ORIGINAL ARTICLE
Utilization of Simulation for the Introduction of New Software Technology to the Clinical Setting Eugene Richie, RN,* Conrad Dove, BS,* Shannon L. Crowe, RN,Þ Vickie DeArment, RN,Þ Jimmie Manwiller, RN,Þ Michael Wallace, MD, MPH,Þ and David D. Thiel, MD*
Introduction: ProVation Medical documentation software was introduced in our Department of Gastroenterology (GI). We evaluated the use of a simulation module to improve the introduction of new documentation software into a tertiary care center GI department. Materials and Methods: Train-the-trainer education was provided by the vendor of the new documentation module. A simulation module was developed to simulate the preparatory, intraprocedural, and postprocedure phase of active utilization of the software. A standardized patient (SP)/medical actor was used for provision of data to be entered in to the ProVation Medical preprocedure module. A procedural suite was configured to allow for staff to assume their roles during endoscopic cases. A checklist of key activities was used by observers during the training. A postscenario evaluation document was collected for perceptions of training. Results: Twenty-one GI nurses and technicians spent 3 hours in groups of 7 over a 3-day period completing activities commensurate with these procedural phases. Nineteen of 21 learners felt the simulation was nonthreatening, and the same number gave the course an overall 5/5 rating. There were no specimen labeling errors, patient identification errors, or sentinel events related to the software rollout. All learners felt that physician involvement in the simulation would have been beneficial. Conclusions: Simulation can be used to improve the rollout of new software in a tertiary care center. Staff satisfaction associated with this type of learning activity was high, and a communicated level of comfort was achieved as a result of the simulation-based experiential learning. Key Words: simulation, process improvement, health-care software (J Patient Saf 2014;10: 176Y180)
I
mplementation of new technologies to advance the efficiency of providers, improve the ability to monitor key metrics, and enhance the capturing of revenue through compliance with coding regulations requires a comprehensive remodel of practice. Poorly planned user training of new software can decrease the application’s effectiveness or cause staff to resist using the software.1 Standard training on new health-care software often involves vendor-led courses, and it is theorized that only 30% of the information in those courses is retained by the future software users.1 Our tertiary care facility decided to implement ProVation Medical software as a computer endoscopic reporting database in the department of gastroenterology (GI). The goal of implementing this software was to manufacture a single electronic document that captured all needed data for physicians From the *Multidisciplinary Simulation Center, and †Department of Gastroenterology, Mayo Clinic, Jacksonville, Florida. Correspondence: David D. Thiel, MD, Department of Urology Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 (e-mail: [email protected]). The authors disclose no conflict of interest. Copyright * 2013 by Lippincott Williams & Wilkins
176
www.journalpatientsafety.com
and nurses and to standardize these data across the institution. The creation of this document eliminates the need for transcription and improves the overall efficiency of documentation, reporting, and billing. ProVation Medical software captures procedural images and builds procedure and laboratory reports while simultaneously compiling physician and nursing documentation. To make this transition effective and to improve learning retention rate by future software users, our institution decided to roll out the technology using our multidisciplinary simulation center (MSC). The hypothesis was that this type of implementation would provide opportunities for learning and modification during training, which could potentially add value to the process. To this end, we hoped to demonstrate the use of experiential learning to augment didactic education as a method to enhance staff awareness and improve training with the implementation of ProVation Medical software as a documentation tool in the GI lab. Herein, we describe the simulated rollout of new documentation software into the clinical setting in a tertiary care medical center.
MATERIALS AND METHODS A planning team met to plan the activities and establish general strategies for the documentation and procedures of live software rollout in the GI lab (‘‘go live’’ date). The planning team was established by senior institutional leadership to represent potential users of the new software. The team was given 2 months to plan for the ‘‘go live’’ date. The team met three times before the simulation activity that precluded the software ‘‘go live’’ date. The team included the GI coordinator, the nurse supervisor of the clinic GI lab, the nurse supervisor of the hospital GI lab, the operations manager of the MSC, and a technical specialist from the MSC. The goal of the meetings was to establish who would be included in the training and to set up the training exercise. Included as adjunct members of the implementation team were specialists from the Systems and Procedures unit, who were trained to identify process oriented challenges and opportunities. A plan was developed in which successive organizational implementation would occur. The clinic and hospital GI personnel learned economies from other sites that had implemented the software. The first phase of the rollout included the ProVation Medical support team providing 2 hours of didactic training for physicians and allied health. This training took place in the computer lab to allow for individual manipulation of the software. All physicians and allied health personnel were required to attend the didactic session. A local team of train-the-trainers was given more extensive software training during this time. These trainers consisted of one nurse and one technician from the hospital and clinic GI labs. These trainers would later train staff who were not available during the initial training period and would provide support during the rollout. Systems and Procedure staff were able to chronicle the activities, identifying process-related issues. At the request of GI leadership, a member of the multidisciplinary J Patient Saf
&
Volume 10, Number 3, September 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf
&
Volume 10, Number 3, September 2014
New Health-Care Software
FIGURE 1. Process flow chart. The chart outlines the flow of the learners through the simulated exercise.
