Building and Implementing a Comprehensive Educational Program

By Chad Whelan, MD*

A comprehensive educational program usually involves educating the staff as well as the patients.

Staff Education

The role of education in quality improvement is complex. Educational efforts alone do not usually result in major changes in practice, as the other sections of this workbook have made very clear. However, it would be unrealistic to believe that an institution could enact major changes in the attitudes, knowledge, and practices of its staff without some kind of information transfer. How much the success of a quality improvement effort depends on education is contingent on the complexity of the intervention and the baseline knowledge of the key staff members in the areas of interest. For example, if the goal of a quality improvement effort were simply to increase the number of patients with ACS taking an ACE inhibitor, a simple electronic reminder system might be effective, which might not require any education beyond what is stated in the reminder. However, if the goal is to change practice in more substantial ways, particularly if the desired change depends on the acquisition of new knowledge, education takes on a more important role. When developing educational materials for use in a quality improvement project, a few rules should be kept in mind:

1. Direct educational efforts toward imparting both general and institution-specific knowledge, the former to support the initiative and the latter about the practical applications of the interventions (such as familiarity with an order set or institutional policy). The first step in any educational initiative is to define the learning objectives. Specifically noting what it is you want to change in an area, such as knowledge, attitudes, skills, or behaviors. These learning objectives will drive what you teach, how you teach, and how you measure the effects of this initiative.
2. Define the target audience (and the objectives for them). Educating people about what they do not need to know is wasteful, but failing to educate even a few of those who do need to know can undermine the success of the project. Recognize that educational efforts often need to be directed toward people from many professions and with different levels of training and that the objectives and strategies may differ depending on whom you are targeting.
3. Do not reinvent the wheel. In many cases, at least some of the necessary educational materials (especially the general knowledge part) may already exist.
4. Plan the delivery. After creating the objectives and the material, you will need to determine how to deliver the content. Factors that go into this decision include how large and diverse the audience you are trying to reach is. Easy access to training is a key factor. Usually, the most cost effective way to accomplish broad-based training is Internet- or intranet-based learning modules, often augmented with hands-on or lecture ma­te­ri­als. However, even if the educational materials are widely accessible, it might still be difficult to make sure all key personnel participate. Some methods to optimize participation include:
   1. Make participation mandatory for important topics. Mandatory participation is fairly common among nursing, pharmacy, and ancillary staff and is usually well accepted. It is more difficult to mandate physician staff to participate in educational programs, particularly at institutions that use the open medical staff model, but it may be possible if the education is directed toward a discrete group whose leadership is committed to the project (eg, a residency program). Although mandatory educational programs can assure exposure, they are not always the most effective educational method. You should use mandatory education only when absolutely necessary.
   2. Make the educational program as enjoyable as possible. Regardless of whether the training is mandatory, educational programs are more effective if they are concise, clear, case based, and interactive. If the learning objectives are stated to affect behavior, make sure that the program does not simply provide education aimed at improving knowledge, but also provides specific guidance about how to change the behavior.
   3. Create other incentives for participating if the education cannot be made mandatory. The incentives offered usually depend on the resources available. Hospitalist groups or other providers may get recognition or a competitive advantage for certification or full participation in training. CME, CEU, and Pharmacy educational credits may by valuable for many learners. Remember, food can be a very cost-effective and effective incentive.
5. Evaluate and track the participation and performance of staff in the educational program and the impact of the educational program as a whole. Even the best educational module will have no effect on those not exposed to it. Keeping track of who has and has not been educated will allow the latter to be identified for special intervention. If the process is mandatory, the intervention might be disciplinary, but even for nonmandatory programs, the QI team might be able to come up with innovative ways of making sure that everyone is educated. For examples, members of the QI team could provide abbreviated, one-on-one education for noncompliant members of the target group (academic detailing). The worst-case scenario would be to post an educational module on the Internet and just assume that everyone has completed it. Likewise, it is important not to equate participation with performance. You should always consider evaluating performance, and this evaluation should again be based on the learning objectives that you initially developed. Modern Web-based learning modules allow evaluation of performance on questions as well as tracking participation.

In the future, hospitals might require completion of some educational modules as part of the credentialing process for its professionals. Many hospitals already use this type of online education for topics that are mandated by regulatory agencies (such as infection control or fire safety) because they can be tracked and reported. This mechanism is appealing from a QI standpoint, where the success of a project often hinges on the education of many people with diverse backgrounds. However, it is important to remain cautious about relying solely on the mandatory approach, as the effectiveness of these mandatory educational modules may be lessened if they are overused.

