What knee surgery taught me about access to education

Unplanned additional costs and complicated, unexpected additional steps are issues in both healthcare and education. Instead of finding ways for people to navigate these challenges, true change will come when we find ways to eliminate them. And, when we can’t, finding ways to ensure they aren’t unplanned or unexpected.

About six months  ago, I had knee surgery to correct the damage done by years of athletics.  I anticipated the issues that come with any surgery, but what I didn’t realize was how closely the process would mirror the experiences of so many in the United States attempting to access education and afford educational necessities like textbooks.

The “hidden” costs of surgery, college

Luckily, I have good insurance, so the surgery itself only cost $200. A good deal, right? It is, but what you don’t think about is all of the additional costs that no one tells you to plan for, such as:

  • Special soaps and bandages
  • Special food/drink
  • Ice for an ice machine
  • Prescriptions for after the surgery
  • Over the counter medicines for after the surgery
  • Physical therapy and follow-up visit co-pays

These “unplanned costs” totaled over $2,000.

Often in the Open Educational Resource realm (OER) we hear the argument, “Tuition is the huge cost, so why not work on that instead?” Indeed, tuition is a huge cost and does need to be addressed. Thankfully there are groups that are addressing this very thing.

But the students that get past the tuition hurdle find themselves facing unexpected costs that can make or break their success. The College Board does a great job of estimating some of these, but so many people just look at the bill from the college or university and think “this is the cost” when in reality, it isn’t the cost. They’ve planned for that big cost, some saving for years to afford it, so while a $100 extra may not seem like a lot, when you find yourself in a position where “I have no money left” and someone says “here’s another $100 you need to spend,” all of a sudden $100 is the straw that broke the camel’s back and causes someone to give up.

When I was working at a community college, I saw how quickly an unplanned, hidden cost of college could impact student enrollment. The state I worked in passed a law requiring each community college student to get a meningitis vaccine before coming to college.  But here’s the kicker, the shot was $125. And that was the last straw for these students. They’d given all they had to give, paid all of the other fees, there simply wasn’t $125 left. And so, students started dropping out in record numbers.

Hey look! More hoops to jump through

If there’s one complaint I have against doctors in general, it’s that they can be notoriously bad about communicating all of the steps and expectations of something like a major surgery. Or, as some have posited, this may be intentional to keep you from backing-out, but I digress.

Major things my doctor missed telling me:

  • There’s a pre-op appointment you must attend, during working hours. In total, this’ll cost you an hour of driving (and gasoline) and 2 hours at the appointment, for a grand total of 3 hours.
  • You can’t drive for at least 10 days after the surgery. To really get the context of this shock, we found this out about 20 minutes after I came out of surgery. Imagine someone walking up to you right now and saying “Starting right now, you can’t drive for the next 10 days.” But wait Nicole, you say, shouldn’t that have been obvious since there’s crutches involved? Not really. I’ve been able to drive with a right foot injury and crutches before.
  • You’ll be averaging 2-3 follow-up appointments per week for 4 weeks. All must be done within normal working hours.
  • You’ll be averaging 2 physical therapy appointments per week for 12 weeks. Each appointment will take 1.5 hours plus 60 minutes of driving, for a total of 5 hours per week.

I’d like to take a moment to especially focus on bullet points two and three above, I couldn’t drive and I had to go to four appointments per week during working hours. This meant that my now-husband would have to take off from his work to drive me, or I would need to incur ride-sharing costs. On one hand, this really made me grateful for the flexibility in both my and my husband’s work, that we were able to do so many things within normal working hours with no issue. But it also left me wondering, how do people manage that don’t have someone who can do this for them and don’t have the money to pay for ride sharing?

This reminds me the processes that a student has to go through during higher education.  When I was the marketing director at a community college, I asked a friend of mine, who was enrolling in college, to let me shadow her during the whole process.  The first appointment to get her enrolled took 4.5 hours, the second one took more than 2. Orientation was a third night (did I mention she has 3 small children?) and was another 2 hours, which culminated in us both staring at a computer screen, trying to figure out to build her class schedule, at a total loss. I can see why so many give up.

tl;dr (in summary)

Unplanned additional costs and complicated, unexpected additional steps are issues in both healthcare and education. Instead of finding ways for people to navigate these challenges, true change will come when we find ways to eliminate them. And, when we can’t, finding ways to ensure they aren’t unplanned or unexpected.

