1 Introduction
For safe and high-quality healthcare, the people working in the system need diverse expertise – including but not limited to the fundamental technical skills required to implement a best practice and adapt as needed,Reference Barsuk, Cohen, Feinglass, McGaghie and Wayne1 teamwork skills to coordinate care,Reference Schmutz, Meier and Manser2 the attitudes and behaviours underlying a robust safety culture,Reference Halligan and Zecevic3 and the leadership skills to bring about change and improvement.Reference McFadden, Stock and Gowen4 Education and training are therefore foundational approaches in healthcare improvement.
Education and training both describe the systematic provision of instruction intended to teach new competencies (knowledge, skills, and attitudes) to learners. Education generally refers to broader and more fundamental instruction taking place within degree-granting and continuing education programmes. Training refers to instruction with a narrower scope, targeting competencies within a specific task, technology, or improvement project. In this Element, our primary focus is on training as a component of interventions aimed at specific healthcare improvement efforts, though we do also consider broader education within the health professions.Reference Cooke, Ironside and Ogrinc5 Our emphasis is on evidence-based practices of training design, implementation, and evaluation.
In the following sections, we:
identify historical and current trends in the science and practice of education and training for quality and safety
detail evidence-based principles and practices for developing, implementing, and evaluating training interventions
provide case examples of how education and training have been applied to healthcare improvement efforts
critically examine the current state of research and practice, highlighting productive avenues for future research and innovation.
2 A Brief History of Training Research
Multidisciplinary improvement studies and professional education research literatures have generated a broad and deep knowledge base. A complete overview of this topic would fill many volumes on specific topics such as needs analysis, evaluation,Reference McGaghie, Hinkamp and Harden6 specific learning strategies,Reference Ritter, Nerb, Lehtinen and O’Shea7, Reference Nestel, Kelly, Jolly and Watson8 and overall systems of trainingReference Kraiger, Passmore, NRd and Malvezzi9 and educational designReference Thomas, Kern, Hughes and Chen10, and is beyond the scope of this Element. Here, we review some key trends in this research and then briefly summarise developments in education and training for healthcare improvement.
2.1 Trends in Training Research
Researchers have studied training in organisations widely for over a century.Reference Bell, Tannenbaum, Ford, Noe and Kraiger11 Early efforts were less than ideal: a landmark review characterised the state of the research up to 1970 as ‘voluminous, nonempirical, nontheoretical, poorly written, and dull’.Reference Campbell12 Much has changed in the past 50 years, and there is now a rich theory-driven and empirical literature to inform the development, implementation, and evaluation of education and training programmes.Reference Salas and Cannon-Bowers13–Reference Salas, Stagl and Locke18 Practical implications of this work are discussed in detail in Section 3. Next, we highlight four key trends.
First, early research on training evaluation focused heavily on trainee reactions (e.g. self-reported learner perceptions of the training). This slowed down progress in the field; training reactions demonstrate negligible associations with outcomes of more value to organisations, such as behaviour change and improved performanceReference Alliger, Tannenbaum, Bennett, Traver and Shotland19 and are more related to learner characteristics (e.g. motivation to learn, anxiety) than to the training itself.20 Over time, researchers have grown more sophisticated in how they view training effectiveness, with a focus on its multidimensional, multilevel, and dynamic nature (Box 1).
Multidimensional: cognitive (e.g. knowledge, strategies), skill or behavioural (e.g. psychomotor or procedural skills), and affective (e.g. reactions to training, attitudinal changes) outcomes based on the objectives of a training programme. Often, training will target multiple dimensions concurrently.
Multilevel: impact of training individuals, teams, and larger organisational units is assessed. Assessing the impact on overall organisational performance remains a critical challenge for the field.Reference Schmutz, Meier and Manser2Reference Barsuk, Cohen, Feinglass, McGaghie and Wayne1
Dynamic: outcomes may change at different rates and therefore should be looked at over different timescales. For example, evaluation of team training interventions in healthcare indicates faster improvements for cognitive and behavioural outcomes, but slower changes for attitudinal outcomes (e.g. it takes longer for learners to adjust their beliefs in the importance of teamwork or team cohesion).Reference Hughes, Gregory and Joseph22
Second, it is now clear that education and training outcomes are influenced by a wide range of learner characteristics, including motivation, self-efficacy, goal orientation, age, cognitive ability, values and perceptions of organisational support and climate, among many others.Reference Bell, Tannenbaum, Ford, Noe and Kraiger11, Reference Kraiger and Ford17 As a result, strategies to adapt training design for the unique characteristics of learners or to allow for increased learner control over their experiences have been developed. Self-directed learning, where learners take an active role in planning and executing their own training, is at least as effective as more traditional methods.Reference Murad, Coto-Yglesias, Varkey, Prokop and Murad23 However, the focus on learner characteristics has also resulted in notable missteps. Specifically, the strategy of accommodating different learner styles (e.g. preferences for learning modalities – the way in which individuals receive, give, and store information), while often deployed, lacks empirical support. People do consistently express preferences for different learning modalities, but aligning learning modalities with different preferences does not result in better learning outcomes.Reference Aslaksen and Lorås24, Reference Aslaksen and Loras25
Third, the importance of context is increasingly well recognised: education and training do not occur in a vacuum. Factors within organisations – such as peer and leader support, culture, and opportunities to apply what was learned – impact on training effectiveness,Reference Kraiger and Ford17, Reference Baldwin and Magjuka26 for example, by affecting learners’ pre-training and post-training motivation.Reference Kraiger and Ford17 What happens in the learning environment (e.g. classroom, simulation centre, and online learning platform) is important, but what happens to learners before and after a training session matters just as much, and a comprehensive approach to managing training effectiveness needs to account for this. This has led training researchers to call for systems-based approaches to managing training design and delivery.
Fourth, decades of empirical work and theory development have yielded a broad evidence base to guide training design. Multiple versions of integrated instructional principles and methods now exist,Reference Ford, Baldwin and Prasad15–Reference Kraiger and Ford17, Reference Salas27 but they share many commonalities as they translate the same evidence base into practical approaches to training design. One such practically focused synthesis of the training literature is presented in Section 3, where we describe five pillars of effective training.
2.2 Recent Trends in Training to Improve the Quality and Safety of Healthcare
The increased emphasis on healthcare quality and safety in policy, practice, and research over the past couple of decades has been accompanied by reform and modernisation initiatives in health profession education. At the same time, a wide variety of training programmes have emerged seeking to target quality and safety-related competencies, both broad, such as communication and safety culture, and narrow, such as protocols for reducing risks of specific preventable harms.
