In here, um, for, um, joint anesthesia and general surgery, uh, uh, grand rounds. Um, very exciting talk today by, um, uh, Doctor Peter Weinstock and, uh, um, uh, guest-starring, uh, uh, Doctor Joe Zaleas. Um, Doctor Weinstock is, um, the, um, is a, a, an associate professor at Harvard Medical School and the, um, anesthesia chair in pediatric simulation. And, um, is doing very exciting work in, um, in, uh, stimulation to the, uh, to our benefit as As trainees and as all stages of our careers. Um, and Doctor Zeki has been, um, working along the same lines, um, from the surgical standpoint. And, um, I look forward to, to hearing what you have to say. So, thank you. Thanks for Well, good morning, everyone. Um, I wanna put out a special thanks to everyone who's in this room today. It was, uh, probably not the easiest commute, uh, to get here at 7 o'clock this morning, so I appreciate that. Hope you all simulated it first, just to make sure you could do it correctly. Um, just to set the stage, I always tell this story, uh, just to give you a sense of where we're gonna go here. Um, and it's a story about my son from many years ago, but I think it just holds true. Um, he, many years ago, needed to, um, come back to his class and tell his class what his parents did for a living. So he went to my wife and he said, Mom, what do you do for a living? And she said, I'm a school teacher and teach special education. He wrote down school teacher parentheses, special education. He said, what does dad do for a living? She said, why don't you ask dad? He said, I don't wanna know that much. Yeah. So, I'm gonna tell you a little bit about simulation. Um, and I'm really psyched that Jill's here with me and uh we're gonna tag team, uh, through the next 40 minutes or so, take you on a bit of a journey. Um, I thought I would start actually with, uh, a bit of a, a mentor of mine and a hero of mine. I, I've, I've watched Steve Jobs for a long time. Um, I like the way he thinks. Uh, and here he's talking, he's being interviewed, and he's talking about, um, innovation, and he's, he's talking about the idea of starting something new, about cultural change. And I just thought we could start with this concept. It's probably true of everyone in this room has had that feeling at one time or another in something that they've been doing, so I thought that would be kind of unifying to play that for everyone. What I really wanna talk about, not, I'm not gonna talk about the technical side of simulation very much, but I wanna talk about this idea of making a dent in the universe. And this is something that Steve Jobs talked about a lot. This idea of just ever so slightly changing the rotation of the universe, uh, and trying to do that in medicine, trying to do that in healthcare. Just making healthcare ever so slightly different in a way that kind of may change it fundamentally. Um, and that's what I wanna get at today. And what I, what I'm getting at a little bit is this idea of taking simulation out of the garage, out of a mom and pop kind of shop, and really docking it into healthcare. And I wanna try to go through why I think this may be the time to do this and why it's so urgently important to think about how to do this. Well, the data is in and I, I could spend a lot of time showing you literature about the benefits of simulation. I couldn't do that probably 10 years ago. It's amazing what's happened uh in the field. Um, this is from Market of Markets. They recently put out a res a report about the overall industry market of, of medical simulation. In 2017, it was about $1.2 billion dollar industry. It is now at about a $2.6 billion dollar industry, uh, with a rate of growth of about 15%. Uh, we also, as many of you probably know, we're doing quite a bit of 3D printing. I just pulled this out just as another marker of kind of work that we're getting very engaged in. Uh, this is the growth of 3D printing since 2013 to 2021, and these are in billions of dollars in terms of indus market. Uh, market size and industry market. So, um, there's tremendous growth going on in this field. I just came back from a meeting about a week ago, which is the largest international meeting in simulation. It was in San Antonio. That meeting, about 12, many of you may have, I'm noticing some of you here have been to that meeting. About 1012 years ago when it started, it was about 150 people. Uh, I was now one of about 4000 people, uh, in 2019. It's just amazing, uh, what is happening, uh, in this field. As I embark on this talk, I wanna make something really clear, that it is always effect before tech. And that is getting even more and more tempting to go the opposite direction in this day and age when you go to and even consumer electronics shop and the technologies that are available to you in terms of virtual reality, augmented reality, and so on are just exploding. Uh, but we haven't lost our focus. It really is about what is it we're trying to achieve, and pulling the right technology off the shelf, or I'm seeing Steve Wilson from the engineering group right here, or building that very technology, uh, when it is needed. Uh, but the effect drives. I've shown this slide, uh, in every talk I've ever given, and I, I always think about, well, maybe it's time to retire it, and the answer is it's never time to retire this video. I'm gonna show it to you, it's about 40 seconds. This is Seve Bolisteros, uh, one of the greatest golfers of all time, uh, taken from us way too, too early from a, a brain tumor, but he is, um, known as, um, really an amazing golfer. I just wanna show you a shot of his at Augusta at the Masters tournament. Um, Just watch the mechanics of this swing. No matter what you do in medicine, I think we all strive for these kind of mechanics. And people have like CGI'd this, have digitized it to understand how he swings the way he does. And what I really wanna bring your attention to is not what he did at the, when he came up to the tee, but what he did right before. He stepped back about 4 ft. And he took a practice swing. And that's a big part of the recipe of his effectiveness when he actually goes and hits the ball. In fact, if you told Seve Bolisteros, um, I'm gonna bring you to Augusta and you cannot step back and take practice swings, you need to go immediately to the ball and hit, uh, he