Category Archives: return on investment

Education may NOT be the Return on Investment Value of Healthcare Simulation

Its January 2019 and I am flying to San Antonio, Tx to attend the International Meeting for Simulation in Healthcare. While traveling (in coach) I cannot help but to ponder where we are in simulation and where we are going. While I feel that simulation has a bright future and will earn a deservedly important role in healthcare it feels as if it is taking longer then it should.

In my overly simplistic view of simulation I envision two primary user groups. Those who utilize simulation to teach students of various healthcare professions (schools) and those who use simulation to somehow improve the quality of the delivery of healthcare. The latter of which likely includes education of individuals as well, but more of the ilk of practicing healthcare professionals and those in the apprentice phases of training such as resident physicians.

For the purpose of this post, I will be focusing on simulation efforts associated with healthcare delivery. Toward the end, I will circle back to the “school” environment again.

As healthcare dollars for the delivery of healthcare continue to be under more pressure and harder to come by there is great interest in controlling spending and increasing vigilance by corporate overlords on money being spent on investments. Investments or capital purchases are under higher levels of scrutiny than ever before. Simulationists must bear in mind that simulation is an investment, or at the least a capital expense for healthcare systems. This realization is accompanied by the stark reality that whatever you want to purchase for your simulation efforts whether it be a single simulator, or a suite of training equipment is competing against other “things” also associated with the delivery of care. Pesky things such as CT Scanners, ultrasound machines, laproscopic surgical equipment for the operating room or dialysis machines.

Why pesky? From my view as a simulation and safety leader I am envious. I am flat our jealous that it is so easy for the purchasers of the above listed examples, it is so easy for them to justify their return on investment (RPOI). Huh? What’s that? In simple terms the ROI is the business term and calculations that allow spreadsheet drivers to determine how much profit an investment of dollars in a “thing” will bring back to the

Perhaps looking at an overly simplistic explanation will help. Let’s say somFemale patient undergoing MRI - Magnetic resonance imaging scaneone wants to put in a new CT Scanner. The costs of the scanner and installation, maintenance, staffing, and operational expenses are calculated. Then how much can be charged for each scan, how many scans can be done by the hour, and how many hours per day the scanner will be running calculates the revenue that the new CT scan will bring in. After the install is paid for, all of the rest of the revenue coming in once the expenses are deducted is profit. Thus at least when justifying the new CT scanner a requester of funds will create a fancy business proposal with colors and graphs that show money flowing in as a result of the purchase after a given period time. Purchase approved!

Now let’s take a typical cost justification scenario discussion between a simulationist (sim) and a Chief Finance Officer CFO of a healthcare system:Corporate Bean Counting

Simulationist (Sim): I’d like $250,000 to buy a simulator.

CFO: How is that going to make us more money?

SIM: To educate people and make them smarter and reduce mistakes?

CFO: We have lots of smart doctors and nurses working here. You should be reducing mistakes anyway.

SIM: There is a study showing a reduction of central line infections saves money.

CFO: Save who money? We still make money when the patient is in the hospital. And besides, your not asking for central line simulator.

SIM: But insurers are not going to pay for errors and hospital acquired infections anymore

CFO: Maybe not. We still make money when the patient is in the hospital. What’s your return on investment for this doll?

SIM: We are buying the simulator to train people to work together better. To work as highly functional interdisciplinary teams.

CFO: Right. We have lots of smart doctors and nurses working here. You should be reducing mistakes anyway. They are smart enough to work as teams. They do it every day.

SIM: But we can make the teams work better and make people enjoy working together more and improve patient care.

CFO: People like working here. You should be improving patient care. Where is the proof that simulation is needed to train teams AND that team training improves patient care?

SIM: The airlines have been doing it for years.

CFO: Where is the proof that airline simulation improves the airlines?

SIM: everybody just knows. It makes sense. And planes don’t crash as much as they used to.

CFO: Hospitals don’t burn down either. You know, we bought the new CT Scanner last year, and we have been able to make money on it. Its just like radiology predicted in their purchase proposal. Let me think about your request and I’ll get to you.

While the above scenario is somewhat tongue in cheek, sadly, I think it is closer to real life then many simulations we conduct. The fact of the matter is the true ROI of simulation is buried in nuances, potential opportunities, mired by anecdotal enthusiasm with a scant amount of hard-core evidence that provides the black and white spreadsheet numbers that make the bean counters excited.

It is upon us to figure out ways to describe the ROI of simulation more coherently, accompanied by facts and figures that make a difference to the leaders of healthcare systems. Let me give you a hint……. It aint about education.

