Evaluating Inpatient Crisis Response

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As the Medical Director of patient safety for a large healthcare system I can say that conducting unannounced “mock codes” (Inpatient Crisis Response Evaluation System is the title of our program) is a critical pillar of safety quality improvement efforts. WISER oversees our program and provides the evaluation and consultation service to many of our 20 hospitals in conjunction with and close collaboration with the local hospital physician and nursing leadership.

The unannounced part allows true system evaluation of such a response. The events are closely choreographed with our simulation team (led by a physician medical director), as well as the local hospital leadership. Our evaluation system has afforded us as a system, the opportunity to unveil many latent system threats as well as identify opportunities for targeted training efforts. With regard to simulation and training it is a TRUE needs analysis in this way.

With regard to acceptance, I believe that it is related to the maturity of the overall organization and the simulation personnel conducting the events. In the words of James Reason on high reliability organizations “They anticipate the worst and equip themselves to deal with it at all levels of the organization. It is hard, even unnatural, for individuals to remain chronically uneasy, so their organizational culture takes on a profound significance. Individuals may forget to be afraid, but the culture of a high reliability organization provides them with both the reminders and the tools to help them remember.” Thus I believe in highly mature safety culture organizations it is incumbent upon both the leadership and the healthcare clinicians to be accepting of “external” evaluations for such critical moments as inpatient crisis events.

I also believe that the naming of the program has significant implications. The title “Mock Code” in my opinion sounds somewhat trivial, extra, perhaps of marginal utility, or at the very least “fake.” If that is the intent, then I believe that is easier to argue that the events should be pre-planned and/or avoid being completely “unexpected”. However if the intent is to seriously evaluate a high reliability organization’s response to an unexpected patient situation, and identify needs, process improvement opportunities and uncover latent threats, I would argue for the unannounced methodology.

Our health system shares a deep commitment to continue on the journey to high reliability and believe our Inpatient Crisis Response Evaluation System is an important component of our success. As WISER is accredited by the SSH in Systems Integration (among other categories) we believe a fully integrated approach is necessary, very safe, feasible and our responsibility to execute and provide feedback to our health system.shutterstock_78054850_a

As anyone who provides actual care for patients there are risks and benefits to ALL decision that are made from therapeutics, to staffing, to salting the parking lot. There are certainly safety items that must be attended to in any of our simulation efforts, particularly those which occur in proximity to actual care. However carefully crafted programs, process and execution will ultimately ensure the benefits outweigh the risks.

I truly believe the undiscovered system latent threats to inpatients are a greater risk than the conducting of the mock code itself.

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Lecture: It’s not Dead Yet

LectureNotDeadFellow simulationists, let’s get real. We should not be the enemy of lecture. Lecture is a very valuable form of education. What we should be campaigning against are bad lectures, and the use of lecture when it isn’t the best tool for the associated attempt at education.

We have all listened to lectures that were horrific and/or lectures presented by speakers who have/had horrific public speaking or presenting skills. But in essence a good lecture can be an incredibly efficient transfer of information. The one to many configuration that is in inherent in the format of lecture can lead to an amazing amount of materials covered, interpreted and/or organized by the presenter to raise the level of knowledge or understanding of the people in attendance.

Like anything else in education we need to stratify the needs of what we are trying to teach and create solutions by which to teach them. With regard to lecture as a tool, we need to find ways to engage the audience into active participation to enhance the comprehension, learning and attention of the participants. There are many tools available for this, some involving technology, some not. The onus is on the presenter to seek out techniques as well as technologies or creative ways to engage people in the audience into an active learning process.

I don’t think of simulation as an alternative, or better way to teach, then lecture. I view lecture and simulation as two different tools available to the educational design process to affect good learning. Much the same way that I would not say a screwdriver is a better tool than a pair of pliers.

Too many times at simulation meetings and in discussions with simulation enthusiasts I hear empirical lecture-bashings if it is old school, out-moded or something lacking value. During these conversations it becomes readily apparent that the person speaking doesn’t have full command of the fact that the main goal is education, not simulation, and that there are many ways to create effective learning environments.

Now lecture can get a bad rap deservedly. Go to a meeting and listen to a boring monotonous speaker drone on and read from their powerpoint slides while not even recognizing that there is an audience in front of them. Unfortunately that is still more common than not at many physician and nursing meetings. Or worse yet, in the new age of converting to flipped classrooms and on-line learning, people are taking the easy way out and moving videos of lectures and plopping them on-line and calling it on-line learning. How pitiful. How painful. The only thing I can imagine worse than a bad lecture in person, is a bad lecture on web based learning that I would have to suffer through.

