Lecture: The Building Blocks of a Successful Simulation Center

Amelia Geary: Hello, I’m Amelia Geary, I’m a training specialist working with Orbis International. And I’m going to take a few minutes just to present what are the key building blocks to creating a successful simulation center. We see the increasing popularity of simulation training in ophthalmology and in other healthcare professions related to ophthalmology, such as nursing and anesthesia. But how do we successfully construct a program to deliver that simulation training and really maximize the impact we have on our surgical outcomes and our patient care?

So before I start, I want to say why simulation? Why are we making the effort to endeavor to increase our simulation training? And here are the principle reasons from Orbis’ perspective. First of all, it gives you an opportunity to train residents in new techniques and competencies. So things they have never seen before, you can practice repetitively in a safe environment. You can also refresh existing skills. Perhaps a resident has done one or two cases of small incision cataract surgery. But via the simulation center, you can have them do that case over and over and over again until they reach perfection or competency in the simulated environment.

You can also introduce complications in a safe manner. So rather than the first time a resident faces vitreous loss being in the operating theater, they can actually do this in a simulated environment. And it allows them, again, to repetitively manage common complications and even rare complications that they might see in the operation room so that they’re really prepared for when those occur in real life. And all of this, obviously, is to improve patient safety. The more we can do to reduce the complications that a patient might experience in surgery and improve the skills and confidence of our surgeons, the better outcomes we’re going to see.

But most importantly, the reason that Orbis is moving into simulation and promoting simulation as a key element in any residency training program is because of the evidence.
What does the evidence prove? So there’s a mounting body of evidence exploring the impact of simulation training in ophthalmology. And what it shows us is one, simulation is reducing the learning curve for difficult techniques. All techniques, but specifically difficult techniques. And then it really accelerates the surgical and clinical competency of a resident or trainee. It’s reducing those surgical complication rates in those early surgeries. So what we know from the evidence is that the highest complication rate in a surgeon’s career happens in their first, anywhere between 50 and 150 cases. And in particular between 50 and 80 cases. And what the evidence is showing is with structured simulation programs, we can radically reduce those complication rates in those early surgeries of any surgeon.

And this not only has benefits for our patients, and obviously the surgeons themselves, but this can have a big impact in hospitals. So there should be investment from teaching institutions because there is an actual benefit to the hospital itself. And that benefit comes in the form of cost savings. So both cost savings because there is a reduction in complication rates, so repeat surgeries or complicated surgeries can be reduced. And also a financial incentive to the hospital because residents are able to get through surgeries quicker, it increases surgical volume, and therefore increases the revenue that can be generated at a center.
Simulation is not only valuable from a skill development perspective, a surgical skill development perspective, but we also see that it improves problem solving and crisis management skills. So again, by being able to simulate a crisis, you’re able to put in place with a surgeon, quick problem solving skills that when they face that crisis in real life, they already have an internal game plan, which they can use to overcome that crisis.

And finally, simulation is not only available and proven to work among surgeons, among ophthalmologists, but we see similar effects on other key members of the eye care team. Most importantly ophthalmic nurses and anesthesiologists.

So I have included in this slide, a number of journal articles supporting simulation. Some of the ones that I think make the case the most strongly. I would highly encourage anyone who’s interested in exploring simulation and including that in your residency program, to visit these journal articles and become more informed on the impact of simulation and what the evidence is saying.

So returning to our building blocks. I listed here six key building blocks that I think are essential to any simulation program. The first and second I think are fairly obvious. You need to have the appropriate equipment, supplies, and consumables in place that allow you to deliver the simulation training that you’re interested in producing.

The third is a structured curriculum. This is probably the building block that we find more commonly absent, or the largest gap from our visiting residency programs. It isn’t enough just to have a wet lab or a dry lab, but you actually have to have a structured program by which you deliver your training in the wet and dry lab.

Building block four looks at assessment tools. So structured tools that let you objectively monitor progress and confirm competency in the simulation setting. Debriefing tools that allow for feedback and development of a learner of a resident. And finally, an ideal building block is access to internet-based resources that really allow further support to foster your growing simulation program. So I’m going to take a few moments to go through each building block in turn.

Equipment, supplies and consumables. I just put up a picture, just to give an idea, but these are obviously wet microscopes, external monitors, teaching scopes. Someone may be actually looking at what your learner is doing, so you can provide real-time feedback. If model eyes are outside of the budget of your center, you can use animal eyes, you can use fruit. We’ve had a lot of success teaching capsulorhexis on grapes, cherry tomatoes, and like food items. As well as needing some instrumentation, which allows them to actually conduct the surgery. And we highly recommend that the instrumentation, as best to your ability, matches what the resident will find in the operating room to smooth the transition between the simulation setting and the theater.

