University of Kansas Healthcare Simulation Institute - Committee Report

 

Many professional fields, such as aeronautics and the military have used simulation for years to help in decision making.  The use of simulation in medicine is much more recent.  Training in factual knowledge alone is valuable but not sufficient in the complex world of healthcare, where problems often involve uncertainty and rapid change.  Learning from textbooks and lectures is useful, but can be amplified by direct experience.  Developing that experience by treating actual patients can be risky and unacceptable in the current competitive healthcare systems.  Errors made in a simulated setting provide excellent teaching opportunities to identify strengths and weaknesses for the trainee without compromising patient safety.  Simulation can be used in training all types of learners and teams of learners as well.  A simulation center that can provide this experience to diverse users within the Medical Center as well as throughout the state would enhance our training programs, decrease medical errors and improve patient outcomes.

Medical simulation as an educational tool is currently used in select disciplines now, but will likely undoubtedly expand significantly in the future.  The American College of Surgeons and the American Society of Anesthesiologists have already defined simulation accreditation requirements for simulation centers providing training in these disciplines.  The validation of simulation as an effective training modality has occurred in laparoscopic surgery where it has been proven to improve technical skills and reduce errors.  It is almost certain licensing agencies for medical schools, nursing schools and schools of allied health will introduce standards that will make simulation training essential for student education.

For the reasons stated above, it is critical that KUMC develops a formal center for simulation education.  It is interesting to note that isolated disciplines within KUMC are already extensively involved in simulation education.  Areas within the school of medicine, the school of nursing as well as residency programs in surgery, anesthesiology, otolaryngology and obstetrics are performing some degree of advanced simulation education.  Many other groups are interested in simulation training, but lack either the expertise or funding to support these complex programs.

KUMC must organize a centralized center for medical simulation education.  We should be the leader in our region in providing the most advanced level of simulation training to our learners.  The scope of learners is broad and expanding.  KUMC should position itself now to lead for the future of simulation education.

1. Mission and Vision Statements.

 

Kansas University Healthcare Simulation Institute

Mission

The mission of the Kansas University Healthcare Simulation Institute is to promote and enhance quality patient care by providing an atmosphere that fosters development of critical analysis through participant engagement in an interactive learning environment. 

Vision
The vision of the Kansas University Healthcare Simulation Institute is to provide a world-class simulated learning environment utilizing advanced simulation techniques.  The center is a place where multidisciplinary participants of all levels can safely develop skills required to care for patients in complex healthcare systems.  The center’s educative staff will be supportive, non-threatening, and encourage development of:

• Teamwork
• Enhanced communication
• Identified roles in practice
• Technical skills
• Research
• Enhanced practice skills

 

The center will be an active resource to the University of Kansas Medical Center participants with extended support to area healthcare services as feasible.  Systems within the center will be designed to support the required learning environments needed to meet the simulation needs of the medical center schools and hospital.

2. Current State of Simulation Education at KU Medical Center.

Cumulatively, the University of Kansas Medical Center has a multitude of simulation capital equipment already in existence.  Purchase of this equipment has been through individual hospital departments, medical services and other organizational entities. The equipment ranges from high fidelity human simulators to low fidelity task trainers.  The equipment is usually stored within the department that purchased it. The estimated cost of this vested equipment exceeds $1.75 million.  In some cases, isolated resources have resulted in suboptimal utilization and application that has lead to poorly used and maintained equipment.

Listed are examples of this issue:

• One department had a $2100 pediatric simulator while another department had the corresponding $2500 control system.  Neither knew they needed both components to make their systems work.  This equipment remained in two separate closets for more than 2 years. 

• One department owns high fidelity simulators but does not have the time or expertise to use them beyond simple task training. 

• One department owns defibrillators and fully stocked training crash carts.  Other departments were unaware of this equipment’s availability for training; therefore its use was infrequent.

Reasons for these issues include: individuals not being aware of the extent of the equipment’s capabilities, lack of resources including time to adequately prepare human resources to use the equipment maximally and lack of communication between organizations that own the equipment and organizations that could utilize equipment.    

Opportunity for simulation training is lost because of decentralization, inexperience and lack of trainer availability.  Development of a formal center for training will allow this equipment and the allocated human resources to be available for maximum utilization by all entities.  The results will be better prepared staff and students to care for the complex clients within our healthcare system. 

3. Potential for simulation education at KU Medical Center

 
Estimating the potential user base of a simulation center at KU is an important, but daunting challenge.  To accurately estimate the needed size of such a center, the committee recognizes that we must have an accurate assessment of its potential use.  Overestimation may result in wasted resources while underestimation risks a center that is obsolete at opening and unable to meet growth in simulation training. 
User estimates are based on current usage (where known) and estimates of future usage based on discussions with program directors, nursing personnel, allied health personnel, the chief of staff’s office, and other KUMC leadership.  Although we have a reasonable idea of current usage, a number of factors may impact future usage that is hard to quantify.  Users who currently do not employ simulation or standardized patients in their programs may see the success of the center and be encouraged to embrace it as an educational resource, greatly expanding the application of this training. 

