Step 1. Needs assessment/statement

The needs assessment helps us answer ‘Why’? In the case of curriculum development, the answer may be quite broad and should point to the distinction between the current teaching strategy surrounding a learning need and what should be changed about it.2 At the start, it is wise to consider whose needs are the priority. This may start with a learner’s needs (either attitudinal and knowledge-based needs, readiness to learn or timing), but likely extends to the patients and communities for whom the learner will be caring. When justifying time or funding, an articulation of how this curriculum might meet regulatory or board requirements can be useful.

The mechanics of a needs assessment includes readily available information and the collection of new information.2 The acquisition of new information can be structured (survey or medical knowledge assessment), semi-structured (series of discussions or a call to action based on sentinel event), research/data driven (data on learners’ performance or clinical quality data) or based on regulatory requirements.3–5

A very basic example (see table 1),2 experienced by one of the authors was the identification of a gap in knowledge leading to the development of a newly structured educational activity.

Once the needs assessment is finalised, and the needs have been articulated, a rationale statement should be agreed on.3–5 This rationale statement is 1–3 lines that articulates the fundamental findings from the needs assessment to guide the development of the curriculum. The rationale statement can then be used to keep the curriculum on task. It is intended to be modified only if there is a serious oversight in the development. In this way, the needs assessment and rationale statement can truly render a solid foundation for the curriculum in development.

Step 2. Determining and prioritising content

This is the first step in beginning to articulate what is going to be included, a general description of the content, along with a prioritisation of that content. In the example of the communication skills curriculum referenced above, the content was determined both by working backwards from the milestone goals and also from reviewing what experts in the field have identified. In some cases, there will not be expert knowledge or milestones to work from, and in these cases, original research might be needed, such as surveys of experts in the field, or analysis of conversation around a difficult topic needing to be addressed. An example of this last strategy can be seen in a recent publication on addressing the topic of racism in medical education (see table 1).2 6

Step 3. Writing goals and objectives

Although goals and objectives are often thought of as similar, there is a nuanced difference to them that should be considered. A goal is a general statement of the knowledge, skill or attitude to be attained by the learner and is often a description of the important content as determined in your earlier steps. In contrast, an objective is a specific measurable skill or attitude that the learner will be able to demonstrate at the end of the educational activity. While goals are helpful in defining the overall strategy, the objectives are necessary in order to measure if your curriculum is successful.

While writing goals is relatively simple, as they are general statements of knowledge, the writing of an objective is more challenging and will be discussed in more detail. Objectives need to be understood by both learners and instructors, and to that end, need to be as specific and measurable as possible.

This statement asks us to simply consider the basic elements of an objective: ‘Who will do how much of what by when? (page 51)’.2 Perhaps, the most important component of this is the verb, or the ‘will do’ piece, which should be open to as few interpretations as possible. Good verbs to use may include ‘list’, ‘define’, ‘execute’ and ‘differentiate’, as opposed to verbs that should be avoided such as ‘know’, ‘understand’ or ‘appreciate’, which are vague and difficult to measure.7

Table 2 below provides examples of how an important content area is translated into a goal and an objective and some examples of both poor and well-written objectives.

Step 4. Selecting teaching/educational strategies

Selecting the teaching or educational strategies to deliver new curriculum helps predict its success. One early alignment to consider is the congruence between the topics (knowledge, affective or psychomotor) and teaching method.2 Options for curriculum delivery are summarised in table 3. When selecting a strategy, it is helpful to consider both the learner(s) and the teacher(s), as well as the material. If the relationship between teacher and learner is intended to be formative, or longitudinal, the strategy may favour the person teaching and likely incorporates some element of discussion. If the priority is garnering a basic level of skill/understanding of a stable topic and potentially assessing that knowledge, a web-based tool may be the right approach. When planning multiple sessions, it is helpful to consider overall structure to promote cohesiveness, but with variability between the sessions to meet the educational goals and objectives for that session. In Family Medicine, we are also especially attuned to consider the role of the team in implementation of new teaching, as team-based care is central to the practice of Family Medicine. This may push us to consider cross or interdisciplinary educational approaches. See tables 2 and 3 for examples.

Step 5. Implementation

The implementation phase can be divided into several different steps starting with the identification of resources. Resources fall into four basic categories which include personnel, time, facilities and funding.2 Personnel are the teaching faculty, administrative support, informational technology (if needed for computerised modules) and patients (if curriculum involves direct patient care). Time is often one of the most precious resources, given all that learners have to accomplish in the short time they are in school or residency, and includes didactic time as well as the time of all the personnel listed above. Facilities are the spaces such as classrooms or clinic sites where the learning will take place. Funding is all the direct financial costs or faculty compensation, along with any other hidden costs. Utilising existing resources (educational materials already developed, time already put aside in the curriculum, rooms already dedicated to teaching) can lower costs and increase the likelihood of success.

