US Army Centralization and Standardization of Simulation-Based Training - Medical Training Magazine

US Army Centralization and Standardization of Simulation-Based Training

Dr. Shad Deering and Dr Taylor Sawyer explain the Central Simulation Committees’ goals, foundation, program components and collaborative efforts to enhance training and simulation in the US military healthcare system.

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Residents at Medigan engaged in Mobile Emergency Simulation (MOES) exercise developed by Shad Deering, MD, USA. (Photo: Dr. Shad Deering)

Sources of simulation-based medical education in the U.S. Army today include the Army Medical Department (AMEDD) Center and School, which provides oversight of nursing simulation and policies, the Medical Simulation Training Centers (MSTC) that are responsible for all Army medic simulation training, and the Central Simulation Committee (CSC) which provides centralized oversight and support of graduate medical education (GME) simulation-based training and simulation-based redeployment training for physicians returning from the wars in Iraq and Afghanistan. The goals of the CSC are to create and implement standardized simulation-based curricula for resident education in the Army, provide a program for the redeployment training of physicians, and to improve patient safety throughout the AMEDD. In this report, we will describe the development, structure, accomplishments, and future vision of the CSC.

Development of the CSC

The concept of a central committee to oversee and support GME and redeployment simulation-based training throughout the AMEDD was first proposed at the Uniformed Services Joint Service Selection Board in 2006. Following that presentation, a model for a ‘Central Simulation Committee’ was briefed to the Office of the Surgeon General (OTSG) in March 2007. The model was developed to overcome several of the challenges identified by individuals at medical treatment facilities (MTFs) conducting SBME at that time which included: challenges obtaining funding to purchase simulation equipment, difficulties with program sustainment in the face of frequent duty assignment changes and deployments, lack of validated curriculum for specific subspecialties, and limited administrative support. The mission of the CSC is to, “be a worldwide leader in managing and directing multi-disciplinary simulation training to enhance GME, assist in redeployment training, and improve patient safety.” Funding for the CSC was first approved by the OTSG in April 2007 for an initial equipment purchase of $2.88 million. Since that time, funding for the CSC has been appropriated yearly through the OTSG with an estimated annual operating budget of around $1.5 million.

Structure of the CSCThe governance of the CSC consists of both central and local oversight and support. Leading the CSC is the CSC Chairman who is assisted by the CSC Administrative Staff, located at the Anderson Simulation Center in Fort Lewis, Washington. The CSC Administrative Staff is comprised of a Chief Administrator, an Information Technology Support Technician, an Educator, and a Research Scientist. Each medical subspecialty has an assigned Simulation Specialty Advisor who is appointed by their respective consultant to the Army Surgeon General. Presently, 14 medical specialties are represented on the CSC including: Anesthesia, Dermatology, Emergency Medicine, Family Medicine, General Surgery, Internal Medicine, Obstetrics/Gynecology, Orthopedics, Ophthalmology, Otolaryngology, Pathology, Pediatrics, Psychology and Urology. In addition to the medical Specialty Advisors, the CSC also includes advisors from the Army Nurse Corp, the Uniformed Services University of Health Sciences, the Army MSTC (Medical Simulation Training Centers) program, and the Director of Medical Education (DME) from each of the 10 MTFs with CSC Simulation Centers. At the individual MTFs, CSC members include the DME, Residency Program Directors (PDs), the Simulation Center Director and the Simulation Center Administrator. Some simulation centers also have a Surgical Director and a dedicated Simulation Technician, depending on the specialties covered and training volume. The individual DMEs are responsible for choosing the Simulation Center Directors at the MTF level. All Simulation Center Directors are active duty military physicians, and are required to have at least 0.25 full-time equivalents (FTEs) dedicated to the Simulation Center in order to fulfill their duties. The CSC Simulation Center Director and Administrator are members of the MTF’s graduate medical education committee (GMEC) and local oversight is provided by the DME and GMEC. The CSC currently has Simulation Centers in all 10 Army MTFs that house residency training programs. These include: Brooke Army Medical Center (BAMC), Carl R. Darnall Army Medical Center (CRDAMC), Eisenhower Army Medical Center (EAMC), Fort Belvoir Army Community Hospital (FBACH), Madigan Army Medical Center (MAMC), Martin Army Community Hospital (MARTIN), Tripler Army Medical Center (TAMC), Womack Army Medical Center (WAMC), William Beaumont Army Medical Center (WBAMC) and the Walter Reed National Military Medical Center (WRNMMC). (Figure 1) The size of the Simulation Centers varies from 400 sq ft to 8,000 sq ft. In total, the CSC oversees over 21,000 sq ft of simulation center space within the continental United States and Hawaii. Training volumes vary across the 10 centers, and have been increasing on an annual basis. In the past two years, CSC Simulation Centers have trained over 50,000 Army medical students, residents, physician assistants, nurses, enlisted Soldiers and DoD civilian medical personnel. A table with the dedicated square feet and number of personnel trained in 2009 and 2010 at each of these CSC Simulation Centers can be seen in Table 1.

