Evaluating Outcomes

Marshall (Mark) Smith, MD, PhDDirector, Simulation and Innovation

Banner Health

Lecture today is adapted from presentation given at last Laerdal SUN meeting by Geoffrey T. Miller, and some of the slides today are used/modified

from that presentation.

Geoffrey T. MillerAssociate Director, Research and Curriculum Development

Division of Pehospital and Emergency HealthcareGordon Center for Research in Medical Education

University of Miami Miller School of Medicine

Acknowledgement and Appreciation

The wisdom of a

group is greater

than that of a

few experts…

Session Aims

• Discuss the importance and use of outcomes

evaluation and challenges to traditional assessments

• Discuss some learning models that facilitate

developing assessments

• Discuss the importance of validity, reliability and

feasibility as it relates to assessment

• Discuss types of assessments and their application in

healthcare education

Evaluation

• Systematic determination of merit, worth, and

significance of something or someone using

criteria against a set of standards.

– Wikipedia, 2009

Assessment

• Educational Assessment is the process of

documenting, usually in measurable terms,

knowledge, skills, attitudes and beliefs.

Assessment can focus on the individual

learner,……– Wikipedia, 2009

Assessment vs Evaluation

• Assessment is about the progress and

achievements of the individual learners

• Evaluation is about the learning program as a

whole

Tovey, 1997

So why measure anything?

Why not just teach?

Measurement

• What is measured, improves

• You Can't Manage What You Don't Measure

• You tend to improve what you measure

Measurement

• Promotes learning

• Allows evaluation of individuals and learning

programs

• Basis of outcomes- or competency-based education

• Documentation of competencies

Measurements in Future

• Credentialing• Privileging • Licensure • Board certification • High stake assessments for practitioners

All involve assessment of competence

What are the challenges today

of traditional methods of

measurement/assessment

for healthcare providers?

Challenges in traditional assessments

• Using actual (sick) patients for evaluation of skills

– Cannot predict nor schedule clinical training events

– Compromise of quality of patient care, safety

– Privacy concerns

– Patient modesty

– Cultural issues

– Prolongation of care (longer procedures, etc)

Challenges in traditional assessments

• Challenges with other models

– Cadaveric tissue models

– Animal models / labs

Challenges in traditional assessments

• Feasibility issues for large-scale examinations

• Standardized, perceived fairness issues in high-stakes

settings

• Standardized patients (SPs) improve reliability, but

validity issues exist: cannot mimic many physical

findings

Challenges in traditional assessments

• Wide range of clinical problems, including

rare and critical events

• Availability

• Financial cost

• Adequate resources

• Reliability, validity, feasibility

Kirkpatrick's Four Levels of Evaluation

• Reaction

• Learning

• Performance

• Results

Kirkpatrick's Four Levels of Evaluation

1. Reaction

• Measures only one thing – learners perception

• Not indicative of any skills, performance

• Success is critical to success of program

• Relevance to learner important

Kirkpatrick's Four Levels of Evaluation

2. Learning

• This is where learner changes

• Requires pre and post testing

• Evaluation at this step is through learner

assessment

• First level to measure change in learner!

Kirkpatrick's Four Levels of Evaluation

3. Performance (Behavior)

• Action that is performed• Consequence of behavior is performance• Traditionally involves measurement in the

