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Education and Behavior Change: Measuring the Success of Our Efforts. Graham McMahon MD MMSc Associate Professor of Medicine, Harvard Medical School Division of Endocrinology, Diabetes & Hypertension Brigham & Women’s Hospital. Miller’s Pyramid. Difficulty Cost. 2. Vs.

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education and behavior change measuring the success of our efforts

Education and Behavior Change:Measuring the Success of Our Efforts

Graham McMahon MD MMSc

Associate Professor of Medicine, Harvard Medical School

Division of Endocrinology, Diabetes & Hypertension

Brigham & Women’s Hospital

miller s pyramid
Miller’s Pyramid




the world of medicine is changing fast
The World of Medicine is Changing Fast
  • Hard to anticipate how this generation of learners will be practicing
barriers to learner engagement
Barriers to Learner Engagement


Lack of motivation



Lack of time/competing demands

Lack of awareness of knowledge deficit

Personal reluctance to change


Group mentality

miller s pyramid1
Miller’s Pyramid




triggering behavior
Focus on a behavior you want to change

Find a way to break that behavior down to something really small and doable, then

Find out how to trigger that behavior at the right time

Triggering Behavior
pedagogy for behavior change
Pedagogy for Behavior Change
  • multiple and varied representations of concepts and tasks;
  • encourage elaboration, questioning and explanation;
  • challenging tasks;
  • examples and cases;
  • prime student motivation; and
  • use formative assessments.
restructuring the environment
Restructuring the Environment
  • The environment must facilitate the
    • Learning
    • Doing
    • Reinforcing


the value of teams
The Value of Teams
  • Relationships are nurturing
  • Great learning happens in groups
  • Collaboration is the stuff of growth
why experiment
Why Experiment?

Evidence based education!

Rigor in educational approaches

Improved quality for learners

Personal and professional value

Elevate the field



challenges for educational researchers
Challenges for Educational Researchers

Conflicting demands


Lack of programmatic support

Constrained budget

Activities not valued

creating online engagement
Creating Online Engagement
  • Individualize the offering
    • Relevant and important
    • Build on prior learning
    • Personalized comparative feedback
  • Develop and maintain a longitudinal relationship
    • Curriculum for personal growth
  • Make it rewarding
    • Goal oriented
    • Fun
    • Positive
  • Engage the social instinct
    • Collaborative models
This randomized controlled trial was conducted from March 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.
  • 74% of participants (181/246) completed the SE program.
  • Of these, 97% (176/181) submitted the behavior change survey

J Cont Educ Health Prof, 2011; 31(2):103–8

clinical practice pattern change
Clinical Practice Pattern Change

86% agreed or strongly agreed that the SE program enhanced the impact of the live CME conference.

97% requested to participate in future SE supplements to live CME courses.

J Cont Educ Health Prof, 2011; 31(2):103–8

spaced education for behavior change psa screening
Spaced Education for Behavior Change: PSA Screening

Am J Prev Med 2010;39(5):472– 478

spaced education for osteoporosis care
Spaced Education for Osteoporosis Care

N=545 patients, 50 residents

Clinical outcomes after 10 months

Number needed to educate to prevent 1 fracture/yr = 29


key messages from online learning experiments
Key Messages from Online Learning Experiments

Online learning is




Online learning is best when it is



Uses a variety of programs

Is spaced

Is adaptive

Provides feedback

redesigning our inpatient care model
Redesigning Our Inpatient Care Model

Balance patient-volume relative to education

Dedicate some time for learning

Provide higher-quality feedback

Nurture teams

Enhance collaboration

Focus Groups with Residents, Medical and Nursing Staff

Key themes:

Workload, Continuity, Relationships

Inclusive Redesign Committee

Hospital Funding

& Metric Selection

trial schema
Trial Schema
  • Outcomes:
  • Patient mortality
  • Length of stay
  • Readmission rate
  • Resident activity
  • D/c summary quality
  • Attending, resident and patient satisfaction

2 GMS teams

2 ITU teams

Unselected medical patients

1 year

team differences
Team Differences




resident activity
Resident Activity

ITU residents spent much more of their time in educational activities than GMS residents


primary results
Primary Results

*O/E = observed to expected; LOS = length of stay

quality of discharge summaries
Quality of Discharge Summaries

Blinded evaluation of 142 random discharge summaries

Fraction of reports with all

the required elements

press ganey patient satisfaction data
Press-Ganey Patient Satisfaction Data

*None of the GMS vs. ITU differences were significant

conclusions from this experiment
Conclusions from this Experiment
  • As compared to a typical inpatient care model, introduction of a restructed educational enviroment was associated with
    • improved teamwork
    • significantly lower inpatient mortality
    • significantly lower length of stay
    • significantly increased time for educational activities
    • higher attending, nursing and resident satisfaction
key messages from restructuring
Key Messages from Restructuring

Many types of learning experiences are optimized by social interaction





Need to consider

Process of learning

Structure of the learning environment

Appropriate restructuring can meaningfully affect learning

behavior change by relationship building

Behavior Change By Relationship-Building

(on a team that changes every month or more!)


what makes a good team
What makes a good team?

