A TALENT MANAGEMENT WHITE PAPER

COMPETENCY BASED LEARNING

What Healthcare Organizations Stand to Gain

from Competency Based Learning

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 CONTENTS
INTRODUCTION 3

COMPETENCY BASED LEARNING IN

HEALTHCARE DEFINED 3

THE NEW COMPETENCY BASED

LEARNING IN HEALTHCARE 4

THE EVOLUTION OF ANDRAGOGY TO

COMPETENCY BASED TRAINING 4

REALIZING THE BENEFITS OF

COMPETENCY BASED TRAINING IN
HEALTHCARE 5

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INTRODUCTION
Healthcare Training Evolves: The Case
for Just-in-time Competency Training
Toyota invented the concept of “just-in-time”
manufacturing—making only “what is needed,
when it is needed, and in the amount needed” 1 . No
wasted investment of time and no material delivered
before important in the context of doing the work.
Manufacturing is a busy and complex industry with little
room for things that do not help to directly accomplish
the mission at hand. How is that different from the
average healthcare setting?
Clinicians are busy professionals, moving in systems that
pressure them to do more with less, to deliver quality
outcomes with little time for preparation and even less
patience for iteration. Today’s healthcare landscape is
focused on the efficient delivery of high quality patient
outcomes. It sounds a lot like the focus of companies
like Toyota, and in fact the same processes that drive
manufacturing are becoming more and more prevalent
in healthcare.
Doesn’t it stand to reason then, that the training
solutions should also be evolving? Healthcare clinicians
cannot afford to waste time on anything that is
not important in the context of doing their patient
work. And, much like the manufacturing industry,
healthcare grew to understand that there was a just-
in-time emergent need as the industry matured. For
example, the average patient appointment is now 20
or 30 minutes2, with only a portion of that time spent
with the actual physician. As time pressures mount, a
clinical team needs to know exactly what is relevant
to each patient at the time of the patient visit—a tall
order indeed. When you also consider that more than
half of clinicians take their training while on shift at
the hospital, you have a situation that requires you to
teach differently—to teach just-in-time and in a manner
that produces quantifiable outcomes, skills and most
importantly—competencies.
1. Toyota Global, http://www.toyota-global.com/company/vision_
philosophy/toyota_production_system/just-in-time.html
2. Institute of Healthcare Improvement (IMI), Office Visit
Cycle Time, http://www.ihi.org/resources/Pages/Measures/
OfficeVisitCycleTime.aspx
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3
20 OR 30
MINUTES
AVERAGE PATIENT
APPOINTMENT
COMPETENCY BASED LEARNING
IN HEALTHCARE DEFINED
We have all spent time in a classroom staring at a professor
writing on a board and wondering how, by any stretch of
the imagination, the concept we are busily cramming into
our brains will ever be of use to us. It can be a frustrating
experience. Who then, will actually take the time to step
away and engage in traditional learning when they are on
the job? Not many. And that is OK, because it turns out,
busy professionals do not learn as effectively in classroom
settings as they do when presented with information that
is directly relevant to what is facing them on the job. With
the availability of information today, busy professionals
want to learn just-in-time to solve the problem at hand.
But job-based training has traditionally been very dry.
Vocational training is often seen as job-task training,
devoid of creativity and higher-level problem solving skills.
Healthcare facilities employ a variety of clinicians and a
good portion of them spend thousands of hours and tens
of thousands of dollars building the higher level critical
thinking and creativity skills that vocational training seems
to remove from the picture.
Competency Based Training (CBT) is thus an evolution
of the original thinking around vocational training which
incorporates higher level thinking and creativity.
The CBT movement began to make the workforce more
relevant. Globally, countries like the US, New Zealand and
the UK began to gather skill requirements into groups and
linked them to desired outcomes. The definitions of these
outcomes are what we refer to today as competencies.
On the face of it CBT may seem like the same dry,
creativity-free training zone that most people spend a lot
of time trying to avoid but that is no longer the case. Fast
forward to today’s landscape, and let’s talk about why the
Competency Based Training and Learning movement is
gaining in popularity.
 4
THE NEW COMPETENCY BASED LEARNING IN HEALTHCARE
The idea of measuring learning by evidence based criteria is very attractive. In healthcare, this popularity is partly
fueled by the natural alignment between systems that measure the effective outcomes of a learning exercise as proof
that it is part of the process to get paid for providing patient care. Said another way, how can prove that the training we
provide to healthcare clinicians is actually improving patient outcomes? Competency based training (or learning
from the perspective of the clinician) helps to achieve this.

