Indiana University (IU) Health is overhauling how it trains employees in CPR, significantly changing the process for 20,000 caregivers across the system.

Like many healthcare organizations, IU Health used to require employees to attend CPR courses every two years. Now, they are training every quarter with online simulations and hands-on practice.

The training includes computerized mannequins available in employee workplaces rather than only at specific training sites. Employees can access the mannequins 24/7.

The program is called Resuscitation Quality Improvement (RQI) 2020, says Greg Strine, MA, RN, director of the Center for Physician Education and the Emergency Response Training Institute at Indiana University Health. RQI 2020 uses a simulation-based CPR learning platform, endorsed by the American Heart Association (AHA), that measures and verifies competence, Strine says. The program is subscription-based, and IU Health is investing $7 million in the project.

CPR Skills Degrade

Resuscitation skills can degrade quickly, according to Strine. The AHA reports only about 25% of patients survive an in-hospital cardiac arrest in the United States, not much better than the 12% who survive out-of-hospital cardiac arrest.1 Other research has shown CPR skills can deteriorate as soon as six months after initial training.2

“The old model of going to CPR class every two years is what we had used for decades, but it wasn’t working. It’s a perishable skill,” Strine says. “The RQI platform is based on research that shows reinforcement of that training on a more frequent basis helps maintain that knowledge and skill level. The research had studied various time intervals for reinforcement, and the RQI model landed on every three months as effective but without overwhelming people.”

RQI 2020 provides more frequent training to address that risk, with the goal of improving patient outcomes and decreasing preventable deaths from cardiac arrests, Strine says. The program is designed to deliver “low-dose/high frequency” training in CPR skills.

Pilot Shows Promise

The program was piloted in the ED at IU Methodist Hospital in Indianapolis with about 200 nurses and technicians. The plan was to use a digital learning platform developed by RQI Partners, a partnership between the AHA and Laerdal Medical, for two years to evaluate whether it was effective in improving CPR skills. After a little more than a year, data indicated the program was successful in maintaining CPR skills, consistent with previous research that supported the program’s effectiveness. The ED staff at IU Methodist Hospital not only maintained their skills but showed incremental increases in the performance of chest compressions, Strine reports.

“We felt confident that we had a large number of participants demonstrating the platform was doing what it was designed to do. At that point, we presented the information to our leadership team in quality and safety and the executive leadership team. We got buy-in from all of them that we should do this across all of our system,” Strine says. “Ultimately, this went to the education and research committee of our board of directors for a demonstration. We received support from them to move forward in implementing it across our entire health system.”

IU Health deployed the program to 20,000 healthcare staff members across the system, using a three-phase rollout beginning in the last quarter of 2019. Three facilities in Indianapolis accounted for about half of the 20,000 participants. The other 10,000 were brought into the program over the first two quarters in 2020. Strine notes the entire approval and implementation process took about eight months. The RQI program provides cognitive learning modules that include educational videos, simulated patient cases, and multiple choice exam questions. After completing the learning module, the participant performs self-directed skills drills that take about 10 minutes.

The RQI program delivers the same training as a conventional AHA CPR training program, Strine says, but the content is delivered over a two-year period instead of dumping it all on the participant in a one- or two-day class.

No Classroom Training

One of the biggest benefits is there is no classroom training. This means no dragging people away from their daily duties to attend a CPR class. Instead, IU Health provides “RQI carts” with the learning modules and CPR mannequins, positioned strategically throughout the facilities and available at all times. IU Health provides as many as 17 carts in one facility.

Everyone who is required to earn CPR certification can access the carts when it is most convenient for them. They are required to log in and maintain their training every three months, but they can do so at any time, including on weekends.

“The program is designed to provide a high level of readiness among your staff. We know that high-quality CPR is the difference maker in achieving return to circulation and ultimately survival and discharge,” Strine says. “We’d have people in our classes say they hadn’t been in a code in two years, and the last time they practiced CPR was in the last class they attended two years ago. But they were fully aware that a cardiac arrest could happen at any time, on any shift, and they would be called on to do this.”

In addition to the more frequent training, staff members receive feedback and coaching on their skills while using the RQI carts for their quarterly training, Strine notes. The mannequins provide verbal feedback on the strength and frequency of compressions so staff can adjust their performance regularly.

“It’s not just a matter of having a mannequin to practice compressions and then walking away without knowing if you really did it correctly. You get the feedback the entire time you are doing it [right],” Strine says. “You’re learning if you are getting the right depth, the right rate, the right amount of recoil. We know that getting all those things is the premier factor in increasing the survival rate.”

The goal is to train the staff member to develop muscle memory and an ingrained sense of the right performance measures so that when the time comes, CPR is almost an automatic response.

IT Integration Challenging

The biggest challenges with implementing the program involved IT issues, Strine says. One example was the integration of the laptops provided by the RQI vendor to make them consistent with IU Health security and other standardization.

“There were a lot of moving parts and various teams involved,” he says. “Integrating it into our own education system was something we chose to do so that the users didn’t have to manage two different platforms for their ongoing education. That created more work for us, but we felt it was worth the effort to make this something people could utilize easily.”

The logistics of deploying all the RQI carts to the IU Health System’s 17 hospitals was another challenge. The health system designated a team that was dedicated to traveling to each facility and installing the necessary number of carts, which included making sure the cart laptops were integrated into the facility’s IT network.

COVID-19 complicated the last phase of the RQI integration, necessitating some virtual sessions for the training of “super users” at facilities who would oversee the program, rather than the in-person sessions that had been conducted for earlier facilities, Strine reports.

“One thing we learned was that beyond the ability to maintain our proficiency in things like chest compression and ventilation, our knowledge base, it was advantageous to have this platform during our COVID response. We didn’t have to bring our people together to maintain their CPR training,” Strine says. “Our staff was able to maintain our training throughout that period, whereas we and a lot of other healthcare organizations had to put other training aside because the old traditional model of a lot of people in a classroom was not feasible.”

Strine says if he were to repeat the process, he would not be afraid to jump in with implementing the program across the entire health system rather than conducting a pilot program first. Since IU Health first tried the RQI program at one hospital ED, there have been reports of other experiences at hospitals and health systems demonstrating the program’s worth.

“There is plenty of information out there that this is a good, alternative way to go to meet your training requirements and alleviate some of the barriers you run into with trying to get staff to class and still staff your clinical areas,” Strine says. “This certainly alleviates some of those problems, on top of all the quality enhancement you get with people training eight times over two years instead of once every two years. They’re developing that muscle memory and maintaining their competence in advanced life support skills.”


  1. American Heart Association. Cardiac arrest statistics.
  2. American Heart Association. Resuscitation Quality Improvement program frequently asked questions


  • Greg Strine, MA, RN, Director, Center for Physician Education and the Emergency Response Training Institute, Indiana University Health, Indianapolis. Phone: (317) 962-8111. Email: