%% From Shayna: What does each step look like as applied to a specific in situ sim program? It could be a made up program, but might help illustrate some of the steps/features.  %% ## Benefits of In Situ Simulation You can bring learning and improvement opportunity to the people. They don't need to be taken out of clinical practice to participate. Additionally, the complexities of the real world work in your favor, and you can better learn the interaction between the people and the environment. The key is to consider not the "where" but the "why" of in situ simulation (Brazil, 2017). Don't focus on "education" in your in situ work, it's very hard for people to cognitively disengage from their work day to participate in the exploration of new ways of seeing. Save those for simulations that occur during protected learning time. Use in situ to work on improving the world around your teams. Will people learn by simple rehearsal? Of course they are likely to learn about the equipment, resources, procedures, etc. However, that shouldn't be your focus. Additionally, if your goal for in situ sim is "these residents can rehearse crash airways," for example, the people around them who are called up to participate (often nurses and allied health professionals) unintentionally end up feeling like pawns in someone else's learning experience. (Brazil, 2021) ## Challenges of In Situ Simulation _Everyone is already working as hard as they can._ In order to overcome the pain of being the one who is _adding something_ to their already terrible day, you **must** take a "what's in it for them" philosophy. You also owe it to them to make improvements that stick and that make the world at least just a little bit better for them. So the question is, if everyone's already working as hard as they can, how can you get past the inertia and pain of the day to get people engaged? ## Use and follow a change management philosophy and structure Such as Kotter’s 8 Steps: [https://www.kotterinc.com/methodology/8-steps/](https://www.kotterinc.com/methodology/8-steps/) - Others would include Lean Management, Six-Sigma - You may want to connect with your senior team who will be your sponsors to ensure you use their approach - If they don't have an approach, suggest Kotter ### Kotter's 8 Steps: #### Step 1: Create a sense of Urgency - Start with Why Work together to create a [[shared mental model]] around the “Why” with your colleagues and team – create the sense of urgency and ensure that the sense of urgency is shared before proceeding. [[start with why]], every communication should start with the "Why." The Why needs to be connected to the Vision. Consider the current state to be _gravity._ Your project needs enough escape velocity to launch into orbit. You need to harness the power of a crisis, [[never let a good crisis go to waste]], and confirm with everyone what it will take to get over the barrier of the world. **Focus your In Situ Sims on Organizational Improvement not “education” this will supercharge participation.** Change from doing sims **TO** people at work, to **WITH** people at work. ![[Escape the gravity of the current world.jpg]] #### Step 2: Build A Guiding Coalition Here's where you need to be leading up. Your goal here is partnering with the people who will later be helping you overcome the inevitable barriers the project will face. So, they need to be co-owners of the vision, such that they are invested. Your goal should be using this crisis as an opportunity to understand what success looks like from the perspective of the leaders. __Make your boss look good!__ Ask them: "What would success look like from your perspective?" or "How will you know this project was worth it?" and "From your perspective, what is at risk to the organization if we don't do this?" What happens if they don't support your project? Success is unlikely, keep working this step until they support some version of it. #### Step 3: Co-Create a clear one-line patient-centered vision Get a great patient-centered vision like: “We will be ready to identify and get the right resources to any critical patient in our community.” Use "readiness" language around your vision. Find something that resonates with your leaders _and_ your partners. #### Step 4: Enlist a volunteer army There are two groups on the ground level that you may want to focus your energy on. - **Group 1: the departmental change agents.** These are the people who are respected, listened to, and enthusiastic partners. They are going to cheerlead your program while you aren't there. Ask yourself, "who around here do people listen to who isn't part of management?" Those are people who you want to be on your volunteer army. - The ask: will you support my project? What do you think? How can it be improved? How's the vision? Does it resonate? What might get in our way? - **Group 2: the [[lurking stakeholders]].