Figure1

Each CSC Simulation Center works to focus on the individual educational needs of its MTF, based on the types of training programs located there while taking into account local Army training requirements. The majority of defined training courses offered within CSC Simulation Centers are targeted at GME, involving medical residents from various specialties. A list of the GME programs supported at each MTF is provided in Table 2.

Accomplishments of the CSC

One of the primary goals of the CSC has been to standardize SBME in Army GME programs. To accomplish this, each CSC Specialty Advisor has worked to create a core set of simulation scenarios that comprise a standardized, simulation-based, educational curriculum for their respective specialty. The scenarios were chosen after consultation with providers and residency directors in the specialties and include cases of importance for the specialty. Efforts were made to encourage and facilitate coordination between specialties where overlap is present in order to avoid duplication, and leverage simulation scenarios already developed by one specialty that are applicable to another. For standardization purposes, each simulation scenario follows a standardized CSC format that was developed and agreed upon by the members of the CSC in 2007. All CSC simulation scenarios and specialty curricula are internally peer reviewed by the CSC Specialty Advisor, educators within the specialty, and the CSC Educator. In addition, some scenarios have been externally peer reviewed and published through services such as MedEdPORTAL.1 At present, the CSC has over 60 simulation scenarios available for use. All CSC simulation scenarios and specialty curriculum are available on the internet through a secure Army Knowledge Online website. Electronic grading forms have been developed for several specialties to facilitate centralized data acquisition and allow program directors to track performance and provide real-time feedback to trainees. In addition to the standardized simulation scenarios, some specialties have also developed procedural skills training modules.2

Dr. Taylor Sawyer conducting in-situ simulation training with pediatric residents in the Neonatal Intensive Care Unit at Tripler Army Medical Center (Photo: Author)
Dr. Taylor Sawyer conducting in-situ simulation training with pediatric residents in the Neonatal Intensive Care Unit at Tripler Army Medical Center (Photo: Author)

In order to support the simulation curricula of the various subspecialties, each CSC Simulation Center is provided with a centrally funded, standardized, and specialty specific Simulation Packages (SP). Each SP includes a group of simulation equipment (task trainer, manikins, virtual reality trainers, etc.) to be used for a particular specialty. The simulators included in the initial SPs were chosen at the CSC annual meeting in 2007, when the CSC Specialty Advisors evaluated available simulators and chose items that would support the core curriculum they were developing, provide reasonable fidelity for the assigned task, and would be able to be used by multiple specialties. This central purchasing and distribution was done to save money by avoiding duplicate purchases. It has had the additional benefit of creating an SP that has been used to upgrade CSC sites that have added GME training programs since 2007. At present, minor equipment purchases and distribution takes place on an ongoing basis at a local level directed by simulation educator requests within the CSC and at the individual MTFs. The five-year life-cycle replacement for the initial SPs purchased in 2007 is planned for FY 2012. New SPs will be created and then purchased for each of the specialties.

Simulation-based redeployment “refresher” training for military medical providers returning from duty in Iraq and Afghanistan is available at MTFs with CSC Simulation Centers. The same curricula and equipment used for GME are available for the returning staff physicians. Current OTSG Policy (09-078), published in September 2009, formalizes the process for assessing the needs of providers and offering refresher training after deployment. When providers return to their hospital, they meet with their Department Chair and discuss what, if any, refresher training they feel is needed. Each provider is contacted by the CSC and given an information packet about the policy with contact information for any questions and sent an online survey asking about their deployment experiences both when they return and approximately 6 months later. Within this OTSG policy information packet is an overview of what simulation-based training is available at CSC Simulation Centers and points of contact within the CSC who can coordinate simulation-based redeployment training.

The CSC is dedicated to improving the science of simulation, and is actively involved in simulation-based medical research. Since 2002, members of the CSC have published 40 articles in peer-reviewed journals on medical simulation. The majority of these publications are original research, reporting results of rigorously conducted evaluations of simulation training methodologies and/or the validation of simulation trainers/technologies. Additionally, members of the CSC have authored, or co-authored, several book chapters. As of FY2011, members of the CSC have received and managed over $8.13 million in grants and external funding for simulation-based training and research and the CSC currently has several large-scale, multi-center, ongoing research projects. Currently underway are a multisite validation study of a new laparoscopic nephrectomy simulator, a multi-site study on the retention of pediatrics resuscitation skills by residents, and a multi-center investigation of laparoscopic skills before and after military deployment.

In order to encourage simulation-based research within the AMEDD, the CSC has included a Simulation Research Forum at the annual CSC meeting. Presentations are solicited and accepted from any AMEDD personnel conducting simulation-based research, and the investigators do not have to be members of the CSC. Submissions and presentations are judged and the CSC grants a CSC Research Award, including a stipend for the winner to travel to a national meeting to present their research. The CSC has also encouraged MTFs to support local simulation research by including awards for outstanding simulation research at MTF research competitions.