probably wouldn't compete. Because it is part and parcel of the way that he performs. And um I always stress the fact that as much as I loved him, um, and what he did, let's just face what he did was he hit a white ball into a cup. And he found the necessity of stepping back and taking a practice swing. Um, medicines remains, uh, although at Boston Children's, I'm proud to say, um, with the help of all of you, we are changing this. Uh, but it remains the last stake high stakes industry that doesn't practice prior to game time. Um, we're losing ground, uh, with the airline industry and so on. And so, I, I really do think it's time that we dock simulation into the everyday lives of what we do the same way Seve Ballesteros does before every shot that he takes. So, what is the why of simulation? Why do this? Well, I think I'm hoping I'm starting to gain your attention through some of that. But, but when you really step back and you think about why we do simulation, I'll tell you what it's not about. And this is a reoccurring theme. It's not about mannequins, uh, and it's not about virtual reality or augmented reality. Uh, and you're gonna hear lots about that, and our program is building out some of that for the institution. Um, And it's not about 3D printing, um, even though that's a lot of what we hear about when we hear about simulation recently, cause that's been a hot topic for us is 3D imaging and 3D printing. Um, What it's about, and I don't need to really tell this audience this, but it's really about this. It's about these patients that we care for every day. Many of you are heading off right after this talk to take care of a child that probably looks very, very similar to this. And these children that have very small wiggle rooms of error that are available to them, uh, the fragile nature of these, of these patients. And these environments that we work in, these incredibly complex environments in which multiple technologies and human factors play into the very moment where care is being delivered. Uh, here's an example of a simulation from our cardiothoracic surgery simulation program, one of the only that's regular in the country. And you can see here, um, multiple teams, equipment, Just the intensity of this environment where the margin of error is literally 0. And how do you perform optimally in this type of an environment? So I want to pose this question, what is it that we fear in healthcare? What is it about these environments that may raise our hairs ever so slightly, and may even affect the way that we behave with each other, or the way we may affect the way we behave within our environments. And, and I think if I pulled the audience, I probably would come up with a similar set. of fears, complexity, mistakes, deterioration. We fear disorganization, incompetency, unreliability. And if you take all of this together, I think what we fear fundamentally is the unexpected. We don't like surprises in healthcare. We don't like to be in the operating room and all of a sudden discover something that we hadn't anticipated, really irks us. And ultimately, I think we've, we all fear failure and our bar for failure is so extremely high for this patient population and for all the patients we care for. And we're not alone There's another group that's fearful, that's worried, and that is our patients and families. Um, not knowing what to expect when they enter into the healthcare arena, not knowing what to expect when they enter those doors. Uh, what's this procedure gonna be like? How is it gonna feel? What is it gonna look like? How am I gonna feel afterwards? Where do I, how do I go home with what I need to? What does it look like to go home with a ventilator? How is that gonna feel? So the parents, patients, families have concerns, and there's applications of simulation to try to address these. So, in some ways, the why of simulation, again, is not about the technology. When you really think about it, it's a, it's a sneak peek. When you need it, and, and, and in the moments that matter the most. And so, in some ways, simulation is allowing us to ascribe to Marie Curie's concept of nothing in life is to be feared, it, it's only to be understood. Imagine that, you get a chance to see something before you see it. You operate twice, but you cut once. So what I'm really getting at is this idea of using simulation to change the status quo. Going, walking into environments just a bit more prepared, kind of been there, done that, seen it. Iterated it, designed it, and now I'm just gonna go do it. So, the concept is lifelike rehearsal. Through this conduit of psychological safety, and I can't stress that enough, and I'm gonna come back to that in a bit. This idea that psychological safety can be the pivot point to really change the way we perform medicine. If we feel psychologically safe to actually share how we feel about how something went, not just the good, but also the bad. Then all of a sudden, we have an opportunity to engage in a dialogue that will actually change performance uh in the future. And that involves some emotionality. It involves certainly a lot of self-reflection. And so this is sort of the wheelhouse of simulation, a psychologically safe environment for this to happen. And the goals of this, the outcomes of this are relatively straightforward. We're looking for calm confidence and great outcomes. Calm confidence that then gets distributed among the team. Everyone starts feeling calmer. Everyone feels more successful and more teamed. And so, here's what it looks like. Essentially, now, we are doing surgeries and doing procedures and experiencing medicine before the times that we actually need to deliver it. And I'm gonna feature Jill a little bit here. But here's an example of a first of its kind ECMO training program, where before children are born, We're taking teams, bringing them together. All of you have been involved in, or many of you have been involved in this type of training. Built the adequate trainers to be able to do this kind of training, very high fidelity, so that the surgeons can actually do the surgery, cut down into the neck, isolate the vessels. Our simulator engineers are running everything from behind the scenes, they're never seen. And the entire procedure can be rehearsed as many times as needed. We'll come back to that in