Available online 20 September 2023, 151828

Author links open overlay panel, , Abstract

In situ simulations, those conducted in the actual clinical environment, confer a high level of contextual fidelity and have been applied to the operations testing of new healthcare environments (HCE) to identify potential threats to patient, family and staff safety. By conducting simulation-based operations testing, these latent safety threats (LSTs) – which are weaknesses in communications, human factors, system process and technologies, and the way they are linked together – can be identified and corrected prior to moving patients into the new HCE. Simulation-based operations testing has extended to the neonatal HCE, as neonatal intensive care units (NICUs) transition from open-bay to single-family room design. In this section, we define LSTs, review simulation-based operations testing in new neonatal and perinatal HCEs, review challenges associated with conducting simulation-based operations testing, and briefly review pre-construction simulation-based user-centered design of new HCEs.

Section snippetsLatent safety threats

Latent safety threats (LSTs) are flaws in communications, human factors, systems-based processes, and technologies utilized in the work environment that remain undetected until they interact and manifest as weaknesses and errors that can result in near misses or harm.1,2 Building upon the expertise of high-stakes industries such as aviation and nuclear power, healthcare has long recognized the need to better understand human-systems interactions that underlie LSTs.3,4 Conducting critical

Simulation-based operations testing in new neonatal HCEs

Simulation-based operations testing to enhance team function and systems readiness has extended to new neonatal HCEs.17,23, 24, 25, 26 In 2011, Bender et al. conducted large-scale, immersive in situ simulations prior to transitioning patients, families, and staff from a level IV neonatal intensive care unit (NICU) with an open-bay to a 80-bed single-family room design.23 This major change in floor plan necessitated a proactive approach to understanding how communications, workflows, and the use

Simulation-based operations testing of new perinatal HCE

Simulation-based operations testing has also been applied to new perinatal HCEs. In 2014, Ventre et al. conducted simulation-based testing to evaluate the operational readiness of a newly constructed children's hospital-based obstetrics unit.20 The researchers identified LSTs in four categories that included equipment and supplies, communication, hospital systems, and staffing. Through an iterative process that included modifications between simulation days, the researchers decreased the time

LST mitigation and simulation-based re-testing

It is important that LSTs and issues discovered through simulation-based testing are evaluated and addressed. This is best accomplished by forming subcommittees that include members of the simulation team, quality improvement/quality assurance experts and other key stakeholders, so that strategies to resolve and mitigate LSTs can be developed, implemented and tracked.23, 24, 25 Through the iterative process of LST resolution, process revisions and repeated simulation-based re-testing,

Staff preparation for working in the new HCE

In addition to uncovering LSTs and systems issues, simulation-based operations testing enhances staff readiness and preparation to work in new HCEs.12,24 Studies show that engaging staff in the development and evaluation of new processes positively impacts their level of enthusiasm and preparedness to function in the new HCE.29 This highlights the importance of including frontline staff in simulations and the development of solutions for discovered LSTs. In particular, employing communication

Challenges of utilizing in situ simulation to test new HCEs

While researchers have demonstrated how in situ simulation and debriefing can be utilized as an effective tool to identify LSTs and mitigate the risk of patient harm, several challenges limit its more widespread use (Table 3). Securing full buy-in from hospital leadership and other administrative stakeholders may require negotiation, because simulation-based operations testing requires a significant amount of personnel, material, and time resources. Among other things, resources include the

Pre-construction simulations-based user-centered design

Although operations testing through immersive in situ simulations conducted in new HCEs has proven effective in minimizing safety threats to patients, families, and staff, facilities design flaws and poor workspace configurations that contribute to LSTs cannot easily and cost-effectively be resolved in the late- and post-construction phases.32 Therefore, simulation methods have been applied in the pre-construction design phase to evaluate how structural design may affect end-user experiences

Future directions: virtual reality

Immersive virtual reality (VR) has effectively been applied to health professions education with real-time immersion in specific tasks.38,39 VR has been used in architectural design and more recently has begun to bridge the gap between architectural design teams and hospital stakeholders.40 Fully immersive three-dimensional VR mock-up environments, achieved through a head-mounted display, enable participants to interact with and manipulate the VR environment.41 VR mock-ups have been effectively

Future directions: Testing other neonatal HCEs

While the literature on simulation-based operations testing of neonatal HCEs has focused primarily on new NICU design, the principles and processes of utilizing simulations may be applied to other locations where teams provide neonatal care, including labor and delivery areas, operating rooms, and emergency department and trauma bays.37 In these areas, designers and teams need to consider additional factors such as the number of staff and the types of equipment that might need to be

Conclusion

Transitioning neonatal care to a new HCE can be associated with unanticipated LSTs that can result in near misses or patient harm. Simulation-based operations testing has been used as a powerful tool to identify LSTs. By employing an iterative process of LST discovery, risk mitigation, and re-testing with additional simulations and debriefings, teams are better equipped to identify and resolve human factors and systems-based interactions that are associated with patient care inefficiencies or

Disclosure Statement

The authors did not receive any funding for this work. The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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