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Diagnosing Training Needs

William Brieger, MPH, CHES, DrPH Johns Hopkins University

Section A

What Information Is Needed?

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Diagnostic Questions

What tasks do the workers have to do (job description)?

Have their tasks changed recently?

Are the workers actually practicing their assigned tasks?

What do the workers already know about their tasks?

More Questions

What is the ideal (standard) way that workers’ tasks should be performed?

What do clients expect from the workers; are they able to perform to clients’ expectations?

Answers to these questions form a baseline from which the outcome of training can be evaluated

Understanding Tasks

Think about the work that will actually be done by the trainees when they return to work after training

Improve the list by reviewing existing curricula, job descriptions, and technical literature

Discuss their tasks with potential trainees

Continued

Understanding Tasks

Improve the list by comparing it with what the community needs and the local culture

Seek community input on these needs and on their views of health worker performance

Improve the list by observing what health workers actually are doing on the job and by talking with them about their work

Prepare Oral Rehydration Solution (ORS)

Prepare ORS solution

Assess presence of signs of dehydration

Ask mother/care- giver about the child’s condition

Continued

Prepare Oral Rehydration Solution (ORS)

Determine extent of dehydration

Develop appropriate treatment plan

Treat patient according to plan

Refer cases of severe dehydration to hospital

Continued

Prepare Oral Rehydration Solution (ORS)

Treat or refer for other problems,

Record data of patient in register

Compile data on monthly basis; submit report

Analyzing Tasks as a Basis of Training

Examine the task carefully in the context in which it is expected to be performed

Sub-divide the task into various components: sub-tasks, competencies, or steps

Decide what skills are needed to perform each task and step

Decide what knowledge and attitudes are needed to carry out each task and step

Task Analysis #9: Record Patient Data in Register

Context !  During provision of

diarrhea management services

Components !  Writing on forms and

in register vital information on patient and response

Continued

Task Analysis #9: Record Patient Data in Register

Skills !  Writing, spelling, calculation …

Knowledge !  Specific information required on forms

Attitudes !  Appreciate importance of data recording

A Reminder: Trainee Involvement

Task analysis should not be an external or detached exercise

Continued

A Reminder: Trainee Involvement

The training committee can discuss !  The tasks involved in their work !  And those areas needing updating

Trainee discussion groups can highlight concerns

Section B

Documents and Interviews

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Information Needs: Who and How

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Examples of Documents

Job descriptions and performance standards

Progress reports: monthly, quarterly, annual

Minutes of sta! meetings

Professional literature

Organizational policies

Files and records on events !  Complaints, grievances, accidents !  Absenteeism, sickness, turnover

The Job Description as a Basis for Training

How do people view job descriptions? !  A limitation to my freedom !  A source of argument with my supervisors !  A guide to how I fit into the organization !  A useful structure so I know what to do, where and

when

Thus, a job description can be an asset or a liability depending on how it is used by management

What Are Job Descriptions?

An attempt to define clearly and without ambiguity the duties and responsibilities of each job

A word picture of the: !  Duties !  Responsibilities and !  Organizational relationships !  That constitute a given position in the organization

Continued

What Are Job Descriptions?

An outline of continuing work assignments and scope of responsibility that are su"ciently di!erent to warrant unique job title.

An up-to-date explanation of current work requirements

Detailed information on special knowledge and resources needed to perform the work

Diagnosing Training Needs Based on Job Description

Have duties and responsibilities changed?

Is the employee performing duties and responsibilities as well as before?

Have new organizational structures and relationships been introduced?

Job Descriptions for Diagnosis

Has professional practice changed such that job descriptions are no longer current?

Are new knowledge, resources, and skills needed to perform the job?

Plans and Progress Reports

What do plans and reports contain? !  Activities? outcomes? goals?

What targets have been met, or not?

What activities worked, and which were less successful?

Reviewing Plans and Reports

Do reports over time indicate trends in successes, problems, results?

What training needs can be discerned?

Minutes of Meetings

Are sta! meetings actually held? (Who attends?)

Are meetings used for problem identification and solving?

Are meetings used for continuing education?

Are issues identified during meetings that require more formal IST sessions?

