Everyone has had the experience of being at a workshop or conference, enjoying the company of others, exchanging business cards and, finally, vowing to keep in touch. However, more often than not, conference participants find themselves caught in the moment. Once back at home, their good intentions are fast forgotten as work at the office takes precedence.  

The Executive Training for Research Application (EXTRA) program is different. The goal of this two-year training program is more than the acquisition of skills; EXTRA aims to lead cultural change in the Canadian healthcare system. At the Canadian Health Services Research Foundation (CHSRF), EXTRA takes accomplished healthcare leaders and teaches them the skills they need to find, adapt and use research in the organization, management and delivery of their services. The program incorporates a curriculum designed to link theory to practice, promotes maximum interaction and participation through distance learning and translates the learning from the classroom into effective change management projects (also called intervention projects). This learning is supported by regional mentors, an A-list research faculty and the best research available.

The learning in EXTRA doesn't stop when participants graduate. Instead, the two-year experience lays the foundation for a Community of Practice (CoP), which aims to promote excellence in leadership for evidence-informed decision-making in healthcare organizations (CHSRF 2006a, 2007a, 2007b).  

Etienne Wenger, a globally recognized pioneer and leader in the field of CoPs, has defined these networks as "groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly" (Wenger 2006). Wenger says these communities "are formed by people who engage in a process of collective learning in a shared domain of human endeavor" such as "a gathering of first-time managers helping each other cope" (Wenger 2006). For EXTRA, the building of a CoP is intended to help busy managers find and apply research as well as facilitate cultural change by making it possible to routinely support one another by sharing ideas, solutions and innovations for making evidence-informed decisions.  

Dr. James Worthington, a graduate of the EXTRA program, knows from experience that a CoP can be valuable. Dr. Worthington says that he often contacted fellow alumnae to seek insights and share stories, even before the community's official launch. As vice-president of Medical Affairs at the Ottawa Hospital, he regularly faces difficult questions in his role, questions whose answers are not always available in the research literature. In those cases, Dr. Worthington draws upon the evidence of those who have faced similar challenges and have the knowledge and experience that can help.  

Last year, for example, Dr. Worthington was confronted with the problem of how to best organize his hospital's physician leadership and resources with the initiation of the new Local Health Integration Networks, Ontario's effort to regionalize health services. With little guidance in the current literature, and with the knowledge that he could benefit from the perspectives of peers in provinces that underwent regionalization years ago, Dr. Worthington called upon the expertise of decision-makers from across the country. First, he contacted Dr. Brock Wright, chief operating officer for the Health Sciences Centre in Winnipeg and the vice-president and chief medical officer for the Winnipeg Regional Health Authority, to find out about the difficulties that existed in organizing physician resources and leadership, as well as the subsequent physician decision-making structures within a regional health authority. Then he called Ms. Susan Smith, President of Wayfinder Consulting Incorporated - a healthcare and business consulting firm - and former director of Medical Services at Capital Health in Halifax, Nova Scotia. With Ms. Smith's research expertise and experience in developing and implementing the Capital Health Physician Resource Planning framework, she too was in a good position to advise Dr. Worthington.

Dr. Worthington, Dr. Wright and Ms. Smith are among the first graduates of the EXTRA program. Each year, EXTRA accepts about 24 physician, nurse and health services executives (known as fellows to insiders). Four years in, there are now 100 fellows, including one fully graduated class. As time progresses, the program is expected to build a critical mass of decision-makers adept at putting research into practice.  

With its $25 million budget, EXTRA has been able to make a difference one participant at a time. And this past year, the program began efforts to make a difference one organization at a time too by seeking applications from a team of two or three fellows within the same organization. But the program aims to go beyond the impact to participants and their organizations; it wants to create cultural change across the healthcare system. That is where the EXTRA CoP comes in.  

Expanding EXTRA's Reach through the Creation of a CoP

In its next move, EXTRA wants to capture the energy and lessons learned from its critical mass of healthcare leaders by supporting the development of an EXTRA CoP. It is believed that this community will increase the program's impact by keeping the fellows working together to share knowledge and lead the cultural change toward evidence-informed leadership in healthcare organizations. This systems-level goal is ambitious. It is also one the program's partners have had in mind since its inception.

