a. Case 1: Visiting Angels Home Care Agency

       i)      About

       Visiting Angels is a nationwide network of home care agencies providing non-medical,

personal and companion care. The agency works with a person‘s family and doctors to

determine and schedule necessary services. These services include: hygiene assistance,

medication reminders, meal preparation, simple housekeeping, errands, shopping, and

companionship. The agencies provide services around the clock, including weekends and

holidays, and are able to accommodate seasonal location changes with their national network. (1)

       Visiting Angels was established in 1998 and grew to a nationwide network within 4

years. The network currently consists of over 300 agencies throughout the United States and

Canada (known in Canada as Senior Homecare by Angels). All Visiting Angels home care

agencies are bonded and insured. However, licensing requirements vary by state. This project

focuses on the needs of a local franchise in Bensalem, PA. Act 69 of the Pennsylvania Health

Care Facilities Act was recently amended to include both Home Care Agencies (HCA) and

Home Care Registries. This act requires HCA‘s to be licensed by the state, and furthermore that

all caregivers must complete certified training. (2)

       The Visiting Angels franchise currently employs approximately 53 people comprised of:

30 certified professionals, 20 non-certified individuals, and 3 support staff. The certified and

non-certified individuals are comprised of Certified Nursing Assistants (CNA) and Home Health

Aides (HHA). The CNA‘s follow existing state accreditation guidelines, but HHA‘s do not have

similar training programs available. HHA training typically consists of several days of

instructor-led schooling at an actual health care facility. (see Appendix ―A‖ for complete

guidelines) There is currently no potential for online or self-paced training for HHA‘s. In

addition to the 20 current non-certified individuals, the franchise receives a large number of

phone calls concerning employment and where to get HHA training. This is an opportunity for

the company to offer not only employment, but also host training classes. (3)

       The organization has limited technical and financial resources. This Visiting Angels

franchise is primarily supported by two personal computers to perform operational tasks. Payroll

and scheduling are administered by outside vendors. The support staff manually creates a data

file that is used to create employee checks for each pay cycle. The vendor maintains employee

demographic information. Home care services are scheduled through an online service called

Generations Home Care System (http://www.idb-sys.com/). Scheduling is entered and accessed

by the support staff only. The staff typically calls employees to give them their schedules. The

national Visiting Angels network does not offer specific guidance or financial assistance to

establish training procedures at franchisees.

       Current business practices at this Visiting Angels franchise do not require a typical robust

learning management system. The licensing and setup costs associated with a custom LMS

product would not fit the current budget. The primary requirement for this organization is to

offer or coordinate a single HHA training course to be offered periodically to both employees

and non-employees (prospective employees or other HCA‘s). The proposed system should

maintain scheduling, instructors, facilities, course content, completed certifications and reporting

functionality. The proposed LMS should leverage employee data from and communicate

periodically with existing business applications.

       [cost of researched LMS products $36,000 - $38,000]

       [potential to partner with CHR, Holy Redeemer Hospital, or other larger organization]

       [utilize existing scheduling application for training setup & tracking- least expensive]

   b. Case 2: Complete Healthcare Resources

       i)      About

       Since 1989, Complete HealthCare Resources (CHR), a privately held company, has been

providing strategic solutions for long-term care, assisted living and retirement communities,

other senior housing options and care providers through management and consulting services.

       CHR currently provides full management and consulting services in the Mid-Atlantic

region (Delaware, Maryland, New Jersey, New York, Virginia and Pennsylvania) through its

Eastern subsidiary and comprehensive consulting services in Texas through its western affiliate.

The Eastern subsidiary currently provides full management services to twenty-one independent

living, assisted living communities, continuing care retirement community, or nursing facilities

with approximately 3,738 beds. The western affiliate provides comprehensive consulting

services to another 37 nursing facilities with approximately 4,412 beds.

       In addition, CHR provides assistance to numerous retirement and assisted living

communities and nursing facilities through consulting services. ("Complete Healthcare", n.d.)