a little bit. And we're doing this for our patients and families as well. So this is one of our children who's gonna be coming in for surgery, has no idea what anesthesia is all about, what you guys all do. But now gets the opportunity to come into the simulator suite and actually understand what the operating room looks like, how it's gonna behave when she has to be brought in. What's it gonna be like to have the mask placed to her face? What does the mask look like? Maybe she'll start to put the mask on her teddy bear's face and be in control of that type of technology. So all sorts of implications of that. So, let me build for you what is here at Boston Children's to achieve these goals. And I, I'm sort of a computer geek from years and years ago. And so I think about the simulator program as we would have built a CPU or a desktop computer. It has fundamentally some firmware, it has hardware, it has software, and it has a platform that it delivers to the institution. So to design this, we have to think disruptively, and this is all about disruptive innovation, which fundamentally has to do with this idea that you're always looking to see what the market requires. So rather than continue to iterate and innovate along a single trajectory, you're always looking to see what is it about my technology that I could fit better to this new market that's developing. And for Boston Children's Hospital, a big part of that intuition. Came out of Jeff Burns years ago when he identified the need for bringing a simulator to the hospital. That was a disruptive technology approach to simulation, because until then, simulation suites were in stand-alone centers. And it took quite a bit of effort to get individuals to those centers, particularly busy clinicians. And so, the idea of bringing a simulator into the hospital and making it minimally interrupt the workday was a complete disruption. And now, the way simulation is done through Boston Children's more in a wholesale way. So we've thought disruptively, and I have thanks to my board of advisors for the simulator program, who have generously given of their time to help guide this program over the last couple of years as it continues to maintain the highest degree of relevancy to the institution. So just a, a nod to an incredibly talented, and we're very fortunate to have this group with us. And here was the original SIM suite. This was back where in the old, what was called P5 ICU. And Jeff and Paul had this insight to actually put it right here into the, the ICU so that when we were rounding, literally, we would round on bed space 22, we would then round in the, in the simulator, and we'd round back out into 23. We just integrated simulation into the everyday work environment, right into rounds. And we showed in this paper that a simulator suite of about 250 square feet had the throughput. Of simulator suites at about 8000 square feet, just because we brought it on site. And so The disruption has occurred over 2001 to 2017. We were originally a skills training center, and then we became a team training device, and then it became a system safety threat identifier, a surgical preparedness tool, a procedural design tool, more recently, with the advent of the SIM engineering studio, a facilities design tool. These new buildings that are being built, we're building cardboard reproductions of many of those rooms and simulating and crash testing operating room scenarios to understand if the plans will actually play out and behave the way we would like to in real life. It's a reducer of fear and anxiety, and we're doing a whole series of biometric experiments looking to see whether children, fam kids and their families, when they simulate, does it reduce stress and anxiety when they actually come into the healthcare environment. And we're also being, it's being used as a root cause analysis and ripepid cycle improvement tool. So, a far cry from where we started. And really, SIM 2.0, the simulator program at the hospital has become a clinical service partner, more than an education space, it's become a clinical service partner and really a catalyst of much of the high reliability activities that are going on in the hospital. So, the mission of the program is really about being a unique platform of psychological safety, unusual within a healthcare environment for lifelike rehearsal and improvement at the greatest points of impact. Our vision is to be an anticipatory arm, not reactive, but proactively having these experiences in order to avoid bad outcomes and therefore become a unique protective layer to the institution. It's almost like an insurance policy, in many ways. And our strategy is that all the work we do across the street and in the nodes here in the hospital is really about enhancing human-human and human technology interactions. That is fundamentally what the simulator program does every day. So the hardware is all about reach. And so, as we started in our heritage, we've now evolved, but it's all about a centralized program with a distributed footprint of activity. Started with these carts that made their way into the clinical environments. And now, thanks to leadership in surgery and anesthesia, we now have the only on-site pediatric surgical skills training center in the country. This is a space that is in the OR as many of you know of it. If you haven't, I invite you to go visit. Uh, it has a series of trainers, skills trainers in there. It has technicians in there, and it is for just in time, just in place, the ability to walk in there, do some muscle memory, tune up, maybe get a report card on some of your skills if you're a trainee, and then make your way into the operating room. And this is ongoing evolution of this concept, and we're really kind of pushing the The, the boundaries here at Children's. We've been fortunate in the last 2.5 years, we now have a headquarters. Uh, program was about 18 years old, uh, and built infrastructure and all of the needed tools to deliver simulation all over the hospital was extremely active, but got big enough and really required a space, a dedicated space. So we were fortunate that the hospital, uh, and the departments helped support this space and it's over in the CLSB building on the 18th floor. I invite you to come over and take a look at it if you haven't been there