The Tide Is Turning: Organizational Structures to Embed Simulation in the Fabric of Healthcare (2007)

In this issue of Simulation in Healthcare, there are two papers discussing important issues facing the simulation community at a critical juncture in the development of simulation in healthcare. A full manuscript1 describes an independent organization—Advanced Initiatives in Medical Simulation (AIMS)—that can be considered a “cousin” to the SSH, whereas a meeting report2 describes the 2006 Simulation Summit that the leadership of the Society for Simulation in Healthcare (SSH) convened in November 2006. We must disclose that SSH is the professional society that publishes this Journal. One author of this editorial is the founding and current President of SSH; the other author is a founding member of the SSH Board of Directors and currently an ex officio member of the SSH board. Furthermore, are both current or former board members of AIMS. Still, even looking beyond our biases, it is fair to say that the recent activities of these two organizations represent important milestones in the evolution of simulation as a core component in the revolutionary effect that simulation is having on healthcare education and safety in the United States. Although SSH is an international society, the focus of its SUMMIT was on North American stakeholders. AIMS is specifically focused on US policymakers, although AIMS activities have participants from other countries. The SSH Summit was a chance to take stock of where the field of simulation in healthcare is today and where SSH wants to be in the future, in the context of where we have been. Twenty years ago, there was frequent use of simple part-task trainers (eg, cardiopulmonary resuscitation mannequins, intravenous arms). Standardized patient (actors) exercises, although started in the early 1960s and developed extensively in the 1980s, did not themselves become widespread until the 1990s. In 1990, there were only a few pockets of technological simulation in a narrow spectrum healthcare domain. Today, technological simulation is in widespread use and growing rapidly in many different fields and in locations throughout the world. Part-task trainers and standardized patient simulations are also commonly used, sometimes in various combinations with each other or with technological simulators. When some of us first started our mannequin-based simulation work in the mid- to late 1980s, we believed that simulation would become important to healthcare over the following decade. Now as we are into our third decade of simulation work, we realize that we are still in the early phases of the decades-long process of embedding simulation into the fabric of healthcare. A number of observers—mostly those with a technological or entrepreneurial bent—have asked: “What is the next big invention in simulation?” With a broader view they might ask: “What is the next big step for simulation?” We would contend that while there is abundant need for technology development to make simulation devices of greater veracity and for more applications, the biggest step for simulation going forwards will not be technological, but will be organizational. That is, even with today’s technologies there is an enormous amount that can be accomplished with simulation that is not being done because the institutional mechanisms for providing it are immature. Still, we think it is now clear that the organizational tide is beginning to turn significantly. The evidence is represented by the following list of events that have occurred in the last couple of years: The US Food and Drug Administration has started to require simulation-based training for physicians wanting to deploy a specific carotid stent.3 The American College of Surgeons has begun an accreditation program for skills centers (specifically dealing with simulation). The American Council for Graduate Medical Education Surgery Residency Review Committee has decided to begin requiring simulation-based for simulation-based training of surgical residents. The American Society of Anesthesiologists has established a permanent Committee on Simulation Training and will “approve” simulation programs that demonstrate merit. The American Board of Anesthesiologists has decided to make simulation training one mandatory component of the every 10-year maintenance of certification in anesthesiology (MOCA) program for diplomats receiving initial certification from 2007 onwards. AIMS not only conducts a yearly symposium and Capitol Hill exhibition linking the simulation community to policymakers, but it has also begun to advocate model legislation that would authorize and fund multiple programs in simulation totaling over $50 million in the first fiscal year and such sums as may be necessary beyond that. The International Meeting on Medical Simulation (IMSH) meeting is expecting >1000 registrants; its postgraduate course on creating simulation centers rapidly filled to capacity with a substantial waiting list; the meeting has multiple tracks, dozens of workshops, and more than 70 peer-reviewed research abstracts. The number of companies providing simulation products and supporting components or services (such as audiovisual systems) continues to grow. An interesting development is that a large provider of aviation