We must transcend long hold belief and common assumption that the value of simulation is the education. I think the realization and yet unlocked true potential of simulation remains ties up in the ability to assess. It is tough to pivot from thinking that simulation is primarily an education methodology. But I encourage you to do so. Now before you get your hair on fire and leave me nasty comments, I’m not suggesting that we abandon simulation which we know to be an incredibly powerful education platform/modality. I just believe it you think it the main power is education first and foremost its becomes difficult to strategically plan, document, and provide leadership in other directions.

I think in the healthcare delivery space a more powerful argument that can contribute to the ROI of simulation is to harness the ability of simulation to identify the best deployment of judicious resources. So, what does this mean? Stop teaching with simulation? No, of course not.

Focusing more on the use of simulation as an assessment and surveillance tool can help to create bigger value. When teaching with simulation, conducting assessments of what people or perhaps units are doing well, what they are struggling with in a more quantitative way can help to identify the true needs of the organization. Understanding the local struggle and perhaps what the local community is not struggling with allows for a smarter utilization strategy for simulation.

Now before the heads pop off of the safe learning environment people, I’m not Stressful girl with exploded headsuggesting we need to turn every simulation into a summative performance assessment and give passing and failing grades that will ruin peoples lives. However consideration should be given to the gathering of data to show improvement is critically important as you do all of your great education work. After you collect the data is a systematic way have the courage to abandon what participants always do well on, focus or increase in the areas of greatest improvements.

Carefully collect the data if you use your simulation activities for on-boarding. Don’t ask if they liked the simulation. That’s not the data you need for your ROI justifications. Can you shorten aspects of on-boarding through the use of simulation? Showing credible evidence that nursing on-boarding can be shortened by x number of days or weeks through the strategic and judicious use of simulation will bring music to the ears of the bean counting crew who don’t fancy paying for the training of people when they could be working.

Other thoughts…. Using simulation as an evaluation tool in a human factors applications can assist other departments in increasing efficiency, and improving throughput. Think about the importance of that. What????? Not your cup of tea? Think back a few paragraphs on calculations leading to justifying the need for the new CT Scanner.

Carefully documenting that simulation trained anesthesiologists, CRNA’s , endoscopists and surgeons for example may shorten OR time which means more surgeries can occur, which generate lots of revenue is part of the ROI that should be in capital letters. This is the data that matters for the ROI justifications.

In-situ programs can give valuable feedback to hospital safety and quality leaders to demonstrate volatilities in the system with regard to both process, staffing, human performance etc. It can also demonstrate where the strengths lie. If there is unnecessary training going on where the strengths lie, then redeploy or readjust to the actual needs of your system. Additionally, formulating such relationships with the quality and safety leaders of your institution and letting them know of you true capabilities that are more then making people happy and smarter through education, can win you some powerful allies in the corporate leadership suites.

Lastly circling back to the schools……. Looking past the education benefits of simulation to use it as a tool to create data that can lead to information the underpins significant change, cost savings, and allocations of precious resources (people and money) will do you well. With the exception of more students,  I  don’t think it is likely that windfalls of money are coming your way either…….

So is you are carefully assessing you simulation efforts and activities in a thoughtful manner, you can help to reduce redundancy, unnecessary training intervals, or repetitions and on and on. Doing less of that which is ineffective save money. Saving money is a variable of the ROI that your CFO will pay attention to.

Leave a comment

Filed under assessment, hospital, return on investment, simulation

Don’t Let the Theory Wonks Slow Down the Progress of Healthcare Simulation

AdobeStock_85761977_rasterized

Those of us in the simulation community know well that when used appropriately and effectively simulation allows for amazing learning and contributes to students and providers of healthcare improving the craft. We also know there is very little published literature that conclusively demonstrates the “right way to do it”.

Yet in the scholarly literature there is still a struggle to define best practices and ways to move forward. I believe it is becoming a rate limiting step in helping people get started, grow and flourish in the development of simulation efforts.

I believe that part of the struggle is a diversity of the mission of various simulation programs ranging from entry level students to practicing professionals, varying foci on individualized learning incompetence, versus and/or team working communications training etc. Part of the challenges in these types of scholarly endeavors people try to describe a “one-size-fits-all“ approach to the solution of best practices. To me, this seems ridiculous when you consider the depths and breadth of possibilities for simulation in healthcare.