Identify the Target Audience and the Learning Objectives

Inpatient ACS management requires a broad educational effort for nearly all nurses, pharmacists, and physicians who see patients in the emergency room, on the medical floors, in the intensive care units, or in the cardiac catheterization lab. Practitioners should stay up to date on the current care practices to ensure they provide the best care for their patients. Much of the core clinical care practices can be reviewed in this Resource Room as well as in the Education Resources section of the Resource Room. It is important to remember that this field can change rapidly, so always verify that you are using updated guidelines and references.
It may also be appropriate to create similar lists for clerks or others who may be part of the project. As you review the objectives and desired core knowledge/skill sets, define again who among your staff needs this training.

Don’t Reinvent the Wheel: What Resources Are Available?

The Education Resources section features links to slide sets and other available educational products.
When choosing from these products, make sure that their learning objectives and target audience overlap with your targets.

Planning the Delivery

We advocate mandatory education for most of those on the inpatient nursing and pharmacy staff who will be relevant to the project. The scheduling and logistics of the educational program can be challenging, but Web-based learning modules can make them easier. It is also worth considering who else might be involved in the implementation of clinical pathways. Personnel like clerks or transporters may play a role in your institution’s pathways. If so, they should be targeted as well. These educational initiatives should address why your are doing what you are proposing.

Mandatory training of all pertinent inpatient staff may not be feasible, but targeting ED physicians, hospitalists, cardiologists, CT surgeons, and residents, if applicable, can go a long way toward having a more standardized and rational mode of ACS care.

Evaluating and Tracking Performance of Staff

Create a roster of all those on staff who needing the training, stratified by type of care provider and whether each person’s participation is mandatory or optional.

To try to evaluate not only participation but also actual performance and comprehension, use questions in your educational program that address core knowledge, skills, attitudes, and behaviors that you hoped to address in your learning objectives. Remember, if your objective is to improve the use of beta-blockers, assessing a clerk’s knowledge of the role of these medications in ACS may have less value than in measuring how that same clerk has learned about the process of assuring beta-blocker use in patients with ACS. Map out the time lines for delivery, and plan incentives/strategies for reaching voluntary participants. The overall impact of your program can be assessed in part by the progress you make toward better glycemic control and reduction of hypoglycemia in your institution. Measuring educational outcomes along the way can serve as important intermediate measures for assessing progress towards success.

Building/Implementing a Comprehensive Educational Program: Patient Education

Patient education is important in the management of ACS, given the complexities involved in the medications used in treating patients post-ACS, as well as the dietary and lifestyle modifications that may be required. A successful patient education program requires the following steps:

1. Assess the patient. To be successful, an educator must assess the learner’s current knowledge, cognitive abilities, and motivation to learn. Nonadherence to medication and treatment regimens is often related to a patient’s health literacy, knowledge level, motivation, and willingness to change, which need to be assessed as part of a comprehensive educational program. Hospitals wishing to achieve excellence in patient education will need to incorporate patient assessment into their educational initiatives.
2. Define what knowledge is essential for the patient to know. ACS education cannot take place solely in the hospital. Trying to teach everything about ACS can easily overwhelm inpatients, especially if comorbidities exist such as diabetes mellitus, hyperlipidemia, and/or hypertension. However, some skills and knowledge are considered essential for patients or their caregivers to understand in order to be able to appropriately manage their disease at home. These essential skills/knowledge for secondary prevention are to:
   • Understand the basic definition of ACS.
   • Understand comorbid conditions and know how to manage the comorbid conditions that affect their coronary disease.
   • Have timely follow-up with the primary care physician and a cardiologist, if indicated.
   • Comply with the discharge medication regimen, even if it is a complex mix of medications.
   • Need to return to the ED for any change in the frequency or severity of symptoms.
3. Decide who will teach the patient. This is really dependent on local variables. Qualified candidates to be primarily responsible for this teaching would include nurses, pharmacists, or physicians.
4. Teach the teachers. The best way to ensure that hospitalized patients will learn what they need to know is to standardize the educational process.
5. Decide what will trigger the educational effort. Will it be done for all patients with ACS? Will it be reserved only for those with “special needs” or multiple medications? What mechanism will be used to ensure every patient gets the education he or she needs?
6. Make sure the educational program has been successful. Just as patients must be assessed before an educational effort, they must also be assessed afterward to make sure they can demonstrate mastery of the new knowledge or skills.