Monthly Archives: August 2017

Simulation Programs, Hospitals and Health Systems: Where is the organizational fit?

Some excerpts taken from a plenary speech I delivered in Taipei, Taiwan recently to healthcare leaders and education directors. It is important that simulation programs position themselves within complex healthcare systems to be able to deliver maximal benefit to the organization. High performing simulation programs need to deliver more than educational resources to the organization.





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Embedding Simulation into Patient Safety

Excerpts from a recent plenary presentation regarding embedding simulation into patient safety as related to the Swiss Cheese model from Dr James Reason.

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Operational Realities and Simulation Program Design for Practicing Professionals

Doctor Instructing Nurses In Hospital RoomAs educators involved in the design of simulation based activities we like to have a clear understanding of what we are trying to accomplish in a given educational encounter. We often talk about beginning with a needs analysis to determine what will bring most impact. We ideally design learning objectives that are well matched to our intended participants. We execute scenarios and debrief them expertly covering all the relevant topics. While this is an idealized workflow for the development of a simulation encounter, it doesn’t always translate to reality when we attempt to execute a program. Our success may be in the ability to creatively adapt our educational program to the realities of the environment and situations that it will be conducted.

One reason that such a discordance can occur is that we fail to consider operational realities into the design of our educational gems. The adage of trying to stuff 8-pounds of learning into a 5-pound bag is well known. It also seems to be a constant struggle in the design of simulation programs where there is often an urgency to “teach them everything they need to know.” However, such attempts can put students, faculty members, and programs at disadvantages. This can come from many different perspectives ranging from failing to accomplish the intended learning goals, erosion of confidence in the program, the faculty, as well as hampering the ability of the program to make change as designed and/or desired.

Considering operational realities of simulation program design are critically important when creating programs that are aimed at the training of practicing professionals. In particular, when designing those programs that may interrupt or be embedded into the normal workflow of the caring of actual patients.

Let’s consider the design of a program that provides a mock-resuscitation scenario conducted impromptu in an ICU that the unit nurses, physicians and respiratory therapists (RT) will participate.

During our needs assessment and our expert opinions of the design of an educational encounter we may imagine many things that need to be covered during the debriefing for a specific topic. Such topics may include the demonstration of knowledge of the therapeutics that the patient needs from the nurse, the physician, the RT, the assessment of the patient, further testing needed, communication, teamwork and so on.

First off, is the obvious. Operational parameters should be built-in to provide criteria for a go/no-go decision for the scenario. While in this day and age all healthcare units are busy, it is not advisable ethically, or operationally from a patient safety perspective, to divert healthcare resources to a training activity if the target unit is already overwhelmed. Such decisions are ideally achieved in advance during the program design phase through a collaborative discussion involving the simulation and the clinical unit manager. They are best defined in advance depending on the overall educational and improvement goals.

The obvious next consideration is the time that is available. This includes time for the scenario as well as the debriefing. Carefully considering the needs of the learners as well as the dynamics of the operational realities is particularly important. Additionally, factoring in how the scenario is embedded into the overall curriculum is critical.

For example, is this a scenario that is once and done? Meaning that the participants will not likely encounter any further simulations until next year. Or is this a recurring educational effort in this ICU where we will have repeated engagement with the care providers over time. This could have significant bearing on the length of time you spend in various topics during the debriefing.

Continuing with our above example of the ICU resuscitation scenario it is common to have much less time than anticipated to conduct the debriefing. Design considerations should include a prioritization of learning topics that adapt to the operational reality. For example, imagine there is a fifteen-minute period of time that occurs after the scenario for debriefing and then everyone scampers off back to work. Let’s pretend there are learning objectives SPECIFIC to nursing care, physician care and care provided by respiratory therapy. Then there are learning objectives around communication and team work that cut across the disciplines. We would want to design the debriefing discussion to focus on those topics that are multidisciplinary and would maximally benefit from a group discussion.

Thus, in this case, it would likely do a disservice to the domain specific objectives or learning points by trying to artificially shorten each one AND then also try to cover communications and teamwork. (In other words, none of the objectives get covered very well.) We may be better off focusing on the communication and teamwork while the nurses, physicians and therapists are all still in attendance as that would likely give the biggest bang for the buck for that operational circumstance.

Having achieved successful accomplishment of the communications and teamwork objectives we now need to turn our creative curricular designing efforts to the domain specific learning objective. This is why it is critical for simulation educators to think more-broadly and realize that they are healthcare educators that use simulation as part of a learning method.

As part of our overall design of the goals for the entire learning activity, perhaps we could email the nursing specific protocols or highlights of the intended learning to the nurses after the event. Or perhaps direct them toward a brief on-line learning encounter specific to the goals of the scenario. We could do the same for the physicians and the RT’s. The content in this case would be tailored specifically toward the care providers and will likely seem more relevant to the recipient.

I am of the opinion that once the care team experiences the simulation they will be more receptive to and engaged in the downstream feedback that they may receive after the encounter (meaning simulation and debriefing) is completed.

I believe this is true particularly if the information is specific to the practice domain, succinct, relevant, and tied directly to the simulation activity. Their participation in the simulation likely helps them to realize areas needed for self-improvement as well as an overall heightened engagement in the learning process. Contrast this thought to the education motivation, or lack thereof, that is realized through a list of mandatory on-line training programs that one gets assigned annual as part of a regulatory requirement. (Can you say annual torture?)

So, as you move forward be sure to consider operational realities and try to remain nimble on creative ways to accomplish the learning. It may be different then your initial vision of the activity. Simulation education creators should engage collaboratively with operational leaders particularly if the encounters are embedded into the mix of healthcare operations.

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