already. It's a beautiful learning space, uh, just because of where it's situated, and it has complete reproductions, um, really down to the booms and the pumps of the, uh, of, uh, characteristic spaces at Boston Children's. We made this, uh, 3500 square foot space behave like about 12,000 square feet by making all the rooms transformable using stage design technique. And so this is where we take it from a clinical space to a child's bedroom, and we can do this within about 5 to 10 minutes of conversion. And this allows us now to train, train, to help uh patients and families who are about to go home to understand uh what that environment might be like because we can recreate that home environment. And I'm seeing Brianna O'Connell out in the audience who's our child life specialist. We're the only simulator program also that has a dedicated child life specialist who oversees. are what we call our preparing you program, uh, which is for patients and families. We're also working with augmented reality to try to augment some of these spaces to understand where rooms, uh, where, uh, devices and technology might, uh, go into various rooms. And I'm seeing Kate Donovan in the audience, uh, who's been very involved in helping us pioneer some of those efforts. The firmware is really about integration into the hospital. And I'm proud to say that there are now close to 300 staff members, staff, physicians, nursing, faculty who use the simulator program through their departments and divisions in order to teach, in order to prepare, in order to uh reduce. Errors, uh, throughout the hospital and you can see pretty much every department and division, uh, represented here. Quite a large representation from anesthesia, uh, quite a large and growing representation from general surgery. All of the surgical subspecialties are growing. Big representation from Heart Center and a huge representation from nursing and from the hospital. Um, more recently, in the last couple of years, several of the folks in this group have popped out and have made simulation really their professional development pathway. Uh, and so, we've created actual, um, roles within the program called associate clinical directorships, where they represent their department, division, or area of the hospital, and they, um, help, uh, be a conduit to good simulation activities that's highly relevant. And this is The first group you can see physicians uh from various areas of the hospital as well as a large representation from nursing. These individuals meet quarterly and help guide the very simulator program itself. This is a growing group, uh, and we're always looking for good candidates. Part of our firmware is our debriefing. You may hear about this, that we debrief quite a bit. I always say that simulation is really an excuse to debrief. Uh, it's really just a mutual experience that allows us to get into a room and talk to each other and actually practice what a good conversation looks like. And we've actually developed algorithms of this in, uh, collaboration and really, uh, adapting a lot of work from the Center for Medical Simulation in Cambridge. Um, And we teach these now, uh, several times a year, uh, debriefing, um, approaches, as well as approaches to delivering stimulation. But I thought I would just simplify all of it. You don't need to really take a course. When we walk in and we look at who are effective debriefers, and what I mean by that are really who are effective mentors, who are effective teachers, and when you think back to who your great teachers were in your life, they probably shared some of these qualities. Um, they're typically transparent, they're typically empathetic, uh, vulnerable, open, honest people, they're compassionate to your needs. And they're genuinely curious about what they've observed. Uh, they're not certain, uh, but they're very curious. And when I've looked at this, uh, list, I can't help but think about just people I like. who behave this way. When I have a great conversation or I have a great dinner out with somebody, typically, we've shared this kind of conversation. Um, so, we talk a lot in our program about this, which is, if you're gonna debrief someone, if you're gonna sit down and have a conversation about how you behaved or, or areas of improvement, you have to fundamentally love the learner. Um, sounds kind of squishy, but it actually is true. And, um, it takes all of debriefing education and nails it down to just one thing. If you walk in and you love your students, and they feel that from you, You're off and running and making a big difference in their lives and the lives of our patients. That's all the squishy stuff I'll do, I promise. Software. Well, we have a programming language in the simulator suite, um, and it's called Simzones. It was published in academic medicine and it's now being used in multiple countries around the globe. And really what it is, it's a longitudinal pathway. So, it's everything from skills training all the way through team training, and then even live video capture where we've backed the mannequins out and we're using simulation methodologies to study the behaviors in the actual environments. And so to go through SIM zones, I thought I would bring Jill up. Jill's done an amazing job of developing really a portfolio of activities within general surgery, and she'll use some of those examples to walk you through um the zones. And I've always wanted to introduce Jay-Z. Morning, thank you. Um, I'm gonna show you some of our collaboration with the SIM, um, program throughout our, um, throughout my time here. Um, Baron Mody and I have been doing a stimulation training program for our surgical fellows, uh, since we started here. And our efforts began, um, using adult trainers, um, with adults instruments, um, Because that's all we had. Uh, we try to be creative and adapt, uh, trainers for our fellows, um, by using a smaller box, um, and using infant laparoscopic equipment. So this was our first SEM trainer, uh, for pediatric surgery here. Um, but our trainees, they're coming in with advanced skills and, um, in the, but focused in the adult population, and we struggled with how to mentor the skills that they needed for minimally invasive surgery in pediatric, um, and neonatal surgery because we had no high fidelity trainers, um, Um, to do