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LEARNING & DEVELOPMENT IN HEALTHCARE

11/13/2012 By Peter Tetrault and Maryann Sullivan

“Most healthcare providers are familiar with traditional forms of patient simulations, including mannequins, task trainers, and actors posing as patients. Although valuable for certain applications, these types of simulations are limited in their ability to enhance or assess clinical decision making. In contrast, web-based clinical simulation platforms - which enable clinicians to work with virtual patients - replicate the complex challenges healthcare providers face daily” Bob Yayac, president and co-founder, Decision Simulation LLC

Learning & Development in Healthcare

Copyright © 2012 Wellesley Partners, Ltd. Page 1

Learning & Development in Healthcare A N O P P O RT U N I T Y F O R IM P A C T

EXECUTIVE SUMMARY The following paper explores the maturity of the healthcare learning and development market. It makes the case that simulation, virtual reality and “serious game” technology, are key to the future evolution of healthcare.

We explore four broad themes:

1. The healthcare market is in desperate need of new approaches to shift mindsets about a range of topics. This industry is built on deeply held beliefs about the way care should be delivered that are now being challenged by the brightest minds and supported by evidence-based research. Traditional means of developing people will be too slow and expensive to make the rapid change that is required.

2. The commercial training market is highly fragmented and offers no obvious vendors who will “own” the evolving healthcare learning space. It is even difficult to identify strong players in the healthcare learning market. This vacuum means that new players are needed and are likely to come from other industries given that new approaches have been successfully applied in those industries.

3. The healthcare market is enormous and a reasonable investment by market entrants should provide more than adequate return on capital given the breadth and diversity of this market. Consequently, we expect that in the next few years, we will see capital invested in filling this vacuum.

4. While the use of simulation, games and virtual reality will be the “new approach” that is able to scale efficiently, delivering the required innovation in learning and development needed in healthcare, the concepts are not so foreign to the market that they will be rejected or take too long to gain a foothold. In fact, much is currently being written in healthcare literature about the efficacy of these approaches and the right time is now to begin to develop these solutions.

Our conclusion is that there is an enormous need for the development of new technology-based learning and training environments in the health care industry. Ideally, firms developing this kind of interactive learning in other industries will partner with OD firms working in the healthcare space, to deliver truly transformational capability to enable the required shifts in behavior, skills and perceptions.



A PERFECT STORM OF CHANGE The healthcare marketplace in the U.S. is undergoing rapid, wholesale change with no end in sight. The population continues to grow and, more importantly, age. At the same time the total amount of knowledge and capabilities that exist in the medical field is growing at an exponential rate as scientifically generated results from the laboratory are translated into new treatment protocols at an ever faster pace. The knowledge required to function as a Primary Care Physician today dwarfs that required of the previous generation of physicians.

What has been traditionally known as the healthcare insurance market is also transforming itself – albeit reluctantly – as healthcare consumers are becoming more cost conscious thanks to an increasing number of insureds being covered by high deductable health plans. The focus on wellness and episodes of care, as opposed to the transactional delivery of the recent past, is just taking hold with the result that soon consumers will have ready access to both physician reviews as well as what they charge. The impact on hospitals will be felt quickly as patients will not readily accept Dr. X if his/her charges are out of line, results are inferior or, more importantly, if his/her patient satisfaction scores are not up to that of the competition.

Just as important as the cost elements of the equation, the role of the patient in their care is evolving just as rapidly. The exploding access of care related data on the internet has accelerated the participatory medicine movement. Participatory Medicine is a cooperative model of health care that encourages and expects active involvement by all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to the full continuum of care. Consumers and caregivers no longer allow clinicians (primarily physicians) to dictate care. Clinicians must accept patients as partners. This new relationship is not one that has historically been taught in medical schools, nor reinforced in credentialing and promotional processes for the MD.

Additionally, and regardless of the final details, the role of government will continue to grow. If the Affordable Care Act is not repealed, the scope of the government’s role will expand as implementation is phased in over the next decade. Even if the ACA is repealed, the government’s percentage of involvement will grow as the population ages and end-of-life costs continue to be the majority of an individual’s medical lifetime cost.

Chart 1: Physicians per 100,000 of population

Lastly, we are already facing staffing issues in the U.S. with vast discrepancies of accessibility to physicians based on where you live (Chart 1). According to the Association of American Medical Colleges, there were 744,224 licensed and active physicians in the U.S. in 2011. Of those, 208,802 were aged 60 or older. At the same time there were 80,279 enrolled in the 137 accredited U.S. medical schools. Assuming no attrition, medical school graduates transitioning into their clinical residency (3 to 7 years) will average 20,070 per year, fewer than those retiring. Thus, a diminishing pool of physicians will be serving a dramatically growing population as the uninsured population of the U.S. (40+ Million) is absorbed into the covered population under the ACA.



