Why It Matters
Simulation-based learning can help improve not only clinician performance, but also patient discomfort, complication rates, and costs of care.
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Include Simulation in Your Improvement Plans

By Tejal Gandhi | Tuesday, May 15, 2018
Simulation as an Essential Element in Learning and ImprovementA Patient Safety Congress simulation session.

Years ago, as a physician-in-training, I learned to insert a central venous catheter under the watchful eye of a benevolent senior resident. I was lucky enough to count him as a friend as well, so I was unafraid to show my nervousness or ask questions. It worked out fine — for me and my patient.

Not every young doctor is fortunate to feel that level of comfort with a supervisor looking over his or her shoulder. Yet in a field where “see one, do one, teach one” has long been a standard method of learning new skills, many interns and residents now have something just as good, if not better: simulation training. Using virtual reality simulators, mannequins, and other techniques, clinicians-in-training can practice delicate skills without the risk of harming a patient. Beyond medical and nursing schools, simulation has become an important part of skills training and emergency preparedness at hospitals and health centers.

Although patient outcomes can depend on factors beyond a clinician’s skill, a 2013 meta-analysis of 14 studies found that simulation-based learning helped improve not only clinician performance and task success, but also patient discomfort, complication rates, and costs of care.

Clinicians aren’t the only ones who can learn through simulation. Simulation-based training can be used to teach leadership skills, like solving complex problems, and to educate and empower patients.

Since 2010, simulation has been an essential part of the annual IHI/NPSF Patient Safety Congress, offering attendees a learning experience and, ideally, some inspiration as to how they can use these techniques to teach skills, enhance teamwork, and improve communication, with the ultimate goal of improving quality and safety.  

It’s all about practice

As experts have said, “simulation is a technique, not a technology.” Any method used “to replace or amplify real experiences with guided experiences that evoke or replicate substantial aspects of the real world in a fully interactive manner” falls into the category of simulation.

That means you don’t necessarily need state-of-the-art equipment and dedicated space. Effective learning can be accomplished with low-fidelity (limited realism) methods, just as it does with high-fidelity (very realistic) mannequins and the latest technology. There are also methods for creating highly realistic exercises by conducting in situ simulations, which take place in actual patient care settings. Understanding the purpose, goals, and objectives of the learning experience, as well as organizational constraints, will determine the need for technology and level of realism.

But simulation should never be confused with play-acting. Acting means pretending to be someone else in a fictional situation, whereas simulation encourages people to behave as themselves in a real-life situation. Participants who are not being authentic may not gain the full benefit of the exercise, which includes a debriefing to discuss what happened, who did what, and what could have gone better. The debriefing that occurs with a team after a simulation exercise can be as important if not more important than the exercise itself, because that is where the real learning takes place.

Some examples of how health care organizations use simulation to improve safety and communication:

  • Interdisciplinary training: Although interdisciplinary education is more common today than a few years ago, there is still room for improvement. Teaching hospitals with simulation programs use it to practice emergency response training, where nurses, residents, respiratory therapists, pharmacists, and others learn how to interact and optimize communication as a team.
  • Practicing rarely used skills: Apology and disclosure after an adverse event are skills that no clinician ever wants to use. If the time comes for such a conversation, however, those who have practiced what to say and how to recognize their own vulnerabilities will communicate more effectively than if they go into it as a novice.
  • Drilling for rare, potentially catastrophic, events: In situ simulation in the setting where the event might occur can help staff identify vulnerabilities in their systems or infrastructure. For example, by simulating a fire in the operating room, staff may find that fire extinguishers are poorly placed or that evacuation is hampered by the way the room is arranged. Those are safety issue that can be identified and fixed before any harm occurs.

Putting together a fully functioning simulation center is a costly prospect, which is why most are found at medical schools and teaching hospitals. With more than 100 accredited simulation centers across the country (the American College of Surgeons and the Society for Simulation in Healthcare both have accrediting programs), hospitals and health systems without their own infrastructure can often work with a partner organization to achieve a specific training goal.

At the Patient Safety Congress, we have incorporated health care simulation as an example of an educational and experiential tool that can be used in education, assessment, research, and patient safety. As its use continues to spread, we hope to inspire health care teams to think creatively about how to apply these techniques across disciplines for improving quality and safety for staff and the patients they serve.    

Tejal K. Gandhi, MD, MPH, CPPS, is IHI’s Chief Clinical and Safety Officer.


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