**4. Discussion**

As with any team event, the more that team members practice together, the better they perform together [19]. When the core principles for simulation and debriefing are followed, it is possible to deliver safe, e ffective and e fficient patient care [20]. Simulation improves neonatal resuscitation and patient safety [21]. Participation in CPQCC's Simulating Success has shown that a multidisciplinary approach to quality improvement creates more engagement, enables focus to be directed towards patient safety rather than individual performance and leads to identification of system issues. To highlight one example, in the CHOC experience, a major systems issue identified through simulations was the paging method by which codes were called in the NICU. This led to inconsistencies in sta ff response. This issue was referred to leadership in CHOC's Code White Committee which recommended the change to overhead code white calls, consistent with hospital wide code white calls, for appropriate sta ff response. Similarly, missed pages during simulation sessions were documented in Labor and Delivery which led to a change to iPhones for teams to respond and communicate in real-time.

### *4.1. Future Directions: CHOC*

In 2020, with ongoing simulation exercises, our aim is to improve (1) long-term outcomes including decreasing the rate of chronic lung disease (CLD) from 25% to 20% and severe intraventricular hemorrhage (IVH) from 15.9% to 12%; and (2) short-term measures of decreasing the frequency of Apgar score <8 at five minutes, decreasing the number of intubation attempts in the delivery room, decreasing the frequency of cardiopulmonary resuscitation in the delivery room, and decreasing the time to leave the delivery room to the NICU. Simulating Success has been an impetus to expanding the simulation program at CHOC to involve other specialties including emergency medicine, pediatric intensive care, cardiovascular intensive care and hospital medicine. A temporary simulation center with basic infrastructure for a simulation room and a debriefing room with audiovisual capacities was built to conduct simulation lab exercises. The program at CHOC is able to use the space for procedural skill training for incoming attendings, residents, and fellows. The team at CHOC continues to collect data on resource utilization to emphasize the demand for this program to hospital leadership. A core simulation team has been established which meets monthly. A website for the simulation program has been created that can be accessed through the hospital intranet that contains the mission, training modules, confidentiality agreement, liability and request forms, and a list of facilitators and mentors. A three-tier facilitator program is being developed to help facilitators advance their skills in order to become mentors and grow the program. A tiered approach was created so as to ensure the quality of the program. Several facilitators have completed the online debriefing program through CAPE. Currently, neonatal and pediatric critical care are the main specialties involved in simulation with a plan to develop a simulation task force for both of these divisions. There will be ongoing education through reviews and webinars for facilitators on simulation methodology similar to the CAPE online debriefing course in order to further hone skills. A common debriefing language will be used for all simulations performed in the organization to integrate it as part of our culture of care.

### *4.2. Future Directions: SMB*

In 2020, the SMB core team of facilitators will meet quarterly to review videos of their debriefings with the intent to improve facilitating e ffective simulation scenarios and debriefing using a "debriefing the debriefer" model. The process used by CAPE and CPQCC of providing insightful feedback during face to face sessions has helped to train the team's facilitators. A train-the-trainer model has been implemented whereby experienced debriefers are scheduled with newly trained debriefers. Finally, in order to continue to enhance the program and assess its e ffectiveness among each of the disciplines, a pre–post-survey to elicit ongoing feedback has been created.

### *4.3. Future Directions: VCH*

The team at VCH is working on budget planning to schedule simulations six months in advance, assess for feasibility to schedule sta ff and conduct multiple simulation events in a day. They aim for shared accountability amongs<sup>t</sup> all simulation team members for set up, planning and implementation. They hope to train additional team members to replace those that have moved into other roles and continue the professional development of existing members. The team is eager to continue its work with their partners in Simulating Success through the sharing of experiences, scenarios and best practices.
