The True Value of Simulation into the Future: Assessment. Still.

I recently had the honor of delivering the keynote address at the Annual Meeting of the Association for Simulated Practice in Healthcare (ASPiH) in Nottingham, England. ASPiH has established itself as the simulation association for the United Kingdom and is certainly one of the premiere societies in all of Europe dedicated to simulation. I was asked to talk about incorporating simulation into the assessment of professional practice. The development of the talk gave me a good bit of time to introspect, reflect and consider many of the possibilities.

One thing that became clear in my mind though is a reinforcement of thoughts that the true value over time that will provide the necessary return on investment for simulation is assessment. The ability for simulation to provide opportunity to assess the competency of individuals whether they are completing undergraduate programs leading to a certificate, degree, or some sort of license in healthcare, or they are practicing professionals on the front line is critical to the future of healthcare as well as the community of simulation.

The next decade of global healthcare in the developed world will shift to have tremendous focus on improving quality, value and safety like no other era in the past. Multiple factors are driving this agenda ranging from a demand from the public to improve healthcare as well as a continually rising expectation in excellence, a realistic need to lower the cost of care, the gathering of transparency of quality and safety data just to name a few. Improving the demonstration of clinical competence amongst individuals as well as teams is linked to each and every effort to improve care. Yet despite hundreds of years of evolution of the teachings of healthcare professions we still have not yet developed widespread, valid, reliable performance exams that evaluate the application of knowledge.

So why aren’t more people using simulation for assessment? The answer is complicated. I believe part of it is the assess-o-phobia that I have mentioned in a previous blog posts. Next, defining measures of clinical performance is in general, difficult. In my opinion to develop assessment tools in simulation is much harder than any other facet involved in the creating of simulation scenarios and associated learning programs. This presents a formidable barrier. Lastly, there is a pervasive discomfort felt by many people associated with creating assessment tools that would assign a “grade” or something similar to a simulation.

It is rather interesting with the comfort that we deal out a written examination often times made up of multiple choice questions that we have developed either personally or with groups of people and use it as a knowledge assessment tool. While I’m not disputing the ability of the written test to serve as an assessment of knowledge, the striking thing is the contrast in the discomfort to developing such a measurement tool for simulation, or even actual clinical operations or provision of care of real patients.

Some people profoundly advocate simulation should be used for assessment because it is not appropriate tool, and others feel that it violates the safe learning environment. I think as we shift to a patient centric approach to simulation we should be able to create a reduction in this reluctance that allows assessment forward. In fact, I always find it interesting to point out to people during debriefing training programs, particularly those that are vocal against concepts of assessment, and let them realize that when they watch a simulation and then conduct and/or facilitated briefing they have actually already performed assessment in their minds. The very items that they have formed an opinion on, or “assessed” will play a part in the educational strategy that should ultimately reinforce what participants did well and encourage change in the areas where deficiencies were noted that will lead to an effective debriefing and the accomplishment of learning objectives.

Allowing participants to demonstrate competence could be one of the most important parts of the value equation for simulation. Manager and leaders of healthcare providing institutions are grappling with ways to improve quality and significantly improve patient safety all over the world. A patient centric approach to simulation would certainly suggest that as well.

This inevitably will help us in making stronger arguments for the case for simulation. At the moment many people try to sell the idea of simulation to their leadership. This creates thoughts and visions of expensive investments in technology and the daily pains of leaders. If we shift the point of focus point our sales pitch pivots to the selling of the concept of excellence, improved patient care, and safer patient care it will far better align with the pain points of those running healthcare systems. That becomes harder to deny!