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

Difficulty Cost

Miller’s Pyramid

2

Vs.

Maslow’s Hierarchy of Needs

vs.

The World of Medicine is Changing Fast • Hard to anticipate how this generation of learners will be practicing

Barriers to Learner Engagement

• • • • • • • • Lack of motivation Distraction Fatigue Lack of time/competing demands Lack of awareness of knowledge deficit Personal reluctance to change Ambivalence Group mentality 7

Difficulty Cost

Miller’s Pyramid

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

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

• The environment must facilitate the – Learning – Doing – Reinforcing 11

The Value of Teams

• • • Relationships are nurturing Great learning happens in groups Collaboration is the stuff of growth

Why Experiment?

• • • • • Evidence based education!

Rigor in educational approaches Improved quality for learners Personal and professional value Elevate the field

Challenges for Educational Researchers • • • • • Conflicting demands Isolation Lack of programmatic support Constrained budget Activities not valued

Behavior Change Through Online Learning

Creating Online Engagement

• Individualize the offering – Relevant and important – Build on prior learning – Personalized comparative feedback • Make it rewarding – – Goal oriented Fun – Positive • Develop and maintain a longitudinal relationship – Curriculum for personal growth • Engage the social instinct – Collaborative models

17

Learning Element Page 19 19

• • • 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

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

16 Spaced Education for Behavior Change: PSA Screening

Controls

14 12 10 8

Interactive Spaced Education

6

USPSTF Statement

0 0

p=0.041 overall

p=0.018 for trend Weeks Am J Prev Med 2010;39(5):472 – 478 Control Cohort Time vs Cohort 1 - Interv Time vs Cohort 1 - Interv: 1.0000 Time vs Cohort 1 - Interv: 2.0000 Time vs Cohort 1 - Interv: 3.0000 Time vs Cohort 1 - Interv: 4.0000 Time vs Cohort 1 - Interv: 5.0000 Time vs Cohort 1 - Interv: 6.0000

Spaced Education for Osteoporosis Care

Knowledge score Total DEXA scans

FRAX Score in Resident Note FRAX Recorded

Bisphosphonate Treatment

Intervention % 73 95 19 46 76 N=545 patients, 50 residents Clinical outcomes after 10 months Number needed to educate to prevent 1 fracture/yr = 29 Control % 66 89 17 41 59 P 0.04

0.02

0.89

0.65

0.03

24

Adaptive Learning: Treatment of type 2 diabetes

Key Messages from Online Learning Experiments • • 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

27

Redesigning Our Inpatient Care Model Focus Groups with Residents, Medical and Nursing Staff Key themes: Workload, Continuity, Relationships Inclusive Redesign Committee Hospital Funding & Metric Selection • • • • • Balance patient volume relative to education Dedicate some time for learning Provide higher quality feedback Nurture teams Enhance collaboration

Trial Schema

Unselected medical patients 2 GMS teams 2 ITU teams Outcomes: • Patient mortality • Length of stay • Readmission rate • Resident activity • D/c summary quality • Attending, resident and patient satisfaction 1 year

Team Structure Supervision Workload Team Differences

ITU GMS (control)

2 residents 3 interns 2 co-attgs present on site; set rounds Max census of 15 pts (~4-5 pts per intern) 1 resident 2 interns Multiple care attgs Variable contact Max census per ACGME limits (~6-8 pts per intern) Attending Resident(s) Interns

Resident Activity

ITU residents spent much more of their time in educational activities than GMS residents ITU GMS Direct Patient Care Indirect Patient Care Education** Transitions of care Other 12% 36% 29% 6% 17% 18% 44% 7% 11% 20% **P=0.003

ITU Attending Surveys

Number of Attendings Returning surveys Number of Returned Surveys Agreement (%): Closest to an ideal teaching experience Teaching skills well utilized Liked the dual-attending model Learned from my co-attending Agreement 41 of 47 (87%) 41 70% 82% 90% 93% 32

Resident Survey Data Number of Residents Returning surveys ITU 98 Number of Surveys I agree with this statement (mean % agreement):

I enjoyed the rotation This rotation was closest to an ideal residency experience I had more follow-up than usual

104 77.9

41.4

22.1

I learned new physical exam skills I received feedback from my attending

77.9

85.6

I learned a lot from this activity this month (mean % agreement)

