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Winchester Medical Center


Bethann Mendez, Director of Critical Care at Winchester Medical Center, has been kind enough to write a detailed article describing her experience while implementing Qstream. Beth, a true innovator in her field, sought a cutting-edge solution to support her staff in achieving top patient care in a financially responsible manner. When current methods of education and training, including formal didactic, after shift in-servicing, and LMS module completion fell short, Beth turned to Qstream for a unique alternative. Read about her journey in attaining the desired knowledge reinforcement, quality care, and significant return on investment for her organization.

Current State

This article is aimed at describing my attempts to address the practice problem; how to achieve high-quality patient care within the constructs of the current Intensive Care Unit (ICU) nursing climate. This climate consists of a high acuity and a deep complexity of the intensive care unit patient, calling for care delivery from an expert and knowledgeable nurse. However, the current experience and expertise of the intensive care unit nurse is subject to the same naiveté and shortages as many departments in the acute care setting.

The organization in which I am employed as the director of critical care is a 450 non-profit rural hospital with 48 critical care beds staffed by 150 critical care nurses. Our staffing mix is reflective of the current nursing crisis in the United States, consisting of 58 percent of the nursing staff with less than five years of experience, and 28 percent of those having less than two years of bedside experience. Improving the quality of the ICU nursing staff is a notable obligation, but not an easily obtainable goal.  Missing the opportunity to supply our nurses with the necessary education and training impedes our ability to achieve high quality care and obstructs our journey to high reliability. Facing this practice problem has led me to explore innovative approaches that address experience and knowledge gaps in a financially responsible and staff-friendly manner.

The desire has been to create a safe, high quality, nursing practice environment in which all levels of nursing feel supported to practice. This atmosphere must support not only the novice, still developing nurse, but also the experienced ICU nurse. To date this desired state remains elusive, as we have attempted to use traditional forms of information management and education. Formal didactic, after shift in-servicing, and learning management systems (LMS) module completion have fallen short of achieving knowledge acquisition in a financially responsible manner. These approaches lack a true demonstration of learning outcomes and require staff to complete additional non-productive work time. Paying employees outside of productive hours places a strain on both the organizations financial resources and the employees individual work-life balance.

Innovative Resources

As previously stated, my goal was to provide comprehensive education that is relevant to the patient population and practice environment, while being mindful of the professional and personal resources that are utilized during the process.  In addition, I searched for an approach that met the needs of all staff across the continuum of experience and generations; sensitive to the disparities that exist in the modern ICU. I believe Qstream offers a unique alternative to traditional approaches and provides the needed platform to change the future of professional development and regulatory compliance in healthcare.

Qstream brings the innovative elements of gamification, and micro and spaced learning to an easy to use product that meets the needs of the staff and the organization. This approach eliminates the education reimbursement and financial strain that prohibit organizations from delivering staff educational needs and creates an adaptive learning experience for the end user.


Qstream was implemented in our ICU for our nursing staff in January of 2018. Our ICU is fortunate to employ a clinical nurse specialist, as well as an educator, who have collaborated in the creation and management of Qstream modules.  From an administrator perspective, the Qstream platform was found easy to use. However, as it is very different conceptually to traditional styles of education, it did require the local development team to take time to fully understand its uniqueness and approach. The local Qstream team received initial user training and support from Qstream specialists and began creating our first Qstream for deployment.

Understanding that this would be a very new approach both for our nursing leadership as well as our staff, it was decided that for the first attempt we would create a short Qstream focused on general ICU information. The module was named “Back to Basics” and allowed us to deploy non-intimidating questions, allowing the user to focus on the experience and understand the platform without the distraction of content. This introductory approach proved valuable, permitting the builders and staff to comfortably adapt to the new platform. A multi-modal communication approach was utilized to communicate the new use of Qstream, however, the most effective roll-out technique was staff rounding. During this on-on-one time the leadership team ensured that staff had knowledge of the platform, understood the expectations for how they would interact with the module, and validated their account.

Qstream enrollment and content completion was made a mandatory requirement, and employees received Qstream questions via their corporate email accounts. In addition, the expectation was set that each employee would complete their questions while on shift. The fact that each Qstream question only takes minutes to complete made setting this expectation realistic and removed the necessity to pay non-productive off-shift time. Staff quickly identified the added benefit of no longer being required to attend education sessions outside of their worked hours, improving their perception of work-life balance. The final point of emphasis during implementation was ensuring that users understood the leaderboards and the Qscores. In order to ensure that the platform limited generational and experience biases, we took time to emphasize that the Qscore was based on a combination of their user engagement and proficiency.  Leader boards would, therefore, encourage a new and positive type of competition, one based on engagement as well as knowledge. In essence, leveling the playing field.

The first Qstream allowed us to accomplish our initial implementation goals. Allowing our team to subsequently create and launch three additional mandatory Qstream modules in 2018. With the successive modules we communicated the mobile application option. Many employees quickly adopted the use of the mobile app on their personal cell phones to broaden the convenience of the platform. The facts that the mobile option was completely voluntary, each question takes only minutes, and that there are no obstacles to completing all questions during work time, we have eliminated the obligation to consider additional reimbursement for education.


There are a number of means by which to establish the return on investment for Qstream: financial savings, employee engagement and satisfaction, and increased knowledge and proficiency. As the first-year subscription comes to an end, and despite our conservative use of the platform, we have identified a significant departmental financial return on investment (Fig. 1). Qstream has eliminated the need for a significant amount of non-productive education time as we begin to transition our yearly mandatory requirements. This savings has resulted in the ability to cover the cost of the subscription while also achieving additional financial savings. Although we are still awaiting the yearly employee engagement survey and results, we have had a noteworthy amount of positive feedback from staff regarding their perception of the ease, fun, and accessibility of Qstream. Many staff have expressed an increased sense of work-life balance since its implementation. Although this is early anecdotal data, we do see a correlation with increased user engagement as each additional Qstream is deployed. Finally, and most importantly, our quality metrics have remained stable throughout this transition, indicating that despite our transition to a new approach we have not forfeited quality.

Next Steps

Thankfully, our first-year success has allowed us to budget for a subscription renewal for 2019. We anticipate an increase use of Qstream for 2019, targeting regulatory and compliance training, as well as considering its expansion to our orientation process. We will be utilizing the post completion analytics this year to identify our knowledge gaps and optimize our content design. Our ICU intensivist partners have just launched their first Qstream aimed at ensuring standardization of knowledge regarding institutional policy and practice for their physicians and advanced practice team members. Finally, we have targeted improvements to our celebration and reward structure that will more publicly celebrate the leaderboard and individual user achievements. In summary, I feel fortunate to have engaged with Qstream and I am excited about the positive influence this will allow for changing the landscape of nursing professional development.

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