workplace• Transfer of learning from classroom to work

environment

Kirkpatrick's Four Levels of Evaluation

4. Results

• Clinical and quality outcomes

• Difficult to measure in healthcare

• Perhaps better in team training

• Often ROI that management wants

Kirkpatrick's Four Levels of Evaluation

• Reaction

• Learning

• Performance

• Results

1. Increasing complexity

2. Increasing difficulty to

measure, time

consuming

3. Increasing value!

Kirkpatrick's Four Levels of Evaluation

• Reaction

• Learning

• Performance

• Results

How do we start to develop outcome measurements

Learning Outcomes

Projected Outcomes

Course Objectives

Goals

Expected Outcomes

Development of Curricula

• Analysis– Clearly define and clarify desired outcomes*

• Design • Development• Implementation • Evaluation

ADDIE

Defining Assessments

• Outcomes are general, objectives are specific

and support outcomes

• If objectives are clearly defined and written,

questions and assessments nearly write

themselves

Defining Outcomes

• Learners are more likely to achieve competency and

mastery of skills if the outcomes are well defined and

appropriate for the level of skill training

• Define clear benchmarks for learners to achieve

• Clear goals with tangible, measurable objectives

• Start with the end-goal in mind and the assessment

metrics, then the content will begin to develop itself

Role of Assessment in Curricula Design

Course •Teaching and learning•Assessment and evaluation

Refine •Learner and Course Outcomes•Modify curricula/assessments

Course •Teaching and learning•Assess learners

Use of assessments in healthcare simulation

InformationInformation

DemonstrationDemonstration

PracticePractice

Rosen, MA et al. Measuring Team Performance in Simulation-Based Training: Adopting Best Practices for Healthcare.Simulation in Healthcare 3:2008;33–41.

FeedbackFeedback RemediationRemediation

MeasurementMeasurement DiagnosisDiagnosis

Preparing assessments

• What should be assessed?

– Any part of curriculum considered essential

and/or has significant designated teaching time

– Should be consistent with learning outcomes that

are established as the competencies for learners

– Consider weighted assessments

Clinical competence and performance

• Competent performance requires acquisition of basic

knowledge, skills & attitudes

• Competence =

– Application of specific KSAs

• Performance =

– Translation of competence into action

Three Types of Learning(Learning Domains)

Bloom's Taxonomy

• Cognitive: mental skills (Knowledge)

• Psychomotor: manual or physical skills (Skills)

• Affective: growth in feelings or emotional areas

(Attitude)

Three Types of Learning

Bloom's Taxonomy

• Cognitive = Knowledge K

• Psychomotor = Skills S

• Affective = Attitude A

Bloom’s Taxonomy – Knowledge

Bloom’s Taxonomy – Knowledge

Bloom’s Taxonomy – Knowledge

Bloom’s Taxonomy – Knowledge

Bloom’s Taxonomy – Knowledge

The Anti – Blooms…

Bloom’s Taxonomy – Skills

• Bloom’s committee did not propose a

compilation of the psychomotor domain

model, but others have since.

Bloom’s Taxonomy – Attitude

Five Major Categories• Receiving phenomena• Responding to Phenomena• Valuing• Organization• Internalizing values

Knowledge Competencies

KnowledgeCognitive knowledge• (factual) Recall• Comprehension• Application• Analysis• Synthesis• Evaluation

Knowledge

Skills

Skills• Communication• Physical Exam• Procedures• Informatics• Self Learning• Time Management• Problem Solving

Skill competencies

Knowledge

Skills

Attitudes• Behavior• Teamwork• Professionalism• Key Personal

Qualities• MotivationAttitudes

XAttitude competencies

Continuous process

Knowledge

SkillsAttitudes

Possible Outcome Competencies(GME Based)

• Patient care• Medical knowledge• Practice-based

learning and improvement

• Interpersonal and communication skills

• Professionalism • Systems-Based

Practice

Knowledge

SkillsAttitudes

So we know what we

want to measure, but

how do we do that?

Copyright ©2003 BMJ Publishing Group Ltd.

Norcini, J. J BMJ 2003;326:753-755

Miller’s Pyramid of Competence

Miller’s Pyramid

• Top two cells of the pyramid, in the domains

of action, or performance, reflect clinical

reality

• The professionalism and motivation required

to continuously apply these in the real setting

must be observed during actual patient care.

Miller’s Pyramid

• Top two levels most difficult to measure

• Quality of assessment in the clinical setting lags

far behind

• In training Evaluation Reports and Likert Scale

• Little value as formative, or feedback, instrument

that might contribute to the learner’s education

Miller’s Pyramid of

competence for

learning and assessment

Miller’s Pyramid of Competence

Miller GE. The Assessment of Clinical Skills / Competence / Performance, Academic Medicine, 65:9, S63-S67.

Does

Shows

Knows How

KnowsCognition

Behavior

LearningOpportunity• Reading /

Independent Study

• Lecture• Computer-

based• Colleagues /

Peers

Teaching and Learning “Knows”

Does

Shows

Knows How

Knows

Miller GE. The Assessment of Clinical Skills / Competence / Performance, Academic Medicine, 65:9, S63-S67.