this. Around that time, Um, one of our colleagues in Chicago had published the development of the first neonatal trainer using 3D printing, uh, for oesophageal atresia and tracheoesophageal fistula repairs. So we reached out to the SEM engineering, um, program at the time, um, which was not hosted in this, uh, beautiful suite, uh, to see if we could help, uh, they could help, um, with our ideas building a trainer. What we knew from the STEM engineering program at the time were, were that they were building 3D models already, but for use in OR planning. Uh, Doctor Rogers in plastic surgery had, um, published a pilot study that showed reduced OR time and complications with these 3D models used for practice. And we were hoping that we could draw upon the expertise of the uh SIM uh program to create a product that wasn't for just OR planning, but was for use for repeated skills training with our uh surgical fellows, um, and trainees, so we could teach complex neonatal surgery before they perform the procedures in the operating room. So we started um with the background of um what had been done um by one of our colleagues and uh Doctor Modi and I uh began this uh collaboration to build our own uh EATF, skills trainer here. Um, we started in the infancy of the simulation program, um, before it expanded in personnel and space, and we created, uh, here the first neonatal trainer, uh, at Boston Children's for repeated, uh, surgical skills training using 3D printing and, um, Other techniques. Um, and we've used this in the zone one training, so, um, mentored skills training with our surgical fellows, uh, for the past several years. And because of, uh, the space, uh, that, um, Peter mentioned the OR SIM suite is, or the simulation center is right outside the operating room. Um, this, um, trainer has been used not only for our mentored skills training sessions, but it can be used for just in time training, uh, when the fellows are, uh, waiting for the, the patient, um, uh, in the OR so they can practice those skills, uh, before going, uh, into the operating room. So that was our first trainer and we were interested in, in expanding um the techniques that were available to the fellows and our interest in uh creating a novel trainer uh with the collaboration of the SEM program. began and uh this is a, an abdominal um neonatal trainer that's now used for duodenal atresia repair. After many iterations over a long period of time, um, we've made something that's actually, um, A great skills trainer that our fellows have all done in mentored skills sessions to perform a laparoscopic duodenal atresia repair, uh, before, uh, doing one in the operating room. Some of our other high fidelity trainers are both zone, in zone 1, learning, so mentored skills training, but also in zone 3 or team, uh, training. Doctors Finn Thompson and Allen, um, published work in the first neonatal ECMO trainer here at Boston Children's, and they showed that these skills trainers were actually useful in, um, As a, a skills trainer itself. However, the first trainer was very rudimentary. It was a, um, a module that was applied on top of a mannequin and we were really searching to have something that was more high fidelity when we're doing these multi multidisciplinary team trainings, uh, to engage, uh, the surgeons, um, and, uh, help with their surgical technique for these um high acuity situations. Um, Peter had, uh, formed a partnership with a professional special effects firm in Hollywood, and they had helped us make this more realistic, high-fidelity trainer for neonatal, um, ECMO cannulations. It's been a very interesting, uh, collaboration. Um, because our goal was to create a product that didn't just look real as the special effects firms, you know, we're used to making these beautiful products to use just one time for show, but we were trying to make something that could be used also as a skills trainer and have a reproducible functional um outcome. Um, we have this final product which is now used in all of the, um, multidisciplinary team trainings, uh, for ECMO. In spring, springboarding from this, uh, we were interested in building our own uh pediatric trainer. Um, pediatric uh cannulations are are rare compared to the neonatal cannulations, and they can be technically challenging. And we didn't have an adequate high fidelity trainer to do this. So with the skills and the collaboration, that partnership that had developed with um the special effects firm, our own uh SEM engineering program under the leadership of Greg Loh, one of the SEM engineers, is now creating completely from scratch in-house, a high-fidelity pediatric ECMO trainer. Um, and this is, um, getting close to completion, um, and it's gonna have the capability to do both, uh, femoral and neck cannulations, um, with the addition of virtual fluoroscopy, um, which will help us in some of the techniques that we're, um, expanding into in our, in our field. So, um, when we're looking at team training in the zone 3 training, we've, um, repeatedly heard, um, in simulation that the high fidelity training and skills or team training has historically been limited by the available trainers. And the trauma program specifically recognized this when they're doing their multidisciplinary team training for trauma. And the collaboration with the trauma program and the SEM program. They were able to create a high-fidelity, fully operable pediatric gunshot wound trainer. And this is used in the multidisciplinary trauma, uh, Crisis Resource Management training sessions under the leadership of Doctor Mooney, uh, Maria McMahon, and Doctor Brett Fleegler in, uh, the emergency department. So I've highlighted some of the collaboration and reach of the simulation program uh within general surgery. However, the SEM program collaborates across all departments in the institution. It runs at maximum capacity and is collaborated in over 90 projects and assisted with over 70 3D models, uh, for procedures. Not only uh within general surgery, but also the reach has been within anesthesia and specifically in maintenance of certification training which is now, um, as many of you know, is, um, uh, a requirement for Part 4 maintenance of certification. And Boston Children's, um, with the, uh, simulation center is the first center that has accreditation from the American