Low Road #11: On-going Formative Assessment in Practice


One of the side benefits of low-road (formative only) testing is that it fits well into internally motivated cycles of personal improvement. High stakes testing raises such emotional hurdles that these experiences are avoided rather than anticipated as learning experiences. Formative testing can operate in the background built into rolling audits of performance and outcomes. Electronic health records (EHRs) will increasingly support the data demands of live-time auditing, but even now there are sufficient data sets to move in this direction.

Each individual's performance and outcomes could be matched on an on-going basis with real peers (similar client profiles, similar practice patterns, and similar professional supports) across sufficient sample sizes to result in valid quality comparisons. Trigger levels for follow up should be set by the profession in question.  Something obvious like two standard deviations below the mean should be easily identified as a significant performance or outcomes deficit.   The first step should be another larger sampling of the target individual's work. If the deficit appears regularly over time and increased sampling that would indicate that at least further monitoring and perhaps intervention is warranted.

Interventions should be quick, time efficient, sharply targeted and followed up. Brief well-structured knowledge examinations could be conducted on-line and remediation efficiently provided, also on-line. Skills deficits could be economically addressed through just-in-time (JIT) training formats; learning how to do a specific thing in a specific context. JIT training is widely utilized in manufacturing and other industrial contexts. Libraries of relevant video and audio clips are available in many training programs and are easily produced and disseminated on demand. Some very good models of JIT training are on You Tube available 24/7/365 anywhere in the world. Watching a video clip will efficiently teach you how to make hollandaise, change a tire, factor an equation or change a dressing. The outcomes from JIT training are observable and the quality indicators are clear: the hollandaise is sufficiently emulsified, the changed tire functional, the equation correctly factored and the dressing safely changed. Candidates can make videos demonstrating the required skill and submit that as part of a negotiated remediation portfolio.

More complex skill assesemblies such as working effectively in a surgical team would require placement in an appropriate observed and coached situation.  Note however that this is not necessarily a surical skill deficit.  The head scrub nurse might be the most appropriate coach for surgeons found lacking in this type of team work.

Effective interventions in knowledge or skills should show up immediately in performance and should be sustained over time. Deficient attitudes are another issue.

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