Simulated Patient Care Pathways
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Simulated Patient Care Pathways

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Presented to the 2006 Society in Europe of Simulation Applied to Medicine (SESAM) conference Porto Portugal as part of the Simulation and Safety Culture panel.

Presented to the 2006 Society in Europe of Simulation Applied to Medicine (SESAM) conference Porto Portugal as part of the Simulation and Safety Culture panel.

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  • 1. Simulated Patient Care Pathways Kevin Russell Simulation Learning Consultant Chelsea and Westminster Simulation Centre London, UK
  • 2. My background:
    • Media & Simulation: Signal processing, PONG, TRON etc…
    • BS NYU Music Business & Technology 1985 School of Education, Health, Nursing and Arts Professions
    • Perception 3D audio sonification HRTF audio cues
    • Graphing calculator, SimCity, SimAnt
    • MPS NYU Interactive Telecommunications 1991 Tisch School of the Arts
    • 1991 SRI VPL System VR work Screen based healthcare simulation
    • Apple Advance Multimedia Lab SIGKIDS SIGGRAPH
    • IBM Research- AV cores, intranetworking, iTV, Ecommerce, BBC Digital Curriculum 150M DFeS
    • Family med. Business, Technology, Design, Learning- demo or….
    • Co editor of with Dr. Jeffrey Taekman http://www.simdot.org/simblog/
  • 3. Personal Story
    • July 2005 procedure
    • Typical interaction at bedside
    • Hyper concerned
    • Patient information
    • ‘ transaction concluded’ UK legal framework
  • 4. Strategic choices:
    • Implementing strategic choices that benefit the customers have been identified in December 2005 the mainstream popular strategy and business journals as 2 of the top 10 ideas most likely to endure for another 10 years.
    • Business Week in mid 2005 has stated that the biggest new challeng for managers is making the leap from Six Sigma process skills to new way of thinking such as customer-centric innovation.
  • 5. Delta 7.com Complexity Conference: Improving the NHS through the lens of Complexity University of Exeter 24/25/26 September 2003
  • 6. Delta 7.com Complexity Conference: Improving the NHS through the lens of Complexity University of Exeter 24/25/26 September 2003
  • 7. Delta 7.com Complexity Conference: Improving the NHS through the lens of Complexity University of Exeter 24/25/26 September 2003
  • 8. Delta 7.com Complexity Conference: Improving the NHS through the lens of Complexity University of Exeter 24/25/26 September 2003
  • 9. Delta 7.com Complexity Conference: Improving the NHS through the lens of Complexity University of Exeter 24/25/26 September 2003
  • 10. Delta 7.com Complexity Conference: Improving the NHS through the lens of Complexity University of Exeter 24/25/26 September 2003
  • 11. Delta 7.com Complexity Conference: Improving the NHS through the lens of Complexity University of Exeter 24/25/26 September 2003
  • 12. Definition: Patient Pathway
    • Pathway is a document or set of documents constructed by local healthcare professionals that explains the care provided to a patient or patient group. A pathway is presented as words, diagrams or tables usually in a numbered or block /data flow linear sequence.
    • An Integrated Care Pathway (ICP) describes a discreet section of service activity and provides templates for users to record deviations from planned care in the form of variances.
    • A Patient Pathway generally describes the whole range of activities given to a patient or patient group for one episode of care. A Patient Pathway contains one or more ICPs and describes the route that a patient takes from their first contact with an NHS member of staff, through referral, to the completion of their treatment.
  • 13. Current pathway informatics
    • NHS -Map of Medicine some codified visual protocols
    Fig. 5. High Level System Architecture . Patient Line offers a host of e-services to the bedside, including Electronic Patient Records (EPR), however staff training hasn’t resulted in widely adopted usage of EPR discussions with patients. Fig. 5. High Level System Architecture . Patient Line offers a host of e-services to the bedside, including Electronic Patient Records (EPR), however staff training hasn’t resulted in widely adopted usage of EPR discussions with patients. Fig. 5. High Level System Architecture . Patient Line offers a host of e-services to the bedside, including Electronic Patient Records (EPR), however staff training hasn’t resulted in widely adopted usage of EPR discussions with patients. Fig. 5. High Level System Architecture . Patient Line offers a host of e-services to the bedside, including Electronic Patient Records (EPR), however staff training hasn’t resulted in widely adopted usage of EPR discussions with patients. Fig. 2. Screen shot of GE Healthcare LastWord
  • 14. Problem
    • Simulation and modelling is often used in science, business management, management science and system & operations research. However, it is noticeably absent in healthcare and optimization operational processes.
