Medical Simulation: A Holistic Approach to Highly Reliable Healthcare

March/April 2013

Medical Simulation:
A Holistic Approach to Highly Reliable Healthcare

Medical Simulation: A Holistic Approach to Highly Reliable Healthcare
Courtesy of the Center for Immersive and Simulation-Based Learning at Stanford University

In the next three decades, significant demands will be placed on healthcare systems worldwide. Economic progress in rapidly developing countries and federal mandates closer to home will envelope greater numbers of patients in the healthcare net. In addition, in most parts of the western world, an aging population and rising levels of obesity will further challenge the status quo. Currently in the United States, there are approximately 40 million people over the age of 65. This number is projected to grow to more than 80 million by the year 2050, and represent 20% of the population (Dept. of Health & Human Services, 2010). In 2008, 35.7% of U.S. adults were overweight (Centers for Disease Control and Prevention, 2012), a trend reflected across South America, Australia, and parts of Europe, the Middle East, and Africa (World Health Organization, 2011). Simply providing adequate numbers of trained healthcare professionals to provide care will be a challenge. In the United States alone, approximately 500,000 new nurses will be required to replace existing personnel and another 700,000 to meet demands by 2020 (Dept. of Labor, 2012). Physician requirements will rise as limits on resident physicians’ “duty hours” expand in the United States, similar to current practices in Australia and Europe (ACGME, 2010).

As expenditure on healthcare services soars throughout the world, there is increasing pressure to contain costs and provide more affordable and effective care.

How can we succeed in delivering high quality care reliably and consistently across a variety of healthcare settings? How can we train and maintain the competencies required by healthcare professionals to provide care that is increasing in complexity? How can we provide care in a patient-centered fashion, with the needs of the patient at the forefront and their safety of paramount importance?

A holistic approach to integrating simulation-based learning and other immersive techniques into all facets of healthcare provision may provide some solutions.

The term simulation encompasses areas as diverse as the modeling of natural or human physiologic systems, technologic reproductions of equipment and environments, or entire cyber worlds of computer-generated environments in which individuals can interact (Fanning & Gaba, 2008).

Simulation-based learning in healthcare relies on experiential learning theory: learning by doing, thinking about and assimilating lessons learned into everyday behaviors (Fanning & Gaba, 2007). It also encompasses concepts of mastery and deliberate practice (Ericsson et al., 1993). Simulation lets us role-play events to test a variety of potential solutions, even for events that rarely occur in real life but may be catastrophic if they do. It allows us to road-test processes in real time to evaluate, discover weakness and strengths, and create change within our systems.

Simulation-based activities draw heavily from Crew or Crisis Resource Management principles: communication, team and leadership skills, situation awareness, shared mental models, and flattening of hierarchy—skills particularly suited to teams working in dynamic and challenging situations. Many of the core concepts of simulation are similar to those of high reliability organizations: collective mindfulness, preoccupation with failure, deference to expertise rather than rank, and a commitment to building resilience. A continuous process of probing, testing, training, retraining, modifying, and implementing change is at the core, with safety as the utmost goal(Weick & Sutcliffe, 2007; Roberts, 1990). Where do simulation-based learning and immersive activities lie on the path to delivering highly reliable healthcare in a patient-focused manner?

To enable this to happen, we need to train healthcare teams to provide excellent care in a system that is designed to achieve this aim. Simulation-based techniques can aid this process across six domains:

  • Train healthcare professionals with the knowledge, skills, and attitudes (KSAs) required to provide high quality care.
  • Train healthcare teams to provide high quality care in a coordinated manner.
  • Continuously evaluate, amend, and revise processes and systems
  • Improve patient safety. Explore human- and systems-based errors, near misses, and safety concerns. Identify opportunities for improvement and implement change.
  • Test new equipment and technologies. Train personnel in real-life settings, prior to patient exposure.
  • Test, modify, adapt, and orient healthcare providers to new processes, services, and facilities, before introducing them to patients.

Train healthcare professionals with the knowledge, skills, and attitudes (KSAs) required to provide high quality care.
How do we train healthcare providers in the KSA required to perform competently everyday? In the current environment of reduced working hours for residents and decreased patient contact opportunities for all healthcare professionals, simulation-based learning affords the opportunity to learn, practice, and perfect skills, even for very rare events in a controlled, consistent, and constructive manner. Many nursing schools provide up to 50% of clinical hours in the simulated environment, which has led to a multicenter trial led by the National Council of State Boards of Nursing (n.d.) to evaluate the outcomes of such training measures. Medical specialties, particularly those that are procedure-intensive, have introduced boot camps, procedural competency programs, and open access skills laboratories to enable residents and medical students to gain and maintain a level of proficiency when performing procedures and caring for real patients (Robinson et al., 2012; Sonnadara et al., 2012).