simulation center (MSC) was afforded the opportunity to attend the didactic train-the-trainer sessions to frame the learning in the MSC. GI staff, excluding physicians, were then scheduled to attend a 2-hour hands-on training session in the MSC. Physicians were excluded secondary to scheduling conflicts and prior commitments. Staff from the MSC took photos of the clinic and hospital work environments and configured the MSC to emulate the work environment. All the necessary equipment to complete the procedures in the appropriate locations was positioned to emulate the lab space. Gastroenterology lab nursing supervisors were consulted to ensure accuracy. Training hours were flexed to allow staff to train without impacting the practice. Gastroenterology lab allied health staff were scheduled for 3-hour shifts of training in the MSC on 3 successive days during the week before the clinical rollout. The training was broken into 3 sections of focus: (1) pre-procedural activity, (2) intraprocedural activity, and (3) specimen acquisition. Figure 1 demonstrates the overall process flow through the simulated exercise. This study was found to be review exempt by our institutional review board.
Section 1: Preprocedural Activity The preprocedural phase of activity was created in an inpatient room of the MSC. The ProVation Medical software had been loaded onto the hard drive of the computer in the preprocedural area. A standardized patient (SP) met with the GI Lab nursing supervisor to script answers to the required fields in the ProVation Medical software. These responses required additional questioning of the patient. Liberty was ascribed to the SP to ad lib answers from these key points of entry. Groups of 3 or 4 staff based on their respective roles rotated into this area for training. Staff entered preliminary data into a grouping of test patients established within the registration system/electronic medical record. Staff performed all aspects of the preprocedural * 2013 Lippincott Williams & Wilkins
validation process from consent completion, education related to the procedure, documentation of allergies, medical history, current state of health, medications, and so on. Upon successful completion of the preprocedural documentation process, transfer of the SP into the procedural area was executed.
Section 2: Intraprocedural Activity The intraprocedural portion of the simulation took place in a simulated operating room down the hall from the preprocedural activity. Staff in the procedural area consisted of GI technicians and nurses. Each staff member was afforded an opportunity to function in their appropriate roles performing duties as assigned. The MSC staff entered the room following initiation of the documentation record by the nurse and technician in the role of the scope performing physician. The procedural portion of the simulation was configured using a central line trainer upper torso (Blue Phantom, Redmond, WA) as well as a colonoscopy trainer (Kyoto Kagaku, Kyoto, Japan) (Fig. 2). A standard endoscopic tower and colonoscope were used for training during the procedure. The colonoscopy trainer was prepped with a mucin-like solution combined with flecks of blue latex to simulate specimen material to be obtained (Fig. 3). The ProVation Medical software had been loaded onto the hard drive of the computer located on the light source tower. This accommodated the capture of video images during the procedure and allowed for the transfer of the record to the server. The GI tech prepared the tower computer by identifying the appropriate patient, encounter, and procedure. The scope number was required to be identified and entered. Nursing staff using another computer with network access software was used to engage the patient record into the procedural mode. When the simulated physician (played by MSC staff ) entered the procedure, a procedural pause was conducted to ensure all the safety measures were in place. Sedation was ordered for the procedure, and the nurse administered the medication via a www.journalpatientsafety.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
177
J Patient Saf
Richie et al
FIGURE 2. Procedural portion of the simulation. The patient in the simulation of the procedure was configured using a central line trainer upper torso (Blue Phantom, Redmond, WA) as well as a colonoscopy trainer (Kyoto Kagaku, Kyoto, Japan).
functioning intravenous line while documenting the dose in the software. The procedure continued with the physician advancing the scope into the simulated colon and communicating to the staff any findings. As a part of the scenario, the simulated patient’s vital signs were elevated, signaling the need for additional sedation. The nurse was required to assess the situation, request additional orders for execution, and document the process in the system.
Phase 3: Specimen Acquisition Activity As a part of the procedure, the GI lab nursing supervisor staged the need for specimen collection. Upon recognition of the specimen during the procedure, the physician asked for collection of a designated specimen type. The tech prepared the snare, and the normal collection process would ensue. Labels and forms were preemptively created by the GI Lab nursing supervisor for the appropriate patient encounter. The labeling process was completed according to ProVation Medical software data requests and entered by the RN in the system. Upon completion of the simulated procedure, a pathology pause was executed as required, with the nurse and physician validating the specimen documentation in their respective systems, while the technician confirmed the specimen was labeled properly with accurate test requisitions completed for disposition to the lab. At the closure of this activity, the chart was saved for transfer to recovery, and the record in the tower computer would be saved for the physician phase of documentation. At the completion of the module, the learners completed a questionnaire (see Appendix 1). The questionnaire contained sections inviting comments pertaining to the actual exercise as well as improvements that may be required by our MSC staff.
