Institutionalizing an interprofessional simulation education program: an organizational case study using a model of strategic change

Figures & data

Table 1. Kotter’s 8-step change model (Kotter, 2012)

1	Establish a Sense of Urgency	Change often presents risks and uncertainty about the future and requires significant cooperation, initiative and willingness to make sacrifices from many people. A collective sense of urgency must precede the introduction of any change. A sense of urgency convinces people of the benefits and desired outcomes of the proposed change program. High urgency helps pull together a group with enough power and credibility to guide the effort.
2	Building a Powerful Guiding Coalition	Change often starts with one person, but this is not enough to sustain the process and change a whole organization. A guiding coalition is needed and should consist of a diverse group of members characterized by a) people in position with power, b) expertise, c) credibility and d) leadership. A good mix of managers and leaders is necessary. Managers are responsible for strategic thinking on an organizational level and allocation of resources. Leaders drive the change in everyday business and communicate the vision to the people.
3	Forming a Change Vision	A good vision is the driver for change and a basic component of all great leadership. A good vision should clarify the general direction for change, motivate and inspire people to take action in the right direction and help coordinating the actions of different people.
4	Communicating the Vision	A compelling vision needs to be communicated via all existing communication channels to create a shared understanding of its goals and directions. Communication comes in both words and deeds. The latter is often more powerful, and therefore important people have to lead by example.
5	Empower Others to Act by Removing Barriers	Obstacles will arise that represent a risk for the success of the change project. Four obstacles that often need to be addressed are structures, organizational systems, skills and supervisors. First, organizational structures and systems (e.g., recruiting, performance evaluation) need to support the change. Second, employees need to be trained so that the necessary skills are available and finally, supervisors in powerful positions need to be in favor of the change and not work against it.
6	Generating Short-Term Wins	It is just normal that the enthusiasm for change drops over time. Therefore it is important to plan for short-term wins that additionally empower people and keep the momentum going. In addition, short-term wins need to be visible to show that change is happening.
7	Consolidating Improvements and Produce More Change	Until the change sinks deeply into the companies culture, new approaches are fragile. Change leaders should use the credibility gained through short-term wins to tackle even bigger problems. In a company where change is increasingly the norm, people tend to be more open and more change becomes easier to implement.
8	Institutionalizing New Approaches	Institutionalizing the change in the culture should be the final goal of every change process. It needs to become “the way how we do things here.” Culture refers to the norms of behavior and shared values in a company. These norms and values often persist over time, even when group members change. Thus, changing a company’s culture requires a long time and only happens at the end of the change cycle not at the beginning.

Table 2. Description of case, data from 2019

Beds:	500
Patients:	>250,000 visits/year (28,024 inpatient visits)
Employees:	3294
Departments:	Surgery, gynecology, obstetrics, pediatrics
Institutes:	Anesthesiology, Laboratory Medicine, Pathology, Therapy and Rehabilitation, Radiology and Nuclear Medicine, Radio-Oncology
Interdisciplinary Centers*:	Center for vascular systems, Tumor Center, Perinatal Center, Simulation Center
Faculty Simulation Center:	50 people including nurses, physicians and representatives from medical technology and electrical engineering; 42 of them are trained simulation instructors
Amount of high-fidelity simulation trainings per year:	83 interprofessional simulation trainings on all institutes except Radio-Oncology and Therapy and Rehabilitation
Amount of staff trained per year:	Approximately 900 healthcare workers

*The Interdisciplinary Centers are virtual units that consist of representatives from different disciplines and departments.

Table 3. Characteristics of the high-fidelity interprofessional simulation trainings

Simulator:	High-fidelity simulation mannequins (adult, 5-year old and newborn), AV video system for recording and debriefing (SIMStation, Austria).
Procedure:	Each group participated in a 2.5 h session. The session started with a 30 min teaching block, including introduction to the simulation environment and an introduction to CRM principles (Gaba et al., 2001). Then two simulations were conducted. Scenario duration was between 15–20 min each, followed by a 30–45 min debriefing.
Scenario design:	Scenarios were chosen to correspond to the participant’s areas of expertise. The simulation center supported each department in the development of it's own simulation scenarios.
Group characteristics:	5–10 participants, including nurses, residents and physicians from one department.
Instructors:	At least two trained simulation instructors were leading the sessions and facilitating the debriefings. If requested, additional instructors joined the session to foster peer coaching for the instructors. An additional technician was present, responsible for controlling the simulation mannequin.
Course objectives:	Getting to know and apply the CRM principles, especially in relation to interprofessional collaboration, was a learning objective of every session. In addition, each department formulated specific learning objectives in terms of technical skills.

Table 4. Recommendations to establish an interdisciplinary simulation education program

1	Make a case for interprofessional SBE	Make a case for simulation training being the means to improve individual skills as well as interprofessional collaboration resulting in better patient care Convince the management that an ISEP will make the hospital a more attractive workplace and, over the long run, will save money by lower turnover rates, shorter length of stay and increased quality of care Hire an outside company to conduct simulation trainings to get people interested and familiar with simulation. Invite people from various professions as well as management to experience simulation firsthand
2	Search for healthcare champions	Actively search and approach healthcare champions, preferably persons with power, to promote simulation that embody the desired culture and enthusiasm for simulation and change
3	Define where the ISEP will lead the organization	Formulate a change vision within your guiding coalition. Describe how an ISEP will change collaboration, hospital culture and patient safety
4	Spread the word about interprofessional SBE	Find ways to regularly talk about the simulation activities with HCWs as well as management Make simulation activities and the change vision part of formal and informal meetings
5	Ensure that structures, skills and supervisors align with the change effort	Ensure that structures, skills and supervisors are in line with the change effort Get additional resources so that simulations can be conducted during work hours Educate simulation facilitators in basics of simulation training (communication, debriefing techniques, psychological safety) Get leaders on board with well-designed scenarios relevant to the target group Conduct demonstrations of a simulated case to get people used to simulation and decrease fear of being exposed
6	Win over smaller entities	Apply a step-by-step approach winning over smaller entities (e.g., units, departments) one after the other
7	Enable peer feedback and create more change	Enable peer-feedback among simulation facilitators Use the momentum to create more change (e.g., implementing clinical event debriefings)
8	Institutionalize the ISEP	Encourage the exchange of simulation facilitators between departments to enable interdepartmental learning Establish an interdepartmental network (organizational entity) for simulation to monitor, supervise, support and further develop simulation activities representing and communicating the core values of collaborative practice

Kotter, J. P. (2012). Leading change. Harvard business press.

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Data availability statement

Data includes qualitative interviews, observation data and documents in German. Data is available upon reasonable request from the author.