Skip Navigation Archive: U.S. Department of Health and Human Services U.S. Department of Health and Human Services
Archive: Agency for Healthcare Research Quality
Archival print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to for current information.

Patient Safety Training Evaluations: Reflections on Level 4 and more (Text Version)

Slide presentation from the AHRQ 2009 conference.

On September 15, 2009, Eduardo Salas, Ph.D. made this presentation at the 2009 Annual Conference. Select to access the PowerPoint® presentation (346 KB).

Slide 1

Patient Safety Training Evaluations: Reflections on Level 4 and more.

Eduardo Salas, Ph.D. 
Department of Psychology &
Institute of Simulation & Training
University of Central Florida


Slide 2

Purpose Today.

  1. Challenge
    • Offer some observations & myths
  2. Proposal
    • Time to think differently
  3. Guide
    • Best Practices


Slide 3

A few thoughts about the science of training.


Slide 4

What do we know about training?

  • The science has evolved & matured.
  • The past decade-an explosion of research!
    • More empirical work
    • Research conducted in organizations
    • New, more & deeper theories and models
    • More evaluations reported
  • Huge military investment.
  • Influence of cognitive psychology.
    • Expertise


Slide 5

What do we know about training?

  • Much progress in.
    • Organizational needs analysis
    • Cognitive task analysis
    • Transfer of training
    • Instructional design
    • Feedback
    • Training evaluation
    • Simulation-based training
    • Individual characteristics


Slide 6

Observations From the Science

  • The quality and quantity of research has increased
  • The cognitive and organizational concepts is revolutionizing the field
  • The field is multi-disciplinary
  • The influence of technology will continue
  • Training is part of an organizational system
  • There are more guidelines, tools and approaches for practitioners


Slide 7

Framework for Training Effectiveness


Slide 8

Myths & misconceptions about training.


Slide 9

The Simplistic View of Training

  1. Unskilled Worker
  2. Training Program
  3. Skilled Worker
  • Uninformed About the Science
  • Erroneous Assumptions


Slide 10


Everyone Who Has Ever Learned Anything is a Training Expert


Slide 11


  • Opinions aside, training is a behavioral/cognitive event that can be structured to empirical investigation.
  • There is a science of training that should be exploited to optimize training design.
  • Processes exist which, if appropriately and consistently applied, can help to ensure that effective training is designed.


Slide 12




Slide 13


  • Experts do not have access to their own expertise.
    • Knowledge becomes "compiled"
  • Task experts do not necessarily understand the learning process or how learning progresses.
  • Task experts are crucial, but they must be paired with learning experts.
    • Partnership

Slide 14


Reactions to training = Learning



Slide 15


  • Just because trainees are having fun, doesn't mean that they are learning anything.
    • Very little or no relationship
  • "Instrumentality" does seem to be a factor.
    • Does seem to be related to learning
    • Affects motivation to learn
  • Simple measures of training outcomes are insufficient to judge training quality.


Slide 16


Learning will translate into Behavior change


Slide 17


  • Training transfer is a very complex phenomenon.
  • Some of the factors:
    • Supervisor Peer support
    • Climate for Transfer
    • Opportunity to perform/practice
  • Even when trainees demonstrate learning after training, it does not mean that they can or will transfer back to the job.


Slide 18

Thinking Differently about Training Evaluation.


Slide 19

Kirkpatrick's Model of Training Evaluation

  • Level 5 - Return on Investment
    Was the training worth the cost?
  • Level 4 - Results
    Did the change in behavior positively affect the organization?
  • Level 3 - Behavior / Training Transfer
    Did the participants change their behavior on-the-job-based on what they learned?
  • Level 2 - Learning
    What skills, knowledge, or attitudes changesd after training? By how much?
  • Level 1 - Reaction
    Did the participants like the training? Whad od they plan to do with what they learned?

Slide 20

This Model.

  • Has served as well!
  • Used, misused & abused!
  • Created a misconception that Level 1 is all one needs
  • Over simplified evaluations
  • Links among levels, weak
  • Minimal impact of training on Level 4
    • Clinical outcomes


Slide 21


What if we reverse Kirkpatrick's model?


Slide 22

Start as Level 4.

What are the outcomes/results we want out of this training?


Slide 23

Level 3: Given these wanted outcomes.

What behaviors we want/need of our trainees?


Slide 24

Level 2: Given these needed behaviors.

What KSAs we want our trainees to have?


Slide 25

Level 1: Given those KSAs.

What reactions we want our trainees to have?


Slide 26

What do you get by reversing Kirkpatrick's typology?

  • Precise learning outcomes
  • Better links among Levels
  • Better link of training to outcomes
    • Clinically-relevant
  • Hints for performance assessment/observation
  • Tailor training program better
  • Better accountability


Slide 27

Best Practices after Training Evaluation in.Healthcare, Aviation.


Slide 28

Best Practices

  1. Even before designing your training, start backwards: Think about evaluation first.
  2. Accept that effective training does not exist without effective evaluation.
  3. Strive for robust, experimentation design in your evaluation: It is worth the headache.
  4. When designing your evaluation plan and metrics, ask the experts - your frontline staff.
  5. Do not reinvent the wheel, leverage existing data relevant to training objectives.


Slide 29

Best Practices (cont)

  1. When developing measures: Consider multiple aspects of performance.
  2. When developing measures: Design for variance.
  3. Evaluation is affected by more than just training itself: Consider organizational, team, or other factors which may help (or hinder) the effects of training (and thus the outcome of your evaluation)
  4. Engage socially powerful players early:
    Physicians, nursing & executive management is crucial to evaluation success.


Slide 30

Best Practices (cont)

  1. Ensure evaluation continuity: Have a plan for employee turnover at both the participant & evaluation administration team level.
  2. Environmental signals before, during, and after training must indicate that the trained KSAs & the evaluation itself are valued by the organization.
  3. Get in the game coach! Feed evaluation results back to frontline providers & facilitate continual improvement through constructive coaching.
  4. Report evaluation results in meaningful way.


Slide 31


  • Avoid Myths!
  • Training Evaluation matters!
  • Reverse Kirkpatrick's typology!
Current as of December 2009
Internet Citation: Patient Safety Training Evaluations: Reflections on Level 4 and more (Text Version). December 2009. Agency for Healthcare Research and Quality, Rockville, MD.


The information on this page is archived and provided for reference purposes only.


AHRQ Advancing Excellence in Health Care