September 2008

Grant Results

SUMMARY

The Center for Simulation and Safety in Healthcare at the University of Chicago's Pritzker School of Medicine created and tested approximately 20 mock scenarios for use in "immersive simulation" training sessions for medical-surgical teams.

In immersive simulation sessions, a medical team acts out a mock scenario, which is often modeled after a real-life case. The sessions are videotaped and team members' performances are analyzed later. For a full description, see the Appendix.

Key Recommendations
The investigators identified several steps necessary to promote adoption of immersive simulation training by the health care industry:

  • Conduct research to demonstrate that immersive simulation training can lead health care institutions from a reactive approach to patient safety to a pro-active approach that emphasizes the need to fix processes to prevent errors and reduce risk.
  • Create educational programs to teach instructors how to lead simulation-training sessions.
  • Demonstrate that a financial case can be made that there is a reasonable return on investment in simulation training.

Funding
The Robert Wood Johnson Foundation (RWJF) supported the project with a $105,908 grant from October 2004 to August 2006.

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THE PROBLEM

In medicine, teams of caregivers-doctors, nurses, pharmacists and others-may work in tandem, around-the-clock, to treat a patient. Improvements in teamwork are critical to reducing the number of errors in healthcare, the Institute of Medicine (IOM) concluded in a 2004 study, Keeping Patients Safe: Transforming the Work Environment of Nurses. The IOM study also noted that training focused on "immersive simulation" is an important tool to improve the way team members work together, such as how problems are discussed and resolved.

In immersive simulations, a team acts out a mock event, which is often modeled after a real-life case. A computerized mannequin serves as the patient. This allows team members to perform medical procedures they would never do on an actor playing the role of a patient. However, actors often play the voice of the patient, adding to the realistic feel of the training exercise. A trained instructor leads the sessions, which are videotaped and analyzed later.

The Center for Simulation and Safety in Healthcare at the University of Chicago's Pritzker School of Medicine has been training health care personnel using immersive simulation with video feedback since 2003. The center, which is part of the anesthesia and critical care department, sought to expand its training beyond anesthesia and pediatrics providers to include multidisciplinary teams on medical-surgical inpatient units. See the Appendix.

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RWJF STRATEGY

RWJF has been committed to improving the quality of care delivered through the American health care system almost since its launch as a national philanthropy in 1972. It initiated a dedicated effort to improve quality in January 2003. Among the efforts RWJF supports to improve the quality of care are:

  • Since 1999, the MacColl Institute for Healthcare Innovation and the Institute for Healthcare Improvement have cooperated on the Breakthrough Series Collaborative, to help organizations improve how they deliver care to patients.
  • To encourage better patient self-management, RWJF supports the New Health Partnerships program. RWJF asked the Institute for Healthcare Improvement to manage this three-year, $3.75 million dollar national initiative, which is supported in part by the California HealthCare Foundation. The MacColl Institute for Healthcare Innovation at the Group Health Cooperative of Puget Sound Center for Health Studies and the Institute for Family-Centered Care also participate in this national initiative.
  • Within the "New Health Partnerships: Improving Care by Engaging Patients" initiative is the Quality Allies Learning and Innovation Community. This community is applying proven quality improvement methods and strategies in creative ways to boost the capacity of ambulatory care providers and patients and families to engage in productive, collaborative self-management support.
  • In 2004, the Institute for Healthcare Improvement and RWJF launched Transforming Care at the Bedside, a framework for change on medical/surgical units built around improvements in four main categories:
    • Safety and Reliability
    • Care Team Vitality
    • Patient-Centeredness
    • Increased Value

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THE PROJECT

In October 2004, directors at the center launched a project to adapt immersive simulation training to multi-disciplinary teams in medical-surgical units at the University of Chicago Medical Center.

The investigators:

  • Created training scenarios for medical surgical units that could be used at other simulation training centers across the country.
  • Conducted a literature review focused on immersive simulation team training and its relationship to safety culture in health care organizations. They found no research examining the effect of immersive simulation training on health care institutions' approach to safety culture.

One of the key themes of this exploratory project was to begin to define what happens when immersive team simulation with video feedback is scaled up across "silos" in organizations with the early hypothesis that a key impact is on safety culture.