&
Volume 10, Number 3, September 2014
for diffuse biopsy collections. These modification needs were addressed and corrected. The open comment sections at the bottom of the questionnaire were populated by the trainees. There were 7 comments in the section pertaining to how the exercise improved practice. All of the comments were positive with regard to the exercise and noted that the hands-on training greatly improved knowledge retention. There were no negative comments in the section with regard to the exercise or the staff. The only comment in the section asking about the simulation center improvements was that the MSC should do a better job of marketing their services to the institution so that all new equipment and software rollouts be trialed in the MSC before being introduced to the clinical practice. Supervisory staff reported a smooth rollout. There were no specimen errors attributable to the rollout. There were no patient identification errors and no sentinel events related to the rollout. The course evaluation had an open area for learner comments, where one supervisor reported that more time in the simulation center would have been helpful. It was universally noted that physician involvement in the simulation would have addressed many of the cited process flow challenges.
DISCUSSION Software technology change often elicits a feeling of discomfort in members of a health-care team. Poor training when implementing new mission-critical software can decrease the application’s effectiveness and cause staff to resist the change.1 Typical implementation of new clinical software involves the software vendor providing 2 to 3 days of didactic teaching to future software users. It is theorized that clinical learners only retain approximately 30% of the information in a didactic-only environment.1 GI leadership approached representatives from the MSC about moving from a didactic only approach in software training to hands-on training that would allow for more well-rounded learning. Nurses’ satisfaction and attitude levels toward implementing new clinical software/computer systems plays a major role in successful integration of technology into daily patient care.2 Dillon et al3 demonstrated that better nursing attitudes toward software change processes led to less requirement of external motivation and decreased the required amount of training. One method of improving nursing attitudes toward the planned change is to include the nursing staff in the change process.2,4 The implementation planning team for this particular project included GI leadership, nurses that would be using the system, and specialists from the Systems and Procedures unit.
RESULTS A total of 21 learners went through the program (7 learners each day over a 3-day period). Sixteen nurses and 5 technicians completed the simulation module. The nursing supervisor structured several unique scenarios to augment the learning, and each phase of the simulation averaged 3 scenarios per learner group. Figure 4 demonstrates learner responses to a postcourse questionnaire. Nineteen of 21 learners (90.5%) gave the overall course a rating of 5 of 5. The same amount felt the event was nonthreatening. Eighteen (85.7%) of 21 learners felt the simulation as designed allowed them to reflect on their performance. The simulation event allowed staff to uncover 2 software modification needs related to the recognition of major site determination in double procedures as well as location designation
178
www.journalpatientsafety.com
FIGURE 3. Simulated specimen retrieval. The colonoscopy trainer was prepped with mucin-like solution along with flecks of blue latex to simulate specimen material to be obtained. * 2013 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf
&
Volume 10, Number 3, September 2014
New Health-Care Software
FIGURE 4. Allied Health Staff ProVation Medical Training in the MC. The figure demonstrates that a majority of the learners were able to reflect on their performance during the training, felt nonthreatened, and gave the course an overall excellent rating.
