When Penn’s Simulation Center opened in 2008, it functioned primarily as an education tool, training and assessing the clinical skills of medical students, residents, nurses and other health care professionals. While it still operates in this capacity, it has expanded tremendously over the past decade. Today’s simulations help to reinforce knowledge and improve processes. Interprofessional and interdisciplinary clinical simulations focus on team work and communication. And, in the nonclinical arena, simulations are helping managers tackle challenging conversations, improving work flow and, in some cases, even changing building design!
“The Sim Center supports the goals of PMA [Penn Medicine Academy] to build strong leaders, an agile work force, and engaged teams, and support successful change,” said Cindy Morgan, VP of Learning and Organizational Development.
Behind the Simulation
With each simulation, “we want as realistic an experience as possible… in a safe environment,” said Gretchen Kolb, director of Learning Innovation. But pulling a simulation together requires a lot of work, on the part of both the client and the Sim Center. “A single simulation can take months to achieve and is the result of a close partnership between the client, as the subject matter expert, and our team who advise how best to use simulation to achieve his or her objectives.”
High-tech manikins are often used to add realism. Ron Branca, a simulation specialist, brings them to “life.” With his laptop and control panel, which includes a headset and speaker button, “I can make the manikin seize, sweat, cry, close its eyes… anything.”
His medical background — he was a paramedic before coming to the Sim Center — is a perfect match for manikins that are “suffering” from a wide range of emergencies or diseases. Although each simulation has a script, participants will sometimes go way off and he has to improvise, making use of his medical knowledge. He said many simulation centers use IT people behind the scenes, but “our team members are both savvy with technology and have medical backgrounds,” Branca said. “It’s easier to teach technology than medical knowledge.”
Simulations may also include SPs: Standardized Patients in clinical simulations and Standardized Professionals in nonclinical scenarios. These individuals are actors who receive special training to do these scenarios — including the ability to provide valid feedback — and also help to bring a better sense of realism to the simulation.
Although the majority take place at the Center itself at Penn Medicine Rittenhouse, some simulations are held ‘in situ,’ or at the workplace itself. “Employees have the opportunity to practice teamwork and clinical skills using resources in their own environment,” Kolb said. “If they can’t locate a critical supply, we have the opportunity to address a potential safety issue before it reaches a patient.” In situ simulations are done throughout Penn Medicine — both at hospitals and outpatient facilities/practices.
Forging Team Work and Communication … in an Emergency
In a medical emergency, communication and team work can sometimes fall to the wayside. People yell out orders —“Somebody call 9-1-1” — but no one confirms that any have been followed… and that’s when problems can arise. Even hospitals — full of clinical expertise and knowledge — aren’t immune. In fact, The Joint Commission has found that “human factors contribute to almost every sentinel event.”
Two Sim Center programs, Team STEPPS and First Five Minutes, are helping teams manage these events, reinforcing crisis resource management principles of leadership, delegation and closed-loop communication.
A simulation showed that elevators in the Pavilions initial design were too small to easily
transport patients.
Medical teams with interdisciplinary and interprofessional members can lead to communication issues, but the OR provides an even bigger challenge. Unlike patient care unit teams, which often have consistent health care providers, an OR has constant comings and goings. In addition to the surgical staff, residents and medical students might come in to watch part of a procedure. New nurses come in during long cases to give others a break. And, during an emergency, that number expands to include first responders. Trying to manage this during an emergency “is the equivalent of being a quarterback at fourth and goal in the end zone and suddenly, a whole new team is brought on the field to replace yours,” said Joshua Atkins, MD, PhD, of Anesthesiology and Critical Care.
This is where Team STEPPS (Skills and Tools to Enhance Performance and Patient Safety), comes in. “We’re training people to be equipped with skills that give them the best chance of performing during critical events,” he said. “But these lessons will also provide a stronger basis to work as a team on a regular basis.”
Having a leader in an emergency is key, Atkins said. “The leader’s job is not to fix the problem but rather to process what’s going on and make sure things get done.” For example, rather than someone yelling ‘we need an EKG,’ the leader assigns someone to get the machine and then, minutes later, asks for results.