So I still teach and lead workshops on helping people enhance their lecturing and presentation skills. In part because I continue to recognize that not only will lecture be around for a long time, it should be around for a long time because it CAN be incredibly powerful with the right preparation and in the right hands. Also I continue to recognize the value of seeing modern healthcare education efforts being carefully thought out to understand which tool is best for which phase of learning after careful evaluation of the intended learner group and the topic at hand.

We need to end the silo-like thinking of simulation is better than lecture and convert to a more outcomes oriented thought process that evaluates and implements the appropriate educational tool for the intended educational accomplishments.

So let’s commit to each other to never do a simulation that could be just effective as an engaging lecture, AND lets all agree to never do a lecture that sucks.

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Simulation can be Fun. And Serious.

shutterstock_286597808aI was recently energized by sitting in the back of one of our simulation rooms where two of my faculty colleagues were running simulations for some of Emergency Medicine Residents. They had prepared the session well and had clearly established a previously great and trusting relationship with the residents in a safe learning kind of way.

The residents seemed relaxed, smiling, and many were attending the session dressed in the likes of Khacki shorts, Teva’s and a Hawaiian shirt or two. During one of the scenarios the faculty member operating the simulator made a mistake and the “patient” took a turn for the worse when the correct treatment was ordered. He was on the other side of the glass and immediately said something funny about his mistake over the room speakers in a self-deprecating way. Everyone in the room was cracking up including the other faculty members, me, all of the team members and the resident observers. The simulation came to an end a few minutes later as the rest of the learning objectives were met

During the debriefing the faculty member called out his mistake once again to another round of snickers. Superficially it seemed that he was trying to be funny. Deeper I think he was level setting to ensure there wasn’t confusion of the change in status over the patient. Additionally he was ensuring to demonstrate the safe learning environment in so far as declaring that he was capable of making mistakes as well.

A few moments later the residents were engaged in a debriefing using the Structured and Supportive Debriefing Model and the GAS tool. During the debriefing many topics were covered ranging from teamwork, the initial care and stabilization of the patient, to aberrancies in the electrical system of the heart leading to wide complex tachycardia that can mimic ventricular tachycardia.

A few minutes later the debriefing was wrapped up expertly by the faculty member. Another scenario ensued with a new group of residents and again, unplanned, something funny happened. Again laughter, then back to work, then the end. Debriefing commenced. During the second debriefing led to a discussion of how cyanide poisoning interacts with cellular metabolic pathways of the P450 cytochrome system and the therapeutics that should be considered to save the patient’s life. During the conversation a few light hearted comments by residents created more laughing.shutterstock_261594212a

I sat back thinking….. this is really fun…….There they are dressed in their tevas and shorts…..Learning of all things…… imagine that. This is truly patient-centric simulation. Innovative education occurring in a comfortable atmosphere helping these future emergency physicians perfect their diagnostic, therapeutic and leadership skills. They don’t need to be in scrubs, shirts and ties or wearing hospital badges to optimize this learning opportunity. They are not going to show up to work in the hospital wearing shorts and tevas. They are professionals. You know what? They are in fact adult learners being treated as adults.

I was a bite envious of my faculty colleagues having creating this amazingly relaxed environment where the residents felt comfortable to speak up, right or wrong in front of each other and faculty members alike.  In fact they were encouraged to explore during the cases. And they were learning. Learning new concepts or at least reviewing topics and learning objectives that were appropriate for their training program.

Guys and gals dressed as if they were going to a picnic, learning from each other, laughing and feeling free to explore and demonstrate their knowledge, skills and attitudes for the purpose of improving. Were they not taking it seriously? Cytochrome P450 and conduction aberrancies sure sounded serious to me, as did the discussion of teamwork and leadership.

Sometimes I think we can easily take ourselves too seriously in the simulation world. While I would be the first to argue there are times to do just that, I am reminded that there are times when it is not the case. People seem to be so caught up in defining rules of how things should and shouldn’t be done in simulation encounters that sometimes I observe huge opportunities to find new and interesting ways in which we can engage learners in their prime. I think that these faculty members new their participants well and designed amazing learning opportunities for them that included some of the power of simulation.

