Historically simulation was used as an education and training

technique in healthcare, but now has an emerging role in

improving quality and safety. Simulation-based techniques
can be applied to help understand healthcare settings and
the practices and behaviours of those who work in them.
Simulation-based interventions can help to improve care and Improving Quality and
outcomes – for example, by improving readiness of teams
to respond effectively to situations or to improve skill and Safety in Healthcare
speed. Simulation can also help test planned interventions and
infrastructural changes, allowing possible vulnerabilities and
risks to be identified and addressed. Challenges include cost,
resources, training, and evaluation, and the lack of connection
between the simulation and improvement fields, both in
practice and in scholarship. The business case for simulation Simulation as an
as an improvement technique remains to be established. This
Element concludes by offering a way forward for simulation
in practice and for future scholarly directions to improve
Improvement
the approach. This title is also available as Open Access on
Cambridge Core. Technique
About the Series Series Editors
The past decade has seen enormous Mary Dixon-Woods*
growth in both activity and research Katrina Brown* Victoria Brazil,
on improvement in healthcare. This
series offers a comprehensive and
Sonja Marjanovic† Eve Purdy, and
authoritative set of overviews of the Tom Ling†
Komal Bajaj
https://doi.org/10.1017/9781009338172 Published online by Cambridge University Press
different improvement approaches Ellen Perry*
available, exploring the thinking Graham Martin*
behind them, examining evidence
for each approach, and identifying
*THIS Institute
areas of debate.
(The Healthcare
Improvement
Studies Institute)
†
RAND Europe

ISSN 2754-2912 (online)

ISSN 2754-2904 (print)
https://doi.org/10.1017/9781009338172 Published online by Cambridge University Press
 Elements of Improving Quality and Safety in Healthcare
edited by
Mary Dixon-Woods,* Katrina Brown,* Sonja Marjanovic,†
Tom Ling,† Ellen Perry,* and Graham Martin*
*THIS Institute (The Healthcare Improvement Studies Institute)
†RAND Europe

SIMULATION
AS AN IMPROVEMENT
TECHNIQUE

Victoria Brazil,1,2 Eve Purdy,1,2

and Komal Bajaj3
1
Translational Simulation Collaborative, Faculty of Health Sciences and
Medicine, Bond University
https://doi.org/10.1017/9781009338172 Published online by Cambridge University Press

2
Emergency Department, Gold Coast University Hospital
3
NYC Health + Hospitals
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DOI: 10.1017/9781009338172
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 Simulation as an Improvement Technique

Elements of Improving Quality and Safety in Healthcare

DOI: 10.1017/9781009338172
First published online: January 2023

Victoria Brazil,1,2 Eve Purdy,1,2 and Komal Bajaj3

1
Translational Simulation Collaborative, Faculty of Health Sciences and
Medicine, Bond University
2
Emergency Department, Gold Coast University Hospital
3
NYC Health + Hospitals
Author for correspondence: Victoria Brazil, [email protected]

Abstract: Historically simulation was used as an education and training

technique in healthcare, but now has an emerging role in improving
quality and safety. Simulation-based techniques can be applied to help
understand healthcare settings and the practices and behaviours of
those who work in them. Simulation-based interventions can help to
improve care and outcomes – for example, by improving readiness of
teams to respond effectively to situations or to improve skill and speed.
Simulation can also help test planned interventions and infrastructural
changes, allowing possible vulnerabilities and risks to be identified and
addressed. Challenges include cost, resources, training, and evaluation,
and the lack of connection between the simulation and improvement
fields, both in practice and in scholarship. The business case for
simulation as an improvement technique remains to be established.
This Element concludes by offering a way forward for simulation in
practice and for future scholarly directions to improve the approach.
https://doi.org/10.1017/9781009338172 Published online by Cambridge University Press

This title is also available as Open Access on Cambridge Core.

Keywords: simulation, translational simulation, healthcare improvement,

health professions education, outcomes

© THIS Institute 2023

ISBNs: 9781009338165 (PB), 9781009338172 (OC)
ISSNs: 2754-2912 (online), 2754-2904 (print)
 Contents

1 Introduction 1

2 Healthcare Simulation as an Improvement Technique 1

3 Simulation in Action 10

4 Critiques of Simulation 18

5 Conclusions 24

6 Further Reading 25

Contributors 26

References 29
https://doi.org/10.1017/9781009338172 Published online by Cambridge University Press
 Simulation as an Improvement Technique 1

1 Introduction
Simulation has been employed as an educational technique in healthcare, but is
rapidly evolving as an approach for healthcare improvement. This Element reviews
its current and potential future use. We outline the origins of simulation as an
educational technique and characterise the increasing interest in, and use of,
simulation as a way of improving care. We show how simulation can be used to
explore working environments, and the practices and behaviours of those who work
in them, to improve clinical performance and outcomes, to test planned interven-
tions and infrastructural changes, and to help professionals learn about, and embed
a culture of, improvement. We discuss the challenges of using simulation as an
improvement technique, including the current lack of connection between the
simulation and healthcare improvement fields – both in practice and in scholarship.
We conclude by offering a way forward for simulation as an improvement tech-
nique in practice and for future scholarly directions to improve the method.

2 Healthcare Simulation as an Improvement Technique

This section provides an explanation of terminology, methods, and the scope of the
term ‘simulation’. We consider the history of simulation in healthcare – and its
traditional role as an education and training technique focused on patient safety.
Building on these traditions, simulation is now emerging as a method for examining
and improving systems. Few published real-world examples have been described or
evaluated in sufficient depth to be considered exemplars, so we offer in-depth,
hypothetical case vignettes to provide granular illustration of the method and the
diverse techniques employed under the umbrella term of simulation. We give an
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overview of efforts by the community of practice in healthcare simulation to

crystallise these approaches into a consistent method and to explore the relationship
with existing healthcare improvement methods, including addressing relationships,
reliability, and risk.

2.1 Definition and Description of Healthcare Simulation

Simulation as an imitation of a situation or process has a long history within
fields such as aviation and construction. Since the turn of the century, simulation
has been adopted in healthcare as ‘a technique that creates a situation or
environment to allow persons to experience a representation of a real event
for the purpose of practice, learning, evaluation, testing, or to gain understand-
ing of systems or human actions’.1
In his seminal work, The future vision of simulation in health care,2 Gaba
outlines 11 dimensions that highlight the various applications of simulation.
 2 Improving Quality and Safety in Healthcare

Positing that ‘simulation is a technique, not a technology’, Gaba underscores the

diversity of simulation techniques. Simulation can look like many different
things, in different places, with different people. In a medical school, for
example, students use simulation when they practise suturing on task trainers –
plastic models with fake skin. Within a hospital context, a simulation may be
conducted ‘in situ’ (within a real clinical space) with a manikin acting as the
patient. Equipped with technology to emulate a heartbeat, vital signs, realistic
lungs, and electronic haptic (touch) feedback, this could allow an interventional
cardiology team to catheterize the heart while the intensive care team resusci-
tates the patient. In a resuscitation bay, an emergency department team standing
around an empty stretcher could be engaging in a brief mental simulation
exercise to start their shift.
In short, there is no single recipe for a simulation programme or simulation
exercise. Box 1 describes a hypothetical case vignette of applying simulation
to a specific healthcare improvement goal – improving performance in emer-
gencies on a cardiac surgery ward. The vignette illustrates the complexity of
the clinical performance being explored and the variety of simulation tech-
niques that might be employed to achieve the improvement goal. In Table 1,
we then explore that example through the lens of Gaba’s 11 dimensions of
simulation.2

