Introduction

Healthcare system improvement depends on the ability of a system as a whole to accurately identify critical information from which to create policies and procedures, which then must be translated into initiatives that result in improved patient care and outcomes.  Effective implementation requires the development of interventions that align with improvement goals.[1] To champion these improvement efforts, collaborative teams must be created, incorporating strong physician and clinician leaders who are engaged in patient care.  According to complexity leadership theory, when leaders move to the role of facilitating the flow of information, they can create "the container for change" instead of trying to dictate the change. Simulation program directors are ideally suited to provide this "container for change" by providing diagnostic and therapeutic opportunities demonstrative of translational simulation.[2]

According to the Society for Simulation In Healthcare (SSIH), this functional approach to systems integration incorporates a multi-dimensional evaluation of quality outcomes such as "efficiency, effectiveness, safety, patient-centered in this, and equity." This process involves the utilization of simulation, instructional, and assessment strategies that are "consistent, planned, collaborative, integrated and interactive" while assuring that they incorporate "systems engineering and risk management principles."  Success is achieved through accomplishment of the following goals: optimal bedside clinical care, patient safety enhancement, and improved metrics across the healthcare system.[2]

Issues of Concern

Typical Value Domains of Medical Simulation Center Directors

To establish competency in certain value domains, many simulation program directors have either completed a simulation fellowship program and/or obtained certification as healthcare simulation educators. These values frequently overlap with those of hospital leadership, including educational effectiveness and efficiency, patient safety, quality of care, resource management, research, and scholarship.[3][5] The simulation medical director role frequently incorporates executive and administrative responsibilities associated with the daily operations of the simulation program. These include, but are not limited to, strategic planning, budget preparation, staff training, grant management, reporting, marketing, and outreach. To practically integrate medical simulation activities, simulation directors routinely collaborate with different departments throughout the healthcare system to provide support in gap analysis, curriculum design, and continual improvement efforts.[4] This unique and multidimensional skill set not only offers a robust framework for demonstrating "translational impact" as established by the SSIH but it is also directly applicable to supporting systems integration and process improvement measures. 

Curriculum Development

The bedrock of healthcare simulation is immersive experiential learning for educational engagement. Translational simulation focuses specifically on delivering appropriate simulation-based interventions, regardless of location, modality, or content. The simulation training of the program director provides a framework to meet this purpose. The interventional/curricular design process begins with a needs assessment and determination of the goals and objectives of the simulated experience. The appropriate simulation method is chosen based on functional task alignment of the goals and objectives to the simulation modality, scope, and environmental options available. If multiple environmental options exist (in situ versus simulation lab), the decision is determined by the location in which team composition and the improvement target are best aligned. The simulation leader then matches improvement objectives to the physical, emotional, and conceptual fidelity needed to maximize experiential learning for the participants. By utilizing this approach in creating functional realism as the platform to optimize engagement, the simulation director can best assess and address the knowledge, skills, and attitudes targeted to promote performance improvement.[2]

Procedural Skills Assessment

In addition to efforts at optimizing engagement in the scenario, much of the process improvement work occurs during the debriefing portion of the session. The purpose of debriefing is to provide a safe, potentially reproducible platform to explore performance gaps. These may be related to the knowledge, skills, attitudes, and behaviors of individuals and teams, or more extensive systemic issues. Simulation leaders have a repertoire of debriefing strategies from which to choose, depending on the goals and objectives of the simulation session.[5][6]

Simulations for systems integration are designed for the evaluation of work–system coordination as a whole. Systems-focused debriefing strategies use a blended debriefing approach to identify latent safety threats. Systems-focused debriefing strategies such as PEARLS for systems integration, can target any of the following areas: tools (policies), technology (communication equipment), tasks (goal responsibility), environment (equipment locations), people (team composition), organization (role identity), and processes (procedures). During these sessions, each participant is a representative of their professional role within the institution, rather than as an individual employee. Since institutional stakeholders have pre-determined the objectives of the sessions, the debriefing process is focused on elucidating what worked well and what needs improvement from a systems perspective.[7] As such, individual team member assessment is not the priority. Regardless of whether a simulation is learner-centered, or systems integration-based, the simulation leader is responsible for creating an environment of psychological safety in which participants can effectively discuss, disclose, and reflect on their roles in the process.

