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Medical Simulation 3.0
The document discusses the importance of medical simulation in enhancing patient safety and transforming healthcare delivery. It highlights the substantial impact of medical errors on patient outcomes and healthcare costs, emphasizing the need for improved training and systems integration. The document advocates for continued development and utilization of simulation-based education and research to enhance healthcare quality and safety.
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Medical Simulation 3.0
- 1. Medical Simulation 3.0:Improving Patient Safety and Healthcare Delivery Transformation Yue Dong, M.D.
- 2. Disclosures • The viewsand opinions are expressed in following presentations are presenters’ own, not representative of Mayo Clinic, Society of Simulation of Healthcare(SSH), Healthcare Systems Modeling and Simulation Affinity Group (HSMSAG) • Faculty and organizing committee do not endorse or recommend any specific products or services mentioned on this presentation. • Faculty and organizing committee do not have any personal financial interest related to the presentation.
- 3. ©2011 MFMER |3123886-3
- 4. Mayo Clinic CoreValue： Quality (Outcome + Safety + Service) Value = Cost per over time Smoldt RK, Cortese DA. Pay-for-performance or pay for value? Mayo Clinic Proceedings 2007;82:210-3 “The needs of the patient come first.”
- 5. Surgical never eventsand contribution human factors Mayo Clinic roughly 1 in every 22,000 procedures National Practitioner Data Bank 1 in every 12,000 procedure Thiels CA, et al. Surgery 2015 May 29 http://www.ncbi.nlm.nih.gov/pubmed/26032826
- 6. Minnesota Adverse Events2015 ©2011 MFMER | 3123886-6
- 7. Rates of AllHarms, Preventable Harms, and High-Severity Harms per 1000 Patient-Days, Identified by Internal and External Reviewers, According to Year Landrigan CP et al. N Engl J Med 2010;363:2124-2134 Rates of All Harms, Preventable Harms, and High-Severity Harms per 1000 Patient-Days, Identified by Internal and External Reviewers, According to Year Landrigan CP et al. N Engl J Med 2010;363:2124-2134
- 8. Healthcare systems safety •400,000 Americans die each year as a result of medical errors. (3rd after heart disease and cancer) • $765 billon (35%) US healthcare cost is wasted each year • US annual healthcare cost more than $ 3 trillion (16% GDP) James JT. Journal of Patient Safety 2013;9:122-128; CDC.gov; http://resources.iom.edu/widgets/vsrt/healthcare-waste.html
- 10. ICU as Systemsof Systems Adopted from: Network medicine--from obesity to the "disease". Barabási AL., N Engl J Med. 2007 Jul 26;357(4):404-7. SHOCK DIC AKI ALI Physician RT Pharmacist Nurse Time Baseline PatientOutcome, ProviderSatisfactions
- 11. Learning Healthcare Systems •Significant changes in the health care delivery system, changes largely concerned with organization • quality improvement • operational efficiency • error reduction and patient safety IOM. The Learning Healthcare System: Workshop Summary. Washington, DC: The National Academies Press; 2007.
- 12. “Blue Highways” onthe NIH Roadmap Practice-based research Phase 3 and 4 clinical trials Observational studies Survey research Basic science research Preclinical studies Animal research Human clinical research Controlled observational studies Phase 3 clinical trials T1 Case series Phase 1 and 2 clinical trials Clinical practice Delivery of recommended care to right pt at right time Identification of new clinical questions and gaps in care T2 Translation to humans T2 Guideline development Meta-analyses Systematic reviews Translation to patients T3 Dissemination research Implementation research Translation to practice Westfall JM et al: JAMA 297:403, 2007 Bench Bedside Practice
- 13. The Science ofHealthcare Delivery • Understanding disease biology • Finding effective therapies •Therapies delivered effectively
- 14. 2011, Health ITand Patient Safety: Building Safer Systems for Better Care, Committee on Patient Safety and Health Information Technology; Institute of Medicine
- 15. What is simulation? •Simulation is the imitation or representation of one act or system by another. • Healthcare simulations have four main purposes – education, assessment, research, and health systems integration to facilitate patient safety…
- 16. ©2011 MFMER |3123886-16 Society for Simulation in Healthcare
- 17. SSH Membership ContinuingGrowth 17 180 539 1205 1520 1702 1850 2438 2925 2918 0 500 1000 1500 2000 2500 3000 3500 2005 2006 2007 2008 2009 2010 2011 2012 2013
- 18. History of medicalsimulation 1026 宋代针灸铜人 1969 SimOne Dr. Abrahamson
- 19.
