Healthcare Simulation: An Innovative Tool for Improving...
Transcript of Healthcare Simulation: An Innovative Tool for Improving...
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Healthcare Simulation: An Innovative Tool for Improving
Quality, Patient Safety, and Teamwork
Kelly Wallin MS RN CHSE
Director – Quality Education & Simulation Team (QuEST)
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Fun Fact: A Tale of Two Cities …
• My AUSTIN connection … • My HOUSTON connection …
I have a thing for champion athletes who wear ORANGE.
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Texas Children’s System Academic partner:
Baylor College of Medicine
Main Campus
Pavilion for Women
West Campus
And … • Three research facilities • 50+ local pediatric practices • Global health program
Woodlands Campus
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Simulation at Texas Children’s • 1 central simulation center – Main Campus – opened in 2009
• Total space: 8,600 sq ft
• Multiple satellite simulation rooms • Texas Children’s Pavilion for Women, West Campus
• Growing in situ program including: • Dedicated sim rooms within units
• Service-based in situ teams within comprehensive structure
• Overall activity FY16 • 535+ simulation sessions
• 2130+ total hours of simulation
• 4980+ learner encounters
• 24,630+ learner contact hours
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Simulation at Texas Children’s:
Overall Curriculum Framework
Education
Research and Development
Competency and Assessment
Quality & Patient Safety Initiatives
Advocacy
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Objectives • Describe key elements and unique benefits of healthcare
simulation for inter-professional and organizational learning
• Explain how a simulation-based framework incorporating HRO principles and QI tools can be used to integrate simulation with quality/safety strategies in a healthcare organization
• Discuss a “toolkit” of simulation-based QI tools that can be used to improve quality, safety, and reliability within your organization
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What is Healthcare Simulation?
A technique that uses a situation or environment created to allow persons to experience a representation of a real healthcare event for the purpose of practice, learning, evaluation, testing, or to gain an understanding of systems or human actions
The application of a simulator to training, assessment, research, or systems integration toward patient safety.
- Society for Simulation in Healthcare (SSH)
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Basic Elements of a Simulation
• The Scenario: Immersion of an individual in a realistic situation • The Simulator: Creation of a physical space, equipment, and/or humans designed to replicate real life • The Experience:
• Suspension of disbelief and “near life” experience during the scenario
• Video-assisted debriefing afterward facilitates reflective learning
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History of Simulation in Healthcare
• Modern medical simulation began with the first mannequin … Resusci-Anne
• Developed from the combined efforts of Dr. Peter Safar, anesthesiologist and founder of CPR, and Asmund Laerdal, a Norwegian toy maker
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Healthcare Simulation Has Come A Long Way
• TECHNOLOGY
• Settings
• Methods
• Systems integration
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Healthcare Simulation Has Come A Long Way
• Technology
• SETTINGS
• Methods
• Systems integration
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Healthcare Simulation Has Come A Long Way
• Technology
• Settings
• METHODS
• Systems integration
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Healthcare Simulation Has Come A Long Way
• Technology
• Settings
• Methods
• SYSTEMS INTEGRATION
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Benefits of Simulation Education
• Unlimited exposure to rare and high risk clinical events
• Safe atmosphere for training in risky procedures for both trainees and patients
• Unlimited practice of technical skills
• Hands-on training, relevant to practice, with immediate feedback and learning
• Simulation can help with outcomes that are difficult to teach or assess by conventional methods of education and clinical practice
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Simulation Uniquely Equipped to Serve
Teamwork, Communication, Human Factors
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Teaching TEAMWORK over Autonomy
“We train, hire, and pay doctors to be cowboys …
… But it’s pit crews
we need.”
According to Dr. Atul Gawande (2011)
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What we lack in healthcare is opportunity for PRACTICING teamwork
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A Hospital is Like the Pit
• We work in a complex system
• Specialized clinicians must work together to achieve common goals for patients
• Healthcare requires effective coordination, communication, and standardized practice
• In order to function as a coordinated team, these skills must be taught and practiced
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What is an HRO? High Reliability Organization
Those organizations that are high-risk, turbulent, and potentially hazardous, yet operate nearly error-free. (Weick & Sutcliffe, 2007)
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High Reliability Organizations (HRO) Driven by a passion for safety and “collective mindfulness”
• Prevention (Anticipation) • Preoccupation with failure • Reluctance to simplify • Sensitivity to operations
• Resilience (Containment)
• Deference to expertise • Commitment to resilience
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HRO: Can Healthcare Get There?
