**1. Introduction**

Neonatal resuscitation is one of the most critical events in neonatal-perinatal medicine requiring a high level of individual skill and team performance. Resuscitation of a critically ill newborn cannot occur

in a silo—it requires a team e ffort. Ine ffective communication has been noted to play a role in almost 75% of cases of neonatal mortality or severe neonatal morbidity reported to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) [1,2]. Studies of real-life delivery room resuscitations have elucidated opportunities for improvement in behavioral skills, as well as lack of adherence to the recommended steps of the Neonatal Resuscitation Program (NRP) algorithm [3,4]. Simulation-based training for neonatal resuscitation in an immersive environment replicating a real clinical scenario provides an opportunity to improve behavioral and communication skills [5,6]. Notably, health care professionals (HCPs) who have completed simulation-based training in Adult Cardiopulmonary Life Support (ACLS) better adhere to resuscitation guidelines in the real-life clinical environment [7]. Thomas et al. translated principles of communication and teamwork behavior to neonatal resuscitation practice and developed a framework for assessing teamwork behavior using video recordings [8]. In a randomized trial testing the addition of teamwork training to NRP, those who received the teamwork training intervention exhibited more teamwork behavior than the control group [9,10]. NRP training has increasingly incorporated simulation-based training in these cognitive, technical, and behavioral skills with the aim of improving the quality of newborn resuscitation [11].

Neonatal resuscitation is complex and occurs infrequently. Team training aims to teach and support knowledge acquisition, and skills and attitudes that lead to optimal team performance. Simulation and debriefing methodology provide the tools to conduct team training with the primary goal of patient safety [2,12]. Simulations can be conducted in a simulation center or in situ (i.e., actual setting where participants work, for example Labor and Delivery). There are several benefits for health care teams to conduct simulations in situ [13]: adding realism; ability to identify systems errors or latent safety threats (LSTs) that could lead to changes in practice; and filling of gaps between knowledge and practice [14,15]. California Perinatal Quality Care Collaborative's (CPQCC) Simulating Success program was designed to help participating hospitals implement an on-site, simulation-based neonatal resuscitation training program. In this report, we describe the experience of the first cohort of three hospitals to participate in the program. The structure of the remainder of this paper is such that the three institutions' aims are each presented in the Methods along with the local context in which the project occurred, and the results of the project are then presented for each institution separately in the Results in corresponding order.

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

Simulating Success engaged hospitals over 15 month long periods that included three months of preparatory training followed by 12 months of implementation (Figure 1). Simulating Success was o ffered by CPQCC in partnership with the Center for Pediatric and Perinatal Education (CAPE) at Stanford University. Preparatory training consisted of an online didactic program followed by a 1.5 day, face-to-face training program at CAPE in the core principles of developing and conducting simulation-based training. The online didactic program was made available to an unlimited number of sta ff members at each site. Face-to-face training was attended by a maximum of three sta ff members from each site (referred to as the 'multidisciplinary champion team' for the remainder of this manuscript). Implementation at each site entailed ongoing in situ simulations followed by debriefings and monthly online check-ins with CAPE faculty, in addition to two site visits, for continued feedback and support.

The first cohort of three sites began in April 2018. Principles of quality improvement were incorporated throughout the collaborative with a focus on implementing Plan Do Study Act (PDSA) cycles. A quality improvement expert helped each site develop their Specific, Measurable, Applicable, Realistic, and Timely (SMART) Aim statements to target unit-specific needs. The resulting aim statements reflect the Simulating Success program goals of incorporating quality improvement tools and developing sustainable programs. Performance of the implementation teams as well as the clinical sta ff were used as potential measures of

sustainability. This manuscript details the experience of these sites in implementing a simulation program at their respective hospitals (Children's Hospital of Orange County (CHOC), Sharp Mary Birch Hospital for Women and Newborns (SMB) and Valley Children's Hospital (VCH)).


**Figure 1.** Timeline for CPQCC's Simulating Success collaborative.