Society of Anesthesiologists, um, for, uh, stimulation-based training that, um, involves all zones 12, and 3 training for accreditation. So as we develop educational models across the zones, um, from skills to team training, an extension of this is to bridge simulation to real patient care or this zone 4, training. And Doctor Waters and Doctor Sparks are now leading a CRCO-sponsored study to use live video capture in the operating room studying team dynamics. So this is an exciting, um, Uh, venture, uh, that gets into the real, um, live patient care here. Our simulation program has expanded tremendously in the 5 years or in the 7 years that um we've been here. I've been here, and, um, the collaboration has allowed us to develop high fidelity trainers that have allowed us to have pediatric and neonatal-specific models that enhance the education and the training of our trainees as well as our staff. Um, and rehearsing in an environment that's safe, um, and practicing before we're going into the operating room in live high-stakes situations. Um, we've come a long way and we're, I'm excited about what we can do in the future. I'll go back to Peter. Thanks, Jill. Um, really a special thanks, uh, for Jill to be, um, co-presenting with me today. She really represents, um, a, why I love working with the simulator program, uh, because every day I'm working with people, no one's quite like Jill, but, and Burn, but, but, but people, um, throughout the hospital, and it's really those people that are doing this work. Um, I'm here to tell you about it, but it's, it's really those people who do that work in collaboration with the amazing team. Back home. So, um, thank you, Joel, for doing that. Um, I'm gonna bring it on home just by, um, giving you the remainder of this system that we've developed and really the platform that the SIM program sits on is what we call a reflective surface of the hospital. And I've already emphasized the psychologically safe platform. And so, as you think about how one might utilize the simulator program, we've allowed it to sort of organically develop in response to the needs of the hospital. The greatest needs being skills of some sort or another. And you heard um Joel talk a little bit about how those are applied in the surgical subspecialties, but across the hospital, orientation programs in servicings, uh, all are, are done and can be done through simulation. Uh, environmental testing, testing of new devices. You're gonna bring a new surgical device into the hospital or into your ORs. Well, we can simulate first in a very high fidelity environment, iterate how best to bring that new technology in, or even test kitchen it. Do a cook-off of technology and see whether which one it is you want to use. We just did it with the monitors for the new building. Brought 4 different monitors into the SIM ICU and we're able to vet those monitors without ever having to disrupt patient care across the way. So, lots of work in environment and systems testing. Team training, you heard a little bit about that from Joe as well. Rapid response to particular events, events that we love the outcome of, or maybe an event that we didn't love the outcome of. We can simulate them, we can animate them, and we can have them as a direct response to any regulatory, uh, or even just to quality improvement and quality assurance for your programs. Real is what we call real event analysis and learning. This is the work that we're piloting with orthopedics and Peter's group, as well as in the cardiac ICU. We have intentions that this likely is gonna make its way through the hospital. Many other hospitals in the country are now doing live video capture. There's a lot of attention to it. It's a QIQA initiative, and we're hoping to do that as rigorously as we've done other elements of simulation. And finally, a lot of what Joel described in terms of the engineering facility, we call this BCH SIM 4D because it's not just 3D printing, but it adds on the haptics capable when you add special effects technique. Um, so, you actually have the feel of tissue, and now we're superimposing on that with the help of Jeff Jacobson and the engineering group and XR group, the ability to put augmented reality on top of those trainers to be able to put instructional materials in C2. All of this can be focused towards clinicians, but again, all of this also can be applied to our patients and families, and we're doing that actively. Here's an example of a program which we call SIM Discovery. We did this in collaboration with orthopedics. All patients going for spinal fusion within a period of time, congregated at the SIM Center, all these, it was adorable. All these kids brought their, their bears, and their bears had the very spinal or orthopedic problem that they had. Go figure. And they took that bear through the entire process of Boston Children's Hospital, admitted the bear, got the bear to pre-opp holding, put the IVs in their own bear, brought them to the operating room. There's even an X-ray of their bear with the bone fracture that they had, uh, and then they have the recovery period. They assist their bear through recovery and home. And then we debrief. Uh, with them and with the families. And, um, the, uh, success of this has been, uh, hard to manage because there's lots of programs now that wanna, uh, have a similar, um, type of activity for their families. It's also a nice community builder for families having similar surgeries. Uh, so there's a nice social networking that goes on. The program is extremely busy. We call it Logan Airport. Uh, Michelle Slayer is our, um, our scheduler. Um, we have these 5 different simulation delivery techniques, the headquarters, the point of care, the nodes over in the hospital. Um, we have a van that makes its way out to all of our satellites. We call those our runways, and we have planes landing all day long from various places, and those places are departments and divisions of the hospital. Um, the growth has been continuous. We're shooting for about 8 to 900 SIM, individual SIM courses this year or activities. These are completely unsolicited activities. These are ones that are brought to us from the hospital, frontline providers through chairmen, uh, who say that we'd like to use simulation for this particular, uh, application. I think that's