** On this graphic they are "dangerous stakeholders." They are dangerous because since they lack legitimacy they can seek to attack projects that don't include them. They are out there, and history should be used to determine who they are. These are the people who unintentionally have sabotaged other projects. They are well intended and talk a lot, and when they don't participate in the development of projects, they tend to undermine them. - The ask: What will it take for this project to be a success? Would you be willing to help guide us? With your experience, what would it take for you to support this project? - Here consider the saying "Keep your friends close, and your enemies closer" - If they feel empowered to influence the project before it starts, they can generally become supporters. Remember, they are good people threatened by change who become dangerous because of the situation. Assume the [[Basic Assumption]]. ![[Stakeholder Typology.jpg]] (Mitchell et al., 1997) “Identify how each stakeholder needs to be approached to get them on board: - With data? - By linking it to enterprise impact? - With endorsements from other key stakeholders? - By aligning it with their values? - By linking it to their potential win, their ego, or their advancement? - By linking it to a reduction in a risk that they care about?” (Zigarmi et al., 2024, p. 6) _All of these are "what's in it for them" questions!_ #### Step 5: **Overcome barriers** **Negotiate a “No-Go Considerations” (Bajaj et al., 2018) checklist ahead of time** _It will be political work to determining the conditions under which the in situ simulations can run, this is face-to-face_ - Consider the impacted departments, will you be calling on responses from ICU, Respiratory Therapy, Emergency Department, Anesthesiology, etc? Go to them, and ask (remember, you've already got the support of the senior team, so the project is happening) "What do you need in order to participate safely?" - Here you need to apply your [[Listening to Understand]]. You are going to [[Negotiate to Optimize not Compromise]], find the win-wins. Do not let perfect be the enemy of good, you aren't bullying, your working together. - A key rule: The person in charge of the unit ALWAYS has the right to call off an in situ sim. You won't ask why in the moment, you'll clean up and leave. After, you can find out why, and see if you need to adjust your "No Go Considerations" list. - Ask the leadership: "What percent of the time should our simulations that are planned take place?" Often about 75% is a good number to strive for. - Consider this document a "working draft" and be open to change over time. Your organization will have it's own priorities - See the article _"No-Go Considerations" for In Situ Simulation Safety_ (Bajaj et al., 2018) for a framework for creating your own list - Here's an example draft - see page 1 ![[Simulation No Go List.pdf]] For any other barriers - you need to go to your Guiding Coalition (Step 2 above) for support. They will help you if you got their permission, heard their point of view, and they participated in owning the risks of the world the way it is, the decision to make a new world, and the vision of that new world. ## But we haven't done any In Situ Simulations Yet, what's with all the prework? Yes, this should be considered a **BIG PROJECT**, that means it will take a while to get off the ground. Dubé et al published a guide to all the pre-work for managing this big project. (Dubé et al., 2021) ![[Phases of the in Situ project.jpg]] Make sure everyone knows the first few times will be PILOTS: ![[rules for creating effective pilots]] (Edmondson, 2023) #### Step 6: Generate Short Term Wins Did you actually run an In Situ simulation? Celebrate! Wow, you did the thing. A key here is celebrating it's occurrence. Just doing an In Situ is a cause to celebrate. ![[Celebrate.jpg]] By the way, did you uncover **ANY** systems issues that could be worked on? Celebrate THAT!!! "Hey team, because of your colleagues participation, we found that the code cart was plugged in awkwardly behind the door, making it hard to access. We've moved it to the other side of the door, now it's easier!" Guess what you just did, the thing that no-one gets in healthcare, people had a tiny piece of sand removed from their shoe. And it was done because they were seen and listened to. **Celebrate, celebrate, advertise, feedback, connect to the vision.