The road to excellence


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Experience of a hospital perinatal group striving to become the best TEAM they can be in providing excellent patient care.

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  • WHO Monitoring and Evaluation July 2006
  • The total amount spent on health care in the USA is greater than in any other countryin the world.1 Hospitalization related to pregnancy and childbirth costs some US$86billion a year; the highest hospitalization costs of any area of medicine.2 Despite this,women in the USA have a greater lifetime risk of dying of pregnancy-relatedcomplications than women in 40 other countries.Morethan a third of all women who give birth in the USA – 1.7 million women each year –experience some type of complication that has an adverse effect on their health.6
  • The report, "Deadly Delivery: The Maternal Health Care Crisis in the USA," notes that the lifetime risk of maternal deaths is greater in the United States than in 40 other countries, including virtually all industrialized nations.White women have a mortality rate of 9.5 per 100,000 pregnancies, the CDC said. For African-American women, that rate is 32.7 deaths per 100,000 pregnancies.
  • Maternal mortality rates in the state of California have nearly tripled from 1996-2006 and are 4.5 times higher than the Healthy People 2010 benchmark.  No one is sure of all the reasons for this rapid and troubling increase.  In the 1990s California's rates ranged from 5.6 to 10.7 deaths per 100,000 live births, which is consistent with the overall US rate.  Beginning in 2000 the rate climbed to 10.9, then to 14.6 and in the last  reported year it is nearly 17.  Also concerning is a similar rise in the entire US rate.
  • HSSC staff reviewed many of the OB simulated training programs that have been reported. Some of what we found.PROMPT: practical obstetric multiprofessional trainingTimothy Draycott, Southmead Hospital,Bristol,UKSTORC: from the OHSU led by Jeanne Marie Guise MD. Using check list and training methods for standardization of care.MOSES:Dr. Della Freeth. Journal of Interprofessional Care, October 2006;20(5):552-554: from the St.Bartholomew’s School of Midwifery, and the London Simulation Center. Focusing on communication and team buildingObstetric Crisis Team Training: Wiser Institute; Based on the principles of Crisis Team Training.MOES: Anderson simulation center: Department of Defense, TEAMSTEPS format of team training…
  • The PROMPT (PRactical Obstetric Multi-Professional Training) course is a multi-professional training package which enables midwives, obstetricians and anaesthetists to implement a fully evaluated obstetric emergencies course within their own maternity units.The introduction of multi-professional obstetric emergency training at Southmead Hospital in 2000 was associated with: 50% reduction in Apgars < 7 in term infants (Draycott et al, BJOG 2006) 50% reduction in the incidence of HIE in term infants (Draycott et al, BJOG 2006) 70% reduction in Brachial Plexus Injuries after shoulder dystocia (Draycott et al, Obs Gyne 2008) 40% reduction in median decision-to-delivery time in cases of cord prolapse
  • Multidisciplinary Obstetrical Simulated Emergency Scenarios; J Contin Educ Health Prof. 2009 Spring;29(2):98-104.
  • Article: Sim Healthcare 4:77-83,2009Bethany Robertson, DNP;Michael DeVita MD,FACP. Wiser Institute, Pittsburg,Pa.Resulted in increased confidence in handling obstetric emergencies, improved individual and team performance, and task completion.
  • MOES: Mobile Obstetric Emergencies Simulator system: Developed at Madigan Army Medical Center, Fort Lewis, LTC Shad Deering.MOES has now been licensed to Gaumard Medical, largest obstetric simulation company. Two Important feathres:1) mobility to afford regular practice opportunities on the actual L&D ward, and 2) an emphasis on teamwork as well as technical skills. Targets these Ob emergencies: breech vaginal delivery, eclamptic seizure, postpartum hemorrhage, operative vaginal delivery, umbilical cord prolapse, shoulder dystocia, and neonatal resuscitation.
  • All received a multiple-choice pre-training and pre-testing questionnaire. After 1 month all teams underwent performance testing as a l&d drill. Videotaped and scored by a blinded reviewer. Pre-training/pre- testing questionnaire scores. Performance testing in the l&d drills showed statistically significant higher scores for the sim group for both shoulder dystocia and eclampsia management.
  • Sentinel Event ALERT Issue 30-July 21, 2004.
  • Give more data.
