O T H E R F E AT U R E S Simulation Can Improve the Healthcare Systems We Work Within Ellen S. Deutsch, MD, MS, FACS, FAAP, CPPS Editor, Pennsylvania Patient Safety Advisory Medical Director, Pennsylvania Patient Safety Authority Restroom in a restaurant that encourages employee handwashing. An essential resource is missing: soap. The employees in the restaurant where the photograph was taken are well-trained, capable, and customer-friendly, but I fear they are not washing their hands correctly. I do not doubt their knowledge, skills, or motivation,1 but I know they cannot wash their hands effectively because an essential resource is missing. Stocking a restroom with soap is relatively simple; healthcare delivery is immeasurably more complex, but like the situation for the restaurant employees, the resources in our work environments, as well as the design of the environments themselves, impact our ability to provide effective, efficient, safe healthcare. Sometimes obtaining the equipment or supplies our patients need is neither easy nor efficient. In an emergency, we may have to obtain some of the necessary medications from a local automated dis- pensing system and some from the pharmacy; other supplies, perhaps the intravenous fluids, may have to be retrieved from a different storeroom. Knowing where to find resources is a critical skill required of all healthcare workers and is rarely intuitive. Maybe the resource we need is not as simple—or concrete—as a standard supply item. Sometimes the perfect process or policy, crafted by intelligent and engaged subject matter experts, does not work well in actual clinical practice. Sometimes the electronic health record system, implemented with conscientious planning, creates a cumbersome workflow for the healthcare provider. Our efforts to provide the best patient care are affected by the systems we work within, and we work within extraordinarily complex socio-technical systems. These socio-technical systems can be evaluated and enhanced using simulation, which allows us to test and incrementally improve a wide variety of processes. “Simulating” (by demonstrating) handwashing in the restaurant restroom in the example above would have quickly and succinctly demonstrated the missing resource—soap. Healthcare providers, administrators, insurers, and even patients are recognizing the power and versatility of simulation to improve healthcare. Conceptually, simulation applications fit into three broad domains. The domains are not mutually exclusive but provide a framework for discussion. The first domain of Vol. 12, No. 4—December 2015 Pennsylvania Patient Safety Advisory Page 159 ©2015 Pennsylvania Patient Safety Authority O T H E R F E AT U R E S simulation applications addresses the Perhaps the oxygen tank is found to be team follow to reach the patient promptly? capabilities of individuals. Simulations can empty during patient transport.2 Perhaps Can members of the response team open be designed to help individuals develop the single-use defibrillator pads are not all of the appropriate doors? Who will knowledge, technical skills (such as how the same brand as the defibrillator. secure the elevator? Who will bring the to perform procedures), and nontechnical Perhaps the official policy does not take emergency supply cart? Is the cart located skills (such as how to engage in difficult into account information that makes this close enough to allow sufficiently rapid conversations with patients or perhaps particular patient’s circumstances unique. retrieval? Changes can be implemented, with colleagues). Simulation can be used The third domain of simulation applica- evaluated, and refined using simulation as as a formative process, to enhance the tions addresses improving the systems a testing process. capabilities of individuals, or as a sum- that surround (and integrate with) our We can apply simulation testing even mative process, to assess or test those patient care efforts. When simulations are earlier: during planning, before walls are capabilities. conducted in situ, in actual patient care built and headwalls installed. Facilities The second domain of simulation applica- environments, we may discover and proac- can conduct simulations in room mock- tions addresses the capabilities of teams. tively mitigate hazards before they impact ups to identify unintended consequences Simulation can be used to improve an actual patient. Evaluating the ability of of design and procedural decisions. the knowledge, technical skills, and employees to wash their hands in situ, in Will the emergency response buttons be nontechnical skills of teams, addressing the pictured restaurant restroom, would located close enough to the patients’ beds? communication, leadership, delegation, have provided information that could Where are the best locations for comput- shared mental models, situational aware- have been missed in an artificial environ- ers, physiologic monitoring equipment, ness, and coordination. ment, such as a training center. Perceptive and hooks to hang fluids and medica- As we increase our understanding of how observers and astute healthcare providers tions? Will the patients’ beds fit through to use simulation to the best advantage of may identify workarounds, which are, by the doorways? Even the best planning our patients, there is a third application their nature, clues to problems with the relies on “work as imagined”; simulation domain. This new frontier uses simula- underlying processes. Unsafe conditions can bring our understanding closer to tion to improve the healthcare systems identified in this manner can be reported “work as done.” we work within. No matter how skilled through the Pennsylvania Patient Safety We can use simulation, particularly in situ and engaged an individual or a team is, Reporting System (PA-PSRS) using harm simulation, to test and improve patient if the necessary resources are not readily score A (unsafe conditions; circumstances care processes and identify and mitigate available, the providers cannot accom- that could cause adverse events).3 hazards before they contribute to patient plish their tasks efficiently or effectively. In addition to serendipitous hazard iden- harm. Simulation is a powerful and Capabilities in all three domains are tification, facilities can use simulation as adaptable tool that can be used to help us needed for optimal patient care. an intentional probe (e.g., to test new or better understand, and improve, the com- Unfortunately, sometimes deficits are renovated patient care environments). plex socio-technical systems that impact discovered during a patient care event. What path would the emergency response patient care. NOTES 1. Pennsylvania Patient Safety Authority. 2. Gardner LA. Identify sufficient supple- 3. Pennsylvania Patient Safety Authority Decision-making map to improve hand mental oxygen for patient intrahospital harm score taxonomy [online]. 2015 hygiene behavior [online]. 2014 [cited 2015 transport. Pa Patient Saf Advis [online] [cited 2015 Nov 21]. http://patient Nov 6]. http://patientsafetyauthority. 2015 Sep [cited 2015 Nov 6]. http:// safetyauthority.org/ADVISORIES/ org/EducationalTools/PatientSafety patientsafetyauthority.org/ADVISORIES/ AdvisoryLibrary/2015/mar;12(1)/ Tools/handhygiene/Documents/map.pdf AdvisoryLibrary/2015/Sep;12(3)/ PublishingImages/taxonomy.pdf Pages/121.aspx Page 160 Pennsylvania Patient Safety Advisory Vol. 12, No. 4—December 2015 ©2015 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 12, No. 4—December 2015. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2015 by the Pennsylvania Patient Safety Authority. 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