One important move involves incorporation of quality and safety-related competencies into overall professional competency models and professional development.Reference Wong, Etchells, Kuper, Levinson and Shojania28 Competency models are specifications of knowledge, skills, abilities, and other characteristics required for effective performance in a specific job, role, or task.Reference Campion, Fink and Ruggeberg29 Training can be, for example, on systems-based care, evidence-based practice, or interprofessional communication and teamwork.Reference Moran, Harris and Valenta30, Reference Langins and Borgermans31 Overall, increased formalisation of safety and quality-related competencies is a positive development. However, initial efforts to define quality and safety-related competencies occurred within particular disciplines or geographical areas, resulting in inconsistent content and terminology.Reference Moran, Harris and Valenta30, Reference Tregunno, Ginsburg, Clarke and Norton32 More recent efforts have focused on developing international and interprofessional competencies for general areas like evidence-based practice,Reference Albarqouni, Hoffmann and Straus33 as well as competencies related to specific types or sources of preventable harm, such as diagnostic error.Reference Olson, Rencic and Cosby34 The quality and integration of these competency models are improving, with many resources to support them available. The process of developing and integrating competency models is still not complete and is likely to continue to mature while major questions – for example, about the extent to which there should be standards for all or a mix of standardised and unique competencies capturing the diverse work of different professionals – are addressed.
Another trend seen is in the growth of healthcare improvement projects intended to integrate quality and safety competencies into undergraduate and graduate health professional education.Reference Mathura, Lee, Thompson, McMurtry and Kassam35, Reference Brown, Lafreniere and Freedman36 When disconnected from clinical care delivery, these projects may limit both the learning opportunities and organisational benefit.Reference Wong, Baum and Headrick37 Recent approaches seek to more tightly couple educational improvement projects and organisational priorities. This is achieved through broader stakeholder engagement and participation, including both health system leadersReference Durstenfeld, Statman and Carney38 and patientsReference Wahlberg, Burnett and Muthukrishnan39 and through tighter linkage between formalised quality and safety curricula and practice-based learning experiences within organisations.Reference Chen, Wolpaw and Vande Vusse40 The gap between educational programmes and clinical care delivery systems has not been closed, but there is progress.
Recent years have also seen the expansion of the modes through which training is delivered and made accessible. Quality and safety training can take many forms, including those that are information-based (such as traditional lectures), demonstration-based (such as video-based examples, role-modelling), or practice-based (such as simulation-based training) methods.Reference Rosen, Salas and Pavlas41 The rise of simulation-based training has been a notable feature of recent years (see the Element on simulation as an improvement techniqueReference Brazil, Purdy and Bajaj42). Immersive and interactive experiential learning is a powerful approach, but is resource-intensive, requiring significant investments in infrastructure, such as physical space, costly simulators, and faculty development. Many professionals lack the opportunity to participate in high-fidelity simulations, so scalable and cost-effective methods of simulation-based training for both high-resource and low-resource settings are an active area of development. For example, team training programmes often employ in-person simulation-based training, but one possible way of increasing scalability is to replace practice with demonstration (i.e. videos of simulations) and debriefing.Reference Goodwin, Velasquez and Ross43 Other strategies to improve accessibility of learning opportunities include embedded and real-time or ‘just-in-time’ training (extremely brief reviews of content provided as needed in the work environmentReference Branzetti, Adedipe and Gittinger44, Reference Nishisaki, Donoghue and Colborn45). The COVID-19 pandemic posed several challenges to traditional education and training delivery approaches – limitations on in-person gatherings, a rapid pace of change as best practice evolved – and consequently accelerated the adoption of these ‘just in time’ learning approaches.Reference Clarke, Haze and Sly46, Reference Thompson, Lin and Faithfull-Byrne47
A further major trend has been the recognition of the role of organisations in preparing their managers and leaders for the specialised expertise needed to support healthcare improvement.Reference Pronovost and Marsteller48 Hospitals and health systems have increasingly become more active in this regard, for example, by formalising competencies across roles and areas of the organisation and ensuring everyone has the skills they need to fulfil their role. Management skills for healthcare improvement involve fluency with a wide range of process modelling and analysis tools, improvement cycles, financial planning, and programme evaluation methods, among others.Reference O’Leary, Afsar-Manesh, Budnitz, Dunn and Myers49, Reference Vana, Vottero and Christie-McAuliffe50
Leadership for healthcare improvement requires a specific skillset that includes the ability to engage with others intellectually and emotionally, create a shared vision, negotiation, and conflict management. Important here is the distinction between ‘hard’ and ‘soft’ skillsReference Myers, Lane-Fall and Perfetti51 in healthcare improvement education and training, which is consistent with many long-standing distinctions in the organisational sciences such as Heifetz’s technical work (problems with relatively clear solutions that can be arrived at with existing knowledge of experts) and adaptive work (problems requiring developing novel solutions),Reference Heifetz and Laurie52 or Kotter’s definitions of management (an organisation’s approach to complexity) and leadership (an organisation’s approach to change).Reference Kotter53 For both management and leadership, there is nothing easy about ‘soft’ skillsReference Goldman and Wong54: they are often among the most challenging competencies to master.
3 How Can Education and Training Be Used to Support Healthcare Improvement?
In this section, we describe the core elements of training design and the application to healthcare improvement. Training is more than a singular event (or series of events, such as a workshop or semester/term-long course): it is a process beginning before a learning event takes place and continuing beyond the event’s conclusion. Much needs to happen before, during, and after the learning event to maximise a training programme’s usefulness, applicability, and effectiveness. Salas and colleaguesReference Salas27 extracted five unifying themes from thousands of published best practices. Taken together, these themes – labelled ‘pillars’ – capture fundamental activities that are supported by evidence, as follows:
(1) ensure training is appropriate
(2) create a positive learning environment
(3) design and implement training to be accessible, useable, and effective
(4) evaluate training
(5) transfer and sustain competencies.
These themes are drawn from the broad interdisciplinary literature of the learning sciences; they are not specific to healthcare safety and quality applications but are rooted in theories and principles of human learning. While the safety and quality improvement field grows in the sophistication of its application of this science, recent reviews of training as applied to specific clinical tasks often indicate the existing literature is of low quality, and challenging to synthesise into actionable guidance.Reference Kelly, Redmond and King55, Reference Amaral, Sequeira and Albacar-Riobóo56 Figure 1 depicts the five pillars spanning the before, during, and after stages of training, with important activities under each pillar presented as principles for action in Table 1. These evidence-based principles describe what should happen, and why, throughout the training process. Though we present them in sequential order, the activities within the pillars are, in reality, often iterative and interconnected. For example, results from training evaluation – Pillar 4 – might feed back into understanding training needs – Pillar 1.
Figure 1 An overview of the pillars of training
Table 1 Evidence-based principles for successful healthcare improvement interventions
Pillar 1: Ensure training is appropriate
Principle 1 Conduct a systematic training needs analysis
Principle 2 Confirm that training is an appropriate solution
Pillar 2: Create a positive learning environment
Principle 3 Generate support from organisational leadership
Principle 4 Prepare participants for training
Principle 5 Respect participants’ time and expertise
Pillar 3: Design and implement training to be accessible, useable, and effective
Principle 6 Design training using evidence-based practices
Principle 7 Employ pedagogically sound instructional strategies
Pillar 4: Evaluate training
Principle 8 Decide what to measure
Principle 9 Determine how to measure
Principle 10 Analyse evaluation data to assess training success
Pillar 5: Transfer and sustain competencies
Principle 11 Facilitate the use of competencies in the work environment
Principle 12 Foster continual improvement and use of competencies
Principle 13 Improve training
3.1 Pillar 1: Ensure Training Is Appropriate
Training is a powerful tool in the healthcare improvement toolbox, but it is certainly not the only one. The first pillar is therefore to ensure that training is an appropriate intervention. This involves Principle 1 (conduct a systematic training needs analysis) and Principle 2 (confirm that training is an appropriate solution, or component of a broader solution).
