Welcome to the Clinical Center Grand Rounds,
a weekly series of educational lectures for physicians and
health care professionals broadcast from the Clinical
Center at the National Institutes of Health in
Bethesda, MD.
The NIH Clinical Center is the world's largest hospital totally
dedicated to investigational research and leads the global
effort in training today's investigators and discovering
tomorrow's cures.
Learn more by visiting us online at http://clinicalcenter.nih.gov
TODAY WE'RE HONORED TO HAVE
DR. MARY FEY.
SHE'S A PRINCIPLE FACT MEMBER
FOR MEDICAL SIMULATION HARVARD
AND MANAGING PARTNER AT
TRANSFORMATIVE TEACHING LLC.
SHE RECEIVED HER BACHELOR'S IN
NURSING AND MASTER'S IN
ADMINISTRATION FROM UNIVERSITY
BALTIMORE AND HER RESEARCH
THESIS FOCUSSED ON
SIMULATION-BASED TRAINING
EXPERIENCES.
SHE SERVED AS THE DIRECTOR OF
THE DEBORAH L. CLINICAL
SIMULATION LABORATORY UNIVERSITY
OF MARYLAND SCHOOL OF NURSING
ONE OF THE LARGEST NURSING
SIMULATION TRAINING PROGRAMS IN
THE COUNTRY.
SHE THEN JOINED THE NATIONAL
LEAGUE FOR NURSING FOR THE
CENTER FOR ACADEMIC AND CLINICAL
TRANSITIONS WHERE SHE
CO-AUTHORED THE NLV VISION FOR
TEACHING AND SIMULATION AND THE
NLV VISION FOR DEBRIEFING ACROSS
THE CURRICULUM.
THESE TWO PAPERS HAVE BEEN
DOWNLOADED IN THE SERIES.
AFTERWARDS DR. FEY COMPLETED HER
POST-DOCTORAL FELLOWSHIP AND
JOINED AS A LECTURER,
SPECIALIZING FACULTY DEVELOPMENT
AND HER WORK HAS FOCUSSED ON
FACULTY DEVELOPMENT AND
DEBRIEFING AND SIMULATION
EDUCATION AND TEACHER-LEARNER
RELATIONSHIP.
FROM 1920 TO 2021 SERVED AS THE
CENTER DIRECTOR FOR TEACHING AND
LEARNING.
CURRENTLY SHE TEACHES AS AT THE
CENTER AND IS CONSULTANT
FOCUSSING ON NURSING EDUCATORS
AND ADJUNCT FACULTY AT DREXEL.
SHE'S INTERNATIONALLY RECOGNIZED
FOR HER EXPERTISE IN SIMULATION
TRAINING FROM CONCEPT TO DESIGN
AND IMPLEMENTATION.
SHE'S A FELLOW IN THE NATIONAL
LEAGUE FOR NURSING ACADEMY OF
NURSE EDUCATORS AND FELLOW IN
THE AMERICAN ACADEMY OF NURSING.
SHE'S ACTIVELY INVOLVED IN THE
SOCIETY FOR SIMULATION HEALTH
CARE AS A RESEARCH MENTOR
LEADING THE DEVELOPMENT OF
CERTIFIED HEALTH CARE
STIMULATION ADVANCE D
CERTIFICATION PROGRAM AND HER
TALK IS GREAT MINDS DON'T ALWAYS
THINK A LOT.
SIMULATION'S ROLE IN BUILDING
TEAM COGNITION.
AND BECOME MORE COORDINATED
TEAMS FOR THE BENEFIT OF PATIENT
OUTCOMES.
AS I TALK ABOUT THIS I WANT TO
START TALKING ABOUT A MODEL FOR
TEAM WORK THAT'S BEEN AROUND 20
MILLION YEARS.
JUST LIKE US WHO COME TO WORK
EVERY DAY WE USUALLY FUNCTION AS
HIGHLY SPECIALIZED INDIVIDUALS
THAT ARE INTEGRATED INTO A
LARGER TEAM.
SO THE FIRST MODEL I WANT TO
TALK ABOUT FOR TEAM WORK IS THE
HONEY BEE.
AS I SAID, HONEY BEES HAVE BEEN
AROUND FUNCTIONING IN THEIR
COLONIES, WE HAVE FOSSIL
EVIDENCE FROM ABOUT 20 MILLION
YEARS AGO.
I'M A BEEKEEPER AND LEARNED SO
MUCH FROM MY BEES ABOUT HOW
INDIVIDUALS WITH HIGHLY
SPECIALIZED ROLES BECOME
INTEGRATED INTO A LARGER
ORGANISM AND HOW THAT ORGANISM
PRODUCES SOMETHING GREATER THAN
THE SUM OF THE INDIVIDUAL PARTS.
WARNING, I'LL BE SHOWING HONEY
BEE VIDEOS DURING THE TALK AND
WHEN I SEE ONE MY HEART IS
FILLED WITH BEES BUT IF YOU
DON'T WANT TO SEE THEM PLEASE
LOOK AWAY AND I'LL WARN YOU
BEFORE I SEE THE VIDEOS.
THIS IS THE HONEY BEE HIVE.
THE HIVE IS THE STRUCTURE THEY
LIVE IN.
AS YOU LOOK AT THIS VIDEO IT
KIND OF LOOKS LIKE RANDOM FLIGHT
OF A BUNCH OF BUGS BUT THERE'S A
LOT GOING ON BEHIND THE SCENES.
EACH BEE IN THE COLONY HAS A
HIGHLY SPECIALIZED JOB YET
THEY'RE ALL INTERDEPENDENT ON
EACH OTHER TO ACHIEVE THEIR
ULTIMATE GOAL WHICH IS SURVIVAL
OF THE HIVE.
SO THESE BEES YOU SEE ON THE
OUTSIDE ARE PRETTY OBVIOUS
THERE'S BEES PLAYING A LOT OF
DIFFERENT ROLES.
EACH FEMALE BEE THE FEMALE BEE
PASSES THROUGH SPECIALIZATION.
THE FIRST JOB THE BEE HAS IS
BECOME A CLEANER.
THEY CLEAN THEY CELL THEY WERE
IN AND ANY ADJACENT CELLS SO THE
CELLS ARE READY FOR THE QUEEN
COMES PAST AND WANTS TO DEPOSIT
AN EGG.
THEN THEY BECOME NURSE BEES.
THE NURSE BEES ARE THE BEE FEED
THE LARVAE DEVELOPING FROM THE
STORES IN THE HIVE FROM THE
HONEY AND POLLEN.
THEY'RE UNDERTAKER BEE.
THE INSIDE OF A BEE HIVE IS VERY
CLEAN.
BEES DO NOT ELIMINATE OR ALLOW
DEAD BODIES TO ACCUMULATE SO THE
UNDERTAKER BEES' JOB IS TO PICK
UP THE BODIES AND LET THEM GO
OUTSIDE THE HIVE.
THERE'S ARCHITECT BEES OR THE
BUILDER BEES.
THEY MONITOR THE AVAILABILITY OF
EMPTY HONEYCOMB AND MAKE SURE
THERE'S ENOUGH FOR THE QUEEN TO
LAY HER EGG AND FOR THE BEES TO
MAKE NECTAR UP TO MAKE HONEY IN
AND STORE POLLEN FOR FOOD FOR
THE WIN TER.
THERE'S TWO THINGS ON THE
OUTSIDE OF THE HIVE.
MOST BEE THE FORAGER BEE.
THAT'S THE LAST JOB ANY BEE WILL
HAVE IN HER LIFE AND THEY BRING
THE POLLEN AND HONEY BACK TO THE
HIVE.
WHAT YOU CAN'T SEE THAT'S ALSO
GOING ON THE ENTRANCE OF THE
HIVE IS GUARD BEES AND BEES DO
NOT ALLOW BEE THAT DON'T LIVE IN
THAT HIVE TO COME IN AND IT'S
THE GUARD BEES HIVE SMELL EVERY
BEE OR SOMETIMES INVASIVE WASPS
THAT PREY ON BEES TRY TO GET IN
THE HIVES AND THE GUARD BEES
WILL ATTACK THEM AND DRIVE THEM
AWAY FROM THE HIVE.
I'LL SHOW YOU ONE MORE VIDEO.
THESE GUYS ARE THE VENTILATOR
BEES.
THEY ARE BEATING THEIR WINGS IN
THIS DIRECTION.
