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A recent interview with Dr. Peter J. Pronovost dealt with safer ways to care for patients in hospitals.  Pronovost is the medical director for the Quality and Safety Research Group at Johns Hopkins Hospital in Baltimore.

The interview’s worth reading on its own merits.  I saw in it good examples of performance analysis and efforts to improve performance–with relative few attempts to train people out of non-training problems.

For example, for cardiac catheterization, Hopkins had an infection rate of 11 per 1,000 procedures.  According to Pronovost, at the time that “put us in the worst 10% of the country.”

Here’s a diagram I created to illustrate some influences on performance:

And here are points that Pronovost makes:

• Hopkins developed a checklist to standardize what to do before catheterization (wash hands, clean skin with chlorhexidine, drape the patient, etc.).  To me, this is support for item 3 above.
• Supplies, which had been stored in as many as eight places, were prepped in a cath cart–with someone assigned to make sure it was stocked and handy.  Item 2, equipment and materials.
• The hospital asked nurses to remind doctors to wash their hands–and empowered nurses to stop procedures if this didn’t happen.  Item 8 (standards) and item 9 (feedback) — and, you could argue, item 7 (consequences).

Note also that the Hopkins project defined a specific problem (a high rate of infection), analyzed likely causes, chose action based on those causes, and measured the results.

Pronovost forcefully describes another barrier to performance: workplace culture:

As at many hospitals, we had dysfunctional teamwork because of an exceedingly hierarchal culture…

…in every hospital in America, patients die because of hierarchy. The way doctors are trained, the experiential domain is seen as threatening and unimportant. Yet, a nurse or a family member may be with a patient for 12 hours in a day, while a doctor might only pop in for five minutes.

I mention this not to single out doctors but to emphasize that performance problems usually have multiple causes.  Some you can address in a straightforward fashion (rethinking where to keep the supplies).  Others, you have to keep working at.  In commercial aviation, use of preflight checklists is maintained not only by regulations but by the active support of those who use them: it’s not smarter or more efficient to try memorizing the checklist.  In fact, it’s seen as counterproductive.

(Note what the Skout Group says about workplace culture–and checklists–in terms of USAir 1549, the plane that Sullenberger and Skiles managed to set down in the Hudson River last year, with no loss of life.)

Back to the hospital: isn’t there some need for training?

I couldn’t say; Pronovost’s interview doesn’t have enough detail.  It could be that some hospital staff need training in preparing for catheterization.  If that’s the case, I suspect that inside the generalization of “preparing for catheterization,” there are distinct subtasks: identify and obtain the supplies, prep yourself, prep the patient, assist (or be assisted by) a specialist, and so on.

And perhaps there’s a meta-skill: make sure the individual assigned to this task can first demonstrate an acceptable level of skill.  In other words, something like “we expect you learned this in nursing school (or wherever); here are our standards; we’ll observe you and tell you how you did.”

I don’t know that I’d put the necessary culture change under “training.” I’m pretty sure the label is less important than the goal: having doctors (most not hospital employees) and hospital staff work together to reduce the rate of preventable infection.

Word of the day: nosocomial, meaning “occurring in a hospital.” I came across it in this 2001 CDC report, The Impact of Hospital-Acquired Bloodstream Infections.  Its low estimate for life-threatening bloodstream infections acquired in the hospital is 87,500 per year.  The low estimate of deaths from these bloodstream infections: 8,750.

(And bloodstream infections are estimated at 10% of all nosocomial infection.)

This morning’s Washington Post has an article about college professors banning laptops from their classrooms.  (The first example is from a Georgetown Law lecture on “democracy and coercion.”)

Similar bans, the article claims, exist at William and Mary, the University of Virginia, and other big-name schools.

It’s been years for me since college, so my own notions are just notions.  That rarely stops me from musing.

• That law lecture occurred in a room with a hundred students.  Ipso facto, it seems to me, the average student didn’t get to say ten words.  Not that you have to say something to rework, reconsider, connect what’s new to what’s known–but talking about new material is at least as helpful as writing notes on paper.
• It’s not as if a room without laptops is a room without distractions (or a room that suddenly has interesting lecture).  As a U-Va professor says, “If students don’t want to pay attention, the laptop is the least of your problems.”
• One comment added to the Post story reminds us of all the people who doodled, crossword-puzzled, or just read the sports pages while safely and quietly lodged toward the back of the lecture hall.