Complex skills, algorithms, and protocols, such as ACLS (advanced cardiac life support), and difficult airway skills, in addition to broader leadership and communications skills, are taught in a wide variety of simulated settings (Barsuk et al., 2012; Shah et al., 2013; Howard et al., 1992).

Novice and experienced practitioners alike can practice activities in a “just in time” fashion and even rehearse complex patient-specific procedures (Willaert et al., 2012a; Chan et al., 2011; Willaert et al. 2012b).

Increasingly, immersive techniques are used to certify and credential practitioners for particular skills such as insertion of central lines, laparoscopic skills (Dong et al., 2010; Scott et al., 2008), and at particular refresher points in their career, e.g. simulation for Maintenance of Certification in Anesthesiology.

Multimodal simulations using combined mannequin-based and standardized patient-actor simulations are used to teach professional skills such as breaking bad news and disclosure of error, which are often difficult to address in daily practice (Overly et al., 2009).

Train healthcare teams to provide high-quality care in a coordinated manner.
Training the individual healthcare provider to perform in a highly competent manner is a prerequisite for excellent patient care. Patient care, however, increasingly is delivered by teams of healthcare professionals. Delivering consistent high-quality care is also determined by the strength of the team and the support structures that exist at an institutional level. The average medical patient encounters more than 17 healthcare providers, and the average surgical patient more than 26 providers during a typical hospital stay (Whitt et al., 2007). In addition to their primary care team, patients may interact with many specialist care providers and, if acutely ill, code and rapid-response teams. Coordinating and delivering complex care does not come naturally and needs to be carefully orchestrated to ensure patients don’t “fall between the cracks.”

Whereas there is an increasing move to educate healthcare professionals together, the majority of healthcare providers are trained in silos (Robert Wood Johnson Foundation, 2011). Often the first time this disparate team works together is in the workplace with real patients. Simulation-based team training, in an effort to address this concern, is increasingly incorporated into daily practice. It can improve team skills and staff satisfaction and retention across a myriad of settings, likely improving patient care outcomes (Wayne et al., 2008; Lighthall et al., 2010).

Just as team cohesion is not a naturally occurring phenomenon, neither is coordination of care. Simulation-based training has been shown to be an effective method of bridging this gap particularly when used at crucial points such as handover of care (Berkenstadt et al., 2008). One of the tenets of team training in simulation is building resilience. Enabling team members to perform a number of functions helps build redundancy and strength in the team. Care is less dependent on an individual with a particular skill, as many practitioners can perform multiple functions.

Continuously evaluate, amend and revise processes and systems
How can simulation be used to evaluate current work processes and flow, and to help implement new processes in a safe and effective manner? In–situ simulations—simulation activities that occur within their natural setting—provide the ideal environment to test a process “in real time, in the real world.” Creating a scenario or set of scenarios to probe weaknesses in a system walks the team through an event, often highlighting systematic areas for improvement (Garden et al., 2010). The subsequent findings of such an exploratory simulation may result in changes to process or workflows, or the instigation of training or educational programs to address the concerns unearthed. Simulations such as these, framed as “systems-based probing,” are objective and non-threatening, and produce an open forum to share concerns and suggest solutions in a supportive setting.

Improve patient safety. Explore human and systems-based errors, near misses, and safety concerns. Identify opportunities for improvement and implement change.
Just as simulation can be used to evaluate work processes and systems, it is also a useful technique for investigating errors, faulty systems, and patient safety concerns. Root cause analyses, morbidity and mortality reviews, and failure mode and effect analyses have been reconstructed using immersive techniques (Quraishi et al., 2011; Davis et al., 2008). As the event unfolds in real time, some hindsight bias can be avoided, as the information about the event unfolds in a piecemeal fashion, creating a more realistic reconstruction of what transpired. The investigation can extend from simply “who to blame” to what systematic factors contributed to this outcome and are likely to recur if the system remains unchanged. Simulation may help to improve safety culture and climate, particularly if used in combination with other patient safety improvement techniques.

Test new equipment and technologies. Train personnel in real-life settings, prior to patient exposure.
Typically, when purchasing or interacting with new equipment or technologies, healthcare professionals receive a cursory overview of the new product. Although a significant number of products are FDA-tested, not all are. From design to deployment, the systems being introduced are rarely tested in high acuity or real-life crisis situations. Latent errors, which may become apparent in the early stages of implementation, may compromise patient safety, practitioner confidence, and impact adoption of a new system. Even when no “adverse events” occur, human-machine interfaces may be less intuitive when encountered in highly dynamic situations, reducing their “usability” in times of crisis. Simulation affords the opportunity to test these elements in the environment in which they are used. Simulation has been used to test latent errors, human-machine interactions, usability of equipment, and to train personnel accordingly, reducing potential risk to patients (Mudumbai et al., 2010; Je et al., 2011).

