**5. Conclusions**

In situ simulation aids in identifying system issues and focuses on improving patient safety [22]. Our paper describes the experiences of three sites with some similar, but also di fferent contexts and results of implementing in situ simulation programs for neonatal resuscitation. Lessons learned will inform each institution's continued progress, but may also be useful for others embarking on similar implementation projects. A goal of the implementation for all three institutions was to potentially a ffect systems change, and ultimately lead to improved patient care and outcomes. Each hospital in this collaborative had their own set of challenges and approached their simulation training and implementation methods based on the unique needs and goals of their unit. However, there were commonalities in barriers, such as adapting to fluctuations in clinical acuity and census and having consistent, dedicated team members with time allotted for the program. Establishing a strong foundation in simulation methodology, developing debriefing skills, ensuring multidisciplinary champions for implementation, and following a quality improvement framework are key components in order to achieve the goals of enhancing teamwork in neonatal resuscitation in order to improve clinical outcomes.

**Author Contributions:** Conceptualization, H.C.L. and R.C.; Methodology, N.A., I.A., J.H., R.S., P.T., S.H., R.N., J.N., H.C.L., J.B., J.Q., L.P.H., N.K.Y., J.F. and R.C.; Validation, R.C.; Formal Analysis, R.S., J.N., R.N. and N.A.; Investigation, N.A., I.A., J.H., R.S, P.T., S.H., R.N., J.N., H.C.L., J.B., J.Q., L.P.H., N.K.Y., J.F. and R.C.; Resources, R.C., L.P.H., N.K.Y. and J.F.; Data Curation, R.S., J.N., R.N. and N.A.; Writing—Original Draft Preparation, N.A., R.S., J.N., R.N., N.K.Y. and R.C.; Writing—Review and Preparation, N.A., I.A., P.T., S.H., H.C.L., J.Q., L.P.H., J.F., J.B. and J.H.; Visualization, R.S., J.N., R.N., N.A. and J.B.; Supervision, H.C.L., L.P.H. and J.Q., Project Administration, J.B. and J.Q.; Funding Acquisition, H.C.L. All authors have read and agreed to the published version of the manuscript.

**Funding:** Research reported in this paper was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under award number 1R01HD087425. The content is solely the responsibility of the authors and does not necessarily represent the o fficial views of the National Institutes of Health. Research reported in this paper was also supported by the Endowment for the Center for Advanced Pediatric and Perinatal Education.

**Institutional Review Board Statement:** This study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Stanford University Institutional Review Board, protocol 38601.

**Informed Consent Statement:** Informed consent was obtained prior to recorded simulations. No protected health information was included.

**Data Availability Statement:** The data presented in this study may be available on request from the corresponding author. The data are not publicly available due to privacy concerns and some data not consented to be shared.

**Acknowledgments:** The authors wish to thank CPQCC, CAPE, NeoQIP, and the NICU teams from CHOC, SMB and VCH for their active participation in Simulating Success. Their engagemen<sup>t</sup> in this quality improvement collaborative truly exemplifies their dedication to improving patient safety.

**Conflicts of Interest:** The authors declare no conflict of interest.