Based upon a preestablished organizational timeline, trainthe-trainer education, education of the staff, and rollout of the new product would all occur within 3 weeks of one another. The timing of these steps presented a challenge to train staff in very active clinic and hospital GI labs. Training hours were flexed to allow staff to train without impacting the practice. Gastroenterology lab allied health staff were scheduled for 2-hour shifts of training in the MSC on 3 successive days during the week before the clinical rollout. Based upon the time allotted for training, trainers would incorporate on-the-job training with the physician staff. The MSC staff visited the GI labs in the clinic and hospital to identify room configurations for emulation in the center. This step played a role in making the scenario very realistic for the GI lab staff. The detailed set up in the MSC as well as the incorporation of SPs and task training/high fidelity training equipment allowed experiential learning to be performed with real interactions that dispelled disbelief and allowing for emotional buy-in from the learners. Staff met the training with some tentativeness early in the process. This was overcome as GI nursing leadership provided clarity of safety in the learning environment and encouraged staff to function in the same manner they would routinely in their work areas. Standardized patient use during the preprocedural activity introduced the human interactive factor. The SP was provided a script of nonroutine information, which required atypical interfacing with the software program. This type of training provided staff the ability to search more complex fields for recognition of data required. The learning staff believed this method of learning provided an increased level of confidence during the implementation phase of the process. Scripting ensured all fields of the software were addressed for staff awareness. Other GI staff were tasked with functioning as observers. This provided insight into process considerations and difficulties in navigating the new system. The simple exercise of having learners provide insight and having them feel as though they were listened to increases the potential for successful software adoption.5 Intraprocedural activity was instrumental in providing many breakthrough decisions in process flow and procedural role clarification. As in the preprocedural training, staff became comfortable with manipulating the software and gathering key points for entry to ensure comprehensive analysis would be * 2013 Lippincott Williams & Wilkins
possible moving forward. Particular attention was paid to verifying patient identification and proper specimen labeling. The Joint Commission continues to stress proper specimen labeling secondary to the fact that one of every 18 pathologic specimen identification errors results in a serious adverse event.6,7 Patient identification errors are not only prevalent in the real clinical environment but in the simulated environment as well.8 One weakness of the simulation was that MSC staff functioned in the role of the physician. Staff physicians were not included in the exercise secondary to scheduling conflicts. Because physician activity was not a cornerstone of evaluation, the trainees did not feel that this affected the realism of the exercise. The exercise took place in a simulated environment that lacked the stressors that would normally be found in the GI lab. Another weakness of this trial is that there was not a control group of software users with which to compare the simulated group. In an ideal setting, a separate set of GI nurses would have implemented the new software without the simulated learning, and the results (documentation errors, etc.) would have been compared with the group that had the simulated experience. We did not feel this was an ethical study to perform, so all staff underwent the above simulated exercise as part of their training. It is unclear if this simulation would be effective in other units of our institution or GI units in other facilities. Several lessons were identified as benefits of executing this style of learning. This style of learning is beneficial in that it may even the playing field for those with varied baseline computer skills.9 Staff noted positively that the ability to learn in a simulated environment allowed for error generation without harm to patients. This atmosphere also allowed staff to challenge processes and facilitate conversation to provide clarity to process management and resulted in many process improvement activities. Staff commented anecdotally during the rollout of the software in situ that an increased confidence level was obtained from the use of the MSC for training. Day 1 implementation was noted by the ProVation Medical representative as ‘‘the best trained staff I have ever encountered during a new implementation.’’
CONCLUSIONS Implementation of new clinical software using a MSC was shown to add significant benefit to a tertiary care GI department. The addition of using simulation-based training enhanced www.journalpatientsafety.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
179
J Patient Saf
Richie et al
the learning process of staff and provided insight to many process improvement outlined. REFERENCES 1. Albright B. The training challenge. Careful planning is essential when implementing new software. Behav Healthc. 2008;28:17Y18. 2. Smith D, Morris A, Janke J. Nursing satisfaction and attitudes with computerized software implementation: a quasi-experimental study. Comput Inform Nurs. 2011;29:245Y250. 3. Dillon T, Blankenship R, Crews T. Nursing attitudes and images of electronic patient record systems. Comput Inform Nurs. 2005;23: 139Y145. 4. Burkes M. Identifying and relating nurses attitudes toward computer use. Comput Nurs. 1991;9:190Y201.
&
Volume 10, Number 3, September 2014
5. Smith K, Smith V, Krugman M, et al. Evaluating the impact of computerized clinical . Comput Inform Nurs. 2005;23:132Y138. 6. Rees S, Stevens L, Mikelsons D, et al. Reducing specimen identification errors. J Nurs Car Qual. 2012;27:253Y257. 7. Valenstein PN, Raab SS, Walsh MK. Identification errors involving clinical laboratories. Arch Pathol Lab Med. 2006;130: 1106Y1113. 8. Henneman PL, Fisher DL, Henneman EA, et al. Patient identification errors are common in a simulated setting. Ann Emerg Med. 2010;55:503Y509. 9. McCain CL. The right mix to support electronic medical record training: classroom computer-based training and blended learning. J Nurses Staff Dev. 2008;24:151Y154.
Florida Multidisciplinary Simulation Center Course Evaluation Course Title:__________________________________________ Date:____________ Instructor:________________________________ Please rate the following based on the following scale 1 = Needs improvement to 5 = Top 10%, one of the best OVERALL RATING: COURSE
1
2
3
4
5
The course met my learning needs Faculty knowledge of subject matter Quality of the (task trainer/scenario/other) Opportunity to reflect on my performance during the debriefing session Faculty ability to provide constructive feedback in a nonthreatening manner Overall course rating
OVERALL RATING: SKILL ENHANCEMENT
1
2
3
4
5
N/A
Decision-making skills Communication skills Team management skills Technical skills Problem-solving skills Ability to adapt to changing/unexpected situations
Additional Information: Please identify something that you learned through this session that may strengthen your practice: What can we at the Mayo Multidisciplinary Simulation Center do to improve? Please make suggestions for future patient and/or team scenarios: Anything else you would like to share about your experience here today?
