SimLEARN:

1. SimLEARN: Simulation Learning, Education and Research Network Paula Molloy, PhD SimLEARN National Program Manager Rosalyn P. Scott, MD, MSHA ACOS for Medical Education, Dayton VAMC Professor of Surgery, Professor of Biomedical Industrial and Human Factors Engineering, Wright State University Rachel Ellaway, PhD Assistant Dean Informatics Northern Ontario School of Medicine 1

2. SimLEARN Beginnings July, 2009: VA Under Secretary for Health established the Simulation Learning Education and Research Network (SimLEARN) Program SimLEARN will develop and manage a strategic and operating plan for simulation education, training, and research across VHA The SimLEARN National Center will be the focal point for program delivery 2

3. The SimLEARNVision and Mission VISION: To improve the quality of health care services for America’s Veterans through the application of simulation based learning strategies to workforce development. MISSION: To promote excellence in health care provided to America's Veterans through the use of simulation technologies for process modeling, training, education, and research and to establish VHA as the world leader in the application of simulation based strategies. 3

4. Stakeholders and Governance The SimLEARN National Program will be responsible for the development and deployment of national curricula to address high priority clinical topics as identified by clinical stakeholders A Steering Committee represents clinical stakeholder interests The Steering Committee has met throughout 2009 and 2010 to provide early advice and guidance to the program 4

5. SimLEARN NationalProgram Structure A VHA Employee Education System Program Leadership Team – includes Patient Care Services and Office of Nursing Simulation Educators Information Technology Research and Development 5

6. SimLEARN Program Services Provide operational policies, procedures, standards and guidelines Collaborate with the DoD, academic affiliates and others Collaborate to define the business requirements for an IT infrastructure Assist in specifications and best value choices for equipment and processes 6

7. SimLEARN Center Products Survey to better understand the “as-is” state of VHA simulation training Draft strategic plan Edited volume— Simulation Update: A Review of Simulation-based Strategies for Healthcare, Education and Training SimLEARN Newsletter 7

8. SimLEARN Center Products www.simlearn.va.gov Literature reviews/educational resources Simulation Leadership conference Exhibits at major VHA conferences 8

9. The SimLEARN National CenterOrlando, FL Designed as a flexible facility for “train the trainer” simulation programs Laboratory for developing optimal simulation-based strategies for VHA workforce Multi-modal approaches will add to richness of the educational experience Aspire to establish interconnectivity across system and between simulation modalities 9

10. Using Simulation Rosalyn P. Scott, MD, MSHA ACOS for Medical Education Dayton VAMC Professor of Surgery Professor of Biomedical Industrial and Human Factors Engineering Wright State University 10

11. Spectrum ofHealthcare Education This is where educators think that VPs fit Greatest value is on decision making Positive impact on learning “Not only can VP cases illustrate multiple distinct presentations but deliberate practice can be facilitated by sequencing cases to insure an ideal case mix structuring learning to develop constituent skills and reinforce knowledge structures.” “[Finally,] technology integration requires not only an effective technology tool but also a critical mass of educators trained in the technology’s use and an institutional culture supportive of the innovation.”This is where educators think that VPs fit Greatest value is on decision making Positive impact on learning “Not only can VP cases illustrate multiple distinct presentations but deliberate practice can be facilitated by sequencing cases to insure an ideal case mix structuring learning to develop constituent skills and reinforce knowledge structures.” “[Finally,] technology integration requires not only an effective technology tool but also a critical mass of educators trained in the technology’s use and an institutional culture supportive of the innovation.”

12. Simulation Theory Deliberate practice is essential for development of expert proficiency Permission to fail allows learners to make mistakes and thus learn to recognize, avoid and recover from errors Assessment tools allow learners to train-to-proficiency Formative and summative feedback Can be exposed to clinical scenarios that are uncommon in clinical training 12

13. Fidelity Extent to which a simulator or simulation reflects the real world and patient Necessary level and specific components of fidelity, may vary depending on the task Simple procedural tasks, such as suturing and knot-tying, may be learned effectively with low-cost, lower-fidelity simulators Complex tasks, such as a complete laparoscopic cholecystectomy or management of critically ill patients, may need a much higher level of realism. 13

14. Virtual Patient An interactive computer simulation of real-life clinical scenarios for the purpose of medical training, education, or assessment. Users may be learners, teachers, or examiners. Difficult and costly to author, adapt and share Limited uptake and utility, despite being able to provide high quality learning opportunities A standard to enable exchange across systems has the potential to scale their development and implementation across health professions education, including resource limited settings.

15. Branched Narrative 15

16. Virtual Patient Examples

17. MedBiquitous VirtualPatient Specification

18. eVIP Electronic Virtual Patients In 2005, European e-learning centers in medicine and healthcare formed a working group to define a standard for the interoperable use of VPs across Europe. Funded by European Commission in 2007 for 3 years. Create a shared online bank of 320 VPs, adapted for multicultural and multilingual use Promote the inter-professional sharing of VPs between different healthcare disciplines Further enrich the content of the repurposed VPs with the addition of supporting resources Implement common technical standards for all VPs in collaboration with MedBiquitous

19. Standardized Patients Trained to realistically portray a medical case complete with all parts of history and physical

20. Strengths of Standardized Patients Communication with patients, family, staff and colleagues; history and physical exam skills; clinical reasoning and decision making; ethical and professional behavior; and procedural skills. Learners practice rare or high-risk conversations in a controlled environment SPs provide the opportunity for detailed feedback from the perspective of the patient, promoting patient-centered care. 20

21. Task Trainers

22. Task Simulation Training, practice, and assessment of specific psychomotor skills. Each specialty has its own roster skills Maintain skills and acquire new skills in response to practice needs and introduction of new procedures or technology Ultimate goal is the transfer of a learned psychomotor skill from the laboratory to the clinical environment 22

