©2011 MFMER | slide-1
Medical Simulation 2.0 Improving value-based healthcare delivery
Yue Dong, M.D.Mayo Clinic Multidisciplinary Simulation Center METRIC (Multidisciplinary Epidemiology and Translational Research in Intensive Care)Mayo Clinic Center for Science of Healthcare Delivery
Disclosures
• No financial COI
©2011 MFMER | slide-3
Mayo Clinic Multidisciplinary Simulation Center
Fellows
AnesthesiologistMedical
Pulmonologist
Intensivist
Simulation Medicine
Statistician
Administration
Informatics
ER medicine
Research Coordinator
Collaborators
PediatricianMETRIC (Multidisciplinary Epidemiology and Translational Research in Intensive Care)
Multidisciplinary Collaboration
Dr. Hutian Lu
Dr. Susan Lu, Sura K Ak Qudah
Dr. Ashish Gupta
Dr. Mark Van Oyen, Pooyan Kazemian
Bjorn, Berg
Objectives
• Challenges facing healthcare professionals to improve the healthcare delivery: Systems Thinking and Patient Safety
• Summarize simulation and modeling tools for systematic analysis and optimization complex system processes and interventions
• Describe common computer simulation applications for quality improvement and patient safety in ICU.
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© 2010 Mayo Foundation for Medical Education and Research
Vis-à-vis International Sepsis Campaign
Institution Compliance, % Mortality, %
Spain•Pre-intervention 5.3 44
•Post-intervention
10.0 39.7
International•Pre-intervention 10.9 37•Post-intervention
41.3 30
Mayo
•Baseline 10.5 31.5•Sepsis QI 58.4 22.0
Time, June 22, 2010
Health System Safety
• 33.6 million admissions to U.S. hospitals in 1997
• 44,000- 98,000 Americans die each year as a result of medical errors.
• Total cost $17- $29 billion
*Rate of growth declining in recent years, McKinsey 2011
U.S. spends most, but lower life expectancy relative to developed peers
Source: OECD Health Data, 2008
~$3 Trillion (~1/5 GDP)~ 30% may be waste
USA
Green LW. Making research relevant: if it is an evidence-based practice, where's the practice-based evidence? Family Practice 2008; 25: i20–i24
“Blue Highways” on the NIH Roadmap
Practice-basedresearch
Phase 3 and 4 clinicaltrialsObservational studiesSurvey research
Basic scienceresearch
Preclinical studiesAnimal research
Human clinicalresearch
Controlledobservational studiesPhase 3 clinical trials
T1Case series
Phase 1 and 2clinical trials
Clinical practice
Delivery of recommendedcare to right pt at right timeIdentification of new clinicalquestions and gaps in care
T2
Translationto humans
T2Guideline
developmentMeta-analyses
Systematicreviews
Translationto patients
T3Dissemination
researchImplementation
research
Translationto practice
Westfall JM et al: JAMA 297:403, 2007
Bench Bedside Practice
The fundamental problem with the quality of American medicine is that we’ve failed to view
delivery of health care as a science.
• understanding disease biology
• finding effective therapies
• insuring those therapies are delivered effectively
Peter Pronovost http://www.letstalkhealthcare.org/health-care-costs/how-a-checklist-can-improve-health-care/
Temporal Trends in Rates of Patient HarmResulting from Medical Care
Temporal Trends in Rates of Patient Harm Resulting from Medical Care. Landrigan, et al, N Engl J Med 2010 ; 363 : 2124 - 2134
Complexity in ICU
Critical Care at MayoCardiac SurgeryMedical Cardiac
Medical
Mixed
Neurology
Pediatric
Thoracic and Vascular
Transplant
Surgical/trauma
Neonatal
Courtesy of Dr. Vitaly Herasevich
Health care as a complex adaptive system
W. B. Rouse. Health care as a complex adaptive system: Implications for design and management. The Bridge, 38(1), Spring 2008.
Complex adaptive systems
• nonlinear and dynamic, system behaviors may appear to be random or chaotic.
• composed of independent agents whose behavior is based on physical, psychological, or social rules rather than the demands of system dynamics.