       Complete Healthcare Resources and its subsidiaries currently employ approximately

4,500 employees. The employee breakdown is as follows:

Type                                      Corporate       Eastern Division     Western Division
Information Technology                       14                  0                    1
Human Resources                              10                  0                    0
Accounting                                    5                  5                   15
Executive                                     8                  2                    5
Operation Managers                            0                  1                    4
Facility Administrators                       0                  4                   37
Director of Nursing                           0                  4                   37

Medical Staff                                   0                  825                   4,000

       ii)      Business Case Summary

       CHR operates in a highly regulated industry requiring the organization to insure

compliance in a large number of areas including but not limited to: various medical licenses,

Health Insurance Portability and Accountability Act (HIPAA) compliance, as well as other

professional and long-term care licensing. In order to avoid undue penalties and/or litigation,

CHR desires to implement a solution that will allow them to track their employee certifications/

licenses accordingly.

       While the main focus will be on maintaining employee compliance, CHR desires to also

use this as a vehicle for a wide array of information-based non-required training courses

including: productivity suites (such as Microsoft Office), organizational support systems (such as

PeopleSoft and Cognos), as well as employee health-initiative related courses (such as healthy

heart and proper nutrition type courses – to name a few). These training courses could be

delivered in a number of different formats including PowerPoint presentations, video

presentations, audio presentations, interactive sessions, etc. and will be managed and delivered

by a number of different individuals within the organization.

       To support CHR‘s users the organization provides network access to its users via Citrix.

Citrix is a vendor that provides software capable of facilitating secure access to the

organization‘s applications and information content via a secure Internet gateway. At this point,

only authorized users are permitted to access CHR‘s network and that policy will remain intact

for the implementation of this solution.

       iii)      Network Topology

       CHR‘s network is comprised of 47 servers including: application servers, database

servers, web servers, domain controllers, etc. CHR also hosts 28 Citrix servers which provide

network access to its user community through Wyse terminals, desktops, and laptop computers.

CHR‘s main support systems (software) include:

      Operating Systems: Microsoft Server 2003, Microsoft Windows XP

      Database Systems: Microsoft SQL Server 2000 and Microsoft SQL Server 2005

      Productivity Suites: Microsoft Office, Microsoft Visio

      Organization‘s Main Support Systems:

              o PeopleSoft – Payroll & Human Resources

              o Accpac – Accounts Payable, Accounts Receivable, Cash Management, and

                 General Ledger

             o Cognos – Business intelligence and financial reporting

       iv)      Requirements

       As noted in the summary, a standard learning management system typically includes

functionality that will allow an organization to: catalog, present, and make training accessible to

the organization. Beyond the high level view of the solution, components must exist to meet

specific needs or desires of an organization, in this case – CHR. As such, these components have

been categorized as either:

   a) Required ‗non-measured‘ functions. Those that must meet 100% of the organization‘s

       requirements due to the organization‘s existing technology architecture or topology of the


   b) Required ‗measured‘ functions. Those required functions that the organization will

       measure to determine organizational ‗fit.‘

   c) Desired functions. Those that are not necessary to the success of the project but are

       functions that the organization would like to have included in the solution.

   d) Limitations. Known organizational limitations. These would differ from the required

       ‗non-measured‘ functions as these would include items such as – how many internal

       resources would be dedicated to managing the ongoing solution?

   e) General Questions. General questions posed to either the client or vendor to determine

       general setup or topology.

      Required Functions (Non-measured): (call “Technical Specifications/Requirements”?)

             o Hardware – minimum of an Intel 3300MHz+

       o Operating system/ environment – Microsoft Windows Server 2003

       o RDBMS – Microsoft SQL Server 2000 or Microsoft SQL Server 2005 (preferred)

       o Microsoft active directory integrated

       o Web-based NOT web-enabled or client/server based.