exactly where we wanna be, um, as a resource to the hospital. Everyone talks about return on investment. We take that very seriously. Uh, Marissa Brett's here in the audience. Uh, sorry, uh, Melissa Burke is here. I think Marissa Brett is also here. Melissa is our, uh, director of Business Development and strategy. We think a lot about how do we return, uh, value to the hospital. And we see it in this sort of three-part because we're an academic teaching center. Uh, we are obviously very focused on the mission of Boston Children's. We look at revenue as a, as a sustainability pathway for us, and we also look at academics because many of our That I listed in our ACD group and beyond are on Harvard promotions pathways and are also just interested in publication and sharing of knowledge. Revenue for us is cost savings, cost avoidance, and we do lots of analysis in that direction. And we've been very successful academically, and I mean we, meaning all of the folks that have published uh through. at Boston Children's. We're up to, this is 2017 data. So, we're probably closer to 90 publications now, uh, about 50 investigators, journals throughout the subspecialties, a large representation from surgery and anesthesia. And we currently have somewhere between 20 and 30, 30 active research projects going on throughout the institution. So, I thought I would end with a case that just sort of brings it all together. Um, it's not a general surgery case, it's a neuroplastics case, but I think it just sort of brings all the parts of what can be possible, um, using a simulation resource. And this is, of course, Mark Proctor and uh John Mira. Um, and this was the case. Of Bentley, um, whose, um, whose issue is not subtle, um, has a large encephalocele, um, and, uh, was looking for a corrective surgery. Um, no one in the country was willing to operate on Bentley. There was brain and CSF parenchyma in this encephalocele and it was a very high-risk surgery. Uh, they called, called over to Boston Children's, uh, and Mark and John, uh, called the simulator program. And they asked, could we use simulation as a way to figure out feasibility of this surgery and even iterate and design the surgery itself before we ever put Bentley on a plane. And I always say that, uh, the Jerry Maguire line, I said to John, you had me at hello. And uh I said, of course, we can do that. And so, we brought the SIM engineering suite to bear in a very different way. Um, this was a just in time, just in place way where they built uh Bentley's uh anatomy from the ground up. Um, so, this was, uh, everything from really the neck up, uh, in terms of bone structure, some of, you know, the CSF, um, and brain structure, uh, and was able to iterate that both in two-dimensional space using some volumetric type calculation software. Um, called MATLAB and also, um, in virtual reality and provided these tools to the surgeons for them to take a look and also to start to iterate what they might do surgically. And this was the ultimate repair. It was sort of a baffle type repair. They took apart the skull, numbered them, we say numbered them carefully, uh, and then put everything back, uh, as, as they had planned, and then, uh, returned these parts of the skull back, um, Identified that the surgery was feasible, um, even, um, trialed the surgery in the simulator, uh, using various, um, 3D print models, and then, uh, made the decision to put Bentley on a plane, uh, and do the surgery here at Children's. And this was the result. I happened to be the ICU attending the night that Bentley was admitted. Um, we had all anticipated somewhere between 14 hours of surgery, uh, for this defect. The surgery was closer to about 6 hours. Uh, the patient came to the ICU intubated. Uh, we expected the baby to stay intubated for days while fluid shifts occurred. We extubated the following morning, uh, and the baby was out of the ICU within the week. Um, so, big, big change. Not only the ability to do the surgery, but the outcomes, uh, and how the surgery was managed were affected by the ability to rehearse ahead of time. So, we're talking about docking simulation formally into healthcare. We're talking about uniformity of its application, uh, from sporadic to um regular. I cannot say enough about this team I work with. I feel incredibly fortunate every day to walk into The office and be able to work with this incredibly talented group of passionate, driven people who are doing what they do every day in simulation because they know what they do directly impacts the child, children that we all care for. And that's really just a special vibe among the group. So, I encourage everyone, if you haven't interacted with some of these folks, please do, or just grab a coffee with them cause they're really interesting people, um, and very, very talented, and they're here for you, uh, to make your care better. Thanks very much. Well, Peter, we're without a microphone this morning, but I think you're talking, you're preaching to the choir, so to speak, I think all of us in the audience, uh, value the simulation for both clinical settings, in particularly for us in, in pediatric surgery. We're faced with an issue where a number of the index cases that John Bin and the group have created the simulators for are very infrequent. So you train the the front row here to make sure that they have adequate experience before they get to the operating room for the 1st or the 3rd or 4th duodenal atresia, esophageal intrusion, I think it's. A critical angle when a large institution like us faces this issue, I can only imagine what it is if the smaller training programs for their clinical volumes are Much lower somewhat. So our hope is that this can eventually help other, other centers. Questions from the audience. We talk about night schools. Uh, no, it's on the radar. Um, so, more and more simulations being used at that level. It hasn't formally made its way over yet, um, formally, um, but there's lots of, um, discussion now about how to implement simulation, both as a teaching tool, but also as, we didn't talk about assessment, uh, but also as an assessment tool. Um, so, using some of these cases specifically for the purposes of understanding competency. Um, also starts to talk about a little bit about remediation also within a psychologically safe environment. Other