Test, modify, adapt and orient healthcare providers to new processes, services, and facilities before introducing patients.
Simulation and immersive techniques may be used to test and orient providers to new processes, service lines, and facilities (Villamaria et al., 2008). Introducing simulation in this capacity improves staff confidence and morale, reduces costs, and ultimately lessens patient exposure to untested and potentially faulty systems. Simulation has been used to test systems and train personnel for worst-case scenarios, such as natural disasters like floods or earthquakes, major hazards such as terrorist attacks, or epidemics such as influenza or SARs. Simulation offers the ability to train personnel in a practical fashion to function well in challenging environments, rather than relying on untested emergency protocols when catastrophic events occur.

Creating a system of highly reliable healthcare requires a continuous process of testing, training, retraining, evaluating, modifying, and reassessing processes while remaining preoccupied with failure and ranking safety as the ultimate priority. Incorporating simulation into this process requires a commitment to embed immersive activities into all aspects of healthcare provision, from training individuals and teams, to designing and maintaining systems that enable them to deliver highly reliable care in a consistent fashion. While the majority of healthcare systems have some elements of simulation-based education in their programs, they are typically fragmented. A few healthcare systems are striving to embed simulation holistically, creating simulated hospitals (Banner Health) and introducing wide-scale simulation (Dept. of Veterans Affairs). Increasingly, programs are linking simulation activities to patient outcomes, translating from bench to bedside (Stanford Hosptial and Clinics).

Simulation alone is not a panacea for our changing healthcare needs, but combining simulation with other patient safety and quality care initiatives—for example, TeamSTEPPS or surgical checklists—may be synergistic in improving patient care (Arriaga et al., 2013). When thinking of the role of simulation in the delivery of healthcare, at each juncture, ask, “Why not simulation?” If practice makes perfect and deliberate practice, with guided reflection, leads to behavioral change, why not practice, review, and change how we work? Why not test new equipment or processes, add an immersive component to other quality initiatives such as the universal protocol, bundled care strategies such as CLABSI, comprehensive unit-based safety programs (CUSP), and accountable care organizations.

Simulation if integrated holistically within healthcare programs, can help provide high quality patient-centered care reliably and consistently across a variety of healthcare settings.

Ruth Fanning is a clinical assistant professor, and director of quality and patient safety in the department of anesthesia at Stanford University Medical Center in Stanford, California. She may be contacted at

ACGME (Accreditation Council for Graduate Medical Education). (2010, September 26). Common program requirements. Retrieved from

Arriaga, A. F., Bader, A. M, Wong, J. M., et al. (2013). Simulation-based trial of surgical-crisis checklists. New England Journal of Medicine, 368(3), 246–253.

Banner Health. (n.d.). Banner Simulation Medical Center. Retrieved February 2013  from

Barsuk, J. H., Cohen, E. R., Vozenilek, J. A., et al. (2012). Simulation-based education with mastery learning improves paracentesis skills. Journal of Graduate Medical Education, 4(1), 23-27.

Berkenstadt, H., Haviv, Y., Tuval, A., et al. (2008). Improving handoff communications in critical care: utilizing simulation-based training toward process improvement in managing patient risk. Chest, 134(1), 158-162.

Centers for Disease Control and Prevention. (2012, August 13). Overweight and obesity: Adult obesity facts. Retrieved from

Chan, S., Li, P., Lee, D. H., Salisbury, J. K., et al. (2011). A virtual surgical environment for rehearsal of tympanomastoidectomy. Studies in Health Technology and Informatics, 163, 112-118.

Davis, S., Riley, W., Gurses, A. P., et al. (2008, August). Failure modes and effects analysis based on in situ simulations: A methodology to improve understanding of risks and failures. In K. Henriksen, J. B. Battles, M. A. Keyes, M. L. Grady, [Eds.]. Advances in Patient Safety: New directions and alternative approaches (Vol. 3: Performance and tools). Rockville, MD: Agency for Healthcare Research and Quality.

Dept. of Health & Human Services. Administration on Aging. (2010, June 23). Projected future growth of the older population. Retrieved from

Dept. of Labor. Bureau of Labor Statistics. (2012, February 1). Table 6. The 30 occupations with the largest projected employment growth, 2010–12.  Retrieved from

Dept. of Veterans Affairs. (n.d.). SimLEARN. Retrieved from

Dong, Y., Suri, H. S., Cook, D. A., et al. (2010). Simulation-based objective assessment discerns clinical proficiency in central line placement: A construct validation. Chest, 137(5), 1050-1056.

Ericsson, K. A., Krampe,  R. T., & Tesch-Romer, C. (1993). The role of deliberate practice in the acquisition of expert performance. Psychological Review, 100(3), 363-406.