SIMULATION AS TOOL FOR HRO
Robust process improvement tools
(Adapted from Chassin & Loeb, 2013)
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Simulation Beyond the Educational Toolbox –
A Robust QI Tool • How:
Focus on inter-professional team training and crisis resource management (The Pit Crew) Focus on identifying potential latent threats to patient safety and reducing error (“High-Reliability Organization” Principles) Use patient safety and quality improvement methodology to drive and evaluate impact of simulation-based training programs
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AIM
Reduce harm and improve quality of care
by enhancing high-reliability within
organization through use of simulation
DRIVERS
ANTICIPATION: Pre-occupation with failure
ANTICIPATION: Reluctance to simplify
interpretation
ANTICIPATION: Sensitivity to operations
CONTAINMENT: Commitment to resilience
CONTAINMENT: Deference to expertise
INTERVENTIONS
Simulation-based Clinical System Testing with
Failure Modes and Effects Analysis (FMEA)
Simulation-based Solution Testing using Rapid Cycle
Improvement tools (PDSA)
Simulation-based “Just-In-Tme/Just-In-
Place” Training
SIM-BASED FRAMEWORK FOR PROMOTING HRO
(Wallin et al, 2016) CHAT Quality & Safety Conference 2017
Wallin et al (2016)
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QI Tool: Failure Modes/Effects Analysis (FMEA)
Systematic, proactive method for evaluating a process to: • Identify where and how it might fail • Assess the relative impact of
different failures • Prioritize risk to drive action
planning for changes needed
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AIM
Reduce harm and improve quality of care
by enhancing high-reliability within
organization through use of simulation
DRIVERS
ANTICIPATION: Pre-occupation with failure
ANTICIPATION: Reluctance to simplify
interpretation
ANTICIPATION: Sensitivity to operations
CONTAINMENT: Commitment to resilience
CONTAINMENT: Deference to expertise
INTERVENTIONS
Simulation-based Clinical System
Testing with Failure Modes and
Effects Analysis (FMEA)
SIM-BASED CLINICAL SYSTEM TESTING WITH FMEA
(Wallin et al, 2016) CHAT Quality & Safety Conference 2017
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Simulation-Based Clinical System Test (SbCST) with FMEA
Goals
• Identify and address unintended consequences, unrecognized weaknesses, and latent safety threats (LSTS) in new or existing
• Clinical facilities, environments
• Equipment, devices
• Care processes, procedures
• Patient, provider populations
Methods • Stress system with ‘in situ’ clinical
simulations • Observe workflow “live” and video;
assess using workflow-based checklists
• Learn from participants through scripted debriefing
• Analyze and prioritize findings for resolution through FMEA
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Simulation-Based Clinical System Tests (SbCST) with FMEA
Examples • Test care processes, emergency
response systems for new or existing patient populations
• Test new facility before opening (POST-construction)
• Test design options for proposed new facility before finalizing plans (PRE-construction)
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Example of fidelity of in-situ simulation for system testing
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Outcomes: Managing Data and Determining Priorities
Flip charts, checklists, clipboards, video cards … OH, MY!!!
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Example of FMEA Scoring Tool for Prioritization and Action Planning
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Benefits of POST-Construction SbCST
• Final chance to test systems (humans + environment) and practice high-risk/high-impact workflows without risk to patients
• Enhances culture of safety by building transparency and situational awareness – leaders, front-line staff, families give/hear feedback and develop solutions
• Boosts team-building – often first time teams have worked together to manage “near-real” patient care
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Then, Why PRE-construction Simulation?