The following is a breakdown of potential usage by category:

• Medical Students:  Medical students may well form the bulk of current and future users.  While not strictly simulation, medical students participate in a number of “standardized patients” who help them learn history and physical exam skills.  Currently medical students have a total usage of approximately 7600 sessions/year, but the leadership in the medical school feels expansion could easily occur to 10,000 sessions per year.  This is currently accomplished in a 12 room standardized patient center.  Additional simulations could be developed that are not currently utilized (suturing, casting, ACLS, etc.)
• Housestaff (Residents/Fellows):  This is a diverse group of users with varied needs.  In general, the needs of non-surgical specialties are for standardized patient experiences, while the needs of surgical specialties are largely procedural simulation.   Exceptions to this are specific procedural skills in Medicine, Pediatrics, and Family Medicine.  Generally speaking, Residency Review Committees in the surgical specialties are beginning to require the availability of simulation experiences for housestaff.  There is also need for certification courses (and recertification as needed) such as ACLS, BLS, ATLS, NRP, etc.
• Anesthesiology:  High fidelity simulation training is utilized for 24 residents with a total of 160 sessions per year.  Additional training is provided to medical students on their elective rotation in anesthesiology and critical care.
• Internal Medicine and Subspecialties:  Training for approximately 70 standardized patients per year, plus core skills lab at the beginning of the year for approximately 40 residents.  Additional sessions likely for mock codes and procedural labs for pulmonary, GI and CV and surgical simulation for Dermatology.
• Ob-Gyn:  Currently provides simulation in an obstetrical emergency course (multidisciplinary) and in birthing simulation.
• General Surgery:  Currently do 400 sessions/year, using both live animal wet lab simulations, and dry lab robotic and laparoscopic simulations for 36 residents, but project growth to easily reach 100 to 200 sessions/year with requirements by the American College of Surgeons for all graduates to complete fundamentals of laparoscopic surgery simulation course starting in 2009.  Core Skills Laboratory curriculum is already in place and incorporated into the weekly conference schedule.  We plan to expand simulations for Advanced Trauma Life Support certifications for residents, faculty and community physicians as well as for procedure-based certification of competency for residents.
• Ophthalmology has 9 residents and currently trains with animal labs.  They would like to do a virtual wet lab simulation with multiple sessions/year.    Otolaryngology would use a minimum 15 to 30 sessions/year.
• Pediatrics:  Needs include 27 standardized patients/year with additional sessions at the beginning of the year with core skills lab.  They would also use simulation monthly for mock codes.
• Family Practice: Unknown usage currently, but potential simulation opportunities.
• Neurology:  Does approximately 16 standardized patient sessions/year

• Medical Staff:  There are currently no simulation programs for KU medical staff.  That being said, per the Medical Staff Office, Joint Commission has recently mandated that all faculty physicians (currently 450 physicians and 50 extender providers) must demonstrate knowledge/understanding of the six ACGME-defined core competencies.  The Credentials Committee is exploring opportunities for providing this training, including simulation exercises.  A conservative estimate to provide recertification to the entire staff every other year would include one half day training/ month, with 20-25 participants per session. 
• School of Nursing:  The undergraduate nursing program at KU already has an active simulation program that could be expanded into a larger center.  Currently undergraduate students have a cumulative 2000 sessions per year, with graduate nursing students utilizing an additional 500 sessions per year.  The nursing anesthesia program also uses high fidelity simulation training, with approximately 650 sessions per year.
• KU Hospital Nursing Staff:  Staff nursing’s primary needs are ongoing core competency maintenance, certification training and maintenance in programs such as BLS, ACLS, ATLS, PALS, NRP, etc.  It’s estimated that this usage alone could utilize four rooms full time year round, with four associated dedicated FTEs.
• Allied Health:  Allied Health currently has approximately 500 training sessions per year, involving students from training programs in physical therapy, occupational therapy, respiratory therapy, etc.
• Support Staff:  To our knowledge, no current formal programs exist for simulation training of support staff at KU such as transport services, environmental services, etc.  However, opportunities for novel educational programs for these users certainly exist.  Possible programs include simulation training of safe transport skills for transport personnel, hazardous cleanup for safety personnel, proper cleaning of ICU/isolation rooms for environmental services, etc.
• External Users:   The committee recognizes that our center must fully address internal user needs prior to addressing the needs of users external to the KUMC system.  Nevertheless, we also recognize that these are important groups to serve and are vital sources of political, community, and financial support.  While the committee has no concrete estimates of the number of users external to KUMC’s system, potential users include practitioner CME offerings, community medical personnel education (such as prehospital personnel), State of Kansas medical personnel, military contract personnel (e.g. the Kansas National Guard), disaster training and basic science users.   Communication with other simulation centers have stressed the importance of these interactions from public relations and fund-raising standpoint.  In addition, time and personnel must be dedicated to media presentations and community donor outreach demonstrations.