  • 9 members: Obs, Neonatologists, Anesthesiologist, Perinatalogist, RN managerBegan a Quality Improvement initiative within their department Women’s and Infants Services.
  • 19 members of the committee: L&D Rns, NICU nurses, Perinatologists, neonatologists, anesthesia, and OB .Attended two day training at CAPE, wrote scenarios and returned home.While thinking of what simulation equipment to purchase, the committee learned about the presence of a State of the Art, simulation center just steps away.
  • Steady progression of quality improvement initiatives designed around team training, and communication. Incorporating a variety of learning modalities into the clinical environment.
  • Samuel Merritt University’s Health Sciences Simulation Center sits on the Sutter Health Hospital campus and was virtually unknown to that system administration or institutional educators.
  • The Simulation training would be part of a SKILLS DAY FOR NURSES, half a day spent simulating, the other half doing task traiing.Well it was clear to me that they didn’t know what they wanted. So I’ll give them what I want! And I wanted BIG and Complicated..
  • Direct quote from my follow up email.
  • Thank heavens this wasn’t accepted because we could not have delivered a quality program at that time.
  • Two suggestions: Case One with all the bells and whistles would have trained their Sim Team at the Center and all of their staff in 8 mos. Case Two: HSSC would do a two day simulation training to their Sim Team and then provide 6, 8 hour days of assistance while the ABSMC Sim Team began doing In-Situ training.
  • Used the Laerdal educational format to orient, educate, and instruct the operations of the SimNewB manikin and its graphic user interface. Tought fundamental programming skills, and had Core Team plan, design, write and program their scenarios.
  • Establishing written timelines was essential to progress. It stated the goals of each engagement, the time, location, person(s) responsible for execution and the dates. Kept the Core Team on task and guided their work offsite.
  • Different needs, and focus for training and simulation. So we separated them and did unique educational sessions for each.
  • These became the Primary Learning Objectives for all In-Situ Simulation Sessions.
  • Three page template
  • Core came to realize that there is a great deal of preparation that is necessary before the cameras start to roll, and Team members need to perform in their assigned roles.
  • The full team Simulation Committee now comes to HSSC to participate in the validation and vetting of the scenarios written by the Core Team. Goes through the scenario template for each scenario with a different set of eyes and makes suggestions and changes get made. Then the Core Team assumes the roles necessary to execute a simulation session and uses Team in Training members as confederates, learners, operators, session coordinators. Debrief after scenarios again.
  • We lost our L&D operating room that was adjoining a conference room. Instead, we used a L&D room on the unit for simulations and used the Nurse Managers office in another hallway. This meant that the wireless audio video system had to be hardwired and no longer entirely mobile. This meant the computer operators now had to be present in the simulation room during the scenarios execution.
  • Issue of available space is always a concern with In-Situ simulation.
  • With each practice of the scenarios, THE TEAM gets smoother and smoother in execution.
  • Preparation and Parallel Processes require coordination of Team Members to set up simulation equipment, simulation room, confederates, A/V equipment, cameras and computers. Also time to present Philosophy of Simulation, Safe Environment, Las Vegas Rule, and orient to the room.
  • There was a Morning Session and an Afternoon Session: Each session had 8 learners. Each PPH scenario had 4 learners: Primary RN, Resource RN 1&2, Charge RN.The scenario was performed twice and debriefed after each. Second scenario: Precipitous Delivery requiring PPV was brief, usually 3-4 minutes. Teams of 2 RNs in each scenario. Performed 4 times quickly, then debriefed them all together. Afternoon session repeated same sequence.
  • Roles of Team Leader, Session Coordinator, Operator, and Debriefers were rotated among the Team in Training members.
  • Using an open L&D room required staging to occur in the hallway. Not the best location. Patients and family nearby.
  • Once the action started, the learners forgot about the Team members in the room as operators and evaluators.
  • Team Leaders and Coordinators are constantly reviewing timelines and schedule to stay on time. Most of the scenarios run 10-12 minutes. Precipitous Delivery went 3minutes!!
  • Debriefings can be the time for teaching around Primary and Secondary Learning Objectives.
  • N
  • All physicians in a group must complete the program in order for them all to receive the discount.
  • Requires departmental transformation of care .