After all, we are not trying to simulate reality, we are trying to use simulation to create a milieu that will enhance our ability to carry out learning and assessment objectives that will eventually influence the care that is delivered by the healthcare system.

It was a great day for me, simulation and especially for future patients!

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The Ultimate Hot Potato – The Cost of Patient Safety Training and Why Hospitals Should Pay the Bill

082515_0520_TheUltimate1.jpgThe costs associated with education and training have historically fallen upon the individual professional in pursuit of such effort. The costs associated with a medical, nursing or other professional license or certificate are staggering. However the professional recognizes that such pathways are an investment in themselves. Once complete the education and requisite skills are “owned” by the individual and afford them the opportunity to have a career in healthcare. Thus the bill is paid by the ultimate beneficiary of the education.

When a hospital employs or partners (in the case of non-employee medical staff) with professionals they carefully screen and ensure the educational history and licenses are in order. The hospital expects the professional to be competent in their field. This is a reasonable expectation as the hospital is engaging in a financial relationship with said individual. In common arrangements the costs of certification, recertification, and licensing fall to the responsibility of the individual professional to achieve. Again, you could argue this to be fair, as the healthcare professional “owns” that side of the equation, at least at the level of individual competence. Continuing education and professional development activities enhance the ability of the professional to remain competent as well as competitive in terms or one marketability as a healthcare provider. Largely these efforts are aimed at knowledge based activities that allow one to remain current in their field.

In recent years schools of health sciences have tried to embed some aspects of teamwork and communications into their curriculums. However, these effort thus far are still aimed at what ones individual competency or knowledge is on how to be part of a team. There still remains a huge unmet need to have practicing professional engage in multidisciplinary education efforts surrounding this important topic. Some of these efforts may naturally include simulation.

Hospitals offer healthcare as a service to patients in exchange for payment. Contained within is a “contract”, or at the very least a commitment, to provide excellent care. Inherent in the delivery of excellent care is error-free care that avoids preventable harm from being experienced by the patient as a result of the healthcare service(s) that they receive from a given hospital.

Additionally there is a “contract” between the hospital and the healthcare professional with which they are associated, to provide excellent care, and logically this includes error-free care. In exchange for the professionals providing this service enables the hospital to derive income. This income is shared with the professionals through two basic mechanisms. The salaries paid to employed professionals such as nurses, physicians, pharmacists for example. The second basic mechanism is the ability of non-employed physicians to derive income to their practice for the services provided under the auspices of the hospital. In this latter case, it can be oversimplified to a description of profit sharing for the purposes of this discussion.

While the knowledge and skills of competent individuals are attained during training programs we know that there are education and training efforts that is necessary for professionals to be proficient at the system level. In other words there is training needed for individuals to be competent to work within the hospital of which they are associated. This may include such training as procuring competence in equipment or policies specific to a hospital, training in systems efforts at patient safety, as well as team training just to name a few examples.

While most healthcare providers accept that their education and training to maintain individual competence is their personal responsibility, they will likely draw the line at footing the bill for those needed efforts that are specific to a particular hospital in their systems efforts. Such training efforts represent those areas that the hospital should be responsible for. They represent the training that is above individual competence and afford system competence to the professional. This allows a system of professionals to engage in the delivery of excellent healthcare and keep patients safe so that the hospital can generate revenue from such service provision. Thus it is necessary infrastructure, much like the electric or water bill for the hospital.

In the over-cited United States Institute of Medicine (IOM) report “To Err is Human” from 1999, simulation is mentioned 19 times. Team training and teamwork is frequently mentioned throughout as well. So then how is it that we still don’t have standardized and/or mandatory implementation of team training efforts, patient safety training, or simulation efforts?

The fundamental answer is that the hospitals have not been encouraged, cajoled, regulated or developed the foresight and understanding that training for patient safety is core infrastructure. It is incumbent upon the hospital to invest in this partnership with care professionals who do their part to maintain the competencies, requirements and licensure at the individual level. This will be the only pathway forward to achieve meaningful result from patient safety training efforts. This argument is also predicated on the notion that the reader recognizes that true patient safety training takes more than watching bad powerpoints once a year to satisfy regulatory and accreditation compliance.

So let’s cool the potato, overcome the obstacles and embed the costs of training for systems excellence into the infrastructure costs of hospital care and truly move the needle on patient safety.