To summarize, the potential needs of a simulation center at KU are broad, diverse and complex.  Some of these needs are currently met in a hodgepodge fashion while many others are not.  It is clear that even our current needs are such that a simulation center would be quite busy.  These needs are certain to grow in the coming years as Residency Review Committees increasingly mandate the use of simulation technology. 

Finally, medicine is not practiced in isolation.  In the real world, allied health caregivers, physicians, students, pharmacists, nurses, and a host of other players all interact in an intricate fashion to deliver healthcare.  As such, the committee recognizes that education, particularly simulation education, can no longer occur in isolation.  Key to the success of the center and its participants will be the development of unique multidisciplinary experiences that allow for integrated training of these disciplines.  Given the complexity of these experiences, they will require additional time, space, and human resources above and beyond the simulation experiences currently provided at this institution.

4.  Teamwork in Simulation Education.

Traditionally, medical education has relied almost exclusively on developing the individual provider’s knowledge, skills, and abilities.  While these traits remain the bedrock of quality care, increasingly, providers are challenged to pool their talents, to collaborate across disciplines, and work in teams in routine and high risk/ high stress environments. 

Dr. Elizabeth Hunt, in her seminal article, Simulation: Translation to Improved Team Performance (Anesthesiology Clinics, 2007, 3, 4, p. 301) writes: “health care providers tend to be trained as individuals, yet function almost exclusively as teams, creating a gap between training and reality.” 

Our goal is to try and close that gap by integrating teamwork training with our technical skills simulation training.  This team training will include a knowledge phase and an application phase.  The knowledge phase is where specific teamwork skills such as closed loop communication, problem solving utterances, situational awareness, and assertiveness will be identified and described.  The application phase is where these team skills will be rehearsed and practiced in tandem with the technical skills using a range of high and low fidelity simulations. 

The Institute of Medicine’s: To err is human: building a safer health system (1999), emphasized using simulation to improve teamwork and to increase patient safety. The American College of Surgeons has recently mandated simulation training with attention to teamwork along with technical skills as a key component for all surgical residency training programs.   

The use of simulation in health care training has gained prominence with established simulation centers at the University of Pittsburg, Harvard, Stanford, The Johns Hopkins, and the Mayo Clinic, with new centers being developed at University of Indiana (reportedly a 30,000 square foot center), and the University of North Dakota (reportedly in partnership with Blue Cross and Blue Shield of North Dakota.)

What distinguishes our plans for a simulation programs here at KU, is our intention to integrate the teamwork, and technical skills across disciplines, cultures, and systems.  Our teamwork and technical skills simulation training will be offered to faculty, residents, students, and hospital staff.  This campus wide collaboration will generate positive effects such as increased morale, reduction in staff turnover, and enhanced communication among faculty, residents, students, and hospital staff.  Most importantly, this system wide simulation training will improve the quality of care for the patients and the families we serve.   

5. Size Requirements for the KU Simulation Center.

It is the consensus of the committee that any simulation center initiative at KUMC should become an accredited simulation program.  Currently the American College of Surgeons has an accreditation process in place, as does the American Society of Anesthesiologists.   Additionally, The Society for Simulation in Healthcare is working on its own accreditation standards.   Of these many accreditation bodies, the American College of Surgeons standards are by far the most stringent and in fact establish minimum sizing for simulation centers seeking the American College of Surgeons Level 1-Comprehensive Education Institutes (CEI) designation:
 
Standard III- Technological Support and Resources
            Criterion 3.1
                        Space requirements for the Education Institute are met as described:

• Has no less than 1200 dedicated square feet (contiguous with a face to the public)
• Has no less than 4000 square feet of additional space that shall include conferences rooms, equipment storage, lounge, restrooms, lockers, phone service, kitchenette, and an animate lab as needed.
• Has space to accommodate a minimum of 20 trainees at a time for hands-on training.
• Has capability to accommodate teleconferencing and teleproctoring as needed.
• Has space to accommodate skills simulators.
• Connection to Internet.
• Space to accommodate administrative support staff.

Using the analysis of the volume and types of users noted earlier in this report and considering the requirements for the various groups, the committee studied many simulation centers operating in the United States (including ACS accredited centers).  The number of potential users for the KU simulation center is quite high and will require a center of significant size.  The committee agreed that the center should be initially designed so that it can reach its maximum potential yet still be able to expand for increased needs in the future.  There is little doubt that simulation will play an ever-increasing role in healthcare education and we must plan for this increased utilization. 

