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Connecting simulation and quality improvement: how can healthcare simulation really improve patient care?
  1. Victoria Brazil1,
  2. Eve Isabelle Purdy2,
  3. Komal Bajaj3
  1. 1 Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
  2. 2 Emergency Medicine, Queen’s University, Kingston, Ontario, Canada
  3. 3 Clinical Quality, NYC Health + Hospitals/Jacobi, New York, New York, USA
  1. Correspondence to Dr Victoria Brazil, Bond University Faculty of Health Sciences and Medicine, Gold Coast, QS 4229, Australia; vbrazil{at}

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Simulation has an established role in the education and training of healthcare professionals, but its function as a healthcare quality improvement (QI) tool is more emergent. In this edition of the journal, Ajmi and colleagues report on a simulation-based intervention that improved door-to-needle times and patient outcomes in acute ischaemic stroke.1 This prompts reflection on the positioning of simulation-based methods within QI programmes, the role of trained simulation experts as part of QI-focused teams and the directions for future scholarly enquiry that supports integration of these fields.

The improvement report by Ajmi et al is a comprehensive and thoughtful example among many reports of simulation-based interventions to improve care processes and patient outcomes. Improved time-based targets in trauma,2 stroke and cardiac care are frequently cited in the literature, as are better resuscitation outcomes3 and compliance with practice guidelines.4 The identification of latent safety threats in clinical environments,5 6 including testing of new facilities prior to opening,7 is also well described. Such research is usually positioned as providing ‘proof’ that simulation ‘works’ for improving patient care. However, confounders and balancing measures may not be rigorously examined in this enthusiasm to demonstrate cause and effect.

How, why or when simulation works for improving care is a more nuanced question

Team training using simulation can enable improvements in provider behaviours,8 including those described by Ajmi et al,1 where sequential tasks in time-critical patient journeys can be replaced by ‘parallel processing’. Location is also relevant, as ‘in situ simulation’—“taking place in the actual patient care setting/environment”9—affords a closer connexion to the physical environment for ‘real’, often ad hoc teams, to identify enablers or barriers for QI interventions.10 However, the effect could also lie in simulation shaping the culture and relationships 11 12 that underpin and support structural or process specific interventions.

Most reported simulation-based improvement …

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