I don’t mean to seem one-sided.  No matter how cool your keyboard, even ten people in a room going clickety clickety clickety can be distracting–just as Worlds of Warcraft can be when it’s on the screen of the person in front of you during Conflict in Nineteenth-Century East Asia.

Stepping completely outside things I know about: maybe the tried-and-true formal education approach isn’t always ideal.  A law professor in a lecture hall might not be so impartial about his methods as to concede their shortcomings.  Is a lecture to 100 people an optimal way to achieve whatever the goal is for “democracy and coercion?”

Maybe not–because formal systems like law school have a built-in time and exposure constraint, culminating in not just the law degree but the bar exam.

Mostly I think the question hinges on specifics: what’s the purpose of this (presumably in-person) class?  Why is it in-person?  Am I as the professor dispensing knowledge (the Font of Wisdom approach)?  Am I encouraging people to explore issues, grapple with implications, bring in things from the outside?

Consider the approach of another Georgetown law professor (who does allow laptops).  He told his class that Chief Justice John Roberts was stepping down from the Supreme Court.

That was untrue, as the professor knew–but the news flew out.  It seems the real point of the lesson was: credibility. (Much more on this story at Above the Law, including a follow-up.)

CC-licensed image of lecture notes by Kevin Lawver.

Last week, I found myself in a couple of discussions about the difference between training and learning.  I only took one philosophy course in college, and later on I hollowed out the textbook to hide a gag gift, so it’s clear I’m not that contemplative on this issue.

To oversimplify, many people in more traditional training jobs felt strongly that there is such a thing as “training” and that it has the potential for great value.  Other people, by and large on the you-manage-your-own-learning side, seemed to place little value on structured training as such.

Although I doubt most participants intended it, you could interpret the divergent views as “this is important work I’m doing that helps people become more productive” versus “get out of your rut.”

Maybe not a rut, but at least a well-worn path.  I’ve spent a lot of time in that corporate-training path: 7 years at Amtrak, 18 at GE, and much of my consultant career since.  Usually I’m far from the executive suite, so I have some sympathy for challenges that first-line and middle managers face together with their work groups.

Which is why, over and over, I recommend Robert F. Mager’s What Every Manager Should Know about Training.  Not just to clients (though I’ve even sent the book as a gift when I thought it would be well received) but to the corporate trainers supporting them.

It’s not a scholarly book, nor a thick one; you could probably read the 140 pages in two hours. But in that space, Bob Mager works hard to get managers out of the training-as-dosage mythology.

• Rule 1: Training is appropriate only when two conditions are present:
  • There is something people don’t know how to do, and
  • They need to be able to do it.
• Rule 2: If they already know how, more training won’t help.
• Rule 3: Skill alone is not enough to guarantee performance.
• Rule 4: You can’t store training.
  • Use it or lose it.
• Rule 5: Trainers can guarantee skill, but they can’t guarantee on-the-job performance.
• Rule 6: Only managers, not trainers, can be held accountable for on-the-job performance.

Mager: “If training is only a means to an end, what is the end toward which it strives?  It’s performance.”  Someone familiar with concepts like ISPI’s human performance technology model (links to a PDF document) recognizes exactly what Mager’s doing: smuggling performance improvement into the organization.  He’s just hidden it in a plain brown wrapper that’s labeled TRAINING.

He was clever in choosing the title, because I’d argue the majority of people who supervise or manage in organizations use “training,” at least in casual conversation, to mean a whole complex of things related to getting people to produce valuable results on the job.  Instead of trying to convert them to performance-improvement or informal-learning jargon, Mager starts where these managers are likely to start.  Then he builds on their likely experience in other dimensions of work to help them see how training (as a structured approach toward helping people acquite skills they don’t have) is one part of overall performance.

In the chapter, Where the Magic Goes In, Mager addresses another concern managers have:

Instead of asking, “How long will it take to develop my course?” you might consider asking:

What can you do for me with the lead time I’ve got?…

For example, if [the training department has] only two days for training development, the most useful thing they can do is to verify whether training is a valid solution, and to verify which solutions will have the greatest impact on the problem.