!  Technical/service issues !  Policy/procedures issues !  Human relations/communication issues

Professional Literature

Updates practices and new approaches that health workers require to be e!ective

Changes in Policy: E.g., Malaria Case Management

Resistance developing for chloroquine

SP is second line—but resistance is developing

Continued

Changes in Policy: E.g., Malaria Case Management

Drug policies change

Prepackaged drugs help reduce resistance

But health workers need to learn how to use new, third generation drugs

Files and Records on Events

Records of events like accidents, absences, and complaints tells us directly and indirectly something about workers’ performance

Frequent absences may reflect !  Stress related to inability to perform tasks !  Boredom with tasks assigned

Accidents may indicate skill levels in handling equipment

Feedback from Stakeholders

Feedback = interviews

Stakeholders in the training process are many !  Workers/potential trainees !  Supervisors and managers !  Clients/community members !  Professional bodies/associations

Stakeholders can not only provide information about training needs but should also be involved in collecting and analyzing that information

Interviews in Context

Documents report past actions or planned intentions of an organization or individual

Observations show the behavior of the employee and the environment in which she works

Interviews obtain the direct input of the employee and other stakeholders

!  For example, their knowledge, attitudes, opinions, values, perceptions

Interviewing May Include

In-depth, open-ended interviews with employees, employers, and clients

Questionnaire: structured format to obtain opinions of employees

Tests: specific questions on job knowledge and skills

Continued

Interviewing May Include

Focus group discussions among employees and clients

Group problem analysis: specific discussions among employees around a work site issue that needs to be addressed

Other Ways to Get Input

Suggestion boxes

Brainstorming during sta! meetings

Informal conversations during breaks, lunch, water cooler

Role play of challenging situations

Interviews Can Take Place in the Community

Focus groups provide an opportunity for feedback on health worker

!  Performance !  Attitudes !  Timeliness !  Communication

of information

Section C

Observation of Performance

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Observation

The best way to judge trainee skills and relationships is to observe them on the job

This can be done in a formal, structured way !  For example, through the use of checklists

Or, observation can be informal !  Integrated into normal supervision

Observation Can Look For …

How employees perform tasks (using a checklist to compare with standard

The flow of service

The interaction between employees and clients

Availability of supplies, equipment, etc., that are needed for employees to perform required tasks

Facility Needs Assessment

CDC, under a USAID project called African Child Survival Initiative, developed continuing education units (CEUs) in many State Ministries of Health in Nigeria

Continued

Facility Needs Assessment

CEUs were responsible for training local government health sta! in basic child survival programming skills

!  Immunization !  Oral rehydration !  Maintaining good records

Continued

Facility Needs Assessment

Although training modules on these topics were available from WHO, UNICEF and the Federal Ministry of Health

The CEUs were encouraged first to find out what was happening on the ground before inviting participants for training

Continued

Facility Needs Assessment

Using the checklist, CEU sta! observed !  Sta! at work !  Availability of clinics supplies and materials !  Flow of patients among other factors

They also interviewed clients to determine what they had gained from their clinic visits

A sample of the items from the checklist are found in the course notes

Facility Needs Checklist

Observers and the Observed

Observations may have limitations

The person being observed may not behave “normally”

The observer must establish trust and blend into the background

Triangulate Multiple Methods

Clearly more than one diagnostic method should be used to determine training needs and understand the solutions required

Example: polio eradication e!orts !  Records show that an increasing number of

children were receiving immunizations during state-wide campaigns but

!  Reports from federal sentinel surveillance sites identify new cases of wild polio virus

Legend

Wild Poliovirus type 1 (75)

Wild Poliovirus type 3 (7)

Nigeria: Distribution of Wild poliovirus by type Jan July, 2002

NIE/EPI 16-Dec-03

Maps Are Documents

More Records, Documents

Reports show numbers of children vaccinated during house-to-house exercises approaching targets

But projected census data from the state indicate that these targets may be only 80% of the likely population of children

A newspaper article during the last campaign has a letter complaining about government e!orts to “sterilize our children” with vaccines

Village Where Wild Virus Found

High coverage reported

Discussions were held with elders

Fear was expressed about sterilization

Note was made of male vaccinators, while women hid in houses with children

One elder showed discarded vials of vaccine in the bush outside the village

Health Worker Views

Informal interviews were held with health workers where they said:

!  Political pressure to report good numbers at any cost is strong

!  Village beliefs and customs are an impediment to child health

!  There is no reason to question accuracy of target goals (numbers of eligible children)

Observations

Finally, trainers followed some vaccinators into the field during the next campaign

When they approached a village, some people ran and hid in their huts

The vaccinators ordered the locally selected “guides’” around like servants

No visits were made to the house of the chief

Implications for Training

Need for human relations and cultural respect

Skills in estimating village populations or conducting a local census

Communication skills to better explain vaccines to community members

Information on sentinel surveillance process and implications of wild virus

A Rapid Training Needs Assessment Peter Johnson, CNM, PhD, FACNM

Section D

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rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Education, Training and Curriculum Development