What role do hospital systems play in this scenario? They have their own challenges. In most clinical care settings there are many issues, but the most prevalent is that of the culture of the organization. Most hospitals have legacy structures, roles and technologies that are not well suited for today’s changing paradigm. Rather than operating as a system of care, health care delivery remains fragmented from a cultural perspective as well as from a process and technology perspective. A

The result of historic management practices is that hospital leadership (at all levels) is simply not equipped with the knowledge and experience to manage the systemic challenges of the new health care order. As professionals working in the organizational development space in health care for decades, we can attest to the fact that taking on the leadership and cultural challenges required to succeed in the future is not going to be easy.

standard is to be “right” 99.99% of the time

The organizational development challenges in health care are severe:

Time constrained: 24/7 operations and no slack in the system as everyone is running thin

Relationship based: physician with nurse, patient with clinician, administrator with clinician

Cost conscious: training experiences must be efficiently delivered in addition to being effective

High standard: instantaneous decisions abound and the

perfect example of this is when a Service Line physician leader does not manage the inpatient component of the service line he/she is expected to lead. An added complexity is that about 400 of these medical delivery institutions are also tasked with both doing research and providing the residency experience for graduate medical students, both constituencies that can be entrenched and slow to change.

This environment requires new approaches, tools, techniques and

accountability measures.



Dealing with complexity: high stakes, high volumes and high complexity means instructor led training does not create sufficient “muscle memory”

Speed of change impacts shelf life of most training

THE HEALTHCARE MARKET Everyone understands that healthcare is a large segment of the U.S. Gross Domestic Product (GDP). How big is it really? The Bureau of Labor Statistics in its State Occupational Employment Statistics Survey from May 2011 pegged healthcare related employment at 11,576,610. This number includes medical and health services managers, clinical practioners, technical occupations and healthcare support occupations. According to the AHA Chartbook (2010), there were 1.29 million RNs, a key target market for learning and development.

The CDC/NCHS National Ambulatory Medical Care Survey (April 30, 2010) reports that there are 4,700 non-federal acute care hospitals in the U.S. In fact, Trustee magazine reports (April 2012) that 55% of hospitals are now affiliated with a healthcare system and that nearly 75% of these hospitals are located in an urban setting. Of these 419 hospital systems 117 are made up of 2 hospitals. The six largest systems account for 785 of U.S. hospitals.

HOSPITALS SYSTEMS BY TYPE

The trend nationwide is for hospitals to affiliate into systems in order to meet the ever increasing demands to rein in the cost of medical care. Spurred on by payment intermediaries (insurance companies) as well as the government payer, this cost pressure – or rather value-add awakening – will only accelerate as the end consumer – the patient – has access to more data about their medical providers.

Concurrent with hospital realignment, there is a tremendous push by hospitals to “buy” physician practices in order to vertically integrate their networks to increase the “stickiness” of their current and future customers (patients). Those practices remaining independent are themselves consolidating in order to maintain control over their practice environment as well as to realize economies of scale.

Physicians are also driving consolidation. They seek employment as a way of being shielded from market forces, including reimbursement cuts and increasing costs for malpractice insurance and information technology.

0

100

200

300

Non-profit For-profit Government

292

90 37

Systems System Type



Consolidation of an industry typically is followed by consolidation of its vendors and suppliers. As organizations reach a scale that operates across geographic boundaries, across multiple product lines and across diverse sets of capabilities, so must its vendors. As institutions consolidate, they look for ways to gain efficiencies and have more dollars to invest in achieving efficiencies. In particular, it is highly likely that the Human Resource function and organizational development departments will become more sophisticated and will have more money to “invest” in developing highly effective and efficient development platforms and capabilities.

The culture change that must take place (see below) will put enormous pressure on the OD function of hospital systems. We’ve already seen this trend as CEOs talk openly about deficiencies in their HR function.

In summary, there is much inside of healthcare that is in flux. There is a large in-place population of providers that need training to deal more effectively in the new reality that is unfolding. While this change is in motion, the knowledge available in the field of medicine is growing as never before and is changing how physicians practice.

