Building and Implementing a Comprehensive Educational Program

Dave Wesorick, Cherri Lattimer, Nancy Skinner, Robert Rushakoff, Greg Maynard

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 resource room have made very clear. However, it would be ridiculous 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. For example, if the goal of a quality improvement effort were simply to increase the number of patients with heart failure 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).
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. Identify educational objectives that are both general and institution specific for each component of the audience.
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. Creating the educational materials is the easy part. The hard part is assuring that the content finds its way into the knowledge base of all the right people. If the project is small (eg, focused on only a single unit or service), this is less of an issue. But for bigger projects (eg, spanning an entire institution), getting the message to everyone can be difficult. 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).
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.
3. Create other incentives for participating, if the education cannot be made mandatory. The incentives offered usually depend on the resources available. An example of a common incentive is offering an educational presentation as part of a program that includes a nice dinner. 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.
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. 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, diverse people.

Now how might this framework be applied in the context of a quality improvement project aimed at improving the management of diabetes and hyperglycemia in inpatients

Identify the Target Audience and the Learning Objectives
Inpatient glycemic control and prevention of hypoglycemia require a broad educational effort for nearly all nurses, pharmacists, and physicians.

Objectives for Physicians

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, Teaching and Learning slide sets section of the SHM Glycemic Control Resource Room features a PowerPoint-based educational module for physicians/pharmacists outlining the best practice for the management of diabetes and hyperglycemia in the hospital patient. Soon, we hope to have these available in a more interactive learner–based format, where participation and performance on questions can be tracked. For now, they can be reviewed for self-education or downloaded and/or modified to educate others. Similarly, a host of resources are available that provide information about the use of insulin and the management of diabetes and hyperglycemia in the hospital (see the Education Resources section of the resource room).

A project whose goal is standardization of the use of subcutaneous insulin in an entire institution would need to provide education for every physician who cares for hospital patients, including house staff, virtually all the nursing staff, many midlevel practitioners, pharmacists, clerks, and others.

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. Scheduling and logistics of the educational program can be challenging, but Web-based learning modules can make them easier.

Mandatory training of all pertinent inpatient staff may not be feasible, but targeting pulmonary critical care physicians, hospitalists, and cardiologists/CT surgeons can go a long way toward having a more standardized and rational mode of hyperglycemia 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 areas. 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.

Building/Implementing a Comprehensive Educational Program: Patient Education
Patient education is especially important in the management of diseases like diabetes for which self-management is the rule. Creating a comprehensive inpatient educational program about diabetes and hyperglycemia is a complex task that must include the following steps:

1. Assess the patient.
2. Define which knowledge is essential for the patient.
3. Decide who will teach the patient.
4. Teach the teachers.
5. Decide what will trigger the educational effort.
6. Make sure the educational program has been successful.

1. Assess the patient. To be successful, an educator must assess the learner’s current knowledge, cognitive abilities, and motivation to learn. A health care professional cannot simply walk into a patient’s room and begin lecturing on diabetes (or any topic). Rather, first assess what the patient already knows and is able (and willing) 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. With changes in a patient’s disease status, living circumstances, therapies, and other adherence-related factors come expected changes in both knowledge and motivation. Hospitals wishing to achieve excellence in patient education will need to incorporate patient assessment into their educational initiatives. More information and tools pertaining to patient assessment can be found in the Case Management Society of America’s Case Management Adherence Guidelines and at the CMAG Web site.
2. Define what knowledge is essential for the patient to know. Diabetes education cannot take place solely in the hospital. Trying to teach everything about diabetes can easily overwhelm inpatients, especially if diabetes is not the primary reason for the hospitalization. However, some skills and knowledge are considered essential for patients or their caregivers to understand to be able to appropriately manage their diabetes/hyperglycemia at home. These essential skills/knowledge are to:
   • Understand the basic definition of diabetes.
   • Understand how to manage diabetes medications, including injecting insulin, with special emphasis on any changes made to a prior regimen.
   • Understand how to monitor blood glucose.
   • Understand how to recognize and respond to low and high blood glucose measurements.
   • Understand when to call the managing physician or go to the emergency room.
   Ideally, each hospital would identify the essential diabetes information that all patients must know and use this foundation of knowledge to build a patient education tool that allows both an educational assessment of the patient and documentation of the education. One such educational tool is the diabetes patient education record. Many online resources provide high-quality information for patient education. Some of these can be found in the Education Resources, Patient Education section of the resource room.
3. Decide who will teach the patient. Although it would be ideal for the patient’s nurse to do all the teaching, many nurses lack the expertise to do this well. Some hospitals try to get around this problem by hiring trained diabetes educators to teach patients. However, there are often so many patients with diabetes/hyperglycemia that it overwhelms the few educators available. Therefore, it is likely that hospitals will need to develop programs to ensure that nurses can educate patients, not about every aspect of diabetes, but about the essentials. Hospital patients should also have access to trained diabetes educators for situations that require more sophisticated teaching (eg, a new diagnosis).
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. As noted above, the first step is to identify who will be the patient’s educator. These educators (usually nurses) must then be given the knowledge and tools they need to educate patients in a standardized way. Therefore, providing excellent education to patients in most hospitals depends on providing excellent education to nurses. Nursing education in this area will be enhanced by tools to standardize the educational approach (such as the diabetes patient education record, on the following page).
5. Decide what will trigger the educational effort. Will it be done for all patients with diabetes? Will it be reserved only for those with new diagnoses or “special needs”? 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.