A quality improvement approach to integrating social determinants of health objectives into pediatric simulation

Abstract

Background

Health disparities and the unequal distribution of social resources impact health outcomes. By considering social determinants of health (SDH), clinicians can provide holistic and equitable care. However, barriers such as lack of time or understanding of the relevance of SDH to patient care prevent providers from addressing SDH. Simulation curricula may improve learners’ ability to address SDH in practice.

Objectives

The primary objective was to increase the percentage of pediatric emergency simulations that included SDH objectives from 5% to 50% in 12 months at one institution. As a balancing metric, we examined whether trainees approved the incorporation of SDH objectives.

Methods

Using the Model for Improvement approach, we conducted interviews of residents and simulation facilitators to identify challenges to integrating SDH objectives into the simulation curriculum. Review of interviews and visual representation of the system helped identify key drivers in the process. A team of simulation leaders, residents, and fellows met regularly to develop simulation cases with embedded SDH objectives. Using a plan, do, study, act approach, we tested, refined, and implemented interventions including engaging residency program and SDH leadership, piloting cases, providing facilitators concise resources, inviting SDH‐specific experts to co‐debrief, and eliciting and incorporating learner and facilitator feedback to improve cases. SDH topics include homelessness, undocumented status, and racism.

Results

Prior to the start of the quality improvement work, SDH were rarely incorporated into emergency simulations for pediatric residents. A p‐chart was used to track the percentage of monthly cases that incorporated SDH topics. During the study period, the percentage of simulations including SDH topics increased to 57% per month. Most trainees (94%) welcomed incorporating SDH objectives.

Conclusions

Using the Model for Improvement, we incorporated SDH objectives into pediatric resident emergency simulations. Next steps include examining effectiveness of the curriculum, dissemination to additional learners, and examining sustainability in practice.

INTRODUCTION

Addressing social determinants of health (SDH) in health care can improve health outcomes ¹ and accreditation standards in graduate medical education require curricular elements addressing health care inequities. However, barriers such as limited time, understanding the relevance of SDH issues to medical care, or lack of comfort in addressing SDH prevent providers from routinely addressing SDH in medicine. ² Dedicated health equity curricula are favored by learners, associated with improved trainees’ abilities to identify and address SDH in practice and lead to wider institutional impacts. ³ , ⁴ , ⁵ Trainees endorse the need for simulation‐based learning to practice skills learned through didactic curricula on SDH. ⁵

By integrating complex factors to represent the whole patient, ⁴ simulation provides a unique opportunity to teach trainees methods to better address SDH in practice. Simulation could allow learners to practice integrating considerations of SDH into emergency medical scenarios, and when paired with facilitated debriefing, simulation training may also lead to improved communication with patients. ⁶

The Yale Center for Medical Simulation facilitates in situ interprofessional simulations weekly within the department of pediatrics. Objectives address the American Board of Pediatric content specifications. Simulations are facilitated by core faculty who have completed formal debriefing coursework and are supported by trained technicians using high‐fidelity simulators. Prior to the start of the quality improvement work, SDH were rarely incorporated into pediatric simulations, which addressed common medical emergencies in children.

The specific aim of this study was to increase the percentage of simulations about pediatric emergencies that include SDH objectives from 5% to 50% in 12 months. As a balancing metric, we examined self‐reported trainee acceptance of incorporating SDH objectives into simulations.

METHODS

Context

At our institution, 60 categorical pediatric, 16 internal medicine‐pediatric, four pediatric neurology, and two pediatric psychiatry residents participate in weekly simulations when rotating on any inpatient service. At the start of the study period, two‐thirds of the cases were specifically pediatric emergency medicine scenarios that occurred in the pediatric emergency department (ED) and included participation from ED nurses and techs. The remaining cases occurred on the inpatient unit or the neonatal intensive care unit. Residents participate in two to three simulations annually. On average, five to seven trainees participated in each weekly simulation.

