previously published in MTM issue 3, 2017
Jeffrey P. Gold, MD and Pamela J. Boyers, PhD profile the Interprofessional Experiential Center for Enduring Learning (iEXCELSM) at the University of Nebraska Medical Center (UNMC), which is a bold, interprofessional initiative purposefully designed to transform the current model of healthcare professions education.
Outcomes for education and patient care will be improved through the creation of a “state-of-the art”, comprehensive healthcare education, training and research facility: the Dr. Edwin Davis & Dorothy Balbach Davis Global Center for Advanced Interprofessional Learning (Davis Global Center). This facility is designed to accelerate the adoption of advanced simulation and contribute to the overarching vision for iEXCEL, which is to support the Triple Aim of Health Care: better quality, better health, lower costs (Berwick 2008).”.
iEXCEL has been created to address healthcare concerns faced in the US and support the Triple Aim of Health Care through educating healthcare providers using a new model that begins early and continues throughout a lifetime of training.
Call to Action
Concerns for the current model for health professions education include: an outmoded system that remains heavily reliant on lectures; learning professional skills and procedures on real (and frequently very sick) patients in highly technical and fast-paced clinical settings; and an escalating hospital mortality rate due to what many consider to be avoidable medical errors. Meanwhile, as simulation technologies become increasingly sophisticated, the new generation of learners is demanding digital tools and self-directed and experiential learning opportunities – including the use of mobile platforms, interactive 3D, and Augmented and Virtual Reality (AR/VR).
Traditional real-time supervision and mentorship in the clinical settings by skilled and experienced clinicians has, and likely always will be, of critical importance. However, healthcare professionals at all levels of training are still predominantly learning to take care of patients in highly stressful “hands on” clinical environments, including learning how to develop professional skills and conduct procedures in the real world of medical care. Despite reduced opportunities to spend time with patients, reduced availability of busy faculty clinicians, duty hour restrictions resulting in reduced exposure to procedures, and overcrowded rotations at clinical training sites, future doctors, nurses, physician assistants and allied health professionals are expected to perform at “tournament level” when they graduate. Professional golfers or commercial airline pilots, for example, would not be expected to function under such circumstances without practicing until considered ready (competent) to function at routine as well as high-stakes events.
Adoption of Simulation in Healthcare
While most medical, nursing and allied health education involves simulation experiences, unlike aviation, the current rate of adoption of simulation in health care does not allow learners the opportunity to routinely practice the full range of skills and teamwork necessary to prepare for the safest possible care of patients. In addition, during a lifetime of modern practice, many new procedures, including those using new diagnostic and interventional technologies, the use of new surgical instrumentation, and the successful interface of human-machine interaction is still largely taught by the companies that develop the technologies or medical equipment. A comprehensive simulation center with well-trained faculty and staff can and should provide safe venues for practicing all procedural skills and for training with new equipment or technology. Medical simulation also creates opportunities to learn the “softer skills”, such as the development of interprofessional communication, critical thinking, diagnostic skills, clinical judgement and how to work effectively in healthcare teams.
Applying Lessons Learned
Poised to address the fact that medical errors are now a leading cause of death in the United States by revolutionizing healthcare education, the UNMC iEXCEL program, a center of excellence, is adopting lessons learned from other High Reliability Organizations (HROs), such as aviation, oil and gas, and the military. All HROs address quality and safety in their respective fields by reducing errors and improving efficiencies using a wide range of modeling, simulation and visualization technologies. HROs also demand the certification of operators prior to real world performance, and at regular intervals thereafter. For example, airline pilots absolutely do not fly a commercial airliner prior to being assessed as competent to do so. Aviation also found that assessing technical competency alone was not sufficient and moved to address the human factor element of safety by adding Crew Resource Management (CRM) to their training programs. Since a significant number of aviation catastrophes are due to poor communication (or to a crew member being unwilling to speak up at early signs of trouble), iEXCEL is applying this strategy to healthcare to help reduce medical errors. Hence, the high priority for iEXCEL is interprofessional collaboration, communication and team training.
An iEXCEL Competency-Based Training Model
Deep in the iEXCEL concept of an interprofessional, experiential, career-long learning model is the desire to create a discipline-shared, competency-based training and assessment model. The goal is for healthcare education at UNMC to move beyond a comparatively subjective evaluation of performance by creating valid and reliable methods of assessment that more accurately evaluate the performance of an individual or team. To support this endeavor, the Davis Global Center is fully equipped with cameras in the simulation spaces, including in the corridors, to capture and record all simulated activities. While the practice of simulation capture is common to many simulation centers, the use of this system to reliably analyze and assess performance while providing ongoing feedback to learners has yet to mature. Also desired is a competency-based approach with the capability of forecasting and analyzing performance to meet the demands of working in the modern healthcare system. The ideal competency assessment model in healthcare would include requiring and recording competencies from the time an individual enters the profession to the time they retire, and developing career-long, criteria-based learning models for each individual professional with relevant proficiencies and experiences.
