IAMRA 2008

1. IAMRA 2008 BIENNIAL CONFERENCE Continuing Medical Education: a Block towards Professioanalism DINESH PATEL M.D. BOSTON

2. CME FOR WHAT PROTECT HEALTH , WELFARE AND SAFETY OF PUBLICLICENSURESREGULATORY BOARD COMPETENCY CONTINUED LIFE LONG COMPETENCY MAINTENANCE OF LICENSURE BOARD/SUBSPECIALTY CERTIFICATION

3. CME CONVENTIONAL CATEGORY ONE CATEGORY TWO ATTEND MEETINGS– REST GOLF ETC GET CERTIFICATE KEEP REGULATORY BODY HAPPY 100 HOURS WE ARE ALL SET FOR NEXT TWO YEARS BOARD RECERTIFICATION 10 YEARS!!

4. PROFESSIONALISM MEDICAL ERRORS TECHNICAL ERRORS SYSTEMS ERRORS HOW--------------- MULTIDISCIPLINARY APPROACH TEAM APPROACH HEALTH CARE PROVIDERS HEALTH CARE INDUSTRY REGULATORS

5. AVOIDANCE OF ERRORS SYSTEMS LEARNINGS PSYCHOMOTOR SKILL LAB HANDS ON TRAININGS SIMULATIONS OTHER EDUCATE, LEARN, PRACTICE, BE PROFICIENT, SEE, LEARN OUTSIDE AND DO READY TO GO

6. SIMULATION FOR PATIENT SAFETY And TEAMWORK Or Can Simulation Make Your OR Teams More Effective and Resilient?

8. OR

9. Control Room

10. Patient Safety and Medical Education Challenges Addressed by Simulation Training clinicians in risky procedures on real patients is less acceptable Apprenticeship-based learning depends on chance events There are limited opportunities to experience rare events and crises The 80-hr week has reduced contact hours for physician trainees Training for teamwork is atypical Economics- for some things, simulation will be less costly

11. Using Simulation for Patient Safety and Culture Change • What is “simulation”? • What are the ways simulation is used? • How can simulation contribute to improving teamwork?

12. What is Simulation in General? A “technique”not a “technology” for interactive and often “immersive” activities that re-create experiences of a real-world environment, to amplify or replace actual experiences

13. Spectra of Simulation & Immersive Learning in Health Care Simulation and immersive learning can apply to health care in many different ways There is a spectrum of applications across each of ten (or more) aspects of simulation From Gaba DM: The future vision of simulation in healthcare, Qual Saf Health Care.2004;13 (Suppl 1):i2-10.

14. Spectra of Simulation 1: Purpose of simulation Patient Care Surgical case planning Protocol design Equipment procurement Education (Knowledge) Training (Skills, Tasks, Behaviors) Testing Formative Summative High-stakes Recurrent Research Pedagogy Hum Factors Physiology / Pharmacology Gaba: Q&SHC, 2004

15. Spectra of Simulation 2: Unit of participation Crew (Single-discipline) Team (Multiple disciplines) Organization (Multiple work units + higher administrative structures) Individual Work Unit (Team + administrative structures) Gaba: Q&SHC, 2004

16. Spectra of Simulation 3: Health Care Domains Imaging Radiology Pathology Procedural Surgery OB/GYN Inv. Radiology Anesthesia Critical Care Emerg. Med. In- hospital Internal medicine Pediatrics Surgery OB/GYN Primary Care Clinic Home Dynamic,High Hazard OR ICU ED Cath Lab Gaba: Q&SHC, 2004

17. Spectra of Simulation 6: Knowledge, skills, behaviors Technical Skill Knows how Shows how Does Masters Decision Making Cognition Meta-cognition -Static -Dynamic Conceptual Understanding Knows Attitudes & Behaviors Teamwork Patient-centric Ethics Professionalism Gaba: Q&SHC, 2004

18. Spectra of Simulation 8: Technology applicable to simulation Verbal“what if” Role- playing Multimedia Part-task Trainer Physical VR Patient Simulation Computer- screen Screen-based virtual world Electronic Patient Simulation Replica Clinical Site; Physical (mannequin); Full VR Standardized patient (Actor) Gaba: Q&SHC, 2004