    • This may be influenced by a tendency to focus exclusively on process engineering - the management, planning and forecasting of resource allocation within systems. In healthcare, greater efficiency for ‘the system’ will not translate into quality care for the patient. We may have a systemic organizational problem here.
  • 15. Problem continue
    • Identify potential problems in the pathway nor how to critically think about problems and opportunities for efficiencies within a pathway. For example, pathways may not help health professionals see that it is a poorly designed process resulting in lengthy queues and long delays for the patient.
    • Explore and try out different ‘what if’ scenarios. Pathways are designed to present a linear sequence of events. Pathways do not help health professionals test out a scenario if the patient or the service provider decides to make different choices or to navigate the pathway following a different sequence of events.
    • Make connections among various elements in that pathway. Instead of connecting elements, pathways tend to layer elements on top of each other ending up with a document that explains care but does not help users understand patterns of communication, interaction and exchange.
    • Understand how the patient navigates it. For example, pathways assume the patient arrives at touch point B only after leaving touch point A. In the same line of thinking, pathways do not show where the patient may go after leaving touch point B.
  • 16. Simulated Patient Care Pathways (SPCP)
    • SPCP’s are an innovative online interactive learning and support 3D simulation with an intelligent online avatar that enables staff to construct and immerse themselves in a pathway scenario from the patient’s point of view.
  • 17. SPCP’s
    • SPCP make it possible for staff to learn how to reshape a pathway around the patient experience’s continuity of care by immersing and experiencing that pathway…not biofeedback yet but….I feel your pain soon?
    • Mental model cue: Google Earth ‘drive’, time, cost, pain/comfort
  • 18. Visualization
  • 19. Target Audience
    • Two distinct users groups of SPCPs, one used by patient pathway teams and one used by patients. 
    • Medical and Healthcare management Collaborative teams of SPCP to design and create the optimal patient pathway balancing clinical quality and cost learning quality and systems thinking and modeling skills along the way.
    • SPCP’s can also provide an easy-to-use information resource for patients, enabling them to navigate their pathway, building their confidence and lessening their stress. Patients can access SPCP online and view and interact with the information about a pathway before, during and after their visit. This extends ‘continuity of care’ through good health informatics thinking
  • 20. The two groups…
    • My understanding …
    • Cost
    • Quality
  • 21. Correlated Equilbrium
  • 22. EPSS Central LLC
    • Studies show that 46 – 70% of tasks/activities can and should be supported with embedded, real-time workflow-based performance-centered interventions.
    • Many organizations misapply performance principles by addressing low-risk or very high risk tasks, missing the real opportunities to make a difference, contributing to
    • $5-$10Billion annual global misapplied resources
    Task/activity distribution very low risk medium risk very high risk highly cognitive simple, linear mixed complexity, type
  • 23. Improving Healthcare Systems: By Managing Variation, By Managing Patient Flow. NHS Modernization Agency.
    • The root cause of delays for patients is variability , not volume .Healthcare systems create most of the variability. We can reduce variability by creating a steady flow of patients through the system. “Every process displays variation”
    • Understanding Variation The Key to Managing Chaos Wheeler 1993
    • Common Cause Variation
      • stable, consistent pattern of variation
      • “ chance”, constant causes
    • Special Cause Variation
      • “ assignable”
      • pattern changes over time
  • 24. High Level Architecture
  • 25. Interoperability and Standards
    • Interoperability with enterprise systems is key Return on Investment – ETSA working group
    • Inter-operating distributed e-learning applications can include formats previously excluded
    • ADL, introduction of SCORM and (soon) CORDRA.
    • SCORM 1.2 was stifling, but …
    • SCORM 2004 specification = New architectures combining SCORM with other platforms, new instructional possibilities are wide open .
    • Intelligent Automatic Inc. - combining instruction conforming to SCORM with simulation conforming to the HLA (High Level Architecture) standard for simulation.