A good guideline for equipment supplies and consumables, is the IAPB essential list. The International Agency for the Prevention of Blindness has a series of essential lists that are equipment, supply, and consumable recommendations for given surgical interventions. And in this case, for simulation-based learning in cataract surgery, both phaco and small incision techniques. The tool is divided into essential items, which you must have in order to deliver simulation-based training in cataract surgery and desired items. So the A plus, if your budget allows and you can procure those items, it would enhance the training.

Structured curricula. Just a few elements that are covered in a structured curricula, most importantly, there are explicit learning objectives. So in your simulation training you have specific competency or learning objectives that you expect the resident to achieve by undergoing the program or the training that you’re delivering. Typically, there is some form of pre and post test. So you have an assessment on how effective the intervention was at closing the knowledge gap and how effectively the learners actually reached the competencies you have set. And to enhance that curricula we recommend a prerequisite knowledge reading list. So this could be a list of journal articles, or chapters, or online courses that you recommend that the learner takes in advance of the simulation training, so that you ensure that you have a foundation knowledge before you start delivering a training.

I put an image of the Iowa Ophthalmology Wet Lab Curriculum. They have published extensively around their wet lab curriculum, it’s open source, it’s available at their website, and it really offers a great example of what a structured curriculum could look like. And also to encourage anyone watching this lecture, you don’t have to start from scratch, there’s a number of wet lab curriculum out there. We have some at Orbis that is available at Cybersight, open source. So the best thing to do is take an existing, well-documented curriculum and adapt it to your needs at your hospital.

Assessment tools. I want to talk a little bit about the rationale for an assessment tool. Number one, it allows you to actually, objectively, measure the improvement of knowledge and skills of your learner. So if we do have the structured curriculum, and we have competencies set, but we have no way to measure whether or not our learners are achieving those competencies, then there’s not a lot of value add there. So we do need to be able to constructively measure their progress. And we want a tool that confirms to us that they have actually achieved the learning objectives we set.

Some consideration for your tool, number one it really needs to be objective. It needs to be reliable and it needs to be validated. Meaning if myself and my colleague, Dr. Johnson, both assess the same resident using the same tool, we need to come up with fairly similar results. If we’re coming up with radically different results then we know our tool is very subjective to whoever’s conducting the assessment.

And also it needs to be very practical. So if we come up with a tool that’s 20 pages long, it’s very unlikely that busy faculty are going to have time to complete those assessments every time they deliver a simulation training. So we want something practical and easy to use and apply.

So once again, like with the curricula, I would recommend seeing what’s out there and adapting it to your use, rather than starting from scratch. There’s a number of reliable and validated assessment tools available. I’ve listed some here, the Iowa Wet Lab Examination. So again, at the University of Iowa website, you can find the examination they use to test competency and knowledge. There’s the Objective Assessment of Skills in Intraocular Surgery tool or OASIS. And what we use, there is the ICO-OSCAR. As well as the OSSCAR with an extra S, for simulation, a modified version of the OSCAR, which I have an image of on the screen, that allows us to objectively look at competencies for each step of a given surgery. And a number of assessment tools that are also available on the Orbis Cybersight website.

Next, I’m going to talk about debriefing tools. I would say that debriefing is probably the step most overlooked in delivering a simulation training. But in addition to doing that objective assessment, it’s really important to communicate with your learners, with your residents, after a simulation training, to provide enhanced learning. To really give them feedback to how they performed, where the gaps are, and what are some of the next steps in their progression as a surgeon.

So once again, we base all of our recommendations on the evidence and evidence is showing that post-simulation debriefing supports critical learning and is key to critical learning. And that formative feedback really helps a learner to understand what were their strengths, what were their weaknesses, what are their gaps, what do they need to continue to improve on?

Several considerations to take into debriefing. Number one it really needs to be facilitated by someone who is competent in debriefing. Meaning that whoever’s doing the debriefing should have some training themselves on delivering debriefing. There are best practices and tools related to debriefing that should be engaged.

Your environment of where you do the debriefing is very important. You’re not going to grab your resident in the hallway of a busy clinic, with three of their colleagues standing next to them, and start giving them feedback on their performance. Just like anything, you want a safe, private environment where you can share in an open and confidential manner, with the resident, what your feedback is.

You want to make sure that as a debriefer you have enough time to facilitate that. Once again, you’re not going to give someone debriefing in between two patients that you’re seeing in a clinic in the two to three minutes you might have in a rushed manner. You want to make sure there’s sufficient time so that the resident really has time to process the feedback, ask their own questions, engage in discussion with you, and leave with a critical understanding of what they need to improve on.