19. Central Line Placement Procedural Simulators/Part Task Trainers Intubation

20. Dentistry Labor and Delivery Suturing a hybrid patient simulation R. Kneebone

21. Simulators /Part Task Trainers Laparoscopic skills Ultrasound Colonoscopy

22. Interventional Radiology and Cardiology

23. Mannequin Simulators Trauma Sim

24. Full Team Training with Simulation

25. CRISIS MANAGEMENT TRAINING (based on principles from Gaba, et al, derived from aviation CRM) Teach generic skills in managing critical events Uses full scale realism to motivate and instill new behaviors An introduction (hook) into continuous, deeper training that is needed to really creative effective teamwork

26. Key Concepts in CRM Roles- leaders and followers Communication - closing the loop Support - calling for help Resources - how you get what you need Global Assessment - avoiding fixations

27. Debriefing: The key to learning from simulation

28. Simulation is an Introduction, a motivator and practice instrument for team training: It is not enough by itself to radically change the culture Elements needed to introduce teamwork: Motivating stimulus Set of behaviors to adopt Teaching of the theory Observations and measurements Drills Reinforcement

29. Patient Safety Goals No patient should have to be practiced on by a provider who is not yet KNOWN to be competent to do what they are doing. No provider should have to practice on a patient first. All providers should practice regularly to be good team players.

30. Vision for Simulation Based Training Simulation will become a primary mode of training Simulators will be in every healthcare training facility Virtual hospitals will become common: • -Multiple procedure rooms for realistic simulation, part task trainers Remote training with simulation, e.g., Via internet and teleconferencing

31. Some Indicators Of Simulation Penetration: 2008 3 commercial mannequin simulators • Thousands of mannequin simulators world-wide • ~ 1000 simulation facilities Dozens of types of part task simulators Society for Medical Simulation ~2000 members Advanced Initiative in Medical Simulation (AIMS) seeking federal support National and international meetings for >10 years Journal of Simulation in Healthcare Medical societies promoting simulation Board certification via simulation coming

32. Regulatory Certification The FDA now requires a 5-part training curriculum before any physician can use carotid stents. (Gallagher AG, Cates CU. Approval of virtual reality training for carotid stenting: What this means for procedural-based medicineJAMA 2004 292: 3024-3026)

33. Legitimizing simulation Harvard Risk Management Foundation provides malpractice premium discount anesthesiologists (2001) and obstetricians (2003) with simulation based training Promutual Insurance adopts program for OB(2005)

34. Is Definitive Proof of Effectiveness Required? ...no industry in which human lives depend on the skilled performance of responsible operators has waited for unequivocal proof of the benefits of simulation before embracing it... Neither should anesthesiology {health care} (Gaba, Anesthesiology 76:491-494, 1992)

35. PSYCHOMOTOR SKILL LAB ARTHROSCOPIC SURGERYMGH /HARVARD

36. MANNEQUINS

37. PSYCHOMOTOR SKILL LAB

38. PSYCHOMOTOR HANDS ON TRAINING AND LEARNING CENTERMASS GENERAL HOSPITAL HARVARD MEDICAL SCHOOL

39. SIMULATION

40. RISKS AND REWARDS

41. What Changes Simulation Might Really Bring About Getting closer to high reliability by motivating routine practice Using debriefing skills to create a new way of dialogue between providers and between patients and providers Creating really disruptive change in healthcare

42. THANKS Center For Medical SimulationJeffrey B. Cooper, PhD MGH/HARVARD FOR HIS LEADERSHIP AND HELP IN THIS FIELD

43. New Ideas New paradigm 20 th century Future Innovations New organizations New awareness TRULY SPEAKING NEED ACTION ORIENTED PREPAREDNESS FOR PATIENT SAFETY

44. CME PATIENT SAFETY LICENSURE RELICENSURE RECERTIFICATIONS LIFE LONG COMPETENCY PERFORMANCE PATIENT OUTCOME REDUCE ERRORS

45. THANKS