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Great Debriefing Should Stimulate Active Reflection

shutterstock_284271476_aDebriefing in simulation as well as after clinical events is a common method of continuing the learning process through helping participants garner insight from their participation in the activity. It is postulated and I believe, part of the power of this “conversation” when call debriefing is when the participant engages in active reflection. The onus is on the debriefer to create an environment where active reflection occurs.

One of the most effective ways to achieve this goal is through questions. When participants are asked questions regarding the activity being debriefed it forces them to replay the scenario or activity in their mind. I find it helpful to begin with rather open-ended broader questions for two reasons. The first is to ensure the participant(s) are ready to proceed. Secondly asking broader questions at the beginning such as “Can you give me a recap of what you just experienced?” Helps to force the participant to think about the activity in a longitudinal way. Gradually the questions become much more specific to allow the participant to understand cause and effect relationships between their performance in the activity and the outcomes of the case.

Another thing to consider is that when debriefing multiple people simultaneously, when a recollection of the activity is being recalled by one participant, the other participants are actively thinking about their own recognition of said activity. Thus active reflection is again triggered. It is quite natural for the other participants to not only be thinking about the activity, but actively forming their own thoughts in a comparison/contrast type of cognitive activity. During this period they are comparing their own recollection of the activity with the one of the person answering the initial question.

Question should be focused in a way that the debriefer is controlling the conversation through a structured pathway that allows the learning objectives to be met. Further, when one develops good debriefing habits through the use of questioning it limits the possibility of the debriefing converting into a ”mini – lecture”.

I believe the Structured and Supported debriefing model created by my colleague Dr. John O’Donnell along with collaborators, provides the best framework by which to structure the debriefing. His use of the GAS mnemonic has effectively allowed the model to be introduced to both novice and expert debriefers alike and facilitate an easily learned structured framework into their debriefing work. We have been able to successfully introduce this model across many cultures and at least five different languages and have had significant success.

Worksheets, or job-aids with some example questions that parallel the learning objectives can be written on such tools prior to the scenario commencement. Supplementing the job aid with additional notes during the performance of the scenario can be helpful to recall the important points of discussion at the time of debriefing, and the preformed questions can serve as gentle reminders to the debriefer on topics that must be covered to achieve a successful learning outcome.

So a challenge to you is the next time you conduct a debriefing be thinking in the back of your mind how can I best force my participants to engage in active reflection of the activity that is bring debriefed. In addition, I would recommend that you practice debriefing as often as you can! Debriefing is an activity that improves over time with experience and deliberate practice.

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Why Waste Time Learning On Real Patients?

MannequinMammalsOkay, admit it, this title will be challenging for some. Although the converse of the question is what some of the naysayers say about simulation. What’s the real deal? The real deal is learning from real patients is an invaluable part of the healthcare education experience. At the risk of alienating some we must think of the real patient experience as a “tool” in the educational toolbox. But there are many tools in the toolbox!

We must also recognize the value of learning in the simulated environment as an additional tool in the toolbox. When we have many different tools by which to complete a goal, going through the risks and benefits of each will help us make the proper decisions to allow us to proceed with the most efficiency and effectiveness in our educational endeavors.

When I observe aspects of examples of learning in the clinical environment I become easily frustrated with seeing examples of colossal amounts of time wasted while waiting for some nugget of education to randomly appear in the clinical environment. Paramedic and nursing students working in the clinical environment that are changing bed linens over and over again are clearly being used as a service to someone and not functioning in a capacity that is enhancing their clinical learning. Similarly interns that may be on a specialty care service that are dictating their 30th discharge summary of the month are probably being used more in a service capacity than one in an environment that enhances their education.

Some of the advantages of simulation include being able to structure the learning environment so that the time can be accounted for in a more robust fashion that helps to ensure that valuable learning opportunities are presented, encountered or participated in. Additionally the ability to do and re-do exist in the simulated environment, where as in most cases this is not possible in the actual clinical care environment.  This is important to enhance and create programs of mastery learning with incorporated deliberate practice. And this applies whether we are talking about individual expertise or that of groups of people working on collaborative goals in team training environment. Additionally, in many simulation program designs there is much closer oversight of what a learner or groups of learners is/are accomplishing in the simulated environment when compared to the oversight that occurs in most clinical learning environments.