   Required Measurable Functions

       o Web-based solution. As noted above, a web-based solution is required. This

          measures the overall design of the solution.

       o Training Delivery Methods and Formats. The solution should be capable of

          offering alternative training deliver methods and formats. Examples include:

          computer-based training (CBT), self-paced assessments, as well as applicable

          reading and examples or exercises where appropriate.

       o Collaborative Tools. The solution must be capable of providing collaboration

          tools through methods such as discussion boards, white boards, shared document

          depositories, etc.

       o Scalable. The solution must be capable of supporting a large number of users.

       o Active directory integration. In order to again reduce the amount of

          administrative support a centralized security model has been adopted with

          applicable permissions residing within the system through the security model

          defined groups and roles.

       o Groups/Roles. The solution must provide group or role based security options

          that can be incorporated into CHR‘s existing user access matrix.

       o Notification module. The solution must be capable of supporting, at a minimum,

          POP3/SMTP protocols which allow for user notifications through electronic mail.

       o Self-registration. The solution must provide functionality that would allow a user

           to self-register for desired courses.

   Desired Functions

       o Workflow. The solution should provide workflow functionality allowing for such

           tasks as: proper notification, approval/deny, assessment, and/or evaluation


       o Collaborative Learning. While CHR does not currently plan to offer collaborative

           learning courses, the organization does desire to eventually take advantage of this


   Limitations

       o Cost. CHR has planned to spend no more than $100K in deploying the initial


       o Solution Support. CHR will have one employee who will be responsible for

           managing the application and one network engineer supporting the production

           system deployment. Both employees are also responsible for other organizational

           solutions as well and as such, will only have a portion of their time available to

           dedicate to this solution. Externally, CHR is likely to sign a minimum direct

           vendor support contract and partnering with a with third party vendor that is

           capable of providing specialized support. This is the typical relationship/strategy

           preferred by the organization.

   General Questions

       o Does the vendor recommend separating the database from the application server-

           wise? If so, is CHR planning on acquiring new hardware to support the solution?

            o Does the vendor offer the product as separate modules, thus lowering the overall

               cost of the solution?

       v)      Solution Selection Methodologies

       Once the three vendors/products were identified, we developed a product comparison

matrix and a weighted scoring table to assist us with determining the best solution for the

organization. The selection process would include analysis of the cost/benefit analysis, ROI,

product comparison matrix and weighted scoring table with the executive committee within


       The matrix established a list of the functionality available for each product. This

provided us with a quick checklist of what to look for when reviewing the product to determine

what functionality was available for a particular product. What this did not provide us with was

a way to measure the importance of each function to the organization.

       There were certain minimum required functions such as organizational hardware or

software requirements, to name a few, that were excluded from the weighted scoring table due to

the fact it was a given that the vendor must meet those minimum requirements in order to even

be considered an applicable solution.

               As such, we also created a weighted scoring table which would allow us to assess

through a numeric value (either percentage or value) to the categories, as well as to the detailed

functionality required or desired.

       Through our detailed component analysis we identified five (5) categories that are of

great importance in measuring the success of the project to the organization.

      Cost – how important, relatively speaking, are the total project costs in relation to the


      Integration – how well does the solution integrate with the necessary existing systems of

       the organization?

      System functionality – how important is system or administrative functionality to the

       organization? This includes security & auditing.

      User functionality – how important is specific user functionality to the organization?

      Content management – how important is the overall management and delivery

       mechanisms of the offered content to the organization?

Category        Item                   Description
Cost            Solution costs         The total cost of the solution.

Integration     Active directory       How well does the product integrate with Microsoft‘s
                                       active directory which the organization uses for its
                                       security model.
Integration     Email notification     Does - and if yes, how well does the solution provide
                (POP3/SMTP)            email notification functionality to the user(s)?
Integration     HRIS                   Does and how well does the solution integrate with the
                                       organization‘s existing HRIS solution?