Source: http://www.jhpiego.org/

http://www.jhpiego.org/

Capacity Project

A global initiative funded by USAID

Improved workforce planning and leadership

Developing better education and training programs for the workforce

Strengthening systems to support workforce performance

Developed for CHART

Caribbean HIV/AIDS regional training network

Increase access to HIV/AIDS prevention, care, and treatment through a robust and sustainable training network

National training centers located in Jamaica, Bahamas, Haiti (2), and Barbados

Relationship with OECS

CHART Request

Assess knowledge, skills, and attitudes related to selected HIV/AIDS related competencies

Assess institutional and socio-cultural factors a!ecting HIV/AIDS care

Analyze relationship between human (training related) and environmental (non-training related) factors a!ecting HIV/AIDS care

Assess factors a!ecting communication/collaboration patterns within teams responsible for HIV/AIDS care

Project Work Plan

Prioritize competencies to be measured (October– November 07)

Develop methodology including instruments and data collection forms (December 07–February 08)

Facilitators workshop: Kingston, Jamaica (March 08)

Mentored RNAs: Jamaica (April 08)

Mentored RNAs: Eastern Caribbean (May 08)

Mentored RNAs: Bahamas (June 08)

Present initial RNA findings to CHART (July 08)

Preparing Facilitators

25 trainers attended an orientation workshop in Kingston, Jamaica

RNA process builds on existing trainer proficiency

Mentored RNA experience

Strengths and Weaknesses

Strength Weakness

Observation Record what is actually happening

Obtrusive; Subjective

Survey Gather lots of objective information; Easy to analyze

Timely; Expensive; Poor response

Focus Group Familiar to workers; Brainstorming e!ect

Subjective; Influence of leaders on response

Workshop Familiar; Brainstorming; Stakeholder buy in

Expensive

Traditional Needs Assessment

Strengths and Weaknesses

Strength Weakness

Observation Record what is actually happening

Obtrusive; Subjective

Survey Gather lots of objective information; Easy to analyze

Timely; Expensive; Poor response

Focus Group Familiar to workers; Brainstorming e!ect

Subjective; Influence of leaders on response

Workshop Familiar; Brainstorming; Stakeholder buy in

Expensive

Traditional Needs Assessment

CHART Rapid Training Needs Assessment

Builds on traditional needs assessment strengths

Attempts to overcome traditional weaknesses

Contains interactive and individual responses

Provides immediate feedback to participating workers

RNA Methodology

Focuses on an area of service delivery

Task analysis using importance: performance measures

Competency-based assessment of knowledge, skills, and attitudes

Small mixed group of appropriate participants

Conducted within community

Key stakeholder orientation

Observation

Importance-performance Assessment

Interactive

Survey

Focus group

Interactive

Competency-assessment

Group analysis with participants

Survey

Focus group

RNA Process

Importance: Performance Survey

Individual and confidential

Short: less than 10 minute process !  How IMPORTANT do YOU believe each task is to

achieving optimal client outcome? !  How WELL do you believe that YOU PERFORM

each task?

Workshop ID _________________ RNA Location ____________

Task Importance LOW HIGH

Provides clear and accurate information to client during pretest counseling

1 2 3 4 5 6 7

Maintains confidentiality throughout counseling and testing process

1 2 3 4 5 6 7

Obtains informed consent from client

1 2 3 4 5 6 7

Importance Survey

Workshop ID _________________ RNA Location ____________

Task Performance LOW HIGH

Provides clear and accurate information to client during pretest counseling

1 2 3 4 5 6 7

Maintains confidentiality throughout counseling and testing process

1 2 3 4 5 6 7

Obtains informed consent from client

1 2 3 4 5 6 7

Performance Survey

High

H ig

Low

Lo w

Performance

Im p

o rt

an ce

High training focus area E!ective training system: Maintain

Possibly redundant training: Scale back

Maintain secondary training focus

Importance-Performance Analysis

Importance Performance Results

Calculated immediately by facilitators using a pre- programmed excel spreadsheet

Results plotted on importance performance grids

Interesting findings discussed immediately with participants

Participant feedback collected for analysis and reporting

Data Entry and Analysis

Presenting Importance Performance Findings

Importance Performance Presentation

Importance Performance Interactive Exercise

A laminated scale placed across floor

Five tasks selected from the importance-performance survey

Participants asked to stop next to point on scale representing their individual rating of the team’s perception of importance

Facilitators will guide discussion of team member differences

Process repeated for rating and exploration of team performance

Importance Performance Exercise

Section E

RNA: Competency Assessment

Peter Johnson, CNM, PhD, FACNM

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rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Case Study Related to Essential Competencies

Knowledge Assessment —Higher Order

—Lower Order

What do I need to know?