Please don’t misunderstand; I am not trying to diminish the value of learning on real patients in the clinical environment. I am merely stating that there are pros and cons, limitations and capabilities of all different modalities of learning as we bring people along the journey of what it takes to become a practicing healthcare professional. It is one that is complex that requires multiple repetitions from different vantage points, perspectives, as well as opportunities for learning. Carefully evaluating those opportunities, the resources that are available in a given program are important concepts to ensure that we continue to improve the health care education for creating tomorrow’s healthcare providers.

Those who are in the capacity of creating new curriculum or revamping and revising old, would do well to think broadly about the needs of the learner, the level of learner and what would be optimal exposure to create the most efficient and effective learning at that point in time. We need to begin to challenge the existing status quo so that we can truly move forward in revising healthcare education to continue to allow people to achieve excellence.

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Are Routine Pre-and Post Simulation Knowledge Tests Ethical? Useful? To whom?

shutterstock_77554009X_aDisclaimer (before you read on): This post is not referring to research projects that have been through an institutional review board or other ethics committee reviews.

What I am actually referring to is the practice of many simulation programs that do routine written pre-test, followed by written posttest to attempt to document a change in the learner’s knowledge as a result of participating in the simulation. This is a very common practice of simulation programs. It seems the basis of such testing would be to eventually be able to use the anticipated increase in knowledge as a justification for the effectiveness of the simulation-based training.

However we must stop and wonder if this ethical? I believe as described in some of my previous posts that there is a contract that exists between participants of simulation encounters, and those who are the purveyors of such learning activities. As part of this contract we are agreeing to utilize the time of the participating in a way that is most advantageous to their educational efforts that help them become a better healthcare provider.

With regard to pretesting, we could argue from an educational standpoint that we are going to customize the simulation education to help tailor of the learning to the needs of the learners as guided by the results of some pretest. I.e. using to pretesting some sort of needs analysis fashion. But this argument requires that we actually used the results of said pre-test in this fashion.

The second argument and one that we embark upon in several of the programs of which I have designed is that we are assessing the baseline knowledge to evaluate the effectiveness of pre-course content, or pre-course knowledge that participants are programs to do either complete or possess prior to coming to the simulation center.  I.e.  A readiness assessment of sorts. In other words the question being is this person cognitively prepared to engage in the simulation endeavors that I am about to ask them to participate in.

Finally another argument from an educational standpoint for pretesting could be made that we would like to point out to the participants of the simulation areas of opportunity to enhance their learning. We could essentially say that we are helping the learner direct where they will pay close attention and focus on during the simulation activities or participation in the program. Again this is predicated on the fact that there will be a review of the pretest answers, and/or at least feedback to the intended participants of the simulation program on the topic areas, questions or subjects of which they did not answer the questions successfully.shutterstock_201601739-a

The posttest argument becomes a bit more difficult from an ethical perspective outside of the aforementioned justification of the simulation-based education. I suppose we could say that we are trying to continue to advise the learner on areas that we believe there are opportunity for improvement and hopefully inspire self-directed learning.

However my underlying belief is if we look at ourselves in the mirror, myself included, we are trying to collect the data over time so that we can perform some sort of retrospective review and hopefully uncover there was a significant change in pretest versus posttest testing scores that we can use to justify our simulation efforts in whole or in parts.

This becomes more and more concerning if for no other reason than it can lead to sloppy educational design. What I mean is if we are able to ADEQUATELY assess the objectives of a simulation program with a given pair written tests, it is likely more knowledge-based domain items we are assessing and we always have to question is simulation the most efficient and effective modality for this effort. I.e. if this is the case may be every time I give a lecture I should give a pre-and posttest (although this would make the CME industry happy) to determine the usefulness of my education and justify the time of the participants attending the session. Although in this example if I was lecturing and potentially enhancing knowledge, perhaps one could argue that a written test is the correct tool. However the example is intended to put out the impracticality and limited usefulness of such an endeavor.

As we continue to attempt to create arguments for the value of simulation and overcome the hurdles that are apparent as well as hidden, I think that we owe it to ourselves to decide whether such ROUTINE use of pre-and post-testing is significantly beneficial to the participants of our simulation, or are we justifying the need to do so on the half of the simulation entity. Because we owe it to our participants to ensure that the answer reflects the former in an honest appraisal.