System          Simple                 Due to resource limitations, the organization desires to
Functionality   Implementation         have a solution that will be simple to implement.
System          Ongoing                Due to resource limitations, the organization desires to
Functionality   Maintenance            have a solution that requires very little maintenance.
System          Highly Configurable    The organization requires a system that provides the
Functionality                          flexibility to configure the solution according to their
                                       industry requirements and organizational needs
System        Audit Capabilities       The organization would like a solution that will allow
Functionality                          them to review/ audit not only the system but more

                                      importantly their user activity to insure that the solution is
                                      being accessed and used accordingly
System          Role or Group         The organization‘s security model utilizes a role or group
Functionality   Based Security        based access matrix across the entire enterprise
System          Security Access       Does the security module provide the level of granularity
Functionality   Granularity           to permit/deny a user or group certain permissions across
                                      courses? That is, can the system permit an individual
                                      from only being able to author or administer certain
                                      courses not all courses, etc.

User          Collaboration Tools     The organization would like to move beyond email as the
Functionality                         only communication vehicle used in the organization to
                                      share information or collaborate on issues
User          User Friendly           In order for the solution to be well adopted and used by
Functionality                         the employees an easy to use interface must exist.
User          Course Self             The organization desires to offer courses to employees
Functionality Registration            that go beyond those required for employment.
                                      Employees should be permitted to self-register for these
                                      ‗public‘ courses instead of relying on an administrator or
                                      other to add them to that course
User          Workflow                How does the workflow process work? Is it easy to use/
Functionality                         maintain/ change?

Reporting &     Tracking Reports      Reports that provide progress on individual users, groups,
Auditing                              or departments, etc. Does the report offer time-based
                                      reports (e.g. from M/D/YY to M/D/YY)?
Reporting &     Auditing Reports      Reports that track the actions of users, groups, or
Auditing                              departments in the system.
Reporting &     Ad-hoc Reports        Can users create impromptu reports or organizational
Auditing                              specific type reports? Can the user save these report
                                      templates for later use?
Reporting &     Export Capabilities   Does the system offer exporting capabilities especially to
Auditing                              Microsoft Excel & portable document format (PDF), the
                                      most commonly used delivery and reporting tools used in
                                      the organization
Reporting &     Metric Reports        Does the solution provide reporting metrics that allow the
Auditing                              organization to measure the effectiveness of a course or
                                      assessment, etc.

Content         Authoring             How well does the course content authoring process
Management                            work?
Content         Administration        How well does the solution allow users the ability to
Management                            administer courses and course content?
Content         Assessments           How configurable is the assessment functionality? Does
Management                            the capability exist for a user to re-take a course? How
                                      does that affect the original course taken?

Content         Delivery Methods        What methods exist for course or assessments delivery to
Management                              users? That is, online only, online & offline, etc.

From there, we would score each vendor against each detailed functionality area to derive a

cumulative score for comparison against the remaining vendors.

       vi)      Solution Alternatives

       Given the project requirements we have determined that we would identify and present

three vendors to the organization that offer products capable of not only fulfilling the project

requirements but also positioning the organization so that they have the best opportunity for

long-term success. During our solution selection process, we have focused on facets that go

beyond the required and desired functions, and looked for vendors who not only have a history

of providing excellent products and services, but are financially stable and leaders in their

respective industry. It is imperative that we insure that these vendors are positioned to service

and/or fulfill existing and future endeavors.

     Topic                  Articulate                   Plateau                        Saba CKC
    Founded                   2000                         1996                            1997
    Website        http://www.articulate.com     http://www.plateau.com           http://www.saba.com
   Comments        Established track record in Received numerous awards            Product line motto
                        the LMS industry        in the industry and strong         focuses on people-
                                                 revenue/product growth               centered value
 Product Line      - [Articulate] Studio       - [Plateau] Performance           - [Saba] Learning
                   - Quizmaker                 - Compensation                    - Performance
                   - Engage                    - Career & Succession                Management
                   - Online                    - Learning                        - Talent Management
                                                                                 - Compensation
                                                                                 - Collaboration &
                                                                                    Web Conferencing
                                                                                 - On-Demand

Key Healthcare   - Blue Cross Blue Shield   - American Red Cross       - Sentara
  Customers        of Nebraska              - Blue Cross Blue Shield   - St Jude Children‘s
                 - Johnson & Johnson          of North Carolina          Research Hospital
                 - United Healthcare        - GE Healthcare            - Trinity Health

      vii)   Final Selection

6. Lessons Learned

     The size of the organizational directly affects not only the solution selection process used

      but also the recommended solutions themselves. This became obvious when contrasting

      the requirements for a smaller organization such as the Visiting Angels franchise versus

      the requirements for a larger organization in CHR.

