Operational reflections on what contributes to building a successful Project ECHO network.

Introduction

Project ECHO (Extension for Community Healthcare Outcomes) is an online telementoring programme that uses technologies such as Zoom to facilitate and support communities of practice for health and social care practitioners. It democratises and encourages sharing of knowledge between specialists and practitioners working at different levels of the health system, and improves health outcomes for patients by reducing health disparities and barriers to accessing treatment.1 Using a hub and spoke model, practitioners working at primary and community levels are remotely connected to each other as well as to specialist practitioners working at higher levels of the health system.

Project ECHO has been implemented in over 40 countries,2 while in Northern Ireland over 100 networks (each in specific areas of expertise; eg, neurology, cardiology or prison healthcare) have operated across the health system since 2013. This short report presents reflections from the Northern Ireland Project ECHO operational team (network coordinators, managers, researchers and information technology specialists) on the operational aspects that contribute to a successful ECHO network. As a participatory methodology, the role of the Project ECHO operational team is to support each ECHO network to design, deliver and evaluate their own programme.3

To date, little research on the factors influencing effective ECHO implementation has been published, with research instead focusing on the impact and outcomes of ECHO networks.4 5 One study by Agley et al6 highlighted implementation challenges such as time and scheduling, as well as highlighting factors that are reported as being essential within successful ECHO networks such as the ability to present and the interprofessional nature of networks.

The findings within this short report, generated from thematic analysis of nine semistructured interviews with the Northern Ireland Project ECHO team (including authors of this reflection) and informed by reflective practice literature,7 highlight important additional lessons for other teams and organisations using the ECHO approach. Such lessons will be of broad relevance as the use of ECHO and similar methodologies increase in light of COVID-19, with working, learning and practising all in-part transitioning to online spaces.8

Reflection 1: the importance of collaborative leadership within each network

Network leadership is essential to ensuring success of an ECHO network. Open and collaborative leadership that facilitates space for discussion, input from all participants, and fosters a sense of trust, community and egalitarianism was frequently described by the ECHO team as crucial in building strong networks and communities of practice. Leaders need to guide the development of the network, while also ensuring that design and delivery is participatory. Leadership and good facilitation skills ensure effective time keeping, conflict resolution, and encourage participation. The importance of leadership has implications when it comes to selecting leaders for networks and what values and leadership styles to identify, recruit and foster.

Reflection 2: getting the ‘Right People’ in the room, onboarding and ensuring a strategic fit

Networks need support and buy-in from participant’s managers and supervisors in order to facilitate attendance at sessions; and from practitioners who see relevance and connection to their roles. Investing time for participants to understand the ECHO approach (eg, through curriculum-setting days and other pretasks) and how it differs from traditional webinar approaches to training is essential in ensuring participation and engagement within sessions. Participatory approaches to setting curriculum and programme content, and linking objectives to wider service goals such as integration of care, service transformation and achieving measurable patient outcomes, were consistently present in networks that were considered most effective by the Northern Ireland Project ECHO operational team.

Reflection 3: the need for content to be relevant and engaging

Speakers presenting information that was relevant and engaging (eg, information that is both interesting and delivered in a manner that encourages engagement) to the network was described as important in ensuring discussion and participation. Challenges for speakers include not having access to training on how to deliver effective presentations, not having a specific brief or objective from the network lead, not having time to prepare and having to present information to a diverse audience with varying levels of expertise and knowledge. Identifying good speakers, and/or supporting speakers with the design and delivery of the presentation, was described as a simple yet important element to ensuring dynamic, relevant and engaging ECHO sessions.

Reflection 4: the value of the ECHO infrastructure and support

One of the key differences between Project ECHO and traditional webinars is the presence and role of the Project ECHO operational team. Project ECHO’s recommended structure aligns with the components and phases of effective programme management described in Harvard Business Review.9 10 The operational team is responsible for supporting administration, management and delivery of the sessions. It supports recruitment and registration of participants. This support, which is time intensive and skills based, is a significant component that differentiates ECHO from webinars. ECHO sessions should be dynamic, promote cross-sectoral learning and reflection, smooth in its delivery and without technical faults. The supportive infrastructure provided by the operational team is essential in achieving this. The Project ECHO team is important in building trust and relationships in the network, enforcing rules around participating, and supporting busy clinical leads in preparation and communicating with participants outside of the sessions. Uploading materials onto shared sites, circulating agendas in advance of meetings and ensuring compliance with data security regulations all require the supportive infrastructure provided by the ECHO team.

Reflection 5: the development of trust in networks

Trust is essential in developing a good ECHO network and achieving positive outcomes. Trust is developed over time by modelling good practices of respect, listening, confidentiality and egalitarianism. Participants must feel safe in sharing sensitive information, discussing challenging cases, while being open to learning and critical feedback. Sensitive topics should not be introduced until such trust is established. Other mechanisms, such as ensuring computer cameras are turned on, support building community, trust and accountability. Confidentiality agreements for participants registering to a network may further support such efforts. Ensuring flexibility on whether sessions are recorded, especially if the topic covered is of a sensitive nature, is equally important. Other considerations when developing trust include the size of the network. The Project ECHO operational team described smaller networks, ranging from 15 to 40 members, as being most effective in building the relationships and trust conducive to establishing a strong network that progresses towards achieving its goals.

Conclusion

This report is intended to share reflections and lessons for individuals and teams initiating an ECHO network, and for existing networks seeking to reflect on and evaluate their processes. While many of the reflections may seem simple, it is important to remember that many health systems do not embody many of the ‘simple’ principles underpinned within ECHO. Health systems are often hierarchical. Healthcare workers are frequently isolated and often practise in silos. Spaces for learning and openly discussing challenges between colleagues are limited. ECHO offers some solutions to common problems, but sessions need to be high quality, relevant and appropriately supported. These reflections provide indications on how such sessions can be achieved.