• agents’ needs or desires, their goals and behaviors are likely to conflict. In response to these conflicts or competitions, agents tend to adapt to each other’s behaviors.
• agents are intelligent. As they experiment and gain experience.
• adaptation and learning tend to result in self-organization. Behavior patterns emerge rather than being designed into the system.
• no single point(s) of control.
Rouse, 2000
William Worrall Mayo, MD
“Left open for further thoughtand research”
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System integration
Human beings make mistakes becausethe systems, tasks and processes theywork in are poorly designed.
Dr. Lucian Leape
Every system is perfectly designed to get the results it gets.
Dr. Donald M. Berwick
Systems approach to improve patient safety
Transforming healthcare: a safety imperative
L Leape, D Berwick, C Clancy, et al. Qual Saf Health Care 2009; 18:424-428
Swiss Cheeses Model
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Outcome + Safety + ServiceValue =
Cost over time
Leveraging for Highest Value
Smoldt RK, Cortese DA. Pay-for-performance or pay for value? Mayo Clinic Proceedings 2007;82:210-3
Systems Approach to Improve Patient Safety
Martinez, et al. Anesth Analg 2010 110: 307-311
“ Simply educating and training more physicians will not be enough to address theseshortages. Complex changes such as improving efficiency, reconfiguring the way some
services are delivered and making better use of our physicians will also be needed.”
The Complexities of Physician Supply and Demand: Projections Through 2025. 2008 AAMC http://www.aamc.org/workforce
2011, Health IT and Patient Safety: Building Safer Systems for BetterCare, Committee on Patient Safety and Health Information Technology; Institute of Medicine
Adjust structure and process to eliminate or minimize risks of health care-associated
injury, before they have an adverse event-impact on the outcomes of care
Donabedian. Evaluating of Medical Care. The Milbank Memorial Fund Quarterly, Vol. 44, No. 3, Pt. 2, 1966 (pp. 166–203)
System Interventions
Systems Engineering Initiative for Patient Safety (SEIPS) Work system design for patient safety: the SEIPS model.
Carayon P, et al . Qual Saf Health Care. 2006 Dec;15 Suppl 1:i50-8. Review.
WHO Global Priorities for Patient Safety Research
Bates DW, et al. Global priorities for patient safety research. BMJ 2009;338:b1775
Structure, process or outcome: which contributes most to patients' overall assessment of healthcare quality?
• Experiences regarding process aspects explained most of the variance in the global rating (16.4–23.3%), followed by structure aspects (8.1–21.0%). Experiences regarding outcome did not explain much variance in the global rating in any of the patient groups (5.3–13.5%).
• What is patient-centered care?
BMJ Qual Saf doi:10.1136/bmjqs.2010.042358
“We can’t solve problems by using the same kind of thinking we used when we created them”
Delivery System
Order (2 lanes !)
PayPickup
System Design ThinkingService centered = Customer centered
Escape Fire, Berwick, 2006
Mistake Proofing/Force Functioning
• designing the system to prevent errors
• designing procedures to make errors visible when they do occur so that they may be intercepted
• designing procedures for mitigating the adverse effects of errors when they are not detected and intercepted
Nolan, 2000 BMJ Department of Health and the Design Council in England 2003
Common patient safety improvement efforts
• Culture
• Crew resource management
• Event reporting: close-claim; near-miss
• Root cause analysis
• Human factor design
• Simulation
• Technology
• Lean, six-sigma
• Etc.
Terminology
• Model vs. Simulation (noun)Model can be used WRT conceptual, specification, or computational levelsSimulation is rarely used to describe the conceptual or specification modelSimulation is frequently used to refer to the computational model (program)
• Model vs. Simulate (verb) To model can refer to development at any of the levelsTo simulate refers to computational activity
Steve Park and Larry Leemis
Clinical Micro-system
Clinical Delivery System
Patient Providers Processes
Complexity/SOPBottleneck/ Waste/
no value addedEducation/Training Supply/Demand
• Simulation is the imitation or representation of one act or system by another.
• Healthcare simulations can be said to have four main purposes – education, assessment, research, and health system integration to facilitate patient safety...
• Simulations may also add to our understanding of human behavior in the true–to–life settings in which professionals operate.