7. Future Outlook/ Next Steps

   External Users. CHR hopes to offer training courses to external users/ companies as another

    revenue stream (such as a Visiting Angels). The network topology does not currently

    support offering this solution but eventually could be reconfigured fairly easily to allow for

    training course offerings to individuals who are not employees or partners to CHR.

   Course management.

   Collaborative Learning.

   HRIS Integration. Eventually CHR would like to link course assessments to annual salary

    increases. Potentially, the LMS solution could already have developed an integration tool

    with some of the larger HRIS solutions (preferred) or we could develop that integration tool

    if necessary.

   After successful implementing an HHA training solution, the Visiting Angels franchise

    would like to host Alzheimer‘s training classes – thus opening up a potential new revenue


8. References


Plateau - About us. (n.d.). Retrieved , , from http://www.plateau.com/about/about.htm

Complete Healthcare Resources - About the Company. (n.d.)., , from


       a. Beck, Dennis, Black, Erik W.; Dawson, Kara, DiPietro, Meredith, Jinks, Susan. ―The
       Other Side of the LMS: Considering Implementation and Use in the Adoption of an LMS
       in Online and Blended Learning Environments.‖ TechTrends: Linking Research and
       Practice to Improve Learning (8756-3894) Mar 2007. Vol.51, Iss.2; p.35-39, 53

       b. Dumpe, Michelle L, Hill, Kristin, Kanyok, Nancy. ―Use of an Automated Learning
       Management System to Validate Nursing Competencies.‖ Journal for nurses in staff
       development: JNSD. (1098-7886) 2007. Vol.23, Iss.4; p.183

       c. Falvo, David A., Johnson, Ben F. ―The Use of Learning Management Systems in the
       United States.‖ TechTrends: Linking Research and Practice to Improve Learning (8756-
       3894) Mar 2007. Vol.51, Iss.2; p.40-45

       d. Flandez, Raymund. ―Enterprise: Firms Go Online to Train Employees; Virtual Classes,
       Videos Give Workers Flexibility And Save Owners Money.‖ Wall Street Journal; Eastern
       edition; New York, N.Y. (0099-9660) Aug 14, 2007. p.B.4

       e. Galloway, Linda. ―Measuring Pains: Part 1 - A recent survey finds a high level of
       dissatisfaction with learning management system reporting capabilities.‖ Training.
       (0095-5892) 2007. Vol.44, Iss.9; p.64

       f. Gunter, G, Pan, C, Sivo, S. ―End-user acceptance of a learning management system in
       two hybrid large-sized introductory undergraduate courses: A case study.‖ Educational
       administration abstracts. (0013-1601) 2007. Vol.42, Iss.3; p.355

       g. ―HRIT 'Report Card': Trends for 2008 Plans.‖ HR Focus; New York (1059-6038)

   h. Korn, Melissa. ―Firms, Schools Team Up On Training Programs.‖ Wall Street Journal;
   Eastern edition; New York, N.Y. (0099-9660) Nov 7, 2007. p.B.5E

   i. London, Manuel. ―Performance Appraisal for Groups.‖ Consulting Psychology
   Journal: Practice and Research (1065-9293) Sep 2007. Vol.59, Iss.3; p.175-188 ―

   j. SLA Board of Directors Elections.‖ Information Outlook; Washington (1091-0808).
   Jul 2007. Vol.11, Iss.7; p.9

   k. Steinborn, Deborah. ―Cross-Cultural Training Gains.‖ Wall Street Journal; Eastern
   edition; New York, N.Y. (0099-9660) Apr 4, 2007. p.n/a

   l. ―Take Talent Management to the Next Level.‖ HR Focus; New York (1059-6038).
   Nov 2007. Vol.84, Iss.11; p.1

   m. Watson, William R., Watson, Sunnie Lee. ―An Argument for Clarity: What Are
   Learning Management Systems, What Are They Not, and What Should They Become?‖
   TechTrends: Linking Research and Practice to Improve Learning (8756-3894) Mar 2007.
   Vol.51, Iss.2; p.28-34

