**1. Introduction**

During the last couple of decades, literature suggests there is ongoing patient morbidity and mortality associated with avoidable harm and medical errors, including errors that can be prevented with improved communication and systems design [1,2]. Healthcare is a complex, dynamic process involving many disciplines collaborating in an e ffort to provide optimal care. In the U.S., most births do not require advanced resuscitation (i.e., positive pressure ventilation, chest compressions, or medication administration); however, about 10% of infants born do require some resuscitative e fforts [3]. Approximately one percent will require extensive resuscitation following birth, including chest compressions and medication administration [3]. Because extensive neonatal resuscitation is infrequent,

resuscitation can be compromised because of cognitive and task overload, poor communication, and lack of teamwork. In-situ simulation provides a realistic context and opportunity for sta ff to practice problem-solving, decision-making, teamwork, and critical thinking skills in the actual delivery care setting [4]. Additionally, interprofessional in-situ simulation is a useful tool to help promote quality in neonatal care [5] and has been shown to identify latent safety threats (LSTs) [6]. This is in contrast with simulations conducted in a simulation center, in which there may be incomplete teams or healthcare professionals, who may not necessarily work with each other [6].

LSTs are errors in design, organization, training, or maintenance that can lead to medical errors [7]. LSTs are categorized into medication errors, equipment malfunction/misuse, inadequate teamwork, and other findings [8]. The relatively low frequency of neonatal resuscitation (especially extensive resuscitative interventions) creates an opportunity for LSTs to occur. In a retrospective study examining LSTs in a pediatric intensive care unit through an in-situ simulation program, 41% of the LSTs that were identified had the potential to cause harm. Category analysis showed that the majority of these LSTs were due to either a lack of resources (36%) or lack of education and training (27%) [9]. In-situ simulation training can help identify LSTs in the real-life clinical setting where maternal deliveries and neonatal resuscitations actually occur. As a result, this type of training can test systems and uncover gaps in processes that may delay timely care. In-situ simulations can assist in detecting LSTs and minimize the risk of a serious safety event [7]. For example, the simulation of a placental abruption followed by neonatal hypovolemia and perinatal depression can test the system and processes that are in place to include the blood bank, laboratory, respiratory therapy, and the maternal and neonatal teams. One metric to evaluate the e ffect of this simulated scenario is to measure the time required to obtain emergency O-negative blood from the hospital blood bank. Timely recognition and mitigation of LSTs are essential to reducing preventable harm during neonatal resuscitation.

Quality improvement (QI) collaboratives have grown increasingly popular. As such, there has been an exponential rise in perinatal and neonatal collaboratives across the United States, including California, Massachusetts, Florida, Tennessee, Ohio, New York, and Oregon. Since the inception of collaboratives in many states and regions throughout the United States, QI projects have covered various topics such as antenatal corticosteroid administration, antibiotic stewardship, and neonatal abstinence syndrome [10]. QI collaboratives create an environment for shared learning among healthcare organizations and professionals. In this shared learning environment, QI collaborative participants are supported by a faculty of experts who identify better practices and help facilitate implementation strategies to improve care [11]. Through monthly webinars and face-to-face interactive sessions, shared learning among di fferent healthcare organizations and professionals occurs. Teams come together to learn, apply, and share not only their approaches to QI but also their data, successes, and barriers to improved performance [11].

We describe our unit's experience participating in *Simulating Success*, a QI collaborative hosted by California Perinatal Quality Care Collaborative (CPQCC) and the Center for Advanced Pediatric and Perinatal Education (CAPE) through Stanford. CPQCC, established in 1997, is a non-profit quality improvement organization dedicated to improving the delivery of care and outcomes for California's mothers and vulnerable infants. CAPE, the world's first simulation center founded in 2002, is dedicated to neonatal and pediatric simulation-based training and research. The QI collaborative focused on implementing an in-situ neonatal simulation and debriefing program. Although the collaborative had common principles of implementation across centers, each individual center had their own Aims and process for implementation. We were provided ongoing assistance throughout the collaborative with a QI specialist that helped our team create Aim statements, identify metrics to assess progress in the collaborative, and review the concepts and assist core team members with the development of plan-do-study-act (PDSA) cycles.

### **2. Materials and Methods**

### *2.1. Training and Preparation*

Our Neonatal Intensive Care Unit (NICU) is a 14-bed, community Level III NICU located in Southern California. In 2019, there were 2354 deliveries and 211 NICU admissions with an average daily census (ADC) of six. Training and preparation to implement an in-situ neonatal simulation program consisted of identifying three core team members from our unit: a neonatologist/NICU Medical Director; a clinical nurse IV (the highest position on the clinical ladder for a sta ff nurse) that works the day shift; and a clinical coordinator (charge nurse) for the NICU on the night shift.

