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Provider; Leader
10/20/2017 2:30 AM

Dr. James Ruiter.jpgHow do you build insight with education innovation? Jim Ruiter has the answer: a play in three acts

Jim, can you tell us about your initiative?

Early in 2017 Salus Global™ was asked by District II of the American College of Obstetricians and Gynecologists, as part of their Bundle Implementation workshop in Albany New York, to present to obstetrical and gynecological physician representatives from many of the New York state hospitals. This was a 90 minute session presenting to a group of well-tenured academic obstetricians and gynecologists on how to use simulation effectively.

As I pondered this opportunity, I was nervous. I am not an expert in simulation, nor is the organization I work for. Salus Global™ prides itself on being experts in teamwork, communication and high-functioning teams. With that in mind, I wondered how I could keep such a group engaged for 90 minutes on a topic they were already experts in. I started to reflect on all the successes Salus Global and the MOREOB® program have seen, and began to create a list of pearls of wisdom to share. As I completed the list, I realized this could be another boring lecture. A boring lecture would leave no lasting impact from the presentation. The more I thought about the lecture format the more I realized that I needed to present in a way that allowed others in the room to build their own insights. I wondered if a demo would fit the bill, but I've never been totally impressed with demos. Demos often don't 'cut-it'. I needed a way to create scenarios, which allowed the audience to build their own insight. I found myself building a script. The script process resulted in the creation of a play. A play could highlight the benefits and challenges of simulation. A play could build the insight and impact I was looking for.

How did you build the play?

I built the play in three acts. It's meant to demonstrate potential uses of simulation beyond simply for education purposes. The three acts allow us to run the same clinical simulation scenario twice using two different simulation approaches. These two opposing approaches are what allow the audience to build their own insights. In act I, the narrator comes out and interacts with the audience, trying to pull out from the audience what it knows of simulation – essentially identifying where the audience is starting from. During that first act, the scene is also set for the ensuing two acts.

In act II, we have the actors play out a simulation scenario in one way, what I call a run-through modality (no breaks in the scenario till the end where the team debriefs).

In act III, the same actors play out the same scenario, but with a pause-scenario modality (where the objectives are stated out front, and where the participants are encouraged to pause the scenario to discuss what ever issue on their mind – and then debrief). Act III allows them to demonstrate simulation conducted within a continuous quality improvement framework, using a modality that builds psychological safety and organisational trust. In the denouement, we brought all the actors to the front of the stage and the audience interacted with them, and by a simple show of hands we could show an increase in the number of individuals wishing to develop their own simulation program.

The first time we presented the play, I recruited four actors. I had wanted seven, but the four turned out to be a gift. I quickly re-wrote the script to present the scenario as if another emergency was going on. We could accurately portray the limited resources often available to staff in an emergency. We assigned a narrator, simulation facilitator and staff taking part in the simulation as the roles. I was careful to include the frame of mind the actor was coming from in the script, this was the key to why simulation can succeed or can only be of value.

One of the keys to developing insight in our audience, was not just demonstrating or acting out the play but, it was also the ability to peer into the minds of the actors throughout the play through freezing of the action. How we made this work was by having the narrator, at predetermined times – in response to body language for example – freeze the action on stage. The narrator would then ask the audience what they thought the actors were thinking at that time. The actor would then reveal their state of mind in a soliloquy. Utilizing audience feedback and multifaceted scripts we could demonstrate how complex adaptive systems can adapt, through simulation conducted within a continuous quality improvement framework.

What do you think contributed to the success of this learning approach with your audience?

There were many aspects that made the play a success. Firstly, we utilized real life scenarios. We chose to use the scenario of a post-partum hemorrhage and the secondary emergency that limited our human resources was a cord prolapse "down the hall." The scenario had realistic aspects that created stress that the audience was readily able to identify with.

One aspect of the scenario was the lack of easy access to a refrigerated drug. The need for this drug forced the nurse to leave the physician with the patient alone. As this occurred, we could create insight by freezing the action and teasing out from the audience their thoughts, and then the thoughts of the characters in the play. Freezing the action allowed us to create learning we would not have gotten otherwise.

Lastly, creating the play in three acts to provide an opportunity to act out the same simulation scenario two ways, while allowing the audience time to interpret and pick apart each portrayal. This approach allowed the audience to build their own insights into simulation by providing them two examples to compare. This was integral to the result, which ideally was the audience leaving with new learning they could apply in their own practice.

What would you tell others planning or delivering education on simulation?

My first thought would be, conduct your education in any way you think fits your audience. This example is not a one-size-fits-all solution. Do what works for your audience and helps you meet your goals.

I would remind people that you couldn't bridge process gaps through simulation alone. You can identify gaps through simulation and address them through a continuous quality improvement framework, which may lead to a variety of strategies to close the gap. You need to offer simulation in the context of a continuous quality improvement cycle.

Lastly, I would stress that simulation is a powerful tool, far more powerful that just education. It can help create psychological safety, identify an organization's external safety boundaries (allowing you to then push them), provides opportunities to engage and address issues and builds a more robust care system.

Most importantly, it can build the overall organizational safety culture and creates safer, sustainable systems. If a simulation is used in isolation, nothing will change!

Where can people go to learn more?

You can contact me through Salus Global™ at

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Thank you to Dr. James Ruiter for his time and insights. Join us next month when we sit down with SuperSHIFTer Patrick Nellis to learn more about the launch of his new patient safety book entitled Ready for My Surgery: Be Informed, Stay Safe and Take Control During Your Journey Through Surgery.