PLANNING IS PRICELESS PLANS ARE USELESS....PLANS ARE USELESS. Why are backwards planning and instructional design priceless in medical education? Jo Varney, Ogilvy Healthworld Thursday

PLANNING IS PRICELESSPLANS ARE USELESS.Why are backwards planning and instructional design

priceless in medical education?

Jo Varney, Ogilvy Healthworld

Thursday 7 December 2017, 14:00–15:00 GMT (London)

1. Describe a basic backwards

planning learning process

2. List three features of

an instructional design model

WHAT ARE THE LEARNING OBJECTIVES FOR THIS WEBINAR?

3. Recall the three components

of COM-B

4. Explain why reflection is one of the most

important elements of learning and

improving performance

By the end of this session, you should be able to:

Eisenhower photograph

DWIGHT D. EISENHOWER (1890–1969)

Plans are useless

but the planning is

priceless“ “

Why is

planning

priceless?

AUSTRIA, CIRCA 1900: Auditorium filled with students at a lecture of Julius Wagner-Jauregg, physician and psychiatrist, who became famous for his treatment of mental disease by inducing a fever, which earned him the Nobel Prize in Medicine in 1927. Photo by Imagno/Getty Images.

WIGGINS & McTIGHE CODIFIED ‘BACKWARDS PLANNING’ INTO A THREE-STAGE PROCESS

How will you know if learners have achieved the desired results?

Determine acceptable evidence2

What materials and resources are best suited to accomplish these goals?

Plan learning 3

First, set the goal. What are the outcomes, performance, knowledge needed?

Identify desired results 1

Wiggins G, McTighe J. Understanding by design. Alexandria, VA: Association for Supervision and Curriculum Design; 2005. (p. 8).

THE INFLUENTIAL WORK OF MOORE, ET AL. (2009) DRAWS UPON WIGGINS & McTIGHE

COMMUNITY HEALTH7

PATIENT HEALTH6

PERFORMANCE5

COMPETENCE4

KNOWLEDGE3

SATISFACTION2

PARTICIPATION1

Moore DE, et al. J Contin Educ Health Prof 2009;29:1–15.

A learning needs assessment identifies the gap

between ‘what is currently happening’ (the

current state) and ‘what should be happening’

(the desired state).

GAP: NEEDS ASSESSMENT

WHAT IS CURRENTLY

HAPPENING?

a%

WHAT SHOULD BE

HAPPENING?

b%x%

b−a = x%

A CARDINAL PRINCIPLE OF GOOD EDUCATION IS TO FIRST UNDERTAKE A GAP ANALYSIS


A clear and measurable practice gap

identified through chart audits.

AN ELEGANT GAP ANALYSIS IN PRACTICE GAP: NEEDS ASSESSMENT

WHAT IS CURRENTLY

HAPPENING?

58.4%

WHAT SHOULD BE

HAPPENING?

100%41.6%

100−58.4 = 41.6%

Zisblatt L, et al. J Contin Educ Health Prof 2013;33:206–14.

Woman >65 should be tested for bone mineral

density

Woman >65 currently being tested for bone mineral density

1. An adult learning instructional model

2. A model of health promotion

3. A model for describing behaviour

4. A model for behaviour change

interventions

5. A post-education event debriefing model

QUESTION #1

What does the COM-B model describe?

COM-B: A MODEL FOR DESCRIBING BEHAVIOUR

MOTIVATION BEHAVIOUR

CAPABILITY

OPPORTUNITY

COM-B, capability, opportunity, motivation and behaviour.Michie S, et al. Implement Sci 2011;6:42.

COM-B COULD HELP DESCRIBE THE GAPS BETWEEN WHAT IS CURRENTLY HAPPENING AND WHAT SHOULD BE HAPPENING

Reflective

MOTIVATIONAutomatic

BEHAVIOUR

Psychological

CAPABILITYPhysical

Physical

OPPORTUNITYSocial

CAPABILITY can be:

• PSYCHOLOGICAL – having knowledge, psychological

skills, strength or stamina to engage in necessary processes

• PHYSICAL – having the physical skills,

strength or stamina to perform the behaviour

OPPORTUNITY can be:

• PHYSICAL – what the environment allows in terms of

time, resources, locations, cues, physical barriers, etc.