So what is the new Competency Based Learning in healthcare? Like any popular methodology, there are a broad
number of pieces to the definition. Some are as dry and devoid of creativity as you would imagine. Other more
recent definitions, however, take advantage of the adult learning trends that have been evolving in the training
world and incorporate them into CBT. Take Malcolm Knowles for example, who introduced the concept of
Andragogy in 19683. Knowles knew that working adults – busy professionals – are motivated to learn in different
ways and thus introduced the tenants of Andragogy.

THE EVOLUTION OF ANDRAGOGY TO CBT

The tenants of Andragogy are simple. Adults are motivated
to learn when they are facing a problem. They go looking
for learning moments in the context of need and want only
the information necessary to solve that problem at hand.
Additionally, adults are self-empowered. They know that
they are the only person who truly understands what they
need to learn. Malcolm Knowles laid this out in his 1973
publication, The Adult Learner: A Neglected Species4. He
also highlighted that adults are self-directed and want to
be responsible for the outcome of applying learning to real
problems. Adults inherently learn through application of
knowledge and evaluation of the results – trial and error.
Busy professionals are interested in just-in-time solutions.
They want you to tell them only what they need to know
at the moment that they need to know it so that they
can apply it to the problem at hand and achieve desired
outcomes. The sum of their learning then comes in chunks
or modules that eventually form into an aggregated
competency.
You can see the influences of Andragogy in the following
three tenants of modern day CBT:
1. Discrete competencies directly related to the
work of an individual are measured using evidence
based criteria
2. Instructors are facilitators and not presenters in the
process of teaching and measuring
Based on the foundational principles of andragogy,
competency based learning embraces the idea that
effective learning is learning that is applied to real
problems. Instead of focusing on high level abstract
concepts and frameworks that can be applied across
multiple job contexts, the Competency Based Learning
approach encourages teachers to take a very specific set
of job related output requirements – discrete competencies
– and create measureable situations where knowledge can
be applied and measured to determine if an outcome has
been reached.
The instructor acts more like a facilitator than a presenter.
Instead of telling an individual what to do in the situation,
they provide upfront guidance around how to think about
and approach the task at hand. Followed by this, the
facilitator then encourages learners to create their own
path through the problem in front of them – a path that
creates “Artifacts” that act as evidence that the learning
has been correctly applied. This leads to a greater sense
of confidence in the efficacy of the learning where
confidence is extended to the idea that this application can
be replicated to the next problem, and result in another
successful outcome.
For example, in a recent article titled “Smart Jobs,
Smart People” published by the Association of Talent
Development, Jonathon Levy said “what is required is

3. The learner is engaged in a self-correcting process of

application that leads to an outcome 3. Knowles, Malcolm S. The modern practice of adult education. Vol.
41. New York: New York Association Press, 1970.