 

Implementing change series: It’s all or nothin’, baby

“If you want to make a significant change, it’s all or nothing, baby,” was my final thought during a presentation about increasing OER use at a college or university at this years CAMEX college bookstore conference.

a boy jump into a lake
“all in” by popofatticus, via Flickr Creative Commons is licensed under CC BY 4.0

“If you want to make a significant change, it’s all or nothing, baby,” was my final thought during a presentation about increasing OER use at a college or university at this years CAMEX college bookstore conference.

Instinctively, we all know this, but we favor the route of least resistance. And, in our time and resource-pressed world, with so many competing interests, it’s difficult to dedicate what we need to make something work. With that said, we have to go all-in if we truly want to make a big impact.

For example, if you want to lose a good amount of weight, you may go to your doctor and ask your doctor how to lose weight. The doctor tells you:

The people who really lose a lot of weight and keep it off do ALL of these things:

  • Eat breakfast
  • Eat primarily fruits and vegetables
  • Exercise at least 30 minutes per day, 6 days per week
  • Reduce their calorie intake by 500 calories per day
  • Incorporate weight lifting into their exercise routine 3 times per week

And yet, so many people will walk away and pick only one. They may say to themselves “Ok, I’ll start eating breakfast each day” and ignore the rest. And then they wonder why they aren’t successful! The doctor said “do all of these” and the patient heard “do one of the following” and did just that.

Similarly, you see this in advertising and marketing work often with small businesses. Their agency will say, “your goal is x and this is your program that will get you there.” The client business will then pick-out one thing on that list, do only that, and wonder why they didn’t meet their goal. The client gets mad and fires the advertising agency because their plan didn’t work. Except, the client didn’t follow the plan.

In my work consulting colleges and universities on how to dramatically increase Open Educational Resources (OER) use on their campus, I’ve found there is a specific formula to success:

  • Do a minimum of 8 direct tactics throughout the academic year
  • Have day-to-day involvement from each of the key departments for success (faculty, library, instructional design, disability services, bookstore, etc.)
  • Have one active, vocal senior administrator sponsor that will champion the initiative through communications
  • Plan your year of activities out in advance to keep a continual high intensity level of activities and communications going throughout the academic year
  • Track successes and progress by outcomes for each action: Number of faculty interested, number of faculty adopting OER, number of students impacted, student success metrics.
  • Modify your plan to favor the strategies that you are having the most success from (based on the number of faculty interested, number of adoptions, and number of students for each action)

Schools will contact us regularly saying,  “Our initiative is great, but this OER thing just isn’t working for us.” When I dig deeper, something is missing from above formula, they’ve tried to skip a step or a few steps. I’d love to tell them that less effort could get them the results they want. If it could, I’d recommend less, but the truth is, if they want significant change, they have to do all of the above.

Are there times it makes sense not to go all-in? Absolutely. You may not have all of the resources to go all-in, or your political climate may not be right yet. And that’s ok; it’s not unusual, when working with schools, that I recommend a slower approach until they are ready for the big leap. At that point, however, you need to adjust your results expectations to match your effort. And, if you want to get to the high results, work toward getting in a position where you can go all in.

Implementing change series: Timing is everything

“In most cases, our direct mail piece is worthless. But in the hands of someone who just found out  they need new windows? It’s priceless.”

An owner of a window company made this statement when one of my colleagues asked him how he thought direct mail was working for him. Obviously, we’d need a lot more data to prove that it is, indeed, providing good return on investment (ROI), but the implication of timing is dead-on.

If it’s raining and there’s a crowd, it’s a good time to sell umbrellas and ponchos. If there’s a party or event without food being served, the timing is perfect for a food truck. But, for most large change initiatives (where we’re asking for a big change and/or a long-term change), it can be much more difficult to know when the timing is perfect for two main reasons:

1. The timing isn’t the same for everyone you’re trying to reach.

In the window example at the beginning, not everyone needs new windows at once. There may be parts of the year when it’s more likely someone will find out they need new windows, but it’s still scattered throughout the year.