2.2 How Simulation Became Integrated into Approaches

to Improve Quality and Safety
The benefits of healthcare simulation for education and training in a variety of
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contexts are well described.4 Historically, simulation was assumed to improve

patient safety and care quality through the education of individual healthcare
professionals and teams.
Early use of simulation focused on practising procedural skills using part
task trainers – for example, using oranges to practise intramuscular injection,
plastic arms to practise intravenous cannulation, and plastic head and neck
simulators to practise airway management techniques. As technology has
improved, educational applications for procedural skills now extend to virtual
reality and software-based simulation of complex procedural tasks, such as
laparoscopic surgery.
Improving a wider range of clinical skills such as communication is also
a common use of simulation. Simulated patients are trained educators acting as
patients, recreating everyday and challenging conversations, such as history
taking, discussing bad news, or end-of-life conversations, and offering thoughtful
feedback to learners in real time.5
 Simulation as an Improvement Technique 3

BOX 1 IMPROVING PERFORMANCE IN EMERGENCIES ON A CARDIAC SURGERY WARD

A cardiac surgery ward wants to improve its ability to respond to a rare but
critical event: cardiac arrest in patients after cardiac surgery. This clinical
situation requires a functioning ad hoc team, clinical decision-making that
falls outside of usual cardiac arrest algorithms, and specific equipment.
Four simulation sessions are organised to take place over the course of
a year, with the aim of clinical teams practising together for this critical
event, and reflecting on the human factors that contribute to success or
failure. A scenario is designed by the simulation delivery team – a group
comprised of clinician experts and members with specific simulation
technical skills and group facilitation expertise. The scenario outlines
stages of the clinical encounter: initial patient deterioration 2 hours after
surgery, sudden loss of cardiac output, and recovery after appropriate team
interventions.
The simulation delivery team expects that the four sessions will offer
a chance for iterative improvement if clinical teams identify opportunities
for better teamwork or systems. In each session, staff who would be
involved in such a clinical situation are organised to attend the simulation,
which is conducted in a bed space in the cardiac surgical ward. Each
simulation includes 10 participants from the clinical teams who would
come together for this critical event (rapid response registrar and nurse,
ward nurses, anaesthetics registrar, intensive care unit registrar, cardiac
surgeon, intensive care unit administration clerk, and porterage staff).
Each session involves:
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(1) a short pre-briefing for the clinical team, outlining the aims of the
exercise and clarifying expectations
(2) the scenario, during which the clinical team is required to recognise
the patient deterioration and respond appropriately
(3) a debriefing discussion with the clinical team, facilitated by a member
of the simulation delivery team.

The debrief includes addressing any knowledge gaps (educational out-

comes) but is mostly focused on supporting the clinical team to identify
opportunities for better teamwork, equipment set ups, call systems, and
cognitive aids. After each session, the simulation delivery team creates
a report on the findings from the simulation and a debrief that is circulated
to participants and to departmental leadership.

• In the first simulation, participants identify that having two different

cardiac arrest trolleys on the ward leads to confusion.
 4 Improving Quality and Safety in Healthcare

• In the second simulation, the rapid response registrar voices unfamiliarity

with the alterations to the cardiac arrest algorithm for patients after cardiac
surgery. This provides the opportunity for the expertise of cardiac surgical
ward nurses to be uncovered and amplified in the debrief.
• In the third simulation, a newly designed single cardiac arrest trolley
(based on issues identified in the first simulation) is trialled.
• In the final simulation, the facilitator notices that the ward nurse gives
the rapid response registrar a cue card when they arrive bedside to
remind them of the differences in cardiac arrest management in this
particular clinical situation. This card was designed by the ward charge
nurse and a rapid response registrar after the second simulation.

Computer-based simulation of patient care scenarios, which require learners

to synthesise information and make decisions about investigations and treat-
ments, can improve decision-making and support cognitive aspects of health-
care delivery.6
And, in recognition of the critical role of teamwork in healthcare, simulations
can be focused on teamwork behaviours. These involve teams of healthcare
practitioners caring for a patient to support learning about both common and
rare presentations, while providing opportunities to practise role allocation,
leadership, and communication within the team.
If appropriately embedded within an educational framework,7 these examples of
simulation-based education can lead to faster and more effective learning without
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the attendant risks of subjecting patients to practitioners’ learning curves. Best

practice for educationally focused simulation includes integrating simulation into
curricula, capturing clinical variation, allowing repetitive practice, and incorporat-
ing useful feedback or time for reflection.8,9 An exponential growth in educational
simulation research since 1980 has also led to an increased emphasis on sound
educational principles – for example, maintaining psychological safety for partici-
pants and increasing emphasis on debriefing and reflective practice.
Box 2 describes a hypothetical case vignette illustrating the need for simula-
tion activities to be supported by educational frameworks (including assess-
ment) and cultural change to be successful.
Recent years have seen widespread adoption of simulation in healthcare
professions’ curricula for education, continuing professional development, and
team improvement.9 Here, simulation is seen as an educational adjunct, mani-
fested in a desire for standardised educational opportunities, the need to practise
skills before applying them in a clinical environment, and to supplement scarce
 Simulation as an Improvement Technique 5

Table 1 Applying Gaba’s 11 dimensions of simulation2 to the case vignette

in Box 1

Example (application of
Simulation 11 dimensions to the case
dimension Description vignette)
Aims and purposes Simulation can be used for To train ward and rapid
of the education and training, response teams and to
simulation activity assessment of reflect upon the human
performance, factors associated with
investigation into their response to
organisational cardiac arrest in
practices, investigation patients after
of human factors, and cardiac surgery.
institutional change.
Unit of participation Simulation can be Activity is at the
deployed at the organisational level
individual, team, work across several teams,
unit, or organisational including the ward,
level. intensive care unit,
anaesthesia, and
cardiac surgery teams.
Experience level All levels of training from Participants are practising
of participants undergraduates to healthcare
practising healthcare professionals.
professionals can
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use simulation.
Healthcare domain All health specialties, Cardiac surgery, intensive
including non-clinical care unit, anaesthetics,
areas, can apply risk management,
simulation. environmental services,
pastoral care.
Professional Simulation can be applied Interprofessional
discipline of to all disciplines within
participants healthcare and is often
interprofessional.
Type of knowledge, Conceptual Conceptual understanding
skills, attitudes, understanding, of how postoperative
or behaviours technical and decision- cardiac arrest differs
addressed making skills, or from regular cardiac
attitudes and arrest on the wards.
 6 Improving Quality and Safety in Healthcare

Table 1 (cont.)