I believe another barrier (and FINALLY, the real point of this blog post 🙂  is trying to overly theorize everything that goes on with simulation and shooting down scholarly efforts to publish and disseminate successes in simulation based on some missing link to some often-esoteric deep theory in learning. While I believe that attachments to learning theory are important, I think it is ridiculous to think that every decision, best practice and policy in simulation, or experimental design, needs to reach back and betide to some learning theory to be effective.

As I have the good fortune to review a significant number simulation papers it is concerning to me to see many of my fellow reviewers shredding people’s efforts based on ties to learning theories, as well as their own interpretations on how simulation should be conducted. They have decided by reading the literature that is out there (of which there is very little, if any, conclusive arguments on best practices) has become a standard.

My most recent example is that of a paper I reviewed of a manuscript describing an experimental design looking at conducting simulation one way with a certain technology and comparing it to conducting the simulation another way without the technology. The authors then went on to report the resulting differences. As long as the testing circumstances are clearly articulated, along with the intentions and limitations, this is the type of literature the needs to appear for the simulation community to evaluate and digest, and build upon.

Time after time after time more recently I am seeing arguments steeped in theory attachments that seem to indicate this type of experimental testing is irrelevant, or worse yet inappropriate. There is a time and place for theoretical underpinnings and separately there is a time and place for attempting to move things forward with good solid implementation studies.

The theory wonks are holding up the valuable dissemination of information that could assist simulation efforts moving forward. Such information is crucial to assist us collectively to advance the community of practice of healthcare simulation forward to help improve healthcare globally.  There is a time to theorize and a time to get work done.

While I invite the theorist to postulate new and better ways to do things based on their philosophies, let those in the operational world, tell their stories of successes and opportunities as they are discovered.

Or perhaps it is time that we develop a forum or publication of high quality, that provides a better vehicle for dissemination of such information.

So…… in the mean time….. beware of the theory wonks. Try not to let them deter from your efforts to not only move your own simulation investigations forward, but to be able to disseminate and share them with the rest of the world!

Leave a comment

Filed under Curriculum, design, patient safety, return on investment

True Systems Integration for Hospital Based Simulation Programs

Businessman is using tablet pc and selecting integrationHospital based simulation programs serve a different need than their counterparts housed in schools of medicine and nursing. The stakeholders, the mission, the program assessment and development of curriculum vary significantly. Not to over-generalize but the overall mission of the school focused simulation programs is based around having them integrated into the education processes that contribute to the development of successful students who will be called graduates. Many times, these students end up taking licensing, certifying or other high-stakes examinations that can serve as a convenient data set to assess the impacts of programs.

The mission of hospital, or health-system based programs can be more complex in terms of alignment within the organization. There is a myriad of possibilities within the healthcare delivery environment that can drive the objectives of simulation programs. Examples range from employee training and education; quality, safety or risk based; or perhaps focusing on facilities engineering perspectives. With all of these possibilities the potential strategies for measurement markers to evaluate the success of the program can become blurry, and at times harder to have ready access to the necessary information.

In an era of healthcare cost reductions that we are experiencing now in the United States and many other areas of the world there is significant pressure coming from many different sides to reduce costs and at the same time improve the quality of care. Thus, to prevail in this era of medicine any entity within healthcare delivery system that costs money to operate (like simulation programs) needs to ensure it is providing value to the hospital or system which supports it.

Determining such value can be very challenging. While there are a couple of examples in the literature of isolated value calculations (such as central line training) the utility of such reports is limited in isolation. In total they are only a minute part of the safety problems associated with the delivery of care in the hospital.

Determining the best value of a hospital based program can be achieved through a series of needs assessments that require the simulation leadership to establish relationships in the hospital leadership teams or C-Suites outside of folks involved in education. The true needs assessment comes from participating in a deep understanding of the existing problems, challenges, solutions and successes that the c-suite is incurring to execute the mission of the hospital. This information is often housed in offices of risk management, quality or patient safety.

Integration with the risk management team can better position the simulation program to understand the legal risks from errors and litigation that is currently facing the hospital. Identifying trends and subject matter that could benefit from simulation training can emerge.

Quality offices generally have significant amounts of information regarding the initiatives that the hospital should be, or is focusing on to better provide care to patients. Such initiatives are often based on measurement programs from payers (insurance companies, whether private of government such as Medicare) that result in significant financial risks and/or benefits for the organization. Thus, identifying simulation solutions that could benefit the initiative in some form or fashion can result in value creation for the program.

Patient Safety Offices (sometimes under, or aligned with quality offices) house much of the data on mistakes, small and large, and in some cases near misses, that are occurring in an institution. Such data will also have information on trends, as well as if there was harm transferred to the patient.