The Davis Global Center
When completed in the summer of 2019, iEXCEL will be housed in a new facility, the Dr. Edwin Davis & Dorothy Balbach Davis Global Center for Advanced Interprofessional Learning, on the UNMC campus in Omaha, Nebraska. This new building has been purposefully designed to foster interprofessional collaboration and encourage the practice of procedures, hand-offs and transitions from one level of care to the next – including home and community care. For ease of access, this five-level facility is sited on the UNMC Omaha campus where faculty, staff, students and researchers from the university’s health professions colleges and Nebraska Medicine (NM), UNMC’s clinical partner, have the widest possible array of simulation technology available in a comprehensive range of realistic simulated healthcare environments. Simulation modalities available include: surgical simulation labs (fresh tissue); advanced simulated health care settings (human patient simulators and task trainers); specialized training in biopreparedness, and “state-of-the-art” visualization technologies including 3D/AR/VR and holographic technology. Originally used in entertainment, the worlds of gaming, modeling and simulation are now converging to offer different and exciting ways to transfer knowledge, and learn and apply new skills in what is being referred to in the Virtual Reality (VR) world as “serious games.”
Statewide and Global Connectivity
The Davis Global Center is designed to maximize outreach capabilities, especially to the training sites and hospitals in the rural areas of Nebraska. A strong emphasis on the integration of technologies provides the capability of transferring media and data across distances, thereby enhancing the collaborative nature of the network and standardizing training across the state. This technological integration initiative will support telepresence and telementoring, and will allow expanded connectivity for telehealth in partnership with UNMC’s primary clinical partner, Nebraska Medicine. Currently, iEXCEL is deploying interactive digital touch screen walls and AR/VR technologies in a real-time role at other teaching sites in the rural areas of Nebraska.
Training outreach is also supported by deployable mobile simulation learning laboratories, Simulation in Motion (SIM-NE), a program created by UNMC and the Leona M. and Harry B. Helmsley Charitable Trust to conduct rural simulation training and disaster preparedness exercises for emergency medical services (EMS) providers and rural critical access hospitals. SIM-NE’s experiential training opportunities ensure consistent, quality-driven pre-hospital and hospital emergency training provided free of charge.
iEXCEL: A Federal, State and City Enterprise
Committed to the vision to provide interprofessional and competency-based education using simulation, the State of Nebraska and the City of Omaha, with extraordinary support from private donations, have joined to invest in the creation of this new educational model, the need for which has been much discussed, including by many national accrediting bodies, but has yet to be fully realized.
iEXCEL – Public-Private Partnerships
To stimulate economic growth for the State of Nebraska, the work accomplished in the Davis Global Center will promote and foster research and development through the establishment of public-private partnerships. A recent in-depth study conducted by economic impact consultants (Tripp Umbach) estimates the potential annual economic impact of iEXCEL to reach $40M for the State of Nebraska. Therefore, critical to the success of iEXCEL is the creation of strategic and synergistic relationships with academia, industry, government, military and the Nebraska community. Such collaboration results in mutual learning and grant opportunities, specialized training activities and expanded sources of revenue generation. This academic/business model also opens gateways for faculty and students to engage in innovation initiatives as well as entrepreneurial activities in an ethical, safe and structured environment. Collaboration with disciplines beyond healthcare including engineering, instructional design, and computer science also generates new opportunities for research and development. In cooperation with industry and military collaborators, iEXCEL is already working on the development of new training modules and 3D and VR content, and iEXCEL is exploring and assessing new learning methods. Revenue generated through carefully selected industry and government collaborators will help support the inevitable upgrading of technology and software, and ensure that iEXCEL is consistently growing to meet the needs of the times.
A statewide network of interconnected simulation centers and clinical sites – supported by mobile simulation units. November 2016 Tranquil Surge Exercise: EMS staff transporting Image credit: UNMC.
Economic and Workforce Development
The Davis Global Center is projected to create over 300 jobs (Tripp Umbach, 2016); however, iEXCEL will also educate, train and contribute to a relatively nascent field that lacks sufficient numbers of skilled workers who can operate 3D/VR/AR technology and create 3D/VR/AR and holographic content.
Due to a global shortage of 3D/AR/VR technicians and software developers, the Davis Global Center will house an industry certificate program for training this emerging workforce in the arena of producing content modules for healthcare education as well as for a myriad of settings of clinical practice. Thus, in addition to serving as a hub that stimulates innovation in education, training and research, iEXCEL will be a catalyst for workforce development for Nebraska and nationwide.