3.1.1 Principle 1: Conduct a Systematic Training Needs Analysis
A needs analysis is the process of collecting relevant information about the organisation, department, or unit experiencing a safety or quality concern, the people involved in the issue, and the tasks related to the problem.Reference Gould, Kelly, White and Chidgey58–Reference Taylor and O’Driscoll60 It informs decisions about what to train, how to train, who to train, and what factors might affect training success. A training needs analysis might build on the results of a root cause analysis by informing the content, scope, and application of a training programme. A needs analysis comprises three main components (see Box 2).Reference Sleezer, Russ-Eft and Gupta61, Reference Brannick, Levine and Morgeson62
Task analysis answers the question: What needs to be trained for? It determines job elements, details task requirements, and identifies the specific competencies (knowledge, skills, and attitudes – KSAs) required to successfully complete a job or task.
Person analysis answers the questions: Who needs to be trained and what are their characteristics? It assesses who has (and who lacks) the competencies needed to perform a task successfully, and it may be used to identify who would most benefit from training and what training approaches might be best for the audience.
Organisational analysis assesses strategic alignment with training and environmental readiness by answering the questions: What are the organisation’s priorities? Is it ready for training? What possible barriers to successful training exist? It is an investigation into the strategies, culture, norms, limitations, resources, and stakeholder (e.g. leadership, frontline staff, and patients) support of training. An organisational analysis does not have to be a system-wide investigation; it may be limited to understanding the dynamics in a specific unit or department within a hospital or practice system.
3.1.2 Principle 2: Confirm That Training Is an Appropriate Solution
Deciding whether training is appropriate as a primary or supplementary intervention to support improvement is critical. Though not validated across healthcare broadly, hierarchies of control or intervention effectiveness have been developed across industriesReference Manuele63 and for different types of risks in healthcare including infection preventionReference NIfOSa64 and medication safety.65 For example, the USA’s National Institute for Occupational Safety and Health (NIOSH)’s hierarchy of controls identifies five types of control that can be used to avoid exposures to safety hazards.Reference NIfOSa64 These controls, in decreasing order of effectiveness, include:
elimination (physically removing the hazard)
substitution (replacing the hazard)
engineering (isolating people from the hazard)
administrative (changing the way people work)
personal protective equipment (PPE; providing barriers when encountering the hazard).
Administrative and PPE controls are often used when existing processes do not control hazards particularly well. As such, they are not as effective as other healthcare improvement strategies that require less effort from affected workers. Although training might be used to support or reinforce new procedures related to other types of control (e.g. PPE donning and doffing), training itself falls under the category of administrative control, and is considered a weaker form of intervention. Therefore, healthcare improvement practitioners should critically consider what additional interventions they may pair with training to comprehensively address safety issues. A further consideration is the often resource-intensive nature of training. It can be time-consuming, expensive, and logistically challenging to design, implement, and sustain, and single trainings are often insufficient for long-term change.Reference Nishiyama, Iwami and Murakami66 Therefore, when deciding whether training is appropriate, practitioners need to assess whether resources are available to do it well or whether other options might adequately address the problem.
The validity of the hierarchy of controls concept and its application to healthcare safety and quality is not universally accepted,Reference Liberati, Peerally and Dixon-Woods67 and should not be relied on in a rigid manner. However, the core idea is that improving quality and safety requires changing behaviour, that multiple types of interventions can facilitate that behaviour change, and that context will determine which methods, or combination thereof, will be most effective. For example, the long history of improving hand hygiene compliance demonstrates that, while knowledge of and skill performing hand sanitation is important, it is only part of a larger change solution involving foundational system changes (such as changing from soap to alcohol-based agents to reduce the time burden, physically locating sanitising stations to integrate with workflow).Reference Lotfinejad, Peters and Tartari68 These system changes need to be in place before training and other behaviour change interventions can have maximum effect. In practice, determining if, or to what degree, training should be a part of the change effort can be challenging. Task analysis methodsReference Stanton69, participatory design methodsReference Schuler and Namioka70, and help to identify changes to task workflows, technology, physical spaces, or other work system redesigns may be beneficial.
3.2 Pillar 2: Create a Positive Learning Environment
Creating an environment conducive to learning can help in capitalising on training investment. A positive learning environment can be created in several ways, but important principles include generating support from organisational leadership, preparing participants for training, and respecting participants’ time and expertise.
3.2.1 Principle 3: Generate Support from Organisational Leadership
Leadership support for training can take the form of investing financial and non-financial resources into the development, implementation, and sustainment of training initiatives as well as communicating the organisational value of training to learners. Learners’ perceptions of leadership support for a training programme influence their perceptions of that programme’s usefulness and transfer of training.Reference Blume, Ford, Baldwin and Huang71, Reference Lyubovnikova, West, Dawson and West72 Consequently, early involvement of leaders in planning and designing a training intervention is critical. For example, the Comprehensive Unit-based Safety Program (CUSP) is a method for creating safer, higher-quality care through the combination of teamwork, clinical best practice, and safety science.Reference Pronovost, Berenholtz and Needham73, Reference Pitts, Maruthur and Luu74 The CUSP team is interprofessional, consisting of nurses, physicians, facility or unit management, chief quality officers, and patient safety officers, among others. One key to CUSP’s success has been the partnership between frontline providers and senior executives.
3.2.2 Principle 4: Prepare Participants for Training
Training effectiveness is improved when learners understand its purpose, objective, and expected outcomes.Reference Noe, Colquitt and Kraiger75 Participants develop expectations before training, and those with unmet expectations demonstrate lower self-efficacy, motivation, and commitment to using trained competencies on the job.Reference Sitzmann, Bell, Kraiger and Kanar76 Therefore, preparing participants requires communication early and often with them about the training purpose, who is required or invited to participate, why they have been invited, what they will experience, and when and how they will complete training.Reference Salas, Tannenbaum, Kraiger and Smith-Jentsch14 All formal and informal communications should be clear, concise, and frame training positively. For example, training should be presented as an opportunity for growth rather than as punishment for mistakes or errors, and it should be discussed with enthusiasm rather than as an inconvenience. Participants should be encouraged to set quality and safety goals for themselves and their units to engage them prior to training.
3.2.3 Principle 5: Respect Participants’ Time and Expertise
It is important for trainees to:Reference Kraiger and Ford17, Reference Awais Bhatti and Kaur77
understand why they need to learn new competencies
see the relevance of training and how these new competencies will help them, specifically (and not just the organisation)
experience some level of internal motivation
build on their prior knowledge and experiences during training
have some autonomy with directing their own learning.
In addition to Principle 4, it is helpful to establish ground rules in advance of training, particularly if the intervention is in person or takes place with others. Ground rules include framing practice errors positively (as an opportunity to learn what not to do) and suspending judgments of others. Such expectations can facilitate participant self-efficacy, or the belief that they are capable of meeting performance targets.Reference Bandura78
3.3 Pillar 3: Design and Implement Training to Be Accessible, Usable, and Effective
Well-designed training should not present significant barriers or difficulty to participation (accessibility). It should be easy for participants to navigate and straightforward for instructors or facilitators to implement (usability) and promote maximum increases in targeted competencies (effectiveness).
