Simulating Healthcare

How many rules have been vetted in the literature with regard to how simulation should be designed and conducted? The answer?  (drum roll, please……..)  Not many.  This is an important point to consider when making the decisions that are part and parcel to you creating successful simulations. Healthcare simulation can take on many forms including designs for pure teaching activities through assessment activities, covering a broad range of objectives or simply a few. The bottom line is there are many ways to do simulation correctly. 

One of the first things to be aware of is that you must start with the end in mind. Ask yourself what you really want to accomplish. And by the way, I’m not talking about the simulation. The simulation is actually the means to get to what you want to accomplish. Hopefully! What you a want to accomplish is ensuring that the healthcare providers who complete your learning and/or assessment activity are likely to provide better healthcare in the future by way of increasing their confidence and competence in what they do.

Common rule club fallacies include imposing some magical formula on the length of the debriefing as related to the length of simulation, demanding that you must use video review, demanding that you must design your simulation to mimic real healthcare, demanding that you must use the highest technology available, demanding that you must conduct your simulation in an environment that is as real as possible, demanding that you must debrief in a different room than where the simulation took place, demanding that you must not let the simulator die and on and on and on…… Bunk….. it’s all bunk.

Trying to follow all of the rules of rule club will just slow you down, impede your ability to reach your goals and make you sit around and wonder why you didn’t accomplish what you set out to do even though you were working so hard. Worse yet, it might even make your boss think that you can’t get enough done.

Are their best practices emerging, is there some science to guide us? Absolutely!  Just not much! We know we must provide a safe learning environment, provide feedback that usually will include a debriefing (but maybe not always). But there is no secret recipe hidden on the planet that you will be able to receive at a meeting and go home to bake a magical, successful simulation cake.

Your job however is to try and sort through the best practices, read the science that is available, learn from others, learn from people like me who teach all of the time at workshops, symposiums and conferences. But THEN you must go home and figure out how to design your efforts that fit in the operational constraints that fit your situation. Such constraints may be related to budget, personnel availability, equipment, space or other factors to name a few. Some may be the amount of time that you can actually have access to the participants (this is particularly true if you are working with practicing professionals as your normal learner group.)

So in summary, envision and brainstorm with the end it mind. Then take all of your accumulated knowledge of the science and best practices as well as the information you get from others and make the program fit your realities! Do this non-apologetically, collect data along the way, and you will find yourself becoming much more productive then if you are trying to follow a specific recipe of rule club who tend to stand atop the mountain and issue commandments to make you feel guilty if you don’t follow them!

 Levine et al have knocked it out of the park with their recently released book entitled “The Comprehensive Textbook of Healthcare Simulation”. This book is a must-have for anyone serious about simulation. It covers a lot of ground ranging from historical views of simulation to that which represents the cutting edge at present. There are many, many topics ranging from simulation operations to very highly specialized simulations that occur in subspecialties of the healthcare environment and everything in between.

Prof. John O’Donnell, associate director wiser for nursing programs and co-director of WISER’s research program  and I are proud to point out that we have a chapter featuring the structured and supported model of debriefing that was developed by WISER and is becoming one of the most sought after methods of debriefing because of its scalability, flexibility as well as a method that can be taught and implemented for many different types of simulation as well as levels of learners.

This book is a compendium authored by a list of people who represent the Who’s Who list of leaders in healthcare simulation in 2013.  It is truly a remarkable accomplishment and I am proud to lend my kudos to lead editor Adam Levine, MD.  This book will undoubtedly contribute significantly to continuing to move healthcare simulation forward.

Picture: Drs Phrampus and O’Donnell

I recently was a faculty member on a panel at an international simulation meeting involving a number of senior leaders from the simulation community. One senior leader was ridiculing the collection of what he deemed to be insignificant data. He was critical of spending time and resource in the collection of such data points as number of trainees served by the program last year, number of room hour’s utilized amount of money spent on catering, did the student like the simulation etc. I think it was a sad display of a misunderstanding of the importance of data in the modern era of simulation program start up, existence, and expansion.

Data surrounding simulation centers classically is thought of as metrics that are often reported in educational research studies that may include examples such as test scores, participant feedback, various scoring metrics associated with performances observed during simulation etc. But as a senior administrator I recognize that it is so much more.

I was fortunate enough to be mentored by the founding director of WISER, Dr John J. Schaeffer to understand the power of data in a generic sense. We look at data in a very inclusive way. A unit of data may be the answer to test question number six, how many minutes it took to perform a cricothyrotomy on a simulated patient, how many times room one was used last year, how many hours Dr Jones facilitated in our center last year, or how the student “liked” her simulation efforts.

While some of the metrics mentioned are certainly important and often worthy of research publications, the operational examples given in the first paragraph above are equally as important to a program’s existence, sustainment and justification to grow. Admittedly, they may not be important for publishing in educational research, however the program has to exist to be able to allow the educational research to move forward. While we certainly don’t need another peer-reviewed, scientific publication that states “students like simulation”, this type of information can be critically important to the Dean, Hospital Executive or funding authority of a burgeoning simulation program. Don’t underestimate the importance of data for your simulation program. Having valid, reliable data that is easy to access is a powerful element in the day-to-day decision-making that it takes to run a successful simulation program.

A fundamental key to making data useful is to develop a systematic, embedded way attempt to standardize and streamline the data collection involved with your center’s day-to-day operations. It requires far more effort to determine “the number of times simulator room number one was used last year” or “how many students hours of simulation you provided last year”, with a manual retrospective review process, then if you have a system that provided that information automatically. Yes of course when you’re running a specialized research project there might be additional data metrics necessary to collect. I would argue that if the core fundamental data set that assists you in the running of your center, including the common research metrics are built-in to the underlying simulation curricular development processes it will seem like significantly less work overall to reports on such activities. Developing this automaticity in data collection will continue to build a robust data set for your center.

As the data amasses, combined with systems that allow easy access, analytics, and cross-referencing, your center could potentially soon be sitting on a mountain of data that is right for any type of data mining research necessary. The possibilities include but are not limited to justification for new employees, in-depth education simulation research, quality assurance mechanisms to evaluate faculty, facilities and program development processes.

Go forth and collect the data. All of it 🙂

Some interesting words from a talk from David Gaba. The essence Of his message is that the nuclear power industry has made a significant investment in simulation as well as standardization and protocol development. Lastly if you consider the embedded schedule by which each six weeks nuclear power plant operators undergo simulation testing, one could argue there is a significant investment net being made. Thus far, I don’t know of anybody in healthcare that is made this level of investment in safety. Further, I’ll bet the nuclear power industry didn’t have to justify simulation with randomized, placebo-controlled, double-blind studies To determine if nuclear reactor meltdown was going to occur with and without simulation!!!!!!! We need to get real with the justification, and significant impact that we can have with regard to making patients safer with simulation.

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A study recently published in the journal Resuscitation documents the effectiveness of simulation-based education for Patient Resuscitation. The article entitled “Simulation Technology for Resuscitation Training: A Systematic Review and Meta-analysis” by William Mundell et al became available in the published ahead of print section of the journal this week. The investigators screened thousands of studies for inclusion to finally arrive at 180 to publish studies that involved 16,636 participants evaluating the teaching of resuscitation to various learner groups.

The conclusion was “Simulation-based training for resuscitation is highly effective. Design features of “booster” practice, team/group dynamics, distraction and integrated feedback improve effectiveness.

This is the exact type of work that will assist us in moving the efforts associated with implementation of simulation-based education throughout the healthcare system. I applaud the authors in their hard work ,diligence, and mission.