Psychological safety refers to a participants’ perception that his or her professional identity will remain intact regardless of the outcome of the simulated experience and is absolutely critical for a simulation activity to be effective. Mutual respect can be cultivated by establishing that individual mistakes are kept confidential and that individuals are not penalized or judged on an personal level. Through facilitated conversations across the organizational hierarchy, participants are allowed to reveal their individual and role-specific expectations, as well as to identify the behaviors required to improve partnerships and collaboration. Relationships can be enhanced based on this platform of inter-professional trust and support. By creating this psychologically safe environment, the simulation program director allows for genuine and optimal engagement by participants in the simulation debriefing process.[8][9]

Medical Decision Making and Leadership Development

Traditionally, simulation program directors have had training in many quality, safety assessment, and evaluation methods. On a large scale, proactive methods include crisis resource management strategies such as disaster management and emergency preparedness training. At the point of care, "just in time," training is a method that provides a quick skills refresher. When performance gaps are identified, other quality improvement methods can be employed, such as rapid cycle process improvement, healthcare failure mode and effect analysis (HFMEA) with latent safety threat tracking, and root-cause analysis (RCA).[10][11][12]

More recently, human factors engineering principles have been incorporated into simulation training. When circumstances push a work system beyond its competence boundaries, adaptability is required for the system to be able to accomplish the original goal successfully. Safety and resilience engineering provide a platform to determine which behaviors should be modeled or generalized for other members of the work system. Simulation, thus, provides an opportunity to safely and reproducibly place individuals into situations designed to elicit adaptability and resilience behaviors. By identifying positive behaviors, simulation can create "accelerated expertise," which can be reported to hospital leadership, generalized if appropriate, and disseminated to staff in all applicable settings of the institution in a unified and expedited fashion.[13]

Continuing Education

Simulation research can functionally stand alone or be part of a mixed-methods design. In this way, it can support healthcare research from the bench of the simulation "wet lab" to the bedside. In the literature, it is helpful to differentiate how simulation relates to the research process: assessment of simulation efficacy as a training methodology vs simulation utilization as the investigative technique.[14][11] Simulation techniques are useful from the protocol development and design phase through the walk-through usability process. They are especially applicable to human factors research and engineering since it allows complex components of the healthcare system to interact in an observable manner as a core knowledge elicitation method by "thinking aloud" during the scenario and throughout the debriefing process.[15] As an investigative methodology, simulation uniquely provides the opportunity to evaluate those healthcare studies that would otherwise be difficult, costly, or ethically impossible to complete.  This "wet lab" provides not only for direct evaluation of healthcare quality and patient safety performance but also for research on leadership qualities themselves. By incorporating leaders as participants in simulated processes evaluation, the following questions can be answered: How do leaders at different levels think about safety and quality problems? How do leaders perceive and weigh cues within different scenarios? How do leaders assess risk?[16]

Clinical Significance

Simulation program leaders have not only the facility but access to many strategies to support a multi-modal approach to physician leadership development.[17][18] By matching logistical healthcare objectives with a repository of logistical simulation models (discrete–event simulation, system dynamics, agent-based simulation, and game/participatory simulation), there are opportunities to target physician leadership skills, on many levels. Simulation is able to reach all levels of training, to cover multiple training purposes and apply to multiple different areas; agent-based simulation, in particular, offers flexibility through its ability to model the interaction between system components in dynamic situations.[19]