  • The road to excellence

    1. 1. The Road to Excellence HEALTH SCIENCES SIMULATION CENTER
    2. 2. Tell me What is your background and where do you come from? Hospital simulation centers Nursing School Sim Center University/Junior College Sim Center Free Standing Sim Centers HEALTH SCIENCES SIMULATION CENTER
    3. 3. Tell Me Who has more than 10 years in simulation? 5-10 years 2-5 years 1 year or less? HEALTH SCIENCES SIMULATION CENTER
    4. 4. 2006 Maternal Mortality Rates per 100,000 live births Iceland: 0 #1 ranking in world Sweden: 2 Austria: 4 Canada: 6 Japan: 10 United Kingdom: 13 Singapore: 15 United States: 17 HEALTH SCIENCES SIMULATION CENTER
    5. 5. California Maternal Mortality Rates HEALTH SCIENCES SIMULATION CENTER
    6. 6. Simulation Training Initiatives PROMPT-Draycott T. MD  STORC-OHSU:Jeanne Marie Guise MD MOSES: St.Bartholomew School of Nursing and Midwifery and London Medical Simulation Centre,multidisciplinary obstetric simulated emergency scenarios Obstetric Crisis Team Training. Wiser Institute. MOES: Deering S, Rosen MA, Salas E, Simul Healthc. 2009 Fall;4(3):166-73. HEALTH SCIENCES SIMULATION CENTER
    7. 7. JCAHORecommendations:-conduct team training in perinatal areas toteach staff to work together and communicatemore effectively-for high-risk events, shoulder dystocia,emergency C-section, maternal hemorrhage andneonatal resuscitation, conduct clinical drills toprepare staff for when such events actuallyoccur and conduct debriefing to evaluate teamperformance and identify area of improvement HEALTH SCIENCES SIMULATION CENTER
    8. 8. Alta Bates High volume High Risk >7000 deliveries a year NICU Urban Hospital Setting HEALTH SCIENCES SIMULATION CENTER
    10. 10. Alta Bates Perinatal Group 1999: TLC program; Teamwork Leadership Communication Response to IOM report and low morale.  Year long training before bringing to the unit.  1.) Core Meeting to review each patient, q shift  2.) Debriefings of all occurrences  3.) Adoption of SBAR standard of communication among staff members. HEALTH SCIENCES SIMULATION CENTER
    11. 11. Alta Bates Perinatal Group 2008: Formed a Simulation Committee to explore this methodology for staff education.  CAPE: Center for Advanced Pediatric Education; Stanford University. Lou Halamek MD  Two-day training for 13 core members. HEALTH SCIENCES SIMULATION CENTER
    12. 12. Alta Bates Perinatal Group 2008 First Five Program: initial 5’ management of critical events 2009 Samuel Merritt University’s Health Sciences Simulation Center  Course for L&D, Neonatal Emergencies  Discussion and planning begins 2010 PROMPT shoulder dystocia training. 2010 NICU institutes NRP simulation training for all staff members and rotating residents. 2010 FHR recognition and standardized nomenclature training 2011 In-Situ Program begins . HEALTH SCIENCES SIMULATION CENTER
    13. 13. Awareness How many of you feel that your simulation center and capabilities are well known and integrated into the educational system of your parent organization or affiliated hospital systems? How many of you are integrated into all your undergraduate and graduate training programs? HEALTH SCIENCES SIMULATION CENTER
    14. 14. First Meeting Perinatal Plan and Design September 13, 2009  first meeting with leadership from ABSMC.  “Design a course to train our entire staff for L&D,Neonatal emergencies.” Lack of definition and clarity between the two parties regarding goals, allowed us both to develop completely different concepts. HEALTH SCIENCES SIMULATION CENTER
    15. 15. Perinatal Project November 25,2009 second meeting Plan a Pilot program for introduction of sim to members of the L&D,NICU. Team training with nursing, ob, anesthesia. Three 4-hour sessions of In-Situ sims at ABSMC. Three Scenarios. After building departmental buy-in to sim, design a training plan for all members of L&D,NICU,OB, and anesthesia trained at HSSC over 10 months. 170 RNs. HEALTH SCIENCES SIMULATION CENTER
