measuring outcomes geoffrey t. miller associate director, research and curriculum development...
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Measuring Outcomes
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
Session aims
• Discuss the importance of outcomes evaluation and challenges to traditional assessments
• Discuss the importance of validity, reliability and feasibility as it relates to assessment
• Discuss types of assessments and their application in healthcare education
A little terminology…
• Assessment and evaluation are often used interchangeably
• However for our purposes…– Assessment = learner outcomes– Evaluation = course/program outcomes
Why is assessment important?
Because… assessment:
• “Drives learning”• Allows measures of individual and programmatic
progress• Fundamental to outcomes- or competency-based
education• Assures public that providers are competent• Credentialing, privileging, licensure, board
certification – high stakes for practitioner and patient/society– All involve assessment of competence
Formula for the effective use of simulation
TrainingResources
TrainedEducators
CurricularInstitutionalizationX X =
EffectiveSimulation-
basedHealthcareEducation
Issenberg, SB. The Scope of Simulation-based Healthcare Education. Simulation in Healthcare. 2006.
Formula for effective outcomes measurement
DefinedOutcomes
Instruments& TrainedEvaluators
AppropriateSimulatorX X =
EffectiveOutcomes
Measurement
What are some challenges totraditional methods of assessment
for healthcare providers?
Challenges in traditional assessments
• Ethical issues: “using” real pts (substitutes)– Invasive procedures (patient safety)– Sensitive tasks (cultural concerns, pt modesty)– Problems using cadaveric tissue models– Animal welfare issues
Challenges in traditional assessments
• Real patients for evaluation of physical exam skills• 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• Cost• Reliability, validity, feasibility
Developing outcome measurements
“Any road will get you there, when you don’t know where you are
going”
Curricula development
• Analysis– Define expected outcomes
• Design • Development• Implementation • Evaluation
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• Plain goals with tangible, measurable objectives• Start with the end-goal in mind and the assessment
metrics, then the content will begin to develop itself
Curricula/assessment process
CurricularDevelopment
-DefineOutcomes
Teaching andLearning
+/- Refinement Assessment andEvaluation
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?– Every aspect of curriculum considered essential
and/or has significant designated teaching time– Should be consistent with learning outcomes that
are established as the competencies students should master/perform at a given phase of study
BlueprintingGlobal Global
ObjectiveObjectiveRecognize a potential terrorist incident and initiate incident operations
UM-ERT
Module Obj.2.3
Recognize and describe scene hazards and appropriate personal protective measures
FloridaFlorida
Objective(s)Objective(s)Tier 1: I (L), III (D), (F), (N), IV (J), V (A), (D), VI (B)
LearningLearning
OpportunityOpportunityLectureLecture TabletopTabletop
VideoVideo
ExerciseExerciseSkillSkill OSCEOSCE
X X X X
AssessmentPrePre
MCQMCQ
PostPost
MCQMCQSkillSkill OSCEOSCE
5, 23 6, 19, 20 X
Clinical competence and performance
• “Competent performance” = requires acquisition of basic knowledge, skills & attitudes
• Competence = – Application of specific KSAs
• Performance = – “Translation of competence into action”
“Can they do it? Do they do it?”
Possible outcome competencies
• Patient care• Medical knowledge• Practice-based
learning and improvement
• Interpersonal and communication skills
• Professionalism • Systems-Based
Practice
Knowledge
SkillsAttitudes
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
Attitude competencies
Continuous process
Knowledge
SkillsAttitudes
Relating Miller’s pyramid of competence to 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
Knows
LearningOpportunity• Reading /
Independent Study
• Lecture• Computer-
based• Colleagues /
Peers
Teaching and Learning “Knows”
Does
Shows
Knows How
Knows
Assessment of “Knows”
Factual Tests
Does
Shows
Knows How
Knows
The Tools of “Knows”
• Multiple Choice Questions (MCQs)
• Short Answer
• True / False
• Matching (extended)
• Constructed Response Questions
Example - MCQ
Information Input (Facts)
Information Input (Facts)
Factual Output (Answers)
Factual Output (Answers)
“Wheezes are continuous, musical, whistling sounds during difficult breathing such as in asthma, croup and other respiratory disorders.”
FACT
Q. Whistling sounds associated with an asthmatic patient are called?
A. Rales B. RhonchiC. Wheezes D. Vesicular
ANSWER
Learning Opportunity
Assessment
Computer-based model
Choose the best description of the patient’s finding:
A. Myoclonus
B. Partial Seizure
C. Tic
D. Fasciculations
E. Tremor
Click on picture to play video
LearningOpportunity• Problem-based Ex.• Tabletop Exercises• Direct Observation• Mentors
Teaching and Learning - “Knows How”
Does
Shows
Knows How
Knows
Clinical Context
Based Tests
Assessment of “Knows how”
Does
Shows
Knows How
Knows
• Multiple-choice question
• Essay
• Short answer
• Oral interview
The Tools of “Knows How”
Example – Clinical Context MCQ
• 64-year-old man• No past medical Hx• 1 week of intermittent
– Headache
– Double vision
• R pupil dilated
Which of the following is most likely the patients problem?
A. Migraine
B. Myasthenia gravis
C. Multiple Sclerosis
D. Ischemic Stroke
E. Cerebral aneurysm
LearningOpportunity• Skill-based
Exercises•Repetitive practice
• Small Group• Role Playing
Teaching and Learning - “Shows”
Does
Shows
Knows How
Knows
Assessment of “Shows”
PerformancePerformanceAssessmentAssessment
Does
Shows
Knows How
Knows
• Objective Structured Clinical Examination (OSCE)
• Standardized Patient-based
The Tools of “Shows”
Variables in Clinical Assessment
ClinicalAssessment
Examiner
Patient
Student
Control as many variables as possible
LearningOpportunity• Experience
Teaching and Learning - “Does”
Does
Shows
Knows How
Knows
Assessment of “Does”
PerformanceAssessment
Does
Shows
Knows How
Knows
• Undercover / Stealth / Incognito Standardized Patient-based
• Video
• Portfolio
• Service ratings (customer satisfaction)
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.
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
Formative assessment example
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.
Individual self-learning and assessment
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 - standard setting
• 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 - standard setting
• 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 - standard setting
• 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
Choosing appropriate assessment methods
• When choosing the assessment instrument, the following should be answered:– Is it valid– Is it reliable– Is it feasible
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 (content, predictive, and face)
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)
Both archers are equally reliable.
Archer 1 hits bulls eye every time.
Archer 2 hits outer ring in same spot every time.
Reliability as Consistency
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
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 valid
Not reliable, not valid
Reliability and Validity
Improving reliability and validity
• Base assessment on outcome/objectives- event triggers- observable behavior- behavioral rating-assess against competence
• Define:– Low-medium-high performance– Use of rubric or rating metric– Use (video) training examples of performance– Employ quality assurance/improvement system
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
• It is important, if feasible, to use more than one assessment instrument and more than one assessor when looking at skills and attitudes
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)
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 “threats” to the effectiveness of
the measurement• Feedback to individual candidates• Feedback to training programs
Questions and discussion
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