3.3.1 Principle 6: Design Training Using Evidence-Based Practices
Subject matter expertise needed to inform the training content needs to be complemented by instructional design expertise in supporting the design process, including formulating learning objectives, establishing performance criteria, providing controlled learning experiences, conducting performance assessments, and providing helpful feedback.Reference Goldstein and Ford16 Goldstein and FordReference Goldstein and Ford16 provides an expansive overview of the training design and development process. Those using education and training as an improvement strategy should form partnerships with learning or instructional design professionals when integrating training into quality and safety initiatives.
Regardless of who is part of the instructional design team, the most fundamental step is to identify and describe the training goals as well-written learning objectives. Learning objectives state what learners are expected to be able to know, do, or feel upon completion of training.Reference Thomas, Kern, Hughes and Chen10 Learning objectives should be drawn from needs analysis findings (Principle 1), which will inform the content scope (what needs to be trained) for the selected training audience (who needs to be trained). Desired training outcomes may focus on cognitive (knowledge-based), affective (emotion-based), or psychomotor (action/skill-based) changes and learning objectives can range in complexity. For example, cognitive learning may involve rote knowledge recall, comprehending new facts, applying facts to novel situations, analysing information into component parts, evaluating information and ideas for validity and quality, or synthesising information to build new understanding.Reference Bloom79, Reference Krathwohl80 For these reasons, it can be difficult to write clear learning objectives. Many resources exist that offer guidance for crafting concrete and measurable objectives.Reference Chatterjee and Corral81
Once finalised, learning objectives identify the specific competencies to be addressed in the training programme. Competencies are the required knowledge, skills, and attitudes (KSAs) an individual must possess to complete a particular task. Many examples of these competency models exist for healthcare quality and safety.
The Health Professions Education: A Bridge to Quality reportReference Knebel and Greiner82 was produced in response to the Institute of Medicine’s 2001 call for an interdisciplinary summit to outline reforms for health professional education to meet the challenges outlined in the Crossing the Quality Chasm Report.83 The panel advocated that all health professional education programmes should prepare individuals to:
provide patient-centred care
work in interdisciplinary teams
employ evidence-based practice
apply quality improvement
use informatics.
In 2006, the Canadian Patient Safety Institute (CPSI) designed The Safety Competencies for healthcare professionals.Reference Ritter, Nerb, Lehtinen and O’Shea7, Reference Olson, Rencic and Cosby34, Reference Wong, Baum and Headrick37 The revised framework incorporates six patient safety domains:
patient safety culture
teamwork
communication
safety, risk, and quality improvement
optimise human and system factors
recognise, respond to, and disclose patient safety incidents.84
Under this framework, CPSI has identified numerous key and enabling competencies related to each of these six patient safety domains. The enabling competency statements describe concrete, measurable, and specific KSAs relevant to each of the patient safety domains which can be mapped to training programme learning objectives to facilitate a robust, evidence-based curriculum.
3.3.2 Principle 7: Employ Pedagogically Sound Instructional Strategies
Instructional strategies refer to the tools, methods, and context used in forming an overall approach to training delivery. A thorough training strategy incorporates four methods to guide, teach, and prepare learners, with each method strategically building on the other:
information
demonstration
practice
feedback.Reference Salas and Cannon-Bowers13, Reference Salas, Tannenbaum, Kraiger and Smith-Jentsch14
Training should provide the necessary information that learners need to be able to perform at a minimally acceptable level of competency. Precisely what and how much information is needed will be driven by needs analysis findings, but should always be made meaningful to learners. In the case of adult learners, it is critical, for example, that information is job-relevant and builds on their current expertise and experience – otherwise, training may lose their attention or waste their time. Beyond information, demonstration allows learners to observe behaviours, their results, and contextual cues. Social learning theory suggests that new behaviours can be learned by observing and imitating others.Reference Bandura85 Positive demonstrations showcase proficiency with a competency, while negative demonstrations show what does not work well. Both types allow learners to analyse behaviour and emulate what works and avoid what does not. Moreover, demonstration-based learning can be interactive, allowing training participants to discuss and analyse together the successes and failures of the models they observe.
Observation and information alone are unlikely to be sufficient strategies for helping learners reach proficiency with a competency: most KSAs require some amount of practice to master. Opportunities to enable learners to experiment with different behaviours and refine their own performance are therefore important. Practice in low-stakes environments where errors have minimal consequences are ideal situations for learners still new to a competency. Learners with more proficiency may benefit from higher-stakes practice situations in which they can be challenged to improve their performance under different stressors. Key to successful practice opportunities, no matter how novice the learner, is ensuring that the learning environment is physically and psychologically safe.Reference Noe, Colquitt and Kraiger75
Finally, constructive feedback – reinforcing, or corrective – is a critical complement to practice.Reference Noe, Colquitt and Kraiger75 Reinforcing feedback confirms for the learner the desirability of their performance. Corrective feedback explains what was flawed about a learner’s performance and offers suggestions for improvement. Some forms of training actively encourage mistakes to test competency progression and enhance learning. Error management training (EMT), for example, is a highly effective method that encourages trainees to explore their performance and make errors.Reference D’Angelo and Kchir86–Reference Metcalfe88 Errors are considered an expected consequence of active learning and can help instructors and learners identify competency gaps. An expected practical outcome of EMT is that trainees will learn how to manage errors in the moment.
In summary, practising newly learned KSAs in a physically and psychologically safe environment where learners can observe and interact with each other while receiving feedback from content experts, instructors, and peers helps to maximise learning.Reference Noe, Colquitt and Kraiger75
3.4 Pillar 4: Evaluate Training
Evaluation, the systematic collection of data to assess training effectiveness, informs understanding of whether quality and safety competencies have improved and how far change can be attributed to the training programme. Evaluation can refer to the effectiveness of the programme itself, where a training programme’s strengths, weaknesses and usefulness for meeting organisational objectives are assessed. Evaluation can also refer to the learners, where assessing growth in participants’ competencies allows for more targeted feedback or remediation tailored to participants’ unique needs. These aims are important to articulate at the outset of evaluation planning, as they will drive choices of what and how to measure. The evaluation strategy should be developed and implemented alongside the training itself. Evaluation metrics should match learning objectives and capture specific KSAs. We offer three additional principles to guide evaluation strategies: Principle 8: Decide what to measure, Principle 9: Decide how to measure, and Principle 10: Analyse evaluation data to infer training success.
3.4.1 Principle 8: Decide What to Measure
Evaluation frameworks guide evaluation planning. Although many have been described, Kirkpatrick’sReference Kirkpatrick89, Reference Kirkpatrick90 is among the most commonly used. It comprises four evaluation criteria domains:
reactions
learning
transfer
results.