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RESULTS

The investigators:

  • Developed approximately 20 simulation-training scenarios for medical-surgical units based on the National Quality Forum's measures for nursing-sensitive care. The scenarios were informed by a combination of factors: the emergence of the Medical Emergency Team movement, reviews of key issues in patient safety and expert opinion of the team and consultants. See the Appendix.
  • Tested the scenarios on approximately 200 caregivers. The caregivers, who worked in teams of six to eight, generally included nurses, physicians and residents. In cases where a physician or resident was not available, either an actor or Project Director Stephen Small, who is a physician, played the physician's role in the scenario.
  • Co-sponsored, with the Metropolitan Chicago Healthcare Council, a symposium on simulation and patient safety on April 10, 2006. Approximately 80 people from more than 40 institutions attended the event.

Recommendations

The investigators identified several steps necessary to promote adoption of immersive simulation training by the health care industry:

  • Conduct research to demonstrate that immersive simulation training can lead health care institutions from a reactive approach to patient safety to a pro-active approach that emphasizes the need to fix processes to prevent errors and reduce risk.
  • Create educational programs to teach instructors how to lead simulation-training sessions.
  • Demonstrate that a financial case can be made that there is a reasonable return on investing in simulation training. Simulation training is typically between 10 to 20 times more expensive than traditional classroom training, Small says, because it requires significant investments in trainers and infrastructure and cannot be delivered to large groups.

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LESSONS LEARNED

  1. Be prepared to overcome two hurdles when you schedule multi-disciplinary training sessions:
    • Training at hospitals historically has been done on a department-by-department or discipline-by-discipline basis. (Project Director Stephen Small and Final Narrative Report)
    • Schedules of physicians and nurses are typically hectic, making it difficult to get them together at the same time for training. (Project Director Stephen Small and Final Narrative Report)
  2. Involve managers in debriefing sessions. The performance of team members during simulation sessions illustrates the realities of patient care. In addition, widespread change in institutional culture cannot happen without support from all levels of management. (Final Narrative Report.)

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AFTER THE GRANT

The investigators received a grant of $248,497 in November 2006 from the federal Agency for Healthcare Research and Quality (AHRQ) to study the impact of immersive simulation team training on patient safety.

The investigators launched an updated Web site in late 2007, which included information on some of the scenarios developed for this project.

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GRANT DETAILS & CONTACT INFORMATION

Project

Improving the Performance of Health Care Teams Using Simulation Team Training

Grantee

University of Chicago, The Pritzker School of Medicine (Chicago,  IL)

  • Amount: $ 105,908
    Dates: October 2004 to August 2006
    ID#:  050541

Contact

Stephen Small, Ph.D., M.D.
(773) 834-2309
SSmall@dacc.uchicago.edu
Kay Tavill Metis, M.S., M.A.
(773) 834-9834
ktavill@dacc.uchicago.edu

Web Site

http://patientsafety.uchicago.edu

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

Immersive Simulation

An immersive simulation session at the University of Chicago typically involves a team of six to eight people and lasts a minimum of two and one-half hours. The session includes:

  • An introduction from a trained instructor, who explains the confidential nature of the exercise, the ground rules and the technology involved.
  • A 25-minute scenario in which the team acts out a complex situation on a computerized mannequin. The scenario often is based on a real-life case. Props turn the simulation center into a realistic medical setting that matches the scenario.

    Examples of scenarios include:
    • A young child with a history of asthma is admitted to a medical surgical floor via the emergency room for management of an infected foot wound. As a result of a reaction to an intravenous antibiotic, the child begins to wheeze, have reduced oxygen levels and lower blood pressure. The parent is very upset.
    • An adult in kidney failure comes to the medical-surgical floor after a surgical procedure on an extremity. As a result of transportation problems, he did not get a dialysis treatment before surgery. It is unclear how much pain medication he was given before arriving on the floor, but he is complaining of pain so he is given pain medication. The electrical activity in his heart becomes irregular.
  • The session is videotaped using technology that records the performance from numerous cameras stationed throughout the simulation room. This allows instructors and participants to review the team's performance from various points of view.
  • In addition to analyzing the team's performance, the team may also discuss or practice specific techniques to improve teamwork, such as how to use nonjudgmental language to question the directive of a superior. On occasion, managers may attend debriefing sessions.

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Report prepared by: Linda Wilson
Reviewed by: Richard Camer
Reviewed by: Marian Bass
Program Officer: Rosemary Gibson