Access to this data over time can help to identify the true needs of organization, and help direct a value-based implementation of the simulation efforts. Importantly though, a careful analysis of this data can also help the simulation program recognize what is not likely to bring as much value to the organization.

Two things are important when considering such integration efforts. The first is, even though there is a new era of transparency emerging regarding patient safety, the information is sensitive. To achieve true integration the simulation program leadership needs to establish relationships across the organization. Ideally you desire not only access to the data, but also a presence that positions themselves closer to the core of the analysis and decision making. Many simulation programs remain peripheral to such processes and thus experience a contractor-vendor type of relationship instead of one more akin to an active partner. It takes time, trust and effort to develop such relationships.

Secondly, a dispassionate evaluation of the data that is achieved from the needs analysis is necessary with regard to properly interpreting the value provided by the simulation program. Many simulation programs are born of a passion to simulate, a passion of the first faculty members, and an attachment to legacy programs that have been running for years. For true alignment within an complex organization and surviving future value analysis initiatives (ie. Remaining supported and funded) a program needs to take a hard look at its existing programs and ensure they are pegged to the overall “true” needs of the institution at large.

While this post is not representative of all the possible strategies to integrate a simulation program, it is meant to give insight into a few examples of possibilities, and articulate the depth of the relationships that should be developed.

 

Leave a comment

Filed under hospital, patient safety, return on investment, Uncategorized

Fire Alarm Systems and Simulation Programs in Hospitals – What is the ROI?

shutterstock_278643779How do you respond to your financial administrator or controller of the purse strings when they ask you what the return on investment is for your hospital-based simulation program? It’s quite complicated.

Return on investment in today’s vernacular implies that there is a financial spreadsheet that can show a positive bottom line after revenue (or direct cost savings) and expenses are accounted for. This is really difficult to do with simulation.

I have seen business plan after business plan of simulation centers that have promised their administration that they will become financially positive and start bringing in big bucks for the institution in some given period of time. Usually it’s part of the business plan that justifies the standing up of the simulation center. I think I can count on one hand the simulation programs that have actually achieved this status. Why is this?

The answer is because calculating discrete return on investment from the simulation alone is extraordinarily difficult to do. While there are some examples in the literature that attempt to quantify in dollar terms a return on investment, they are however few and far between. It is largely confined to some low hanging fruit with the most common example and published in the literature focusing on central line training.

Successfully integrated hospital focused simulation programs likely have found a way to quantify part of their offerings in a dollars and cents accounting scheme, but likely are providing tremendous value to their organizations that are extraordinarily difficult, if not impossible to demonstrate on spreadsheet.

What is the value the simulation center may bring to the ability of a hospital to recruit more patients because the community is aware of patient safety efforts and advanced training to improve care? What is the value of a simulation center in its ability to create exciting training opportunities that allow the staff to feel like the system is investing in them and ultimately helping with recruiting of new staff, along with retention of existing staff members?

What is the value or potential in the ability to avoid causing harm to patients such as mismanaged difficult airway because of simulation training of physicians and other providers who provide such care? What is the value of litigation avoidance for the same topic?

Also, the value proposition of the successfully implemented simulation program for patient safety extinguishes itself over time if it significantly reduces or eliminates the underlying problem. This is the so-called phenomenon of safety being a dynamic, nonevent. Going back to the more concrete example of airway if your airway management mishap rates have been essentially zero over several years, the institutional memory may become fuzzy on why you invest so much money and difficult airway training….. A conundrum to be sure.

I think of fire alarm systems in the hospital as similar situation Let’s compare the two. Fire alarm systems detect or “discover” fires, began to put the fire out, and disseminate the news. Simulation programs have the ability to “detect” or discover potential patient safety problems for the identification of latent threats, poor systems design or staffing for example. Once identified, the simulation program develops training that helps “put out” the patient safety threat. One could argue that the training itself is the dissemination of information that a patient safety “fire” exists.

Fire alarm systems and hospitals cost hundreds of thousands, possibly millions of dollars to install and run on the annual basis. But the chief financial officer never asks what’s the return on investment? Why is that?

Well, perhaps it is a non-issue because fire alarm systems have successfully been written into law, regulations of building codes and so on. Regulation is an interesting idea for simulation to be sure but probably not for a long time.