• SOCIAL – including interpersonal influences, social cues

and cultural norms

MOTIVATION may be:

• REFLECTIVE – involving self-conscious

evaluations and planning (Type 2, ‘slow’ thinking)

• AUTOMATIC – emotional reactions, desires, impulses,

inhibitions, habits and reflex responses (Type 1, ‘fast’ thinking)


COM-B COULD INFORM LEARNING DOMAINS TO HELP US FOCUS ON AND TACKLE AUTOMATIC MECHANISMS OF MOTIVATION

Reflective

MOTIVATIONAutomatic

BEHAVIOUR

Psychological

CAPABILITYPhysical

Physical

OPPORTUNITYSocial

KNOWLEDGE – An individual’s cognitive capacity to engage in the

activity concerned; having knowledge; psychological skills, or stamina

SKILL – An individual’s physical capacity to engage in the activity

concerned; having physical skills, strength or stamina

MOTIVATION – An individual’s reflective processes involving

evaluations and plans (Type 2, ‘slow’, reflective, effortful thinking)

ATTITUDE – An individual’s automatic processes (involving emotional

reactions, impulses, inhibitions, habits and reflexes (Type 1, ‘fast’ thinking)

SYSTEM – Factors that lie outside the individual that make behaviour

possible or not; systems-level domains include ecosystem infrastructure


RECAP: THREE TAKE-HOME MESSAGES

Three-stage process:start with the end in mind

Backwards planning1

Backwards planning and gap analysis ensures learning is learner-centric and outcomes focused

Learner-centric2

Potentially elegant way of analysing gaps across Moore’s outcomes levels

COM-B3

COM-B, capability, opportunity, motivation and behaviour.

Predisposing–enabling–

reinforcing, one of

the most commonly

used instructional

models in health

CASE STUDY

CME-accredited HCP training to increase radiologists’ knowledge,

skills and confidence in performing and interpreting breast MRI,

thereby improving patient care

PREDISPOSING–ENABLING–REINFORCING INSTRUCTIONAL MODEL PROVIDED AN OVERARCHING FRAMEWORK

Green LW, Kreuter MW. Health promotion planning: an educational and environmental approach. Mountain View, CA: Mayfield Publishing Co.; 1991. (p. 151–77).

The training conducted under auspices of EUSOBI and CME-accredited by EACCME.

BREAST MRI

EUSOBI, European Society for Breast Imaging; EACCME, European Accreditation Council for Continuing Medical Education.

PREDISPOSING ACTIVITIES

Elicit a ‘learning moment’ in the

mind of the learner, meaning they

will be more likely to pursue the

learning.

Needs analysis: pre-course

online survey

Self-reported knowledge and

confidence gaps identified.

Predisposing language

Language in invitation and advertising

materials to create cognitive

dissonance.

Key needs identified in

needs analysis included:

• Lack of knowledge

around specific breast

imaging interpretation

• Lack of skill in using

MRI in clinical

diagnostics


ENABLING ACTIVITIES

Supply learners with knowledge/

resources they need along with

opportunities to use knowledge in

'authentic' situations.

Mix of instructional

methodologies

• Expert plenary lectures

• Case-based learning: practice and

feedback

Working through case studies in small

groups at workstations was the main

learning format.

Case-based learning

ensured the learning was

as close as possible to a

‘real-world’ work setting.

Authentic cases provided

learning opportunities

that are considered

relevant to HCPs.

Cervero & Gaines’ (2015) systematic review concluded that learning activities that lead to more positive outcomes in clinical behaviour and patient outcomes are characterised by being focused on outcomes considered important to physicians. Cervero RM, Gaines JK. J Contin Educ Health Prof 2015;35:131–8.

ENABLING ACTIVITIES: CASE-BASED LEARNING

Small working groups: six or seven

delegates.

Workstations allowed delegates to view

large images and DICOM series files,

and work through cases together.

Expert faculty on hand to provide

feedback and facilitate group discussion.

REINFORCING ACTIVITIES

Happen after the learning

intervention as follow up.

Post-course confidence levels in

knowledge and skill improved

considerably from pre-course

levels.

Pre-course (n=72)

Post-course (n=76)

Learning objective 1: Describe the history of breast MRI, from NMR to unenhanced and contrast-enhanced MRI.

Learning objective 2: Explain how sensitivity and specificity can be maximised in clinical practice.

CASE STUDY

Using taxonomy of 93 BCTs (behaviour change techniques)

ADHERENCE SUPPORT: WHY DON’T PATIENTS JUST TAKE THEIR MEDS?

Increasing the effectiveness

of adherence interventions

may have a far greater

impact on the health of the

population than any

improvement in specific

medical treatments

Sabate E. Adherence to long-term therapies: evidence for action. Geneva, Switzerland: World Health Organization; 2003.

“ “

DEFINING THE PROBLEM & DESIGNING A SOLUTION:PERSONAL BUT NOT COMPLEX

OGILVY PROPRIETARY CASE

STUDY

AN EVIDENCE-BASED APPROACH TO A PATIENT SUPPORT PROGRAMME: TAXONOMY OF 93 BCTs

1 Goals & planning

2 Feedback & monitoring

3 Social support

4 Shaping knowledge

5 Natural consequences

6 Comparison of behaviour

7 Associations

8 Repetition and substitution

9 Comparison of outcomes

10 Reward and threat

11 Regulation

12 Antecedents

13 Identity

14 Scheduled consequences

15 Self-belief

16 Covert learning

BCTs, behaviour change techniques.Michie S, et al. Ann Behav Med 2013;46:81–95.