Example (application of
Simulation 11 dimensions to the case
dimension Description vignette)

behaviours can be Explore decision to

addressed using reopen the chest in the
simulation. cardiac arrest.
Trust between team
members.
Communication between
rapidly constructed
team.
The simulated Simulation is applicable Patients include a 4-year-
patient’s age to every type and age of old with a congenital
patient. heart defect and a
65-year-old with
coronary artery
disease.
Technology Simulation can be Manikin-based simulation
applicable or accomplished through with cardiorespiratory
required low-technology monitoring and
methods, such as voice.
standardised patients Physical adjustment to
(actors), or high- the manikin to allow
technology options, for surgical reopening
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such as computer-based of the chest, and a

or full-body electronic fake, beating heart to
simulators. allow internal cardiac
compressions.
Site of simulation Simulation may take Cardiac surgery ward.
place at home/office
through screen-based
simulations, in
a replica clinical
environment such as
a simulation centre, or
within an actual
working unit.
 Simulation as an Improvement Technique 7

Table 1 (cont.)

Example (application of
Simulation 11 dimensions to the case
dimension Description vignette)

Extent of direct Simulations may be view- 10 participants are

participation only, involve remote- directly involved.
viewing with some
level of verbal or haptic
interaction, or
immersive in nature.
Method of feedback The opportunity to reflect Structured debriefing with
used on a simulated an experienced facilita-
experience greatly tor using an established
increases the impact of framework (PEARLS
the intervention. This for systems
can be accomplished integration)3 for a large
through automated group.
critique provided by Opportunity for additional
simulator and by one-to-one coaching
coaching/debriefing for participants who
during or after the identify personal learn-
event. ing gaps.
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clinical training sites. The educational focus mostly reflects a person-centred

approach to safety, in which the purpose of training is to decrease the number
of errors by individuals and teams.
Coinciding with the integration of simulation into education has been a growing
understanding of the contribution of behaviour and other non-technical skills to
team performance in complex health systems.10–13 Team-based, crew-resource
management training that includes simulation has been associated with improved
teamwork and confidence among a variety of healthcare teams.14,15 Such an
approach has undoubted value: training for teamwork, communication, and pro-
cedural skills is necessary for improved patient care. But there remains limited
understanding of how long these improvements persist and what impact they have
on clinical outcomes. Further, on their own, educational uses of simulation are
unlikely to be sufficient to address the need for more systems-based approaches that
are now recognised as fundamental to securing quality and safety.16
 8 Improving Quality and Safety in Healthcare

BOX 2 ATTEMPT TO IMPROVE OPERATING THEATRE EFFICIENCY THROUGH SIMULATION

A hospital wants to improve its operating theatre efficiency. One factor
affecting current performance is the time taken for trainees to perform
operations, including laparoscopic appendicectomies. Relatively junior
trainee surgeons are allowed to perform these procedures, taking on the
role of the primary operator, but they may be slow since they are going
through a learning curve.
A training programme is developed to improve the skills of trainees
through laparoscopic simulation, using both simple task trainers (which
trainees can even take home) and highly complex, virtual reality simu-
lators (Figure 1). Attendance at training is variable, due to competing
clinical demands on trainee surgeons’ time. Trainees who do attend
demonstrate rapid improvement in skills. The supervising consultants
are aware of the training, but they still consider the laparoscopic appendi-
cectomies on real patients as excellent opportunities for the trainees to
practise, and they allow the slow operations to continue. There is no
accepted credentialing process to become a primary operator at the insti-
tution. Nurses and technical specialist staff in the operating theatre are not
involved in any of the training exercises, and administrative staff are not
engaged to review the scheduling of operations. After 12 months, no
change is demonstrated in operating theatre efficiency.
Those with oversight of the training programme reflect that the lack of
robust assessment and credentialing process, and their inability to change
supervision practice and operating theatre culture, has meant that the
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simulation training has had minimal impact on operating theatre efficiency.

Figure 1 A simple task trainer (A) and a virtual reality simulator

(B) for laparoscopic simulation
© Victoria Brazil
 Simulation as an Improvement Technique 9

There is a growing understanding of the positive roles that simulation can

play, beyond education and training, in improving quality and safety in organ-
isations. Consistent with Gaba’s proposal that ‘using simulation to improve
safety will require full integration of its applications into the routine structures
and practices of health care’,2 there is evidence of increased use of simulation
for the express purpose of healthcare improvement, such as identifying latent
safety threats or improving processes. The term translational simulation was
coined in 2017 to describe those simulation activities ‘connected directly with
health service priorities and patient outcomes, through interventional, testing
and diagnostic functions’.17 A brief PubMed search shows that in the year 2000,
there were 21 publications related to ‘simulation and “patient safety”’; in 2021,
that same search yielded 741 results. Many institutions, teams, and researchers
are realising, honing, and advancing Gaba’s original vision.
These shifts are occurring alongside – and to some extent inspired by– the
evolution of paradigms for safety thinking. In 2013, a white paper by Hollnagel
et al.18 prompted a shift towards what the authors call a ‘Safety II’ perspective.
They argue that we should cease to focus exclusively on how to stop things
going wrong, and emphasise instead why things go right. A Safety I approach to
healthcare presumes that things go wrong because of identifiable failures of
specific components of a system, but such an approach does not address the
contribution of the system as a whole, including its culture and variability.10–13
By contrast, Safety II focuses on proactively fostering a system that allows as
many things as possible to go right, with an effort to continuously anticipate
issues and embrace humans as contributors to flexibility and resilience.10–13
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Simulation has emerged over the past decade as having potential to purposefully
uphold and complement a Safety II approach.19–22 This is recognised in the
Society for Simulation Healthcare’s accreditation of programmes that undertake
‘systems integration’ simulation:

A category of simulation program accreditation that recognizes programs

that demonstrate consistent, planned, collaborative, integrated, and iterative
application of simulation-based assessment, research, and teaching activities
with systems engineering and risk management principles to achieve excel-
lent bedside clinical care, enhanced patient safety, and improved outcome
metrics across the health care system(s).1

Many simulation researchers and practitioners embraced this change in the

safety paradigm, and began to reconceptualise the role of simulation as going
beyond an educational adjunct. Simulation techniques emerged that were sys-
tem focused23 and more integrated into improvement approaches.
 10 Improving Quality and Safety in Healthcare

3 Simulation in Action
This section considers the mechanisms by which simulation can be applied to
improving healthcare. As an emerging methodology, there is no consensus on
best practice. Expert guidance has been offered on theoretical and practical
approaches.24–29 Recent publications offer operational frameworks and prac-
tical toolkits for practitioners of translational simulation.23,30
We look at four areas in turn.

• Simulation can be used to explore working environments (or the practices and
behaviours of those in them) to identify latent safety threats or other oppor-
tunities for improvement.
• It may be employed as an intervention to improve healthcare through targeted
activities focused on clinical performance or outcomes (e.g. time-based
targets, resuscitation outcomes, teamwork, culture change, and healthcare
professional relationships).
• Simulation may be used as a technique for testing planned interventions and
changes to infrastructure (e.g. checklists, care pathways, electronic health
records, and commissioning new facilities).
• Simulation-based educational activities may support healthcare professionals’
learning about improvement principles and practice.