Reactions refer to learners’ attitudes towards the training programme, such as enjoyment (i.e. training satisfaction) and perceived usefulness (i.e. beliefs that they gained important new KSAs). Learning refers to changes in targeted competencies because of training participation. Often, learning assessment is where many training evaluations begin and end, but the next level of evaluation criteria, transfer, will be critically important for patient safety improvement initiatives. Transfer (also known as behaviours) describes learners’ application of new patient safety competencies to their work environment. Results refer to the organisational benefit achieved because of training. Results expected from patient safety training initiatives might include improved workflow, reduced burnout, shorter hospital length of stay, or any other number of desirable outcomes. Typically, results only manifest when acquired competencies are transferred to the work environment. Results can include patient outcomes, though including measures more proximal to the behaviour change in addition to patient outcomes is advisable. Phillips extended Kirkpatrick’s model by including a ‘return on investment’ (ROI) domain,Reference Phillips91–Reference Phillips, Phillips, Silber, Foshay and Watkins93 a measure of how much the organisation saves on costs as a result of training. The ROI is frequently driven by results (e.g. fewer medical errors or malpractice lawsuits).
These training outcomes can be measured in several ways. Good, content-relevant measures will inform performance diagnosis (i.e. understanding the reasons why behaviour may or may not have changed) and meaningful and constructive feedback. Measurement can be useful before and during (not only after) training, particularly during practice opportunities. Measures that target the specific competencies framed in the objectives will offer the most precise estimate of the training’s usefulness. Similarly, organisational results should be linked to training learning objectives. For example, if training was intended to help providers navigate an electronic health record more efficiently, it may be reasonable to expect a decrease in burnout in the long term. However, it may be less appropriate to expect a reduction in surgical site infections.
3.4.2 Principle 9: Decide How to Measure
When thinking about what to measure, it is easy to begin to consider how it will be measured. As with the other principles, choosing how to measure should be tied to what, precisely, it is that training is intended to improve. Section 2.1 introduced training evaluation outcomes. Some types of learning outcomes lend themselves naturally to certain measurement methods. For example, data on training reactions (i.e. learners’ perceptions of the quality and value of the learning experience, and their ability to apply what they’ve learned) may be suited to self-reported responses to Likert-style rating scales (i.e. standard surveys). Learning – the knowledge, skills, and attitudes changed by the learning experience – may be captured using some form of declarative knowledge or situation judgement test (i.e. specialised surveys asking people how they would respond in different situations).Reference Patterson, Zibarras and Ashworth94 Learning and transfer can be measured observationally, either during simulation exercises or on the job through trained observers, supervisors, or peer assessments.
Measures that capture both outcomes and processes are also important. Changes in processes often precede changes in outcomes, so measuring both will give a finer understanding of where quality and safety competencies are being enacted. In a systematic review of the literature, Okuyama and colleagues identified 34 published tools for assessing patient safety competencies, including teamwork, risk management, and communication.Reference Okuyama, Martowirono and Bijnen95 Choosing validated measures aligned to targeted KSAs (Principle 6) from among this toolkit of existing metrics is a good starting point for developing a training programme evaluation plan.
3.4.3 Principle 10: Analyse Evaluation Data to Assess Training Success
After collecting various types of evaluation criteria (e.g. reactions, learning, transfer, and results, see Principle 9), data can be used to understand whether training has been successful and why. The descriptive and analytical methods appropriate for assessing training success will depend on the types of data collected and the goals of analysis. For more details on precisely how to use statistical methods to analyse training evaluation data, see references such as Philips and Philips.Reference Phillips and Phillips92 The interpretation of the findings will guide the next steps (e.g. sustaining new competencies, strengthening the training programme).
3.5 Pillar 5: Transfer and Sustain Competencies
While structured training events have a distinct start and end point, the learning process is ongoing, involving competency transfer to new environments, repetition to strengthen newly formed skills and attitudes, and continued use or refreshers to sustain performance. The following three principles support transfer and sustainability.
3.5.1 Principle 11: Facilitate the Use of Competencies in the Work Environment
Learning without transfer to the work environment does not secure improvement, but transfer is not an automatic extension of learning. Special effort must be made to promote the application and adoption of new competencies at work.Reference Blume, Ford, Baldwin and Huang71 Encouraging the application of trained KSAs requires organisational support – even a single disparaging comment about training (e.g. ‘That was a waste of your time’) can halt transfer.Reference Smith-Jentsch, Salas and Brannick96 Therefore, healthcare improvement practitioners, organisational leadership, and unit management need to be highly intentional in encouraging, reinforcing, and even modelling the desired behaviours. Such behaviours send strong signals about what is expected in the organisation, increasing the likelihood that similar behaviours will be adopted by other employees.Reference Morgenroth, Ryan and Peters97
A lack of opportunities to use new skills is one of the strongest barriers to transfer.Reference Clarke98 Learners need to be given plenty of opportunities to use their new KSAs, as otherwise skill decay may occur.Reference Burke and Hutchins99 Feedback remains important in transferring KSAs, as well as creating comfort and dexterity with them. Even though these opportunities may be real-life events and not simply ‘practice’ opportunities, learners need to be encouraged to voice questions or comments regarding the appropriate use of KSAs. Practice should be as soon as possible after training events. Where it is not possible to practice immediately, for example, if training is intended to address competencies needed during rare events, dialogue may be important to preventing decay.
3.5.2 Principle 12: Foster Continuous Improvement and Use of Competencies
Training may, in principle, create long-term or permanent changes in competencies. But sustaining newly acquired KSAs requires consistent use, reinforcement, and correction to mitigate skill decay.Reference Lazzara, Benishek and Hughes100 The beneficial impact of training can be sustained for a longer duration with regular attention to performance through strategies like team debriefings and reward systems.Reference Kraiger and Ford17 Debriefings are meetings during which employees can evaluate their performance as a team, offering suggestions for improvement and recognising successful use of KSAs.Reference Lee, Lee and Kim101 Recognition can be a powerful driver for perpetuating desired behaviour.Reference Rai, Ghosh, Chauhan and Singh102 Showcasing ‘bright spots’ (teams or individuals who have done an exceptional job demonstrating valued competencies) can reinforce behaviour among both individuals being recognised and other organisational members. Finally, embedding quality and safety competencies as part of the organisational reward structure can also help promote long-term sustainment of competencies. Recognising and promoting individuals based on safe practice helps to formalise performance expectations.
3.5.3 Principle 13: Improve Training
Data collected from training evaluation may point to weak spots within the training curriculum itself. Perhaps the programme was not well-suited to the audience (either because the learning objectives were too simple or too advanced) or minimal shifts in learning, transfer, or results were seen. It will be critical to assess whether failures to see desired outcomes are due to the training curriculum or some other explanation (e.g. an incompatible organisational culture). Updating training format, methods, and content in response to evaluation findings may be an ongoing, but necessary, process. Otherwise, using inadequate or outdated training curricula becomes a waste of organisational resources. While often an informal learning process, several formal approaches for training redesign and continuous improvement have been proposed. These include methods that incorporate content experts’ ratings of the importance of competencies included in training, and cyclically re-establishing training needs to ensure existing training is addressing those needs.Reference Ford and Wroten103
4 Education and Training in Action
The principles detailed previously outline a rigorous and evidence-based approach to training design. In this section, we describe two cases where education and training played a critical role in a healthcare improvement initiative, illustrating both the importance of education and training and the common challenges faced. They show how, like any design process, training design is often iterative, adapted to manage constraints, and deviates from the idealised process. The first example of the Practical Obstetric Multi-Professional Training (PROMPT) programme describes a pure training intervention (i.e. the main intervention is skill building) which has been widely adopted and evaluated. The second two cases are from the authors’ experience and demonstrate how training is integrated as a part of multicomponent quality and safety improvement interventions.