THEY'RE BRINGING FRESH AIR INTO
THE HIVE SO THEIR MANAGING THE
OXYGEN AND CARBON DIOXIDE LEVELS
INSIDE THE HIVE AND THEY'RE
MAINTAINING THE TEMPERATURE OF
THE HIVE.
THE INSIDE OF A BEE HIVE STAYING
BETWEEN 93 AND 96 DEGREES
FAHRENHEIT AT ALL THESE TIMES.
WE SOMEWHERE ALL THESE BEES WITH
SPECIALIZED ROLLED AND ALL
DEPENDENT ON EACH OTHER TO STAY
IN THEIR ROLE AND DO THE JOB AND
THE VENTILATOR BEES DON'T WORRY
ABOUT WHETHER THE UNDERTAKER
BEES DO THEIR JOB BECAUSE THEY
HAVE THEIR JOB.
SO INSIDE THE BEE HIVE ABOUT 95%
OF THE BEE FEMALE.
AND ABOUT 5% ARE THE BOY BEES.
AND THEN WITHIN EACH BEE HIVE
THERE'S ONE QUEEN.
SO LET'S TALK ABOUT THE OTHER
SPECIALIZED ROLES.
FIRST WE'VE GOT THE BOYS.
THE BOYS SADLY CONTRIBUTE VERY
LITTLE TO THE DAILY WORKING OF
THE HIVES.
BUT THEY HAVE ONE VERY
APPRECIATION RESOURCE AND THAT
IS THEY HAVE THE SPERM THAT IN
THE EVENT THE PRESENT QUEEN DIES
AND A NEW QUEEN EMERGES THE BOY
BEE THERE TO CONTRIBUTE SPERM
FOR THAT PURPOSE.
WHEN A NEW QUEEN IS FORMED SHE
GOES ON HER NUPTIAL FLIGHT AND
MATE BETWEEN 12 AND 40 DRONE
BEES AND COLLECTS ALL THE SPERM
SHE'LL NEED FOR THE REST OF HER
LIFE AND NEVER LEAVE THE HIVE
AGAIN AND LAYS BETWEEN 1,000 AND
1500 EGGS EVERY DAY OF HER LIFE
FOR HER WHOLE LIFE SPAN WHICH
USUALLY LAST BETWEEN TWO AND
THREE YEARS.
SO EACH OF THESE BEES HAD A
HIGHLY SPECIALIZED ROLE.
THEY ALL HAVE TO WORK DWEJ AND
ALL HAVE ONE COMMON GOAL WHICH
IS SURVIVAL OF THE HIVE.
AND I THINK IT'S PRETTY EASY FOR
PEOPLE TO LOOK AT THE QUEEN BEE
AND THINK SHE'S THE MOST
IMPORTANT FOR THE LEADER BUT
SHE'S REALLY JUST ANOTHER BUG
WITH A JOB.
BUT EVERY DAY AS THE BEES ARE
GOING THROUGH THEIR ROLES,
THINGS DON'T USUALLY GO TO
DISRUPTIVE AND THINGS GO ALONG
PRETTY WELL AND EASILY BUT EVERY
ONCE IN A WHILE IT'S NOT
BUSINESS AS USUAL.
YOU'VE PROBABLY ALL SEEN
PICTURES OF SOMETHING THAT LOOKS
LIKE THIS WHEN THIS IS CALLED
THE SWARM WHEN A SWARM ENDS UP
IN THE DUGOUT OF A BASELINE
FIELD WE SEE IT ON THE NEWS OR
SOMETIMES YOU'LL SEE IT ON THE
NEWS IF THEY ARE IN A PUBLIC
PLACE.
I WANT TO TALK ABOUT WHAT'S
GOING ON WITH A SWARM BECAUSE
THIS IS WHEN THINGS OUT OF THE
ORDINARY THINGS HAPPEN AND JUST
LIKE US COMING TO WORK EVERY DAY
MOST DAYS IT'S KIND OF BUSINESS
AS USUAL.
WE DO OUR VERY IMPORTANT JOBS
AND DO THEM PRETTY WELL BUT ONCE
IN A WHILE MORE CHALLENGING
THINGS COMES UP AND WHAT'S
HAPPENING TO THE BEE COLONY WHEN
THERE'S A WARM AND THIS IS A
NATURAL LIFE SICKLE AND THE BEE
HIVE GROWS AND THE POPULATION
GROWS AND IT'S NOT THAT GOOD FOR
THE BEES TO STAY BECAUSE THERE'S
TOO MANY BEES AND THEY KNOW HALF
THE HIVE HAS TO LEAVE.
I HAVE NO IDEA HOW THEY DECIDE
WHO'S GOING AND STAYING.
IN THE DAYS AND WEEKS LEADING UP
TO WHEN HALF THE HIVE IS GOING
TO BE LEAVING THE FORAGER BEES
START TO GORGE ON HONEY AND PROD
THE QUEEN AND START TO PUSH HER
AROUND SO SHE HAS TO MOVE MORE
SO SHE LOSES A LITTLE BIT OF
WEIGHT TO MAKE IT EASIER TO FLY
AND THEY DO THINGS IN
PREPARATION FOR THE BIG MOMENT.
ONCE THE QUEEN REALIZES
EVERYBODY IS READY TO GO SHE
SETS OFF A SERIES OF CHIRPING
NOISES THAT TELLS THE BEES WE'RE
READY TO GO AND SHE LEAVES THE
HIVE AND HALF THE HIVE LEAVES
WITH HER ABOUT 20,000 BEES AND
SHE'S IN THE MIDDLE AND THEY'RE
ALL AROUND HER TRYING TO KEEP
HER WARM.
NOW WE HAVE REALLY SOMETHING OUT
OF THE ORDINARY GOING ON AND
THEY HAVE TO SWITCH THEIR ROLES
IN THE SAME WAY AS IF I'M A
NURSE ON THE WARD TAKING CARE OF
MY PATIENT BUT THEY HAVE CARDIAC
ARREST NOW I BECOME THE PERSON
AT THE MEDICATION CART DRAWING
UP THE EMERGENCY DRUGS OR MAYBE
I BECOME THE NURSE RECORDING AND
KEEPING TRACK AND MAKING SURE
THE TEAM IS ALL ON THE SAME
PAGE.
SAME WITH BEES.
SO THE FORAGERS SWITCH ROLES AND
BECOME SCOUT BEES.
THEY START TO LOOK FOR NEW PLACE
TO LIVE.
THE SCOUT BEES WILL ALMOST
INVARIABLY PICK A CAVITY THAT
HOLDS ABOUT TWO LITERS ABOUT 22
FEET OFF THE GROUND AND FACE THE
SOUTHEAST.
THEY KNOW WHAT THEY'RE LOOK FOR.
HOLLOWED OUT TREE, EMPTY
BUILDING.
AS THE SCOUT BEES FIND A GOOD
ONE THEY COME BACK AND TELL THE
HIVE WHERE THE NEW HOMES ARE AND
THERE'S SEVERAL SCOUT BEES WITH
MULTIPLE OPTIONS.
AND SO CERTAIN BEES START TO FLY
OUT TO THESE TWO HOMES AND CHECK
OUT WHAT THE SCOUT BEES ARE
TELLING THEM TO DO UNTIL
EVENTUALLY ALL THE BEES START TO
GO TO ONE PLACE.
THEY'VE ENGAGED IN A DECISION
MAKING PROCESS WHERE THEY'VE ALL
HAD TO PROCESS INFORMATION,
COMMUNICATE WITH EACH OTHER WHAT
THE OPTIONS ARE, UNDER A LOT OF
TIME PRESSURE AND UNDER A LOT OF
ENVIRONMENTAL THREATS.
IF THE TEMPERATURE DROPS, IF
THERE'S A COLD RAIN IT ALL GOES
TO THE SURVIVAL OF THE HIVE AND
IN CLINICAL CARE WHEN WE'RE
EXPECTED WITH LIFE AND DEATH
SITUATIONS WE HAVE TO MAKE
DECISIONS AN SHORT PERIOD OF
TIME OR WE HAVE A RESEARCH
PROTOCOL WE WILL GO THIS WAY,
STEP ONE, TWO, THREE, FOUR AND
BECAUSE HUMANS ARE HUMANS WE GET
THROWN QUICK BALLS AND HAVE TO
ASSESS AND CHANGE OUR ROLES TO
MEET THE DEMANDS OF THE
SITUATION.