180
www.journalpatientsafety.com
* 2013 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Utilization of Simulation for the Introduction of New Software Technology to the Clinical Setting Eugene Richie, RN,* Conrad Dove, BS,* Shannon L. Crowe, RN,Þ Vickie DeArment, RN,Þ Jimmie Manwiller, RN,Þ Michael Wallace, MD, MPH,Þ and David D. Thiel, MD*
Introduction: ProVation Medical documentation software was introduced in our Department of Gastroenterology (GI). We evaluated the use of a simulation module to improve the introduction of new documentation software into a tertiary care center GI department. Materials and Methods: Train-the-trainer education was provided by the vendor of the new documentation module. A simulation module was developed to simulate the preparatory, intraprocedural, and postprocedure phase of active utilization of the software. A standardized patient (SP)/medical actor was used for provision of data to be entered in to the ProVation Medical preprocedure module. A procedural suite was configured to allow for staff to assume their roles during endoscopic cases. A checklist of key activities was used by observers during the training. A postscenario evaluation document was collected for perceptions of training. Results: Twenty-one GI nurses and technicians spent 3 hours in groups of 7 over a 3-day period completing activities commensurate with these procedural phases. Nineteen of 21 learners felt the simulation was nonthreatening, and the same number gave the course an overall 5/5 rating. There were no specimen labeling errors, patient identification errors, or sentinel events related to the software rollout. All learners felt that physician involvement in the simulation would have been beneficial. Conclusions: Simulation can be used to improve the rollout of new software in a tertiary care center. Staff satisfaction associated with this type of learning activity was high, and a communicated level of comfort was achieved as a result of the simulation-based experiential learning. Key Words: simulation, process improvement, health-care software (J Patient Saf 2014;10: 176Y180)
I
mplementation of new technologies to advance the efficiency of providers, improve the ability to monitor key metrics, and enhance the capturing of revenue through compliance with coding regulations requires a comprehensive remodel of practice. Poorly planned user training of new software can decrease the application’s effectiveness or cause staff to resist using the software.1 Standard training on new health-care software often involves vendor-led courses, and it is theorized that only 30% of the information in those courses is retained by the future software users.1 Our tertiary care facility decided to implement ProVation Medical software as a computer endoscopic reporting database in the department of gastroenterology (GI). The goal of implementing this software was to manufacture a single electronic document that captured all needed data for physicians From the *Multidisciplinary Simulation Center, and †Department of Gastroenterology, Mayo Clinic, Jacksonville, Florida. Correspondence: David D. Thiel, MD, Department of Urology Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 (e-mail: [email protected]). The authors disclose no conflict of interest. Copyright * 2013 by Lippincott Williams & Wilkins
176
www.journalpatientsafety.com
and nurses and to standardize these data across the institution. The creation of this document eliminates the need for transcription and improves the overall efficiency of documentation, reporting, and billing. ProVation Medical software captures procedural images and builds procedure and laboratory reports while simultaneously compiling physician and nursing documentation. To make this transition effective and to improve learning retention rate by future software users, our institution decided to roll out the technology using our multidisciplinary simulation center (MSC). The hypothesis was that this type of implementation would provide opportunities for learning and modification during training, which could potentially add value to the process. To this end, we hoped to demonstrate the use of experiential learning to augment didactic education as a method to enhance staff awareness and improve training with the implementation of ProVation Medical software as a documentation tool in the GI lab. Herein, we describe the simulated rollout of new documentation software into the clinical setting in a tertiary care medical center.
MATERIALS AND METHODS A planning team met to plan the activities and establish general strategies for the documentation and procedures of live software rollout in the GI lab (‘‘go live’’ date). The planning team was established by senior institutional leadership to represent potential users of the new software. The team was given 2 months to plan for the ‘‘go live’’ date. The team met three times before the simulation activity that precluded the software ‘‘go live’’ date. The team included the GI coordinator, the nurse supervisor of the clinic GI lab, the nurse supervisor of the hospital GI lab, the operations manager of the MSC, and a technical specialist from the MSC. The goal of the meetings was to establish who would be included in the training and to set up the training exercise. Included as adjunct members of the implementation team were specialists from the Systems and Procedures unit, who were trained to identify process oriented challenges and opportunities. A plan was developed in which successive organizational implementation would occur. The clinic and hospital GI personnel learned economies from other sites that had implemented the software. The first phase of the rollout included the ProVation Medical support team providing 2 hours of didactic training for physicians and allied health. This training took place in the computer lab to allow for individual manipulation of the software. All physicians and allied health personnel were required to attend the didactic session. A local team of train-the-trainers was given more extensive software training during this time. These trainers consisted of one nurse and one technician from the hospital and clinic GI labs. These trainers would later train staff who were not available during the initial training period and would provide support during the rollout. Systems and Procedure staff were able to chronicle the activities, identifying process-related issues. At the request of GI leadership, a member of the multidisciplinary J Patient Saf
&
Volume 10, Number 3, September 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf
&
Volume 10, Number 3, September 2014
New Health-Care Software
FIGURE 1. Process flow chart. The chart outlines the flow of the learners through the simulated exercise.