In anticipation of the opening of the Davis Global Center, the prototype for iEXCEL is well underway. A team of iEXCEL staff currently serves many important roles, including supporting curriculum redesign, fostering the adoption of experiential learning, testing and trialing simulation technologies, training simulation and technology specialists, beginning the journey into visualization, engaging students with digital technologies, and contributing to the design and functionality of the Davis Global Center. Due to these initiatives, the UNMC/NM “early adopters” are already creating innovative content and enduring learning experiences.
National Center for Health Security
Nebraska Medicine and UNMC received a $19.8 million federal grant as well as enduring annual operations support from the U.S. Department of Health and Human Services to create the National Center for Health Security and Biopreparedness, which will be housed in the Davis Global Center enabling UNMC to teach federal health care personnel procedures in the treatment of highly infectious diseases.
Bringing Learning to Life
Case Study I
Interprofessional Education: Visualization & Simulation
Students from the University of Nebraska Medical Center’s Diagnostic Medical Sonography and Medical Nutrition Education programs collaborated to combine traditional learning with new technologies: a 2D interactive digital iWall, standardized patients and an ultrasound machine. This combination allowed students to engage in interprofessional teamwork while learning how each discipline addresses pregnant patients with normal and abnormal fetal growth patterns. Using actual patient case studies in a highly interactive exercise, the sonography students assisted the medical nutrition students in analyzing ultrasound growth reports. They used the interactive digital wall to view and manipulate real patient data and, for example, circled the measurements of interest and determined the type of intrauterine growth restriction (IUGR) present by drawing a fetus reflecting the type of IUGR. These skills are being applied in the Medical Center’s high-risk OB unit to enhance instruction and clinical care.
“The activity provided students with a collaborative and interactive learning experience which allowed them to work together to critically think through issues which they will encounter in the clinical practice,” Tanya Custer, MS, RT, UNMC
Case Study II
Interdisciplinary Education: Advanced Clinical Simulation
An interdisciplinary team of Nebraska Medicine faculty and staff incorporated a nationally recognized course to help standardize the approach of all disciplines for the insertion of a central line catheter. The overall goal was to enhance the quality and safety for this procedure and reduce the central line-associated bloodstream infection (CLABSI) rate. Using ultrasound machines, central line simulation models and central line kits, learners were trained in a standardized approach for central line insertion. Using simulation technology, they practiced and were assessed on the proper use of ultrasound and maintenance of sterile process throughout the procedure. Through this course and other focused initiatives, UNMC has experienced a dramatic reduction in the hospital acquired CLABSI rate.
“Far better is it to dare mighty things, to win glorious triumphs, even though checked by failure, than to rank with those poor spirits who neither enjoy much nor suffer much, because they live in that grey twilight that knows neither victory nor defeat.” – Theodore Roosevelt
About the Authors
Jeffrey P. Gold, M.D., is a nationally recognized leader and tireless advocate for transforming academic medicine and health care delivery. Based upon his medical and engineering background, he had a major dedication to advanced simulation and high technology blended education, now spanning several decades. A board-certified thoracic surgeon, Dr. Gold is the eighth chancellor of the University of Nebraska Medical Center and chairs the board of UNMC’s principal clinical care system partner, Nebraska Medicine. Dr. Gold is responsible for all aspects of UNMC campus administration, academic and clinical leadership. UNMC is known for prolific medical science research, cutting-edge education and a decade-plus building boom of state-of-the-art infrastructure, including the Fred & Pamela Buffett Cancer Center.
Pamela J. Boyers, Ph.D., is the Associate Vice Chancellor for Clinical Simulation for the Interprofessional and Experiential Center for Enduring Learning (iEXCEL) at the University of Nebraska Medical Center (UNMC). With significant experience in designing and operating medical simulation centers, Dr. Boyers is well-published and speaks nationally and internationally about the need to address the quality and safety of care through transforming the education of health care professionals. To help improve the outcomes of care, Dr. Boyers believes in working closely with industry collaborators as well the U.S. military in order to learn from their experiences, thus ensuring best practices related to the application of simulation technologies to improve the outcomes of training and patient care.
1.Berwick D., Nolan T., Whittington J., The Triple Aim: Health Affairs, May 2008, Vol 27, no3, pp759-769
2.Tripp Umbach Report on iEXCEL at the University of Nebraska Medical Center; 2016
Acknowledgement: Christopher J. Kratochvil, M.D., Associate Vice Chancellor for Clinical Research, University of Nebraska Medical Center.