SAME WITH BEAUS.
-- BEES.
ONCE THE BEES HAVE PROCESSED
THEIR INFORMATION TOGETHER AND
MADE A NEW PLAN NOW FOR WHAT
WE'RE GOING TO DO IN THE
IMMEDIATE FUTURE THAT GETS
COMMUNICATED TO THE QUEEN AND
AGAIN SHE MAKES A SERIES OF
CHIRPING NOISES AND AT THAT
MOMENT THE ENTIRE SWARM LEAVES
AND THE INTERESTING PART, ONLY
20% OF THE BEES IN THE SWARM
HAVE EVER BEEN TO THE NEW HOUSE
AND YET AT THE SAME MOMENT THEY
ALL LEAVE THE BRANCH, FLY EN
MASSE TO THE NEW HOME AND ARRIE
TO THE NEW HOME TOGETHER.
IN ORDER FOR THAT TO HAPPEN
THERE HAS TO BE SOME SORT OF
AMAZING COMMUNICATION STRUCTURE.
NOW THEY'RE GOING IN THE
UNKNOWN, HOPING FOR THE BEST,
COMMUNICATING WITH EACH OTHER
ALONG THE WAY TO MAKE SURE
EVERYBODY STAYS SAFE AND WE
ACHIEVE OUR GOAL.
SOMETHING ELSE HAPPENS IN THE
SWARM.
YOU BASICALLY HAVE A BUNCH OF
BUGS THAT HAVE A CENTRAL
ANNIVERSARY SYSTEM BUT WHEN THEY
ALL CONNECT AROUND A SHARED GOAL
SOMETHING NEW EMERGES FROM THE
LITTLE BUGS AND IT'S A FORM OF
INTELLIGENCE.
AND DR. TOM SELEY AT CORNELL
TERMED IT SWARM INTELLIGENCE.
IN MY MIND WHAT WE DO AS WE FORM
AND REFORM AROUND OUR PATIENT
CARE AND INTELLIGENCE IS MORE
THAN EACH INDIVIDUAL
INTELLIGENCE EACH INDIVIDUAL
BROUGHT TO THE PATIENT CARE
SITUATION.
FOR US WE CALL IT TEAM
COGNITION.
FOR BEES IT'S SWARM
INTELLIGENCE.
THE KEY PART IN ACHIEVING OUR
GOAL IS COMMUNICATE EACH OTHER
IN A WAY WE UNDERSTAND AND
VALUE.
LET'S LOOK AT BEE COMMUNICATION.
BEE VIDEO COMING UP.
>>THERE'S MOVEMENTS AND SOUNDS
SHE PRODUCES.
THE WAGGLE DANCE IS THE ONLY
KNOWN SYMBOLIC LANGUAGE THAT
EXISTS OUTSIDE THE REALM OF
HUMANS AND NON PRIMATES.
THERE'S NOTHING THAT COMPARES TO
THE DANCE LANGUAGE OF THE MONEY
BEE.
>>THIS IS THE PART OF THE
PRESENTATION WHERE I TEACH YOU
ALL HOW TO DANCE.
NO.
BUT THE COMMUNICATION STRUCTURE
THAT EXISTS IN MY MIND PARALLEL
THE COMMUNICATION WE NEED TO
HAVE ON OUR HEALTH CARE TEAMS IF
WE'RE TO REACH OUR SHARED GOAL
OF DELIVERING THE BEST PATIENT
CARE WE CAN WHATEVER THE CONTEXT
MIGHT BE.
SO NOW TO PEOPLE THAT DON'T KNOW
HEALTH CARE THEY MIGHT LOOK AT
THIS PICTURE AND IT LOOKS LIKE A
BUNCH OF PEOPLE DRESSED IN BLUE
SWARMING AROUND ENGAGING IN
ACTIVITY.
TO OUR TRAINED EYE WE KNOW THIS
IS A PICTURE OF PEOPLE THAT
PROBABLY HAVE SPECIALIZED ROLES.
I'M GOING TO GUESS THE PERSON AT
THE HEAD OF THE BED PROBABLY
COMES FROM THE ANESTHESIA
DEPARTMENT AND AT THE BOTTOM IS
PROBABLY THE TEAM LEADER AND
RESPIRATORY SPECIALISTS AND
MAYBE NURSES AND MAYBE
PHARMACIST.
WE'RE VERY MUCH LIKE THE BEES IN
THAT WE HAVE HIGHLY SPECIALIZED
ROLES AND WE'RE INTERDEPENDENT
ON EACH OTHER IF WE ARE GOING TO
EXECUTE OUR TASKS.
AND JUST LIKE THE BEES, THOUGH
WE BRING INDIVIDUAL PERSPECTIVES
AND INDIVIDUAL INTELLIGENCE IN
THE ROOM AS WE COME TOGETHER
AROUND A SHARED GOAL, SOMETHING
LARGER EMERGES AND THE LARGER
THING THAT EMERGES IS TEAM
COGNITION.
NOW, THE GOOD THING ABOUT TEAM
COGNITION IS THERE'S COMPONENTS
THAT ARE MEASURABLE AND
OBSERVABLE AND REPEATABLE AND
ALSO AMENABLE TO TRAINING.
WHAT I WANT TO TALK ABOUT NEXT
IS WHAT ARE THOSE ELEMENTS OF
TEAM COGNITION WE CAN OBSERVE
AND MEASURE AND WE CAN ALSO
TRAIN.
THEN I'M GOING IT LINK THAT TO A
NUMBER OF STUDIES THAT SHOW WHEN
OUR TEAM COGNITION IS STRONGER,
OUR PATIENTS DO BETTER.
THERE IS NO QUESTION IN THE
LITERATURE WHEN WE TRAIN OUR
TEAMS TO COMMUNICATE BETTER AND
CONNECT BETTER AND TO RELATE TO
EACH OTHER PATIENTS DO BETTER.
LET'S TALK FIRST ABOUT WHAT
THOSE COMPONENTS ARE OF TEAM
COGNITION.
THERE'S TWO MAINLY I WANT TO
CONCENTRATE ON.
THE FIRST IS THE IDEA OF HAVING
A TEAM MENTAL MODEL.
AND TEAM MENTAL MODELS
ENCOMPASSES BOTH THE TASK AND
THE TEAM-RELATED KNOWLEDGE HELD
BY THE TEAM AS A UNIT.
THE NURSE HAS A PIECE OF THE
PUZZLE, THE PHYSICIAN HAS A
PIECE OF THE PUZZLE.
THE RESPIRATORY THERAPIST AND
PHARMACIST.
WE ALL KNOW THE PATIENT BUT IN A
DIFFERENT WAY.
AS WE COME TOGETHER AND AS WE
CREATE THIS SHARED MENTAL MODEL
ABOUT WHAT WE'RE DOING HERE IT
ALLOWS US TO DO A COUPLE THINGS.
IT ALLOWS US TO DESCRIBE WHAT'S
GOING ON BECAUSE WE'RE ABLE TO
INTERPRET INFORMATION IN THE
SAME WAY.
AS WE'RE LOOKING AT LAB DATA AND
THE PHYSICAL EXAM FINDINGS OF
THE PATIENT WE CAN ALL DESCRIBE
THEM IN THE SAME WAY.
IMPORTANTLY, IT ALLOWS US TO
ANTICIPATE WHERE WE'RE GOING.
IT ALLOWS US TO PREDICT AND THE
BEAUTIFUL THING ABOUT THIS IF
YOU THINK ABOUT COMPLEX
DISCHARGE I CAN MANY PATIENTS
HAVE COMPLEX DISCHARGE NEEDS AND
IF WE HAVE A SOCIAL WORKER WHO
KNOWS WHAT THE PATIENT WILL NEED
WE CKCAN ANTICIPATE THE RESOURC
IN IN NEED FOR THE PATIENT.
AND A NURSE MAY KNOW I HAVE TO
HAVE A DEFIBRILLATOR READY TO GO
AND ALLOWS US TO PREDICT AND
HAVE AN UNDERSTANDING HOW WE GOT
IN THE SITUATION TO BEGIN AND
ALL IDENTIFY CAUSAL EVENTS.
EACH MEMBER OF THE TEAM MAY HAVE
A SLIGHTLY DIFFERENT
CONTRIBUTION TO THIS.
