Cory Soto, Jamie Stiner and Yue Ming Huang describe making a challenging simulation course look easy to run.

When people feel safe and confident they are more willing to take chances to create better learning environments. Cory Soto, Jamie Stiner and Yue Ming Huang report.

Medical simulation is growing in demand. No matter how busy your center is now, it will inevitably get busier as more and more accrediting bodies require interactive and experiential forms of teaching and assessment. How do you meet the needs of an expanding center and fit it all into your schedule? At the UCLA Simulation Center, we want to share some key elements that we have found to making it feasible. Below, we take a page out of our playbook for one of the busiest times of the year to help illustrate our methods.

Every year, there is one course that regularly pushes us to our limit: College Foundations. Fourth year medical students (172 in total) from the specialty-based colleges within the David Geffen School of Medicine at UCLA participate in week-long simulation sessions and task training stations so they can hit the ground running during their sub-internships. This year, we ran 329 scenario-based simulation sessions and 1,373 task training encounters. That requires 341 hours of instructional time and 100 hours of staff preparation time during the week (not including the many hours of coordination, meeting and programming time that occurred prior to this week!). That’s a lot - especially given that our core team of simulation technicians are five members. So how do we get it all to work? It’s as easy as PIE: Plan, Implement and Evaluate.

Plan

Months ahead of time, we schedule a series of meetings with the coordinators and specialty-based college chairs to set the general expectations of the program. The first details we address are understanding the educational goals and finding out what each group wants to do, and determining the timing for the sessions. We are fortunate that our medical school plans the dates for the curriculum two years in advance, which allows us to reserve that time exclusively for them. Due to the complexity of the course, we make sure not to plan other simulations during that week and find alternative dates for other simulation requests.

Next, we select which rooms and equipment will be needed for the simulation activities. We know our equipment well and can give informed recommendations on which model is appropriate for a specific type of training or whether a room is most suited for a certain group size. Doing so eliminates preventable problems and creates a sense of collaboration with those planning the event. Though the details of your simulation setting and scenarios may differ, you can implement similar ideas at your own center. By paying attention to logistics during the planning phase and creating sensible solutions, you create flow. You can further enhance this by providing proper signage to direct learners to where they need to go, grouping skills station rotations for a certain learner group near each other and avoiding the need to move equipment back and forth between rooms.

Allocating team members is the most difficult aspect of our planning. Simulation technicians at our center are responsible for a wide array of tasks, simultaneously controlling the audiovisual systems, changing vital signs and listening to faculty for guidance on what the next step should be while the case unfolds. This means that each case requires at least one person running the simulator, leaving us short-handed without additional staff to check in on task training skills sessions when multiple scenarios happen concurrently. Communicating this to coordinators and college chairs allows them to decide how they want to address the issue ahead of time. They can decrease number of scenarios and regroup learners, move the skills stations to a time when there are more team members available or come up with some other alternative accommodations. Similarly, planning early around the limitations of your simulation center can give you flexibility.

We also find success in freeing up someone to be the “floater” team member to oversee the set up and maintenance of diagnostic equipment, task training models and disposable supplies for the week. This creates the advantage of maintaining continuity, as this team member will know where items are located as the week goes on. Imagine the difficulty of finding a specific type of guide wire in a stack of boxes for a session that started five minutes ago. That takes time and the amount of time for each individual team member to learn where everything is located adds up quickly. Delegating specific roles saves time in your center’s operations and frees up other team members to focus on running their assignments for that day.

In our planning process, we also engage coordinators and chairs about which items they prefer as the dedicated equipment and the “floater” supply team member on our staff estimates how many items need to be ordered to sustain the planned activities. This is important because manufacturers offer variants of equivalent supplies and there are significant differences in how they are to be used - imagine being an instructor tasked with demonstrating a procedure without being familiar with a tool you’ve been supplied. You want to set up your instructors for success, and keeping an open dialogue with those involved with the course is an important component of that. In addition, to keep up the energy and morale of your team members throughout a challenging course, we emphasize the importance of scheduling a regular lunch time and breaks.

Once the planning meetings end and the details are finalized, we create a document that shows all the sessions for each day with the designated team member and equipment needed. Days are organized into columns and activities are chronologically listed. For each day, we prepare a list of preparation tasks with each team member’s assignments and the times of completion. Producing a document like this for your simulation center can help create a shared mental model among your team members when they are not able to meet. Being synchronized in this way means that everyone knows exactly what they need to do at all times. Furthermore, it takes the human aspect into account: it’s challenging to remain sharp after long days of running simulation, so having a reference checklist to keep you on track is invaluable. We also create folders for each day’s simulation sessions with all relevant imaging, EKGs and lab values ahead of time and organize the disposable items for each skills training session into individual labeled boxes for easy transport and just-in-time use. Reducing unnecessary variables is the easiest way to ensure a better flow for your session, as it has for ours.

Implement

After planning comes implementation, or actually carrying out the plan. This is where we prepare for the unexpected. How do we prepare for what we can’t predict? We believe that the best way to address the unpredictable is by creating a culture of closed-loop communication and mutual support. We practice TeamSTEPPS concepts and skills daily ( http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/index.html).

We use the huddle. The huddle isn’t just for football; it’s a valuable tool to get back on track when the unexpected happens. It is a brief, focused gathering of team members to reassess changing situations or to communicate important information. A proper huddle is initiated at any time by any team member to clear up a question or verbalize a concern. The huddle can consist of any number of team members but works best when it includes everyone involved with the running of the activity. The group discusses the issue and work together to create a game plan and coordinate implementation of the game plan. Huddling promotes a flat power dynamic where all members of the team share a singular goal and can feel safe to verbalize their need for better understanding.