** #### Step 7: Sustain Acceleration Organizations are either building or collapsing, there is no neutral. The goal here is a culture of [[second order problem solving]]. People start participating in the improvement of their own lives. _This cycle is a burnout eraser._ ![[Second Order Problem Solving.jpg]] (Edmondson, 2023) So, how to determine what to work on? **Get the answers you want by asking better questions:** Debrief your in Situ Simulations using Dynamic Plus-Delta (Kainth, 2021) - What enabled us to “be ready to identify and get the right resources to any critical patient in our community” (see how we always connect back to our why?) - What got in the way of us “being ready to identify and get the right resources to any critical patient in our community” (see how we always connect back to our why?) Separate the Plus and the Delta - don't ask "Double Barrel Questions" ![[double barrel plus delta.jpg]] (Cheng et al., 2021) Generally In Situ programs have few minutes for the debrief. Focus attention on the inhibitors and enablers to reach the vision. #### Step 7: Institute Change: - Petrosoniak et al can provide a framework for identifying and working on system-based safety threats using design thinking. (Petrosoniak et al., 2020) - Use simulations of various types to work through prototype solutions ![[Design Based Simulation solutions.jpg]] #### Close open loops: Participation builds momentum when open loops are closed, when people can see the impact of their participation through a commitment to close system gaps identified in the case review. If issues are raised and no follow-through occurs, participation may wane. Not all issues need to be fixed, but all key issues need closure. Organizations should create transparent systems of closure. In essence, don’t ask questions that you don’t want the answer to. The debriefing is a form of asking participants what can be improved that impacts their daily work, when ideas are generated, they need to go somewhere for collection, ranking, action, and closure. ## Takeaways _In the end, In Situ simulation is a key tool in healthcare organizations creating a learning culture, and the people closest to the work get to have a say in making the improvements. These features combine to make In Situ simulation a powerful antidote to burnout, if we perform it **with** our colleagues and not **to** them._ ## Sources: Bajaj, K., Minors, A., Walker, K., Meguerdichian, M., & Patterson, M. (2018). “No-Go Considerations” for In Situ Simulation Safety. _Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare_, _13_(3), 221–224. [https://doi.org/10.1097/SIH.0000000000000301](https://doi.org/10.1097/SIH.0000000000000301) Brazil, V. (2017). Translational simulation: Not ‘where?’ but ‘why?’ A functional view of in situ simulation. _Advances in Simulation_, _2_(1), 20. [https://doi.org/10.1186/s41077-017-0052-3](https://doi.org/10.1186/s41077-017-0052-3) Victoria Brazil. (2021, January 5). _Why simulation-based team training might be a bad idea……_. ICE Blog. [https://icenet.blog/2021/01/05/why-simulation-based-team-training-might-be-a-bad-idea/](https://icenet.blog/2021/01/05/why-simulation-based-team-training-might-be-a-bad-idea/) Cheng, A., Eppich, W., Epps, C., Kolbe, M., Meguerdichian, M., & Grant, V. (2021). Embracing informed learner self-assessment during debriefing: The art of plus-delta. _Advances in Simulation_, _6_(1), 22. [https://doi.org/10.1186/s41077-021-00173-1](https://doi.org/10.1186/s41077-021-00173-1) Dubé, M., Posner, G., Stone, K., White, M., Kaba, A., Bajaj, K., Cheng, A., Grant, V., Huang, S., & Reid, J. (2021). Building impactful systems-focused simulations: Integrating change and project management frameworks into the pre-work phase. _Advances in Simulation_, _6_(1), 16. [https://doi.org/10.1186/s41077-021-00169-x](https://doi.org/10.1186/s41077-021-00169-x) Edmondson, A. C. (2023). _Right kind of wrong: The science of failing well_ (First Atria books hardcover edition). Atria Books. Kainth, R. (2021). Dynamic Plus-Delta: An agile debriefing approach centred around variable participant, faculty and contextual factors. _Advances in Simulation_, _6_(1), 35. [https://doi.org/10.1186/s41077-021-00185-x](https://doi.org/10.1186/s41077-021-00185-x) Kotter, J. P. (1995). Leading Change: Why Transformation Efforts Fail. _Harvard Business Review_, _March-Apri_, 59–67. [https://hbr.org/1995/05/leading-change-why-transformation-efforts-fail-2](https://hbr.org/1995/05/leading-change-why-transformation-efforts-fail-2) Mitchell, R. K., Agle, B. R., & Wood, D. J. (1997). Toward a Theory of Stakeholder Identification and Salience: Defining the Principle of Who and What Really Counts. _The Academy of Management Review_, _22_(4), 853. [https://doi.org/10.2307/259247](https://doi.org/10.2307/259247) Petrosoniak, A., Hicks, C., Barratt, L., Gascon, D., Kokoski, C., Campbell, D., White, K., Bandiera, G., Lum-Kwong, M. M., Nemoy, L., & Brydges, R. (2020). Design Thinking–Informed Simulation: An Innovative Framework to Test, Evaluate, and Modify New Clinical Infrastructure. _Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare_, _15_(3), 205–213. [https://doi.org/10.1097/SIH.0000000000000408](https://doi.org/10.1097/SIH.0000000000000408) Zigarmi, L., Diamond, J., & Mones, L. (2024, January 4). A Guide for Getting Stakeholder Buy-In for Your Agenda. _Harvard Business Review_. [https://hbr.org/2024/01/a-guide-for-getting-stakeholder-buy-in-for-your-agenda](https://hbr.org/2024/01/a-guide-for-getting-stakeholder-buy-in-for-your-agenda)