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The Contract Essential to the Parties of Simulation

If you think about it an agreement needs to exist between those whom facilitate simulation and those who participate. Facilitate the purposes of this discussion is referring to those who create and execute simulation based learning encounters. Sometimes the agreement is more formal other times more implied. This phenomenon has been described in many ways over the yearsshutterstock_226296865 having been branded by such descriptors as fiction contract, psychological contract, or learning contract.

Why does this need to be the case? A contract or agreement is generally called for when two or more parties are engaging in some sort of collaborative relationship to accomplish something. Often times these type of contracts spell out the responsibilities of the parties involved. If you think about simulation at a high level the facilitator side is agreeing to provide learning activities using simulation to help the participant(s) become better healthcare providers. The participants are engaged at the highest level because they want to become better healthcare providers. While not trying to hold a comprehensive discussion, let’s explore this concept and the responsibilities of each party a bit further.

Facilitators are designing simulation activities with a variety of tools and techniques that are not perfect imitators of actual healthcare. They are crafting events for which the participant to a greater or lesser extent immerse themselves in, or at a minimum simply participate. Some of these activities are designed to contain diagnostic mystery, some demand specific knowledge, skills and attitudes be known or developed to successfully complete the program. Facilitators are also putting participants in situations that the must perform in front of others and that can create feelings of vulnerability. So all toll, the role of the facilitator comes with enormous responsibility.

Facilitators are also asking the participants to imagine part of what they are engaging in is a reasonable facsimile of what one may encounter when providing actual healthcare. Therefore another tenet of the agreement is that the facilitator will provide an adequate orientation to the simulation environment pointing out what is more and less real including the role that the participant may be playing and how their role interacts with the environment outside of the simulation, if at all. (I.e. define any communications that may occur during the simulation between the participants and the facilitator.

Facilitators trained in simulation know that mistakes occur sometimes due to a lack of knowledge, incorrect judgement or unrelated issues such as a poorly designed simulation. Facilitators thereby commit to not judge the participant in anything other than their performance during the simulation. While diagnostic conundrums are inevitable in many types of simulations the facilitator should not try to unnecessarily trick or mislead the participant in any way that is not directly contributing to helping the participant(s) improve. The facilitator must attempt to use the time of the participants wisely and responsibly.

The role of the participant shares responsibilities as a part of the agreement as well. Participants agree to a commitment to become better healthcare providers through continuous learning and improvement. This is inherent in a professional, but there are some likely good reasonsshutterstock_147464348 to remind participants of this important premise.

Participants must agree to the use of their time to participate in the simulation. The participants are also agreeing to an understanding that they know the environment of the simulation is not real, and that there will be varying levels of realism employed to help them perform in the simulation. But to be clear they agree to this tenet predicated on the trust that that facilitators are having the participant experience simulations that are relevant to what they do, with an underlying commitment to help them get better. In simulations involving multiple participants, they must also agree to similarly not judge others on what occurs in the simulation, as well as keeping the personal details of what they experience in the simulation confidential.

So in closing, successful simulation or other immersive learning environments require an agreement of sorts between those who create and execute the simulation based learning environments as well as those who participate in them. Each party brings a set of responsibilities to the table to help to ensure a rich learning environment with appropriate professional decorum and commitment to improvement. The agreements range from implicit to explicit, but when they exist and are adhered to will continue to allow the recognition of value that can arise from simulation to help improve the care ultimately delivered to our patients. After all, isn’t that our highest goal?

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Simulation Programs Should Stop Selling Simulation

SimforSaleWhatever do I mean? Many established simulation programs believe that their value is through creating simulation programs for people by which to attain knowledge, skills and/or perfect aspects of that needed to effectively care for patients. All of that is true, obviously. However, I believe that the true value of many established simulation programs is in the deep educational infrastructure that they provide to the institution with whom they may be affiliated. Whether that expertise is in the project management of educational design, educational design itself, the housing of the cadre of people who are truly interested in education, or the operational scheduling and support needed to pull off a major program, I believe these examples are the true understated value of many simulation programs.

Simulation programs tend to attract a variety of people who are truly interested in education. While I don’t think that everyone who is passionate about teaching in healthcare needs to be an educational expert, I do believe that it is important that we have people involved in the development and deployment of innovative education who are truly interested in teaching. Many hospitals and universities rely on personnel to conduct their education programs that are subject matter experts, but may or may not have desire, interest or satisfactory capabilities needed for teaching.