Cognitive biases can influence medical decision making as well, thus creating a more error-prone environment. Specific curricula can be designed to target heuristic clinical decision-making throughout the continuum of healthcare provider development. These can be used either as initial teaching strategies or as the platform on which to provide remediation. One study incorporated the evaluation of trends in "bias–prone" versus "bias–resistant" cognitive frames. Scenarios were designed to highlight a participants' diagnostic decision-making model, allowing for the identification and categorization of these biases. Facilitated debriefing prompted reflection on these observed biases, as well as potential mitigation strategies that could serve as countermeasures. In this psychologically safe environment, participants were able to observe, practice, and apply techniques to prevent further incorporation of biases.[20]

Pearls and Other Issues

Application to Systems-Based Practice Improvement

Simulation program directors are frequently tasked with creating opportunities to test the many aspects of healthcare microsystems. Through the use of virtual patients, electronic health record efficiency and effectiveness can be evaluated and optimized. New clinical workspaces can be evaluated using low or high fidelity models to detect safety threats that are unable to be assessed through other approaches. Sentinel events can be re-created in a simulated setting to aid in the RCA process.[12][21]

Simulation can be employed as a highly effective quality improvement approach to testing and implementing new processes as well. Through collaboration with senior leaders, frontline staff, and other stakeholders, simulation program directors work to assure that the chosen simulation modality and fidelity align with the objectives targeted by the process under evaluation for optimal participant engagement. The information elicited during the system-focused debriefing allows for process refinement and optimization. Subsequently, simulation leaders can develop targeted training curricula via learner-centered simulations to train the appropriate staff. As the system and process mature, best practices for escalation of care can be developed and fine-tuned using other targeted simulation methods. When these efforts are brought from large academic centers to community settings, content experts are available at the bedside to assist in troubleshooting the systems-testing process. This results in appreciation of resource utilization in other settings, collaborative sharing of best practices, improved inter-institutional relationships, and ultimately improved quality of care.[22][23]

Enhancing Healthcare Team Outcomes

Application to Development of High-Performance Teams

Simulation and healthcare leaders often share the perspective that the healthcare macro-system represents one unified team with the overarching goal of safely delivering optimized patient care. The skillset attained by simulation leaders is directly applicable to addressing institutional readiness and disaster preparedness. After completing a needs assessment, directors can review existing policies and procedures, many of which they likely formulated to assess resources and create a bidirectional flow of information regarding the capacity of services. During the Ebola crisis, for example, simulation leaders at the University of Pittsburgh Winter Institute for Simulation, Education and Research (WISER) worked to coordinate and collaborate with multiple microsystems of healthcare to respond to operational needs regarding personal protective equipment training and disaster preparedness.[24]

Communication and teamwork dynamics fundamentally affect an institutions' readiness to deliver highly reliable patient care. Simulation program directors are uniquely suited to support this aspect of systems improvement. Not only do they have access to and training on the equipment necessary to deliver realistic simulation sessions, but they are also trained in the assessment and evaluation of team dynamics. In addition to assessing team performance as a whole, this must also involve assessing team composition and the impact of individual team members on team function. Familiarity with the specific team member attributes that are associated with highly effective teams creates a foundation on which targeted interventions can undergo development to affect change. In one study following six anesthesia teams that participated in four high-fidelity simulation sessions together, they were able to show that explicit coordination decreased while implicit coordination increased. This suggests that within the realm of crisis resource management, simulation can be utilized to train the skill of adaptive coordination, and therefore can influence team performance.[25][26]

According to relational coordination theory, the following three attributes of relationships support the highest levels of coordination and performance: shared knowledge, shared goals, and mutual respect. Shared knowledge transcends role-specific functional goals.  Shared goals allow participants to see the interrelation of role-specific tasks to the whole process. Mutual respect transcends status barriers that interfere with the ability to see and take others' work into account. When these relationship attributes are reinforced by additional aspects of high quality communication such as frequency, timeliness, and accuracy, this further supports coordination and high performance.[9]

Multiple studies have noted that clear role definition and identification is a teamwork behavior that influences high reliability. One study showed that the establishment of a team leader was the most reliably achieved behavioral marker, and the absence of an explicit leadership transfer process was noted as the most active failure. The second and third most active failures noted were a lack of situational awareness and a lack of a shared mental model. This implies that the communication skills of the team leader himself or herself definitively affect team performance.[27] The overall absence of high performance healthcare teams may, therefore, also be a function of the complexity of team dynamics as a whole.