(Wonderful engineering, 2013) (Wonderful engineering, 2013)
(Architecture and design, 2015)
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Simulation for New Hospital Environments
Goal – Systematically evaluate design and systems of care using human factors principles and AHRQ Safe Design Principles:
• Improved visibility • Room standardization • Noise reduction • Room acuity & adaptability • Increased patient privacy • Accessibility to patient information, equipment, & supplies • Minimization of provider fatigue • PATIENT SAFETY (e.g.. Access to hand hygiene, minimization of falls)
(Joseph, Quan, & Taylor, 2012)
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• Traditional methods for engaging clinicians in new hospital design projects:
• Reviewing drawings and architectural designs
• Walking through full scale mock-up
• New approach – “simulate out” the poor designs before it is built!
• Case example: “Warehouse ICU”
Pre-construction Simulation (SbDT)
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Recommendations received on:
• Window vs. door
• Visibility/access into patient room
• Location of technology
• Nurse call
• Physiologic monitors/EPIC monitors
• TVs
• Communication boards
• Clocks
• Boom configuration/mounting
• Fixed vs. mobile storage/counter space
• Locations of lighting fixtures/controls
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• Putting front-line staff , family members in physical space PRE-construction builds enthusiasm and engagement
• Invaluable opportunity for architects to see “proof of concept” and test options before final design decisions
• Opportunity to prevent design flaws that affect patient safety, patient/family experience and provider satisfaction prior to construction
Key Benefits of Pre-construction SbDT
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QI Tool: Plan-Do-Study-Act (PDSA)
Simulation as PDSA cycle
•Conduct simulation
•Record or observe
•Debrief participants and observers with reflective practice
•Analyze AV recordings , surveys if used
•Identify solutions, improvements
•Engage stakeholders
•Identify concerns
•Develop intervention to test using simulation
•Identify measures of success
•Adopt, adapt or abandon based on analysis
•Repeat simulation incorporating new changes
•When refined, move to new cycles based on sim-based training
ACT PLAN
DO STUDY
• Four step process of for continual improvement
• Method for assessing and improving processes in small rapid cycles
• Simple, straightforward way to address an issue
• Can start small, test, and build to become system-wide improvement
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AIM
Reduce harm and improve quality of care
by enhancing high-reliability within
organization through use of simulation
DRIVERS
ANTICIPATION: Pre-occupation with failure
ANTICIPATION: Reluctance to simplify
interpretation
ANTICIPATION: Sensitivity to operations
CONTAINMENT: Commitment to resilience
CONTAINMENT: Deference to expertise
INTERVENTIONS
Simulation-based Solution Testing using Rapid Cycle
Improvement tools (PDSA)
SIM-BASED PDSA CYCLES
(Wallin et al, 2016) CHAT Quality & Safety Conference 2017
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Simulation-Based PDSA Cycles
Goals
• Test and refine complex or high-risk processes in “near-real” systems before training and implementation
• Validate changes to problematic processes to identify and address any unintended consequences
Methods
• Cycles of ‘in-situ’ simulations • Planned as discrete sims to test
options
• Planned in series to build toward project aim
• As close to “real” environment and systems as possible
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Simulation-Based PDSA Cycles
Examples • Developing, validating “best
practice” for complex or high-risk care pathways that depend on highly coordinated inter-departmental response
• Mass transfusion protocol • Disaster response, mass casualty • Ebola • Role clarity, zones during code
response
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Simulation-Based QI Tools Sim-based “Just-in-Time/Just-in-Place” Training
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AIM
Reduce harm and improve quality of care
by enhancing high-reliability within
organization through use of simulation
DRIVERS
ANTICIPATION: Pre-occupation with failure
ANTICIPATION: Reluctance to simplify
interpretation
ANTICIPATION: Sensitivity to operations
CONTAINMENT: Commitment to resilience
CONTAINMENT: Deference to expertise
INTERVENTIONS
Simulation-based “Just-In-
Time/Just-In-Place” Training
SIM-BASED ‘JUST-IN-TIME/PLACE” TRAINING