Participation in *Simulating Success*lasted 15-months, including three months of pre-implementation work prior to the 12-month active implementation phase (Figure 1). During the three-month pre-implementation phase, from July 2018 to September 2018, the core team members viewed nine online modules developed by CAPE. This series of modules covered a broad scope of simulation and debriefing techniques developed by the CAPE faculty. Homework assignments were included with each module; these involved the development of simulated clinical scenarios that our NICU experienced on a daily basis (high-risk, high volume) and scenarios that were not as frequently encountered (high-risk, low volume). During this same timeframe, monthly webinars were conducted with CAPE, CPQCC faculty, and a QI specialist in preparation for the simulation and debriefing course conducted at CAPE. In October 2018, our three-person team attended a 1.5-day intensive CAPE simulation and debriefing course and had the opportunity to engage with CAPE and CPQCC faculty and perform simulated clinical scenario followed by debriefings. During this intensive 1.5-day training, these same core team members also had the opportunity to debrief another NICU team's simulated clinical scenario and have our debriefing critiqued by the CAPE team, essentially a debriefing of our debriefing. During the months of November and December 2018, our team solidified simulation team members, developed Aim statements for the project, procured simulation materials and supplies, and discussed space allocation for simulations and debriefings.


**Figure 1.** *Simulating Success* Project Timeline.

Our core team was provided ongoing assistance throughout the collaborative with a QI specialist that helped our team create Aim statements, identify metrics to assess progress in the collaborative, and review the concepts and assist core team members with the development of plan-do-study-act (PDSA) cycles. CPQCC and CAPE had two patient outcome-related Aims for the overall collaborative. As a small NICU, we were concerned that we would not have enough patient data to demonstrate improved patient care outcomes. Without accurate and timely data evaluation and feedback to sta ff, we were concerned that this could impact short and long-term sta ff buy-in. Our NICU's overall goal and reason to participate in this collaborative were to implement a multidisciplinary in-situ simulation program to improve team performance and debriefing skills. Therefore, our primary Aim statement indicated that the training team would conduct two video-recorded in-situ simulations and debriefings in the NICU every month from January 2019 through December 2019. Our second Aim statement declared that 80% of NICU sta ff would participate in two in-situ simulations and debriefings on an annual basis by December 2019. The QI specialist also worked with our team and provided suggestions on how to implement the simulation and debriefing program.

### *2.2. In-Situ Simulation Implementation Process*

Our team decided to implement an in-situ simulation and debriefing program in which simulations and debriefings are conducted in labor and delivery or the NICU. Leadership in nursing and respiratory therapy supported and promoted the project through budgetary and personnel resources. A presentation explaining *Simulating Success* and the collaborative's goals and objectives were presented at a Maternal Newborn Services Division and Respiratory Services Department meeting. Additional communications occurred via email and during shift change reports.

Initially, the two nurse (RN) members of the core team set up and facilitated the first in-situ simulations utilizing simulations previously developed at CAPE. The neonatologist/medical director and respiratory care professional (RCP) members assisted by fulfilling di fferent roles necessary to make the simulated scenarios realistic. In-situ simulations were held approximately two times per month, starting in January 2019. After a few months of becoming familiar with the simulation-based and audiovisual technologies and gaining practice with debriefing, the core team presented an in-person, interactive in-service training session based on CAPE's simulation and debriefing principles. This learning session was open to NICU RCP and RN clinical coordinators (charge nurses) and the goal was to integrate the CAPE debriefing methodology into routine simulations and utilize the debriefing techniques with real-life events. The in-service was also designed to incorporate other sta ff as part of succession planning for core team leaders. Training additional sta ff allows for the sustainability and expansion of in-situ simulations and debriefings at our institution.

Each month during the one-year implementation phase, January 2019 through December 2019, we submitted our in-situ simulation and debriefing videos to the team at CAPE for their review and critique. Additionally, CAPE and CPQCC faculty hosted monthly webinars attended by our core team members and another NICU participating in Group 2. In June 2019, Group 2 (*n* = 2) combined with Group 3 (*n* = 3) for the monthly webinars. The two groups were combined to enhance the shared learning environment and unit experiences. During these webinars, CAPE faculty o ffered suggestions on scenario design and implementation as well as techniques for enhancing realism. In addition, the CAPE team critiqued our recorded debriefings. Participating NICUs were also a fforded the opportunity to share the barriers to implementation and strategies for success that each experienced.

All subjects gave their informed consent for inclusion before they participated in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Stanford (Project identification 38601).