If the trainers have time to do one more thing, a task analysis would be the most useful action.  These analyses can be turned into checklists in a matter of minutes, and the checklists can be given immediately to the instructors…and to the trainees, to show…what competent performers can do….

If there is time to do one more thing, trainers can derive the objectives of the instruction and then draft skill checks by which instructional success can be measured…

…Which, by the way, isn’t a bad way to think about any sort of guidance you’d like to provide other people.

Yes, you’re right.  Head First Statistics is really a form of teaching, not learning.  As with any book, you could see it as an extended lecture (660 pages, if you count the appendices).  No way to ask anything, easy to slide past questions or problems by turning the page.

Which is why HFS makes such a great example of a tool (depending on your interests) and such a great example of fun (depending on your mindset).

Those two “depending on” clauses are like the uprights for a suspension bridge.  If you’re not interested in learning about statistics and nothing’s pushing you to do so (like your job or your graduate program), then I’m confident (at the 0.975 level) you’re not going to, regardless of the form in which the opportunity to learn appears.  Much the same is true for the other upright: the way you feel about this particular opportunity. 

HFS has given both ends of that bridge some thought. Click the sample page to enlarge; you’ll see what I mean.

♦  ♦  ♦

What Dawn Griffiths has done is sketch a very high-level picture of the learning goals that HFS supports and the types of people who probably respond well to this approach.  Who’da thunk you could do that without the sacred incantation, “At the end of this course the student will be able to…?”

But–how can you be sure of what you’ll learn?

Hmm… the body-of-knowledge approach to learning.  It’s true: in many fields like statistics, there are concepts, principles, terms, equations, and so on that you’re expected to know.

By “know,” I mean you can agree on a description or definition for X with people who aren’t related to you.  Even if their reaction is, “Well, you could put it that way.”

At the same time, despite the sputterosity of purists, zealots, and cranks with time on their hands, most fields don’t have a body of knowledge; they’ve got a herd. Beyond the most basic definitions (like the difference between mean, mode, and media), no one factoid is make-or-break.

Granted, statistics does tend toward the lots-of-specific facts side. So HFS furnishes some tables.

A “Table of Contents (Summary),” which takes up a little more than half a page.  It’s followed by “Table of Contents (the real thing)” with a page for each of the 15 chapters, plus half a page apiece for the intro appendices).  Check the O’Reilly Books preview page for HFS yourself; use the next / previous buttons at the top of the book page to browse.

If I were smart, I’d end by suggesting you also look at a sample chapter (probability, PDF) or explore HFS on your own via Google Books.  The good-humored approach, the absence of dense text–those are obvious at first glance.

Beneath that, though, there’s a lot of cognitive infrastructure, the sort of thing that shifts from “fun” to “learning.”  Chapter 3, “Power Ranges,” is a good example.  It’s got 44 pages dealing with range and variation (the previous chapter dealt with mean, median, and mode).  This is what’s lurking as you turn the title page:

• The coach of the neighborhood basketball team needs one player.  He’s got three candidates.  All three have the same shooting average.  So, which one should he pick?
• Here are their individual stats (points per game and frequency).  What else does the coach need to know?
• Explanation: what “range” means (also, lower bound and upper bound).
• You try it: figure the mean, lower bound, upper bound, and rang for these two players.  Then, draw a histogram (as you learned in chapter 2) for each.
• Feedback for that exercise, and a troubling question about outliers.
• Explanation: why outliers are problematic.  Can you think of how to reduce their impact?
• Explanation: why ranges are quick-and-dirty solutions.
• Sneaky intro (“one way is to measure only part of the range”)
  accompanied by this:

That’s the first 8 pages.  Not only did you have a couple of get-out-your-pencil problems, but also questions to provoke thinking, questions to highlight potential confusion, and even, as in the above example, questions that are intelligent stand-ins for ones a learner might have.

As I said in an earlier post, fun in training (or in support of learning) shouldn’t be an afterthought.  It shouldn’t be force-injected, either, like the fake smoke-flavored streaks applied to frozen burgers to make you think they were grilled.