ESPECIALLY WHEN I THINK OF
CAUSAL EVENTS OFTEN, I WAS A
CARDIAC NURSE OFTEN THERE WAS ED
CHEST PAIN OR SOMETHING AND THE
CARDIOLOGIST WILL LOOK AT HOW
BAD IS THE SITUATION.
WHAT DO WE NEED TO ACHIEVE?
WHERE DO WE NEED TO GO HERE?
THAT'S HAVING A STRONG TEAM
MENTAL MODEL.
THERE'S TWO QUALITIES THAT WORK
IN OUR FAVOR.
ONE IS WE HAVE TO HAVE SIMILAR
MEN MODELS.
EVERYBODY ON THE TEAM SHOULD BE
SEEING THIS IN THE SAME WAY.
THE OTHER THING ABOUT THE TEAM
MENTAL MODELS IS IT'S GOT TO BE
ACCURATE.
ONE PERSON IN THE ROOM IS
THINKING ABOUT ONE THING AND
OTHERS ABOUT THAT AND THAT'S
WHERE SIMULATION CAN HELP US.
IT PUTS OUR TEAM IN A PLACE
WHERE WE KNOW WHO'S ON THE TEAM,
WE KNOW WHAT THEY'RE CAPABLE OF
AND RESPECT WHAT EVERYBODY
BRINGS TO THE ROOM WHICH MAKES
IT EASIER FOR THE ONE PERSON TO
SPEAK UP AND SAY, HANG ON, GUYS
HAVE YOU CONSIDERED -- HOLD ON
ONE SECOND, DID YOU NOTICE?
THAT'S HOW TRAINING AND TEAM
MENTAL MODELS CAN HELP TEAMS
FUNCTION BETTER.
THAT'S ONE WAY THE OTHER
IMPORTANT COMPONENT IS TRANS
TRANSACTIVE MEMORY SYSTEMS.
WE KNOW WHO KNOWS WHAT ON THE
TEAM.
AS I THINK OF BRINGING TOGETHER
A GROUP PEOPLE TO START A NEW
RESEARCH PROTOCOL WE NEED TO
UNDERSTAND THE SKILLS EVERYBODY
BRINGS TO THE TEAM.
WHAT'S THE PHARMACIST KNOW ABOUT
THIS PARTICULAR DRUG?
WHAT DOES THE NURSE KNOW ABOUT
THIS PATIENT?
WHAT THE PHYSICIAN UNDERSTAND
ABOUT THE DIAGNOSIS?
THAT'S ALL IMPORTANT.
IN TRANS ACTIVE MEMORY SYSTEMS
WE OFTEN HAVE A STRONG
TRANSACTIVE MEMORY SYSTEM AND
WHERE PEOPLE ARE SUDDENLY THROWN
TOGETHER TO MAKE CRITICALS CAN
BE UNDER TIME PRESSURE WITH
ENVIRONMENTAL STRESSORS IT CAN
BE MORE DIFFICULT.
THERE ARE THINGS WE CAN TRAIN IN
SIMULATION TO IMPROVE OUR
TRANSACTIVE MEMORY SYSTEMS BY
COMING UP WITH QUICK AND EASY
WAYS TO ELICIT THAT INFORMATION
FROM THE TEAM AND TRANSACTIVE
MEMORY SYSTEMS THERE'S OTHER
PROPERTIES.
THERE'S THE SIMPLE KNOWLEDGE
PROPERTY, WHO DO I KNOW AND DO I
KNOW HOW TO DO WHAT THEY DO AND
THERE'S A HUGE CREDIBILITY ISSUE
WITH THIS SYSTEM AND THAT BY
KNOWING I WORKED WITH DR. GOMES.
I KNOW I CAN DEPEND ON HER FOR
THIS.
THERE BECOMES A CREDIBILITY AND
TRUST ISSUE ON OUR TEAMS WHICH
CANNOT BE DISCOUNTED.
I THINK ONE OF THE IMPORTANT
THINGS ABOUT TRANSACTIVE MEMORY
SYSTEMS IT ALLOWS US TO
DISTRIBUTE THE COGNITIVE LOAD
AMONG THE TEAM.
I OFTEN AS A WASH A NURSE
PRACTITIONER OR PHYSICIAN SAY
RUN A CODE, I OFTEN THINK THE
DECISIONS THEY HAVE TO MAKE, THE
COGNITIVE LOAD THAT PERSON
CARRIES AND HOW NICE IS IT THAT
PERSON CAN JUST SAY, OKAY,
MARY'S AT THE CART.
I KNOW SHE'LL GET THE DRUG READY
AND SUSAN'S RECORDING EVERYTHING
AND LET ME KNOW WHEN THE NEXT
EPI-IS READY TO GO SO THE PERSON
DOESN'T HAVE TO THINK OF
EVERYTHING BECAUSE WE CAN
DISTRIBUTE OUR KNOWLEDGE AROUND
THE TEAM AND HAVE FAITH THE
PEOPLE ON THE TEAM WILL DO THE
RIGHT THING AT THE RIGHT TIME.
THERE'S A DYNAMIC SHIFTING OF
TEAM MENTAL MODELS WHERE
EVERYBODY HAS TO KNOW THE SAME
WAYNE AND TRANSACTIVE MEMORY
SYSTEM WHERE YOU SEE
SPECIALIZATION AND
GENERALIZATION.
IF WE THINK WHAT IT TAKES TO
SEND A PATIENT TO AN OPERATING
ROOM.
IN THE OPERATING ROOM EVERYBODY
IN THE ROOM HAS TO HAVE THE SAME
SHARED MENTAL MODEL ABOUT THE
PROCEDURE WE'RE DOING, THE
CONDITION THE PATIENT IS AT THE
START TO THINK ABOUT THE
COMPLICATIONS THAT MIGHT ARISE
AND BE READY FOR THE
COMPLICATIONS.
THAT'S HAVING A SHARED MENTAL
MODEL.
WHEN WE THINK OF THE TRANS
ACTIVE MEDICAL SYSTEM WE KNOW IF
THERE'S ANESTHESIOLOGIST HAS
THIS.
IF THERE'S A DECISION ABOUT
CHANGING THE APPROACH THE
SURGEON WILL TAKE CARE OF THAT
SO THE ANESTHESIOLOGIST DOESN'T
HAVE TO WORRY ABOUT OUT AND IF
THERE'S SUDDENLY A NEED MORE
RESOURCES THE NURSES HAVE THAT
AND THE ABILITY TO ANTICIPATE.
THAT'S HOW TRANSACTIVE MEMORY
SYSTEMS AND TEAM MENTAL MODELS
WORK TOGETHER.
THESE ARE THE TWO COMPONENTS
THAT ARE AMENABLE TO TRAINING
AND SIMULATION.
AS WE THINK OF SIMULATION IT'S
SO MUCH MORE THAT WHAT HAPPENS
IN THE 15 MINUTE PERIOD.
IT'S NOT MUCH WITHOUT THE
DEBROFING AFTERWARDS.
THAT DEBRIEFING IS THE TIME
WHERE WE CAN DISCUSS CHAPPED IN
THE SIMULATION BE A RESPECTFUL
AND OPEN WAY.
THAT'S NOT EASY WITH
HIGH-ACHIEVING HEALTH CARE
PROFESSIONALS WHO ALL WANT TO
LOOK GOOD IN FRONT OF EACH OTHER
BUT WE ALWAYS DO.
WE ALL ENGAGE IN IMAGE
MANAGEMENT ALL THE TIME.
I GOT UP AND DID MY HAIR AND
PICKED MY OUTFIT BECAUSE I CARE
WHAT YOU THINK ABOUT ME AND IT'S
DIFFICULT TO MAKE YOURSELF
VULNERABLE AND SAY I MADE A
MISTAKE.
I MISSED THAT POSE OF
INFORMATION.
I DIDN'T HEAR HER SAY THAT OR
WHATEVER THE PROBLEM MIGHT BE
THAT HAPPENED IN SIMULATION.
WITH SIMULATION AND THE
DEBRIEFING IT'S CRITICALLY
IMPORTANT WE CREATE A
PSYCHOLOGICALLY SAFE LEARNING
ENVIRONMENT AND DR. GOMES KNOWS
THIS WELL BECAUSE WE BOTH
TRAINED AT THE SAME PLACE.
