Designing Effective Training

by Christina Mayer Duggan

Creating a successful training program begins with asking the right questions and taking time on the plans, as one expert testifies.

Imagine sitting at your desk. The phone rings. It's your boss. You've just been tasked with an electronic health record (EHR) training initiative involving nearly 10,000 learners-and you have 11 months before "go live." Your mind races.

That's how Jane Dowd felt when she received similar news. Dowd serves as chief learning officer at Evanston Northwestern Healthcare (ENH) in Evanston, IL. ENH is an integrated, academic healthcare system comprised of three hospitals, 851 beds, and 65 group practices housed in more than 50 different locations.

"When I first found out, I got an ache in my stomach," she admits. "At the time, none of us really understood what it meant to implement an electronic health record. We didn't know yet who would be impacted and to what degree." Even with 18 years of experience in training and organizational development and a master's degree in education, Dowd was shocked at the task's enormity. But she got the job done.

With full support from hospital administration, Dowd and her team implemented an award-winning software education and communications initiative. It included eight modules, 51 courses, 12,382 training encounters, and 7,886 learners, including 1,287 physicians. The initiative played a key role in ENH's successful implentation of the ambitious EHR system.

You may never be asked to lead a training program on this scale, but whether it serves 10 people or 10,000, good program design is the same. Dowd breaks the process down into five phases, and to illustrate the concept, she compares the process of building an educational program to that of building a house.

1. Needs Assessment and Analysis
Do You Need a House? What Type of House?

When you build a house, you don't just break out the lumber and nails and start pounding. First you ask questions: Why do we need a house? What kind of house? Who will live there?

When starting to work on a training program, you should ask similar questions: Does your organization really need training, or will a written communication do? If training is necessary, who needs it? What do they need to learn? How will they best learn?

A needs assessment and analysis will answer these questions. "Find out what type of a house you need so you don't waste time building a mansion when you need a two-flat," Dowd recommends.

"Most organizations underallocate time to this phase; they jump to solutions," she continues. "If you don't get this phase right, your training won't meet expectations. Many training programs have backfired because trainers weren't clear about learning needs, stakeholders, or necessary business results."

Gather this information from managers, administrators, and other stakeholders whose departments are directly affected by the change-experts in areas like IT, billing, and hospital operations. Assemble groups of experts to discuss what they know, interview people one on one, observe staff at work, and examine job descriptions. Partner with the key people involved.

2. Design
Draw the Blueprint

Now you've determined that you need a house and the kind of house you need. The next step is to create the blueprint showing what the house will look like and what raw materials are required.

Design tools guide training like blueprints guide building. As with step 1, begin by asking questions, says Dowd:

  • What is the scope of training required (e.g., how much content, what level of complexity)?
  • Who is the audience (e.g., their experience, job requirements, biases, PC skills, learning preferences)?
  • How many learners must be instructed?
  • What resources are available (e.g., trainers, facilities, computers, online resources, manuals, quick-reference guides)?

Define your learning objectives and how you'll measure them. Dowd advises, "Write them down-they're the road map for how you'll write materials." Then think about how best to teach learners. Adults prefer just-in-time learning. They're practical-they want to know how information will help them in their day-to-day duties. "They want to know what's in it for them. It has to be worth their time," says Dowd.

"Learners are looking for only the essential need-to-know information in an easy-to-read format," she continues. "Quick-reference guides and easy-to-read self-study resources are some of our most popular learning tools."

In her own project, Dowd knew learning preferences at ENH favored quick-reference guides, but these would not be enough for the overwhelming scope of the software. Online learning couldn't be used, since the software was still rapidly changing. So Dowd decided on instructor-led courses, supplemented by other tools such as newsletters, a CD-ROM, e-learning modules, and individual coaching.