Simulation based medical education
The 11 dimensions of simulation applications.
Gaba D M Qual Saf Health Care 2004;13:i2-i10
©2004 by BMJ Publishing Group Ltd
The 11 dimensions of simulation applications
Medical Education
• Study the effectiveness of simulation based medical education (SBME)
• Developing valid outcome assessment instrument, stretch measurement endpoints from the simulation lab into clinical practice (association studies)
• Provide highly reliable data for decision support and high-stakes testing.
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Simulation-based objective assessment Discern Clinical Proficiency in Central Line Placement, Dong, et. al, 2010
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Patient Outcomes
Masteryn=26
Controln=24
Adjusted Analysis
OR (95%CI) p-value
# Patients/Repairs 48/72 38/58
Intra-op Complications*
At least one of any type 5 (7) 17 (29) OR 0.15 (0.04, 0.59)
0.006
Post-op Complications*
At least one of any type 4 (9) 15 (26) OR 0.17 (0.04, 0.74)
0.018
Overnight Stay* 5 (7) 12 (21) OR 0.37 (0.08, 1.67)
0.20
*N (%)
Simulation-Based Mastery Learning Improves Patients Outcomes in
Laparoscopic Inguinal Herniorrhaphy, Benjamin Zendejas, MD, MSc
Skill Acquisition CurveImpact of Zero-Risk Training
CP1345275-1
Clinical competence
Me
tric
ass
ess
me
nt
(e.g
., co
mp
osi
te s
core
)
Time
Traditional training
Safety standard
Simulation-based training
Dong et al, Chest 2010
The First Research Consensus Summit of the Society for Simulation in Healthcare
• Simulation for Learning and Teaching Procedural Skills: The State of the Science
• Simulation-Based Team Training in Healthcare
• A Path to Better Healthcare Simulation Systems: Leveraging the Integrated Systems Design Approach
• The Study of Factors Affecting Human and Systems Performance in Healthcare using Simulation
• Literature Review: Instructional Design and Pedagogy Science in Healthcare Simulation
• Evaluating the Impact of Simulation on Translational Patient Outcomes
• Research Regarding Methods of Assessing Learning Outcomes
• Research Regarding Debriefing as Part of the Learning Process
• Simulation-Based Assessment of the Regulation of Healthcare Professionals
• Reporting Inquiry in Simulation
Simul Healthc. 2011 Aug;6 Suppl:S1-9.
ALL MODELS ARE WRONG BUT SOME ARE USEFUL
George Box
Simulation in Healthcare
Simulation 1.0
• Simulation as subject
• At simulation center
• EducationTraining effectivenessPsychometric qualitiesEcological validity
Simulation 2.0
• Simulation as tool
• Everywhere
• Daily practicesSystem integrationHuman factorsUsability of device, process, etc.
O Research
O Education
O Clinical Practice
Military Simulation Spectrum
J G Taylor, Modeling and Simulation of Land Combat, ed L G Callahan, Georgia Institute of Technology, Atlanta, GA, 1983
Human factor and Usability research
• Using simulation as a tool to study human performance variation under different “stress conditions” (fatigue, cognition, workload, etc.)
• Investigating provider behaviors/tasksObservation “in the wild” (Ethnography)Simulation environment
• Conduct usability testing of devices instrument and processes, using information driven approach for new system design
• Evaluation of the impact on clinical practices
The effect of drug concentration expression on epinephrine dosing errors: a randomized trial
Wheeler DW, Carter JJ, Murray LJ, Degnan BA, Dunling CP, Salvador R, et al.. Ann Intern Med 2008;148:11-4.
(1 mg in 1 mL) (1 mL of a 1:1000 solution)
Ahmed, et al. Critical Care Medicine, 39(7) 1626-1634
The effect of two different electronic health record user interfaces on intensive care provider task load, errors of cognition, and performance
Complexity of Sepsis Resuscitation in ICUComplexity of Sepsis Resuscitation in ICU
Adopted from: Network medicine--from obesity to the "disease". Barabási AL., N Engl J Med. 2007 Jul 26;357(4):404-7.