4.1 Improving Obstetric Emergency Outcomes for Mothers and Babies
The Practical Obstetric Multi-Professional Training programme is an internationally implemented training programme designed to build the individual and team skills needed to effectively respond to obstetric emergencies.Reference Draycott, Sibanda and Owen104 The programme began in 2006 at Southmead Hospital in Bristol, United Kingdom. The course directors of an obstetrics emergency training day conducted a post hoc evaluation of the programme’s impact on maternal and neonatal outcomes, finding substantial improvement across measures in the post-implementation period.105 This programme was further refined and evaluated in the Simulation and Fire-drill Evaluation randomised controlled trial, which demonstrated a positive impact on both team and technical performance.Reference Siassakos, Fox and Crofts106 From there, the PROMPT training was packaged for broader regional, national, and international dissemination.
The appropriateness of training as a solution, and specific competencies targeted (Pillar 1), were initially established through observed gaps in adherence to best practice responses to infrequent but critical obstetric emergencies. Childbirth is a heavily litigated area, and evidence from cases where best practice was not followed has informed the development of PROMPT and similar training programmes.Reference Weiner107 PROMPT focuses on two distinct sets of competencies: evidence-based interventions for the management of obstetric emergencies, and team skills needed to manage these stressful environments and time-critical tasks. The technical competencies include the knowledge and skills required to perform evidence-based best practice care for an annually updated list of conditions such as shoulder dystocia (where one or both shoulders get stuck during labour), neonatal resuscitation, vaginal breach births, maternal sepsis, and cord prolapse. The teamwork skills drew from general principles of crew resource management first introduced in aviation and subsequently adapted and broadly adopted in healthcare.Reference Salas, Rosen and King108
PROMPT employs methods that are both information-based (a comprehensive training guide including information on the evidence behind emergency management) and simulation-based, giving learners the opportunity to practice technical and teamwork skills in a controlled environment, and participate in team debriefs to facilitate learning (Pillar 3).Reference Winter, Crofts, Draycott and Muchatuta109 PROMPT has undergone numerous rigorous evaluations (Pillar 4), and has demonstrated impact on teamwork climate, neonatal outcomes, and maternal outcomes.Reference Shoushtarian, Barnett, McMahon and Ferris110 Somewhat uniquely for training programmes targeting quality and safety, it has also shown financial return on investment (reduction in litigation expenses).Reference Weiner107 Finally, the recommended training model for PROMPT requires annual retraining of 100 per cent of ward staff, emphasising the need to sustain training gains with recurring opportunities to refresh previously learned skills and understand changes to evidence-based management strategies as the underlying literature evolves (Pillar 5). Managing this sustainment over time requires organisational support across many levels of leadership.Reference Ghag, Bahl and Winter111
The success of PROMPT is impressive and encouraging for the value of training as a solution to important quality and safety challenges. A systematic review and meta-analysis of the broader obstetric emergency team training literature indicated mixed evidence and suggested that programmes employing in situ team simulations demonstrated the most benefit.Reference Brogaard, Glerup Lauridsen and Lofgren112 This underscores the importance of choosing appropriate methods of training delivery (Pillar 3).
4.2 Improving Paediatric Cardiopulmonary Resuscitation
Approximately 6,000 children have an in-hospital cardiac arrest every year in the United States. While there have been marked improvements in outcomes in recent years, most children do not survive. However, there are large differences in survival between facilities, indicating potential for improvement. In 2013, the Johns Hopkins Hospital set a goal of improving adherence to the American Heart Association’s Paediatric Advanced Life Support chest compression guidelines. Full details of the programme to achieve this goal are available elsewhere,Reference Hunt, Jeffers and McNamara113 but in the following, we describe the overall programme structure and the critical role training played in achieving consistent increase in the quality of cardiopulmonary resuscitation (CPR) for children.
The healthcare improvement programme began by developing key infrastructure for a learning process. A data surveillance system was created to identify any potential in-hospital cardiac arrests through code button pushes, rapid response team activations, electronic health records, and billing codes for CPR. Subsequently, a data capture system to investigate each potential event and centralise all performance data for events verified to be in-hospital cardiac arrests was created. This infrastructure was key to defining performance gaps, and as a source of evaluation data (Pillar 4). A weekly debriefing meeting was established to discuss all verified cardiac arrest resuscitations from the preceding week, based on the principle that debriefing is an effective method of learning from collective experience.Reference Lee, Lee and Kim101, Reference Keiser and Arthur114 The effectiveness of debriefing relies on establishing a psychological safe learning environment for people to question assumptions and voice their perspectives, which was achieved in these meetings through introductions to the session and debrief facilitation practices aimed at promoting trust and openness (Pillar 2).Reference Kolbe, Eppich and Rudolph115
The data-informed debriefing process was extremely effective at surfacing challenges and generating potential solutions. Over time, these issues and ideas were organised into themes, evaluated for efficacy, and integrated into the ongoing cycle of training and certification for Paediatric Advanced Life Support and other reinforcing training activities (e.g. in situ simulations) if proven effective. Specifically, action-linked phrases, choreography, and ergonomics were three components of the resuscitation quality improvement bundle developed from debrief lessons learned.
First, action-linked phrases combined call-outs (e.g. ‘there’s no pulse’) and task delegation (e.g. ‘start compressions’), two widely recognised patterns of high-functioning teams. This addressed the common pattern observed in resuscitation events where team members would share critical information, but others would fail to respond to it. The effectiveness of training using action-linked phrases was demonstrated in simulation.Reference Hunt, Cruz-Eng and Bradshaw116 Second, choreography involved defining structured plans for how the resuscitation team should interact physically with one another, the room, and their equipment. Variations of choreography were explored in simulations, and a gold standard was established.Reference Sullivan, Duval-Arnould, Perretta, Rosen and Hunt117 A video of this gold standard was created and used in future training sessions. Third, ergonomics of room layouts and equipment were thoroughly assessed, and modifications made where appropriate and practical (e.g. redesign of resuscitation carts).
Action-linked phrases and choreography relied mostly on behavioural competencies of the team members, so training was chosen as a primary intervention in addition to cognitive aids (i.e. graphic and textual depictions of resuscitation algorithms). Training, which included practice opportunities for action-linked phrases, choreography, and ergonomics during simulated resuscitation events, extended learning beyond the group participating in the debrief, as important innovations were codified into new curricula and integrated into existing training opportunities. This served to spread lessons learned as far as possible, but also to minimise the training burden on staff (e.g. a new training programme wasn’t developed, but new learning objectives and competencies were integrated into existing learning opportunities; Pillar 5).