Morning report

95.1

My attendings on rounds Preparing teaching topics Resident-led didactics

83.6

78.9

80.0

GMS 62 62 54.8

6.4

8.1

30.6

30.6

58.3

66.1

74.4

44.1

P-value 0.002

<.0001

0.02

<.0001

<.0001

<.0001

0.009

0.59

<.0001

Number of Patients % Female Race Category White African-American Hispanic All Others Declared Mean age (sd) Insurance Private Medicare Medicaid No insurance Diagnosis Category Cardiovascular Pulmonary Gastronenterology Renal

ITU

1892 58.0% 78.0% 14.1% 4.9% 3.0% 68.9 (17.6) 37.7% 32.3% 25.9% 4.0% 17.2% 15.8% 12.7% 8.3%

GMS

2096 60.0% 80.7% 13.3% 3.8% 2.2% 69.6 (17.2) 39.6% 33.2% 23.5% 3.7% 15.1% 15.0% 15.2% 7.3%

p-value

0.13

0.11

0.22

0.29

0.1

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Primary Results

ITU Discharge Volume (number of patients) Mean daily census per first-year resident 1892 3.5

1.4

In-patient mortality (%) Expected mortality (%) O/E Mortality Ratio Average LOS (mean days [se]) Expected LOS (mean days) O/E LOS Ratio Readmissions within 30 days (%) 1.7

0.79

4.1 (.09) 4.0

1.03

6.9

GMS 2096 6.6

2.2

1.7

1.26

4.6 (.10) 4.0

1.15

8.0

*O/E = observed to expected; LOS = length of stay P-value 0.04

<.0001

0.0002

<.0001

0.19

Inpatient Metric

Pneumonia

Pneumococcal Vaccination Adult Smoking Cessation Advice Influenza Vaccination

Acute Myocardial Infarction

Aspirin at Discharge ACEI/ARB at Discharge Adult Smoking Cessation Advice Beta-blocker at Discharge

Heart Failure

Discharge Instructions LVEF Assessment ACEI/ARB for LVSD Adult Smoking Cessation Advice

ITU

37/53 (70%) 8/8 (100%) 25/42 (60%) 11/11 (100%) 2/2 (100%) 1/1 (100%) 10/10 (100%) 50/63 (79%) 91/91 (100%) 17/17 (100%) 9/9 (100%)

GMS

34/48 (71%) 5/6 (100%) 30/42 (71%) 3/3 (100%) 1/1 (100%) 0/0 (0%) 4/4 (100%) 47/53 (89%) 74/74 (100%) 11/11 (100%) 10/10 (100%)

• Quality of Discharge Summaries Blinded evaluation of 142 random discharge summaries

Press-Ganey Patient Satisfaction Data Number of Patients Returning surveys % Satisfied Admission Doctors Tests and Treatments Discharge Overall Prior Yr 599 80.7

86.1

84.9

81.2

86.5

ITU 315 83.3

88.9

86.0

83.1

90.1

GMS 306 82.9

87.1

85.9

82.5

89.9

*None of the GMS vs. ITU differences were significant

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 • • • 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

(on a team that changes every month or more!) 41

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

• • • • • 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

• • • • Articulate the expectation Model Monitor, Coach, Feedback Create team-based activities – Structured rounds – Simulator Program – Museum Program

Interdisciplinary team

45

Interdisciplinary Team

• • • • • • • • • Two attendings Two residents Three interns Two medical students Nurses Social worker RN Care Coordinator Physical therapist Pharmacy students and faculty supervisor

Daily Rounds

• • • • • 2hrs Bedside rounds Resident-led Attending Teaching Patient-grps by nurse

Multidisciplinary Rounds

• • • • Meeting with – – Social work Physical therapy – Medical residents – Nursing Shared purpose Differing perspectives Unique insights 48

Simulation Lab Teambuilding

• • • • Involve multidisciplinary team Practice leadership Illustrate team dynamics Reflect and debrief

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 “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

Question

I can readily reach a team member with questions/concerns The medicine resident and interns generally know my name I am regularly invited to contribute to the team’s deliberation about patient care

New Team

(n=27) 100% I can usually recognize a medicine resident or intern when I see them 83% 53% 88% I regularly contribute to the medicine team’s deliberations about patient care 95%

GMS-14-15

(n=36) 76% 50% 12% 54% 69%

•

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.“ 53

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

• • • 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?

Five Future Changes

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 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 Future

• 3. More emphasis on relationships – longitudinal peer-to-peer – Longitudinal observation and supervision – Longitudinal engagement with patients

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 education.

professional

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

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