We recommend that it follows a theoretical framework. So a structured tool is employed that really helps you deliver debriefing in an objective way using best practices. Just like with assessments. And finally, that whatever debriefing you’re giving is actually related to the objectives and outcomes of your simulation training. I don’t want to start debriefing a learner on how they communicated with a patient in my clinic when the simulation was on how to do a successful trabeculectomy, for example. So make sure whatever you’re debriefing on really aligns completely with the objectives of the simulation learning are.

I included a reference in this slide to a really excellent resource that gives some best practices around debriefing that I recommend, once again, after this lecture that you make some time to review. And I’ve also included two popular debriefing tools that we use at Orbis. The first is PEARLS. PEARLS is a structured script that allows you to formulate a specific series of questions and facilitate specific communication with your learner in order to deliver that debriefing. It takes a bit more time. This is something that really has to be used sparingly, I would say, because faculty are incredibly busy. And as I said before, when you have time to sit for a half an hour, 45 minutes with your learner and really go through in detail the debriefing on their simulation training.

A more user-friendly tool that can be engaged when that time is not available, is the SHARP tool. The SHARP tool is five, as you can see, a five-set feedback and debriefing tool. You ask very specific questions which quickly allow you to review the learning objectives and assess how well the person did and what the impression of the simulation experience was, and make an action point for a future training.

What we typically recommend is using a combination of these tools. Maybe using SHARP as your regular debriefing method because of the time constraints and your workload. And then at critical learning points in the resident’s career, employ the PEARL tools so they can get a more indepth debrief. So perhaps that’s used once a quarter or twice annually.

And finally, access to internet-based resources. We specifically recommend this in a blended learning approach. We define blended learning as a combination of in-person training with online education. And we think there’s a number of advantages to doing a blended learning approach. Specifically, it accomplishes your educational objectives and builds your skills more effectively. So we have seen a growing body of evidence that really shows that blended learning is more impactful than either exclusive online or exclusive in-person education. So we highly recommend taking that approach. It gives the mentor, or the faculty, more flexibility by moving a lot of the learning online.

For example, typically in a wet lab program, you would lecture with the resident or deliver a didactic lecture or discussion for an hour and then go into the skilled practice session. With blended learning, that can all be delivered in advance through an online platform. The learner can see your lecture, see your talks, read the prerequisite learning material. Even allow you to upload tasks or engage in case discussion in advance, so that in person you can really focus on skills transfer or skilled building techniques. This not only has been shown to improve learner outcomes, but it reduces the time responsibility on the faculty of being in the simulation training themselves. So it’s a win/win.

And finally, a blended learning approach really allows for a more personalized learning experience for each user. I am able to choose when I watch my lectures, when I do my reading, I can do it around my work schedule, I can do it when I’m sharpest, I can do it when I’m the least fatigued. And being able to personalize my learning in a way that most suits my schedule, once again has shown to have the greatest impact on the learner’s ability to retain that knowledge. So we highly recommend having a digitized wet lab, dry lab, an access to internet and taking a blended learning approach to delivering your simulation training. And once again I’ve included a useful resource on this slide that talks more about that method and that approach.

Finally, I want to give a list of online resources. I’ve spoken a lot throughout this presentation of different tools and different locations that support simulation training. Here are a handful of those locations, those groups that are really providing good instruction and tools and resources to deliver simulation training. Once again, I recommend visiting all these sites when you’re able.

And I always like to end my lectures with some quotes from users themselves, from residents, from learners. Those that are actually participating in the simulation training. Just so we can hear from our audience why it’s important that we continue to do simulation training. So in this case, Flor, a third year resident said it was incredibly different to go directly to the patient, as you may cause a complication to the patient, because you had not had an opportunity to practice, because you are not aware of certain things or tips. And having already this induction, the simulation, she thinks she’ll go to the OR with greater confidence and knowing what to do with each step.

This is a first year resident, Vanessa Rocha, who said this training really increased her confidence. And she felt better able to face surgical procedures that before she was doing her simulation she was training with about 10% confidence. And after simulation, she felt like she could start learning in the OR with 90% confidence.

That’s just a quick overview introduction of some essential building blocks to creating a simulation center. For anyone who is interested in pursuing either enhancing their simulation center further, or just starting a simulation from scratch, I really recommend several of the resources that were presented in this presentation. Nothing has to be started from scratch, no one is reinventing the wheel here. There are a number of successful simulation programs in operation, globally, and most of them share their information and their resources open source. Orbis International, for example, is gladly sharing all of our resources and simulation training open source.

And for anyone pursuing this I would just say use what’s out there, adapt it to your needs, reach out to colleagues, and several of those organizations I presented, and Orbis as well, for support. And build your simulation center. It’s the future, it’s going to be the best thing that’s happened to our patients since some of these surgical interventions were invented in the first place. And we are highly supporting it at Orbis. So thank you very much.