SHOCK
DIC AKI
ALI
Physician RTPharmacist
Nurse
Time
Bas
elin
e
Pat
ien
t O
utc
om
e,
Pro
vid
er S
atis
fact
ion
s
Trial and error
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http://www.economist.com/node/174411 http://www.wired.com/magazine/2011/12/ff_causation/all/1
How about the population at risk
Modeling & Simulation
Computer Simulation
R. P. Science, New Series, Vol. 256, No. 5053 (Apr. 3, 1992)
Simulation in manufacturing and business: A review
M. Jahangirian, T. Eldabi, A. Naseer, L.K. Stergioulas and T. Young, Simulation in manufacturing and business: a review, European Journal of Operational Research 203 (2010), pp. 1–13
Simulation-based Engineering and Science
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Simulation and Healthcare Delivery
System Engineering Tools for Healthcare Delivery
Proctor P. Reid, W. Dale Compton, Jerome H. Grossman, and Gary Fanjiang, Editors, Committee on Engineering and the Health Care System, Institute of Medicine and National Academy of Engineering, 2005
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Systems Engineering: Modeling and Simulation
• Using system engineering/operation research approach and readily available software(discreet event simulation, etc.) build a “test and learn” capacity to study system performance and identify the bottleneck,
• provide re-designed alternatives to improve safety and efficiency of healthcare delivery system.
• conduct a valid test of quality improvement innovations before clinical implementation
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Project 1: Sepsis Workflow Redesign
Sepsis Care Optimization by Discrete Event Simulation (S-CODES)
Place Central Line
Central Line Approval
Etc, etc, etc
Dong Y, Lu H, Rotz J, et al. Simulation Modeling of Healthcare Delivery During Sepsis Resuscitation. Critical Care Medicine 2009;37:A334
Project 2: Scheduling for Critical Care Fellows using Modeling and Simulation: The Trade Off Between Duty Hours and Hand-offs
Fellow A Fellow B Fellow C
7 am 7 pm
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Handoffs
0
2
1
0
1
4
Provider Transfer
Patient Handoff
Comparison of Provider Scheduling
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Provider Transfers (H/L)
per month
Patient Handoffs (avg./mo)
ICU Coverage(hrs/wk)
Average Duty Hours
(hrs/wk)
Old Schedule 84 (84/0) 650 ± 4 294 73.5
New Schedule 112 (67/45)(+25%)
860 ± 5 (+33%)
312 (+6%)
62.4 (-15%)
Janish, Dong, SCCM, 2011
Project 3: Time-motion observational study of multidisciplinary ICU rounding in a teaching hospital
• To describe the current practice, and structure of the morning multidisciplinary round in the ICU practices (MICU, SICU)
• Prospective field observation of ICU provides task (consultant, fellow, resident/intern, nurse, pharmacist) based on systems engineering approach
• Task categories defined based on provider survey
• Purpose strategies (work-flow redesign, new EMR interface) to improve
the efficiency of ICU round, reduce MEOWpatient outcomeprovider satisfaction
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Project 4: Education Game: The Friday Night at ER ™
Professional Society
Challenges and opportunities
• Fragmentation of care delivery
• Access information from various sources
• Clinical implementation
• System integration
• Health IT (mobile, cloud, social networking, big data)
• Provider education and change culture
• 1920’: BME, Biophysics, Medical Physics
• 1943: German Biophysical Society
• 1948: Annual Conference of Engineering in Medicine and Biology/Radiation Research Society
• 1961: International Federation of Medical and Biological Engineering
• 1968:Biomedical Engineering Society
Road map for better healthcare delivery
Road map for better healthcare delivery
Dong Y, et al. ICU Operational Modeling and Analysis. In: Kolker A, Story P, eds. Management Engineering for Effective Healthcare Delivery: Principles and Applications. Hershey, Pennsylvania, USA: IGI Global; 2011.
Key Messages• The complexity of healthcare delivery
systems contributes to preventable medical error and insufficient quality
• Computer modeling/simulatio coupled with realistic patient simulation represents a potent catalyst in adapting systems engineering principles to healthcare
• The medical community needs partnership with the systems engineering community to best deliver high value care
©2011 MFMER | slide-87
Medicine: Human interactions
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