Anyone could be leader, he stressed. “It’s a flattening of hierarchy. This is not about medical knowledge or having the right answer to every question. It’s purely about making sure medical knowledge bubbles up to the surface and is applied.”
Key lessons are hitting the mark. A day after Meghan Foley, BSN, of Cardiac, Vascular, and Transplant Surgery, did the simulation, a patient suffered an emergency in the OR similar to the simulated case. “I truly believe it led to preventing a very negative patient outcome.”
Brittany Moshen, BSN, of Perioperative Services, too, experienced an emergency situation during a neurosurgery procedure a week after the session. She took the lead and a bad situation was averted. “During the simulation, you think, ‘this isn’t real. What would I do in an emergency?’” Now she knows.
Of course, medical emergencies can happen at any time, anywhere — and often outside of a hospital. Nobody knows that better than Chet Zaremski, Life Support Program administrator in the Sim Center and a trained paramedic. Indeed, just last summer, he helped save the life of an elderly man in the parking lot of the PM Rittenhouse facility. Thanks to the Sim Center’s First Five Minutes Program, he’s passing along that knowledge to staff in ambulatory practices throughout Penn Medicine.
Much like Team STEPPS, Zaremski’s training focuses on working as a team during those first vital minutes before emergency responders arrive. The scenarios are realistic, for example, a patient getting an MRI with contrast suddenly goes into anaphylactic shock. And to add realism to the scenario, “We create a patient profile in Penn Chart — name, date of birth, past medical history…” he said. The debriefing examines the practice’s strengths in responding and areas for improvement, e.g., did they gather the appropriate equipment? Do they have the right meds to reverse the reaction? “There is no negative feedback,” he stressed. “It’s all about teamwork and communication.”
It Looks Good… But Does it Work?
Kristin Quinlan, simulation educator, helps turn ideas into scenarios that improve processes in the workplace, keeping it “as close to real life as possible,” she said. When it comes to using simulation for health care facility design or orientation to a new building or space, the simulation often takes place before a facility even opens. When Penn Medicine’s first inner city urgent care center was under construction, simulations at the Sim Center examined the flow of patients from the front desk to patient exam rooms. These scenarios facilitated using a new Penn Chart interface created specific to the urgent care environment. Then, a week before the urgent care center opened, another simulation, this time at the new location with real equipment, an actual medical record, and an SP, “allowed staff to orient themselves to their environment and self-identify opportunities for improvement,” Quinlan said.
Simulation also played a role in the design of the Pavilion, HUP’s new inpatient building opening in 2021, before construction had yet begun. One simulated an urgent transport of a critically ill patient, in a to-scale foam mock-up of a proposed facility design, which showed that elevators on patient care floors couldn’t comfortably fit a patient on a bed, a transporter, patient care equipment, and other staff members needed to push equipment. Another showed EVS staff having problems navigating a cart into a trash room. A third showed that curved hallways were not ideal for transporting patients on beds and stretchers. All led to design changes.
Having Tough Conversations
Another simulation program focuses on performance management. “It’s about helping managers develop an approach and get comfortable providing performance feedback,” said Ann Mokris, course facilitator. Held at the Simulation Center, the course carefully guides managers in the “best practices” approach to addressing employee issues, with a focus on the cause of a problem and then brainstorming with an employee to develop potential strategies to help resolve issues or improve their performance.
“Most people are initially nervous but then find that the course one of the best they’ve taken,” Mokris said. “We allow them to apply what they’ve learned in a safe way … and then use it back in their offices.”
During the debriefing, comments from the SP, who plays the role of the employee, represent an important part of the process. According to Denise LaMarra, MS, director of the Standardized Patient Program, simulation participants have said that the SP feedback was “spot on,” and “beyond helpful. I wish all managers had this opportunity.”
Learn more about Penn Medicine’s Simulation Center at http://www.uphs.upenn.edu/simcenter/.