Similarly, in my work promoting Open Educational Resources (OER), every faculty member doesn’t consider new textbooks and alternatives to textbooks at the same time. They may consider new books every year, every three years, or whenever they decide it’s a good time to. There’s no set formula.

2. The timing depends on external factors (usually beyond your control).

For someone to decide to make a change, usually there’s some sort of event that precedes that decision. Again, looking at our windows example, a homeowner considers new windows when they are told they need them by a home inspector or if their current set of windows is damaged somehow.

With OER, the event could be a complaint of the high cost from a student, or a publisher raising their prices again, or a technical error with the publisher’s system, or a discussion within the department of how to reduce high drop/fail rates.

Sometimes you’ll be able to anticipate these events happening, like monitoring publisher prices, but many times you may not even know they’ve occurred.

Being in the right place at the right time

A young man jumping off of sand. The timing is such that you see a trail of sand.
“jump” by Barry Badcock, via Flickr Creative Commons is licensed under CC BY 4.0

The simple solution would be to shout from the rooftops about the change you’re encouraging all the time. But, in practice, this is not only costly, but can leave those that you are trying to reach tone-deaf to your message. Think about that person who sends you too many irrelevant emails, do you read them all anymore? I’m guessing not.

The better solution is a pulse schedule. This is where you keep a low hum of communication about the change out there at all times, but you amp-up your messaging around those critical events and external factors you can predict.

A great example of a pulse schedule is candy manufacturers. In the U.S., candy manufacturers are always advertising, but for a couple of weeks (lately a few months!) leading up to major holidays (Halloween, Christmas, Easter, Valentine’s Day)? They are everywhere, there’s no escaping the barrage of marketing from them. These are their pulse times.

With OER, the pulses are around the academic calendar. The first pulse to encourage faculty to consider OER should happen when the faculty come to the welcome back event for faculty at the beginning of the fall semester. They are refreshed and ready to start a new year. The second pulse comes mid-way through he semester, faculty are in between their busy start-up period and exam periods. Similarly, there’s another great pulse time mid-way through the spring semester, leading up to the bookstore deadline for Fall (usually early-mid April).

By keeping a constant hum of communication about the change initiative and ramping-up (pulsing) when people are most open to the change, your can maximize your efforts for encouraging change.

Implementing change series: Combine active and passive strategies for high-impact results

Implementing a new project, cultural change, movement, etc. is never easy. But one thing that can make it easier is to define each of your strategies as either active or passive.

Dog actively chasing a ball
“photomarathon15” by Delphine Savat, via Flickr Creative Commons is licensed under CC BY 4.0

Implementing a new project, cultural change, movement, etc. is never easy.  But one thing that can make it easier is to define each of your strategies as either active or passive.

Passive vs. Active Strategy

Most of us are familiar with the line from the movie Field of Dreams, “If you build it, they will come.” This is the classic example of a passive strategy; they build the place for people to enjoy, but they make no effort to encourage people to come. The idea is, if it’s there and people want it, they will find it. While it makes for an inspiring movie, it’s only partially true when it comes to implementing change with results. These types of passive, or indirect strategies, do help support the overall strategy, but they must be mixed with active strategies as well.

An active strategy is much more direct; if you do this action, you can expect a specific result related to your goal directly from that action. For example, in a business, if your goal is to increase sales, branding marketing (image ads, corporate sponsorships of community causes) would be passive to making a sale, while sales representatives asking for purchase, coupons, special sales offers etc. are direct/active strategies.

Examples: Politics and OER

One example that I think can hit home for everyone right now is politics. Instinctively, we all know that complaining about politics or debating with our contacts on social media isn’t going to lead directly to change. We may change a mind, eventually, but that isn’t going to solve the larger issues.

  • Holding a demonstration or protest: Most people would think that this is active, but, since it usually won’t lead to changing someone’s mind or changing an outcome, it’s passive
  • Calling your elected representatives and asking them to vote a specific way on a bill: Active
  • Venting on Facebook: Passive
  • Donating to an organization who will directly go and advocate for change: Passive for you, but active in the sense that you are financially supporting someone else to directly ask for change (which you may not be able to do on your own)

In my work for Rice University’s OpenStax, I consult with colleges and universities to encourage faculty to transition to Open Educational Resources (OER), including free textbooks. As part of this process, each school writes a strategic plan that includes specific strategies they will complete to encourage faculty to adopt. 