Things I need to decide

Skills Assessment Things that I need to do

Attitude Assessment Things that I am feeling

Team Assessment Who is team leader?

Why was team leader selected?

How was team leader selected?

Where were team members assigned and why?

Consultations among team members (when, who initiated, where, why)

Environment Assessment Infrastructure and equipment

Supplies and medicines

Infrastructure

Logistics

Referrals

Competency Assessment

Team Processes

Team role play based on realistic case study

Tables are used to represent facilities in the health care system

Team elects a “team leader”

Providers are assigned to a “facility”

Resource and competency cards distributed to each “facility”

Flip charts at each facility used to record competencies and resources

Hospital Table

Clinic Table

Pharmacy Table

Lab Table

Competency Flip Chart

Resource Flip Chart

Resource Flip Chart Resource Flip

Chart

Resource Flip Chart

Team Decision

Flip Chart

Competency Assessment Exercise Layout

Competency/Resource Cards

Competency

Feelings

Knowledge

Actions

Resources

Cadre

Infrastructure and equipment

Supplies and medications

Infrastructure and Equipment

Hospital: Infrastructure and

Equipment

Infrastructure and Equipment

Private Counseling Room

——

Hospital I&E

Infrastructure and Equipment

Medical Records Area

——

Hospital I&E

Infrastructure and Equipment

Chairs

——

Hospital I&E

Infrastructure and Equipment

Phlebotomy Area

——

Hospital I&E

Infrastructure and Equipment

Examination Room

——

Hospital I&E

Infrastructure and Equipment

Tables

——

Hospital I&E

Infrastructure and Equipment

Exam Tables

——

Hospital I&E

Infrastructure and Equipment

Waiting Room

——

Hospital I&E

Infrastructure and Equipment

Reception

——

Hospital I&E

Infrastructure and Equipment

Beds

——

Hospital I&E

Infrastructure and Equipment

Workbench/Countertop

for Testing

——

Hospital I&E

Assessment of Actual Available Resources

Providers at each facility table are asked to consider resources

Estimate number of providers within cadre available for HIV service delivery area being explored

Estimate su!ciency/insu!ciency of infrastructure and equipment, supplies and medications

Resource Data Collection Physical Resources Hospital Clinic Pharmacy Laboratory

Infrastructure and Equipment A B A B A B A B

S I Used S I Used S I Used S I Used

Anti-diarrheal drugs

Beds

Centrifuge

Chairs

Cold boxes to transport blood samples

Computer

Drugs to treat skin rash

Electricity

Exam tables

Examination room

Fan or air conditioner

Filing cabinet

Medical records area

Phlebotomy area

Private counseling area

Reception

Record forms/data sheets in confidential envelope

Refrigerator

Sink

System for transferring blood to lab

Tables

Estimating System Resources

Competency Role Play

Facilitator plays standardized patient

Presents at table with scripted concern

Participants manage care at their table “facility” as they believe appropriate

Time out called at point of referral to another facility

Participants post feelings, knowledge, and actions cards based on their experience managing patient

Participants post infrastructure and equipment, supplies, and medication cards

Collecting Competency Data Stage of Service

Provision ! Key Feelings ! Key Knowledge ! Key Actions

Accepting or receptive Appropriate referral procedures Answers client’s questions and refers to appropriate person, as necessary

HIV Testing

At which facility table was HIV testing conducted?

___Hospital

___Clinic

___Lab

___Pharmacy

___Not conducted

Comfortable, relaxed, or at ease Communication techniques Assures confidentiality

Confident, certain, or sure How to use rapid HIV test kit Appropriately collects blood sample for testing

Determined or intent Knowledge of rapid test storage Calls client by name

Understanding, sympathetic, or concerned

Length of time or client to receive results

Completes and stores all records and reports in secure place with limited access

Process for receiving results Conducts rapid HIV test

Testing guidelines and standards Confirms informed consent from client (and refers back to counselor, if appropriate)

Universal precautions/ infection prevention measures Disposes instruments and medical wastes properly

Ensures universal precautions

Explains the testing procedures to the client

Explains that blood will be tested for HIV and other tests

Informs client about the safe elimination of bandages from where blood sample is taken

Invites client to sit

Labels blood samples with appropriate identification

Refers to clinic for HIV post-test counseling and results

Treats client with respect

Uses appropriate hand hygiene

Underlines the need to come to the appointment to pick up test results

Wears gloves

Score for HIV Testing Stage ___ ticked out of 5 = ___% ___ ticked out of 8 = ___ % ___ ticked out of 19 = ___ %