                                 Wayne’s References

1) http://en.wikipedia.org/wiki/Learning_management_system

2) http://www.emlrc.org

3) http://www.trinity.edu/rjensen/290wp/290wp.htm#1994

4) http://newmedia.com/NewMedia/98/09/feature/trip.html

5) www.noverant.com

6) http://elearning.icsi.edu/about_elearning2.html

7) http://www.e-learningwmb.co.uk/e-learning/contentmanagementsystem.htm

8) http://www.learningcircuits.org/2005/nov2005/carliner.htm

9) http://bersin.wordpress.com/2007/07/29/choosing-an-lms-what-to-do\

10) http://aspe.hhs.gov/admnsimp/faqcode.htm

11) www.tricareonline.com

12) http://www.csuchico.edu/tlp/LMS2/pressrelease.shtml

13) http://www.illumina-interactive.com/pj_case3.html

                                      Visiting Angels

(1) http://www.visitingangels.com/, http://www.visitingangels.com/faq.asp,



(2) http://www.dsf.health.state.pa.us/health/cwp/view.asp?A=189&Q=245787

(3) Citation for meeting with Rob?


     a. National Standards of Home Health Aide training program.

     These are guidelines for the course that Visiting Angels would have to offer to Home Health

Aides for certification per the newly established Pennsylvania guidelines. (from



§ 484.36 Condition of participation:         healthy environment.                         (B) To permit an individual that does
Home health aide services.                   (vii) Recognizing emergencies and            not meet the definition of ‗‗home
Home health aides are selected on            knowledge of emergency procedures.           health aide‘‘ as specified in § 484.4 to
the basis of such factors as a sympathetic   (viii) The physical, emotional, and          furnish home health aide services (with
attitude toward the care of the              developmental needs of and ways to           the exception of licensed health
sick, ability to read, write, and carry      work with the populations served by          professionals
out directions, and maturity and ability     the HHA, including the need for respect      and volunteers);
to deal effectively with the demands         for the patient, his or her privacy and      (C) Has been subject to an extended
of the job. They are closely supervised      his or her property.                         (or partial extended) survey as a result
to ensure their competence in                (ix) Appropriate and safe techniques         of having been found to have furnished
providing care. For home health services     in personal hygiene and grooming that        substandard care (or for other reasons
furnished (either directly or                include—                                     at the discretion of the CMS or the
through arrangements with other              (A) Bed bath.                                State);
organizations)                               (B) Sponge, tub, or shower bath.             (D) Has been assessed a civil monetary
after August 14, 1990, the                   (C) Shampoo, sink, tub, or bed.              penalty of not less than $5,000 as
HHA must use individuals who meet            (D) Nail and skin care.                      an intermediate sanction;
the personnel qualifications specified       (E) Oral hygiene.                            (E) Has been found to have compliance
in § 484.4 for ‗‗home health aide‘‘.         (F) Toileting and elimination.               deficiencies that endanger the
(a) Standard: Home health aide               (x) Safe transfer techniques and             health and safety of the HHA‘s patients
training—(                                   ambulation.                                  and has had a temporary management
1) Content and duration of training.         (xi) Normal range of motion and              appointed to oversee the management
The aide training program must address       positioning.                                 of the HHA;
each of the following subject                (xii) Adequate nutrition and fluid intake.   (F) Has had all or part of its Medicare
areas through classroom and supervised       (xiii) Any other task that the HHA           payments suspended; or
practical training totalling at              may choose to have the home health           (G) Under any Federal or State law
least 75 hours, with at least 16 hours       aide perform.                                within the 2-year period beginning on
devoted to supervised practical training.    ‗‗Supervised practical training‘‘            October 1, 1988—
The individual being trained must            means training in a laboratory or other      (1) Has had its participation in the
complete at least 16 hours of classroom      setting in which the trainee demonstrates    Medicare program terminated;
training before beginning the                knowledge while performing                   (2) Has been assessed a penalty of not
supervisied practical training.              tasks on an individual under the direct      less than $5,000 for deficiencies in
(i) Communications skills.                   supervision of a registered nurse or         Federal
(ii) Observation, reporting and              licensed                                     or State standards for HHAs;
documentation                                practical nurse.                             (3) Was subject to a suspension of
of patient status and the                    (2) Conduct of training—(i)                  Medicare payments to which it otherwise
care or service furnished.                   Organizations.                               would have been entitled;
(iii) Reading and recording temperature,     A home health aide training program          (4) Had operated under a temporary
pulse, and respiration.                      may be offered by any organization           management that was appointed to
(iv) Basic infection control procedures.     except an HHA that, within the               oversee the operation of the HHA and
(v) Basic elements of body functioning       previous 2 years has been found—             to ensure the health and safety of the
and changes in body function                 (A) Out of compliance with                   HHA‘s patients; or
that must be reported to an aide‘s           requirements                                 (5) Was closed or had it‘s residents
supervisor.                                  of this paragraph (a) or paragraph           transferred by the State.
(vi) Maintenance of a clean, safe, and       (b) of this section;                         (ii) Qualifications for instructors. The