    16. 16. What they said: 12/2/09 “The goal would be to train all the FT RNs and many of the PT RNs. (176) “Each 4 hour training period would train 2 teams of 3RNs / 2MDs in 3 scenarios, scheduled as two 4-hr sessions per day, twice a month for 8 months.” (3rn+2md) x 2/d x 2/mo x 8mo= This would be 96 RNs and 64 MDs!! 13 member Team training 1 or 2 days In-Situ training assistance 8hours x 6 days training a total of 12 RNs in three months. HEALTH SCIENCES SIMULATION CENTER
    17. 17. WHAT I HEARD December 18,2009 “I am hearing this to mean that we will use two simulation suites here at our center, running two sessions per day, of four hours duration, performing three scenarios for five learners; 3RNs/2MDs. 20 learners/day x 2d/month x 8 months= 320! With 192 RNs and 128 MDs.” HEALTH SCIENCES SIMULATION CENTER
    19. 19. Sanjeet Gill, HSSC south lab director; Jeanette Wong BSN,MPA,OperationsSandManager; Kevin Archibald, Admin Assist; bill, Lina Gage-Kelly RN,SimulationCoordinator; Celeste Villanueva CRNA,MS, Director of HSSC, Director ofthe Program of Nurse Anesthesia Samuel Merritt University HEALTH SCIENCES SIMULATION CENTER
    20. 20. HSSC Proposal December 18,2009 Case One: Team Training 13 members,2 days= $26,000 Staff Training: 320 members,8mos= $80,000 $106,000 Case Two: Team Training = $26,000 3 Months In-Situ Assistance= $30,000 $56,000 HEALTH SCIENCES SIMULATION CENTER
    21. 21. Affiliated Discounts? How many programs have fee schedules that differ for their affiliated institutions vs outside clients? How much is that discounted rate?  10-20%?  30-40%?  50-60%?  70-80%? HEALTH SCIENCES SIMULATION CENTER
    22. 22. HSSC: Real Costs Develop Program: 40 hrs@$125=$5000 Core TeamTraining: 16hrs@$250=$4000 Simulation: 40 sessions,160hrs SBT@$320=$51200 In-Situ Training: 48hrs@$50=$2,400 Supplies:40 sessions@$150=$6000 Equipment depreciation:28d@$150=$4200 Food ………………………………..$2025 Total---------------------------------$76,850 Total Hours: 264 HEALTH SCIENCES SIMULATION CENTER
    23. 23. Agreement PHASE I  Program Development: 40 hrs PHASE II  Team Training: 16 hrs PHASE III  In-Situ Faculty assist: 48 hrs Total hours: 104 HEALTH SCIENCES SIMULATION CENTER
    24. 24. Final Contract Phase I Phase I: Only Core Team (9), 40 hrs.  Location: HSSC  Course design, scenario selection, writing scenario objectives, writing scenarios, programming into software, operation of software, vetting and validation, dress rehearsal, and debrief.. HEALTH SCIENCES SIMULATION CENTER
    28. 28. Celeste VillanuevaExcels at Processes HEALTH SCIENCES SIMULATION CENTER
    29. 29. “I don’t know what I want!” HEALTH SCIENCES SIMULATION CENTER
    31. 31. Learning Objectives are KeyABSMC had 3 Distinct Primary Learning Objectives  1. Learning objectives of Core Team  2. Learning objectives of Trainers in Training  3. Learning objectives for In-Situ learners HEALTH SCIENCES SIMULATION CENTER
    32. 32. 1.Core team objectives HEALTH SCIENCES SIMULATION CENTER
    33. 33. Phase I Two Teams Emerge Different Objectives  Labor and Delivery Team  PPH, Eclampsia, Cord Prolapse, Shoulder Dystocia, Code C, Breech delivery.  NICU Team  Neonatal Resuscitation Protocols HEALTH SCIENCES SIMULATION CENTER
    34. 34. 2.Trainers in Training objectives HEALTH SCIENCES SIMULATION CENTER
    35. 35. 3.In-Situ Objectives.1. State the major components of maternal-child emergency response protocols according to the Alta Bates obstetrical and neonatal guidelines.2. Endorse the standardized obstetrical and neonatal emergency response protocols for Alta Bates, based on debriefing responses and post-session evaluations3. Demonstrate the ability to perform assigned roles in a coordinate response to per/neo-natal emergencies according to AB obstetrical and neonatal guidelines.4. Execute the essential skill sets required to complete the roles and functions of the assigned role, according to AB specific practices.5. Employ/Demonstrate best practices skills of team communication, indicated by adherence to AB defined definitions of SBAR, briefings, and call-backs6. Engage in self-reflective learning and practices, as indicated on post-session evaluations and feedback from debriefers. HEALTH SCIENCES SIMULATION CENTER
    36. 36. Secondary Learning Objectives Unique to the Scenarios HEALTH SCIENCES SIMULATION CENTER