- 20. Mayo Clinic MultidisciplinarySimulation Center
- 21. Ultrasound guided centralline insertion
- 22. Precourse- literature review Precourseexam (Online) Cadaver lab (Procedural Skills Lab) (1 hour) Ultrasound hands-on station (1 hour) Gown/Gloving/Universal Precautions (1 hour) Certification Station (following with feed back) Briefing Experience Debriefing Learninggoaldriven Central Line Workshop Courtesy of William Dunn, MD
- 23. Clinical competence Metricassessment Time Traditional training Safetystandard Simulation-based training Simulation-based objective assessment Discern Clinical Proficiency in Central Line Placement, Dong, et. al, CHEST 2010
- 24. ©2011 MFMER |3123886-24
- 25. ©2011 MFMER |slide-25 WHO Global Priorities for Patient Safety Research Bates DW, et al. Global priorities for patient safety research. BMJ 2009;338:b1775
- 26. ED Trauma TeamTraining ©2011 MFMER | 3123886-26
- 27. Learning Objective Faculty Development Curriculum Facilityand Technology Assessment Debriefing Simulation based education Learners
- 28. Key questions forSBT? • Does the simulation-based education work • How does simulation compare with other instructional approaches? • Why are some simulation interventions better than others (and how can we improve them all)? • Is simulation-based education worth its costs? David Cook, The literature on healthcare simulation education: What does It show ? http://webmm.ahrq.gov/perspective.aspx?perspectiveID=138#ref8
- 30. ROI of Simulationbased training • Approximately 9.95 CRBSIs were prevented among MICU patients with CVCs／year • Cost of CRBSI were $82,000 in 2008 dollars and 14 additional hospital days (including 12 MICU days). • Cost of the simulation-based education $112,000. • 7 to 1 rate of ROI
- 31. Shannon DW. Howa Captive Insurer Uses Data and Incentives to Advance Patient Safety. PSQH. Nov/ Dec 2009.
- 32. Simulation 1.0 ©2011 MFMER| 3123886-32 Education Assessment Systems Integration Research Simulation
- 33. ©2011 MFMER |3123886-33 Five steps to develop checklists for evaluating clinical performance: An integrative approach。 Schmutz J, Eppich WJ, Hoffmann F, Heimberg E, Manser T. Academic Medicine. 2014 Jan;89(7):996-1005
- 34. Central Line ProcedureChecklist Simulation-based objective assessment Discern Clinical Proficiency in Central Line Placement, Dong, et. al, CHEST 2010
- 35. ©2011 MFMER |slide-35 Simulation-based objective assessment Discern Clinical Proficiency in Central Line Placement, Dong, et. al, CHEST 2010
- 36. Short-term and Long-termImpact of the Central Line Workshop on Resident Clinical Performance During Simulated Central Line Placement。 Laack, Dong, et al. Simulation in Healthcare 9 (4), 228-233
- 38. “Medicine used tobe simple, ineffective and relatively safe. Now it is complex, effective and potentially dangerous” Sir Cyril Chantler
- 39. Information overload 2012, IOM,Discussion Paper1: The Clinical Trials Enterprise in the United States: A Call for Disruptive Innovation
- 40. The Complexities ofPhysician Supply and Demand: Projections Through 2025. 2008 AAMC http://www.aamc.org/workforce “ Simply educating and training more physicians will not be enough to address these shortages. Complex changes such as improving efficiency, reconfiguring the way some services are delivered and making better use of our physicians will also be needed.”
- 41. Simulation 2.0 ©2011 MFMER| 3123886-41 Education Assessment Systems Integration Research Simulation
- 42. Human Factor Research •Using simulation as a tool to study human performance variation under different “stress conditions” (fatigue, cognition, workload, etc.) • conduct usability testing of devices instrument and processes
- 43. The effect ofdrug concentration expression on epinephrine dosing errors: a randomized trial Wheeler DW, Carter JJ, Murray LJ, Degnan BA, Dunling CP, Salvador R, et al.. Ann Intern Med 2008;148:11-4. (1 mg in 1 mL) (1 mL of a 1:1000 solution)
- 44. Arriaga AF, BaderAM, Wong JM, et al. Simulation-based trial of surgical-crisis checklists. N Engl J Med 2013;368:246-253
- 45. Ahmed, et al.Critical Care Medicine, 39(7) 1626-1634 The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance
- 46. Simulation 3.0 ©2011 MFMER| 3123886-46 Education Assessment Systems Integration Research Simulation
- 47. Dr. Lucian LeapeDr. Donald M. Berwick Transforming healthcare: a safety imperative L Leape, D Berwick, C Clancy, et al. Qual Saf Health Care 2009; 18:424-428
- 49. A technical systemsgrow in complexity and connectedness, inevitably will lead to accidents with catastrophic potential • the degree of system complexity • tight coupling of processes, • and the inability of a single individual or small group of individuals to manage all the potential interactions • Stochastic escalation ©2011 MFMER | 3123886-49 Perrow, C. Living with high-risk technologies. Princeton University Press: John Wiley and Sons Ltd; New Jersey: 1999.
- 50. What is systemintegration？
- 51. Caffezo, et alrom discovery to design, Human factor in healthcare, 2012
- 53. Modeling Complexity (Rouse,2007) “ Starting with this model of the enterprise, the overarching strategy should focus on increasing complexity where it can be managed best and decreasing complexity for end users.”
