The limited impact of education as an improvement intervention

Numerous studies have reached similar conclusions—that relying on educational interventions to change clinicians’ behaviours tends to produce no improvement, making this category of interventions the most predictably disappointing among improvement efforts. For instance, two systematic reviews examining the effectiveness of quality improvement interventions involving outpatient diabetes management analysed the relative effectiveness of different categories of intervention components (eg, case management, team changes, audit and feedback and clinician education).20 21 When compared with other intervention types, clinician education had negligible impact on glycaemic control. Other systematic reviews have demonstrated similar findings of little to no improvements when examining the impact of education on physician behaviour and clinical outcomes.22 23 Recognising this reality, the Infectious Diseases Society of America’s guideline on implementing antimicrobial stewardship explicitly recommends ‘against relying solely on didactic educational materials’ as a strategy to reduce antimicrobial overuse.24

In the classic ‘hierarchy of effectiveness’ often shown in human factors engineering (figure 1), education ranks as the least effective intervention, right below new rules and policies and far below more system focused categories such as forcing functions and automation.20 21 25 26 Passive educational activities, such as didactic sessions, online modules and delivery of informational materials, produce particularly low impact. Active educational strategies such as educational outreach to clinicians (similar to the ‘academic detailing’ undertaken by pharmaceutical representatives) can achieve better results with improvements comparable to those of audit and feedback and computerised decision support.26 While active educational interventions tend to produce greater improvements than do passive ones, they also require greater investments of personnel time, hence their lower uptake as improvement strategies.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

The hierarchy of intervention effectiveness (Adapted from the Institute for Safe Medication Practices25 and Patientsafe Implementing effective safety solutions.43

As a sole strategy, education rarely results in sustained behaviour change, earning it a ‛necessary but insufficient’ status among improvement interventions. A classic adage in quality improvement recommends making the right thing to do the easy thing to do. Education never achieves this. Just as clinical practices can have low value, so can improvement interventions. Passive educational interventions, such as lectures and educational handout materials, often fall into this category. If educational interventions consistently delivered small to moderate improvements, they would have moderate value since they cost so little to deliver. Unfortunately, educational interventions often achieve minimal to zero improvement while requiring at least some resources to implement, hence our characterisation of education as having low value as an improvement strategy.

Below, we describe common scenarios in which over-reliance on low-value educational interventions fails to produce results.

Scenario #1: education applied to problems that do not involve knowledge deficits

When a nurse or physician forgets to check for allergies before administering or prescribing a medication, this oversight usually represents a ‘slip’, not a conscious mistake reflecting a lack of knowledge. Consequently, education about the importance of asking patients about allergies will achieve little to no reduction in the frequency with which clinicians forget to check for allergies. A successful intervention would prompt clinicians to check for allergies at the time of entering a medication order or administering a medication—as with alerts in electronic prescribing or bar-coded medication administration systems. These systems are problematic in other ways,27 28 but they at least address the correct underlying problem.

Hand hygiene provides another example. Few clinicians do not know the recommendation to perform hand hygiene to prevent spread of infections. But, hand hygiene has not become an ingrained habit for most healthcare workers.29 Some investigators have looked at ways to foster the development of this habit.30 But, the need for hand hygiene arises so often throughout a given day that slips can constitute a problem even for clinicians with the habit. Thus, effective educational interventions need to focus on appropriate knowledge targets (eg, common misconceptions about when hand hygiene might not be needed) and must be accompanied by interventions involving cues to remind clinicians as they enter and exit patient rooms, as well as attention to convenient placement of sinks and hand hygiene dispensers.

Forgetting to apply knowledge may also occur as a result of distraction in the midst of other considerations during a given patient encounter. For instance, a GP seeing a patient with diabetes may focus on the patient’s glycaemic control, the need for referral to an eye specialist and other aspects of chronic disease management, but forget to discuss discontinuation of the PPI the patient has been taking for several years.

Various researchers have highlighted the importance of ‘having a theory’ for an improvement intervention—a clearly articulated mechanism for how a proposed intervention addresses the main causes of a target quality problem.31–33 Too often an educational intervention is chosen without a plausible theory for lack of knowledge as the main cause of a quality problem. And, even when aspect of knowledge does play a role, a compelling theory for solving the problem on the basis of education alone seldom exists.

Scenario #2: education makes sense in principle but requires too frequent repetition

Even when a target quality problem clearly involves a lack of knowledge or skills, the opportunity to apply successfully acquired educational content may occur infrequently. In such circumstances, initially successful acquisition of the requisite knowledge or skills may erode over time. For this reason, an intervention to help emergency physicians with a rarely performed but potentially life-saving intervention used a ‘just-in-time’ educational video.34 This video included a brief (30 s) refresher with audio narration of the key steps in the procedure, followed by a step-by-step interactive checklist for performing the procedure. Delivering this information in a lecture or other passive educational intervention would almost certainly have achieved no improvement, as clinicians would simply forget what they had learnt by the time (months or years later) they had to perform the procedure.

Repeated delivery to sustain education directed at uncommon situations clearly represents a low-value proposition. But, education can have low-value even when the subject of educational interventions involves more common situations because staff turnover necessitates periodic re-delivery of the same education. This represents a particular problem in teaching hospitals, where trainees deliver much frontline yet rotate in and out of units and clinics on a monthly (sometimes weekly) basis.

Scenario #3: other factors impede application of the requisite knowledge or skills

Educating clinicians about the lack of benefit from, say, prescribing antibiotics for the common cold35 does not make it any easier to dissuade a patient who came to the clinic desiring precisely this outcome from the visit.36–39 Similarly, education delivered to clinicians about recommendations against routine screening for prostate cancer in men over 75 years of age40 does not equip clinicians with the materials or communication techniques likely to reassure patients interested in such screening.

System factors may also thwart the objectives of educational interventions. A GP may have taken on board the educational message of a Choosing Wisely initiative not to order advanced imaging for patients who have low back pain without any high-risk features.9 But, she might also know that the only way to obtain a timely consultation with a spine surgeon is to have an MRI available for review. A patient admitted to the hospital with heart failure might have had an echocardiogram 6 months ago at an outpatient facility, but it seems more expedient for the inpatient medical team to order another echocardiogram to have it handy right away.

In teaching hospitals, there is also the issue of ordering tests to show that one knows what one is doing—a trainee may order a number of tests unlikely to show anything useful for the patient but do serve to demonstrate to the attending physician that the trainee has considered an appropriately broad differential diagnosis.41 And, of course, financial incentives can drive practice, rewarding clinicians for the volume of care delivered rather than the health outcomes achieved or consistency with best practice.