3.1 Exploring Working Environments and the Practices

and Behaviours of Those in Them
Simulation offers a broad range of opportunities and methods for examining current
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healthcare practice, including the various factors that shape performance at an

individual, team, technology, working environment, or system level.31,32
Simulation is an attractive option when study in an actual clinical setting
would be difficult due to practical constraints or ethical concerns – for example,
interrupting nurses during medication rounds to determine error rates.
Increasingly, simulated explorations are now frequently undertaken as part of
an initial or ongoing improvement strategy too. Diverse techniques can be
employed: for example, task trainers to study procedural skill performance
(e.g. a plastic arm that allows for intravenous cannula insertion); scenario-
based immersive simulations to study team performance; role play with simu-
lated patients to review communication; and computer modelling simulation to
examine patient flow through an emergency department.
Simulations conducted within the actual care setting (in situ simulation33)
may be particularly valuable in evaluating system performance and identifying
latent conditions that pose threats to patient safety. This more naturalistic
 Simulation as an Improvement Technique 11

approach enables participants to practise within the same physical environment,

healthcare team, and care processes that are used in real clinical practice. It
recognises that clinical practice happens under conditions of ‘considerable
complexity, change and surprise’,21 which are difficult to capture in dedicated
simulation laboratories.
In situ simulation programmes claim to ‘ . . . accomplish . . . the dual goals of
identifying and remedying [latent safety threats] as well as providing continuous
opportunities to deliberately practice technical and non-technical skills’.33 Parallel
exploration may also occur within team relationships, roles, and culture20,21,34 –
which are equally likely sources of latent safety threats to health service perform-
ance or safety. A typical approach might involve a hospital department simulating
scenarios that are representative of their patient profile and require a team-based
approach to care, located within an actual patient care space. Exercises are
generally accompanied by a debriefing session in which the professionals involved
reflect on their performance and the opportunities and constraints afforded by the
physical space and other resources available. Programmes have been conducted in
emergency departments, operating theatres, maternity units, general wards, pre-
hospital environments, and primary care contexts.
Importantly, simulations that explore working environments are also an
opportunity for learning from success,22 as they enable tacit expertise and
examples of positive deviance can be identified and elaborated35 (the positive
deviance approach is explored in another Element in this series36). In situ
exercises become an opportunity to ‘investigate and optimize human activity
based on the connected layers of any setting: the embodied competences of the
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healthcare professionals, the social and organizational rules that guide their
actions, and the material aspects of the setting’.22 As such, we see alignment
with trends in patient safety towards Safety II approaches – reinforcing the role
of efficient adaptation and organisational resilience in the face of errors and
obstacles arising.37
Box 3 outlines a hypothetical case vignette in which in situ simulation is used
to explore the working environment, latent safety threats, team function, and
positive deviance in caring for paediatric patients with anaphylaxis. It illustrates
some of the challenges in translating to change in practice.
When using simulation to explore working environments, the delivery
methods vary greatly. Scenarios may be conducted in actual patient care
areas or nearby to facilitate team attendance. Sessions may be unannounced
and unexpected, simulating real response processes, or they may be planned
and scheduled in advance.29 Each design decision is likely to require some
trade-offs between the feasibility of conducting simulation exercises in
a clinical environment and the veracity of the system-probing function.38
 12 Improving Quality and Safety in Healthcare

BOX 3 MANAGING PAEDIATRIC ANAPHYLAXIS IN AN EMERGENCY DEPARTMENT

A paediatric emergency department is interested in improving its manage-
ment of children presenting with life-threatening anaphylaxis. A series of
10 immersive, team-based simulation sessions are delivered to staff who
work in the department, conducted in the departmental resuscitation bay.
Due to rosters and staffing, each simulation session involves a different
mix of team members, and many staff in the department don’t get to
participate in any of the sessions. In each simulation, the clinical team is
notified of a 5-year-old child en route with a life-threatening allergic
reaction. The child (represented by a manikin) arrives in the resuscitation
bay 5 minutes later, requiring rapid assessment and treatment with intra-
muscular adrenaline.
Observation of the clinical team’s performance by the simulation
delivery team and subsequent debriefing conversations reveal a series of
issues: difficulty accessing adrenaline in the appropriate concentration due
to the location of the drug cupboard, knowledge gaps within the clinical
team about dosage and route of administration, and inadequate pre-
briefing before the patient arrives via ambulance. However, the simulation
also identifies some better practices by some clinical teams during the
scenario: the use of appropriate cognitive aids located on the computer in
the room, and earlier calls for help to senior staff.
The simulation delivery team records the issues and prepares a report
for departmental leadership with suggestions for changes in practice
relating to equipment, environment, and teamwork. After 6 months,
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some of these suggestions have been actioned, but staff turnover and
waning enthusiasm have stalled other improvements.

At present, however, there are no design standards nor even a consensus on

terminology.29 Frequently identified practical challenges include those relat-
ing to equipment, medication, use of physical space, and call systems.
Using in situ simulation to explore working environments is a potentially
attractive approach in healthcare improvement, but is immature in its methods,
consistency, and integration with other improvement strategies. Auerbach et al.
report, for example, that most paediatric simulation programmes they surveyed
used in situ simulation, but also found inadequacies in how latent safety threats
were identified, reported, and acted on.24 A systematic review of studies
reporting in situ simulation activities found that ‘approaches to design, delivery,
 Simulation as an Improvement Technique 13

and evaluation of the simulations were highly variable across studies’, and that
performance measurement practices were suboptimal.39
Colman et al. have developed a more standardised approach to simulation-
based testing of clinical systems,40 providing documentation and evaluation
tools to help in identifying inefficiencies and risks to safety. But as yet there is
no consensus on the best approach. There is also conflicting evidence about
whether improvements to working environments are sustained, with some
arguing that it is most likely to be effective if seen as a long-term commitment
requiring regular participation that is intrinsic to an ongoing patient safety
strategy.27

3.2 Improving Clinical Performance and Outcomes

Simulation can be applied to a broad range of healthcare targets: anything from
a single patient journey at one institution to improvement of system outcomes.
The clearest examples include simulation projects designed to improve time-
based targets or other easily measurable indicators related to individual patient
journeys, such as time to thrombolysis in stroke care,41 time for trauma patients
to go to CT scan,42 resuscitation outcomes,43 teamwork in trauma,44 or success
rates in paediatric intubation.45 Simulations designed for such a purpose may
include dedicated educational programmes to improve individual and team
performance – for example, deploying part-task training for procedural skills
and immersive simulations for team-based tasks, combined with appropriate
didactic or other training methods. The hypothetical case vignette in Box 4 is
a typical example.
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In a review of the clinical outcomes of simulation-based ‘mastery learning’

(learning that helps students to master or reach a high level of achievement),
Griswold-Theodorson et al. identified studies reporting improvements follow-
ing training interventions, including better performance level, better procedural
success rate, reduced patient discomfort, shorter procedure times, reduced error
rate, and lower healthcare costs.46 Reviews of in situ simulation practice have
also demonstrated improved patient morbidity and mortality.47 In situ simulation
is likely to be especially important given that outcomes are dependent on how
individuals and teams perform within the constraints and opportunities of hospital
systems and complex departmental interfaces.
Reported examples of successful improvement programmes often relate to
interventions conducted in a single institution, but simulation has the potential to
impact healthcare beyond these examples. Simulation may be used to improve
healthcare management and policy-making at a state or national level,48 where
the impact is more distributed. Nataraja et al. report a significant national
 14 Improving Quality and Safety in Healthcare

