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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

Difficulty

Cost

2





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

7

Lack of motivation

Distraction

Fatigue

Lack of time/competing demands

Lack of awareness of knowledge deficit

Personal reluctance to change

Ambivalence

Group mentality


Miller s pyramid1
Miller’s Pyramid

Difficulty

Cost

8


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

11


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

13

13


Challenges for educational researchers
Challenges for Educational Researchers

Conflicting demands

Isolation

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



Learning Element

19

Page 19


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


Clinical practice pattern change
Clinical Practice Pattern Change 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

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 knowledge
Spaced Education for knowledge 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.


Spaced education for behavior change psa screening
Spaced 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.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 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

N=545 patients, 50 residents

Clinical outcomes after 10 months

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

24


Adaptive learning treatment of type 2 diabetes
Adaptive Learning: Treatment of type 2 diabetes 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.


Key messages from online learning experiments
Key Messages from Online Learning Experiments 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

Online learning is

Acceptable

Effective

Efficient

Online learning is best when it is

Relevant

Interactive

Uses a variety of programs

Is spaced

Is adaptive

Provides feedback


Behavior change by restructuring

Behavior Change By Restructuring 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

27


Redesigning our inpatient care model
Redesigning Our Inpatient Care Model 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

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 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

  • 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 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

Attending

Resident(s)

Interns


Resident activity
Resident Activity 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

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

**P=0.003


Itu attending surveys
ITU Attending Surveys 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

32


Resident survey data
Resident Survey Data 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.


34 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.


Primary results
Primary Results 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

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


Quality of discharge summaries
Quality of Discharge Summaries 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

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 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

*None of the GMS vs. ITU differences were significant


Conclusions from this experiment
Conclusions from this Experiment 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

  • 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 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

Many types of learning experiences are optimized by social interaction

Interaction

Sharing

Supervision

Observation

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 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

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

41


What makes a good team
What makes a good team 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.?

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 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

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


Teambuilding
Teambuilding 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

  • Articulate the expectation

  • Model

  • Monitor, Coach, Feedback

  • Create team-based activities

    • Structured rounds

    • Simulator Program

    • Museum Program


Interdisciplinary team
Interdisciplinary team 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

45


Interdisciplinary team1
Interdisciplinary Team 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

Two attendings

Two residents

Three interns

Two medical students

Nurses

Social worker

RN Care Coordinator

Physical therapist

Pharmacy students and faculty supervisor


Daily rounds
Daily Rounds 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

2hrs

Bedside rounds

Resident-led

Attending Teaching

Patient-grps by nurse


Multidisciplinary rounds
Multidisciplinary Rounds 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

48

  • Meeting with

    • Social work

    • Physical therapy

    • Medical residents

    • Nursing

  • Shared purpose

  • Differing perspectives

  • Unique insights


Simulation lab teambuilding
Simulation Lab Teambuilding 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

Involve multidisciplinary team

Practice leadership

Illustrate team dynamics

Reflect and debrief


Sackler museum program
Sackler Museum Program 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

  • 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 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

“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 survey
Nursing Survey 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.


Nursing comments
Nursing Comments 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.:

“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.“

53


Quantitative data after teambuilding
Quantitative Data after TeamBuilding 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

  • 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 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

  • 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? 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

Five Future Changes


Changes for the future
Changes for the Future 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

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 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

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 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

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 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

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 2009 to April 2010, immediately following the PriMed live CME conference in Houston, Texas.

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



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