A case for Funding Large Scale Simulations in Australian Healthcare Marcus Watson PhD Senior Director Queensland Health Skills Development Centre School of Medicine, The University of Queensland

Does size matter?

Cairns Townsville Mackay Bundaberg Hervey Bay Rockhampton Toowoomba (not an official centre) Roma QH SDC

Skills Development Centre

28.Fundamentals of Laparoscopic Surgery 29.Minimally Invasive Surgical Techniques 30.Introduction to Laparoscopic Surgery 31.National Endoscopic Training Initiative 32.Operative Laparoscopy Workshop for O&Gs 33.Perioperative Advanced Laparoscopic Skills Surgical and Psychomotor Skills Intensive Care and Anaesthetics 7.Intensive Care Crisis Event Management 8.Anaesthetic Crisis Resource Management 9.Anaesthetic Crisis Resource Management for GPs 10.Paediatric Anaesthetic Crisis Resource Management 11.Recovery Room Crisis Resource Management 12.Basic Assessment & Support in Intensive Care 13.Effective Management of Anaesthetic Crises 14.Advanced Paediatric Intensive Care Critical Skills 15.Physiotherapy and Critical Care Management 16.Introduction to Physiotherapy Cardiorespiratory Management Emergency and Rural 19.Advanced Life Support – Interns 20.Advanced Cardiac Life Support 21.Clinical Rural Skills Enhancement 22.Emergency Events Management 23.Emergency Crisis Resource Management 24.Emergency Technical Skills Course for Doctors 25.Acute and Critical Medical Emergencies 26.Pre-Hospital Trauma Life Support 27.Paediatric Emergency Crisis Resource Management Communication Skills 5.Frontline Communications 6.Friday Night in the ER 34. Emergo Train Disaster Medicine Courses Delivered by the SDC Medical Radiations 35.Introduction to Vascular Ultrasound 36.Basic Skills in O&G Ultrasound 37.Practitioner Initiated X-ray 17.Maternity Crisis Resource Management 18.Newborn Crisis Recourse Management Maternity and Newborn Faculty Training 1.Simulation With Integrated Mannequins 2.Crisis Resource Management Train the Trainer 3.Difficult Debriefing Training 4.Grad Dip Health Simulations

Changing the face of healthcare What healthcare needs is clinical training on an industrial scale with simulation efficiently integrated into clinical practice along with other educational methods.

Identifying the Critical Motivation TrainingSystems Technical skills Non-Technical skills Interdisciplinary learning Specialty skills Human Factors Organisations design Equipment design Technology integration Pre-employment skills Process design Workload assessment Performance assessment Workplace orientation Competency assessment Safety Quality Quantity Efficiency

Identifying the Critical Motivation TrainingSystems Technical skills Non-Technical skills Interdisciplinary learning Specialty skills Human Factors Organisations design Equipment design Technology integration Pre-employment skills Process design Workload assessment Performance assessment Workplace orientation Competency assessment Safety Quality Quantity Efficiency

Identifying the Critical Motivation Training Safety Quality Quantity Efficiency

“Australia must address the serious issues in clinical education to meet the needs of the expanding healthcare workforce and improve safety in health care settings. The required transformation of clinical education can only occur if significant funding is allocate to the integration of simulation into all levels of clinical training. Funding should centre on the standardisation of curriculum around core clinical competency, especially non-technical skills….”

“…. Major funding is also required to expand the number of instructors and simulation coordinators skilled in the delivery of immersive learning and debriefing. Effective simulation administration hubs that minimise the time clinical instructors are away from clinical practice need to be established nationwide….”

“….The national investment in simulations equipment should be linked to curriculum delivery capacity to avoid inadequate equipment use. Commonwealth funding is required to develop the human capital required to effectively integrate simulations into clinical education.”

Quantity of Quality argument We have a clinical skills shortage Increasing the number of students increase the burden on already overs stretched clinical mentor We can provide more simulation experience but we cannot guarantee more experience on clinical placements We can control the quality of simulations experience

Quantity of Quality argument The opportunity for clinicians to develop clinical skills is often haphazard and there are examples of clinicians graduating without having been assessed or in some cases performing crucial clinical skills. Wall, Bolshaw, & Carolan, 2006, Medical Teacher Fox, Ingham Clark, Scotland, & Dacre, 2000, Medical Education Remmen, et. al., 2001, Medical Education In the 1960s medical students received 75% of their teaching at the bedside, in the late 1970s this dropped to 16% and since then it has decreased further. Ahmed, & El Bagir, 2002, Medical Education The acquisition of basic clinical skills suffered when there is limited supervised hands-on experience, skill levels in health are likely to drop unless alternate training methods are used. Remmen, et. al., 2004, Medical Education Seabrook, 2004, Medical Education

Education in Healthcare Education in healthcare already uses workshops, seminars, lectures, e-learning, simulations and clinical placements. Little is systematic or standardized, with a range of disparate packages used that rarely link. They should be highly integrated with a focus on developing the skills required for clinical practice. Other industries use of e-learning, decision games, virtual reality or immersive simulations, which could deliver the learning opportunities that are no longer available in clinical placements.