PSYCHOLOGICAL SAFETY IS THE
ENVIRONMENT IN WHICH THIS HAS TO
HAPPEN.
I'M REFERRING TO THE WORK DONE
BY A HARVARD BUSINESS SCHOLAR
AND STUDIED OPEN HEART SURGERY
TEAMS AT MASSACHUSETTS GENERAL
HOST IN 1999 SHE WAS ABLE TO TIE
PSYCHOLOGICAL SAFETY TO BETTER
OUTCOMES.
IN A PSYCHOLOGICALLY SAFE
LEARNING ENVIRONMENT WE ARE ALL
WILLING TO BE VUL VERBAL IN
FRONT OF EACH OWNER.
-- VULNERABLE AND THE ONE
QUALITY SHE SAWS WAS LEADER
INCLUSIVENESS WHERE THE SURGEON
AT THE BEGINNING WOULD SAY
CLEARLY I'M IN CHARGE HERE, I'M
GOING IT MAKE DECISIONS HOW THE
SURGERY GOES BUT I NEED ALL OF
YOU TO HELP ME.
IF YOU SEE ANYTHING UNUSUAL OR
DON'T SEE ANYTHING RIGHT LET ME
KNOW RIGHT AWAY.
IT'S THE LEADER INVITING PEOPLE
TO SPEAK UP ENCOURAGING
EVERYBODY TO BE RESPECTFUL WHEN
PEOPLE BRINGS TO THE TABLE AND
THAT'S WHAT THEY DO IN A
PSYCHOLOGICALLY SAFE LEARNING
ENVIRONMENT AND RECOGNIZE
EVERYTHING DOESN'T GO PERFECTLY
IN SIMULATION AND IN REAL LIFE
BUT IN SIMULATION WE TAKE THE
TIME TO EXPLORE AND DISCUSS AND
TO QUESTION.
SOMETIMES WE TAKE THE TIME TO
PUSHBACK AND SAY LOOK THIS IS
THE WAY WE'VE ALWAYS DONE IT BUT
I'M NOT SURE THAT'S THE BEST WAY
TO DO IT.
SIMULATION AND DEBRIEFING CAN
TRAIN US IN GIVING LEADERS TO
QUICKLY CREATE MENTAL MODELS.
IT CAN HELP TRANSACTIVE SYSTEMS
WITH ABLE AD HOC TEAM.
WHO IS EVERYBODY HERE IN THE
ROOM.
I'M A NURSE AND I'M A
RESPIRATORY THERAPIST.
NOW THE TEAM LEADER KNOWS WHO IS
IN THE ROOM AND THESE ARE THE
KINDS OF THINGS AMENABLE TO
SIMULATION TRAINING.
WHEN WE BRING TEAMS TOGETHER IN
SIMULATION, WE ARE NOT USUALLY
BRINGING THOSE TEAMS TOGETHER TO
WORK ON THEIR TECHNICAL SKILLS.
WE DON'T BRING THE TEAM TOGETHER
TO SEE IF DR. SMITH KNOWS HOW TO
APPROPRIATELY DIAGNOSE SOMETHING
OR NURSE SMITH KNOWS HOW TO GIVE
X, Y, Z DRUG.
WE BRING THEM TO WORK ON TEAM
WORK PROCESSES.
THERE'S A LOT OF FRAMEWORKS OUT
THERE TO DO THIS.
I THINK TEAM STEPS SAY WELL
KNOWN ONE.
-- IS A WELL KNOWN ONE THE
GOVERNMENT HAS.
TONS OF FREE RESOURCES ON THEIR
WEBSITE TO TEACH AND MEASURE
TEAM WORK.
THE IMPORTANT THING WITH TEAMS
IS WE DON'T BRING PEOPLE IN
PEOPLE SAY LOOK WE DO
INTERPROFESSIONAL SIMULATION AND
AFTER SHOULD THE NURSES BE
DEBRIEFED BY A NURSE AND THE
DOCTOR BY A DOCTOR AND, NO, YOU
MISSED THE POINT IF YOU SEPARATE
THE PROFESSIONS IN THE
DEBRIEFING BECAUSE THAT'S WHERE
LEARNING GETS CONSOLIDATED.
WHEN WE LOOK AT TEAM BASED
DEVELOPMENT THERE'S A COUPLE
PRINCIPLES I'D LIKE TO SHARE.
WE SHOULD BE USING THE
SIMULATION TO TARGET INFORMATION
SHARING BEHAVIORS.
ASKING QUESTIONS, SEEKING IN PUT
CLOSED LOOP COMMUNICATION.
AND WHEN I USE SIMULATION I'M
NOT TALKING ABOUT TRAINING
PEOPLE IN SKILLS AND WE MAY ADD
A NEW RESEARCH PLAN OR PROTOCOL
OR MEDICAL EMERGENCY.
DESIGN YOUR SIMULATIONS SO THEY
HELP YOU INFLUENCE THOSE MENTAL
MODELS IN THE TRANSACTIVE MEMORY
SYSTEMS AND THE STIMULATIONS
THAT ARE GREAT ARE WHERE THE
TEAM HAS TO ENGAGE IN PLANNING
BEHAVIORS.
ONE OF THE SIMULATIONS WE DO IN
OUR COURSE -- DON'T ANYBODY COME
TO THE COURSE BECAUSE I'M ABOUT
TO TELL YOU WHAT THE SIMULATION
IS.
ONE WE DO AT HARVARD IS WE HAVE
OUR INTERPROFESSIONAL TEAM OF
CLINICIANS AND HAVE THEM IN THE
ROOM AND TELL THEM THEY'RE THE
EMERGENCY ROOM DEPARTMENT STAFF
FOR THAT DAY AND IT'S FULL AND
WE TELL THE PATIENT AND THE
DIAGNOSIS AND TELL THEM THERE'S
A CRASH AND THEY'LL GET TRAUMA
PATIENTS.
THEY HAVE TO DECIDE HOW TO GET
THE E.R. READY AND STARTS WITH
WHO'S ON THE TEAM AND WHAT DO
YOU KNOW AND WHAT DO YOU DO AND
WE HAVE TO GATHER INFORMATION
ABOUT THE ORGANIZATION AND THEN
PLAN.
WE'LL MOVE THIS PATIENT AT THIS
TIME AND PATIENT ON THIS TIME
AND THEY FIND THEY DON'T HAVE
TIME TO GET ALL THE PATIENTS OUT
FOR ALL THE PATIENTS COMING IN
AND HAVE TO AD HOC SET UP SPACES
TO TAKE CARE OF THE PATIENTS.
THOSE KINDS OF SIMULATIONS
REQUIRE US TO ASK QUESTIONS OF
EACH OTHER AND LISTEN TO EACH
OTHER AND THAT CAN HELP BUILD
THE TRANSACTIVE MODELS AND
MEMORY SYSTEMS.
I TALKED ABOUT STIMULATIONS TO
EQUIP TEAM LED -- LEADERS AND
THERE'S A FRAMEWORK WE DEVELOPED
AT THE CENTER FOR MEDICAL
SIMULATION THAT'S A QUICK CLAIM
CLAIM AIM.
THAT'S THE CONSEQUENCE WE USE
WHICH IS THE TEAM LEADER COMES
IN THE ROOM, NAMES WHAT'S GOING
ON, SAYS THEY'LL BE THE TEAM
LEADER AND THEN SAID TO THE OF
THE TEAM, I'LL TAKE CHARGE BUT I
NEED HELP.
QUICKLY CAN YOU TELL ME WHO'S IN
THE ROOM?
THIS TEAM LEADER CALLS OUT WHAT
THEY THINK THEY SEE AND ASKED
OTHERS AND KNOWING WHAT THEY'RE
GOOD AT CAN BUILD THE
TRANSACTIVE MEMORY SYSTEM IF
IT'S AN AD HOC TEAM.
AND REALLY IMPORTANTLY
STRUCTURING THE DEBRIEFINGS SO
WHAT WE'RE TALKING ABOUT ARE ALL
THOSE THINGS THAT INFLUENCE TEAM
COGNITION.
IT'S SO IMPORTANT FOR ALL OF US
TO REMEMBER THAT WHEN WE COME IN
OUR DAILY WORK AND SIMULATION
AND DEBRIEFING, I BRING MY WHOLE
SELF WITH ME AND THAT MEANS ALL
MY EXPERIENCES AND EDUCATION AND
VALUES AND WHAT MY MOM AND DAD
TAUGHT ME, WHAT I LEARNED IN 15
YEARS OF BEING A NURSE.