4. Knowles, Malcolm. “The adult learner: A neglected species.” (1973).

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real-time learning: learning how to do a job while you are
actually doing it, and then upgrading your skills while you
are mastering the skills you just learned.” While Levy takes
this to a visionary place where performance support is
available every step of the way, the tenants are real today.
CBT can be structured as the foundation of a learning
culture that trains you on what you need to learn (input)
at the time you are undertaking the new challenge to
produce desired outcomes (output)—again drawing back
to the idea of Just-in-time competency training.
In fact, the biggest challenge to healthcare is to create
cultures that embrace the competency based training
approach. Healthcare needs to overcome the vocational
training stigma that comes with an approach focused
solely on discrete output. While it will take time to change
the culture of learning in healthcare, what follows is a
discussion of CBT benefits that will help sway decision
makers to take steps forward to make this change.
Metaphorically Understanding
Competency Based Learning
Take the activity of fishing for example. Instead
of giving the learner a description of fishing,
the instructor teaches the learner to fish by
explaining the steps and then standing by
to answer questions as the hungry would-
be fisherman baits his hook and finds his
own style of casting the line. The evidence of
“fishing” success is measured by the instructor
and the desired – did the man catch a fish?
Was it the right kind of fish? Was it
done in the appropriate amount of
time? All measurable, all relevant to the
competency of fishing, and all
guided. But best of all – the man
was catching fish while
he was learning to fish.
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5
REALIZING THE BENEFITS OF
COMPETENCY BASED TRAINING
IN HEALTHCARE
Paying for Performance
There is no question about the benefits of
CBT for a healthcare facility as one of the
fundamental advantages to this training
approach is the ability to measure the outcomes delivered
after training and during the performance period that
follows. With the “Pay for Performance” movement in
healthcare, it is natural that we would seek a shift from
measuring skills – and paying for skills – to measuring
outcomes and paying for performance. However, some
clinicians may see this competency based approach as too
rigid – all procedural regulation with no room to engage
in creative problem solving. So how do you get them to
swallow the medicine?
The key lies in leveraging their natural passion for the
career track they have chosen and engaging them in
meaningful learning. In this context, meaningful refers to
the direct application of the learning upon a problem facing
them today. Clinicians want to be effective in their jobs.
By targeting the CBT to focus on the competencies that
are immediately relevant, you are not just reinforcing the
learning with on-the-job application that improves retention,
you are also giving the clinician a skill they can immediately
apply to barriers preventing them from feeling effective
and capable in their chosen profession. Overcoming those
barriers has a built in reward and will motivate them to
continue with the learning as it has proven to be relevant
and beneficial to what they really care about – doing their
jobs well.
This brings us to the next point – motivation is deeply tied
to building the Competency model correctly. Weighing
too heavily in areas that are not immediately relevant
could actually demotivate a learner. Competencies must
be clear, relevant to the clinical context where the job
is held, and measurable in a way that the learner feels
is fair. In many instances, the broad application of core
competencies for a practice area can be structured into
a learning journey that walks each clinician through the
competencies in the personalized order that reflects
what is most relevant to them in their own career path.
This personalized path may help the clinician to feel
that the CBT approach is targeted, relevant, and helpful
throughout the full curriculum suggested.
A Relevant Learning Cycle
That Never Stops
We are familiar with the growing shift in
postgraduate medical education where Competency Based
Training is fast becoming the norm. However, a full career-
long focus on Competency Based Training would allow all
clinicians to blend the practicality of vocational training—
learning the skills necessary for each new position, new
specialty and new emerging standard—with the relevancy,
learner focus, and immediate applicability to business
contexts that is valued in Adult Learning. This approach
would be engaging, immediately useful, and empower
clinical education—and it would be delivered just-in-time.
Building on the tenants of Andragogy, the Competency
Based Learning approach gives busy professionals a
way to learn enough to accomplish a discrete outcome
relevant to their daily responsibilities. Competency Based
Learning focuses on creating environments where learners
can identify where there are discrete areas that they need
to build competency. Systems and training approaches
can then use multiple ways to transfer knowledge and
provide opportunities for application and measurement of
outcomes in a structured (often auto-didactic) evaluation
and correction cycle. Once the discrete competency is
mastered and demonstrated, the next is layered on top and
the cycle continues until all of the competencies needed
for the job at hand are mastered.
Cost Savings
From the organizational perspective,
there is a lot of benefit to building a
competency based learning approach.
First and foremost, it is expensive to put people into the
classroom seats for training. Not only do you often pay
them to learn, but you are usually paying for the backfill of
their responsibilities on the floor as well.
And this is the crux of the issue with most traditional
training. Formal classroom training programs are painted