Learning methods Learning Method Non-Technical Skill Situation AwarenessCommunications Decision- makingTeamworkLeadership Didactic learning Poor Video examples Fair StrongFair Discussion forum Poor FairPoor Decision games Fair Strong Virtual reality Fair StrongFairPoor Immersive learning Strong Debrief learning Strong

How we learn now

How we should be learning in 2015

How we should be learning in 2025

Safety and Efficiency argument Patient error is estimated to have a direct cost in Australia of $2 billion a year Patient are treated by ‘teams’ of clinicians not by a clinician Patient safety reports indicated that non-technical skills are involved in the majority of adverse events reported that cause harm Wilson, Runiman, Gibberd, Harrison, Newby, & Hamilton, (1995) Medical Journal of Australia Other industries have become safer by a combination of standards, regulations and appropriate preventative Healthcare needs to provide the right training

Team training Crisis Resource Management Tertiary Hospital 2007 Births ~ 4,800 Annual mandatory fire drills Fires = 0 Annual mandatory basic life support Cardiac emergencies = 0 Maternity emergencies that occurred in 2007 Cord prolapse = 22 Placental abruptions = 41 Shoulder dystocia = 71 Maternity Crisis Resource Management MaCRM 2 day multidisciplinary workshop including scenarios and structured debriefing

Standardising skills development Non-technical skills require teaching programs that provide continuity throughout a clinician’s career from undergraduate through to senior clinician or specialist. Continuity must be provided across disciplines and across facilities so that doctors, nurses, allied health, paramedics, etc. can effectively work together. Standardising the curriculum for non-technical skills will help to reduce the cost in developing teaching material and reduce the discrepancy that contributes to patient safety errors.

Training – when, where and how Multidisciplinary training in healthcare is starting to occur in hospital systems with varied levels of success. Most issues arrive when clinicians undergo concurrent training rather than training as a team. El Ansari, Russell & Willsc (2003) Public Health Australia has simulation centres that provide excellent immersive learning for technical and non-technical skills. The training capacity of most centres is not limited by the number of simulators or rooms but rather by the number of instructors and the support staff available to deliver training An analogy is cottage industries that provide high quality products to a small proportion of the population.

Training – when, where and how 1.Tertiary Skills Development Centres –Inter-disciplinary training –Specialty training –Technical hub –Supports University training –Conducts major research –Staff FTE, – PT instructors 2.Affiliated Skills Development Centres –Inter-disciplinary training –Supports University training –Conducts major research –Staff 3-9 FTE, PT instructors 3.Portable Simulations –Inter-disciplinary training –Specialty training –Opportunistic training –Supports University training –Staff 2-3 FTE, PT instructors 4.Departmental ‘Pocket’ Simulations –Department training –Inter-disciplinary training –Opportunistic training –Rehearsals –Research –1-2 FTE, 3-20 PT instructors

How quickly can we grow? Based on 2007 Queensland Health clinical population - Actual training Days required will increase

How many people will it take? Per participants training day inInstructors Simulation Coordinators Administration and Logistics Support current ratio estimated economy of scale Queensland Health 30,000 training days ,000 training days

Six Critical Training Issues 1.The right blended learning environments, 2.Emphasis on the knowledge and skills likely to prevent harm, 3.Standardisation of curriculum and reliable assessment, 4.Training as teams not just as individuals, 5.The use of skilled instructors, 6.Dedicated support staff to provide efficient and accountable education.

What Australia has to do RankPriorityDescription 1 Curriculum exchange program  Centrally funded core curriculum to meet graduate and new clinicians training requirements (PGY 1-3 for all disciplines) with a focus on non-technical skills  Validate and mandate one or more methods of assessing non-technical skills  Curriculum that supports a continuity throughout a clinician’s career across disciplines and facilities 2 The development of immersive learning capability  The rapid development of skilled simulation coordinators and instructors  Formal training and recognition of their educational and technical skills  Significant administration and logistic support to minimise clinicians’ time away from clinical service 3 The development of administrative hubs for simulation  Dedicated management and governance to ensure quality and appropriate coverage of simulations training integrated into clinical placements  Dedicated staff to provide the coordination and logistic support for course delivery in each state to ensure a continuum of interdisciplinary training across facilities for all clinical staff 4 The development of equipment and infrastructure for simulations  A review of existing simulation equipment to increase use through better access, regular maintenance by skilled instructors and simulation coordinators  The development of affordable portable audio visual systems to improve learning through effective debriefing  The expansion of simulation equipment to meet the needs of the expanding training capacity

Questions 1.We can do things in simulation we cannot or should not do with ‘real’ patients 2.We can apply simulation systematically and opportunistically to develop a leaner and safer healthcare system 3.We can develop more simulation-based training but we cannot rely on more quality clinical training opportunities