Many people who are passionate about teaching in healthcare have a particular topic or two that they like to teach about, but lack the skills of critical analysis, and deeper knowledge of educational design principles to help them parse their education efforts into the appropriate methods to create maximal efficiency in the uptake of the subject matter.  This very factor is likely why we still rely on good old-fashioned lecture as a cornerstone of healthcare education whether we are evaluating that from the school perspective, or the practicing healthcare arena. Not that I believe there is anything wrong with lecture, I just believe that it is often overused, often done poorly, and often done in a way that does not encourage active engagement or active learning between the lecturer in the participant’s.

Simulation programs are often the water cooler in many institutions around which people that are truly interested in and may have some additional expertise in an education will tend to congregate. The power of this proximity creates an environment rich for brainstorming, enthusiasm for pushing the envelope of capabilities, and continuous challenge to improve the methods by which we undertake healthcare education.

Simulation programs that have curricular development capabilities often have project management expertise as well as operational expertise to create complex educational solutions. This combination of skills can be exceptionally valuable to the development of any innovative education program in healthcare whether or not simulation is part of the equation.

Many times healthcare education endeavors are undertaken by one or two people who quickly become overwhelmed without the supporting infrastructure that it takes to put on educational activities of a higher complexity than a simple lecture. Often times this supporting technology or set of resources resides inside the walls of “simulation centers” are programs. By not providing access to these para-simulation resources to the rest of the institution, I argue that simulation programs are selling themselves short.

If you consider the educational outcomes from a leadership perspective (i.e. CEO, Dean etc.), They are much less concerned about how the educational endeavor occurred, but far more focused on the outcomes. So while there are many topics and situations that are perfect for simulation proper, we all know there is a larger need for educational designs with complexity larger than that of a lecture that may not involve simulation.

If a given simulation program partners with those trying to create complex educational offerings that don’t directly involve simulation, but are good for the mission of the overall institution with whom they are aligned, it is likely going to endear, or create awareness for the need for continuing or expanding the support of that particular program by the senior leadership team.

If you sit back and think about it, isn’t that an example of great teamwork?

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SIMULATION AND THE ELECTRONIC HEALTH RECORD: MIND YOUR OBJECTIVES

There is a lot of disEHRandSim'cussion recently about incorporating electronic health record (EHR) into simulations. Which vendor? Which product? What features are needed? The disturbing thing about most of these discussions in my mind is that no one is talking about what they are trying to accomplish with the inclusion of electronic health records into the simulation environment.

What is the purpose of the EHR in it in a simulation? Is it simply to provide realism? If so, is the EHR that is implemented likely to be the one in the practice environment experienced by the student? Because if not, it is missing the mark likely adding confusion as well as increasing the orientation time necessary for a given simulation. Is the EHR supposed to provide crucial information that will help make healthcare decision during the simulation encounter? Is the entire simulation designed around an efficient query for specific information of a patient’s history? Are entries in the EHR made by the participants of simulation going to be analyzed for knowledge or critical thinking regarding a case? There are so many possibilities! I would argue however that integrating the EHR into the simulation simply for reality will likely be a colossal waste of time.

Much like any other component included in simulation the EHR should be included thoughtfully and carefully driven by needs analysis based on the learning objectives of the educational encounter. EHR technology can be overwhelming by itself to understand and navigate, combined with the fact that there are many different types of systems for different practice environments make it unwieldy to become expert in all brands, systems or examples.

Similarly, it if you have successful implementation of the EHR into your simulations I would recommend that you carefully decide for each and every simulating counter whether you need to include it or not. Again, this decision should rest upon the learning objectives and the intended educational outcomes of the event. Interacting with the EHR can be a time-consuming, frustrating part of the delivery of healthcare and it is up to the creator of the educational encounter to determine the usefulness and necessity of such integration.

The thoughtful use of EHR into select simulated encounters can significantly lead to increased observations of critical thought process, attention to detail, as well as overall understanding of the depth and breadth of understanding of a given case. Additionally it could serve as another avenue for assessment. If the integration of the EHR is predicated around these efforts and clearly the addition of the EHR component is both worthwhile and necessary. Additionally, simulations involving workflow and human factors can possibly benefit from such integration knowing that in today’s delivery of healthcare the interaction with the EHR is a daily reality.

I must close however with reminding the simulation community it is not our job to re-create reality, it is our job to create an innovative educational encounter from which we can form opinions to engage in discussions to help healthcare providers on their quest towards excellence.

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