    37. 37. Critical Elements Essential actions, demonstrations, or communications by the learners that are required for successful completion of the scenario. HEALTH SCIENCES SIMULATION CENTER
    38. 38. Select the subject of scenarios Best to use real case experience  Sentinel events  Root Cause Analysis  Near Miss data Gives a voice to the objectives Build scenarios backward from objectives HEALTH SCIENCES SIMULATION CENTER
    40. 40. Phase II Trainers in Training Phase II 16 hours: Simulation Committee members (19)  Location: HSSC  Members of the Simulation Committee and the Core team members first validate, vett, and amend the scenarios. Then execute the four scenarios, assume all the roles required, instruct, mentor, and orient the TnT’s to simulators, environment, scenarios, and debriefing. HEALTH SCIENCES SIMULATION CENTER
    42. 42. Trainers in Training Dress Rehearsal HEALTH SCIENCES SIMULATION CENTER
    44. 44. Phase III Phase III:48 hours: In-Situ Simulation  Team in Training members; 6 days, 8 hours of in-situ training for L&D RN staff. Execution by Core Team. Manikins, video, computers, mentoring, and debrief assistance supplied by HSSC staff. 104 Total hours: all three Phases HEALTH SCIENCES SIMULATION CENTER
    45. 45. In-Situ Dress Rehearsal March 15,2011 Difficulty of In-Situ sessions:  Room not available  Short staffing calls  Distractions to staff  Inconvenient to patients  No suitable spaces Must be flexible!! Make it work. HEALTH SCIENCES SIMULATION CENTER
    46. 46. In-SituDress Rehearsal March 15, 2011  Advantages of In-Situ  Work with your own environment  Systems issues revealed  Familiarity is not distraction  Increased fidelity  Abundance of resources  Administration can pop in! HEALTH SCIENCES SIMULATION CENTER
    47. 47. Debriefing Make it Comfortable On the day of In-Situ dress rehearsal no conference space was available so the team debriefed in the nurse managers office. Debriefing space was not close-by. Audio/Video limited Small Spaces Too hot Learned for next time!! Better to move downstairs to conference room with space and A/V. HEALTH SCIENCES SIMULATION CENTER
    48. 48. Debrief the Rehearsal  Members of the entire team review issues of realism, sequencing, moulage, dialogue, and fulfilling of roles.  Note taking scribs all debriefing elements for summative emails and discussions in follow-up. HEALTH SCIENCES SIMULATION CENTER
    49. 49. The Big DayMarch 29,2011 HEALTH SCIENCES SIMULATION CENTER
    50. 50. Active Learners have been assigned Team Leaders Pre-Brief HEALTH SCIENCES SIMULATION CENTER
    51. 51. Debriefers have been assigned HEALTH SCIENCES SIMULATION CENTER
    52. 52. “I don’t want my picture taken” Orientation to Simulation  Safety of the environment  Not Evaluative  Discuss the power of self reflection. That’s why we video.  Its practice!! If you know it why worry, if you need help this is the place.  No harm no foul.  Celebrate mistakes.  Las Vegas rule.  Honor code. HEALTH SCIENCES SIMULATION CENTER
    53. 53. Confederates  Confederate “patient” is mic’d and reviewing her role with Team members Megan and Kristin.  Team Leaders communicate with confederates & operator via walkie talkies.  Consider scripting dialogue for confederates.  Know your roles, be able to react to learner behaviors HEALTH SCIENCES SIMULATION CENTER
    54. 54. Action Team and Observers HEALTH SCIENCES SIMULATION CENTER
    56. 56. Timing and Coordination HEALTH SCIENCES SIMULATION CENTER
    57. 57. Debriefing are Comfortable and Safe HEALTH SCIENCES SIMULATION CENTER
    58. 58. 654 Series 13 Series 22 Series 310 Category 1 Category 2 Category 3 Category 4 HEALTH SCIENCES SIMULATION CENTER
    59. 59. Lessons Learned Do the hard work up front.  Be methodical and realistic. Define the Goals and work  Schedule and Plan and then backward from there to the do it again. beginning.  Keep good debriefing notes of Engage all members of the all meetings and rehearsals. team.  Don’t use more fidelity than Share the responsibilities you need. among RNs and MDs to gain both perspectives  Confirm your space and availability. Identify a small group of Core champions.  Use the learning objectives to guide debriefings. Evaluation Tools for Teams. Work closely with RN union. HEALTH SCIENCES SIMULATION CENTER