Simulation program leaders can positively influence team dynamics by creating an environment that allows both team members and team leaders to meet on the same page. When simulation scenarios are targeted towards teaching leadership behaviors that engender inclusiveness, and coaching behaviors including thinking aloud, team members feel their effort and input is valued. By helping team members to reframe success and failure in a way that supports mastery learning, simulation leaders model behaviors that support team efficacy. In these circumstances, teams are more likely to demonstrate a focus on problem-solving instead of blaming when problems do arise.[28]

Simulation directors can further influence patient safety by using the debriefing process as a method to promote team reflexivity[8].  By fostering psychological safety, team members are allowed to identify multifaceted issues that facilitate or hinder optimal team performance. This can sometimes lead to consideration of systematic issues related to the collaboration of administration and quality improvement on the teamwork process itself.[27] Some studies suggest that through the development of mutual respect, this psychological safety can persist beyond the simulation exercise itself, and translate into a positive effect on clinical practice, creating a higher level of training effectiveness. In this way, simulation provides not only the opportunity to observe but also the platform for training effective team members and team leadership principles.[9]

Affect on Patient Perceptions and Outcomes  

There are multiple current and potential applications of simulation that can directly enhance education and experience to improve patient-centered care. One group of simulation leaders created a nomenclature of patient-related simulations based on the specifics of the approach. "Patient-driven" simulations developed through a collaborative process where a partnership with patients allows interventions to be created with an authentic patient voice. Patient-driven interventions consist of a mastery learning model much like traditional medical simulation training, but tailored to the learning needs of individual patients and families. "Patient-specific" simulation utilizes a particular patient's unique anatomy and/or physiology to inform patients and families about the healthcare process expected. Through simulation methodologies like 3D printing, the providers are able not only to determine the best approach to patient care but practice it safely before the actual intervention, which will be performed on the patient. By creating and sharing these analyses, simulation leaders can help to provide a common language by which simulation research and education are assessed.[29]

Simulation directors can utilize partnerships with other healthcare leaders to affect change in the outcomes of whole patient populations as well. After creating a collaborative, multi-professional simulation-based crisis resource management training course, obstetric teams were able to link their training intervention to the improvement of five patient-reported scores related to feelings of safety during labor. This suggests that skillful simulation training design can translate into improvements in patient-reported outcomes.[30] These collaborative techniques have also been employed through the iterative refinement of an in-hospital stroke protocol. Survey results from frontline acute stroke team members about streamlining the process were solicited; this information was then incorporated into in situ team-based simulation training sessions. In their assessment of Kirkpatrick's four levels of training effectiveness, the group was able to show a significant reduction in the door to needle times (from 27 down to 13 minutes), as well as improved patient outcomes. This is further evidence that by utilizing this unique skill set, simulation program directors can create high fidelity interventions that lead to translational outcomes and improved patient care.[31]

By partnering with healthcare leaders to assess the strengths and challenges of the healthcare system, simulation leaders can apply their knowledge of education, research, patient safety, and implementation science to develop targeted and meaningful simulated healthcare experiences. The psychologically safe environment provided in the debriefing of the simulation sessions allows simulation leaders to facilitate the ability of individuals, teams, patients, and families to reflect on their journey through the healthcare process. By transcending hierarchical clinical status through the development of mutual respect, they promote collaborative problem-solving opportunities, identify gaps, highlight best practice, and enhance inter-professional and multidisciplinary relationships. By communicating these findings to decision-makers, they inform the development and refinement of policies and procedures. They can then use targeted simulation strategies to bring the system improvement initiatives back to the front lines to evaluate how work, as imagined, translates to work performance and ultimately, how it improves the ability to provide safe and optimized patient care.