3. Development
Build the House

Now build your program by producing the course materials-quick-reference guides, online courses, classroom-style courses, overheads, as required-using the right people with the right tools. If you have a lot of content to develop or are using multiple staff to design the materials, your organization can benefit from using standardized document templates. Using templates allows designers to focus on the content and not worry about the details of document formatting. Templates create a consistent look and feel, which can be tough to maintain in a large education initiative with many designers.

And look and feel are important. "Regardless of how you roll out the training, you still need to draw learners in," notes Dowd. "Design quality training materials that excite and involve. Visual appeal is critical-people generally do not like to read [instructional materials] and can easily get lost. They make split-second decisions as to whether to give something their attention based upon the visual quality of a document. This can make or break your learning investment."

Select your trainers, invest in them, write materials, and rehearse. The right instructor makes all the difference. "All the beautiful content can be blown out of the water with a bad instructor," warns Dowd. "Not everyone is meant to be a classroom trainer. Do you come across as confident, credible, and professional? Our trainers practice their introductions over and over."

Dowd advises tapping into internal resources such as learning and development or nursing education colleagues. Consult a training vendor if you don't have in-house resources to develop training.

4. Implementation
Move in and Observe

Finally, it's time to move into your new house. The first few weeks feel like a test. You open and close the doors, operate the dishwasher, and arrange the furniture.

Before going live with training, perform a test run. You can beta test with a few real trainees, some experts, and other instructional designers; pilot test (a dress rehearsal) with real trainees as the audience; or reviewer test, where participants look at the courses through the eyes of the end-user. Use feedback to tweak classes. You'll save time, money, and energy down the road.

Then it's time to go live and track who registered, took the courses, and passed the tests. "This step is critical, but often forgotten," says Dowd. "You can build a great training program, but if you don't know who's taken the course or how well they did, you won't make it to 'go live.' My executives needed regular, sometimes daily, updates. If you don't have solid systems in place, you can't easily schedule learners to get in or report on who comes out. Compliance tracking was a major responsibility for my team in our HIPAA and EHR training rollouts."

ENH used learning management system software to track attendance, course completion, and competency. "Tap into already existing systems," Dowd encourages.

5. Evaluation
Is the House Functional?

Look back and see how it went. Do you need to move a wall? Redecorate? Similarly, how did training go? Did it work? Was it worth the investment? Did learners like instructors and course materials? Were business goals met?

Most evaluation tools, like satisfaction surveys, measure the reaction of the trainees, allowing them to evaluate instructors, facilities, course material, and even refreshments. More extensive evaluation tools measure learning levels (to see if learners can pass a test), behavior change (to see if trainees actually use the skills they learned), and return on investment (to determine if money was saved or safety ratings increased). In addition, your partners will give you immediate feedback. Use all of these measures to determine how you can improve the program.

The Keys to Success

In addition to performing the phases thoroughly, Dowd emphasizes partnering with internal educators. "Don't leave out learning and development, especially if you need large-scale training expertise. They may not be subject matter experts or know medical informatics, but they should have insights into training strategy."

Also, remember you're not alone. "Rely heavily on your peers," says Dowd. "Chances are that others have been faced with similar tasks. Network and share-benchmark with others who have done it."

Another key is using existing materials. Can you use current training or workshop documentation to create new training documents? Can your vendor help? Can you contact organizations that have already done similar programs?

Finally, realize training never truly ends. "Keep your eyes on learning needs over time," Dowd advises. "One wave of training might not do it. With EHRs, it is a continuously moving target with new users and system changes."

Further Resources

American Society for Training and Development. Available online at

Blanchard, P. Nick, and James W. Thacker. Effective Training: Systems, Strategies, and Practices. Upper Saddle River, NJ: Prentice-Hall Publications, 1999.

Clark, Ruth Colvin, and Chopeta Lyons. Graphics for Learning. New York, NY: Pfeiffer Publications, 2004.