23. Haptics in Task Trainers Refers to sense of touch or force Mechanical simulators have inherent haptic feedback, as they use real objects to simulate tasks VR simulators have no inherent force feedback or haptics, as the environment is entirely generated within the computer. VR simulators incorporate mechanisms to provide the learner with haptic feedback through special interfaces and equipment. No evidence links haptics to improved clinical outcomes or to cost-effectiveness in laparoscopic trainers 23

24. Mannequins Range from passive mannequins to very complex computer-controlled mannequins with physiologic models Can include part-task components allowing specific invasive procedures Electronics in the neck allow an instructor or actor to speak as the “patient” Do not object to being poked with needles, having tubes inserted, receiving injected drugs, or suffering lethal diseases 24

25. In Situ Simulation Workforce is challenged in their own environment Layout, equipment and supplies are used as they would be with real patients Especially useful for unannounced mock events that can both train individuals and teams and probe the effectiveness of an institution’s clinical operating systems. Costs are lower than with a dedicated center, where construction capital and operational funding are required 25

26. Multidisciplinary Simulations Creates cross-discipline awareness of goals and issues. Participants can exchange roles, a teaching technique that enhances the appreciation of the skills of colleagues 26

27. Debriefing Reflect on what went well and what did not, and what lessons can be extracted Explore and evaluate with participants the alternatives they had at various junctures of the scenario Greater emphasis on participant-driven discussion and more inquiry/advocacy; less on instructor-driven critique Aided by playback of video-recordings Most important component in effective simulation-based clinical education 27

28. Immersive Environments Virtual worlds Stereoscopic rear projected room with head/hand tracking Incorporates gaming theory

29. Immersive Virtual Patient and Breast Examination Simulator

30. Technologies 3D virtual models of anatomical structures more sophisticated and form the basis for task training Displays range from being head-mounted to complete rooms with life-size 3D representations Social VEs are used as a platform for the education and training of medical professionals world wide 30

31. Process Modeling A technique for using computers to imitate/simulate the operations of various kinds of real-world facilities or processes Perform accurate, highly detailed predictive analyses of the specific and systemic impact of operational, process, and layout changes Can provide deeper insights into the barriers and incentives to adoption 31

32. Optimizing Patient Stay in Emergency Department 32 After analyzing several possible changes to the ED process and resources such as beds, doctors, and nurses, it was determined that static resource allocation creates inefficient resource utilization – some resources are over-utilized and some are under-utilized. Furthermore, using simulation, it was found that real-time resource movement between process areas will minimize cost and still achieve the LOS goal. This project demonstrated that computer modeling can be used as a real-time dashboard to assess status and make sound resource allocation decisions in real-time. The optimization of resources recommended by the model can lead to increased productivity by reducing LOS and enhancing the utilization of resources. A real-time dashboard provides “future-cast” capability, permitting the simulation of a future state based on the current state and contemplated changes. After analyzing several possible changes to the ED process and resources such as beds, doctors, and nurses, it was determined that static resource allocation creates inefficient resource utilization – some resources are over-utilized and some are under-utilized. Furthermore, using simulation, it was found that real-time resource movement between process areas will minimize cost and still achieve the LOS goal. This project demonstrated that computer modeling can be used as a real-time dashboard to assess status and make sound resource allocation decisions in real-time. The optimization of resources recommended by the model can lead to increased productivity by reducing LOS and enhancing the utilization of resources. A real-time dashboard provides “future-cast” capability, permitting the simulation of a future state based on the current state and contemplated changes.

33. SimLEARN National Center 33

34. HSVO: Simulation Integration Rachel Ellaway, PhD Assistant Dean Informatics Northern Ontario School of Medicine 34

35. Simulation in Healthcare Education Safe environment - forgiving of mistakes Trainee focused cf patient focused Controlled, structured Proactive clinical exposure Reproducible, standardized, objective Critical to patient and crew safety

36. Simulation in Healthcare Education Education, training, assessment Part task trainers, box trainers and haptics Mannequins - various ‘-fi’s Simulated patients (actors) Virtual patients and other OSS Environments … always with the centers!

37. Limitations Physical resources rivalrous Online resources non-rivalrous + access, presence, integration & interoperability Challenges of distributed programs, users, communities Limited ROI and affordances of contemporary simulators … mashup and continua cultures

38. Integration? Vendor platforms: METI müse VP interoperability: MedBiquitous Military sims HLA and SID Augmentation – Kneebone - SPs + prosthetics Integration – HSVO - devices and activities

39. Health Services Virtual Organization CANARIE funded project Network-enabled platform - NEP Connecting and controlling devices as services Multi-site Multi-disciplinary Multi-year

40. HSVO Network

41. HSVO Connects

42. Services

43. HSVO Devices

44. HSVO NEP

45. HSVO In Use

47. HSVO Scenarios and Sessions Scenarios Services Rules Sessions Users and locations Scheduling 1 scenario spawns multiple sessions

48. HSVO Scenarios

49. HSVO Scenarios

50. HSVO Scenarios

51. Multiple Scenarios and Sessions

52. HSVO Distributed-Integrated Simulation

53. HSVO Sim Challenge

54. Next Steps Improve workflows BICF New services Extended services – esp camera arrays New activity designs Open source release Evaluation and dissemination

55. What if? Simulation devices could be coordinated Simulation devices could talk to each other Simulation devices could control each other Simulation devices could use services from elsewhere Simulation devices could use each other as services

56. What if? Instructors and learners could have access to services and devices at any time and location Instructors and learners could have access to on demand practice or instruction All of this was easy to set up and control All of this was open source All of this was possible …

57. Questions? 57