simulation center (MSC) was afforded the opportunity to attend the didactic train-the-trainer sessions to frame the learning in the MSC. GI staff, excluding physicians, were then scheduled to attend a 2-hour hands-on training session in the MSC. Physicians were excluded secondary to scheduling conflicts and prior commitments. Staff from the MSC took photos of the clinic and hospital work environments and configured the MSC to emulate the work environment. All the necessary equipment to complete the procedures in the appropriate locations was positioned to emulate the lab space. Gastroenterology lab nursing supervisors were consulted to ensure accuracy. Training hours were flexed to allow staff to train without impacting the practice. Gastroenterology lab allied health staff were scheduled for 3-hour shifts of training in the MSC on 3 successive days during the week before the clinical rollout. The training was broken into 3 sections of focus: (1) pre-procedural activity, (2) intraprocedural activity, and (3) specimen acquisition. Figure 1 demonstrates the overall process flow through the simulated exercise. This study was found to be review exempt by our institutional review board.
Section 1: Preprocedural Activity The preprocedural phase of activity was created in an inpatient room of the MSC. The ProVation Medical software had been loaded onto the hard drive of the computer in the preprocedural area. A standardized patient (SP) met with the GI Lab nursing supervisor to script answers to the required fields in the ProVation Medical software. These responses required additional questioning of the patient. Liberty was ascribed to the SP to ad lib answers from these key points of entry. Groups of 3 or 4 staff based on their respective roles rotated into this area for training. Staff entered preliminary data into a grouping of test patients established within the registration system/electronic medical record. Staff performed all aspects of the preprocedural * 2013 Lippincott Williams & Wilkins
validation process from consent completion, education related to the procedure, documentation of allergies, medical history, current state of health, medications, and so on. Upon successful completion of the preprocedural documentation process, transfer of the SP into the procedural area was executed.
Section 2: Intraprocedural Activity The intraprocedural portion of the simulation took place in a simulated operating room down the hall from the preprocedural activity. Staff in the procedural area consisted of GI technicians and nurses. Each staff member was afforded an opportunity to function in their appropriate roles performing duties as assigned. The MSC staff entered the room following initiation of the documentation record by the nurse and technician in the role of the scope performing physician. The procedural portion of the simulation was configured using a central line trainer upper torso (Blue Phantom, Redmond, WA) as well as a colonoscopy trainer (Kyoto Kagaku, Kyoto, Japan) (Fig. 2). A standard endoscopic tower and colonoscope were used for training during the procedure. The colonoscopy trainer was prepped with a mucin-like solution combined with flecks of blue latex to simulate specimen material to be obtained (Fig. 3). The ProVation Medical software had been loaded onto the hard drive of the computer located on the light source tower. This accommodated the capture of video images during the procedure and allowed for the transfer of the record to the server. The GI tech prepared the tower computer by identifying the appropriate patient, encounter, and procedure. The scope number was required to be identified and entered. Nursing staff using another computer with network access software was used to engage the patient record into the procedural mode. When the simulated physician (played by MSC staff ) entered the procedure, a procedural pause was conducted to ensure all the safety measures were in place. Sedation was ordered for the procedure, and the nurse administered the medication via a www.journalpatientsafety.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
177
J Patient Saf
Richie et al
FIGURE 2. Procedural portion of the simulation. The patient in the simulation of the procedure was configured using a central line trainer upper torso (Blue Phantom, Redmond, WA) as well as a colonoscopy trainer (Kyoto Kagaku, Kyoto, Japan).
functioning intravenous line while documenting the dose in the software. The procedure continued with the physician advancing the scope into the simulated colon and communicating to the staff any findings. As a part of the scenario, the simulated patient’s vital signs were elevated, signaling the need for additional sedation. The nurse was required to assess the situation, request additional orders for execution, and document the process in the system.
Phase 3: Specimen Acquisition Activity As a part of the procedure, the GI lab nursing supervisor staged the need for specimen collection. Upon recognition of the specimen during the procedure, the physician asked for collection of a designated specimen type. The tech prepared the snare, and the normal collection process would ensue. Labels and forms were preemptively created by the GI Lab nursing supervisor for the appropriate patient encounter. The labeling process was completed according to ProVation Medical software data requests and entered by the RN in the system. Upon completion of the simulated procedure, a pathology pause was executed as required, with the nurse and physician validating the specimen documentation in their respective systems, while the technician confirmed the specimen was labeled properly with accurate test requisitions completed for disposition to the lab. At the closure of this activity, the chart was saved for transfer to recovery, and the record in the tower computer would be saved for the physician phase of documentation. At the completion of the module, the learners completed a questionnaire (see Appendix 1). The questionnaire contained sections inviting comments pertaining to the actual exercise as well as improvements that may be required by our MSC staff.