(Wallin et al, 2016) CHAT Quality & Safety Conference 2017
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Simulation-Based “Just-in-Time/Just-in-Place” Training (JIT/JIP)
Goals • Provide frequent “refresher”
training in complex or high-risk tasks and situations to reduce risk to patient/provider safety
• Risk assessment for latent safety threats (LST) at point-of-care through ongoing simulations
• Clinical rehearsal for rare or complex patient care situations
Methods • ‘In-situ’ simulation - Portable
simulation equipment or dedicated room on unit/setting
• Expected as part of providing safe patient care
• Streamlined for efficiency, relevance to current needs, reporting of LSTs
• Integrated in safety event investigation and action planning
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Simulation-Based “JIT/JIP” Training
Examples • Simulation-enhanced root cause
analysis (RCA) - “near-real” re-enactment
• Frequent, hands-on refresher training for post-event action planning (eg – timely RRT activation, CVC dressing change, tracheal intubation)
• Clinical rehearsal for actual patients • Practice for “watcher” patients • Rehearse coordination of care in
complex patients
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In Summary: Simulation-Based QI Tools
As a Toolkit for Increasing Reliability
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AIM
Reduce harm and improve quality of care
by enhancing high-reliability within
organization through use of simulation
DRIVERS
ANTICIPATION: Pre-occupation with failure
ANTICIPATION: Reluctance to simplify
interpretation
ANTICIPATION: Sensitivity to operations
CONTAINMENT: Commitment to resilience
CONTAINMENT: Deference to expertise
INTERVENTIONS
Simulation-based Clinical System Testing with
Failure Modes and Effects Analysis (FMEA)
Simulation-based Solution Testing using Rapid Cycle
Improvement tools (PDSA)
Simulation-based “Just-In-Tme/Just-In-
Place” Training
SIM-BASED FRAMEWORK FOR PROMOTING HRO
(Wallin et al, 2016) CHAT Quality & Safety Conference 2017
Wallin et al (2016)
#IMSH2017
Thank You! QUESTIONS?
• Kelly Wallin MS RN CHSE
Director, Quality Education & Simulation
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Simulation-based QI Toolbox: Drive for Higher Reliability
• Simulation-based FMEA • Clinical system testing before opening new facilities
• Before construction (PRE-Construction) • Before opening for patient care (POST-Construction)
• To test existing systems for latent safety threats
• Simulation-based PDSA • To test and refine new care processes and roles
• “Just-in-time/just-in-place” simulation • Practice rapid response modes for high-risk patients on unit • Clinical rehearsal before performing rare, complex, or high risk procedures
• Simulation-based Education • Bundled with quality safety initiatives (eg – sepsis)
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References • Callaghan WM, Creanga AA, Kuklina EV (2012). Severe maternal morbidity among delivery and postpartum hospitalizations in
the United States. Obstetrics and Gynecology, 120(5), 1029-1036.
• Centers for Disease Prevention and Control [CDC] (March 3, 2014). Retrieved on May 26, 2014 from http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PMSS.html
• Chassin MR and Loeb JM. The ongoing quality improvement journey: Next stop, high reliability. Health Affairs 2011;30(4):559–68.
• Chassin MR and Loeb JM. High-reliability healthcare: Getting there from here. The Milbank Quarterly 2013; 91(3):459–490.
• Dong Y, Maxworthy JC, Dunn WF. In: Palaganas, JC, Maxworthy, JC, Epps, CA, and Mancini, ME, eds. Defining Excellence in Simulation Programs. Philadelphia: Wolters-Kluwer; 2015:153-162.
• Gaba D, Fish K, Howard S. (1994). Crisis Management in Anesthesiology. New York: Churchill-Livingstone.
• Institute for Healthcare Improvement [IHI] Retrieved on September 30, 2014 from http://www.ihi.org/topics/rapidresponseteams
• Kohn LT, Corrigan JM, and Donaldson MS, eds. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000.
• Maxworthy JC, Kutzin JM. Quality improvement. In: Palaganas JC, Maxworthy JC, Epps CA, Mancini ME, eds. Defining Excellence in Simulation Programs. Philadelphia: Wolters-Kluwer; 2015:49-64.
• Wallin KD, Kelly F, Sembera KA. Building high reliability through simulation. In: Achieving high Reliability through Patient Safety and Quality – A Practical Handbook. Sigma Theta Tau; 2016 (in press)
• Weick K, Sutcliffe K. 2007. Managing the Unexpected: Resilient Performance in the Age of Uncertainty. 2nd ed. San Francisco: John Wiley & Sons, Inc.
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