4.3 The Resilience in Stressful Events (RISE) Programme
Health workers involved in adverse events, including medical errors, often experience serious harm themselves. The term ‘second victim’ was first coined in 2000 to describe healthcare providers who are involved in an incident in which a patient is harmed, and who may be emotionally traumatised as a result.Reference Wu118 Common emotional responses include grief, anxiety, guilt, fear, and loss of confidence. Workers may experience flashbacks and disturbed sleep, and symptoms can sometimes progress to post-traumatic stress disorder (PTSD). In the short term, the functioning of affected workers may be impaired, and some may develop burnout. Health workers can also be traumatised by other stressful events, such as a patient’s death, unexpected complication, conflict with family members, or workplace violence.Reference Busch, Scott and Connors119 Studies have found that up to half of workers have experienced the second victim syndrome, and the majority are not supported by their institutions.
To address this gap, in 2011, the Johns Hopkins Hospital instituted the Resilience in Stressful Events (RISE) peer support programme.Reference Edrees, Connors and Paine120 After a stressful patient-related event, health workers can call RISE using the hospital’s intranet or electronic paging system, 24 hours a day, 7 days a week. Peer responders are volunteers who work in the hospital and include a diverse group of nurses, physicians, social workers, chaplains, pharmacists, technicians, first responders, and others. The on-call peer-responder calls back immediately and schedules a meeting. Meetings are often scheduled at the end of a shift, can be in-person or virtual, and can accommodate an individual or a group.Reference Barsuk, Cohen, Feinglass, McGaghie and Wayne1Reference Garavan, McCarthy and Sheehan21 Responders provide psychological first aid and emotional support. The responder also provides information on organisational resources, such as the internal employee assistance programme, or external resources like community counsellors. Encounters are completely confidential, and reports are not shared with managers, risk management, patient safety, or anyone else.
Although responders were people to whom workers naturally gravitated for advice and support, and the programme was designed to be accessible and convenient, in the initial years after the programme launched it received very few calls. In retrospect, there were problems with implementation. After this initial launch, and lower than expected utilisation of the programme, a needs analysis was conducted to understand barriers that may exist to access and use of the RISE programme resources (Pillar 1). Three important barriers to using RISE were identified:
lack of recognition of the high prevalence of the second victim phenomenon in hospital workers
lack of knowledge that the programme exists and is intended for them
the natural aversion of healthcare workers to ask for help, which many have internalised as showing weakness.
At a minimum, taking action to overcome these barriers would have required greater efforts in marketing and education, neither of which was delivered sufficiently in the early programme. In the initial phase of the RISE rollout, some efforts were made to engage staff. Members of the development team delivered presentations at staff meetings on nursing units in the hospital. The presentations featured some of the origin stories for patient safety at the Johns Hopkins Hospital, and how these critical incidents adversely affected providers. While these presentations engaged some of the staff, many more staff members were never reached. After the initial meetings, presentations were not repeated regularly, even on units with the highest patient acuity. Some units never received a formal presentation or other education. Insufficient attention to the engagement and education decreased the likelihood that individuals or their managers would activate RISE when it was needed – the actual execution of the intervention.
Evaluation posed an additional problem (Pillar 4).Reference Connors, Dukhanin, Norvell and Wu122 Because of the potentially sensitive nature of patient adverse events, a top priority for the development team was to emphasise the confidentiality of the programme. The team thought that to use the programme, healthcare workers would need to feel that it was safe. Therefore, the programme did not collect identifying information on callers, and did not follow up systematically. Although this may have been necessary to reassure potential users, it made it impossible to collect representative data on user experience of the programme.
In subsequent years, these barriers received greater attention, and increased efforts were devoted to engaging and educating as many of the healthcare staff at the hospital as possible. RISE and the second victim phenomenon began to get broader attention from hospital leadership and media channels. Screensavers with information about RISE were added to every computer screen in the hospital, to reinforce messages delivered in training (Pillar 5). RISE played an important role following several high-profile adverse events and was recognised for this. The COVID-19 pandemic demonstrated the near-universal prevalence of distress among hospital staff members, and helped to normalise the use of RISE and other supporting resources.Reference Wu, Buckle and Haut121 Marketing and communications teams mounted a campaign to publicise the availability of services and how to reach them. All this led to much greater willingness to call RISE and receive support. Increased emotional engagement of health workers was accompanied by the incorporation of material related to staff wellbeing and support into the formal curriculum. These topics were introduced into the patient safety course taught to every second-year medical student, as well as to some nursing students.Reference Aboumatar, Thompson and Wu123 They were also added to the orientation for new house officers in the major specialties. Optional training in psychological first aid was offered to interns and residents. This alignment of RISE training with existing training programmes was critical for achieving broad awareness.
In summary, RISE was an intervention designed to improve the well-being of healthcare workers, and indirectly the quality of care they deliver, patient safety, and outcomes.Reference Wu124 The implementation of RISE would have benefitted from a more systematic application of the training needs analysis early in its development process. In this case, key elements include identification of barriers to successful implementation and efforts to overcome them.
5 Critiques of Training as an Improvement Approach
Education and training can be powerful tools for change and improvement but have limitations and weaknesses. Some are inherent in the methods (e.g. transfer of training from the learning environment to the work environment is always challenging), and some are related to misuse (e.g. failure to follow evidence-based practices for design and delivery) or abuse (e.g. use of training when it is not the right solution). Next, we explore recurring themes in inherent limitations, misuse, and abuse of education and training as an approach to healthcare improvement and provide thoughts on future directions of research and application to address these challenges and gaps.
5.1 Training Interventions Are Resource-Intensive
Well-developed training that adheres to the principles and practices outlined previously requires several key resources, all of which are scarce and costly. First, expertise in the training development process itself is required. Larger organisations may have skilled instructional designers, programme evaluators, and other educators, but smaller organisations often do not. Second, there is growing empirical literature indicating that the quality of the trainer impacts outcomes.Reference Glerum, Joseph, McKenny and Fritzsche125 Skilled and effective trainers may be a rate-limiting factor in disseminating effective training. Third, and likely to be most important, the end users of training programmes (i.e. the frontline healthcare workforce) are experiencing increased workload, staff shortages, shifting role structures and a rapid pace of change (i.e. the ‘shelf life’ of knowledge and skills is decreasing), and a large volume of updates to evidence-based practices. These factors appear to create conditions where the need for education and training has never been greater, but the available time of staff to participate has never been a scarcer resource.
Future research in this area will involve technology-driven solutions to increase the efficiency of the design, delivery, and evaluation of training. Just-in-time training, particularly pre-procedure simulations, is one means to reduce overall time spent in dedicated training and to minimise the time between learning and performance. While evidence of effectiveness remains sparse, studies suggest this may be an effective and time-saving approach.Reference Patocka, Pandya and Brennan126 The often promised, yet infrequently documented, efficiency gains of artificial intelligence will no doubt occupy researchers for years to come. Applications relevant to training and education include automated training needs analysis (automating the analysis of relevant research, policies and procedure guides to define competencies, and learning objectives), and serving the role of tutors or coaches in personalised and interactive training programmes.Reference Bhatt and Muduli127–Reference Maity129 If proven effective, these approaches could dramatically reduce the burdens of developing and implementing training programmes.
5.2 Alignment across Training Programmes Is Challenging
Education and training programmes are often designed in relative isolation from one another and may fail to connect in important ways. As training programmes grow in number, they should (but frequently fail to) reinforce and elaborate upon one another – for example, when they target related competences. Some progress has been made in consolidating competency models across professions and geography, but much remains to be done. This lack of alignment compounds the challenges of resource scarcity described earlier, as much of the work of training design is replicated across different training programmes instead of pulling from or linking to existing and related resources (e.g. needs analyses or competency models created for different, but very related training efforts).