- 54. Adjust structure andprocess to eliminate or minimize risks of health care-associated injury, before they have an adverse event-impact on the outcomes of care Donabedian. Evaluating of Medical Care. The Milbank Memorial Fund Quarterly, Vol. 44, No. 3, Pt. 2, 1966 (pp. 166–203)
- 55. Systems Engineering Initiativefor Patient Safety (SEIPS) Work system design for patient safety: the SEIPS model.Carayon P, et al . Qual Saf Health Care. 2006 Dec;15 Suppl 1:i50-8. Review.
- 56. Simulation, modeling andAnalysis, Law and Kelton, 2000
- 57. Robert Pool, Science,Vol. 256, No. 5053 (Apr. 3, 1992) “ Computation has become a ‘third branch’ of science, alongside theory and experiment”
- 59. McDonnell , G.(July, 2007).Workshop on Multiscale Modeling using AnyLogic 6 with Health Examples at International System Dynamics Society Conference. Boston, MA Simulation Application in Healthcare
- 60. Operation Research usingDES (Discrete Event Simulation) 1. Formulate the research question 2. Define the operational process (workflow) 3. Collect date to fit distribution 4. Construct and validate the model 5. Run experiment ©2011 MFMER | 3123886-60
- 62. Crit Care Med2007 Vol. 35, No. 11 Critical Importance of Timing
- 63. Spain Study Ferrer R,et al. Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. JAMA. 2008;299(19):2294-2303.
- 64. Research Methodology Baseline Process IdentifyCauses of Delay Process Modeling Suggestions for Improvement Measure ImpactSensitivity Analysis Statistical Analysis Root Cause Analysis & FMEA Discrete-Event Simulation ANOVA Design of Experiment User Requirement and Scope
- 65. Workflow analysis byproviders
- 66. Data Collection • Timeframe • Dec 2007 to June 2009 • Sample size: • 600 sepsis patients • Source of data • Sepsis QI Project (Courtesy of Dr. Afessa) • EMR: ICU Datamart • Direct observations: CVC, fluid infusion, etc. • Expert opinions: MD, RN, RT, Pharmacist, et al • Administration database • Obstacles with data • Uncompleted dataset • Care process variation
- 67. Fellow ResidentConsultant PharmacistBedsideRN Sepsis Recongnition Antibiotics/ Source Control Fluid Resuscitation Central Venous Catheterization Vesopressor Administration Inotrope Administration Transfusion Patient SepsisResuscitationGoalReached Simulation Modeling of Healthcare Delivery During Sepsis Resuscitation Dong Y, et al. Optimization of healthcare delivery during sepsis resuscitation by simulation and modeling. Simulation in Healthcare 2010;5:423.
- 68. Accelerated T&X CVC Efficiency ScVO2 Monitors No CXRDelayEarly Recognition ResuscitationRecognition Sepsis Care Optimization by Discrete Event Simulation (S-CODES)
- 69. Model Validation Empirical Data Model Data % Variance Duration (months)18 18 0% Total Sepsis Patients 597 600 0.5% Average number of patients/day 2.4 2.7 -1.3 % Average Cycle Time (min) 382 418 9.4 %
- 70. Sepsis Resuscitation TimeReduction by Different Options Clinical Data Sepsis Resusiation Time Reducation by Different Options 29.16 26.81 7.81 137.92 16.11 55.94 0.00 30.00 60.00 90.00 120.00 150.00 Opt 1 - Early Recog Opt 2 - Quick CVC Opt 3 - No X-Ray Opt 4 - Pre Type/Cross Opt 5 - ScVO2 Monitors Opt 6 - All Time(min)
- 71. DES study inclinical practices • Analyze & Visualize patient flow (Batarseh 2014) • Optimize unit bed capacity (Zhu 2012) • Forecast near-future operation status (Hoot 2009) • Study interaction between providers (Lim 2013) • Evaluate ED/EMS interaction (Stahl 2003) • Decrease inpatient boarding (Levin 2008) ©2011 MFMER | 3123886-71
- 73. Recent Major Reports •Executive Office of the President President’s Council of Advisors on Science and Technology: Report To The President Better Health Care And Lower Costs: Accelerating Improvement Through Systems Engineering (May 2014) • National Science Foundation: Operations Research - A Catalyst for Engineering Grand Challenges (May 2014) • The ASQ Healthcare Division Marshall Plan: "Put Me In The Game, Coach! ” (The Quality Management Forum, Winter 2014)
- 75. Simulation to improvequality and safety Constructive Virtual Live Training Assessment Research and Integration Patient Healthcare Providers Healthcare Systems
- 76. ©2011 MFMER |3123886-76
- 78.
- 79. Summary • Quality andpatient safety are the driver for value based healthcare delivery • Use more simulation to • Improve provider and team skills • Improve systems performance
- 80. From Mayo ClinicCenter for Innovation
- 81. Healthcare Systems Modeling& Simulation Affinity Group goo.gl/PRIkog goo.gl/0r5mOs http://www.ssih.org/Interest- Groups/Healthcare-Systems-Modeling- Simulation goo.gl/7QuuQd