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Simulation to improve quality: save time, save lives, provide insight

Martin Bromiley
Martin Bromiley
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Recently I had the privilege of visiting a simulator centre for the day. The centre provided training to a large teaching hospital and on the day of my visit had year 5 medical students attending. The ‘patient’ for the scenarios lay in bed in a ‘ward’ and the students took it in turns, in pairs or threes, to be called to the patient who had a variety of deteriorating conditions throughout the day.

The medical students were clearly a little nervous when they arrived; they’d never experienced anything like this. Despite being year 5 students it would be their first and only exposure to a ‘simulator’ prior to the final exams. Ironically I was impressed with how much time they’d all spent in real wards, working alongside real medics. I was also impressed with their own knowledge; they knew the text book stuff.

But in the simulator on this September day they were the ones called to the patient by a concerned nurse, the first ones ‘on site’. In teams they had to make an initial assessment, take some initial steps to stabilise the situation and/or the important decision whether or when to call for help, and how to do it. As I listened to the debriefs and informal discussions after each scenario it was clear that the day was a real eye opener – in fact I won’t beat about the bush: it was a revelation to many of them.

For most this was the first chance to properly apply their theoretical learning, but without fear of error causing harm. It reminded me of my first day in a simulator. I already knew how to fly an aeroplane, but I’d never faced an ‘emergency’. On my first session in the simulator I didn’t even notice the emergency until I was about to lose control; the instructor kindly stopping proceedings and showing me what I could already see – but hadn’t interpreted.

What was fascinating about the medical simulator team – just as had been the case in my first experience in the simulator – was that although mention was made of human factors and non-technical skills, the real benefit was applying theoretical technical knowledge and turning it into a competency. A very low level to start at, but probably the first and last experience of its type before they’re let loose on the real world with some degree of authority, at least in the eyes of others.

I’d been taken to see a simulator centre about five years ago. We turned up at 5.05pm, the doors were locked, and everybody had already gone home for the day. I laughed. When my colleague asked why I was laughing I explained that in aviation simulators work 24/7. Yes, that does mean I could end up in the simulator at two in the morning, but then emergencies are 24/7 as well. (As an aside, a colleague told me recently that in her own hospital they’re now pretty good at using the Safer Surgery Checklist; but when she wanted to use one prior to an emergency procedure in the middle of the night her team said ‘Oh, we don’t use it out of hours’!)

Simulators allow an amazing insight into ourselves. The European Working Time Directive has restricted training time and the curriculum is full; yet in a few hours in a simulator you can experience a year, or even a lifetime’s worth of issues, and you can really learn about handling the real world. Providing resources, i.e. staff and money, to run simulator centres 24/7 would cost money; but the business, safety and education cases are clear.

And a final thought. This week I sat through the pain of Channel 4’s Dispatches programme about the competency of GPs. The point was forcefully made that there still is no check on competency throughout a clinician’s career. How much work would be saved if we replaced ‘revalidation’ by a few hours’ observation and training in a simulator? I bet the simulator would be cheaper, quicker and more effective. Paperwork proves what you want it to prove.

Martin is a pilot and the founder and current Chair of the Clinical Human Factors Group.





 
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