with broad strokes. They cover all of the topics in a broad
area with the hope that whatever needs the training
participants have will all be covered in the single training
session. This is a very unfocused method of teaching.
It also puts the focus on preparatory learning—learning
ahead of the exposure to a context where you can apply
the knowledge.
5. Ebbinghaus, Hermann. Memory: A contribution to experimental psychology. No. 3. Teachers college, Columbia university, 1913.
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The work of Hermann Ebbinghaus on human memory and
specifically the “forgetting curve” shows the degradation in
information retention over time. Ebbinghaus’s theory tells
us that if the knowledge is not reinforced with application
it will often erode to a point where it has not been learned
at all. That is not time or money well spent.
CBT Targets Learning
where it is Needed Most
With a more targeted learning program,
addressing the discrete competencies
necessary to do a daily job, the learning focus is highly
relevant. Knowledge is given, and then reinforced through
hands-on application of the knowledge to a real world
problem. The training path is also shorter, as it focuses on
those competencies the individual learner needs to evolve.
A shorter training path also means less time away from the
job. As described above the CBT approach is more cost
effective, as is the evidence based measurement of the
learning outcomes because it gives organizations a level
of confidence that the discrete competency has truly been
learned by the individual. Time and money can be clearly
shown to have a direct impact on job output.
CBT is Flexible and can
take place Online
In many organizations modern
Competency Based Learning happens
online meaning that time away from the job can be
reduced even further. By creating a learning management
system that tests for discrete competency needs up front,
the results can focus the training path for any user. By
supporting blended learning environments, the upfront
knowledge acquisition can be completed online, with
follow-up simulations and team training exercises to
provide evidence based outcomes to measure the learning.
Transitioning away from classroom or grand round “seat
time” measurements for continuing education, CBT favors
a flexible structure that allows clinicians to pursue learning
that is relevant to their clinical job, allows progress to
be measured in the criteria associated with each of the
discrete competencies and also is measured immediately
in performance on the floor as relevant knowledge is taken
back to patient care.
 7
Successful CBT Programs ABOUT LAMBDA SOLUTIONS
will be supported by Learning Founded in 2002, Lambda Solutions is a full service
Management Systems agency focused on reducing the cost of your learning
and training while increasing the value of your human
Clinical education will be transformed by learning
capital. To help you achieve this, Lambda offers powerful,
management systems that provide access to the
flexible and open source talent and learning management
evaluation and personalization of training paths focused
systems—Totara and Moodle—which are 80% more cost
on discrete competencies with clear measurement criteria.
effective and match leading systems feature for feature.
Providing that access any time, in any place, and providing
By managing your system in the most powerful and
flexibility in the way that knowledge can be applied, is a
secure cloud hosting environment worldwide, Lambda
proven strategy for engaging clinicians in learning. This
Solutions reduces your IT operating costs by more than
is because it engages them in real-time problem solving
40%. And, with responsive and prove expertise from over
relevant to the problems that they will encounter either
600 customer implementations, our HelpDesk ensures
today or tomorrow. For more information on Totara, a
fast and efficient Totara and Moodle set-up so your time
learning management system that provides an organized
to use is within weeks not months. More than half a million
system for competency based training, give us a call.
people learn on Lambda’s managed hosting platforms
This leads us to the Holy Grail of training—training that everyday—let your learners be one of them!
is fully integrated into the workflow. In a recent article,
Lambda Solutions is focused in healthcare, education
Jonathon Levy encourages us to “skip the classes and
and corporate training providing solutions for
workshops and embed the needed information directly
enterprise-class customers such as Mt. Sinai Hospital,
into the tools that people use to do their job”6. By
Children’s Hospital of Los Angeles, Rutgers University,
integrating talent development systems into workflow
and Four Seasons Hotels and Resorts. Lambda Solutions
tools, we can bake the training and the competency based
is a Totara Platinum Partner. The company has offices
learning right into the process of doing work. As we watch
in the United States, Canada and Europe. For more
the CBT model develop over time, Levy’s predictions
information, visit www.LambdaSolutions.net.
may be part of the future application of CBT for clinical
positions. It is not out of the question to imagine that this
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In the meantime, Competency Based Training continues to
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be adopted widely, driven by the changing landscape and
payment models of healthcare, and the need for outcome
based measurement to improve patient safety.
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COMPETENCY
BASED
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LMS

6. Levy, Jonathon; Training and Development Magazine; http://www.astd.

org/Publications/Magazines/TD/TD-Archive/2014/08/Webex-Smart-
Tools-Smart-Jobs?mktcops=c.learning-technologies~c.learning-and-
development&mktcois=c.innovation~c.e-learning~c.tools-platforms~c.
training-delivery

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