training of home health aides and the      listed at paragraphs (a)(1) (iii), (ix), (x),   or nursing services, assistance in
supervision of home health aides during    and (xi) of this section must be evaluated      ambulation
the supervised practical portion of        after observation of the aide‘s                 or exercises, and assistance in
the training must be performed by or       performance                                     administering medications that are
under the general supervision of a         of the tasks with a patient.                    ordinarily
registered                                 The other subject areas in paragraph            self-administered. Any home
nurse who possesses a minimum              (a)(1) of this section may be evaluated         health aide services offered by an HHA
of 2 years of nursing experience, at       through written examination, oral               must be provided by a qualified home
least 1 year of which must be in the       examination,                                    health aide.
provision of home health care. Other       or after observation of a                       (d) Standard: Supervision. (1) If the
individuals may be used to provide         home health aide with a patient.                patient
instruction                                (4) Competency determination. (i) A             receives skilled nursing care, the
under the supervision of a                 home health aide is not considered              registered nurse must perform the
qualified registered nurse.                competent in any task for which he or           supervisory
(3) Documentation of training. The         she is evaluated as ‗‗unsatisfactory‘‘.         visit required by paragraph
HHA must maintain sufficient                The aide must not perform that task            (d)(2) of this section. If the patient is
documentation                              without direct supervision by a licensed        not receiving skilled nursing care, but
to demonstrate that the requirements       nurse until after he or she receives            is receiving another skilled service
of this standard are met.                  training in the task for which he               (that is, physical therapy, occupational
(b) Standard: Competency evaluation        or she was evaluated as                         therapy, or speech-language pathology
and in-service training—(1)                ‗‗unsatisfactory‘‘                              services), supervision may be provided
Applicability.                             and passes a subsequent evaluation              by the appropriate therapist.
An individual may furnish home health      with ‗‗satisfactory‘‘.                          (2) The registered nurse (or another
aide services on behalf of an HHA only     (ii) A home health aide is not considered       professional described in paragraph
after that individual has successfully     to have successfully passed a                   (d)(1) of this section) must make an
completed a competency evaluation          competency                                      onsite
program as described in this paragraph.    evaluation if the aide has an                   visit to the patient‘s home no less
The HHA is responsible for ensuring        ‗‗unsatisfactory‘‘ rating in more than          frequently than every 2 weeks.
that the individuals who furnish home      one of the required areas.                      (3) If home health aide services are
health aide services on its behalf meet    (5) Documentation of competency                 provided to a patient who is not
the competency evaluation requirements     evaluation.                                     receiving
of this section.                           The HHA must maintain documentation             skilled nursing care, physical or
(2) Content and frequency of evaluations   which demonstrates that                         occupational
and amount of in-service training.         the requirements of this standard are           therapy or speech-language
(i) The competency evaluation must         met.                                            pathology services, the registered
address each of the subjects listed in     (6) Effective date. The HHA must                nurse must make a supervisory visit to
paragraph (a)(1) (ii) through (xiii) of    implement                                       the patient‘s home no less frequently
this section.                              a competency evaluation program                 than every 60 days. In these cases, to
(ii) The HHA must complete a               that meets the requirements of                  ensure that the aide is properly caring
performance                                this paragraph before February 14, 1990.        for the patient, each supervisory visit