Assessment of “Knows”

Factual Tests

Does

Shows

Knows How

Knows

Miller GE. The Assessment of Clinical Skills / Competence / Performance

Assessment Tools for “Knows”

• Multiple Choice Questions (MCQs)

• Short Answer

• True / False

• Matching (extended)

• Constructed Response Questions

LearningOpportunity• Problem-based

Ex.• Tabletop

Exercises• Direct

Observation• Mentors

Teaching and Learning - “Knows How”

Does

Shows

Knows How

Knows

Miller GE. The Assessment of Clinical Skills / Competence / Performance

Clinical Context

Based Tests

Assessment of “Knows how”

Does

Shows

Knows How

Knows

Miller GE. The Assessment of Clinical Skills / Competence / Performance

• Multiple-choice question

• Essay• Short answer• Oral interview

The Tools of “Knows How”

LearningOpportunity• Skill-based

Exercises• Repetitive practice

• Small Group• Role Playing

Teaching and Learning - “Shows”

Does

Shows

Knows How

Knows

Miller GE. The Assessment of Clinical Skills / Competence / Performance

Assessment of “Shows”

PerformanceAssessment

Does

Shows

Knows How

Knows

Miller GE. The Assessment of Clinical Skills / Competence / Performance

• Objective Structured Clinical

Examination (OSCE)

• Standardized Patient-based

The Tools of “Shows”

Variables in Clinical Assessment

ClinicalAssessment

Examiner

Patient

Student

CONTROL VARIABLES as much as possible…

LearningOpportunity• Experience

Teaching and Learning - “Does”

Does

Shows

Knows How

Knows

Miller GE. The Assessment of Clinical Skills / Competence / Performance

Assessment of “Does”

PerformanceAssessment

Does

Shows

Knows How

Knows

Miller GE. The Assessment of Clinical Skills / Competence / Performance

• Undercover / Stealth / Incognito

Standardized Patient-based

• Videos of performance

• Portfolio of learner

• Patient Satisfaction Surveys

The Tools of “Does”

Influences on clinical performance

Does

Performance

CompetenceSyste

m related Individual related

Cambridge Model for delineating performance and competence

Rethans JJ, et al. The relationship between competence and performance: implications for assessing practice performance, Medical Education, 36:901-909.

Reliability

and

Validation

Assessments - Reliability

• Does the test consistently measure what it is

supposed to be measuring?

– Types of reliability:

• Inter-rater (consistency over raters)

• Test-retest (consistency over time)

• Internal consistency (over different items/forms)

Inter-rater Reliability

• Multiple judges code independently using the same criteria

• Reliability = raters code same observations into same classification

• Examples• Medical record reviews• Clinical skills• Oral examinations

Factors Influencing Reliability

• Test length• Longer tests give more reliable scores

• Group homogeneity• The more heterogeneous the group, the higher

the reliability• Objectivity of scoring• The more objective the scoring, the higher the

reliability

Assessments - Validity

• Are we measuring what we are supposed to be measuring

• Use the appropriate instrument for the knowledge, skill, or attitude you are testing

• The major types of validity should be considered– Face– Content– Construct

Both archers are equally reliableValidity = quality of archer’s hits

Archer 1 hits bulls eye every time

Archer 2 hits outer ring in same spot every time

Validity is accuracy

Reliable and Valid

Reliable, not valid

Not reliable, not validNot reliable, not valid

Reliability and Validity

Improving reliability and validity

• Base assessment on outcome/objectives- event triggers- observable behavior- behavioral rating-assess

• Define:– Low-medium-high performance– Use of rubric or rating metric– Use (video) training examples of performance– Employ quality assurance/improvement system

Assessments types

Choose the appropriate

assessment method:

– Formative

– Summative

– Self

– Peer

Assessment• Formative Assessment

– Lower stakes – One of several, over time of course or program– May be evaluative, diagnostic, or prescriptive– Often results in remediation or progression to next level

• Summative Assessment– Higher stakes – Generally final of course or program – Primary purpose is performance measurement– Often results in a “Go, No-Go” outcome

Assessments - self

• Encourages responsibility for the learning process, fosters skills in making judgments as to whether work is of an acceptable standard – it improves performance.

• Most forms of assessment can be adapted to a self-assessment format (MCQs, OSCEs, and short answers)

• Students must be aware of standards required for competent performance.