opportunities to, to capture someone who might be struggling in one way or another, and be able to get them back on task and get them back on track. So, all of those are very hot topics. Um, and I think it's, it's coming. The two areas, uh, Jill had talked about MOCA training was a big leap and a big step forward. Um, certainly, FLS training in general surgery now is becoming a standard. Um, What's interesting here in this institution is that RMF CRICO, which is our insurance carrier, as you know, um, is partnered with us pretty deeply in developing OR team training. Uh, because they're seeing on their end that, um, equal to technical error, really, um, non-technical human factors elements that play a big part in where things go wrong, much like the airline industry. So, now, there's actually a program here, which is a three-year cycle, uh, for all surgeons and anesthesiologists to be able to, um, engage in simulation where there's an incentivized program even from, uh, from risk management because it's such an important endeavor. So we're starting to move. Those are where the numbers are just, they matter, and they're, they're, they're, they're speaking the truth. Um, and so we're gonna see more and more of that, I think, in the future. Peter, thank you. That was just a fabulous. You have a small amount of what you do on a day to day basis, um. We are fortunate to work in a place where we have all of these resources at our fingertips and Uh, that is a reason a lot of us are here. But, uh, many of us, uh, as you know, think about what's happening in the real world outside of us, and we get patients every day from other institutions where we think if only they had had the opportunities, the training, the rehearsal that we're able to do. And I know you've brought this to the satellites. Can you talk a little bit about um any vision that you have of how we could scale this to more resource-limited settings, and I'm not necessarily talking about the countries that Tracy's working in. I'm talking about, you know, even like small community hospitals in Massachusetts that rarely see a critically ill child and how we might look at this benefiting, uh, those patients who aren't here for their care, but ultimately come to us. Yeah, it's a great question. Um, so, we've been working, uh, over the last couple of years, we have a division of the work called SIM Network, uh, which is the van, uh, which makes its way out into the community of care, uh, for Boston Children's. And the goal of that has really been to harmonize the care delivery. Figure out, you know, what is the standard regardless of where you go, uh, for that care. So, so, we've had some experience looking at that. I think that, um, fundamentally, it comes down to the, the methodology is what's paramount. Um, and we've now done this in India and in Africa, a bunch of other areas where they don't have all the 3D printing and the, you know, the anatomical reproduction, but what they do have is they have the methodology about how to create psychological safety. And how do you engage in some of these conversations to unroof the major patient safety initiatives and start having teams talk to each other uh in ways that are functional and productive. That's really the bottleneck very often, as you know, is in the communication issues. And that's actually low-budget kind of work. It, it, but it, it requires um a knowledge of the methodology and how to go about it. So, we spent a lot of time looking at what we do here methodologically and how do you adapt it. To the culture, and that can be international, it could be national, you know, to the culture and the language uh of what's happening locally. So, that would be another approach. And I think also, as you, you mentioned, Tracy's work, I think that there is definitely a, a part of this, and we're starting to do more of that together where you, you unify asynchronous learning. So, there's this online, but offline type of work that complements when the simulators do arrive, um, you get the most out of that experience, almost the flipped classroom. So, I think that's the next phase for all of us is this kind of two-part series of asynchronous, computer-based, and then on, on-site simulation. But the mannequins can be relatively inexpensive. Final question for Doctor Weinstocker, Doctor Zeleus. Steve Peter and Joe, just really exciting. I, I wanted to ask you about ROI. Model cost avoidance. In a way that that that isolates your interventions in individual interventions, the global interventions from other things that are happening in the hospital or in the environment. It's a great question, Steve, um, and a tough one. In this business. Um, I would refer you that we, we had a really great paper that, um, Chris Russin, I think is here, um, Chris, uh, published with Don Bay in Orthopedics. They looked at, um, simulation to reduced castor burns. Um, and it was fascinating. Um, they showed 11 to 1 rate of return on doing these simulations and what you can reduce in terms of castsau and the cost that comes from Cassau burns and the complications derived from it. Um, so, it's a great example of where you, you really have to site direct the intervention. Study that intervention and pick a metrics that's measurable, um, and, and describable. There's a lot out there that isn't, that's a lot more vague, that's, that's, that's more difficult. Um, but we're getting better at creating some of these internal experiments, uh, through the work, uh, so that we can come out the other end and show, and value. I'll just mention that um we've developed a pathway now for the, because of this issue, we've developed a pathway now where the first, it's a five-phase pathway to implement any new activity. And the first phase of that pathway is called the discovery phase, and in the discovery phase, a metric must be identified. Because we're gonna look at that metric afterwards to figure out is what we did, was it effective? Was it useful? Because we're gonna be in some situations where it wasn't and we're gonna have to adapt it or remove it. Um, so, so being very intentional, um, and, and site-directed in your metric selection. Happy to talk more about it. It's great, great, great question. Peter and Joe, thank you for all of the work. I
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