T H E H E A L T H C A R E M A R K E T I N S U M M A R Y :

The health care market has consolidated and will continue to consolidate further and as markets consolidate, vendors to an industry consolidate as well

The health care market is in need of efficient mechanisms to change the behaviors and attitudes of the vast percentage of the workforce

If simulation is more cost effective than instructor-led training, while requiring an investment mentality to take advantage of it, a consolidated industry will be positioned to take advantage of this innovative capability

HEALTHCARE LEARNING & DEVELOPMENT

Focus of Learning in Today’s Healthcare Provider There are common threads of what the healthcare provider market must address to be successful. While not every organization will prioritize in the same way, the top training requirements are as follows:



Clinical training – what to do Quality training – tends to focus on what clinical oversight organizations (e.g.: Joint

Commission on Accreditation of Healthcare Organizations - JCAHO) measure Safety training – how not to harm a patient Organizational improvement – focusing on culture, staff satisfaction, patient satisfaction,

physician – nurse relationships

While in theory, the “hard” training would seem to be the prioritized focus area (clinical, quality and safety); we find that the attention today is frequently on the cultural elements that are required to be in place in order for the “hard” training to be effective. We have found a focus on areas like “Culture of Safety”, “Culture of Service”, and “Just Culture”. For anyone who has been heavily involved with TQM or “Lean” methodologies, one quickly realizes that the surrounding culture is as critical as the quantitative training and is frequently cited as the most critical success factor.

As the excerpt from the article above demonstrates (and this is just one of hundreds of citations we could list), improving personal interactions of healthcare professionals with each other and with the patient is essential for improvement of the overall healthcare system. As interpersonal and relationship development tends to be some of the more complex and dynamic learning that a human can ever be exposed to, it is perfectly suited to simulation and the complex decision paths that only a serious multi-player game technology can replicate in a scalable way.

It is critical to recognize that physicians are equally the target of this interpersonal training as nurses. In its report on Physician Competency Development, the American Hospital Association listed the highest core competencies for physicians as: medical knowledge, patient care, practice-based

Ward rounds: what goes around comes around The Lancet, Volume 380, Issue 9850, Page 1281 13 October 2012

Long before evidence-based medicine – long before treatments that worked reliably, in fact – people needed doctors. The gift of time and concern was important therapeutic intervention in itself.

Ward rounds in medicine, the guidance document by the UK’s Royal College of Physicians (RCP) and the Royal College of Nursing (RCN) released on October 4, 2012, makes much the same point, if rather less artfully: “Healthcare professionals should not underestimate the importance of interactions on the ward round from the patient’s perspective”. The importance of communication between medical professionals and their patients is underlined by figures released by the UK General Medical Council (GMC) in September 2012, showing that complaints to the GMC about doctors increased from 7153 in 2010 to a record high of 8781 in 2011. Among the top three complaints made by patients against their doctors were allegations of poor communication and a lack of respect, which increased by 69% and 45% respectively from 2010 to 2011. While GMC Chief Executive Niall Dickson stated that he did not believe these rising complaint figures resulted from falling clinical standards, one take-home message from the statistics might be this: if you do not communicate with your patient clearly, and do not treat your patient in a dignified manner, you are not providing even the bare minimum of health care.



learning and improvement, systems-based practice, professionalism, interpersonal & communication skills and the use of informatics. As measured against the current evidence of skill competency, compared to overall importance of the competency, the biggest gaps were:

Provide cost-conscious, effective medical care (System-based practice) Coordinate care with other providers (System-based practice) Interpersonal & communication skills (demonstrate skills that result in effective information

exchange) Interpersonal & communication skills (work effectively with health care team)

The importance of teamwork is echoed in the May 2011 commencement address to the Harvard Medical School graduating class posted in New Yorker magazine, authored by Dr. Atul Gawande (Creator of the World Health Organization surgical checklist), entitled: Cowboys and Pit Crews.

“THE SKILL THAT YOU MUST HAVE BUT HAVEN’T BEEN TAUGHT [IS] THE ABILITY TO … GET COLLEAGUES ALONG THE

ENTIRE CHAIN OF CARE FUNCTIONING LIKE PIT CREWS FOR PATIENTS. THERE IS RESISTANCE, SOMETIMES VEHEMENT

RESISTANCE, TO THE EFFORTS THAT MAKE IT POSSIBLE. PARTLY, IT IS BECAUSE THE WORK IS ROOTED IN DIFFERENT

VALUES THAN THE ONES WE’VE HAD. THEY INCLUDE HUMILITY, AN UNDERSTANDING THAT NO MATTER WHO YOU

ARE, HOW EXPERIENCED OR SMART, YOU WILL FAIL. THEY INCLUDE DISCIPLINE, THE BELIEF THAT STANDARDIZATION, DOING CERTAIN THINGS THE SAME WAY EVERY TIME, CAN REDUCE YOUR FAILURES. AND THEY INCLUDE TEAMWORK, THE RECOGNITION THAT OTHERS CAN SAVE YOU FROM FAILURE, NO MATTER WHO THEY ARE IN THE HIERARCHY.