However, if you think about it beyond a regulatory requirement, the likelihood of a given fire alarm system actually saving a life is probably significantly less probable then a well-integrated simulation program that is providing patient safety programs designed around the needs of the institution it serves. Admittedly the image of hundreds of people being trapped in a burning building is probably more compelling to the finance guy then one patient at a time dying from hypoxia from a mismanaged difficult airway.

Do you really know what to do when the fire alarm system goes off in your hospital? I mean we have little rituals like close the doors etc. But what next? Do we run? If we run, do we run toward the fire? Or away from the fire?  Do we evacuate all the patients? Do we individually call the fire department? Do we find hoses and start squirting out the fire?

When we conduct simulation-based training in hospitals that are aligned with the patient safety needs of the given institution we are extinguishing or minimizing the situation that patients will undergo or suffer from unintended patient harm. The existence of simulation programs and attention to patient safety education are a critical need for the infrastructure of any hospital caring for patients.

The more we can expand upon this concept and allow our expertise in simulation to contribute to the overall mission of the institution in reducing potential harm to patients and hospital staff, the more likely we will receive continuing support and be recognized as important infrastructure to providing the highest quality and safety to our patients.

Just like the fire alarm systems.

 

 

Leave a comment

Filed under return on investment, Uncategorized

Value and Learning Propositions for Safety through Simulation – Don’t Sell Your Efforts Short

shutterstock_561835375aAll too often it is easy to be stuck in a mindset which can create tunnel vision. One of those time frames in the simulation world can come from an overall short-sightedness, into the usefulness, power, wisdom and change that can result from well-run simulation efforts. Many people have heard the adage “with simulation is within the debriefing that all the learning occurs.”  While phrases like this are meant to underscore the importance of the debriefing following a simulation if they are taken too literally they can result in a lack of recognition of total value of the simulation program investments and contributions.

This phenomenon is prevalent when evaluating the impact of simulation programs as part of patient safety efforts in healthcare systems in hospitals. In-situ simulation programs, or mock code evaluation programs are of unquestionable value to those of us who are in leadership in patient safety roles. Undoubtedly learning can occur during the simulation itself as I discussed in a previous blog post. Further, we all recognize the value of learning that can occur during well-run debriefing sessions. Lastly and perhaps most importantly great value can come from the information obtained during the simulation.

Scenario and debriefing sessions involved in in situ and other simulation programs that occur with practicing professional’s as participants have their limitations. First, and most practically is the operational recognition that healthcare professionals can only be kept “off-line” for a certain period of time to accomplish the simulation and debriefing. Secondly, some topics may be more sensitive than others and are not appropriate to be addressed directly with individuals during a debriefing that involves peers, as well as other healthcare colleagues. This point may be considered when evaluating the political and perceptions of your in-situ programs as received by the staff. Lastly, when you execute such a simulation there is only so much that can be absorbed at one point in time before cognitive overload becomes a significantly limiting factor.

Thinking traditionally from a “simulationist” point of view, is easy to think that all of the learning that will be recognized comes from the performance of the simulation combined with debriefing. With structure, planning and a systems-based approach to the simulation efforts, data can be gathered and analyzed to help a given hospital, or health system, understand the capabilities and limitation of their various clinical delivery systems. This can be invaluable learning for the system itself, which can then be incorporated into a plan of change to improve safety or in other cases efficiency in the delivery of care.

The given plan of change may incorporate additional educational efforts, policy, procedure or process changes that will be made in a more informed way than if the data from the simulation was not available. To garner such useful information at a systems-based level it is important that the curriculum integration be developed with consistent measurement strategies, objectives and tools that will allow meaning information to accrue.

A well planned, needs based targeted implementation strategy will create larger value than the simulation efforts occurring in a silo not connected to a larger strategic plan of improvement. If you think about a simulation event it is easy to picture small groups of people learning a great deal from the participation in the scenario or program. Simulation has the unique capability to abstract information to help provide insight into aspects of the patient care that both go smoothly as well as identify opportunities for improvement simultaneous with deployment of useful learning.

Once these opportunities are catalogued and recognized, a transformation of greater scale can take place through careful planning and implementation of further patient safety efforts with defined targets. Partnering with your risk management or patient safety colleagues to work on the integration plan can be valuable for increasing leadership buy-in for supporting your simulation efforts.

So I challenge you! If you are running relations in situ make sure that you keep in mind that your educational efforts during the simulation scenario are part of a bigger picture of increasing the safety and/or efficiency for providing care to patients, thus bringing a higher return on investment for the simulation efforts that you are conducting.

Until next time…… Happy Simulating!

1 Comment

Filed under return on investment