BOX 4 IMPROVING TIME TO TREATMENT FOR MYOCARDIAL INFARCTION

A multidisciplinary group of health professionals in a regional centre want
to improve their ‘call-to-balloon’ time, which describes the time from
receiving a call about a person who is experiencing a myocardial infarc-
tion requiring urgent coronary angioplasty and stenting to the person
receiving the procedure. Following an audit showing that their local
performance was below national benchmarks, a group of pre-hospital
providers (e.g. ambulance crews), emergency department staff, and car-
diac catheterisation laboratory (cath lab) teams work with simulation
experts to design a simulation programme to improve.
Weekly simulations are conducted for 2 months, each involving
a simulated call to the ambulance communication centre, prioritisation,
dispatch of ambulance crew, and provision of initial treatments. An actor
is employed to be the patient with a heart attack. The patient is transported
to the emergency department and then transferred to the cath lab. All
members of the clinical team are aware that their target time is 60 minutes.
The staff members participating in the simulations are drawn from those
rostered to work on those days, so each session involves a different team.
Over a period of 2 months, the call-to-balloon times reduce. Teams
find better ways to communicate and to process tasks in parallel, such as
preparing the emergency department and cath lab after initial pre-hospital
reading of the electrocardiogram. Emergency department staff become
more familiar with the cath lab environment and can help the clinical team
to set up faster before the procedure.
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In an evaluation, healthcare staff report that they are more confident,

have enjoyed the simulations, and have changed their practice as a result.
While this process has improved call-to-balloon median time for real
patients by 20% in the 6 months following the simulations, mortality
and length of stay at 12 months is unchanged, indicating that there is
further work to do. The lack of improvement in patient-centred outcomes
may suggest other factors (e.g. catheterization lab procedures, provision
of evidence-based critical care, and rehab practices) may be important
next targets for improvement.

improvement in the management of paediatric intussusception (an acute bowel

emergency) in Myanmar following the introduction of a focused, simulation-
based intervention.49 Preparing a disaster plan or evaluating strategies to minim-
ise infections during a pandemic such as COVID-19 might involve computer
 Simulation as an Improvement Technique 15

modelling techniques, combined with live simulations to test protocols for safe
patient care,25 and training simulations to determine if personal protective equip-
ment is adequate.50
Relationships and culture within and between healthcare teams are less fre-
quent targets for simulation-based interventions, despite the recognised role they
both play in health system performance. In one study of a relationship-based
approach to improve trauma care at an institution, Purdy et al.34 illustrate the
considerable impact of regular interprofessional, multidisciplinary, in situ simu-
lation on the relational aspects of care and the development of a collaborative
culture.20 Another study of a programme involving regular emergency depart-
ment simulation showed that simulation is a place to foster familiarity and
psychological safety, which can have a direct impact on clinicians’ work in real
clinical settings.51 For further discussion of some of the issues relating to culture
in healthcare, see the Element on making culture change happen.52
Overall, the simulation techniques used for targeting system improvements are
variable – combinations of in situ simulation, educationally focused simulation in
dedicated facilities, procedural skills practice, and scenario-based team training.
The design requires clarity on the hopefully meaningful target(s) and appreciation
of the relative benefits of various simulation methods to achieve improvement,
while being feasible and cost-effective to implement.17,28 Simulation itself is
agnostic towards healthcare improvement frameworks and is frequently one part
of a more comprehensive improvement strategy,45 which is pragmatic and appro-
priate, but which makes it difficult to ascertain the specific impact of the simula-
tion elements on the overall effectiveness of the approach.26 Liberati et al.
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highlight this interrelationship by outlining how a host of quality and safety

mechanisms within a maternity unit were ‘nurtured and sustained’ through the
simulation-based Practical Obstetric Multi-Professional Training (PROMPT)
programme.53 The PROMPT course is focused on multi-professional teams
learning how to manage obstetric emergencies, working on their own labour
ward, using their own emergency equipment, local procedures, and systems.54

3.3 Testing Planned Interventions and Infrastructural Changes

Simulation can enable evaluation of the feasibility, safety, acceptability, or
effectiveness of planned interventions, new healthcare facilities, and changes to
infrastructure. This provides opportunities to develop and test ergonomics and
workflows, and to identity human factors flaws and latent safety threats before
going live or being introduced into the real clinical environment.31,40,55–57
Effectively designed simulations can also be used to test new processes. For
example, they have been used to test cognitive aids for emergencies,58 guidelines
 16 Improving Quality and Safety in Healthcare

for massive transfusion and other care pathways, and the introduction of new
equipment or bundles, such as boxes for the management of postpartum
haemorrhage.59 Strategies can encompass a range of techniques and targets,
with success dependent on the authenticity of the simulation and the adequacy
of data collection.55 Simulation can be used as one part of a mixed-methods
design, where data collected through simulation can be triangulated with other
sources of information and intelligence.31
Testing may include tabletop mock-ups, full-scale recreations of facilities,
and individuals or teams working within test environments to varying degrees
of realism. This requires more than a single event – it requires a strategy for
testing and data collection. Petrosoniak et al.57 propose a ‘design thinking’
approach, with multimodal simulation techniques and an emphasis on end user
engagement, to iteratively test and improve planned changes to a trauma resus-
citation bay in an emergency department. Although frameworks have been
described in the literature,40 there are no endorsed standards and no accepted
consensus approach for using simulation to test new healthcare facilities.
However, some important examples are appearing. Prior to the opening of
a newly constructed paediatric outpatient clinic, Colman et al.60 conducted 31
simulated scenarios over 3 months to identify system flaws (latent safety
threats) that posed a potential risk to patients. Failure mode and effects analysis
was used to prioritise threats. In all, the authors identified 334 latent safety
threats, including 36 ‘very high priority’ threats. High-priority examples
included emergency preparedness and the emergency notification system, the
proximity of antibacterial hand sanitiser to clinic rooms, the location of the
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sharps disposal container, infection control regarding the movement of cystic

fibrosis patients throughout the building, the accessibility of resuscitation bags,
and the impact of the building’s climate on testing reagents.60 In a subsequent
paper, Colman et al. offer guidelines for simulation-based testing of clinical
systems to develop, implement, and evaluate newly built clinical environ-
ments using principles and tools derived from the Agency for Healthcare
Research and Quality.40
An iterative approach to testing and embedding was evident in the response to
the COVID-19 pandemic, when many healthcare workflows and practices had to
be rapidly adjusted to minimise infection risks.25,61 Simulation strategies were
used to explore the risks of COVID-19 transmission within current practices, and
to assess changes designed to reduce risks at the individual, team, and system
level. Some initially promising interventions, such as Perspex boxes to protect
airway teams from exposure to COVID-19 during intubation, turned out not to be
effective or feasible when tested in simulated practice.50
 Simulation as an Improvement Technique 17

Box 5 describes a hypothetical case vignette in which a design thinking

approach is used to rapidly design a fever clinic for COVID-19 testing, drawing
on anecdotal experience of colleagues during the COVID-19 pandemic.
Simulation can be used proactively to test and refine planned changes in
specific contexts, but the generalisability of the findings is not always straight-
forward. For example, the findings of simulations of the effectiveness of
specific cognitive aids in helping to select paediatric anaesthesia equipment in
one hospital may, if the human factors principles are the same, be useful across
multiple contexts. But the success of modifications to a massive transfusion
protocol developed through simulation may depend on the interrelationships of
that care pathway with local hospital systems, teams, and capabilities, and
hence require development and testing at a local level.

