William K. Atkinson, PhD, MPH, President & CEO, WakeMed Health & Hospitals shares valuable insights on how to enlist and maintain the support of senior organizational leaders and other important stakeholders for medical simulation programs. 

A team of critical care nurses resuscitating SIM Man after a significant cardiac event. Image Credit: WakeMed
A team of critical care nurses resuscitating SIM Man after a significant cardiac event.Image Credit: WakeMed

If you were a member of the Navy Seal team engaged in the now infamous 2011 raid in Pakistan on Osama Bin Laden’s hide-in-plain-sight compound, you know it took years of preparation, specialized training, and intense simulation to culminate in the successful 40-minute on-site operation.

Likewise, if you were one of the passengers on US Airways Flight 1549 piloted by Captain Chesley “Sully” Sullenberger on January 15, 2009, you would have been thanking your lucky stars for the simulation training that helped prepared Captain Sully to bring the plane down safely on the Hudson River. Three and a half minutes to determine the best course of action to save 155 passengers and crew – not to mention the lives on the ground. Sullenberger, a former US Air Force fighter pilot and 30-year veteran as a commercial pilot, specialized in accident investigations and instructed flight crews on how to respond to crises in the air. He had spent hundreds of hours in flight simulators and thousands more in the cockpit.

These are extreme examples demonstrating the value of simulation, but simulation in healthcare has untold impact each and every day in both routine and complex procedures. If you are reading this article, you may already be a believer in the value of simulation in healthcare looking to share this knowledge with others to increase awareness, support, utilization, and funding. The reality is simulation can mean the difference between life and death for patients. But how do you convince non-believer senior leaders that simulation is worth the investment?

Recently, while at an international simulation conference, a presenter made the comment that hospital CEOs in general are not engaged in simulation and do not understand the impact it can have in the healthcare arena. As a president and CEO of a large multi-hospital system serving North Carolina’s capital city, I was compelled to dispel this myth, but how can you too get your hospital’s CEO to stand up in support of simulation?

Value of Personal Experience

When it comes to understanding the value of simulation, I have the benefit of personal experience. Military boarding school and an early career in emergency medical services (EMS) have given me opportunities to participate in simulation and experience the value first hand.

When I was initially training for a career in EMS, training was limited to classroom-based presentations and discussions. EMS providers would walk and talk through the process, often using themselves as mock patients. Teachers would ask questions and students would respond with the textbook answer. But what if things on-scene don’t go according to plan? A textbook cannot teach the response, and in the moment during a scene response, providers may not be mentally or physically prepared for what can and often does happen.

It quickly became evident to me that education, practice and reeducation were critical for healthcare providers to become comfortable and adept at caring for the sick and critically ill. The ability to orchestrate realistic simulations has significantly improved since my first experiences, and it is changing how providers are taught and the way healthcare is delivered in almost every healthcare setting.

Today, scenario-based programs more and more frequently involve computer games and human patient simulators, enabling providers to have the opportunity to practice a response or a skill repeatedly in a safe, realistic environment. This repetitive, realistic practice helps engrain second-nature responses to early morning car crashes, baby deliveries in rural communities, cardiac arrests and so much more. Simulation-enabled training also offers the opportunity to practice skills complete with snafus and what ifs, and simulation training helps instill competence and confidence, improve and enhance communication, impart experience with uncommon situations and procedures, and identify areas of opportunity.

Speak the Language of the Leader

As great as simulation is, leaders are challenged to balance the needs and desires of patients, board members, physicians, employees, volunteers, funders, politicians, students and more. Leaders are pulled in many different directions. There is pressure to provide quality services and expand access to meet the needs of constituents all while meeting or beating budget.

Every decision a leader makes must be tied back to the end goal – in healthcare this means providing access to a quality service at a reasonable cost. When you are speaking to a leader trying to convince them of the need for or value of simulation, it is important to speak their language. Tell them, or better yet show them, the value simulation can provide to the organization, student or patient. This is best communicated via a well-thought out business plan proving value and showing a return on investment (ROI) either in dollars, system-wide improvements, or lives saved. Nothing speaks stronger to a CEO (or funder) than a professional who is organized, motivated and can provide strong examples of the positive impact their program is having on the organization.

The initial start-up costs for simulation are high, but believe it or not, finding funding for equipment and simulators is (although still challenging) actually the easy part. Endowments, grants and personal donations are a great place to find the money to start a program. The difficult funding conundrum for simulation facilities is securing long-term support and funding sources for staffing, space, equipment and expansion. This long-term funding problem is exacerbated by the fact education is typically one of the first discussion points when leaders are faced with a budget crunch.

To combat these funding issues, simulation professionals within an organization must all be singing from the same song sheet and must be able to easily show their value at every opportunity. The business plan must clearly demonstrate the impact of simulation - whether that be training more students, attracting more students into the college, providing a place for healthcare professionals to do clinical rotations to maintain competencies, or retaining additional employees. Whatever it is, define the value you bring and translate that value into measurable results.

Evaluate how your business plan can support your organization’s mission, vision and values. At WakeMed, our mission is to provide outstanding and compassionate care to all who seek our services. We are the safety net healthcare provider in Wake County, North Carolina, providing nearly $200 million in charity care and unreimbursed Medicare and Medicaid per year.

Maintaining the ability to meet our mission in the face of healthcare reform is challenging. We are already beginning to see major changes in the way healthcare is being reimbursed, and everyone in the industry is bracing for significant declines in reimbursement.

With reform, there will be an increased demand for efficiency, measurable quality, and a more highly skilled workforce. These are areas where simulation training can be made relevant for even the most skeptical leader because simulation enables the workforce to learn, not solely by reading (although reading is very important), but by doing and practicing. Simulation presents a new interface tool that is real time and allows providers to repeat activities, hone skills, improve teamwork, and alleviate risk and stress that comes with inexperience.

