In a debriefing with good judgment, the leader ensures an atmosphere of safety, in which teammates can speak up freely and must be mutually respectful and accountable to each other. Suggestions that arise from a debriefing session should be viewed as an opportunity for improvement, not a time to assign blame or impose penalties.
After the session is over
The steps you take after debriefing are the most important of all ( TABLE 4 ). To have a real impact, a simulation program must include mechanisms for assessing and documenting measurable outcomes, staff satisfaction, and improvements in patient safety. Ongoing feedback to, and from, the staff—by way of newsletters, announcements, grand rounds, and social gatherings—is crucial. Last, assessment and feedback must be used to inform regular updates of the simulation program.
TABLE 4
What ongoing program elements are needed?
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What simulation does best
According to a “root cause” analysis by the Joint Commission on Accreditation of Healthcare Organizations, most (72%) cases of perinatal death and permanent disability can be traced to problems with organizational culture and communication among caregivers.16 These are precisely the kind of issues that simulation training is best suited to confront: Simulation allows participants to identify system-based issues and staff responses that are inadequate for managing critical clinical events.
The impact of simulation training programs can be assessed by monitoring trends in key maternal and neonatal outcomes.17 A downward trend in adverse events (e.g., low Apgar score for term newborns, maternal or neonatal birth-related injury), for example, would underscore the value of simulation in improving patient safety and quality of care.
Liability insurance. Professional liability carriers are beginning to incorporate simulation training into patient safety and risk-reduction initiatives. Harvard University’s medical malpractice insurer, Controlled Risk Insurance Company/Risk Management Foundation, established a voluntary incentive program in 2003 that provides a 10% premium credit to providers of OB services who complete risk-reduction activities that include simulation-based and didactic team training. A downward trend in obstetrical claims in association with this incentive program was recently noted.18
Resident and continuing medical education. The Council on Resident Education in Obstetrics and Gynecology featured simulation at its annual meeting in 2007 as a credible way to augment the curriculum for resident education.19 Simulation is also being used to train OBs who need to learn new skills and procedures, refresh infrequently needed skills (cesarean-hysterectomy, laparoscopy), or reenter the workplace after an extended absence.20
What does the future hold?
Simulation provides a safe environment, in which mistakes are tolerated without harming patients and appropriate responses can be learned and practiced.21 Benefits of the technique are acknowledged in England, where annual skill drills, using simulation, are recommended by the Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists.
In the United States, the use of OB simulation in residency and postresidency training programs is growing. This change is likely to trigger the introduction of simulation into board certification and credentialing procedures.
Work is needed to validate and standardize simulation-based scenarios. Studies will need to show that simulation improves clinicians’ and teams’ performance not only on simulators but in practice. Despite these hurdles, it is reasonable to conclude that respect for patients and a desire to learn without doing harm will expand and diversify the role of simulation in OB training and practice.