Why is it that, even though you conducted a thorough needs assessment, identified knowledge, skills, and/or competence gaps, and got the best possible faculty on board, your outcomes assessment reveals that your learners didn’t learn what you thought they would, much less put it into practice?

One possibility is that your educational design was missing a key element: Adherence to what we know about how adults learn.

As Marcia Jackson, PhD, president of CME by Design, and Kathleen Geissel, PharmD, CCMEP, vice president, learning design and measurement, with Medscape Education, told participants at a session during the Alliance for Continuing Education in the Healthcare Professions’ annual meeting in San Francisco in January, we’re moving from “should we use it?” to “how do we use it?” when it comes to adult-learning principles.

For those who have or want to earn Accreditation Council for CME accreditation, it’s not even a choice. It’s codified in ACCME’s Essential Area 2, Criteria 5: “The provider chooses educational formats for activities/interventions that are appropriate for the setting, objectives, and desired results of the activity.”

To provide education that results in knowledge acquisition or behavior change, activities must engage the learners with the content, according to established adult learning theory. That means designing the event so it will get learners’ attention from the very first contact and hold it throughout the activity. Jackson and Geissel both told—and showed—their session participants what it takes to do that.

What’s the Draw?

Jackson and Geissel began their presentation by asking those in the room why they decided to come to this particular session. The big draws included the session topic, its learning objectives, and the faculty. This mirrored data from a learner preferences survey Geissel conducted online with 2,900 U.S. physicians: 92 percent said they choose CME activities because the topic is of interest to them, and 89 percent said it’s because the topic is one they need to learn more about to provide the best patient care. Just over one-quarter said they choose CME activities because of the faculty/author, while approximately 65 percent indicated it is the learning objectives and activity titles that tip the scales for them.

Clinicians are required to be masters at knowing what they don’t know in order to stay current in their fields after formal education. The problem, however, is that it takes a lot of time to figure out what they need to learn, and to find education on the topics they’re interested in, said about 90 percent of survey respondents. Almost one-third don’t even get that far, saying they don’t know what they should be learning, much less which activities will help them address a specific learning need. “If you can tap into their EHRs [electronic health records], you can use that data” to help them identify their educational needs, said Geissel.

Match the Format to the Goal

Don’t put the cart before the horse. Before you decide on whether to take your activity live or online, simulation-based or case-based, figure out what you want your learners to come away knowing.

There are no shortage of single or mixed formats providers can use, including text-based print and online activities; local, regional, national, and televised/streamed live sessions; live, online, and simulated interactive, case-based instruction; and recorded audio and video presentations. Which to choose? The first step is to determine what you plan to accomplish, then match the format to that goal.

For example, if you are looking to raise awareness of new guidelines or the results of an important clinical trial, a print piece in a journal or online, or a live lecture would be a good fit. If one of your learning outcomes is to ensure that a clinical team will be able to function effectively in delivering patient care, however, you’re more likely to achieve that outcome if you use live or online interactive case-based instruction. For a tricky outcome, such as teaching nurses how to have constructive conversations with a physician colleague about his brusque manner in treating patients, simulation could join live or online case-based instruction that provides an opportunity for deliberative practice. Another format to consider is for learners to participate in role-playing, then everyone discusses what happened. If you don’t have the physical facility or time to do this with everyone, consider using the “fishbowl” method, where one group participates in the role-play in front of the audience, then everyone discusses what happened. If you use this method, however, be sure that you choose willing participants who will be comfortable playing out their roles in the “fishbowl.”

Some other elements to think about include whether to use text, audio, or video. The physician learning preferences survey found that 77 percent said they choose CME that’s available in a readable text format. “They like to go at their own speed,” said Geissel. Forty percent preferred audio and video formats. Less than one-third said they choose CME that is comprehensive but longer than 30 minutes, while 53 percent liked CME that takes less than a half-hour to complete. “If yours is longer, think about breaking it up into 30-minute chunks,” said Jackson.

Layer in Engagement Elements

Once you choose the format that will best help you reach your goals for the activity, you can go back and add elements that will make it more engaging. Geissel pointed out that she and Jackson chose a live session for their presentation at the Alliance meeting, but added a quiz, feedback, and handouts. “You need to get people involved in the content every three to five minutes,” said Geissel.

Some other elements you can add to keep people engaged include polling (via an audience-response system, or an old-fashioned show of hands), asking for feedback and insights as you go along, and providing video vignettes and patient testimonials. “Storytelling is engagement,” said Jackson. Asking them to stop and assess their knowledge, skills, or competence level periodically also can help create cognitive dissonance, which reminds learners that they do, in fact, need to learn something during the activity. Inviting learners to discuss what they learn, perhaps on discussion boards, also can keep them engaged. Live video and/or social feeds also can enhance engagement.

Post-Engagement Strategies

No matter how well designed your activity is, though, adult education theory also tells us that a one-time event is seldom enough to make learning stick. Think about how you can continue engaging your learners after the fact. For example:

• Ask them to make a commitment to change.
Literature suggests that the simple task of writing something you will do after participating in a learning event increases the probability you will actually do it. Geissel presented a summary of 12 Planned Change Assessments® conducted by Healthcare Performance Consulting among participants in online CME activities from 2011 to 2012. The assessment measures the changes physicians intended to make immediately after participation, and actual changes in practice 4–6 weeks later. On average, 70 percent who said they’d make a change did.

• Provide online discussion boards.
Establishing communities of practice via discussion boards can enhance an education event. Literature suggests participation rates in discussion boards are highest when the communities are first established in a face-to-face meeting, and when experienced facilitators continuously engage learners in the discussions (Gaun, JCEPH 2008: Social Interaction and Participation: Formative Evaluation of Online CME Modules). One tip to getting more engagement online: Have your faculty commit to participating on the boards at certain times after the educational event.

• Followup surveys:
Tests are teaching tools, said Geissel and Jackson. In addition to supporting outcomes evaluations, followup surveys can reinforce the key takeaways from the event and facilitate retention.

3 Questions for Choosing Your Format

“Start with the end in mind when considering your options,” said Jackson.

1. What competency are you addressing?
If the core competencies outlined by the Accreditation Council for Graduate Medical Education are important at the graduate level, should they not also be for CME? The American Board of Medical Specialties believes that they should apply to board-certified physicians. These competencies include not just medical knowledge and patient care and procedural skills, but also professionalism, interpersonal and communication skills, practice-based learning and improvement, and systems-based practice. Once you know the competency, then you can match it to your format.

2. What are your intended outcomes or objectives?
“Use the Bloom’s Taxonomy pyramid, which has a broad base of knowledge and rises through comprehension, application, analysis, and synthesis, and peaks with evaluation, to figure out what you’re aiming for,” said Jackson. Then find action verbs you can use at each level to determine what format to use. (See chart for examples.)

3. How feasible is it to accomplish?

Can you actually do what you want to do? Does it need to be done on a national level, or could your goals be better accomplished with a local or regional activity? Do you have the financial and personal resources to pull it off? And who is your intended audience—physicians-only, multiple types of docs, clinical teams? Because topics often pull across several competencies, think about who needs to be involved in the planning, from CME staff to clinicians to quality-improvement professionals.

There are many ways to engage learners, using different models, formats, and design elements to enhance the instructional impact of the education, said Jackson and Geissel. Multimedia can enhance the learning experience. Providers should select elements for a specific project based on the competency to be addressed, the intended outcome, and feasibility limitations. When done strategically, providers can use these tools to increase engagement and improve the results of their educational activities.