The requirements of the stakeholders in the KU simulation center mandate a center with four basic areas:

• The first type of training area would be the exam room/standard patient room.  These are basic exam rooms with full AV capabilities to conduct standardized patient exams and other standardized exams.   The large number of students requiring these exams dictates many rooms of this type.  The committee estimates 18-20 rooms of this type will be needed.  Some of these rooms should be able to merge together to allow simulation of large multiple bed environments. 

• The second type of training area would be the high fidelity patient simulator environments.  These areas would have multiple high fidelity patient simulators including adult, pediatric, infant, neonate and obstetric devices.  These environments would be constantly changing to meet the requirements of the various stakeholders including ICU bays, operating rooms, emergency rooms, delivery suites, etc.  These rooms would require extensive AV support to document the training that occurs and allow educational feedback.  The committee estimated the need for 6-8 of these types of environments with the ability to combine some of the rooms for large-scale simulations. 

• The third type of training area is space for partial task trainers and surgical skills simulators.   These types of task trainers require significant space, as multiple trainees are present during sessions on the trainers.  One or two larger rooms would be needed to accommodate these trainers. 

 

• The final training areas are conference rooms and debriefing rooms located immediately adjacent to the other training areas.  These conference/debriefing rooms are vital as this is where reflection occurs on what just happened in the other training areas.  Full AV systems are needed in these rooms to allow replay of the training that occurred.  The ACS requires teleconferencing and teleproctoring and large conference rooms would be excellent locations for these endeavors.  Additionally, there would need to be significant storage space within the center for the various equipment and simulators when they are not in use.  The committee believes that for a center to meet the needs as outlined above it will require a location with approximately 16,000 square feet.

6. Organizational Structure for the Simulation Center.

The KU simulation center shall be a collaborative effort between entities at the University of Kansas Medical Center interested in simulation education.  The KU simulation center shall have an organizational structure as follows:

Institute Advisory Board: A multidisciplinary group comprised of Deans, Clinical Chairs, senior hospital administrators, and directors of the collaborating entities.  This group should provide the strategic direction of the Institute.
Board of Directors:  Clinical directors from the collaborating entities that provide budgets along with usage and assessment reports from the various departments.
Curriculum and Assessment Board:  Reviews and provides feedback on programs as well as assessing educational outcomes.
Director of Institute:  Must have term of no less than 3 years, and have 25% protected time for Institute.  They must also demonstrate dedication to teaching.

7. Recommendations of the committee.

1. With the creation of the KU Simulation Center, a major focus is to ensure that requirements and initiatives from national governing bodies including Residency Review Committees and accreditation bodies such as the Liaison Committee on Medical Education, American College of Surgeons, the American Urology Association, the Society for Simulation in Healthcare and the Advanced Initiatives in Medical Simulation, are met as part of the projected timeline for both current and future goals of the center.
2. Organize a planning committee to identify space and a location for the simulation center.  The simulation center should be built in a centralized location to maximize its accessibility to the many different users of this center.  The space should be designed to allow expansion of the center as future developments in simulation education take place.
3. Engage a group to identify funding sources for the construction and materiel costs of the center.  It is expected that a variety of funding sources may be sought to support the creation of the simulation center.  A major philanthropic effort is likely needed to support the initial costs for this new center.
4. Create a business plan for the administration and operational functions of the center.  Ongoing committed support for the simulation center is crucial for its success.  Annual financial support and expenses must be developed to insure that the center can reach its potential and provide the maximum learning to our users.

Acknowledgements - Committee Members

James D. Kindscher, M.D.
Chair, Committee for the Evaluation of Simulation Education

Janice Benjamin                      
KU Hospital Vice President Fund Development

Giulia Bonaminio, Ph.D.         
Associate Dean for Medical Education, School of Medicine

Mark Cohen, M.D.                 
Vice Chair for Research, Department of Surgery

Helen Connors, R.N.               
Associate Dean for Integrative Technologies, SON

Carol Cleek, R.N.                   
KU Hospital, Director of Intensive Care Nursing

David Duchene, M.D.              
Department of Urology

Stephanie Grinage                    
KU Endowment

Kelly Hewins, R.N.                 
KU Hospital Education Specialist

James Kindscher, M.D.           
Chair Anesthesiology

Julie Mack, M.S.                     
Director Neis Skills Lab, School of Medicine

Chris Ruder, R.N.                   
Vice President Patient Services KU Hospital

Doug Peterson, R.N.               
KU Hospital Manager, Medicine ICU

Pam Shaw, M.D.                     
Phase II Director, School of Medicine

Steve Tarver, M.D.                 
Director Simulation Education, Anesthesiology

Robert Weatherly, M.D.          
Department of Otolaryngology

Tim Williamson, M.D.
Associate Program Director, Internal Medicine