&
Volume 10, Number 3, September 2014
for diffuse biopsy collections. These modification needs were addressed and corrected. The open comment sections at the bottom of the questionnaire were populated by the trainees. There were 7 comments in the section pertaining to how the exercise improved practice. All of the comments were positive with regard to the exercise and noted that the hands-on training greatly improved knowledge retention. There were no negative comments in the section with regard to the exercise or the staff. The only comment in the section asking about the simulation center improvements was that the MSC should do a better job of marketing their services to the institution so that all new equipment and software rollouts be trialed in the MSC before being introduced to the clinical practice. Supervisory staff reported a smooth rollout. There were no specimen errors attributable to the rollout. There were no patient identification errors and no sentinel events related to the rollout. The course evaluation had an open area for learner comments, where one supervisor reported that more time in the simulation center would have been helpful. It was universally noted that physician involvement in the simulation would have addressed many of the cited process flow challenges.
DISCUSSION Software technology change often elicits a feeling of discomfort in members of a health-care team. Poor training when implementing new mission-critical software can decrease the application’s effectiveness and cause staff to resist the change.1 Typical implementation of new clinical software involves the software vendor providing 2 to 3 days of didactic teaching to future software users. It is theorized that clinical learners only retain approximately 30% of the information in a didactic-only environment.1 GI leadership approached representatives from the MSC about moving from a didactic only approach in software training to hands-on training that would allow for more well-rounded learning. Nurses’ satisfaction and attitude levels toward implementing new clinical software/computer systems plays a major role in successful integration of technology into daily patient care.2 Dillon et al3 demonstrated that better nursing attitudes toward software change processes led to less requirement of external motivation and decreased the required amount of training. One method of improving nursing attitudes toward the planned change is to include the nursing staff in the change process.2,4 The implementation planning team for this particular project included GI leadership, nurses that would be using the system, and specialists from the Systems and Procedures unit.
RESULTS A total of 21 learners went through the program (7 learners each day over a 3-day period). Sixteen nurses and 5 technicians completed the simulation module. The nursing supervisor structured several unique scenarios to augment the learning, and each phase of the simulation averaged 3 scenarios per learner group. Figure 4 demonstrates learner responses to a postcourse questionnaire. Nineteen of 21 learners (90.5%) gave the overall course a rating of 5 of 5. The same amount felt the event was nonthreatening. Eighteen (85.7%) of 21 learners felt the simulation as designed allowed them to reflect on their performance. The simulation event allowed staff to uncover 2 software modification needs related to the recognition of major site determination in double procedures as well as location designation
178
www.journalpatientsafety.com
FIGURE 3. Simulated specimen retrieval. The colonoscopy trainer was prepped with mucin-like solution along with flecks of blue latex to simulate specimen material to be obtained. * 2013 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Patient Saf
&
Volume 10, Number 3, September 2014
New Health-Care Software
FIGURE 4. Allied Health Staff ProVation Medical Training in the MC. The figure demonstrates that a majority of the learners were able to reflect on their performance during the training, felt nonthreatened, and gave the course an overall excellent rating.
