Education and Behavior Change: Measuring the Success of Our Efforts

1. 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

2. Miller’s Pyramid Difficulty Cost 2

3. Vs.

4. Maslow’s Hierarchy of Needs

5. vs.

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

7. 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

8. Miller’s Pyramid Difficulty Cost 8

9. 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

10. 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.

11. Restructuring the Environment • The environment must facilitate the • Learning • Doing • Reinforcing 11

12. The Value of Teams • Relationships are nurturing • Great learning happens in groups • Collaboration is the stuff of growth

13. Why Experiment? Evidence based education! Rigor in educational approaches Improved quality for learners Personal and professional value Elevate the field 13 13

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

15. Behavior Change Through Online Learning

16. 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

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19. Learning Element 19 Page 19

20. 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

21. 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

22. Spaced Education for knowledge

23. Spaced Education for Behavior Change: PSA Screening Am J Prev Med 2010;39(5):472– 478

24. 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 24

25. Adaptive Learning: Treatment of type 2 diabetes

26. 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

27. Behavior Change By Restructuring 27

28. 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

29. 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

30. Team Differences Attending Resident(s) Interns

31. Resident Activity ITU residents spent much more of their time in educational activities than GMS residents **P=0.003

32. ITU Attending Surveys 32

33. Resident Survey Data

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35. Primary Results *O/E = observed to expected; LOS = length of stay

37. Quality of Discharge Summaries Blinded evaluation of 142 random discharge summaries Fraction of reports with all the required elements

38. Press-Ganey Patient Satisfaction Data *None of the GMS vs. ITU differences were significant

39. 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

40. 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

41. Behavior Change By Relationship-Building (on a team that changes every month or more!) 41

42. 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

43. 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

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

45. Interdisciplinary team 45

46. Interdisciplinary Team Two attendings Two residents Three interns Two medical students Nurses Social worker RN Care Coordinator Physical therapist Pharmacy students and faculty supervisor

47. Daily Rounds 2hrs Bedside rounds Resident-led Attending Teaching Patient-grps by nurse

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

49. Simulation Lab Teambuilding Involve multidisciplinary team Practice leadership Illustrate team dynamics Reflect and debrief

50. Sackler Museum Program • Create openness and vulnerability • Illustrate value of differing perspectives • Use art to explore • Team dynamics • Communication styles • Hierarchy • Interdisciplinary relationships