Shared knowledge structures

Mutual respect

Coordination of collective behaviors (leadership)

Effective communication

Cross-monitoring team members actions

Engaging in back-up behavior

Appropriate assertiveness/conflict management

Wise use of resources

Jeffrey B. Cooper “Teamwork in Healthcare” Update in Hospital Medicine 2010

team characteristics
Team Characteristics

Two or more members

Common goals and purpose

Members are interdependent on one another

Has value for acting collectively

Accountable as a unit

Needs to be created

Jeffrey B. Cooper “Teamwork in Healthcare” Update in Hospital Medicine 2010

  • Articulate the expectation
  • Model
  • Monitor, Coach, Feedback
  • Create team-based activities
    • Structured rounds
    • Simulator Program
    • Museum Program
interdisciplinary team1
Interdisciplinary Team

Two attendings

Two residents

Three interns

Two medical students


Social worker

RN Care Coordinator

Physical therapist

Pharmacy students and faculty supervisor

daily rounds
Daily Rounds


Bedside rounds


Attending Teaching

Patient-grps by nurse

multidisciplinary rounds
Multidisciplinary Rounds


  • Meeting with
    • Social work
    • Physical therapy
    • Medical residents
    • Nursing
  • Shared purpose
  • Differing perspectives
  • Unique insights
simulation lab teambuilding
Simulation Lab Teambuilding

Involve multidisciplinary team

Practice leadership

Illustrate team dynamics

Reflect and debrief

sackler museum program
Sackler Museum Program
  • Create openness and vulnerability
  • Illustrate value of differing perspectives
  • Use art to explore
    • Team dynamics
    • Communication styles
    • Hierarchy
    • Interdisciplinary relationships
museum night reflections
Museum Night Reflections

“More relaxed, people interacted with each other more as friends. “

“How differently we all approached the same painting—but also how we could see each other’s perspective easily, and discover how different perspectives fit together cohesively”

“Brought the team together. Everyone was on the same footing—there were no experts, no right or wrong interpretations.”

nursing comments
Nursing Comments:

“We have established a more team-approach to patient care with the doctors. We have more face time with the doctors. I have learned more rationale for treatments during rounds thus able to convey a greater detailed plan to/with the patient.”

“The communication and quality of patient care has improved immensely.”

“Since the team innovation the patients have received better care through enhanced communication, better teamwork and more availability of physicians on the floor.

“The team innovation has made the nurse a more integral part of planning care for patients and physicians are taking stronger interest in nursing-care related issues.“


quantitative data after teambuilding
Quantitative Data after TeamBuilding
  • Significantly
    • Higher satisfaction among nurses and residents
    • Higher nursing empowerment
    • Lower nursing stress
    • Fewer electronic pages sent
key messages from teambuilding
Key Messages from Teambuilding
  • Teamwork is a key skill for healthcare providers
  • Learning is social experience
  • Through shared experiences and debriefs, effective collaboration can be
    • Nurtured
    • Facilitated
    • Learned
    • Valued
what s next

What’s Next?

Five Future Changes

changes for the future
Changes for the Future

1. Increased use of multidimensional and adaptive educational interventions and assessments

Merge pedagogy and technology

Blended learning environment

changes for the future1
Changes for the Future

2. A shift towards more skills-based training and assessment

Less abstract knowledge

More practical assessment

more simulation, experiential learning, inquiry learning, action learning, and communities of practice

changes for the future2
Changes for the Future

3. More emphasis on relationships

longitudinal peer-to-peer

Longitudinal observation and supervision

Longitudinal engagement with patients

changes for the future3
Changes for the Future

4. A shift from the individual to the team as the primary “unit of learning.”

more knowledge about how teams actually change their practice and the role educational interventions can and do play in the change process.

A greater focus on inter- professional education.

changes for the future4
Changes for the Future

5. More research to advance our understanding of not only what works, but also under what conditions and why

increased use of qualitative and mixed methods approaches to systematic inquiry

More behavioral outcomes