3.4 Helping Healthcare Professionals to Learn about and Embed

a Culture of Improvement
Learning about the theory and practice of healthcare improvement is now
a requirement in many undergraduate and postgraduate training programmes in
medicine and other health professions.62 Simulation techniques can support
experiential methods of education on reporting and investigating patient safety
incidents, process mapping, plan-do-study-act cycles, intervention design, and
culture change.63 Simulation-based activities can invite practitioners to reflect on
their practice through a quality and safety lens and the actions and behaviours that
might be needed to improve it. In one study involving a collaborative ethnography
of a trauma service, on-the-ground care providers with no formal role in health-
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care improvement reflected that a programme of regular in situ simulation

allowed them to feel engaged in ‘process review and improvement’ and
empowered teams to form a habit of ‘team reflection’.20 Other examples involve
inviting professionals to explore problems such as emergency room crowding or
hospital-acquired infections using tabletop or computer simulations. In these
exercises, professionals are asked to develop and undertake healthcare improve-
ment efforts that have consequences as the simulation unfolds. After the simula-
tion exercise, they take part in facilitated reflection on the impacts of their
improvement efforts in the example and to draw out wider learning. Another
useful technique is debriefing to marginal gains – that is, exploring what went
well and what could go just 1% better at an individual, team, or systems level.
This is a simple way to inspire an improvement mindset in individuals and teams
and further support the cultural foundation of a Safety II approach. The hypothet-
ical case vignette described in Box 6 illustrates how a mindset can be engendered
in simulation and then translated to learn from real patient care.
 18 Improving Quality and Safety in Healthcare

BOX 5 RAPID DESIGN OF A FEVER CLINIC

At the onset of the COVID-19 pandemic, representatives of a hospital,
a public health unit, and paramedics in a Canadian city collaborated to
design and implement a fever clinic, where community members could
attend for COVID-19 testing if they developed concerning symptoms. To
meet the rapidly escalating demand for COVID-19 testing, conception to
rollout took just 3 days. There were many practical considerations and
environmental barriers to ensuring efficient flow and safety of patients in
an unconventional space.
The stakeholder team used multiple simulation methods to support
a design thinking approach to create the clinic. First, a large venue – an
ice hockey arena – was identified as the city location most accessible to
the general public. The team brainstormed potential options for flow
through the space using a tabletop and to-scale mock-up, taking into
account the need to facilitate a one-way flow while maintaining social
distancing and minimising contact between providers and patients. This
exercise enabled the team to identify three possibilities for the most ideal
use of the space.
The next day, the team went to the site to test the three different plans
using 20 actors to simulate patients. Stakeholders from each of the groups
involved in providing care were present and took part in the exercise.
Collectively, they identified that the second option – entrance and exits at
opposite ends of the arena, and a two-stage approach to assessment and
swabbing – was most efficient and safe. Simulated patients and staff were
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able to provide further information about what would make the experience
better. These considerations were taken into account when the final infra-
structure was put in place for opening the next day. During the clinic’s first
week, members of the team were on site; they interviewed patients and
staff and facilitated debriefs at the end of each day. The process and space
were adapted in real time in response to user experience.

When simulation is used to explore and enhance healthcare performance

in this way, it has the added benefit of signalling improvement as a priority
and may also contribute to changing the safety culture of the system.33

4 Critiques of Simulation
This section offers critiques of published literature and examples through an
effectiveness, efficiency, and return-on-investment lens. We explain some
 Simulation as an Improvement Technique 19

BOX 6 DEBRIEFING TO MARGINAL GAINS

For years, a hospital emergency department has run a weekly simulation
programme for registrars (emergency medicine trainees) and nurses with
typical resuscitation cases. The simulation facilitators decide to debrief to
marginal gains for a period of 6 months after hearing about the theory at
a conference. This involves asking the groups to collectively reflect on what
could have gone 1% better during the simulated case as part of the regular
weekly debrief. They do not plan to measure any specific outcomes.
One evening, a patient with an ST elevation myocardial infarction
(STEMI) arrives in the department during a very busy shift. There is
a delay in getting the patient to the catheterisation lab. At the end of the
shift, the attending physician overhears a casual conversation between one of
the emergency nurses and a registrar. The nurse has initiated a conversation
with the registrar by saying: ‘That was a hard night, what do you think we
could have done 1% better for that patient with the STEMI?’ Both the nurse
and the registrar were able to identify small, individual improvements within
their control that could have facilitated more streamlined and timely care.
This reflection has become a habit engendered by the simulation.

practical considerations for and barriers to the delivery of simulation as an

improvement technique, including cost, faculty development (for simulation
delivery teams), technical issues, safety risks, and ethical considerations. We
consider the connection between simulation and healthcare improvement – as
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fields of practice and scholarship, governance relationships within institutions,

and a comparison of tools, terminology, and frameworks. We discuss how
simulation may influence other organisational learning approaches, such as
clinical event debriefing programmes.

4.1 Is Simulation an Effective Technique for Improvement?

The challenges of evaluating simulation as an educational technique have been
extensively discussed,64 and similar challenges surface when considering
evaluation of simulation-based interventions for healthcare improvement.
Given the variety of techniques encompassed by the term simulation and the
diverse contexts in which the method may be applied, no single study is likely to
provide the answer to what works and why in simulation, notwithstanding some
interesting examples.26,41,45
Potential unintended negative consequences of simulation in the setting of
healthcare improvement remain underreported and underexplored. Simulation
 20 Improving Quality and Safety in Healthcare

can be intuitively appealing as a safe approach to improvement – practising

skills and teamwork seem likely to improve performance, and practising on
plastic manikins or with actors who simulate patients seems inherently safer
than with real patients. But there are also well-described safety risks of con-
ducting simulation activities.65,66 Ironically, for example, in situ simulation
exercises can themselves pose a potential threat to safe and efficient service
delivery to real patients in clinical areas: by deploying staff from clinical care
into a simulation, by preventing a real patient from using a physical space, and
by mixing simulated and real equipment and medications.65 Simulation pro-
grammes have adopted systems and processes to mitigate these risks, includ-
ing the development of formal no-go criteria for cancelling in situ simulation
exercises,66 and guidance on developing simulation safety policies.67 If simu-
lation sessions are poorly facilitated, there are also potential threats to the
psychological safety of teams, which could have downstream effects on
patient safety.
Simulation will always be an imperfect recreation of the complex healthcare
environment, and there are risks of embedding bad habits (e.g. medical students
not wearing gloves in simulation) or even perpetuating culturally embedded
bias or prejudices (e.g. using predominantly white-skinned and male
manikins).68 Growing interest in equity, diversity, and inclusion within health-
care has prompted important reflection among simulation facilitators,69 and
there is increasing interest in simulation as a technique for addressing equity,
diversity, and inclusion issues.70
One challenge for evaluation is that simulation is often used as one part of
a more comprehensive improvement strategy.45 While often pragmatic and
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appropriate, it can complicate efforts to evaluate the specific contribution of

the simulation elements to the outcomes.26 As such, it can be difficult to
determine the interrelationships between findings from exploratory simulation
informing other improvement strategies, versus simulation design being
informed by data collected as part of the broader improvement effort.17 Even
though academic reports commonly separate or seek to separate the two cleanly,
the reality is that simulation may have roles in both informing and being
informed by other healthcare improvement efforts that cannot easily be
distinguished.53,54