THESE VALUES ARE THE OPPOSITE OF AUTONOMY, INDEPENDENCY, SELF-SUFFICIENCY. MANY DOCTORS FEAR THE

FUTURE WILL END DARING, CREATIVITY, AND THE JOYS OF THINKING THAT MEDICINE HAS HAD.”

A Brief Survey of Healthcare Training and Learning Today Today, healthcare training reflects the same market dynamics as training in general: fragmented target markets, diverse methods and a complex matrix of governing bodies to satisfy. The market consists of formal, degree granting academic settings as well as training programs. Each is undergoing change, including medical schools, and has its own market characteristics. There is an opportunity to fundamentally change the paradigm of training using state-of-the-art technology.

Nurse training and certification is controlled by the states. The Robert Wood Johnson Foundation and Institute of Medicine has called for 80% of nurses to hold baccalaureate degrees by 2020 – today the percentage is 50%. Continuing education is required too, with the amount and type varying (e.g.: Alabama requires 24 contact hours every two years).

Consistent with the fragmentation of the overall training market, the American Nurses Credentialing Center lists 316 accredited training providers, 53 accreditation approvers and 6 Joint Accreditation providers.

The Time is Now While there is an opportunity to change the training/learning paradigm to utilize technology for “soft” skill development, the good news is that professionals in health care are generally comfortable with technology. That is a start.

In fact, “simulation” (mostly “physical” simulation to mimic care delivery scenarios), has become a well accepted methodology. This is excellent news in moving to the next level of technology.



The proliferation of technical medical devices has left little room in the system for those who are techno-phobic. Resusci-Anne, the first mannequin used for the training of CPR was developed in 1960. The first realistic anesthesia simulator, Sim One, was produced in the late 1960's, based on work done by J.S. Denson and Stephen Abrahamson at the University of Southern California. The mannequin had outputs for peripheral pulses and heart sounds, but no outputs for electronic monitors. The system was clearly advanced for its time, but was eventually phased out.

Today, medical related training is employed utilizing a range of technological complexity from reading online text and slide decks to the use of virtual reality. The range of frequency utilized ranged from high to low are: simulated patients (mannequins), computerized role play, live actor role play and lastly serious gaming or virtual reality.

The Society for Simulation in Healthcare has strong opinions regarding the use of technology:

“Healthcare simulation is coming of age, and has begun to share much with established methods in aviation, spaceflight, nuclear power, shipping and the military.”

“The rapid advance of computer science, bioengineering, and design has met demands from all stakeholders for safer, more effective and efficient ethical healthcare.

When the stakes are high and real settings do not lend themselves to artificial handling for other purposes, simulation methods will find applications.”

The efficacy of the use of simulation in medical education has now been studied and reported on more frequently. As reported in the Mount Sinai Journal of Medicine (2009) by Yasuharu Okuda, MD “The increasing amount of medical information and research makes it difficult for medical education to stay current in its curriculum…. clinical medicine is becoming focused more on patient safety and quality than on bedside teaching and education….a disconnect still exists between the classroom and the clinical environment…medical simulation has been proposed as a technique to bridge this educational gap.”

Current Marketplace Adoption

According to the Archives of Surgery in its January 2009 publication entitled The Formula for Successful Laparoscopic Skills Curriculum “although multiple simulators have been validated as effective training tools, many training programs struggle to incorporate simulation into their residency curricula”. This seems to be consistently true – while the efficacy and desirability of simulation is accepted, it is not yet in wide-spread use. In the March 2012 edition of the Journal of Graduate Medical Education Dr. Cor Kalkman, Professor of Anesthesiology, University Medical Center Utrecht, the Netherlands, points out that medical education is “firmly rooted in centuries of history” and that the industry struggles “to find the most appropriate formats” for medical education. He also points out that “Doctors are by tradition not the most forward-thinking group” and that “on average it takes more than 10 years before an evidenced-based intervention makes it into mainstream clinical practice”.

