Medical Simulation Center Director as a System Improvement Leader

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 effectively integrate medical simulation activities, simulation directors frequently collaborate with various departments throughout the healthcare system to provide support in gap analysis, curriculum development, and ongoing improvement efforts.[4] This unique and multidimensional skill set not only offers a robust framework for demonstrating "translational impact" as established by the Society for Simulation in Healthcare 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 provided by the program director offers a framework to achieve 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 the functional task alignment of the goals and objectives with the simulation modality, scope, and available environmental options. 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 and potentially reproducible platform for exploring 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 session's goals and objectives.[5][6]

Simulations for systems integration are designed to evaluate 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 represents their professional role within the institution, rather than as an individual employee. Since institutional stakeholders have predetermined the objectives of the sessions, the debriefing process focuses 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 participant’s perception that their professional identity remains intact regardless of the outcome of the simulated experience. A simulation activity must 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 encouraged to share their individual and role-specific expectations, as well as identify the behaviors necessary to enhance partnerships and collaboration. Relationships can be enhanced through this platform of interprofessional trust and support. By creating a psychologically safe environment, the simulation program director enables genuine and optimal engagement from participants in the simulation debriefing process.[8][9]

Medical Decision Making and Leadership Development

Traditionally, simulation program directors have received training in various 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 with latent safety threat tracking, and root-cause analysis.[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 accomplish its 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 in situations designed to elicit adaptive and resilient 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 between how simulation relates to the research process: the assessment of simulation efficacy as a training methodology versus simulation utilization as an investigative technique.[14][11] Simulation techniques are useful throughout the protocol development and design phase, as well as the walk-through usability process. They are especially applicable to human factors research and engineering, as they allow complex components of the healthcare system to interact in an observable manner, serving as a core knowledge elicitation method through "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 not only have the facility but also 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, including discrete–event simulation, system dynamics, agent-based simulation, and game/participatory simulation, there are opportunities to target physician leadership skills on multiple levels. Simulation can reach all levels of training, covering multiple training purposes and applying to various 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 also influence medical decision-making, thereby 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 evaluated 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 often tasked with creating opportunities to test various aspects of healthcare microsystems. Through the use of virtual patients, the efficiency and effectiveness of electronic health records can be evaluated and optimized. New clinical workspaces can be evaluated using low- or high-fidelity models to detect safety threats that cannot be assessed through other approaches. Sentinel events can be re-created in a simulated setting to aid in the root-cause analysis process.[12][21]

Simulation can be employed as a highly effective quality improvement approach for testing and implementing new processes. 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 gathered during the system-focused debriefing enables 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 escalating care can be developed and fine-tuned using 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 an appreciation for resource utilization in other settings, collaborative sharing of best practices, improved inter-institutional relationships, and ultimately, an 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 1 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 worked to coordinate and collaborate with multiple healthcare microsystems to address operational needs related to 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 assessing and evaluating team dynamics. In addition to assessing team performance as a whole, this also involves evaluating team composition and the impact of individual team members on team function. Familiarity with the specific team member attributes associated with highly effective teams creates a foundation on which targeted interventions can be developed to bring about change. In a study following 6 anesthesia teams that participated in 4 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, thereby influencing team performance.[25][26]

According to relational coordination theory, the following 3 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 enable participants to see the interrelationship of role-specific tasks with the overall process. Mutual respect transcends status barriers that hinder the ability to recognize and consider others' work. 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 are teamwork behaviors that influence high reliability. One study found that the establishment of a team leader was the most reliably achieved behavioral marker, and the absence of an explicit leadership transfer process was identified as the most common failure. The second and third most frequently noted failures were a lack of situational awareness and a lack of a shared mental model. This implies that the communication skills of the team leader themselves 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 at teaching leadership behaviors that foster inclusiveness, and coaching behaviors such as thinking aloud, team members feel that their effort and input are 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 rather than blaming when problems arise.[28]

Simulation directors can further enhance patient safety by utilizing the debriefing process as a means 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 the development of mutual respect can lead to psychological safety that persists beyond the simulation exercise itself and translates into a positive effect on clinical practice, ultimately 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  

Multiple current and potential applications of simulation can directly enhance education and experience, thereby improving patient-centered care. One group of simulation leaders developed a nomenclature for patient-related simulations based on the specific approach. "Patient-driven" simulations are developed through a collaborative process, where a partnership with patients enables the creation of interventions with an authentic patient voice. Patient-driven interventions employ a mastery learning model, similar to traditional medical simulation training, but tailored to the individual learning needs of patients and their families. "Patient-specific" simulation utilizes a patient's unique anatomy and/or physiology to inform them and their families about the healthcare process expected. Through simulation methodologies like 3D printing, providers cannot only determine the best approach to patient care but also practice it safely before the actual intervention is performed on the patient. By creating and sharing these analyses, simulation leaders can help establish a common language for assessing simulation research and education.[29]

Simulation directors can also utilize partnerships with other healthcare leaders to influence change in the outcomes of entire patient populations. After creating a collaborative, multi-professional simulation-based crisis resource management training course, obstetric teams were able to link their training intervention to improvements in 5 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 demonstrated a significant reduction in door-to-needle times (from 27 minutes 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 during the debriefing of simulation sessions enables simulation leaders to facilitate individuals, teams, patients, and families reflecting 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, evaluating how work, as imagined, translates to work performance and ultimately, how it improves the ability to provide safe and optimized patient care.