review of each home health                 The HHA must provide the preparation            must occur while the home health aide
aide no less frequently than every 12      necessary for the individual to                 is providing patient care.
months.                                    successfully                                    (4) If home health aide services are
(iii) The home health aide must receive    complete the competency evaluation              provided by an individual who is not
at least 12 hours of in-service            program. After August 14, 1990, the             employed directly by the HHA (or
training during each 12-month period.      HHA may use only those aides that               hospice),
The in-service training may be furnished   have been found to be competent in              the services of the home health
while the aide is furnishing care          accordance                                      aide must be provided under
to the patient.                            with § 484.36(b).                               arrangements,
(3) Conduct of evaluation and training—    (c) Standard: Assignment and duties of          as defined in section 1861(w)(1)
(                                          the home health aide—(1) Assignment.            of the Act. If the HHA (or hospice)
i) Organizations. A home health            The home health aide is assigned to a           chooses to provide home health aide
aide competency evaluation program         specific patient by the registered              services under arrangements with
may be offered by any organization         nurse. Written patient care instructions        another
except                                     for the home health aide must be                organization, the HHA‘s (or hospice‘s)
as specified in paragraph (a)(2)(i)        prepared by the registered nurse or             responsibilities include, but are
of this section.                           other appropriate professional who is           not limited to—
The in-service training may be offered     responsible for the supervision of the          (i) Ensuring the overall quality of the
by any organization.                       home health aide under paragraph (d)            care provided by the aide;
(ii) Evaluators and instructors. The       of this section.                                (ii) Supervision of the aide‘s services
competency evaluation must be              (2) Duties. The home health aide                as described in paragraphs (d)(1) and
performed                                  provides                                        (d)(2) of this section; and
by a registered nurse. The inservice       services that are ordered by the                (iii) Ensuring that home health aides
training generally must be supervised      physician in the plan of care and that          providing services under arrangements
by a registered nurse who possesses        the aide is permitted to perform under          have met the training requirements of
a minimum of 2 years of nursing            State law. The duties of a home health          paragraphs (a) and (b) of this section.
experience at least 1 year of which        aide include the provision of hands-on          (e) Personal care attendant: Evaluation
must be in the provision of home           personal care, performance of simple            requirements—(1) Applicability. This
health care.                               procedures as an extension of therapy           paragraph applies to individuals who
(iii) Subject areas. The subject areas                                                     are employed by HHAs exclusively to

furnish personal care attendant services     those services for which a competency     is not required to furnish.
under a Medicaid personal care               evaluation is required by paragraph       [54 FR 33367, August 14, 1989, as amended at
benefit.                                     (b) of this section and which the         56 FR 32974, July 18, 1991; 56 FR 51334,
(2) Rule. An individual may furnish          individual is required to perform. The    Oct. 11,
                                                                                       1991; 59 FR 65498, Dec. 20, 1994; 60 FR
personal care services, as defined in        individual need not be determined         39123,
§ 440.170 of this chapter, on behalf of an   competent                                 Aug. 1, 1995; 66 FR 32778, June 18, 2001]
HHA after the individual has been            in those services listed in paragraph
found competent by the State to furnish      (a) of this section that the individual


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