1. Improved Patient Safety By Comprehensive Simulation-Based Training in Cardiac Surgery AHRQ 2012 Annual Conference September 10, 2012 Richard H. Feins, MD Professor of Surgery University of North Carolina at Chapel Hill Chapel Hill, NC

2. Disclosures Equity interest in KindHeart, Inc., a company developed to maximize the use of simulators in surgical and medical education. This does not include any simulators used in the AHRQ grant Donations of instruments and sutures have been made in support of the AHRQ grant by Teleflex, Inc

3. Improved Patient Safety By Comprehensive Simulation-Based Training in Cardiac Surgery AHRQ 2012 Annual Conference September 10, 2012 Richard H. Feins, MD Professor of Surgery University of North Carolina at Chapel Hill Chapel Hill, NC

4. Changes Negatively Impacting the Apprentice Model 2012 Loss of the ward services Faculty priority change from teaching surgery to doing surgery Increase in number of married residents Decrease in amount of time allowed in hospital

5. Problems with Patient Care Model of Surgical Education The apprentice model curriculum depends almost exclusively on what happens to walk through the door for its clinical experience

6. Problems with Patient Care Model of Surgical Education “with good judgment coming from experience and experience, unfortunately, coming from bad judgment” Dr. Scott Hultman University of North Carolina at Chapel Hill

7. Problems with Patient Care Model of Surgical Education We violate the basic principle by which people become masters of a skill - DELIBERATE PRACTICE

8. K. Anders Ericsson, PhD

9. Characteristics of Deliberate Practice Focused Carried out over extended periods of time Guided by an experienced coach Identifies errors and concentrates on procedures directed at eliminating those errors Constantly moves out of the trainees comfort zone Has a consistent means of evaluating the level of performance

10. Characteristics of Deliberate Practice Not “play” Not reimbursed May not be fun

11. Problems with Patient Care Model of Surgical Education No ability to actually TRAIN surgeons in how to handle adverse events

12. American Board of Thoracic Surgery Case Requirements - 2012 Congenital Heart10 Adult valves50 Myocardial Revasc80 Conduit harvest10 Aortic procedures10 Arrhythmia surgery 5 Transplant/VAD10

13. Comprehensive Simulation Based Training

15. Improved Patient Safety by Simulator Based Training in Cardiac Surgery AHRQ Grant # 1R18HS020451-01

16. Cardiac Surgery Simulation Consortium University of North Carolina at Chapel Hill (PI) Massachusetts General Hospital Johns Hopkins University Vanderbilt University University of Rochester Mayo Clinic Stanford University University of Washington

17. Deliberate Practice Component Task Training

18. Schema for Simulation Based Training in Cardiac Surgery 1.Determine the operative procedures to be addressed 2.Break each down into smaller component tasks 3.Create a comprehensive syllabus for simulation based training for each of the component tasks for each procedure 4.Create “component task simulators” to allow for training in the component tasks using deliberate practice 5.Combine the component tasks mastered into the whole procedure 6.Use deliberate practice to master the whole procedure 7.Assess (using OSATS/ 5 point Likert tools) and video record each part of the process

19. AHRQ Grant Simulation Modules BASIC PROCEDURES Cardiopulmonary Bypass (CPB) Coronary Artery Bypass Grafting (CABG) Aortic Valve Replacement (AVR)

20. AHRQ Grant Simulation Modules Significant Adverse Events Air Embolism (AE) Acute Intra-operative Aortic Dissection (AIAD) Sudden Deterioration of Cardiac Function (SDCF)

21. Schema for Simulation Based Training in Cardiac Surgery Component Task Component Task Component Task Procedure or Adverse Event Procedure or Adverse Event

23. Improved Patient Safety by Simulator Based Training in Cardiac Surgery AHRQ Grant # 1R18HS020451-01 Simulation Syllabus for Each Week of Training Overview Goals and Objectives Teaching Plan Simulator(s) Set-up Conduct of Simulation Assessment Tools

30. Aortic Cannula Placement

31. Acute Intra-operative Aortic Dissection (AIAD)

38. Improved Patient Safety by Simulator Based Training in Cardiac Surgery AHRQ Grant # 1R18HS020451-01 Year 1 16 Residents participating Over 11,000 data points recorded Over 120 individual simulation hours per resident Over 2000 total simulation hours Component task simulators for all component tasks 210 page comprehensive curriculum syllabus written Extensive video library recorded