Healthcare Simulation: An Innovative Tool for Improving ...chatexas.com/wp-content/uploads/2013/02/Wallin... · Healthcare Simulation: ... Director – Quality Education & Simulation

#IMSH2017 #IMSH2017

Healthcare Simulation: An Innovative Tool for Improving

Quality, Patient Safety, and Teamwork

Kelly Wallin MS RN CHSE

Director – Quality Education & Simulation Team (QuEST)

CHAT Quality & Safety Conference 2017

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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

4 CHAT Quality & Safety Conference 2017

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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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Early Simulation …

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Healthcare Simulation Has Come A Long Way

• TECHNOLOGY

• Settings

• Methods

• Systems integration


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• Technology

• SETTINGS

• Methods



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• Technology

• Settings

• METHODS



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• 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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Pit Crew Video


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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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Video of Sim-PDSA #2


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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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Simulation-Based QI Tools Sim-based FMEA


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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




DRIVERS



interpretation




INTERVENTIONS

Simulation-based Clinical System

Testing with Failure Modes and

Effects Analysis (FMEA)

SIM-BASED CLINICAL SYSTEM TESTING WITH FMEA


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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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Example of FMEA Scoring Tool


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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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De-centralized Nursing Alcove - before


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De-centralized Nursing Alcove - AFTER


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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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Simulation-Based QI Tools Sim-based PDSA


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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




DRIVERS



interpretation




INTERVENTIONS



SIM-BASED PDSA CYCLES


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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




DRIVERS



interpretation




INTERVENTIONS

Simulation-based “Just-In-

Time/Just-In-Place” Training

SIM-BASED ‘JUST-IN-TIME/PLACE” TRAINING


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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




DRIVERS



interpretation




INTERVENTIONS

Simulation-based Clinical System Testing with

Failure Modes and Effects Analysis (FMEA)



Simulation-based “Just-In-Tme/Just-In-

Place” Training

SIM-BASED FRAMEWORK FOR PROMOTING HRO


Wallin et al (2016)

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Thank You! QUESTIONS?

• Kelly Wallin MS RN CHSE

Director, Quality Education & Simulation

[email protected]


mailto:[email protected]

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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.


http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/PMSS.html

http://www.ihi.org/topics/rapidresponseteams

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