The next step is obtaining support internally from stakeholders to the curriculum, and at times externally, when funding or support for other resources is needed. Stakeholders are those most directly impacted by the curriculum and often include learners, the faculty doing the teaching and any administrative personnel needed. Having their support and enthusiasm is crucial to the success of any curriculum. External support becomes necessary when resources beyond what is available to the programme or school are needed, either financially or in terms of facilities. A great example of finding resources and support is seen in Noriea et al, where a curriculum to teach health disparities was developed which used nationally developed resources and partnered with local clinics for the offering of clinical experiences.8

The next step is the design of the management plan, which details the actual step-by-step process of how the curriculum will be delivered. This should include the who, what, where and how for each component or teaching strategy. This is where anticipating any barriers that might arise during the role out of the curriculum may be anticipated in advance, with a plan to mitigate the barriers. A great example of this level of detailed plan is also seen in Noriea et al’s study where they include a table that details out each didactic component of their curriculum, along with the assignments to the students and the teaching strategies being employed.8

The last step in implementation is the actual role out. This is where all the work you have put in so far will pay off. It is important to pilot sections of the curriculum to enthusiastic stakeholders initially to both gain more support and also to identify and rectify any barriers to implementation so that the odds of success are increased. This pilot can be followed by a phasing-in, where new portions are added until the full curriculum is implemented.

Step 6. Evaluation

Evaluation is a process of determining the merit, value or worth of a programme.9 Evaluation is often considered the final phase of curriculum development, but it should span the entire process and is often cyclical and iterative. Two major types of educational evaluation included here are formative and summative.10 Formative evaluation is conducted early on, or at key points, during a programme in order to inform changes and identify opportunities for improvement. Summative evaluation, however, is an evaluation of outcomes that occurs in a more final phase of implementation. Summative evaluations are useful to make a judgement about whether a curriculum was successful, and for whom, in order to report back to stakeholders. A preparatory step is to consider early on whether to conduct either formative or summative evaluation, or both. Drawing from utilization-focused evaluation11 and the steps in any research process,10 the major steps of an evaluation are: (1) develop a clear plan to use evaluation results; (2) determine how to measure objectives; (3) collect data; (4) analyse data and (5) use evaluation results by applying lessons learnt.

Although it may seem counterintuitive, the first step of an evaluation is to consider who will use the evaluation results and how. Simply, an evaluation that is never used will not be worth the effort. A utilization plan should include and describe the dissemination plan (eg, a written report, presentations, discussion sections) and the specific audience for each. In addition, the utilization plan should detail what types of actions may be anticipated based on the results. For example, could the report lead to changing, ending or expanding the programme? The actual utilization occurs after the evaluation, but having a clear plan ahead of time can help to ensure the evaluation will actually influence the curriculum, with the goal of improving the learning itself, the experience of the learners and teachers and ultimately, patients and community members who will benefit from more skilled providers.

The next step is to determine how to measure learning objectives. This process is often called assessment and consists of operationalising objectives and determining how to collect data. Consider the learning objective: ‘The learner will be able to explain the difference in the pathophysiology of acute versus chronic pain’. Considerations include how to assess this objective, such as through tests, or other learner output. Of course, it must be more specific, such as whether the test is written or uses another form, the timing of the assessment, whether it will be repeated and what is considered proficiency. A norm-based assessment might compare student performance to other students to determine relative differences. A criterion-based assessment would have a particular cut-point that determines acceptable performance.

With planning efforts completed, the next steps are to collect and analyze data. Data collection might involve tests, interviews with students or instructors, performance assessments or other methods.4 10 12 When using quantitative data, analysis occurs after all data have been collected. Analyzing pre-post differences can be particularly helpful in assessing whether learners may have changed. When using qualitative data, analysis begins as data are being collected and tends to be more iterative, with analysis informing subsequent data collection.13

The final step is to use the evaluation results and apply lessons learnt to the curriculum. Guided by the utilization plan, this step consists of disseminating information to relevant stakeholders, and making use of the results to improve learning outcomes or the learning experience. This feedback and use of evaluation results is critical for continuing improvement of medical or professional education. Thus, the evaluation process often repeats as educators apply lessons learnt and then evaluate and iterate the improved curriculum.