Focus Group Discussion

A focus group discussion conducted immediately following the competency assessment exercise explores:

!  Feelings stimulated by exercise !  Knowledge needed to help patient !  Actions taken !  Resources needed !  Team dynamics

Facilitator Debriefing

Synthesis of observations

Synthesis of comments made by participants

Process evaluation

Fitting within a broader CHART and Country M&E framework

Reporting

Local report prepared by lead facilitator and provided to single point of contact within the community shortly after RNA completion

CHART report sent to regional coordinating unit in Kingston, Jamaica

CHART report used to enter qualitative and quantitative data into a regional database

Next Steps

Data analysis plan

Use regional data to guide CHART training plan

Develop tools to measure other areas of service delivery !  Other HIV/AIDS, i.e., PMTCT !  Other IDs, i.e., malaria and tuberculosis !  Reproductive health !  Chronic diseases

Thank You

Lecture Evaluation

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Training Needs to Deliver a Basic Package of Services

William Brieger, MPH, CHES, DrPH Johns Hopkins University

The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.

Alma Ata Declaration

n  Primary health care (PHC) is: u  Universally accessible to individuals

and families in the community through their full participation

n  Primary health care relies on: u  Health workers—including

physicians, nurses, midwives, auxiliaries, community workers, and traditional practitioners

u  A response to the expressed needs of the community

u  The spirit of partnership and service

n  Ideally PHC should be based on the perceived needs of the community

n  These, whether they be first aid for farm accidents or treatment of febrile children, would form the basic package of services from which training would be designed

What Does the Community Want and Need?

n  The reality is that PHC was quickly hijacked by health professionals who wanted an efficient package of effective services focusing on children, such as: u  Oral rehydration therapy u  Growth monitoring u  Breastfeeding promotion u  Immunization u  Family planning

Selective Primary Health Care

n  Community-directed intervention (CDI) began in the mid-1900s with the annual distribution of ivermectin to control river blindness (onchocerciasis)

n  The basic concept is that: u  The health system provides training, supplies, supervision, and monitoring tools u  The community makes and carries out the major operational tasks of census,

volunteer selection (community-directed distributors—CDDs), volunteer support, collection of supplies, submission of monitoring forms

n  This approach is hybrid: selective in its focus on a particular disease and more broadly PHC-oriented in its involvement of the community as a partner

Community-Directed Intervention

n  CDI began with a one- commodity package (ivermectin)

n  Health systems opportunistically added other tasks to community responsibilities

n  Eventually WHO systematically tested whether CDDs could handle more tasks

CDI

n  The “package” tested by WHO included: u  Ivermectin u  Malaria medicine u  ITNs u  Vitamin A u  DOTs for TB

Systematically Testing a CDI Package

n  Integrated community case management (iCCM) has become a major way of delivering treatment to children below five years of age who need timely and appropriate management of: u  Malaria u  Diarrhea u  Acute respiratory illness, especially pneumonia

n  This basic package is sometimes supplemented with: u  Deworming medicine u  Insecticide treated nets

n  Being in the community does not guarantee that iCCM volunteers are selected according to community participation principles

Integrated Community Case Management

n  The World Bank Booster Program supported the MPP interventions in seven states in Nigeria

n  These MPP interventions consist of key maternal and child health interventions that can reduce morbidity and mortality with marginal cost increase compared to malaria- specific interventions alone

n  The MPP can include up to 19 specific services ranging from specific commodities (malaria medicines) to community health education

n  Clearly not all can be incorporated at the start-up of a VHW/CHW training program

Malaria Plus Package (MPP) in Nigeria

n  Increasing access to, and utilization of, preventive measures

n  Expanding access to, and utilization of, effective diagnostic and treatment services

n  Strengthening community mobilization and communication for behavior change

n  Improving state- and municipality-specific monitoring and evaluation (M&E) for evidence-based management

n  Strengthening partnerships for resource mobilization and implementation

n  Enhancing capacity of the states/municipalities for oversight and project coordination

Malaria Plus Includes …

n  Once the basic or start-up package is determined, one must use diagnostic tools to review: u  Community perceptions u  Volunteer capacity u  National technical guidelines

n  … Around the package components

Training Needs for a Package

n  As we have seen, determining training needs can be open ended and based on community defined and requested services

n  Needs diagnosis can be based on a minimum care package that had been determined for community health volunteers

n  In either case, we need to learn about the trainee’s needs through: u  Interviews u  Review of documents u  Observation of performance

Summary