In addition to continued maturation of quality and safety as concepts in health profession education, future research to address this challenge will have to involve individual organisations creating more sophisticated and integrated strategic approaches to learning, including both formal training and informal learning strategies.Reference Aboumatar, Weaver and Rees130 The solutions to the challenge of alignment involve organisations providing a consolidated and integrated approach to learning and development that informs the design and delivery of each individual learning experience or training event.
5.3 Training Is a Misused and Abused Method
In healthcare improvement, one of the most often violated of the 13 principles introduced in this Element is Principle 2: Confirm that training is the best solution. Despite being resource-intensive, training is often a default response to operational challenges or risks, even when other solutions (e.g. work process, technology, or policy changes) would be more effective. Many times, low-quality training is offered as a poorly conceived solution to a multifaceted problem. Training is, for example, one of the most common recommendations resulting from root cause analysis,Reference Hibbert, Thomas and Deakin131 and often is an action taken for the sake of action, especially as low-quality training that skips many if not all evidence-based design practices can be created and fielded quickly. This has led to the characterisation of training as a low-value improvement method,Reference Soong and Shojania132 but higher-quality training programmes, used more judiciously and focused on clear knowledge, skill, or attitude gaps, would likely have a larger effect.
Future research to address this challenge requires developing more practical methods of task and needs analysis. Many of the traditional methods (e.g. hierarchical task analysis) are time-intensive and may not yield insight into the broader system, where other interventions could more effectively improve overall system performance. Human factors researchers have noted these limitations of current approaches, and research on more effective approaches is ongoing.Reference Holman, Walker and Lansdown133 Additionally, developing reporting standards for training interventions in quality or safety improvement studies will enable synthesis of evidence that could inform more general guidance on the tasks or conditions under which training is most likely to be an effective intervention.
6 Conclusions
Healthcare delivery systems rely on the expertise of dedicated professionals. Formal education and training are central methods for building and maintaining that expertise, and are one of the primary mechanisms that organisations use to cultivate their performance and improvement capacities. Existing literature provides good guidance for how to design, deliver, and evaluate effective training. However, pressures in the workplace are creating the need to rethink how to practically deliver effective learning interventions. But the needs are clear. For developing healthcare improvement professionals and leaders, education programmes are and will remain critical for building the complex set of technical and adaptive capabilities needed to affect change in healthcare settings. For specific healthcare improvement projects, training is often one component of a broader change intervention. Adhering to the evidence-based principles outlined here can help ensure the overall success of the programme.
7 Further Reading
Salas et al.Reference Salas27 provide more specific details on the content in Section 3 of this Element.
Thomas et al.Reference Thomas, Kern, Hughes and Chen10 provide a practical approach to developing curricula for medical education that is broadly applicable to foundational educational activities.
Kraiger and FordReference Kraiger and Ford17 provide a comprehensive review of training studies, and discuss future direction for research as well as offering a synthesis of the science helpful for guiding the development of a strategic learning plan for an organisation.
The Canadian Patient Safety Institute84 report is an example of efforts to integrate patient safety competencies across the health professions.
Kraiger and colleaguesReference Kraiger, Passmore, NRd and Malvezzi9 provide well-researched broad guidance and a valuable resource on many issues in training and development in organisations.
Soong and ShojaniaReference Soong and Shojania132 discuss many of the common misuses and abuses of training as a healthcare improvement method, offering a helpful reminder of what not to do with training and emphasising that training is one of the many tools for improving quality and safety.
LEB, AWW, and MAR contributed to initial outlines, drafting, and editing of the manuscript. AWW and MAR have approved the final version.
Conflicts of Interest
None.
Acknowledgements
We thank the peer reviewers for their insightful comments and recommendations to improve the Element. A list of peer reviewers is published at www.cambridge.org/IQ-peer-reviewers.
Funding
This Element was funded by THIS Institute (The Healthcare Improvement Studies Institute, www.thisinstitute.cam.ac.uk). THIS Institute is strengthening the evidence base for improving the quality and safety of healthcare. THIS Institute is supported by a grant to the University of Cambridge from the Health Foundation – an independent charity committed to bringing about better health and healthcare for people in the United Kingdom.
About the Authors
Lauren E. Benishek was an organisational psychologist and patient safety researcher who focused on the power of relationships to improve wellness and safety. She passed away prior to the final publication of this manuscript and is missed greatly by her colleagues.
Albert W. Wu is a health services researcher studying the impact of safety problems on patients and health care workers, and on patient reported outcomes. He is Director of the Center for Health Services and Outcomes Research (CHSOR), and Editor in Chief of Journal of Patient Safety and Risk Management.
Michael A. Rosen is a human factors psychologist studying how teams and technology enable safe operations. Simulation for both analysis and improvement is central to his work. He is Director of Research at the Armstrong Institute for Patient Safety and Quality, and the Johns Hopkins School of Medicine Simulation Centre.
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Mary Dixon-Woods
THIS Institute (The Healthcare Improvement Studies Institute)
Mary is Director of THIS Institute and is the Health Foundation Professor of Healthcare Improvement Studies in the Department of Public Health and Primary Care at the University of Cambridge. Mary leads a programme of research focused on healthcare improvement, healthcare ethics, and methodological innovation in studying healthcare.
Graham Martin
THIS Institute (The Healthcare Improvement Studies Institute)
Graham is Director of Research at THIS Institute, leading applied research programmes and contributing to the institute’s strategy and development. His research interests are in the organisation and delivery of healthcare, and particularly the role of professionals, managers, and patients and the public in efforts at organisational change.
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THIS Institute (The Healthcare Improvement Studies Institute)
Katrina was Communications Manager at THIS Institute, providing editorial expertise to maximise the impact of THIS Institute’s research findings. She managed the project to produce the series until 2023.
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Sonja Marjanovic
RAND Europe
Sonja is Director of RAND Europe’s healthcare innovation, industry, and policy research. Her work provides decision-makers with evidence and insights to support innovation and improvement in healthcare systems, and to support the translation of innovation into societal benefits for healthcare services and population health.
Tom Ling
RAND Europe
Tom is Head of Evaluation at RAND Europe and President of the European Evaluation Society, leading evaluations and applied research focused on the key challenges facing health services. His current health portfolio includes evaluations of the innovation landscape, quality improvement, communities of practice, patient flow, and service transformation.
Ellen Perry
THIS Institute (The Healthcare Improvement Studies Institute)
Ellen supported the production of the series during 2020–21.
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THIS Institute (The Healthcare Improvement Studies Institute)
Gemma is Senior Communications and Editorial Manager at THIS Institute, responsible for overseeing the production and maximising the impact of the series.
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THIS Institute (The Healthcare Improvement Studies Institute)
Claire is Editorial Project Manager at THIS Institute, responsible for editing and projectmanaging the series.
About the Series
The past decade has seen enormous growth in both activity and research on improvement in healthcare. This series offers a comprehensive and authoritative set of overviews of the different improvement approaches available, exploring the thinking behind them, examining evidence for each approach, and identifying areas of debate.
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