Fanning, R. & Gaba, D. (2008). Simulation based learning as an educational tool. In K. Ruskin & J. Stonemetz [Eds.]. Informatics and Anesthesia. NY: Springer.

Fanning, R. M. & Gaba, D. M. (2007). The role of debriefing in simulation-based learning. Simulation in Healthcare, 2(2), 115-125.

Garden, A. L., Mills, S. A., Wilson, R., et al. (2010). In situ simulation training for paediatric cardiorespiratory arrest: initial observations and identification of latent errors. Anaesthesia and Intensive Care, 38(6), 1038-1042.

Howard, S. K.,  Gaba, D. M., Fish, K. J. et al. (1992). Anesthesia crisis resource management training: Teaching anesthesiologists to handle critical incidents. Aviation, Space, and Environmental Medicine, 63(9), 763-770.

Je, S. M., You, J. S., Chung, T. N., et al. (2011, April). Performance of an automated external defibrillator during simulated rotor-wing critical care transports. Resuscitation, 82(4), 454-458.
Lighthall, G. K., Poon, T., & Harrison, T. K. (2010). Using in situ simulation to improve in-hospital cardiopulmonary resuscitation. The Joint Commission Journal of Quality and Patient Safety, 36(5), 209–216.

Mudumbai, S. C., Fanning, R., Howard, S. K., et al. (2010). Use of medical simulation to explore equipment failures and human-machine interactions in anesthesia machine pipeline supply crossover. Anesthesia & Analgesia, 110(5), 1292–1296.

NCSBN (National Council of State Boards of Nursing). (n.d.). NCSBN national simulation study. Retrieved from

Overly, F. L., Sudikoff, S. N., Duffy, S., et al. (2009). Three scenarios to teach difficult discussions in pediatric emergency medicine: Sudden infant death, child abuse with domestic violence, and medication error. Simulation in Healthcare, 4(2), 114-130.

Quraishi, S. A., Kimatian, S. J., Murray, W. B., et al. (2011). High-fidelity simulation as an experiential model for teaching root cause analysis. Journal of Graduate Medical Education, 3(4), 529-534.

Robert Wood Johnson Foundation. (2011, November 28). Teamwork and collaborative decision-making crucial to health care of the future. Retrieved from

Roberts, K. H. (1990). Some characteristics of high-reliability organizations. Organization Science, 160-177.

Robinson, W. P., Schanzer, A., Cutler. B. S., et al. (2012). A randomized comparison of a 3-week and 6-week vascular surgery simulation course on junior surgical residents’ performance of an end-to-side anastomosis. Journal of Vascular Surgery, 56(6), 1771-1780.

Scott, D. J., Ritter, E. M., Tesfay, S. T., et al. (2008). Certification pass rate of 100% for fundamentals of laparoscopic surgery skills after proficiency-based training. Surgical Endoscopy, 22(8), 1887-1893.

Shah, A., Carter, T., Kuwani, T., et al. (2013). Simulation to develop tomorrow’s medical registrar. The Clinical Teacher, 10(1), 42-46.

Sonnadara, R. R., Garbedian, S., Safir, O., et al. (2012). Orthopaedic boot camp II: Examining the retention rates of an intensive surgical skills course. Surgery, 151(6), 803-807.

Stanford Hospital and Clinics. (n.d.). Project TRANSFORM: Simulation training improves clinical outcomes. Retrieved from

Villamaria, F. J., Pliego, J. F., Wehbe-Janek, H., et al. (2008). Using simulation to orient code blue teams to a new hospital facility. Simulation in Healthcare, 3(4), 209-216.

Wayne, D. B., Didwania, A., Feinglass, J., et al. (2008). Simulation-based education improves the quality of care during cardiac arrest team responses at an academic teaching hospital: A case control study. Chest, 133, 56–61.

Weick, K. E., & Sutcliffe, K. M. (2007). Managing the unexpected: Resilient performance in an age of uncertainty (2nd ed.). San Francisco: Jossey-Bass.

Whitt, N., Harvey, R., McLeod, G., et al. (2007). How many health professionals does a patient see during an average hospital stay? New Zealand Medical Journal, 120(1253):U2517.

Willaert, W. I., Aggarwal, R., Daruwalla, F., et al. (2012a). Simulated procedure rehearsal is more effective than a preoperative generic warm-up for endovascular procedures. Annuals of Surgery, 255(6), 1184-1189.

Willaert, W. I., Aggarwal, R., Van Herzeele, I., et al. (2012b). Role of patient-specific virtual reality rehearsal in carotid artery stenting. British Journal of Surgery, 99(9), 1304-1313.

World Health Organization. (20, January 2011). WHO global infobase. Retrieved March 3, 2013, from