KEY BCTs: GOALS & PLANNING

1 Goals & planning

1.1 Goal setting (behaviour)

1.2 Problem solving

1.3 Goal setting (outcome)

1.4 Action planning

1.5 Review behavioural goals

1.6 Discrepancy between current behaviour & goal

1.7 Review outcome goal(s)

1.8 Behavioural contract

1.9 Commitment

OGILVY PROPRIETARY

CASE STUDY

1.4 Action planning

“Prompt detailed planning of performance of the behaviour (must include at least one of context, frequency, duration and intensity). Context may be environmental (physical or social) or internal (physical, emotional or cognitive)”


KEY BCTs: SOCIAL SUPPORT OGILVY PROPRIETARY

CASE STUDY

3 Social support

3.1 Social support (unspecified)

3.2 Social support (practical)

3.3 Social support (emotional)

3.2/3.3 Social support

“Advise on, arrange, or provide practical help/emotional support (e.g. from friends, relatives, colleagues, ‘buddies’ or staff) for performance of the behaviour”


AN EVIDENCE-BASED APPROACH TO A PATIENT SUPPORT PROGRAMME: WHY SHOULD WE PAY ATTENTION TO AUTOMATIC THINKING?

Patient Support Programme frequently

addresses a patient’s ability to think

reflectively.

But 95% of the decisions we make every

day are said to originate from automatic

thinking and habit.

Dolan P, et al. J Econ Psychol 2012;33:264–77.

MessengerIncentivesNormsDefaultsSaliencePrimingAffect CommitmentEgo

MINDSPACE EXAMPLE: MESSENGER OGILVY PROPRIETARY

CASE STUDY

MESSENGER:We are heavily influenced by who communicates information to us

sCHE, severe chronic hand eczema.Dolan P, et al. J Econ Psychol 2012;33:264–77.

MINDSPACE EXAMPLE: NORMS OGILVY PROPRIETARY

CASE STUDY

NORMS:We are strongly influenced by what others do

“Did you know that 50% of

patients decided to …”

“2 out of every 3 patients

prefer...”

Pause & Reflect


MINDSPACE EXAMPLE: COMMITMENT OGILVY PROPRIETARY

CASE STUDY

COMMITMENT: We seek to be consistent with our public promises


RECAP: TWO TAKE-HOME MESSAGES

Intuitive, straightforward instructional model, associated with effective, outcomes-based education

Predisposing–enabling–reinforcing1

Models of behaviour and behaviour change interventions now have a much sounder scientific basis than they used to

93 BCTs: evidence-based2

BCTs, behaviour change techniques.

1. Comprehension, Observation, Motivation

2. Comprehension, Opportunity, Motivation

3. Capability, Observation, Motivation

4. Capability, Opportunity, Motivation

QUESTION #2

What are the three components of the COM-B model?

Reflection, feedback

and debriefings.

Why are these critical

components of

improving

performance?

REFLECTION, FEEDBACK AND DEBRIEFINGS: WHAT’S THE EVIDENCE?

Rafael Nadal

Image courtesy of Pexel.com.

AN EXTRA DAY’S WORK A WEEK

Organisations can improve

individual and team

performance by up to 25%

by conducting effective

team debriefings.

Tannenbaum SI, Cerasoli CP. Hum Factors 2013;55:231–45.

ONE OF THE BEST KNOWN DEBRIEFING FORMATS IS THE US ARMY’S AFTER-ACTION REVIEW

1 What was supposed to happen?

2 What actually happened?

3 Why did it happen?

4 How can we improve next time?

AAR constitutes four simple questions:

AAR, after-action review.

AAR debriefing format has been incorporated

into healthcare education and practice.1

84 neonatal intensive care units participated in

the Vermont Oxford Network Days Delivery

Room Resuscitation audit:

• Of the 84 intensive care units, the audit found

only 19% conducted post-event debriefings2

POST-EVENT DEBRIEFINGS ARE A FOUNDATIONAL BEHAVIOUR OF HIGH-PERFORMING TEAMS

AAR, after-action review.1. Sawyer TL, Deering S. Simul Healthc 2013;8:388–97.2. Edwards EM, et al. Matern Health Neonatol Perinatol 2015;1:2.

Structured reflection and feedback

Post-event debriefing is where learning

comes to consciousness.

FEEDBACK IS FUNDAMENTAL TO LEARNING, BUT FEEDBACK OPPORTUNITIES ARE OFTEN TOO SCARCE

Backwards planning, and

planning structured

reflection & feedback are

priceless. But the plans

are still useless

“ “

THANK YOU

PLANNING IS PRICELESS PLANS ARE USELESS....PLANS ARE USELESS. Why are backwards planning and instructional design priceless in medical education? Jo Varney, Ogilvy Healthworld Thursday

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