Vision of the CSC

The vision of the CSC is to ensure that all Army providers are, “trained, competent, safe, and ready to care for our Soldiers and their families.” Since its inception, the CSC has been involved in numerous performance improvement activities and patient safety initiatives throughout the AMEDD. One example is the Mobile Obstetric Emergencies Simulator (MOES). 3 This manikin-based simulation system includes a birthing manikin and integrated software program used to display a fetal strip. The system can be used to conduct simulation training in multiple common obstetric emergencies including shoulder dystocia, post-partum hemorrhage, and eclamptic seizure. The MOES includes a standardized curriculum, debriefing system, objective grading forms, and integrates TeamSTEPPS® concepts in order to identify and address actual individual, team, and system issues that arise during training. The MOES was recognized with the 2007 Patient Safety Award from TRICARE Management Activity and the CSC was given funding to propagate the program (which included funding to train a physician and nurse from each institution and also purchase the equipment for each MTF) to all 54 MTFs within the Army, Navy, and Air Force that provide obstetric care.

 

The CSC recognizes the importance of faculty development and has a program in place to train simulation educators, operators, and facilitators. Each year at the annual CSC meeting there is a Faculty Development Day. The goals of the CSC Faculty Development Day is to allow simulation educators to become familiar with the simulation equipment available within the CSC Simulation Centers and improve the quality of simulation-based training in the AMEDD. In past years, topics presented at the CSC Faculty Development Day have included; facilitating and debriefing in simulation (2009), simulation curriculum development (2010), and simulation evaluation tool design and validation (2011). In addition, the CSC Faculty Development Day is approved for American Medical Association Physician’s Recognition Award (AMA PRA) Category 1 credits through the U.S. Army Medical Command Continuing Medical Education (CME) Office. On a local level, several of the CSC Simulation Centers have developed faculty development courses that are offered on a regular basis to build and sustain internal simulation educators. The CSC is currently working to develop a standardized simulation educator course. Additionally, the CSC is collaborating with the Uniformed Services University of the Health Sciences (USUHS) and the Naval Postgraduate School in Monterey, California to create a postgraduate course in advanced medical simulation.

 

Key to the mission of the CSC is to validate the quality of the education provided within its Simulation Centers. In order to do this, the CSC has placed an emphasis on application for accreditation by its individual Simulation Centers. As of 2011, 10% of the CSC Medical Simulation Centers have received Accreditation by the American College of Surgeons (ACS), and 20% have received Accreditation by the Society for Simulation in Healthcare (SSH) Council for Accreditation of Healthcare Simulation Programs. This year, two additional CSC centers have submitted accreditation packets to the SSH and one has submitted a packet to ACS. Strategic plans for the CSC include a goal of 100% accreditation of all CSC Simulation Centers by 2013.

 

Conclusion

In this report we have described the development, structure, accomplishments, and future vision of the CSC. We hope this report provides simulation educators within the military, and our civilian simulation colleagues, insight into the workings of our organization. The CSC was established to provide a central and standard approach to implement simulation-based curricula for resident education in the Army, provide a program for simulation-based redeployment refresher training of physicians, and improve patient safety throughout the AMEDD. Although the CSC has made great progress towards many of these goals, there is still a significant amount of work that remains to be done, and research is needed to define the impact of the CSC on patient safety within the AMEDD. Building on the momentum the CSC has generated, and working with our civilian colleagues in academia, the CSC will continue to work to optimize the training our centers provide and improve patient safety both within and outside the AMEDD.

The views expressed in this manuscript are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the U.S. Government.”

REFERENCES:

  1. Hemann B, Hall N, Mikita J. Surviving Simulated Sepsis. MedEdPORTAL; 2010. Available at: http://services.aamc.org/30/mededportal/servlet/s/segment/mededportal/?subid=8196 Accessed February 2, 2012.
  2. Sawyer T, Creamer K, Puntel R, Lin J, Steigelman D, Lopreiato J, et al. Pediatric Procedural Skills Training Curriculum. MedEdPORTAL; 2010.       Available at: http://services.aamc.org/30/mededportal/servlet/s/segment/mededportal/?subid=8094 Accessed February 2, 2012.
  3. Deering SH, Rosen MA, Salas E, King HB. Building team and technical competency for obstetric emergencies: The Mobile Obstetric Emergencies Simulator (MOES) System.”       Sim in Healthc. 2009;4:166-173.

 

Figure Legends:

Figure 1.

The locations of the 10 current Central Simulation Committee (CSC) Medical Simulation Centers within the continental United States and Hawaii.

Figure 2.

The Mobile Obstetric Emergencies Simulator (MOES).

Figure 3.

One of the authors (T.S.) conducting in situ simulation training with pediatric residents in the Neonatal Intensive Care Unit at Tripler Army Medical Center.