    60. 60. Next Steps Twice monthly In-Situ training with HSSC faculty assist. Then independently. Select Simulation equipment needs Incorporate more of the scenarios Develop didactics and educate staff. Distribute Team in Training members to use fewer per session. HEALTH SCIENCES SIMULATION CENTER
    62. 62. Perinatal Project Building Buy-In  Where is the pain? Bad outcomes raise insurance premiums. Mandated by hospital Administration. Began Discussions with med-mal insurer about premium discounts for completion of risk reduction course. What would the insurer like to see in this course? HEALTH SCIENCES SIMULATION CENTER
    63. 63. CRICO and RMF CRICO: The Controlled Risk Insurance Company RMF: Risk Management Foundation Both of Harvard Medical Institutions, promoted sim-based team training as a risk control strategy for OB providers. Patterned after the successful Anesthesia program. Simulation in Healthcare: vol.3,No 2, 2008. Gardner R, Raemer D, et al. HEALTH SCIENCES SIMULATION CENTER
    64. 64. CRICO The course was designed around Closed Claim ob cases of Harvard affiliated Perinatal units as the basis for simulated cases involving teamwork and communication. In 1 year follow up surveys, 87% said they had experienced a critical clinical event since the course and that various aspects of their teamwork had significantly or somewhat improved as a result of the course. 89% said the CRM principles were useful and 59% recommended repeating q 2yrs. HEALTH SCIENCES SIMULATION CENTER
    65. 65. CRICO The course is now a central component of CRICO/RMF’s obstetric risk management incentive program that provides a 10% reduction in annual malpractice premiums. Approximately $6000/per physician. Too early to know if it has changed claims. However, the same program for anesthesia was so successful that premium incentives were raised in 2007 to 19% for participants. HEALTH SCIENCES SIMULATION CENTER
    66. 66. The Doctors Company Patient Safety First: online program built around the most common types of OB claims, rewards physicians who successfully implement the patient safety steps. Offering a 10% premium discount HEALTH SCIENCES SIMULATION CENTER
    67. 67. Requirements are combersome Complete the Perinatal Bundle of Courses (Advanced Fetal Assessment and Monitoring, Managing Shoulder Dystocia, Operative Vaginal Delivery, and SBAR+R: Structuring Communication in Healthcare) offered online through Advanced Practice Strategies (APS). Access to these courses is available to you through our online member login at Develop written protocol for communication (SBAR+R or similar) between you and the labor and delivery nurses to be utilized in the event that any of the following situations occur:  Nonreassuring fetal heart rates using the guidelines as outlined in the APS Advanced Fetal Assessment and Monitoring course and any other change in the fetal tracing that you feel is reportable  Elevated systolic BP of >140 mm Hg or diastolic BP of >90 mm Hg  Vaginal bleeding  Meconium  Suspected abnormal presentation  Elevated maternal temperature >100.4 or per hospital protocol  Other criteria occur that you have identified (e.g., rise in fetal heart rate baseline of greater than 10 bpm, more than five variable decelerations in X minutes, etc.) Post the communication protocol in L&D, and implement it in coordination with nursing leadership. HEALTH SCIENCES SIMULATION CENTER
    68. 68. The Doctors Company We are working with TDC to satisfy their patient safety requirements for receiving the same 10% premium discount. Following the CRICO formula for simulation based risk reduction. HEALTH SCIENCES SIMULATION CENTER
    70. 70. OUTLINE Statistics about OB safety Perinatal Team and their commitment to excellence Simulation and Team Training Plan and Design of Simulation Program Budget and Schedule Training Rehearsals In-Situ Experience HEALTH SCIENCES SIMULATION CENTER