In Situ Simulation With Human Factor Design Enhances Patient Care

Simulation plays a vital role in sharpening clinical skills and educating future medical practitioners. While advanced simulations often take place in dedicated centers, holding exercises in situ, or on site, with an eye toward human factor design, provides opportunities to ensure that hospitals are running at peak safety and efficiency. This can help identify workflow, equipment and process issues that can adversely affect patient care.

“In the last two decades, as the medical community has placed more focus on safety, quality and patient experience, we have realized the importance of reducing operational unpredictability,” says Eduardo Mireles-Cabodevila, MD, Medical Director of Cleveland Clinic’s Simulation & Advanced Skills Center. “We’re doing that by using human factor design simulations to reduce variability and improve predictability in clinical workflows.”

How does human factor design apply to simulation?

Human factor design studies how humans interact with systems, equipment and processes to optimize safety and efficiency. The simulation focus is on optimizing relationships between people and environments. Exercises measure a medical team’s efficiency, clinical accuracy and ability to think on their feet as a group. Simulation administrators must observe not only caregivers but also facilities and medical equipment to identify care gaps. At Cleveland Clinic, the Human Factors Simulation Team is led by Catherine Allan, MD, a core faculty member with the Simulation & Advanced Skills Center.

Optimizing critical patient transport with simulation

A clear example is when ICU caregivers at Cleveland Clinic’s Main Campus used in situ simulation to help a critically ill patient receive lifesaving care. The patient, who was on ECMO, required immediate radiation treatment from the Cleveland Clinic Taussig Cancer Center, located about a half-mile away from the ICU. Caregivers would need to move the patient to the ICU elevators, bring him up to the skyway, transport him through the skyway to the Cancer Center and then bring him down to a radiation therapy room. The bulkiness of the ECMO machine combined with the critical condition of the patient meant transportation was a high-risk maneuver.

To prepare for the patient’s transport, his medical team conducted a simulation. Caregivers took a medical manikin attached to ECMO equipment through the transfer route, paying careful attention to any logistical issues that needed to be addressed before the actual transfer took place.

The caregiver team discovered that they would need to stack equipment on the patient’s bed and leave one caregiver with the patient when traveling in hospital elevators. The rest of the team would take the stairways to meet the patient and help reconfigure the equipment layout to continue transport. By rehearsing these steps and identifying these issues, the team was able to smoothly and speedily transfer the actual patient to receive radiation treatment.

Using simulation to identify latent threats

Cleveland Clinic’s Resuscitation Simulation in situ Mock Code Program ensures that caregivers are ready to respond to sudden medical emergencies quickly and effectively. Using a human factor design approach, simulation education specialists design scenarios that assess not just practitioner skills but also equipment efficacy and environmental safety.

Caregivers do not work in a vacuum; their work depends on the tools they use and the places where they deliver care. In situ mock codes can uncover facility issues that may impede caregivers’ ability to provide safe and effective care to patients.

During 2024, the program to detect latent safety threats has discovered nearly 130 potential safety issues, which are documented into Cleveland Clinic’s Safety Event Reporting System. For example, as a result of resuscitation simulation in situ mock codes, simulation staff worked with hospital administration to evaluate all 1,000-plus defibrillators throughout Cleveland Clinic Main Campus and regional hospitals and ensured they were fully operational.

Other drills have revealed possible operational inefficiencies. In one instance, participants realized that numbers used to call emergencies had become outdated. Another drill highlighted the importance of easy access to backboards during code blues. When they are caught early, process issues like these can be addressed before they ever reach patients.

Simulation to optimize new facilities

Cleveland Clinic London’s Portland Place Outpatient Centre used in situ simulation to prepare for its 2021 opening. Simulation operations managers designed a rehearsal to simulate patient flow from arrival at the facility to placement in a doctor’s office. At first, the staff took hours to check in patient actors and get them assigned to rooms. As the exercise continued, caregivers and administrators worked together to address logistical challenges that were slowing down patient processing. Front desk staff, for example, needed to determine how they would quickly print wristbands and distribute them. Practicing on patient actors meant that staff could home in on optimizing microprocesses without having to worry about actual sick people. Thanks to the rehearsal, the Outpatient Centre opened smoothly, securing its reputation in the London community as a premier care provider.

Cleveland Clinic is currently constructing a new Main Campus building for its Neurological Institute. While the facility is not scheduled to open until 2026, Simulation Center staff are already thinking about ways to maximize its efficiency. Besides patient flow, simulation operations managers will assess emergency transport routes and pediatric emergency procedures to make sure the new environment is prepared for high-intensity neurological care.

Takeaways

In situ simulation goes beyond honing and assessing clinical skills. Using a human factor design framework, simulation experts can:

• Model high-risk patient transport so caregivers can practice difficult maneuvers
• Identify latent operational threats that could impede efficiency and quality of care
• Optimize new clinical environments by testing workflows and acquainting staff with new surroundings

While simulation can be expensive and complicated, the benefits far outweigh the costs.

“Having medical teams exposed to this sort of training helps improve efficiency and guarantee safe processes,” notes Dr. Mireles-Cabodevila. “Not only does medical simulation enhance patient safety by ensuring the highest standards of care, but it also helps save money in the long term. Medical simulation is no longer a niche field. It is rapidly becoming a critical requirement for healthcare safety.”