Yet there are reasons to be more hopeful about market adoption going forward. In the June 2011 issue of the AAMC (Association of American Medical Colleges) Reporter, Scott Harris points out that a “2008 survey from the Pew Internet and American Life Project, 97% of children ages 12 through 17



play video games, with little difference in percentages along racial, ethnic or socioeconomic lines”. He refers to the use of video games (serious gaming) in the military sectors as examples where realistic dry runs have a clear value given the high-risk actions that are difficult, if not impossible, to simulate in reality.

Dr. Jeffrey M. Taekman, Director at the Duke University Medical Center’s Human Simulation and Patient Safety Center, has stated “There’s plenty of evidence that shows that lecture-based learning does not change behavior. Simulation, whether it’s mannequin-based or games-based, will have a growing role. If you believe immersive learning is a way to change behavior, simulation is the gold standard. We saw a role for this in undergraduate, graduate, and continuing medical education.”

FREQUENCY OF SIMULATION USE IN MEDICAL SCHOOLS & TEACHING HOSPITALS

The data in Table 1 demonstrates there is more potential for adoption regarding simulation technology. In fact, even within some procedures where simulation is the most easily translatable, there is wide variance in the usage of simulation. The table below reflects the percentage of usage of sample procedures by teaching location. While these procedures are not the focus of what we have found to be healthcare’s largest opportunities, they are reflective of how the use of technology has not come close to being widely implemented in training.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Standardized Patients Full-scale Mannequins Part or Partial Task Trainers

Screen-based Simulation

All Types Standardized Patients & Full-scall Mannequins

& Task Trainers

Full-scale Mannequins & Task Trainers

94% 95% 93%

60%

52%

84% 90%

65%

87% 88%

55%

39%

57%

81%

Medical School Teaching Hospitals



TABLE 1

Laparosco-pic skills

Cholecystec- tomy

Ventral hernia

Gastric bypass

Arthro- scopy

Ophthal- mic surgery

GI skills, endoscopy

Broncho-scopy

Endovascu-lar skills

Medical School

45% 26% 8% 7% 8% 4% 30% 26% 15%

Teaching Hospitals

39% 30% 9% 6% 8% 2% 31% 28% 16%

In fact, we believe the lowest scores in Table 2 are more “on point” to the purposes which we believe provide the greatest opportunity in the shortest period of time – the “low hanging fruit” for rapid implementation of technologically based training in healthcare.

Table 2

Medical School Use of Simulation

Education Assessment QI or Research Medical knowledge (86) 96% (80) 89% (46) 51%

Patient care (88) 98% (78) 87% (50) 56%

Interpersonal Communication skills (88) 98% (81) 90% (47) 52%

Professionalism (83) 92% (75) 83% (34) 38%

Practice-based learning/improvement (65) 72% (53) 59% (22) 24%

System-based practice (63) 70% (42) 47% (22) 24%

Psychomotor tasks (81) 90% (68) 76% (37) 41%

Leadership (62) 69% (41) 46% (25) 28%

Team training (78) 87% (52) 58% (40) 44%

Critical thinking/Decision making (82) 91% (72) 80% (38) 42%

Overall Usage 86% 71% 40%

Today, much of clinical simulation is centered on the utilization of mannequins. The development of clinical subject matter simulation will require partnerships with academic medical centers which bring together the hands-on teaching component of the real world for post medical school residents. Funding for this type of opportunity may be partially dependent upon grants (long lead time for funding) or the development of compelling business cases that show return on investment results that can’t be ignored.

Today, very little virtual reality is currently in use, particularly for leadership, system-based practice, professionalism, interpersonal communication skills, decision-making and critical thinking. The need for “soft” skills training has been well documented. (See the October 24, 2012 New England Journal of Medicine article: Talking with Patients about Dying) The key advantage of focusing in these areas is that they are not considered core curriculum for medical education. Thus, funding for these types of simulations may be available from individual departmental operating budgets or HR budgets. The dollars required need not be incremental but could replace current, less effective training programs and models.



CONCLUSION The information provided in the foregoing paper demonstrates clearly that there is an enormous opportunity to utilize new technology-based learning and training environments in the health care industry. The opportunities are diverse. The need is well recognized, yet the solutions are few and highly specialized.

With regard to vendors, there are none with mature capability and content in the healthcare market.

The need is now to:

Enable healthcare leadership to see demonstrable, measurable progress toward achieving the new standards for

Physician leadership

Value-based health care

Transparency

Patient Loyalty

By engaging health care employees in the required changes in behavior, skills and perceptions utilizing new technology and techniques that are more effective and less costly than traditional methods.

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Learning & Development in Healthcarewellesleypartners.com/wp-content/uploads/2016/05/... · learning and training environments in the health care industry.Ideally, firms developing