The question I always ask them is: Does this strategy involve you directly asking faculty to adopt an OER? If the answer is yes, then you have a active/direct strategy, if the answer is no, then you have a passive strategy.

  • Having a display of OER textbooks on the campus. The faculty will see them and look at them and consider adopting them: Passive
  • Going to a faculty member’s office and asking them to pilot an OER:  Active
  • Hosting a faculty panel discussion about OER: Passive
  • Having a sign-in sheet at the above panel and following-up with each attendee afterward individually to ask them to adopt an OER: Active
  • Offering grants in exchange for adoption: Active

Combining Passive and Active Strategies for Results

The key is not to eliminate passive strategies, the goal is to mix both passive and active strategies in a way that creates momentum.

For example, this blog post is a passive strategy, but if I send it to people so they know the difference between the two types of strategies and then use that to help them incorporate both into a strategic plan, that creates momentum. If the protest/demonstration you hold drives PR and traffic to your website, you can use that traffic to ask them to sign-up for more information, sign a petition, etc. thus turning that passive strategy into a way for you to move forward with more resources and support.

The most important thing is that you identify and consider your combination of passive and active strategies and plan for effective results.

Measure success by results, not actions

Quick quiz: Which answer would you prefer if you were the one asking the question?

 

Did you get your grades up?

a) I studied more and spent more time at school.

b) Yes, my grades now all B’s or better, up from C’s and D’s.

 

Did you sell more of our company’s chocolate?

a) We spent $100,000 in advertising and had sales reps pitch over 100 grocery store chains a special chocolate package.

b) Our sales of chocolate are 50% higher this year than last year, increasing our profits by $500,000.

 

Have you impacted our school’s students with free textbooks?

a) We formed a committee that meets regularly. We also held a workshop and a webinar.

b) Compared to last year of 600 students using free textbooks, we now have 3,000 students using free textbooks, saving them approximately $300,000 this year. Our class drop rate has declined by 10%, and our students are doing as well or better in the courses with free textbooks.

 

Did you increase our employee retention?

a) We conducted a survey and found out why our employees are unhappy. We plan to have a forum to share the results. Then we will decide next steps.

b) Currently we’re losing 10% of our workforce each year. We conducted a survey and used those results to create the following next steps. Our goal in the next 12 months is to use these steps (including a forum) to reduce our employee turnover to 5% from the current 10%.

 

Actions (all a’s above) are important steps to results and they can be powerful goals on the way to results, but they aren’t results. To be truly successful in your initiative, decide what result (all b’s) you want to see, and measure your success by that.

Where is the “break” in your campaign or initiative?

A chain with a link that is broken
“Las cadenas se cortan por el eslabón mas débil / Chains break by the weakest link” by Hernán Piñera, via Flickr Creative Commons is licensed under CC BY-SA 2.0

Previously, I discussed measuring marketing/initiative success based on outcomes, not actions. So what if your campaign isn’t successful? How do you find the “break”?

The best way is to compare to previous data and industry standards.

Previous data

Previous data is your data from previous campaigns.

Examples:

  • During your last three sales events, percent of people who walked into your dealership purchased a car.
  • Percent of people who click on your web ad who then come in to purchase a car.
  • Percent of the faculty you invite to a workshop who attend the workshop.
  • Percent of the faculty who attended a webinar and then adopted an OER textbook.
  • Last year, you upped your gym time to x hours per week and lost x inches within x months.

Industry standards

Most industries, especially trade organizations, publish industry standards and research studies that show data comparison points.

Examples:

  • Health experts say that if you cut x calories every day, you will lose x pounds in a year.
  • A national statistic shows that x% of faculty who attend an Open Educational Resource workshop and write a public review of a book will adopt the book they reviewed.
  • Auto industry statistics say that x% of people who walk in the door will purchase a vehicle on that day.
  • Email campaigns have an average of a x% click-through rate.