Assessments - peer

• Enables learners to hone their skills in their ability to work with others and professional insight

• Enables faculty to obtain a view of students they do not see

• An important part of peer assessment is for students to justify the marks they award to others

• Justification can also be used as a component when faculty evaluates attitudes and professionalism.

Assessments – Setting Standards

• Should be set to determine competence• Enables certification to be documented, accountable

and defensible• Appropriately set standards for an assessment will

pass those students who are truly competent• Standards should not be two low (false positives) to pass

those who are incompetent, nor too high (false negative) to fail those who are competent.

Assessments – Setting Standards

• Those responsible in setting standards must

also have a direct role in teaching students at

the level being examined and assist in

providing examination material

Assessments – Setting Standards• Standards should be set around a core curriculum that

includes the knowledge, skills and attitudes required of all students

• When setting a standard the following should be considered:– What is assessed must reflect the core curriculum– Students should be expected to reach a high standard in

the core components of the curriculum (For instance an 80-90% pass mark of for the important core and 60-80% for the less important aspects.)

– Students should be required to demonstrate mastery of the core in one phase of the curriculum before moving on to the next part of the curriculum

Assessments - Feasibility• Is the administration and taking of the assessment

instrument feasible in terms of time and resources• The following questions should be considered:

– How long will it take to construct the instrument?– How much time will be involved with the scoring process?– Will it be relatively easy to interpret the scores and

produce the results?– Is it practical in terms of organization?– Can quality feedback result from the instrument?– Will the instrument indicate to the students the important

elements within the course?– Will the assessment have a beneficial effect in terms of

student motivation, good study habits and positive career aspirations?

Practicality

• Number of students to be assessed

• Time available for the assessment

• Number of staff available

• Resources/equipment available

• Special accommodations

Assessment

Instruments

Assessments - Instruments

• Be aware of the types of assessment

instruments available as well as the

advantages and disadvantages of each

• Use more than one assessment instrument

and more than one assessor if possible

when looking at skills and attitudes

Choosing appropriate assessment methods

• When choosing the assessment instrument,

the following should be answered:

–Is it valid

–Is it reliable

–Is it feasible

Assessments – Knowledge Instruments

• Objective tests (short answer,

true/false, matching, multiple choice)

• Objective Structured Clinical

Evaluations (OSCEs)

• Constructed response questions

• Rating scales (used on clerkships)

Assessments – Skill Instruments

• Objective tests (Simulation based)• OSCEs• Constructed response questions• Critical reading papers (interpreting literature)• Checklists• Rating Scales• Portfolios (self-evaluation, time management)

Weighted Checklists

• List of items to measure

• Set of weights of each

• Summary score

Assessments – Attitude Instruments

• Portfolios• Essays / Modified essay questions• OSCEs• Checklists• Rating scales• Patient management problems• Short/long case assessments

Assessment Metrics

• Procedural or Check List assessment

• Global Rating assessment

Assessment Metrics• Procedural or Check List assessment

BCLS Y N

Open Airway

Check Breathing

BCLS Y N

Open Airway(< 5 sec of LOC)

Check Breathing(< 5 sec of Airway)

BCLS Y N

Open Airway

Check Breathing

A

Rating Score +1 -1 0 *Assist

Assessment Metrics• Global Rating assessment

Code Blue P F

CPR and

ACLS

Code Blue

CPR<1(low) - 5(Hi)> points

ACLS<1(low)- 5(Hi)> points

Code Blue H M

CPR

ACLS

L

Rating Score +1 0 -1

Pts.

Review

• Assessment drives learning• Clearly define the desired outcome,

ensure that it can be measured• Consider the effectiveness of the

measurement• Feedback to individual candidates• Feedback to training programs

Questions and discussion

Good Luck

101

CompetencyCompetency is noted when a learner is observed performing a

task or function that has been established as a standard by the profession. The achievement of professional competency requires the articulation of learning objectives as observable, measurable outcomes for a specific level of learner performance. Such specific detailing of performance expectations defines educational competencies. They are verified on the basis of evidence documenting learner achievement, and must be clearly communicated to learners, faculty, and institutional leaders prior to assessment.

____________Identified by members of work group on competency-based women’s health education at APGO Interdisciplinary Women’s Health Education Conference in September, 1996, Chantilly, VA.