This document outlines plans to develop a sustainable simulation-based medical education program in Ethiopia through a train-the-trainer approach. Barriers to past efforts included a top-down structure and lack of follow up. Next steps include distributing a source book, developing a guide book, re-analyzing stakeholders through SWOT analysis, and establishing governance under a director and patron. The goal is to train local educators to independently run simulation-based skills training programs using Ethiopia-specific content and methods.

1. Teaching the Trainers in Simulation Based Education: Barriers and Solutions Dubrowski A., MiliardDerbew, Byrne N., Pittini R., Satterthwaite L., and Tajirian T. Roger Kneebone Alison Barnet Fernando Bello Supported by DelPHE

2. Ethiopia Maternal mortality ratio in 2005 (lifetime risk of maternal death) was 1 in 27 720 of every 100,000 births result in maternal death. Canada Maternal mortality ratio in 2005 (lifetime risk of maternal death) was 1 in 11,000, and 7 of every 100,000 births result in maternal death.

3. Ethiopia Maternal mortality ratio in 2005 (lifetime risk of maternal death) was 1 in 27 720 of every 100,000 births result in maternal death. Canada Maternal mortality ratio in 2005 (lifetime risk of maternal death) was 1 in 11,000, and 7 of every 100,000 births result in maternal death.

4. The World Health Organization (WHO) estimates that the majority of fatalities and disabilities could be prevented if deliveries were to take place at well-equipped health centres, with adequately trained staff. Guilbert JJ. The World Health Report 2006: working together for health. Educ Health (Abingdon). 2006;19(3):385-7.

5. The goal of a partnership between Addis Ababa University, University of Toronto, and Imperial College London is to develop a sustainable plan for training cohorts of educators capable of developing and evaluating training programs in technical skills related to surgery [trauma], gynecology & obstetrics (OBGYN), nursing and midwifery using simulation.

6. simulation Replication of a task or an event for the purpose of training or evaluation

7. November 2006 Medical Education, 2009

8. t=2.81, p=.012 t=3.42, p=.003 25 14 20 12 10 15 8 Checklists GRS 10 6 Post-test 4 Pre-test 5 2 0 0

9. Pre-training Post-training

10. In November 2008 a group of individuals representing the three partners conducted an extensive environmental scan and stakeholders analysis in order to set an agenda for the upcoming 3-year funding period.

11. Three primary objectives during this meeting were: To identify current use of simulation resources in the Surgical Simulation Laboratory (SSL, The Black Lion hospital, Faculty of Medicine, Addis Ababa University), to identify potential areas for faculty development (Train the Trainer) programs to enable optimal use of the SSL, and to develop a plan for Train the Trainer program and its implementation.

12. Methods: The group met with four groups of stakeholders: Trainees from medicine, surgery, OBGYN, nursing and midwifery – current and potential users of the SSL, faculty members from medicine, surgery, OBGYN, nursing and midwifery – current and potential users of the SSL, university governance, external stakeholders: CINS, and British Council. The group also visited the site and participated in a training session in the facility.

13. Results: The undergraduate medical program and surgical residency utilize the SSL extensively by: Following the Essentials of Surgical Skills (ESS), providing self-guided learning opportunities to students, providing special skills training (e.g., laparoscopic skills) encouraging other departments including OBGYN, nursing and midwifery to become involved in skills training courses.

14. Results: Four significant areas for future development were identified: Development and implementation of reliable and valid learner assessments, Implementation of learner-centered educational approaches, implementation of more realistic forms of simulation training, shift towards inter and multi professional simulated training.

15. Conclusion: The collective expertise within the partnership group will be applied to the development of Train the Trainer program aimed to expand on skills necessary to plan, implement and assess simulation-based courses offered to the medical students, surgical residents, OBGYN residents, nurses and midwifes.

16. Planned activities: Year 1: “This is how we do it” March 2009: Train the Trainer workshop March 2009: Independent research studies indentifying institutional facilitators for the progress and the effectiveness of the program (Drs. MaisamFazel).

17. Planned activities: Year 2: “Now it is your turn” A selected group will be asked to re-develop the workshop (objectives  simulation  evaluation) Tangible outcome: Train the Trainer Guidebook 2-day module in advanced assessment in evaluation and new simulation approaches (contextualized simulation).

18. Planned activities: Year 3: “Sustainability” Evaluation of the program. Exporting the program to other schools in Ethiopia and Sub-Saharan Africa.

19. In March 2009 a group of individuals from Toronto lead a 3 day hands on Train the Trainer course on simulation-based program development and performance assessment.

