**4. Discussion**

While the *Simulating Success* QI project involved experienced neonatal healthcare professionals, much of the literature that describes debriefing, centers on training relatively inexperienced learners, not practicing healthcare professionals. Most authors convey the need for four phases of debriefing: reaction, description, analysis, and summary [14–23]. This is done primarily because of a belief that psychological distress is frequent during participation in simulated clinical events and, without first having an opportunity to "ventilate" pent up emotion, trainees being debriefed will not be able to participate effectively in a debriefing. Henricksen et al. examined the expression of psychological distress in 3900 subjects undergoing debriefing after simulated healthcare scenarios and found that <1% were perceived to manifest such distress [24]. Finally, patient outcome is not routinely emphasized and some authors state that discussion of patient outcome should be avoided, especially when outcome is poor [25]. These aspects of debriefing in healthcare conflate the difference between a technical performance debriefing (used to critique human and system performance) and a critical incident stress debriefing (conducted to provide psychological support after an emotionally and/or psychologically challenging event). A fundamental difference with CAPE's Guiding Principles for Healthcare Debriefings [26] emphasizes that learning is better achieved through facilitated trainee discussions rather than didactic teaching provided by the facilitator. This facilitated discussion can be best achieved using a series of four "drill-down" questions [26]. CAPE's debriefing principles also guide trainees to develop approaches to replicate actions that strengthen human and system performance and avoid activities that are ineffective or harmful [26]. Integrating CAPE's Guiding Principles for Healthcare Debriefings was a change from our unit's previous style of debriefing. There was a learning curve for the core team members to adapt and incorporate various elements of CAPE's debriefing principles. Additionally, participants commented on the differences they experienced themselves and that utilizing CAPE's debriefing principles opened more opportunities for discussion and active learning.

CPQCC's *Simulating Success* collaborative was designed to assist participating NICUs implement a patient safety neonatal simulation and debriefing program. In the context of this QI collaborative, our community NICU benefitted from the expertise of CAPE and CPQCC faculty, and the QI specialist who helped critique our processes and support our goals. At its foundation, CPQCC utilizes the Institute for Healthcare Improvement (IHI) improvement framework—the Model for Improvement—which focuses on three questions and conducting Plan-Do-Study-Act (PDSA) cycles during the implementation phase of a collaborative [10]. The three questions are: What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? To address these questions, we conducted PDSA cycles that developed the change (plan), implemented the change (do), evaluated the change (study), and determined whether any modifications or revisions were needed (act) [27]. To answer the IHI's three questions:


It is worthwhile to note that, from a QI collaborative perspective, a unit's readiness for change is assessed before embarking in a QI collaborative. This assessment of the readiness for change can be evaluated by various unit and/or organizational context factors. Relevant stakeholders who can effect change, especially from a financial and human resource standpoint, should assess and understand the unit's culture, leadership and financial support, and evaluation capabilities [28]. We have been involved with past CPQCC collaboratives; however, those collaboratives focused on reducing variation in the performance of healthcare professionals and/or standardizing changes in practice (e.g., antibiotic stewardship and increasing the frequency of breastmilk feedings). With *Simulating Success,* our goal was to implement and develop processes to sustain a simulation and debriefing program. To achieve this goal, we needed to ensure the significant financial resources necessary to support personnel, assistance from information technology services, allocation of su fficient time to allow core team members, nurses and respiratory therapists to participate in the simulated clinical scenarios. We were fortunate that our hospital's nursing, respiratory, and physician leadership recognized the importance of a simulation and debriefing program to neonatal care. This support facilitated buy-in with the program by our sta ff.

Undertaking a QI project also means having the ability to collect and evaluate data, and then provide feedback to team members to advance QI improvements. While we acknowledge that our project's Aim statements did not focus on patient outcome data, the LSTs identified by the trainees and the resultant process improvements did act to foster sta ff buy-in. We cannot underscore the importance of evaluation and feedback in quality improvement work—they are the foundations of "study" and "act" in PDSA cycles.