At WakeMed, simulation training occurs in our Center for Innovative Learning, a facility featuring a nurses’ station, intensive care/trauma suite, and a flexible patient care room that can be used for general medical or birthing. The center is a key to helping our system achieve and succeed under healthcare reform by being an important component to the safety program and serving as a testing ground and solution incubator. Its impact spans from information services to infection control to error prevention to physician education and beyond. Specific examples of the center’s impact include but are by no means limited to:

  • Infection Prevention: Staff from the Center for Innovative Learning coordinated simulated IV starts and studied videos of the procedures. They then broke down the 61 processes to start an IV and identified that the biggest chance for infection occurs between steps 15 and 16 during site cleaning and IV insertion. By identifying when the biggest risk occurs, the staff can then educate providers and significantly reduce the chance for infection during such a routine procedure.
  • Patient Safety: In the course of running simulation classes, many of the participants expressed concern with the layout of the crash carts throughout the system. In response to the voiced concern, Center for Innovative Learning staff evaluated the concerns and observed how crash carts were used during real codes in our hospitals. Through a comprehensive feedback and review process involving nursing administration, pharmacy, and the “code blue” teams, every crash cart across the system was modified, standardized, and uniquely identified as pediatric or adult. If it were not for students practicing responding to codes in a simulated environment, the need for modification would not have been identified.
  • Information Technology: We, as an organization, will soon be transitioning from a best of breed information system to investing nearly $100 million into Epic, a comprehensive electronic health record. This is a massive investment and getting the implementation right is critical. Having the opportunity to work out the bugs in the Center for Innovative Learning is going to be a key component where we test the solution and identify issues before rolling it out to our providers.
In addition to a well-developed business plan, it is also important to create and distribute an annual report showing progress toward goals and explaining, where appropriate, why you didn’t meet certain measures. Show in this annual report how many students you impacted, hours of simulation completed, downtime, total number of visitors, total number of sessions, student and teacher evaluations, and if possible, hard evidence of simulation working within the system. This annual report is also nice to have as a “sales piece”, but it means more than that because data rules when requesting funding or justifying the need for extra personnel, equipment or space. These hard facts are messages that will be well received by any leader.

Members of WakeMed Mobile Critical Care Services simulate transporting a critically ill neonate from the ambulance to the unit. Image Credit: WakeMed.
Members of WakeMed Mobile Critical Care Services simulate transporting a critically ill neonate from the ambulance to the unit.Image Credit: WakeMed.





Selling Your Program

Having a business plan, an annual report, and being able to communicate your value are not the only keys to success. You must also be able to get an audience with your leaders. This can happen formally and informally, but regardless communicating value has to be an ongoing focus. It is also important to realize everyone who has experience with your program has the potential to be a strong and powerful advocate from the freshman allied health student to the most experienced physician to your CEO, so do not self-limit the individuals who can have a positive influence on your program. If you are asked to give a tour, accept the request whenever possible. You never know if a member of the random chamber group, pharmaceutical company employee, or nurse may have strong influence in the overall decision process.

It is always excellent to be able to bend the ear of the high-level decision makers, but it is more reasonable and equally as important to build local and regional collaborations and relationships. This means meeting administrators at all of your local hospitals, building relationships with your state’s medical society, seeking out key academic leaders outside of simulation, and connecting with other educational institutions in your field even if they are not in your immediate area.

Invite decision makers and key stake holders to be a part of your program by creating a volunteer board or steering committee. Meet your organization’s grant writers as these folks can be exceptionally helpful in getting you to the table and helping you secure additional resources. The health planning council or similar organization in your state also has a great deal of influence. Additionally, know your elected officials. Continuously work to educate the parade of officials who can have influence at the legislative or administrative level in health care. Often this can be done through a trade organization or, in some organizations, your institution’s government affairs department.

Through simulation, providers have the opportunity to train and improve until they have skills down perfectly, honing individual performance, teamwork and quality to produce exceptional outcomes. Through simulation, students are able to experience an error and identify where and how the error occurred and then make changes so the error disappears. Through simulation, students are able to prepare for the unexpected. Simulation-inspired changes in behavior and increases in preparation for the unexpected prove the value of simulation.

The value of simulation to your organization will not be as dramatic as a plane landing on the Hudson or an early morning raid on Bin Laden’s compound, but the real results will be evident when employees or others are using their new, advanced skills on the job. That’s when you’ll see the real return on investments, so be sure to share those opportunities and successes frequently with decision makers including but not limited to the CEO or other designated senior leaders in your work place.

Amar Patel, director of the WakeMed Center for Innovative Learning, runs a simulation experience with a team of nurses from the ICU control room. Image Credit: WakeMed
Amar Patel, director of the WakeMed Center for Innovative Learning, runs a simulation experience with a team of nurses from the ICU control room. Image Credit: WakeMed

About the Author

William K. (Bill) Atkinson, PhD, MPH, MPA, EMT-P, is President & CEO of WakeMed Health & Hospitals. Atkinson, a Greensboro, NC, native, became involved in health care as a member of North Carolina’s initial paramedic class and remains passionately involved in a wide-range of emergency services, public health and public policy issues to this day.

Dr. Atkinson has more than 25 years of experience as a hospital president and chief executive officer in rural and urban settings in several states. He is only the third CEO in the 50-year history of WakeMed Health & Hospitals, a private, not-for-profit multi-hospital system and one of the top health care providers in the state. With more than 7,000 employees WakeMed is one of Wake County’s largest private employers. WakeMed’s heart program is North Carolina’s largest.