    • Details of this work can be found in Haynes, Marshall, Manikonda and Maloor (2004).
  • 26. Standards:
    • “ SCORM 2004 provides huge improvements in the instructional architectures that can be implemented, due to implementation of new sequencing and navigation rules. SCORM sequencing and navigation (SSN)
    • individualize the instructional experience
    • more efficient; motivating; and effective
    • learners experience greater control over their personal learning experience by selecting options best suited to their preferences for detail, learning modality, or level
    • Social learning and interaction with other learners, and stakeholders - employers, schools, or the military, for example) can also benefit from more complex learning environments that
    • can facilitate better quality training and better assessment information about learners performance.
  • 27. Standards: SCORM
    • From Wikipedia, the free encyclopedia
    • Sharable Content Object Reference Model ( SCORM ) is a collection of standards and specifications for web-based e-learning . It defines communications between client side content and a host system called the run-time environment (commonly a function of a learning management system ). SCORM also defines how content may be packaged into a transferrable ZIP file.
    • SCORM is a specification of the Advanced Distributed Learning (ADL) Initiative, which comes out of the Office of the Secretary of Defense .
    • SCORM 2004 introduces a complex idea called sequencing, which are rules that specify the order in which a learner may experience content objects. The standard uses XML , and it is based on the results of work done by AICC , IMS , IEEE , and Ariadne .
  • 28. New Standards
  • 29. New Standards
    • CORDA and High Level Architecture 4 (HLA)
    • SITA (Simulation-based Intelligent Training and Assessment) is a prototype system1
    • SITA provdes a model of combining simulation-based training (conforming to HLA) with instruction conforming to SCORM. SITA includes a variety of sequences of
    • Instructional events that can be used to explore the ‘edges of the envelope’ in terms of SSN in SCORM. SITA includes instruction in declarative knowledge =learning ‘what’and ‘why’
    • procedural knowledge =learning ‘how,’ ‘when’ and ‘where’
    • Applied knowledge =using the prior knowledge to perform one or more tasks).
    • distributed simulation conforming to HLA Source: Haynes and Maloor
  • 30. Literature
    • Aumann, R.J. 1987. Correlated Equilibrium as an Expression of Bayesian rationality . Econometrica 55, 1-18.
    • LTSC. 2000. Learning technology standards committee [online]. http:// ltsc.ieee.org /
    • Wiley, D. 2000 Learning Objects and Sequencing Theory. Dissertation and workshop 2003. The Future of Learning Objects
    • Prensky, M. 2000. Digital Game-Based Learning. New York: McGraw Hill.
    • Bjork, S., Holopainen, J. 2004. Patterns in Game Design. Hingham, MA: Charles River Media.
    • Aldrich, C. A Field Guide To Educational Simulations. ASDT
    • Lendon, R., Silvester K., Steyn, R., Rogers, H., 2006. Improving Healthcare Systems: By Managing Variation, By Managing Patient Flow [presentation] NHS Modernization Agency.
    • Dickelman, G. 2006 Performance Centered Design. EPSS Central LLC [prensentation] Tata 2006 Interactive Learning Forum
    • Haynes, Marshall, Manikonda and Maloor . 2004 Simulation Sequencing and Natvigation. Intelligent Automation Inc.
  • 31. Conclusion
    • We are investigating how to integrate SPCP with the National Clinical Assessment Service (NCAS) National Reporting and Learning Systems (NRLS).
    • We believe that SPCP, linked but not ‘driven’ by EPR systems, can provide staff and patients with new insights into systems thinking help them share mental models and collaborate effectively.
    • SPCP have the potential to raise efficiency, minimise delays and shape services around the needs of the patient by looking at the full care requirements, thus giving healthcare professionals the opportunity to align information about the latest evidence-based research with information about patients, costs, risks, location, service providers, and events.
  • 32. Thank you … Obrigado Contributing author: Francis Maietta Panel: Stephan Monk, Brendan Flanagan, Stephen Small SESAM: Willem and all the SESAM organizers Simulation Centre: Mervyn Maze, Janet Wyner, Shann Sieg, Kevin Haire Orla Lacey, Manisha Kulkarni … and you the Audience!