simulation services (including building and operating training centers and the production of simulators) has recently disclosed its intent to enter the healthcare simulation market with multiple business approaches including center design, center operations, curriculum development, and (eventually) simulator production. As detailed in the meeting report, the summit assembled representatives from a large number of organizations who recognize this as a pivotal time for the future of simulation in healthcare. Granted, there is some selection bias of those organizations that chose to attend the meeting (and similarly the biases of those who chose to complete the SSH survey described in the report). The main themes of the deliberations in the meeting clearly revolved around the organizational issues of the wider-spread adoption of simulation and the delineation of where and how it can best be used. In particular, the discussions centered on: The need for common standards and metrics The need for coordination and oversight of disparate efforts The desire for partnerships between the simulation community and other organizations The need to align and regularize regulatory mandates and funding streams for simulation development and use The need to engage the public about the need for and benefits of simulation Important drivers for the adoption of simulation, and the organizations that will implement the evolving mandates for its use have been delineated over the last few years.4,5 A key role has been identified for the professional societies of the simulation community. SSH has emerged as the leading professional society by virtue of its large (more than 1,000) and growing multidisciplinary membership, its sponsorship of the equally burgeoning IMSH meeting, and (if we may say so) its publication of an outstanding peer-reviewed Journal. Although a professional society has no line authority, the mere existence of a multidisciplinary society is evidence to policymakers that simulation has gone beyond the stage of a fad among healthcare techno-geeks. Perhaps the most important role is to provide the multidisciplinary neutral forum for deliberations about simulation by other organizations that represent driving forces or implementing bodies. The SSH Summit represents one example of this role, where the Society acted as the convener of multiple organizations who might never have come together for any purpose, and least of all to discuss simulation. As central as SSH will be, Dawson et al. articulate the limitations of a 501(c)3 professional society (like SSH) to directly influence policymakers. AIMS—which is designated as a 501(c)6 “trade organization”—has a wider scope to specifically promote legislative and regulatory changes, at either the federal or state level. The synergies between these organizations are clear. In other industries, such as aviation or nuclear power, many of the enabling processes of mandates, coordination, standardization, and oversight of implementation are conducted by government through legislation and by centralized regulator (in the United States, the Federal Aviation Administration for aviation or the Nuclear Regulatory Commission for nuclear power). In US healthcare, the story will almost certainly be different. Whereas in aviation there is only the single federal regulator, healthcare in the United States has over 50 jurisdictions (the 50 states and various federal healthcare systems including those in the Department of Defense and Department of Veterans Affairs). In each jurisdiction the authority is typically distributed between organizations representing different disciplines or components of the healthcare system. Federal institutions like the Food and Drug Administration (FDA) regulate the drugs and devices used, but not the practice of healthcare. Similarly, although federal payers (such as the Centers for Medicare and Medicaid Services) control much of the flow of money in healthcare, they have weak control over many elements of practice such as training or certification of clinicians as individuals or teams. Add to the mix the approximately 8,500 hospitals, 140 medical schools, and over 1,000 nursing schools—all of which have disparate voluntary oversight in the form of accrediting bodies, societies, and collaborations—and the analogy to the aviation or nuclear power industry further weakens. Thus, in healthcare (especially in the United States) we can expect a much more mixed organizational model for the adoption of simulation with a patchwork of organizations providing de facto regulation rather than de jure regulation. In such a setting, the simulation community itself should—in fact, must—take a leading role in helping to find a meaningful structure to achieve the community’s long-term goal of using simulation to achieve safer patient care. Thus, the SSH Strategic Summit reported herein can be expected to be the first of many activities for SSH as convener and generator of common ground, while AIMS will continue its focus on promoting simulation to “officialdom.” The members of the Society—the primary readers of this Journal—should support both organizations in these endeavors and be prepared to lend their assistance on committees and projects to bring the simulation community’s leadership role to maximum fulfillment.