THAT INFLUENCES OUR BEHAVIOR AND
THE LEVEL WE NEED TO GET TO THIS
WE NEED TO HAVE REFLECTIVE
CONVERSATIONS OF WHAT YOU KNEW
AND NOT KNOW.
PSYCHOLOGICAL SAFETY IS SO
IMPORTANT AND ONE THING WE KNOW
IS THAT WHEN PEOPLE HAVE A
PERCEPTION THEY'RE PSYCHOLOGICAL
SAFE THEY'RE WILLING TO TAKE
INTERPERSONAL RISKS AND THEY'RE
ADMITTING THEY DON'T KNOW
SOMETHING, ASKING FOR HELP,
ASKING QUESTIONS.
IN ESSENCE THEY'RE WILLING TO BE
VULNERABLE IN FRONT OF EACH
OTHER.
FOR THE LONG TERM GAIN OF
IMPROVED COGNITION DOWN THE
ROAD.
ONE THING WE TEND TO DO IN
DEBRIEFING IS TEND TO DO THE
SIMULATION AND BRING PEOPLE INTO
DEBRIEFING AND SPEND TIME ON THE
MISTAKES THEY MADE.
I WANT TO ENCOURAGE EVERYONE TO
START DEBRIEFING THE GOOD STUFF.
THERE WAS AN IMPORTANT WHITE
PAPER ABOUT PATIENT SAFETY A
NUMBER OF YEARS AGO GOING FROM
SAFETY 1 TO SAFETY 2.
THE CONCEPT IS OR QUESTION THEY
ASKED WAS WHEN WE'RE TRYING TO
UNDERSTAND PATIENT SAFETY AND
ERRORS WHY DO WE SPEND ALL OUR
TIME STUDYING THE 2% OF THE TIME
THINGS GO WRONG BUT STUDY THE
98% OF THE TIME THAT THINGS GO
WELL.
UNDERSTAND THERE'S GREATER VALUE
IN TALKING ABOUT WHEN THINGS GO
WELL.
WHEN WE CREATE A SIMULATION WE
KNOW WHERE PEOPLE ARE GOING TO
BE CHALLENGED.
IF A GROUP COMES IN AND KNOCKS
IT OUT OF THE PARK WE NEED TO
DEBRIEF THAT AND WE NEED TO
FIGURE OUT WHAT WAS AT PLAY.
WHAT WERE THE COMMUNICATION
STRUCTURES?
WHAT WAS THE RELATIONSHIP AMONG
THE TEAM THAT ALLOWED THAT TEAM
TO DO SO WELL.
I PUBLISHED A PAPER A COUPLE
MONTHS AGO USING A PSYCHOLOGICAL
APPROACH USING A COGNITIVE TASK
ANALYSIS TO DEBRIEF GOOD
PERFORMANCE AND IT ELEVATES THE
TEAM UP THEIR OWN MIND AND GIVES
THEM CONFIDENCE THEY'RE DOING
GREAT THINGS AND LOTS OF
POSITIVE REINFORCEMENT FOR THAT.
SO WE TRAIN OUR TEAMS TO DO
THESE THINGS AND THERE'S ALSO
BRUSHING UP OF TECHNICAL SKILLS
BUT THERE'S INTERESTING RESEARCH
FROM AUSTRALIA NOW.
TWO COLLEAGUES AN EMERGENCY ROOM
PHYSICIAN AND AN ANTHROPOLOGIST
TURNED EMERGENCY ROOM PHYSICIAN
HAVE AN ACTIVE SIM PROGRAM IN
THEIR EMERGENCY DEPARTMENT AND
STARTED TO NOTICE THEY'RE TEAMS
WERE RELATING TO EACH OTHER
DIFFERENTLY OUTSIDE OF
SIMULATION.
THERE WAS MORE DISCUSSION GOING
ON MORE FEEDBACK GIVEN AND
QUESTIONS ASKED.
PEOPLE WERE FINDING IT EASIER TO
SPEAK UP.
VICK AND EVE DECIDED TO DO
QUALITATIVE STUDIES ABOUT THE
PHENOMENON THEY WERE OBSERVING.
THE FIRST PAPER TALKS ABOUT
TAKING SIMULATION OUT OF THE
SAFE CONTAINER.
THAT'S A METAPHOR THAT
SIMULATION TO TALK ABOUT THE
PSYCHOLOGICALLY SAFE LEARNING
ENVIRONMENT AND WHAT VICK AND
EVE SAY IS IT LEAKS AND LEAKS
INTO REAL CLINICAL AREA.
SO THE PSYCHOLOGICAL SAFETY THAT
ALLOWS US TO BE VULNERABLE IN
FRONT OF EACH OTHER, TO ASK FOR
HELP AND ADMIT WHEN WE'RE
STRUGGLING AND TO SAY WHEN WE
DON'T KNOW SOMETHING STARTS TO
TRANSFER TO THE REAL CLINICAL
ENVIRONMENT.
I THINK THAT'S ONE OF THE
REASONS PATIENTS DO BETTER WHEN
WE TRAIN OUR TEAMS.
AND THEN ANOTHER STUDY IS EVE
LOOKED AT THE RELATIONSHIP
ASPECTS, HOW WE RELATE TO EACH
OTHER AND ITS AFFECT ON TRAUMA
PATIENTS.
I REALIZE I'M AT THE NATIONAL
INSTITUTES OF HEALTH, OUR
PREMIER HEALTH SCIENCE CENTER IN
THE UNITED STATES AND KNOW I
BETTER HAVE EVIDENCE TO BACK UP
ALL I'M SAYING.
I WANT TO SHARE WITH YOU SOME
STUDIES.
THEY TIED SIMULATION TRAINING TO
BETTER OUTCOMES AND DR. GOMES
HAS THE REFERENCE LIST IF ANYONE
IS INTERESTED FURTHER IN THE
STUDIES.
LET'S LOOK AT SOME OF THIS.
IN A HOSPITAL THAT DID OB
EMERGENCY SIMS THEY'RE FOUND THE
APGAR SCORES DECREASED PER
10,000 LIVE BIRTHS AND THE
INCIDENCE OF HYPOXIC ISCHEMIC
ENCEPHALOPATHY DECREASED.
IN AN EMERGENCY DEPARTMENT THE
TRAINED PEOPLE AROUND TRAUMA
CARE THEY WERE STUDYING THE TEAM
WORK MEASURES AND SITUATIONAL
AWARENESS, CROSS-MONITORING.
THEY IMPROVED BUT WHAT THEY ALSO
FOUND WAS PATIENTS GOT TO SCAT
SCAN FASTER.
TIME TO INTUBATION DECREASED.
I THINK A FOUR MINUTE REDUCTION
IN TIME TO INTUBATION IS
PROBABLY CLINICALLY SIGNIFICANT.
ANOTHER HOSPITAL TRAINED THEIR
TEAMS AROUND APPROACHES TO
ISCHEMIC STROKE.
THE DOOR TO THROMBOLOSIS WAS CUT
IN HALF AFTER TEAM TRAINING.
ANOTHER SYSTEM HOSPITAL PROGRAMS
SOME HAD ACTIVE SIMULATION
PROGRAMS AND SOME NOT SO ACTIVE.
THEY FOUND IN THEIR HOSPITALS
VERY VERY ACTIVE SIMULATIONS THE
ARD -- CARDIAC ARREST SURVIVAL
RATE WAS HIGHER THAN THE
HOSPITAL WITHOUT A SIMULATION
PROGRAM AND THERE WERE REDUCED
ODDS RATIO FORWARD -- FOR
CARDIAC ARREST AND SIM CENTERS
YOU SEE ALL THE OUTCOMES THE
SYSTEMIC REVIEW HIGHLIGHTED.
INCREASED SURVIVAL RATES, LOWER
RATES OF SEPSIS AND RESPIRATORY
FAILURE.
ONE HOSPITAL THAT WASN'T REALLY
DO SIMS ABOUT HOSPITAL-WIDE
DEATHS BUT AFTER THE SIM PROGRAM
WAS UP AND RUNNING THEY FOUND A
STATISTICALLY SIGNIFICANT
DIFFERENCE IN HOSPITAL-WIDE
DEATHS.