Comparing data to find the “break”

Examples:

  • Previous car sale weekends drew in x number of people and industry standard is a closure rate of x%.
    • The number of people coming in was higher than previous data.
    • The close rate was lower than industry standard.
    • So the break is your closure rate.
  • In the past, x faculty have attended your Open Educational Resource conference, and x% of faculty who attended adopted OER.
    • The number of faculty who attended was down this year from previous years.
    • The percentage of faculty adopting was the same as previous years.
    • So the break is the number of faculty attending.
  • You’ve increased your workouts, which has worked in the past, and you’ve cut back your calorie count as industry statistics have suggested.
    • The break could be either your diet or your workouts, or something else.

A word of caution

Just because you find where your “break” is, doesn’t mean the reason for the break is easy to identify. You need to do a lot of research to find why the break happened.

For more information on this, read Addressing the Question: Measuring Advertising ROI.

From the above examples:

  • If more people walked into the door for your car sale event but less people bought, there are a number of potential reasons:
    • Your advertising campaign attracted the wrong type of people, such as non-buyers.
    • The economy is uncertain, so the industry standard closure rate isn’t accurate currently.
    • Your sales team is new and not at the normal closure rate yet.
    • The computer system to check people’s credit scores went down, which significantly slowed the sales process.
  • If you have fewer people coming to your Open Educational Resource workshop, but the rate of adoptions amongst those that do show is still good, there are a number of potential reasons:
    • The workshop was on a day with competing events going on.
    • The way you marketed the workshop didn’t work.
    • Bad time of year for the workshop.
    • Another initiative (and meetings surrounding it) are the priority right now.
  • If you increased your workouts and cut your calories but are still not seeing a reduction in your waist, some potential reasons are:
    • Not enough variance in your workouts (only doing cardio, doing the same thing every day).
    • There’s “hidden” calories, such as in sauces, that you aren’t factoring into your daily caloric count.
    • Your calories are down, but they are mostly from processed foods (high sodium, sugar, etc.).

Considering conducting a survey? Remember that what people say they do or say is important to them does not usually match their behavior

According to the Community College Survey of Student Engagement (2012 Cohort), 73% of students say tutoring is somewhat or very important. But, only 29% of students participate in tutoring at their college.  So, students say tutoring is important, but that isn’t reflective in their behavior.

What people say they do or say is important to them does not usually match their behavior

This isn’t a new phenomenon and not shocking, but it does serve as a good reminder that what people say they do or say is important to them does not usually match their behavior. Why is this? There are a wide variety of reasons:

  • They understand it’s important, but it’s just not important ENOUGH. We have a limited amount of time and so many choices of what to do with our time. It’s not a factor of what is important to us, but what is MOST important to us. I may know that exercising six times per week is important, but, after a sleepless night, I might deem skipping my morning workout and getting some sleep as more important.
  • They may feel that a behavior is important for someone else, just not them. For the tutoring example, a student with a 4.0 GPA may truly believe that tutoring is important, just not for them. They may feel it’s very important for students who aren’t making a 4.0.
  • Sometimes, it’s not socially acceptable to say something isn’t important. As an extreme example, if you conducted a survey asking if saving the lives of starving children was important, I can’t see anyone saying no. But, in reality, there might be some people who honestly don’t feel that it is important. It’s just that they don’t feel comfortable expressing that view because it’s not socially acceptable to do so.
  • They don’t really know what their behavior is. We’ve seen this in study after study. People don’t know how many calories they consume or how much time they spend on Facebook. And, the infamous advertising question, “How did you hear about us?” they don’t know (for more on this, read Addressing the Question: Measuring Advertising ROI).

How this relates to conducting surveys

So, having people self-report what’s important to them isn’t usually the best way to conduct a survey because it doesn’t really reflect behavior.  Having people self-report their behavior is slightly better, but as I said above, it has limitations as well. The best way, and unfortunately usually the most costly way, to really understand behavior is to actually track behavior.

What this says to us in higher education

Well, the good news is, we’ve done a great job of telling students that tutoring is important. The bad news is, it hasn’t resulted in students actually taking advantage of  tutoring services. It’s time to rethink our marketing strategy.

What it says to us about our own lives

What’s really important to you? Do a time and money study and you will know. Track how you spend your time and how you spend your money for a month. I’ve done this before and trust me, it’s eye-opening.