Evanston Northwestern Healthcare. ENH has received numerous requests for information and has been heavily benchmarked for its learning strategies and resources. It has thus made its learning library available for purchase, including course manuals, instructor guides, competency exams, exercises, training policies, and online modules. Information is available by e-mailing Jane Dowd at

Knowles, Malcolm S., Elwood F. Holton III, and Richard A. Swanson. The Adult Learner. Woburn, MA: Butterworth-Heinemann, 2005.

Learning Circuits Web site (produced by ASTD). Available online at

Piskurich, George M. Rapid Instructional Design: Learning ID Fast and Right. New York, NY: Jossey Bass/Pfeiffer Publications, 2000.

T+D magazine (published by ASTD). Available online at

ENH's Training Program

Evanston Northwestern Healthcare's EHR journey began in fall 2001. Dowd and her staff ramped up in 2002, simultaneously hiring staff, performing needs analyses, determining facilities, and creating policy. Go-live training ran from September 2002 to February 2004. Here's how they did it.

Phase 1: Needs Assessment and Analysis

Dowd's goal was straightforward: train staff and physicians on the new system.

First, ENH determined that anyone who touched health records needed training-employees, medical group physicians, professional staff, residents, students, and others. Dowd also knew training must coincide with ENH's business goals of improved safety, satisfaction, quality of care, and coding; increased productivity; reduced errors; and organizational efficiencies.

To learn more, Dowd's team reviewed job descriptions and workflows, interviewed management and administrators, ran focus groups, and partnered with experts in billing, operations, and other departments. Dowd also identified potential trainers and common groupings of learners.

Phase 2: Design

ENH needed multiple delivery methods to meet the learning needs of its large, diverse audience-a "blended-learning" approach.

Dowd and her staff decided on instructor-led training to introduce the broad EHR concept; quick-reference guides for just-in-time reinforcement; newsletters for periodic updates; preview panes for urgent communication; CD-ROMs for hard-to-reach populations; Intranet for one-stop materials and most recent document versions; and individual coaching for immediate relief and custom solutions.

Phase 3: Development

ENH used common online learning, clip art, animation, and video software to develop course materials.

Partnering with key stakeholders was critical to success. Dowd's team got input on both the needed software functionality and workflow of specific trainee groups. "Teach learners how to use the software for their work," Dowd stresses. "They don't want to be overtrained or undertrained."

Dowd enlisted nearly 60 staffers to design and teach. Trainers took an intensive six- to eight-week course and had to pass proficiency exams. They also completed a two-day "Enhance the Trainer" workshop that reviewed adult learning theory, facilitation skills, and effective training. Participants gave presentations that were videotaped and critiqued.

Based on partner input, designers used premade templates to create courses. The design and development phases took nearly four months for the initial wave of courses.

Phase 4: Implementation

Before training officially began, trainers ran pilots, gathering immediate feedback. Classes were tweaked accordingly.

Tracking was also critical. "We became a massive reporting house," says Dowd. "Because of the vast number of scheduling options, courses, people, and rolling go-live dates, registration and tracking software proved critical." Dowd reported on who registered, attended, completed the course, and passed. ENH used more than 200 training coordinators to register staff and track scores.

Phase 5: Evaluation

Immediately following classes, ENH issued online satisfaction surveys. Ninety-five percent of participants felt training met or exceeded expectations.

Several weeks following training, users were required to pass demonstrated-competency tests with scores of at least 85 percent. A lower score resulted in no password. "No password meant they couldn't do their jobs," Dowd says.

Effective training helped ENH reach business goals. "Entire categories of medical errors, like those due to illegible handwriting, disappeared," Dowd says. "Reported medical errors overall dropped 20 percent. The system has halved the time it takes to deliver the first antibiotic to patients. And more accurate registration and billing saves ENH $12 million annually."

Results like these are sure signs of a good training program.

Christina Mayer Duggan ( is a freelance writer based in Cleveland Heights, OH.

Article citation:
Duggan, Christina Mayer. "Designing Effective Training." Journal of AHIMA 76, no.6 (June 2005): 28-32.