THERE'S A LOT OF REASONS FOR US
TO DO SIMULATION.
I'LL NEVER SAY WE SHOULDN'T DO
INDIVIDUAL PROFESSION
SIMULATIONS.
WE SHOULD.
SOMETIMES NURSES NEED TO DO
THINGS ON THEIR OWN AND DOCTORS
NEED TO DO THINGS ON THEIR OWN
AND RESPIRATORY SPECIALISTS NEED
TO DO THINGS ON THEIR OWN AND
WHEN WE'RE A TEAM IF WE CAN
BRING THAT TO BEING IN A SIM LAB
AND FINE TUNE IT SO WE'RE MORE
ON THE SAME PAGE SO WE RELATE TO
EACH OTHER IN HEALTHY WAYS THEN
WE IMPROVE OUR TEAM COGNITION.
IF WE CAN IMPROVE OUR TEAM
COGNITION, WE CAN IMPROVE OUR
PATIENT OUTCOME AND IN THE END
THAT'S WHAT WE'RE ALL HERE FOR.
WITH THAT THANK YOU FOR YOUR
KIND ATTENTION AND OPEN UP THE
FLOOR TO QUESTIONS.
>>THANK YOU FOR THE
PRESENTATION AND DR. GOMES'
FOCUS ON DEVELOPING THE
SIMULATION TRAINING PROGRAM
SINCE WE HAVE A SMALL NUMBER OF
TRAINEES WORKING WITH FULLY
TRAINED CREDENTIALED PRIVILEGED
STAFF AT PROVIDER LEVELS AS WELL
AS NURSING.
IT'S NICE TO KNOW WE'RE ON THE
RIGHT PATH WHEN WE'RE FOCUSSED
ON TEAM TRAINING EDUCATION AND
NOT PROCEDURAL SKILLS.
WITH THAT.
>>THAT WAS INTRIGUED WITH THE
RELATION AND WONDERING IF THEY
DID THE STUDY THE RELATION OF
THE QUEEN BEES.
>>THAT'S A REALLY GOOD QUESTION
AND DOCTOR TOM SELEY IS THE GUY
AT CORNELL UNIVERSITY THAT
STUDIES ALL THAT STUFF.
I'M NOT AN EXPERT ON HONEY BEE
PHYSIOLOGY SO MUCH.
>>SECOND QUESTION, THOUGH I
HAVE A Ph.D. IN NUCLEAR PHYSICS
I ENDED STUDYING COMPLICATION
SOFTWARE AND LOOKING AT SOME OF
THE COMPLICATIONS AND AT THE
MAYO CLINIC AND FOR NIH TO OPEN
SURGERY I FOUND OUT A RESIDENT
WILL HELP ME IN MY STUDY PHASE.
IT HELPED ME LOOK AT THE ISSUES.
FROM THE CLINICAL STUDIES, ALSO,
WE HAD ANOTHER SESSION,
DR. MAGOON AT MAYO CLINIC IS IN
CARDIO VASCULAR STUDY AND SHOWED
UP AT 7:30 WITH DONUTS AND
COFFEE AND THE CARDIOLOGIST AND
RADIOLOGIST WHO GAVE WRONG
INFORMATION TO THE SURGEON, THIS
IS THE TIME TO TELL ME, HEY, YOU
GAVE ME THE WRONG INFORMATION
AND IT WAS DIFFERENT THAN WHAT I
WAS THINKING.
ALL THIS FEEDBACK AND EVERYTHING
ELSE WORKS NICELY.
IT REMINDS ME OF SOMETHING I DID
IN A WAY AND WE HAD A LOT OF
FUN.
THIS IS WHAT WE HAVE TO LEARN
NOT ONLY ACADEMIC LEVEL BECAUSE
WE HAVE SIMILAR THE WAY THEY
ORGANIZE THE SYSTEM.
THIS IS WHAT THE POLITICIANS
NEED TO LEARN HOW TO MAKE THINGS
WORK AS A TEAM.
>>I THINK AS THINGS GET MORE
COMPLEX THERE'S SO MUCH MORE
INFORMATION TO MANAGE WE CAN'T
KNOW EVERYTHING AND HAVE TO
DISTRIBUTE THAT KNOWLEDGE AROUND
OUR TEAMS AND SHARE THAT
KNOWLEDGE.
[OFF-MIC]
>>INTERESTING.
[OFF-MIC]
>>THANK YOU VERY MUCH.
>>THANK YOU FOR AN EXCELLENT
TALK.
ONE COMMENT OR A QUESTION YOU
HIGHLIGHTED ABOUT TEAM COGNITION
AND TEAM TRAINING BEING
SOMETHING THAT POTENTIALLY
IMPROVES PATIENT OUTCOMES.
ONE THING WE STRUGGLE IN ALL WE
TEACH IS THAT'S THE HOLEY GRAIL
AND THERE'S A REAL OPPORTUNITY
AND THERE'S SOME DATA AS YOU
POINT OUT.
I THINK THE QUESTION WHICH IS
MAYBE A MORE DIFFICULT ONE I
THINK AT MORE JUNIOR LEVELS
STUDENTS, RESIDENTS, FELLOWS AND
NURSING STUDENTS AND PHARMACY
AND THERE'S A CULTURE OF GOING
THROUGH SIMULATION-BASED
TRAINING AND WORKING TOGETHER IN
THE TEAM-BASED THERAPY.
TO ME THE BIGGEST CHALLENGE AND
THE LARGEST WHERE THERE'S A
VULNERABILITY IS FACULTY.
WE HAVE A HARD TIME GETTING
PEOPLE IN THE SIM, FACULTY WISE.
THAT'S THE GROUP I THINK WE CAN
MAKE TREMENDOUS STRIDES IN IN
IMPROVING OUTCOME.
I DON'T KNOW IF YOU HAVE TIPS OR
CONSIDERATIONS OF HOW DO YOU GET
THAT GROUP IN THERE TO GO
THROUGH THIS TRAINING?
>>I THINK IT'S A GREAT
CHALLENGE AND GREAT QUESTION AND
A CHALLENGE THAT WE ALL HAD TO
DEAL WITH.
I THINK TO SOME DEGREE IT HAS TO
BE A CULTURE CHANGE IN MEDICINE.
WE TEND TO THINK SIMULATION
TRAINING IS ONLY FOR BEGINNERS.
BUT IF YOU GET OUTSIDE OF HEALTH
CARE AND THIS IS AN IMPORTANT
MESSAGE TO CARRY TO THE MORE
SENIOR FOLKS IT'S NOT ONE
PROFESSIONAL, IT'S ALL THE
SENIOR FOLKS.
I GOT THIS, I DON'T NEED ANYBODY
TO TELL ME HOW TO DO MY JOB BUT
IF WE THINK OF THINGS LIKE THE
MILITARY, THEY SIMULATE A LOT OF
THEIR COMMAND AND CONTROL
EXERCISES.
IF WE THINK OF AVIATION, THE
FIRST TIME A PILOT FLIES A PLANE
WITH PEOPLE IS THE FIRST TIME
HE'S FLYING THAT PLANE.
EVERYTHING ELSE ASSIMILATION AND
THEY'RE REQUIRED TO HAVE
SIMULATION TRAINING EVERY YEAR.
AND PEOPLE WHO OPERATE POWER
PLANT, THE SAME.
NASA SIMULATES EVERYTHING.
AN EXAMPLE OF SENIOR PEOPLE WHO
GOT BETTER BECAUSE OF SIMULATION
IS AT CHILDREN'S HOSPITAL THEY
WERE GOING TO BE DOING A
COMPLICATED NEUROSURGERY ON THE
CHILD AND 3-D PRINT THE KID'S
CENTRAL NERVOUS SYSTEM AND
SIMULATED THE ENTIRE SURGERY AND
THEY WERE ABLE TO SAVE 25
MINUTES OF TIME THE CHILD
DIDN'T HAVE TO BE UNDER A
ANESTHESIA.
THE BALTIMORE ORIOLES, WHAT'S
THEIR RATIO OF PRACTICE TO PLAY?
THEY PRACTICE FOR FIVE DAYS FOR
ONE GAME AND WE SHOW UP EVERY
DAY IS GAME DAY AND WE TEAM
PEOPLE WHO ARE ALREADY EXCELLENT
HOW TO BE 1% BETTER.