4.2 How Should We Integrate Simulation into Healthcare

Improvement?
The integration of simulation into the healthcare improvement strategies of
organisations offers considerable potential but is often not fully realised.
 Simulation as an Improvement Technique 21

Aligning simulation with contemporary approaches to healthcare improvement is

important, and should prevent conflicting or competing agendas, philosophies, or
claims on resources. For example, testing whether planned interventions are
feasible, acceptable, or effective in simulated environments and teams aligns
well with the Safety II approach to focusing on ‘work as done’ rather than ‘work
as imagined’.18 Barlow et al.55 use language and tools drawn from healthcare
improvement when outlining a framework for documenting and reporting latent
system threats unearthed during simulation scenarios. Drawing on human factors
and plan-do-study-act constructs, the framework supports the capture and report-
ing of findings on system deficits to key decision-makers. Connecting simulation-
based approaches to other improvement initiatives within an organisation can
help in the same way. For example, simulation experts with skills in managing
reflective conversations might take a lead in developing clinical event debriefing
programmes for healthcare teams, which can be used to discuss opportunities for
improvement after real patient care encounters.
However, barriers in integrating simulation-based strategies in overarching
healthcare improvement approaches are posed by different traditions of schol-
arship and practice.26 This may be manifest in disconnected terminology and
in organisational structures and professional groups. With some notable
exceptions,71 healthcare management journals tend not to cover simulation-
based healthcare improvement. Within organisations, simulation programmes
may be situated in educational structures and staffed by educational experts,
while healthcare improvement teams may use tools and language unfamiliar to
simulation delivery teams or clinicians. Where a simulation programme sits
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within a healthcare organisation, it will tend to drive both the organisation’s

focus and sphere of influence.72 Simulation programmes that have weaker
links to the quality and operational structures within their organisation are less
likely to help inform the organisation’s strategic direction.
The consumer voice has not been well established in design or delivery of
simulation activities, either for education or for improving quality and safety.
Drawing on established frameworks for healthcare consumer engagement,73
there clearly is a role for consumers in simulation design, delivery, and strategy
development,74 but it so far appears to be a missed opportunity.
While the field continues to develop, the questions posed in Box 7 may be
helpful. Also important is recognition that skills in running simulations –
including design and execution of scenarios, skills in managing debriefing or
reflective practice conversations, and systems-focused debriefing3 – are highly
specialised and require specific training. Although simulation techniques are
varied and evidence of the relative benefits of various simulation methods to
achieve improvement is still emerging, we do know that it is essential for the
 22 Improving Quality and Safety in Healthcare

BOX 7 QUESTIONS TO HELP ENSURE GOOD PRACTICE WHEN USING SIMULATION

AS A HEALTHCARE IMPROVEMENT TECHNIQUE

• Is simulation the right method to address this issue?

• What are the explicit and specific objectives of the simulation?
• Are we effectively matching objectives to our simulation technique(s)?
• Who should be involved in the design, delivery, and debriefing
processes?
• How are we going to measure and understand impact?
• What are the potential unintended consequences?
• How does simulation fit into the larger healthcare improvement plan?

goals to be clearly defined and the design to be feasible and cost-effective to

implement.17,28

4.3 Can We Build a Business Case for Simulation?

While there is increasing awareness of simulation as a quality and safety
technique, building a business case for simulation at scale remains challen-
ging. Simulation activity is often resource-intensive, and, for all its potential
to improve quality, there are significant downsides to simulation. Activities
can be expensive – for example, in relation to equipment, staff time, and use
of clinical areas for simulation. There is also limited information about what
dose and frequency of simulation is effective. Recruiting and training simu-
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lation facilitators to the required level of expertise in both simulation tech-

niques and the skills needed for clinical redesign and healthcare
improvement is difficult.
Evidence of return on investment may therefore be much in demand, but
little published data are yet available.75 The lack of evidence arises partly
because of the emerging nature of the field and because some important
impacts of simulation and debriefing are in areas such as team trust
and psychological safety, which are difficult to place on a balance sheet.
Lin et al.76 offer steps to gather the necessary information to conduct
an economic evaluation of simulation-based education programmes and
curricula, and describe the main approaches to conducting an economic
evaluation.
A useful framework is offered by Shah and Course to ‘help identify, under-
stand, and evaluate return on investment from large-scale application of [quality
improvement]’.77 It describes six domains:
 Simulation as an Improvement Technique 23

• patient, carer, and family experience outcomes

• staff experience
• productivity and efficiency
• cost avoidance
• cost reduction
• revenue.

Although the framework has limitations, including the absence of links to

patient outcomes and provider effectiveness, it encourages a focus on domains
that the clinicians undertaking improvement-focused simulation work may not
instinctively think about. We encourage those involved in healthcare improve-
ment simulations to begin framing design and measurement of impact around
these domains to support a business case for simulation in their organisation.
In Box 8 we apply the Shah and Course framework to two of our prior
hypothetical examples.

77
BOX 8 APPLYING THE SHAH AND COURSE FRAMEWORK TO HYPOTHETICAL EXAMPLES

Team Training Related to Cardiac Arrest in Patients after Cardiac

Surgery (Box 1)

Return on investment could be considered through the primary domains of

patient, carer, and family experience outcomes and through staff experi-
ence. The simulation programmes should be co-designed by simulation
providers and the target units to ensure that the intervention is relevant to
their goals as a group. This will maximise staff engagement and ensure
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that it meets their objectives. Collaborative design and facilitation may

demonstrate organisational support and commitment to employees and
enhance provider experience. Measuring the impact of the simulation
activity could include simple patient metrics (e.g. rate of return of spon-
taneous circulation and survival after cardiac arrest, time to delivery of
epinephrine in anaphylaxis), but also in numerous ways that the staff
experience could be measured. The researchers should collaborate with
social scientists to apply frameworks such as relational coordination
theory,78 which allows for the quantification of the quality of working
relationships between groups, or to conduct interviews and focus groups
that explore the relationship between simulation and the psychological
safety of the team. The impact of in situ simulation activities on patients
and families on the wards where these programmes are run would be
a further avenue to demonstrate impact.79
 24 Improving Quality and Safety in Healthcare

Task Trainers to Improve Operating Theatre Efficiency (Box 2)

Return on investment could be considered though the domains of prod-

uctivity and efficiency, cost reduction, and revenue. This intervention
was specifically designed to improve operating room efficiency, but
there was no measurable improvement at an organisational level.
Anecdotally, engaged residents seemed to perform more efficiently.
This negative study provides valuable insight. Not surprisingly, without
appropriate, thoughtful, supportive infrastructure (i.e. curriculum and
credentialing) the cost of providing LapSim trainers to residents does not
outweigh the benefit for the hospital. The next step would be to under-
stand whether more defined, milestone-based curriculum for residents
and a credentialing process can translate into organisationally relevant
outcomes. In measuring the impact of the simulation activity, those
tasked should go beyond operating theatre metrics (e.g. time on the
table, cases per day) and collaborate with healthcare finance experts to
evaluate the impact on cost reduction (per case) and revenue generated
through increased turnover.

The application of return-on-investment frameworks to simulation activity is

unfamiliar territory for many of those who plan and facilitate simulation. This
highlights why early collaboration between simulation facilitators, those with
improvement expertise, and those with skills in economic evaluation should be
the standard for simulation programmes seeking to demonstrate return on
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investment.

