15 Jun Medical simulations identify potential problems before they can pose a real threat
Madison, Wis. — As the medical business struggles with the problems of clinical risks and litigation, one emerging method for dealing with potential problems is through the use of war-game exercises, in which scenarios that could last for several chaotic days in the real world can be simulated in the course of hours and allow for systemic problems to be identified and dealt with before they can pose a real threat.
While simulations have been used for a long time in the corporate world, the use of war-games in the medical business is relatively new, bringing a new understanding of those risks that do pop up.
“War-gaming allows us to focus on the process holistically instead of focusing on pieces of the care-giving system,” said Melissa Chapman, Principal of Booz Allen Hamilton, a management and consulting firm based in Rockville, Md., which has been doing medical simulations for the last two-and-half years.
Barry Chaiken, Associate Chief Medical Officer for Boston-based consulting firm BearingPoint, participated as an observer in a war-game session in October. “I thought it was fantastic because even though you feel awkward when you’re doing it, you are learning a lot in the middle of it. What was evident was you would actually see people start sweating because they were so nervous.”
In the scenario, participants played a hospital staff dealing with the death of a local celebrity in their intensive care unit. Various complications could be thrown their way, including inquiries by relatives, the local media and even a report that the death had been caused by a medical error in the hospital. The different groups of participants could in turn cooperate and divide the different tasks: some people could be doctors or nurses while others could be public affairs or other categories.
“You learn mostly from doing the scenario itself,” Chaiken said “For example, one thing you learn is not to make things up. You have to tell the truth. You have to say “we’re investigating, we’re not sure, those are only rumors. We have not had contact wit the family, we are trying to contact them as we speak,’ things like that. You have to be very careful on how you do it.”
A major benefit of war-gaming, according to Chapman, is that it builds an institutional awareness among practitioners who have grown comfortable operating in an established individual role. Not only will staff members work together in the scenarios, but roles can be changed; a doctor can play the role of public relations, or a lab technician can take on the job of administration, all of which helps to foster a sense of empathy across the institutional structure.
The simulation of roles can extend beyond even the institution, with doctors playing the parts of patients and their families as well as other outside actors, which Chapman said would better foster a sense of empathy between the staff and the customers.
“War-games are different from other types of systems analysis because it personalizes real processes and can lead to greater insight. You are all of a sudden a player in this scenario rather than studying the scenario retrospectively as you would in a root-cause analysis.” said Kendra Jacobsen, administrator of the Madison Patient Safety Collaborative.
The key is the analysis that takes place after the game, when participants have to look at the simulated outcome and determine what they did wrong, what they did right, and how the imaginary circumstances of the game parallel the everyday operations of real-life practices.
Part of this is setting up games where the object was not about individual blame, where the setup didn’t really allow for individual finger-pointing. Dr. Arthur Border, chairman of the American Board of Quality Assurance and Utilization Review Physicians, participated in such a game in September of 2004. The game involved a diabetic being transferred from his physician’s office to the emergency room with multiple complications ensuing along the way.
“And what we did is we really addressed it from a multi-disciplined, multi-system involvement,” Broder explained. “This wasn’t about who was at fault if we had an adverse outcome. It was to prevent this from happening again, what could have been done.”
A major lesson, according to Chapman, is that communication technology alone cannot solve problems. Indeed, new technology and the transition associated with it can exacerbate problems if the fundamental issues of enterprise structure are not also addressed. The key is to address the overall manner in which communication between different actors takes place as well as the original actions at the individual level.
“All too often, depending on your role, if you’re a doctor you work only with doctors or if you’re a nurse you work with nurses,” Chapman explained. “And the war-games present people an opportunity to cross those boundaries and better understand how everyone in the health-care delivery chain can help prevent medical errors, and in the even there is one how everyone in the chain can work together to mitigate the risk of it”