WHEN I TALK THE IDEA OF HOW DO
WE CONVINCE SENIOR PEOPLE THIS
COULD BE HELPFUL IS BECAUSE
THERE'S ALWAYS ROOM TO BE 1%
BETTER AND OFTEN A SLOW CULTURE
CHANGE IN AN ORGANIZATION.
WHEN WE START TO SEE BETTER
OUTCOMES IT HELPS PEOPLE GO
UNDER THE BUS BUT IT'S A CULTURE
CHANGE THAT TAKES TIME.
>>THANK YOU.
A QUESTION AND COMMENT THAT
RELATE TO WHAT YOU'RE SAYING IS
THE FACT TO WHAT YOU TOUCHED ON
WAS THE ISSUE OF PSYCHOLOGICAL
SAFETY.
WHEN YOU GET MORE SEASONED I'LL
SAY YOU DON'T WANT TO SEEM
VULNERABLE TO NOT HAVE KNOWLEDGE
AND SKILLS OR WHATEVER.
WHEN WE TALK TO GROUPS OF
PARTICIPANTS WHAT HAPPENS IN SIM
STAYS IN SIM.
BEYOND THAT HOW DO YOU CONVEY
THAT?
IS THERE A STRATEGY HOW DO YOU
MAKE PEOPLE TRULY FEEL
COMFORTABLE WITH THE
PSYCHOLOGICAL SAFETY?
>>THERE'S AN IMPORTANT TIME
BEFORE PEOPLE GO INTO SIMULATION
WE CALL THE PREBRIEFING OR THE
BRIEFING BEFORE AND THIS IS THE
TIME WE SET THE SAFE CONTAINER
AS WE SAY IN SIMULATION.
IF I'M A NURSE AND KNOW I GOT
THE CHIEF OF CARDIAC SURGERY
COMING TO MY SIMULATION I DON'T
PRETEND THEY'RE NOT THERE.
I DON'T PRETEND THEY'RE LIKE
EVERYBODY ELSE AND I'LL DO MY
TALK ABOUT WE ALL CAN BE 1%
BETTER AND WE HAVE DR. GOMES THE
HEAD OF CARDIAC SURGERY AND SO
GLAD YOU'RE HERE AND SURE YOU'RE
EXPERTISE AT DEBRIEFING.
THE BEST THING YOU CAN
ACKNOWLEDGE THE EXPERTISE IN THE
ROOM AND TELL THEM HOW MUCH YOU
VALUE THEM BEING THERE AND
REITERATE THE MESSAGE WE'RE ALL
HERE TO BE 1% BETTER AND I TELL
PEOPLE WHEN I'M DOING PRE
BRIEFING I'VE NEVER HAD A
PERFECT DAY IN MY LIFE BUT
THERE'S SO MUCH TO BE LEARNED
WHEN WE'RE NOT PERFECT.
WHEN I THINK OF PSYCHOLOGICAL
SAFETY AND WHAT IT COMES DOWN TO
IS EVERYBODY BEING TRANSPARENT
ABOUT WHAT THEY'RE THINKING.
>>ONE THING WE'RE SEEING TOO IS
MANY OF OUR NURSES IN THE EARLY
PART OF CAREERS AND FELLOWS AND
RESIDENTS PARTICIPATED IN
SIMULATION IN THEIR SCHOOLING.
IF WE START TO ROLL THIS OUT IT
BECOMES A MORE COMFORTABLE
SETTING IT'S THE OLD FOLKS LIKE
MYSELF THAT THINK YOU'RE GOING
TO TELL ME HOW TO DO YOUR JOB.
>>WE ARE HERE TO WORK ON TEAM
COGNITION NOT TO TELL YOU HOW TO
DO YOUR JOB.
>>EXCELLENT TALK AS ALWAYS.
SOMETIMES SIMULATION REQUIRES
ASSESSMENT.
HOW DO COMBINE THE SAFE
CONTAINER WITH INFORMATIVE
ASSESSMENTS.
>>GREAT QUESTION.
WHEN I BRING PEOPLE TO THE SIM
LAB I'M ALWAYS DOING SOME SORT
OF ASSESSMENT.
MY FORMATIVE ASSESSMENT IS HOW
ARE THEY DOING WITH
CLOSED-LOOPED COMMUNICATION.
THAT'S MY FORMATIVE ASSESSMENT
AND WHAT A TALK ABOUT IN
DEBRIEFING.
WHEN I THINK OF PSYCHOLOGICAL
SAFETY A SURE WAY IS THERE'S NO
CONSEQUENCES IF I MAKE A
MISTAKE.
IF THERE'S A SUMMATIVE
ASSESSMENT I'M SEEING IF I CAN
ALLOW THEM TO INTUBATE A REAL
HUMAN BEING OR A PROCEDURE A
REAL HUMAN BEING.
IT'S DIFFERENT BUT THERE'S A WAY
TO SET UP A TRUSTING ENVIRONMENT
AND WE'RE WORKING ON THIS ON
COMPETENCY BASED EDUCATION IN
NURSING THE PEOPLE BEING
SUMMATIVELY ASSESSED NEED TO BE
INFORMED ON WHAT THEY'RE BEING
ASSESSED ABOUT.
IF I'M BRINGING IN SOMEONE WHO
WILL BE A CODE TEAM LEADER AND
THEY'RE JUST LEARNING IT THE
OTHER PEOPLE IN THE SIMULATION
WOULD NOT BE PEOPLE ALSO
LEARNING BUT MAYBE ACTORS SO
THIS PERSON IS THE ONLY PERSON I
HAVE TO WATCH AND I WOULD LET
THIS PERSON KNOW HERE'S WHAT
WE'LL BE ASSESSING YOU ON, YOUR
ABILITY TO CREATE A SHARED
MENTAL MODEL AND INVITE OTHER
PEOPLE INTO DECISION MAKING ON
THE TEAM AND HAVE MY ACTORS HAVE
DIFFERENT BITS OF INFORMATION
THE TEAM LEADER DOESN'T HAVE AND
NEEDS.
AND THAT'S HOW I WOULD DO THAT.
THE KEY WITH SUMMATIVE IS TO BE
SUPER CLEAR WHAT THE ASSESSMENT
POINTS ARE GOING TO BE.
NOT EXACTLY.
SO THEY NEED TO BE WELL INFORMED
WHAT THEY'RE GOING INTO AND HAVE
HAD MULTIPLE TIMES TO PRACTICE
IN SIMULATION IN A FORMATIVE WAY
BEFORE THEY'RE SUMMATIVELY
EXIST.
YOUR COMMITTEE CHAIRS SHOULD
NEVER LET YOU DO YOUR DEFENSE
UNTIL THEY'RE SURE YOU'RE GOING
TO PASS AND I WOULD SAY THE SAME
IN SIMULATION.
SO WHEN IT SEEMS LIKE SUMMATIVE
IT SEEMS LIKE ANOTHER DAY IN THE
SIMULATION LAB.
>>WHEN OUR CEO ESTABLISHED THE
PROGRAM HERE WITH THE MISSION
STATEMENT IT APPLIES TO EVERYONE
IN A CLINICAL CENTER NOT JUST
PROVIDERS OR NURSES OR
TECHNOLOGISTS BUT EVERYONE.
I DIDN'T -- HAVE YOU EXPLORED
DOING SIMULATIONS AT OTHER
ARENAS WITHIN THE ENVIRONMENT
BUT OUTSIDE PROVIDERS LIKE
HOUSEKEEPING AND ADMINISTRATION
AND WHAT THOSE LOOK LIKE?
AND THE WARD ADMINISTRATIVE
SESSION AND I'VE WORKED WITH
PLACES ESPECIALLY IN EMERGENCY
DEPARTMENTS WHERE EVERYONE
INVOLVED IN THE SIMULATION AND
SOMETIMES IT'S TURNING THE ROOM
OVER QUICKLY.
>>A COMMENT IN SOUTHERN
CALIFORNIA, EXCELLENT INFO INTO
TEAM MODELS AND LEARNED A LOT
ABOUT BEES.
I'M CONTEMPLATING MY OWN ROLE
HERE ABOUT MALE BEES BUT THAT'S
A DIFFERENT THING.
WITH THAT I WANT TO SAY THANK
YOU FOR YOUR TIME AND SHARING
YOUR EXPERTISE AND WE GREATLY
APPRECIATE YOUR COMING.
>>THANK YOU FOR INVITING ME.