1. Robert Sweet, MD Task Deconstruction and Metrics Robert M. Sweet, MD Assistant Professor Urologic Surgery and General Surgery Clinical Director of Simulation Programs Founding Director, CREST

2. Robert Sweet, MD Procedure vs. Task vs. Exercise Procedure-is a “series of steps taken to accomplish an end” Task-“piece of work to be done” Exercise-”effort performed to develop or maintain fitness or increase skill” Webster’s Dictionary

3. Robert Sweet, MD Task deconstruction Procedures can be broken down into logical components Guidelines for the “order by which this occurs” –Safety considerations –Natural progression of skills from simple to complex –Resources and expense Independent opportunities for learning loaded on the front end, but sprinkled throughout

4. Robert Sweet, MD CognitiveTechnical + Performance = Dependent Independent Automatic + Communication Situational Awareness Closed-Loop Communication Leadership Transfer Team Formation and Reformation Psychomotor Visual-spatial Learning Domains in Simulation Training

5. Robert Sweet, MD Classify your learners Who are your learners Where are they as far as their level of understanding?

6. Robert Sweet, MD Types of Knowledge Declarative –Knowing “what” Procedural –Knowing “how” Schematic –Knowing “why” Strategic –Knowing how and when to apply Wilson et al, Systems for State Science Assessment, 2005

7. Robert Sweet, MD Learning Domains-Cognitive “Discriminate the differences between IJ and Subclavian central lines” “What would you do if.....” “Asking for the proper equipment you need to have available to put in a central line” “Name the venous branches leading to the SVC” Bloom’s Taxonomy

8. Robert Sweet, MD

9. Cognitive Domain Tasks Usually good to load on the front-end of the curriculum as it meets the criteria –Safe –Low resources –Logical to understand before doing –Estimated to comprise 75% of what we learn in procedures (Spencer et al.)

10. Robert Sweet, MD Teaching and assessing judgment Red Llama, Inc.:SimPraxis

11. Robert Sweet, MD Communication Domain Situational Awareness Closed loop communication Leadership Transfer Team Formation and Reformation

12. Robert Sweet, MD Psychomotor/Visual-spatial Domain Imitation Manipulation Precision Articulation Naturalization Dave’s Taxonomy Dave, R. H. (1975). Developing and Writing Behavioural Objectives. (R J Armstrong, ed.) Educational Innovators Press

13. Robert Sweet, MD Psychomotor/Visual-spatial Domain Imitation Manipulation Precision Articulation Naturalization Dave’s Taxonomy Dave, R. H. (1975). Developing and Writing Behavioural Objectives. (R J Armstrong, ed.) Educational Innovators Press Observing and patterning behavior after someone else

14. Robert Sweet, MD Psychomotor/Visual-spatial Domain Imitation Manipulation Precision Articulation Naturalization Dave’s Taxonomy Dave, R. H. (1975). Developing and Writing Behavioural Objectives. (R J Armstrong, ed.) Educational Innovators Press Observing and patterning behavior after someone else Performance after training, with errors

15. Robert Sweet, MD Psychomotor/Visual-spatial Domain Imitation Manipulation Precision Articulation Naturalization Dave’s Taxonomy Dave, R. H. (1975). Developing and Writing Behavioural Objectives. (R J Armstrong, ed.) Educational Innovators Press Observing and patterning behavior after someone else Performance after training, with errors Refining technique with few errors

16. Robert Sweet, MD Psychomotor/Visual-spatial Domain Imitation Manipulation Precision Articulation Naturalization Dave’s Taxonomy Dave, R. H. (1975). Developing and Writing Behavioural Objectives. (R J Armstrong, ed.) Educational Innovators Press Observing and patterning behavior after someone else Performance after training, with errors Refining technique with few errors Multi-tasking

17. Robert Sweet, MD Psychomotor/Visual-spatial Domain Imitation Manipulation Precision Articulation Naturalization Dave’s Taxonomy Dave, R. H. (1975). Developing and Writing Behavioural Objectives. (R J Armstrong, ed.) Educational Innovators Press Observing and patterning behavior after someone else Performance after training, with errors Refining technique with few errors Multi-tasking High-level of performance on auto-pilot

18. Robert Sweet, MD Psychomotor/Visual-Spatial Skills Basic skills (adapted from Satava et al., 2002) –Patient positioning –Knowing steps of procedure –Knowing equipment needed –Sterilization procedures –Instrument handling –Bimanual Dexterity –Navigation –Suturing –Knot-tying –Intubation –Palpation –Cannulation –Cutting –Incising –Exploration –Tissue handling Berkley et al.,2000

19. Robert Sweet, MD Psychomotor/Visual-Spatial Skills Intermediate Skills (adapted from Satava et al., 2002) –Complex wound closures –Hemorrhage control –Endoscopy –Excision –Anastomosis –Debridement –Complex seldinger technique

20. Robert Sweet, MD Psychomotor/Visual-Spatial Skills Advanced skills –Sewing in a “deep hole” –Reconstruction –Adopting techniques to abnormal anatomical/physiologic situations (cognitive too!) –Advanced minimal invasive skills –New adoptions of technology once done with formal training –Occurring in animal labs

21. Robert Sweet, MD With each curricular subtask, choose a learning domain that predominates

22. Robert Sweet, MD Task deconstruction Methods to do this? –Look at operative reports/atlases –Practical experience –Remember when you were a student –Ask an introspective student/resident to “keep a diary” of What they are learning Self-assessment of “level” of comprehension When they are learning it

23. Robert Sweet, MD Competence vs. Capability COMPETENCE What individuals know or are able to do in terms of knowledge, skills, attitude CAPABILITY Extent to which individuals can adapt to change, generate new knowledge, and continue to improve their performance Brit. Med. J. 323:799- 803, 2001

24. Robert Sweet, MD Learning curves/criterion levels MASTERY COMPETENCY PROFICIENCY Hypothetical Learning Curve for a technical skill set

25. Robert Sweet, MD Learning curves/criterion levels MASTERY COMPETENCY PROFICIENCY Hypothetical Learning Curve for a technical skill set Simulator Remedial training

26. Robert Sweet, MD Learning curves/criterion levels MASTERY COMPETENCY PROFICIENCY Hypothetical Learning Curve for a technical skill set

27. Robert Sweet, MD Metrics for Assessment Each task has two components –The performance task itself –A clearly defined scoring scheme/rubric

28. Robert Sweet, MD Metrics  Make a list of what is it that is important to measure to determine competence for each subtask?  Establish Criterion levels based on subject matter expert consensus and performance

29. Robert Sweet, MD Metrics examples (adapted from Satava et al. 2002)  Quality metrics  Errors/”near misses”/events/complications  Blunt end vs. sharp end  Missed target  Improper delivery of energy  Bleeding  Final product (leaking or inaccurate)  Patient outcomes  Ability to recover from error  Efficiency metrics  Time to task  Economy of motion  Path lengths  Response latency  Use of resources  Use of assistant(s)  Proper sequence of steps