Dawn Griffiths shows that part of the engagement comes from a general approach (irreverence, retro photos, quirks of layout); another part comes from sample problems that offer real statistical challenges placed in…let’s say surreal settings.  (In chapter 7, you use Poisson distributions to figure out how often a movie theater’s popcorn machine is going to break downnext week.)

Maybe we can get Griffiths and the folks from Head First to have a long lunch with von Merriënboer and Kirschner.

The other week, a #lrnchat discussion explored large training efforts.  Eventually the topic turned to fun.  In real life, when organization trainers start talking about fun and learning, I start looking for the exit.  I figure it’s not long before the Happy Gang shows up, determined to make you laugh no matter what, and I want to clear out before they do.

“Making Performance Reviews Fun.”  Sounds ghastly.

I think I have a good sense of humor.  It’s just that institutional attempts to impose humor are a lot like institutional attempts to compose music.  I end up feeling in tune with the universe’s most morose android.

Here’s what got me musing about this: at one point (around 9:35 in the transcript), the #lrnchat question was,  “What are some creative ways, in a mass approach, to make training stick?”

• Cammy Bean said: Use humor. Turn things upside down. Make it worth repeating.
• A bit later, Craig Wiggins said: @cammybean you know, i’m a big fan of humor and levity in elearning, but in some hands the idea of humor is…not humorous.

Craig’s right. Not everyone has a knack for humor.  That doesn’t mean you shouldn’t try to be open to it.  You shouldn’t force it, thought, as if it were the interpersonal version of making people eat their brussels sprouts.

Which is what I meant when I said in two tweets:

• I am NOT a fan of “fun” sprinkled over learning like pixie dust (clown noses, loud noises, what veg are you)…
• … But humor or just enjoyable attraction can arise from relevant context that has value in eyes of participants.

In the genial chaos of a #lrnchat discussion, people don’t always pause to define their terms.  I have the luxury of taking that time here.  What does “humor” mean in a structured-learning context?  What does “fun” mean in a training program?  Depends on who’s talking.  And on who’s listening.

I believe what people are striving for is engagement: how do you create opportunities for learners to involve themselves with what they’re learning?  This is the sort of thing Carl Sagan meant while about new discoveries in cosmology: they “remind us that humans have evolved to wonder, that understanding is a joy.”

Admit it: some stuff just doesn’t seem all that joyful from the outside.  Adopting vendor-managed inventory systems, for instance.  Deciding whether a building needs an elevation certificate in order to qualify for flood insurance.  Shepardizing a legal case.  Learning basic statistics.

The answer is not (necessarily) to provide balloon animals and confetti, or to toss miniature chocolate bars at the participants while they chant answers to quiz questions.  Often that’s like putting frosting on those brussels sprouts.  Even if people try eating that, all they’re going to remember is a weird taste.

For an organization, the challenge is helping people learn and apply skills that will achieve the group’s goals.  Assuming the people in question do in fact need to acquire or strengthen those skills, of course, so you’re not boring them to death “teaching” things they already know.

That depends much more on relevant, realistic, worthwhile experiences.  Out of those, levity can emerge–if it makes sense.  Horse first, then cart, then passengers and cargo, and then (maybe) mood lighting.  (Later this week, I’ll give a couple of examples from one of those dry topics I mention above.)

So, instead of trying to sneak brussels sprouts pass some unsuspecting diner, work on finding fresh sprouts, demonstrating recipes and cooking techniques that capitalize on their flavor and texture.  Then work them into, say, creating a meal for a restaurant guest who insists on having five different colors of food as dinner.

The customer’s a bit of an outlier, but the core skills (menu planning, item selection, preparation, technique, timing) actually matter.

Humor as an addition to the main topic can also emerge naturally.  By naturally, I mean people use humor to make new connections with the main focus, or to reinforce the connections they’ve made.

• Marcia Conner (at the end of that #lrnchat session) : Last 2 days spent at 100% pixiedustfree event (#wire) & can attest to the fact it can be done beautifully
• And Mason Masteka added a final garnish: My name is Mason, I am a eLearning Dev in Maine and I am celery.

CC-licensed images:
Marvin the android from Wikimedia Commons.
Sprouts with bacon by sling@flickr / Steve Ling.