Based out of CHSRF, EXTRA is also supported by a group of organizational partners including the Canadian College of Health Services Executives, the Canadian Nurses Association, the Canadian Medical Association (CMA) and a consortium of 12 Quebec partners represented by the Agence des technologies et des modes d'intervention en santé. Together, these creators anticipated that EXTRA would spur relationships among the fellows, their academic and decision-making mentors and faculty. They were right. The partners also hoped that the fellows would stay in touch after the program, not only to foster friendships but to carry the torch for evidence-informed decision-making.  

In a video podcast available through the CMA website, Dr. Worthington speaks fondly of his networking opportunities in EXTRA. "One of the real joys I've found was that you met people from across the country, you heard about their issues and they were able to provide input to you," he says. "It has left me with a lasting network to go to when I've got questions, when I need collaboration and when I need other viewpoints about a problem that I might have within any part of my normal responsibilities at The Ottawa Hospital" (CMA 2007).

The idea of a lasting CoP may seem a natural step for EXTRA, but there are notable barriers to its success. For example, senior health system managers are under incredible time constraints, inherent in their day-to-day jobs, which may interfere with a strong commitment to the CoP. Also, the fellows come from a variety of disciplines - engaged in everything from patient safety to financial and governance arrangements - so the CoP may face additional challenges in holding widespread interest. There are language barriers to consider too: EXTRA prides itself in offering fully bilingual services, but its CoP does not have the capacity to continue these.

In addition to these barriers, CoPs are usually intended to be organic, naturally occurring entities that arise in response to a need, interest or issue that affects the practice or field (CHSRF 2006b; Wenger et al. 2002). At its most successful, its membership is committed to developing and validating best practices in their profession over time and through sustained interactions. Demonstrating excellence in leadership for evidence-informed decision-making in healthcare organizations is an aspect in which the fellows already believe. It's why they joined the EXTRA program. But the idea to create an EXTRA CoP was the brainchild of CHSRF and its partners, not a grassroots effort led by fellows.  

Cultivating an EXTRA CoP

Certainly, a willing and able "green thumb" is necessary to cultivate a CoP, as Wenger suggests in his work (Wenger 2006; Wenger et al. 2002). In the book Cultivating Communities of Practice: A Guide to Managing Knowledge, Wenger and his co-authors (2002) liken CoPs to plants:  

A plant does its own growing whether its seed was carefully planted or blown into place by the wind. You can not pull the stem, leaves, or petals to make a plant grow faster or taller. However, you can do much to encourage healthy plants: till the soil, ensure they have enough nutrients, supply water, secure the right amount of sun exposure, and protect them from pests and weeds. (p. 12)

For CoPs to achieve their full potential, the authors argue, organizations can do much to create nutrient-rich bedding. For example, they can help establish clear goals, objectives and a vision that is shared by the membership. Organizations can also provide financial support.

Already, CHSRF has offered the necessary resources to nurture the creation of the CoP by helping to develop its terms of reference, steering committee and ideas for future directions (CHSRF 2006a). The foundation has also agreed to provide continued funding and in-kind support as long as the CoP activity is in line with the foundation's strategic priorities and activities.

Among the first activities is a plan to build space for the CoP within what is known as the EXTRA desktop. The desktop is a custom online database supported by the Centre for Health Evidence at the University of Alberta. It is already available to fellows when they enter the EXTRA program. It provides access to research resources, health news and contact information - and now has a space for CoP developments. This fall, CHSRF will feature resources by theme on the desktop. The first will link to the 2007 dissemination campaign on quality in Canadian healthcare, highlighting evidence, intervention projects and activities supporting the theme. Future ideas include organized face-to-face events in concert with existing partners and using webcast technology to offer "author in the room" learning sessions for members.  

The greatest role of the EXTRA CoP - and its key to success - will be its ability to deliver effective knowledge sharing and knowledge creation among health system leaders. Cutting across organizational, hierarchical and geographical boundaries, it is hoped fellows will be able to share their tacit knowledge about evidence-informed decision-making by sharing experiences, telling stories and coaching peers. Furthermore, it is hoped this knowledge will find its way into practice to improve healthcare decision-making across the country - strong evidence that the members of the CoP have become an entity stronger than the sum of its parts.

For more details about the EXTRA program, including post-program activities, visit the foundation's website at www.chsrf.ca/extra. For more information about the EXTRA CoP, in particular, contact Andrea Smith at andrea.smith@chsrf.ca. More information on the EXTRA CoP will also be available in "The Extra Community of Practice: Incubating Change," a chapter by Coutes et al. (in press) in Communities of Practice in Health and Social Care.  

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