The team can also utilize check-backs for less pressing issues or lower stakes situations. A check-back is an application of closed-loop communication. A team member identifies an incidental task, states their intent to undertake it and later confirms its completion to all members involved. The importance of check-backs is rooted in lowering the cognitive load of the team so they can focus on the task at hand.

The huddle and the check-back serve to unify understanding of the situation within the team. Effective teams identify a task, agree on a method, designate personnel and state when completion is expected. Addressing problems with a systematic approach reduces unproductive stress and confusion because there is faith in the effectiveness of the team. Implementing these changes can make a huge difference in the morale of your team because experiences for when people feel safe and confident they are more willing to take more chances to create better learners.

By practicing huddles and closed-loop communication, our simulation team members not only develop better situation awareness and mutual support to run the productions, but also serve as advocates for the learners. During equipment orientations or brief interactions with learners, team members pay close attention to their body language and look out for those that are particularly nervous. Sharing this information with instructors, allows them to consider how to thoughtfully address student needs. For example, our team members are particularly vigilant in sessions that involve blood drawing. We pay attention to those who seem anxious or who might faint. Having experienced a number of these incidences, we have developed a simulation center policy on emergency events and came up with contingency planning. We are developing handouts for instructors with contingency planning information in the event that a team member is not immediately available.

Sim Tech in control room with medical students in sim room.

Evaluate

The end of the session is just the beginning of the evaluation and reflection period. While we take notes during the session, we feel that debriefing behind the scenes with the team and instructor team after the session ends is just as important as debriefing a simulation scenario with the learners. With feedback, the team actively learns how to provide a better experience and environment for instructors, learners and fellow team members each day. Not sharing those experiences would be a wasted opportunity for improvement. It is also a great time to reflect on our successes.

Immediately after a simulation activity, the team asks instructors for feedback and clarification of questions to enrich subsequent sessions. By comparing the plan to what was actually implemented, we can discuss why things happened unexpectedly, whether good or bad, the time it took to actually do things (time observation, a concept from lean methods to identify waste and increase efficiency; http://mednet.ucla.edu/hii/) and how we can better prepare in the future. Collaboration with instructors during this period can bear many fruits: simulation team members can make recommendations to add fidelity or new elements to cases.

Simulation team members can also make recommendations to streamline cases and make them flow more smoothly. It is important for team members at your simulation center to see their roles within simulation as experts in the field. Instructors depend on team members’ guidance to help them bring their learning objectives to life in a safe learning environment. Many instructors participate in simulation once a month or less and may not have the time or experience to know what your center is capable of accomplishing. In the same way that physicians and nurses must have good bedside manner with patients, simulation team members must help guide instructors with great care to ensure their needs are being met while being honest in your assessment of what to improve on.

It is important to remind your team that their work is appreciated and not unnoticed. Dr. Jason Napolitano, the Assistant Dean of Student affairs and an Associate Professor of Medicine at the David Geffen School of Medicine at UCLA wrote us: “I learned that with an immense amount of planning, hard work, great attention to detail and a little flexibility to deal with the unexpected, the UCLA Simulation Center could not only pull off this case load but do so while providing an amazing, immersive learning environment for our medical students.” Abraar Karan, the President of the Medical Student Council commented that “The simulations were excellent because they provided a hands-on opportunity for us to apply our clinical knowledge in a practical way.” Make sure you celebrate a job well done.

Once the sessions and debriefings are finished, the simulation center team meets as a group to discuss suggestions and update the simulation documents to reflect any agreed-upon changes. The value of this activity is that those not present during the event will know exactly what they need to participate in the session in the future and can give their perspective if they have run that session in the past. Keeping a systematic and organized method of material and document storage is essential. Set rules on how to save versions and keep older ones for future reference. This is also a great time to continue utilizing the check-back so that all members are aware of additions and modifications.

In summary, advanced and detailed planning pays off in the end, implementation is successful when teamwork and communication strategies are in place, and we can only get better if we study what we do and make changes to improve. These are some of the important lessons that we have used to deal with resource-intensive sessions, but what we have realized is that even regular sessions can benefit from implementing these teamwork ideas and communication practices. We challenge you and your center to make simulation better - better for learners, better for instructors, better for your coworkers and, ultimately, better for patients.

About the Authors

Cory Soto is a graduate of UCLA with his B.S. in Biochemistry. He is a certified Pharmacy Technician as well as a Simulation Specialist at the UCLA Simulation Center, an interprofessional healthcare training facility that serves the David Geffen School of Medicine at UCLA, the UCLA Health System, the UCLA School of Nursing, and the local community. He is interested in the development of simulated drugs to promote safety and learning.

Jamie Stiner is the Operations Manager at the UCLA Simulation Center. In 2010 Jamie became the first full time simulation specialist at UCLA. Since then she has served as the Senior Simulation Technology Specialist and Supervisor, and in 2013 became the Operations Manager responsible for overseeing the daily operations and supervising the simulation staff, student workers and volunteers. From administration to operations, Jamie is involved in providing simulation training for all undergraduate, graduate, nursing and continuing medical education programs held at UCLA. She helped design the newly renovated Simulation Center that opened in December 2013. More notably, she was responsible for implementing a complex audiovisual system and continues to manage this system on a daily basis. She is also one of the facilitator for UCLA’s TeamSTEPPS Master Trainer courses. Nationally, she serves on several Society for Simulation in Health committees and is the Vice-Chair to the Sub-Committee for Sections, Affinity and Special Interest Groups

Yue Ming Huang is Associate Adjunct Professor in the Department of Anesthesiology and the Education/Operations Director at the UCLA Simulation Center. She has been working in simulation-based education for over 15 years, is a TeamSTEPPS Master Trainer, and has Gold Certification from the UCLA Lean Academy. She enjoys developing people and researching on teamwork.