5 Conclusions
Simulation offers considerable potential as a technique for improving quality
and safety in healthcare. Achieving its full potential will require building on the
success of simulation as an educational strategy, and shifting from description
of project exemplars towards building consensus on theory and principles to
guide practice. It will also require engaging with questions on when and how
simulation is the right method to address a particular issue, which design factors
might influence success, how effectiveness should be measured, and how to
mitigate potential unintended consequences.
Future research should see direct and purposeful collaboration between those
with expertise in healthcare improvement and those with expertise in simulation
in a deliberate effort to understand, explore, and capitalise on the different
theoretical foundations of these fields. Healthcare organisations should make
 Simulation as an Improvement Technique 25

the intersection of these agendas and skills a priority in organisational struc-

tures. The potential impacts are more likely to be achieved if simulation-based
approaches can demonstrate a multifaceted return on investment and are aligned
with other improvement initiatives at institutional and national levels.

6 Further Reading

• Brazil et al.26 – an overview of the connection between healthcare simulation

and healthcare improvement, as fields of practice and scholarship.
• Maxworthy et al.80 – a comprehensive overview of the field of healthcare
simulation practice.
• Brazil17 – defines translational simulation, and describes a conceptual
reframing of how simulation can contribute to healthcare improvement.
• Nickson et al.30 – an operational framework and practical toolkit for simula-
tion applied to improving quality in healthcare.
• Key professional organisations in the field of healthcare simulation practice:

○ Society for Simulation in Healthcare: www.ssih.org

○ Society for Simulation in Europe: www.sesam-web.org.
https://doi.org/10.1017/9781009338172 Published online by Cambridge University Press
 Contributors

All authors contributed to the design, structure, and writing of each section of
the Element, and have approved the final version.

Conflicts of Interest
Victoria Brazil is Medical Director of the Gold Coast Health Simulation Service,
Director of the Bond Translational Simulation Collaborative, co-producer of
Simulcast, and Senior Editor at Advances in Simulation. Eve Purdy is an emer-
gency physician at Gold Coast University Hospital, and a Research Fellow within
the Bond Translational Simulation Collaborative. Komal Bajaj is Chief Quality
Officer for NYC Health + Hospitals/Jacobi, Clinical Director for the NYC Health +
Hospitals Simulation Center, Professor of Obstetrics & Gynecology at Albert
Einstein College of Medicine, on the Editorial Board of Simulation in Healthcare,
and a member of the Board of Trustees for the Center for Medical Simulation.

Acknowledgements
We thank the peer reviewers for their insightful comments and recommenda-
tions to improve the Element. A list of peer reviewers is published at
www.cambridge.org/IQ-peer-reviewers.

Funding
https://doi.org/10.1017/9781009338172 Published online by Cambridge University Press

This Element was funded by THIS Institute (The Healthcare Improvement

Studies Institute, www.thisinstitute.cam.ac.uk). THIS Institute is strengthening
the evidence base for improving the quality and safety of healthcare. THIS
Institute is supported by a grant to the University of Cambridge from the
Health Foundation – an independent charity committed to bringing about better
health and healthcare for people in the UK.

About the Authors

Victoria Brazil is Professor of Emergency Medicine and Director of the
Translational Simulation Collaborative at Bond University, and a senior staff
specialist in emergency medicine at Gold Coast University Hospital. Her main
interests are connecting education with patient care – through healthcare simu-
lation, team development, and podcasting.
 Contributors 27

Eve Purdy is an applied anthropologist and Emergency Medicine Consultant at

Gold Coast University Hospital. She is interested in understanding how rela-
tionships impact teamwork and the role of simulation in team performance.

Komal Bajaj is Chief Quality Officer at NYC Health + Hospitals/Jacobi/NCB,

Clinical Director of NYC Health + Hospitals Simulation Center, and Professor
of Obstetrics and Gynecology at Albert Einstein College of Medicine. Her
research interests include ingraining equity into healthcare quality, building
agency, and simulation as an improvement tool.
https://doi.org/10.1017/9781009338172 Published online by Cambridge University Press
 Creative Commons Licence

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edition (August 24, 2022): Lippincott Williams & Wilkins; 2022.
https://doi.org/10.1017/9781009338172 Published online by Cambridge University Press
 Improving Quality and Safety in Healthcare

Editors-in-Chief
Mary Dixon-Woods
THIS Institute (The Healthcare Improvement Studies Institute)
Mary is Director of THIS Institute and is the Health Foundation Professor of Healthcare
Improvement Studies in the Department of Public Health and Primary Care at the University
of Cambridge. Mary leads a programme of research focused on healthcare improvement,
healthcare ethics, and methodological innovation in studying healthcare.

Graham Martin
THIS Institute (The Healthcare Improvement Studies Institute)
Graham is Director of Research at THIS Institute, leading applied research programmes and
contributing to the institute’s strategy and development. His research interests are in the
organisation and delivery of healthcare, and particularly the role of professionals,
managers, and patients and the public in efforts at organisational change.

Executive Editor
Katrina Brown
THIS Institute (The Healthcare Improvement Studies Institute)
Katrina is Communications Manager at THIS Institute, providing editorial expertise to
maximise the impact of THIS Institute’s research findings. She managed the project to
produce the series.

Editorial Team
Sonja Marjanovic
RAND Europe
Sonja is Director of RAND Europe’s healthcare innovation, industry, and policy research. Her
https://doi.org/10.1017/9781009338172 Published online by Cambridge University Press

work provides decision-makers with evidence and insights to support innovation and
improvement in healthcare systems, and to support the translation of innovation into
societal benefits for healthcare services and population health.

Tom Ling
RAND Europe
Tom is Head of Evaluation at RAND Europe and President of the European Evaluation
Society, leading evaluations and applied research focused on the key challenges facing
health services. His current health portfolio includes evaluations of the innovation
landscape, quality improvement, communities of practice, patient flow, and
service transformation.

Ellen Perry
THIS Institute (The Healthcare Improvement Studies Institute)
Ellen supported the production of the series during 2020–21.

About the Series

The past decade has seen enormous growth in both activity and research on improvement
in healthcare. This series offers a comprehensive and authoritative set of overviews of the
different improvement approaches available, exploring the thinking behind them,
examining evidence for each approach, and identifying areas of debate.
 Improving Quality and Safety in Healthcare

Elements in the Series

Collaboration-Based Approaches
Graham Martin and Mary Dixon-Woods
Co-Producing and Co-Designing
Glenn Robert, Louise Locock, Oli Williams, Jocelyn Cornwell, Sara Donetto, and
Joanna Goodrich
The Positive Deviance Approach
Ruth Baxter and Rebecca Lawton
Implementation Science
Paul Wilson and Roman Kislov
Making Culture Change Happen
Russell Mannion
Operational Research Approaches
Martin Utley, Sonya Crowe, and Christina Pagel
Reducing Overuse
Caroline Cupit, Carolyn Tarrant, and Natalie Armstrong
Simulation as an Improvement Technique
Victoria Brazil, Eve Purdy, and Komal Bajaj
Workplace Conditions
Jill Maben, Jane Ball, and Amy C. Edmondson

A full series listing is available at: www.cambridge.org/IQ

https://doi.org/10.1017/9781009338172 Published online by Cambridge University Press