Based upon a preestablished organizational timeline, trainthe-trainer education, education of the staff, and rollout of the new product would all occur within 3 weeks of one another. The timing of these steps presented a challenge to train staff in very active clinic and hospital GI labs. Training hours were flexed to allow staff to train without impacting the practice. Gastroenterology lab allied health staff were scheduled for 2-hour shifts of training in the MSC on 3 successive days during the week before the clinical rollout. Based upon the time allotted for training, trainers would incorporate on-the-job training with the physician staff. The MSC staff visited the GI labs in the clinic and hospital to identify room configurations for emulation in the center. This step played a role in making the scenario very realistic for the GI lab staff. The detailed set up in the MSC as well as the incorporation of SPs and task training/high fidelity training equipment allowed experiential learning to be performed with real interactions that dispelled disbelief and allowing for emotional buy-in from the learners. Staff met the training with some tentativeness early in the process. This was overcome as GI nursing leadership provided clarity of safety in the learning environment and encouraged staff to function in the same manner they would routinely in their work areas. Standardized patient use during the preprocedural activity introduced the human interactive factor. The SP was provided a script of nonroutine information, which required atypical interfacing with the software program. This type of training provided staff the ability to search more complex fields for recognition of data required. The learning staff believed this method of learning provided an increased level of confidence during the implementation phase of the process. Scripting ensured all fields of the software were addressed for staff awareness. Other GI staff were tasked with functioning as observers. This provided insight into process considerations and difficulties in navigating the new system. The simple exercise of having learners provide insight and having them feel as though they were listened to increases the potential for successful software adoption.5 Intraprocedural activity was instrumental in providing many breakthrough decisions in process flow and procedural role clarification. As in the preprocedural training, staff became comfortable with manipulating the software and gathering key points for entry to ensure comprehensive analysis would be * 2013 Lippincott Williams & Wilkins
possible moving forward. Particular attention was paid to verifying patient identification and proper specimen labeling. The Joint Commission continues to stress proper specimen labeling secondary to the fact that one of every 18 pathologic specimen identification errors results in a serious adverse event.6,7 Patient identification errors are not only prevalent in the real clinical environment but in the simulated environment as well.8 One weakness of the simulation was that MSC staff functioned in the role of the physician. Staff physicians were not included in the exercise secondary to scheduling conflicts. Because physician activity was not a cornerstone of evaluation, the trainees did not feel that this affected the realism of the exercise. The exercise took place in a simulated environment that lacked the stressors that would normally be found in the GI lab. Another weakness of this trial is that there was not a control group of software users with which to compare the simulated group. In an ideal setting, a separate set of GI nurses would have implemented the new software without the simulated learning, and the results (documentation errors, etc.) would have been compared with the group that had the simulated experience. We did not feel this was an ethical study to perform, so all staff underwent the above simulated exercise as part of their training. It is unclear if this simulation would be effective in other units of our institution or GI units in other facilities. Several lessons were identified as benefits of executing this style of learning. This style of learning is beneficial in that it may even the playing field for those with varied baseline computer skills.9 Staff noted positively that the ability to learn in a simulated environment allowed for error generation without harm to patients. This atmosphere also allowed staff to challenge processes and facilitate conversation to provide clarity to process management and resulted in many process improvement activities. Staff commented anecdotally during the rollout of the software in situ that an increased confidence level was obtained from the use of the MSC for training. Day 1 implementation was noted by the ProVation Medical representative as ‘‘the best trained staff I have ever encountered during a new implementation.’’
CONCLUSIONS Implementation of new clinical software using a MSC was shown to add significant benefit to a tertiary care GI department. The addition of using simulation-based training enhanced www.journalpatientsafety.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
179
J Patient Saf
Richie et al
the learning process of staff and provided insight to many process improvement outlined. REFERENCES 1. Albright B. The training challenge. Careful planning is essential when implementing new software. Behav Healthc. 2008;28:17Y18. 2. Smith D, Morris A, Janke J. Nursing satisfaction and attitudes with computerized software implementation: a quasi-experimental study. Comput Inform Nurs. 2011;29:245Y250. 3. Dillon T, Blankenship R, Crews T. Nursing attitudes and images of electronic patient record systems. Comput Inform Nurs. 2005;23: 139Y145. 4. Burkes M. Identifying and relating nurses attitudes toward computer use. Comput Nurs. 1991;9:190Y201.
&
Volume 10, Number 3, September 2014
5. Smith K, Smith V, Krugman M, et al. Evaluating the impact of computerized clinical . Comput Inform Nurs. 2005;23:132Y138. 6. Rees S, Stevens L, Mikelsons D, et al. Reducing specimen identification errors. J Nurs Car Qual. 2012;27:253Y257. 7. Valenstein PN, Raab SS, Walsh MK. Identification errors involving clinical laboratories. Arch Pathol Lab Med. 2006;130: 1106Y1113. 8. Henneman PL, Fisher DL, Henneman EA, et al. Patient identification errors are common in a simulated setting. Ann Emerg Med. 2010;55:503Y509. 9. McCain CL. The right mix to support electronic medical record training: classroom computer-based training and blended learning. J Nurses Staff Dev. 2008;24:151Y154.
Florida Multidisciplinary Simulation Center Course Evaluation Course Title:__________________________________________ Date:____________ Instructor:________________________________ Please rate the following based on the following scale 1 = Needs improvement to 5 = Top 10%, one of the best OVERALL RATING: COURSE
1
2
3
4
5
The course met my learning needs Faculty knowledge of subject matter Quality of the (task trainer/scenario/other) Opportunity to reflect on my performance during the debriefing session Faculty ability to provide constructive feedback in a nonthreatening manner Overall course rating
OVERALL RATING: SKILL ENHANCEMENT
1
2
3
4
5
N/A
Decision-making skills Communication skills Team management skills Technical skills Problem-solving skills Ability to adapt to changing/unexpected situations
Additional Information: Please identify something that you learned through this session that may strengthen your practice: What can we at the Mayo Multidisciplinary Simulation Center do to improve? Please make suggestions for future patient and/or team scenarios: Anything else you would like to share about your experience here today?
180
www.journalpatientsafety.com
* 2013 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