27. Summary: The course was graduated by 12 clinicians and 2 administrators. UTAASC was formed.

28. Inactivity External factors Lack of follow up from us Internal factors Top down rather than bottom up process

29. Next steps (November 2009): Distribution of a source book Development of a guide book Environmental re-scan and stakeholder re-analysis Assign specific roles

30. Next steps (November 2009): Distribution of a source book

33. Next steps (November 2009): Development of a Guide book Basic Technical Skills [e.g. Suturing, IV Catheterization] Perineal Tear Repair Instrumental Delivery C-section Abortion Care

34. Next steps (November 2009): Environmental re-scan and stakeholder re-analysis

36. Infrastructure: Skill lab inanimate and animal models instructional videos Faculty: Interest of the faculty and leadership in the lab Strong support from department members to have the curriculum designed Strong interest by faculty and department head Interdepartmental cooperation Students: Interested students Expanding post graduate program

37. Infrastructure: Financial constraint/Budget Single and small skills lab Limited resources and times Accessibility to all staff 24/7 Faculty and staff: Management Limited and untrained staff Less advertised even within faculty Poor linkage Incentives for faculty members Program: Absence of well-structured program Under-developed curriculum Infrastructure: Skill lab inanimate and animal models instructional videos Faculty: Interest of the faculty and leadership in the lab Dedicated staff Strong support from department members to have the curriculum designed Strong interest by faculty and department head Interdepartmental cooperation Young surgeons who have good energy Students: Interested students Expanding post graduate program

38. Infrastructure: Skill lab inanimate and animal models instructional videos Faculty: Interest of the faculty and leadership in the lab Dedicated staff Strong support from department members to have the curriculum designed Strong interest by faculty and department head Interdepartmental cooperation Young surgeons who have good energy Students: Interested students Expanding post graduate program Infrastructure: Financial constraint/Budget Single and small skills lab Limited resources Accessibility to all staff 24/7 Lack of time Faculty and staff: Management, committed support staff Limited and untrained staff Less advertised even within faculty Administration Poor linkage (duplication) Incentives for faculty members Program: Absence of well-structured program Less developed curriculum Collaboration with other skills labs Partner with external institution like U of T, Imperial Collage Favorable policy and commitment Huge inter/intra networking Expanding and diversity of graduate studies Support from grants [e.g., DelPHE] Support from CNIS

39. Infrastructure: Skill lab inanimate and animal models instructional videos Faculty: Interest of the faculty and leadership in the lab Dedicated staff Strong support from department members to have the curriculum designed Strong interest by faculty and department head Interdepartmental cooperation Young surgeons who have good energy Students: Interested students Expanding post graduate program Infrastructure: Financial constraint/Budget Single and small skills lab Limited resources Accessibility to all staff 24/7 Lack of time Faculty and staff: Management, committed support staff Limited and untrained staff Less advertised even within faculty Administration Poor linkage (duplication) Incentives for faculty members Program: Absence of well-structured program Less developed curriculum Collaboration with other skills labs Partner with external institution like U of T, Imperial Collage Favorable policy and commitment Huge inter/intra networking Expanding and diversity of graduate studies Support from grants [e.g., DelPHE] Support from CNIS Budget Competition within and between faculties Brain drain IT facilities and Internet access Lack of incentives Lack of adequate monitoring

40. Infrastructure: Skill lab inanimate and animal models instructional videos Faculty: Interest of the faculty and leadership in the lab Dedicated staff Strong support from department members to have the curriculum designed Strong interest by faculty and department head Interdepartmental cooperation Young surgeons who have good energy Students: Interested students Expanding post graduate program Infrastructure: Financial constraint/Budget Single and small skills lab Limited resources Accessibility to all staff 24/7 Lack of time Faculty and staff: Management, committed support staff Limited and untrained staff Less advertised even within faculty Administration Poor linkage (duplication) Incentives for faculty members Program: Absence of well-structured program Less developed curriculum Collaboration with other skills labs Partner with external institution like U of T, Imperial Collage Favorable policy and commitment Huge inter/intra networking Expanding and diversity of graduate studies Support from grants [e.g., DelPHE] Support from CNIS Budget Competition within and between faculties Brain drain IT facilities and Internet access Lack of incentives Lack of adequate monitoring

41. Next steps (November 2009): Assign specific roles Program: UTAASC – DelPHE Director: Dr. FekadesilassieHenok Patron: Dr. DawitDesalegn

42. Director: Dr. FekadesilassieHenok Chair the UTAASC Curriculum Committee Ensure that the UTAASC Curriculum has regularly scheduled meetings with an advanced agenda and recorded and approved minutes of each meeting. Facilitate the individual course participants in completing course planning, implementation and evaluation. Ensure that each course participant completes an evaluation. Act as the key link between the DelPHE Team and the participants. Report regularly with the DelPHE Team on course progress and accomplishments.

43. Patron: Dr. DawitDesalegn Oversee the UTAASC Project in Addis Report twice yearly to the DelPHE Team regarding project progress and accomplishments. Meet regularly with the UTAASC Course Director to review project progress and accomplishments. Provide counsel and direction, if requested, to the UTAASC Course Director. Facilitate communication through Dr. MiliardDerbew between the British Council in Addis and the DelPHE Team.

46. SWOT analysis

47. Guide book in preparation