Study design and interventions

We used the Model for Improvement framework to guide the integration of SDH objectives into the existing pediatric resident simulation curriculum. First, we identified a multidisciplinary team of simulation leaders, pediatric and emergency medicine residents, and pediatric emergency medicine fellows who met monthly and more frequently in small groups to plan the project. To understand the current state and identify challenges and facilitators to integrating SDH objectives into the pediatric emergency simulation curriculum, we created a visual representation of the current process and conducted informal interviews of pediatric residents and simulation facilitators (Supplemental Table S1). Review of the interviews and the process map informed the development of a key driver diagram (Supplemental Figure S1) and identified key drivers in the process to incorporate SDH into simulation scenarios. Drivers included a cultural shift in simulation education to routinely incorporate SDH learning, an understanding that SDH impact acute medical care decisions, facilitator knowledge about SDH topics, and the need for a feasible strategy that overcomes concerns about time constraints.

During the interviews, simulation facilitators emphasized the importance of maintaining psychological safety during the debrief while changing simulation objectives, and residents raised concerns that medical objectives may become secondary to SDH objectives (Supplemental Table S1). Thus, trainee acceptability of incorporating SDH objectives, a proxy for both psychological safety and for approval of the whole simulation, was examined as a balancing metric.

A plan, do, study, act (PDSA) approach was used to test, refine, and implement interventions, which included engaging program and SDH leadership, piloting and refining cases with SDH objectives, providing facilitators concise resources for the SDH objectives, inviting SDH‐specific experts to co‐debrief, and eliciting and incorporating feedback to improve cases.

Individual team members worked on the development of the SDH portion of the cases. Steps included: (1) development of a resource library for SDH topics and an abridged resource document for the facilitator with key points; (2) development and integration of two or three SDH objectives within an emergency medical scenario and creation of an actor script; and (3) review of cases by content experts, including leaders in SDH and preparation with the actor and facilitator to review material, standardize the experience, and assure feasible incorporation of SDH issues into the case. SDH objectives were developed such that they could be paired with most emergency medical scenarios and be addressed without significantly prolonging the case or the debrief. Examples of SDH objectives paired with any simulation case included asthma exacerbation with homelessness, anaphylaxis and undocumented status, sepsis and racial microaggression, and nonaccidental trauma and racial bias (Table 1).

TABLE 1.

Medical scenarios and paired SDH topics.

Medical scenarios	SDH topic	Objectives related to SDH topic
Sepsis, status asthmaticus, supraventricular tachycardia, status epilepticus	Homelessness	Recognize the various manifestations of homelessness Identify the impact of homelessness on a child's health Identify resources for patients experiencing homelessness
Anaphylaxis, status asthmaticus, neonatal resuscitation, placental abruption, tension pneumothorax, congenital diaphragmatic hernia	Undocumented status	Recognize parent hesitancy and ask appropriate questions to understand financial concerns Identify resources such as social work and case management to help provide resources for families with financial hardship Learn ways to ask about documentation status in a nonjudgmental way
Acute chest syndrome	Racial bias	Improve understanding of sickle cell disease and historical conversations regarding race Understand the underlying biases that patients face when interacting with the health care system for pain management Identify strategies to support patients with sickle cell disease presenting for pain management
Nonaccidental trauma	Racial bias	Describe the impact of bias on variation in practice on care for suspected victims of abuse Identify strategies for reducing these disparities
Bronchiolitis, status asthmaticus, status epilepticus	Limited English proficiency	Identify need for and demonstrate use of local interpretation services Discuss the potential impact of language barriers on communication and patient care Understand the unintended consequences of relying on children as interpreters
Abdominal pain	Transgender care	Provide gender‐affirming and compassionate care using gender‐neutral language/preferred labeling of anatomy Demonstrate asking appropriate and inclusive questions about sexual health and gender‐affirming therapies Identify methods to obtain medical evaluation of pelvic pain in a transgender man, ensuring safe and affirming follow‐up plan and resources
Sepsis, status asthmaticus, tension pneumothorax, shoulder dystocia, congenital diaphragmatic hernia, pulmonary hypertension, critical aortic coarctation	Name‐calling (racial microaggression)	Identify/recognize racist statements/comments made by staff member about family Verbalize two antiracist actions that team members can take to address the statements, such as “calling in or calling out” Apply the technique of “ask, learn, practice” to learn ethnically distinct names
Status asthmaticus	Mistreatment of medical staff	Identify workplace verbal abuse/violence Demonstrate verbal deescalation techniques/safety Discuss effects of workplace violence on provider burnout and morale

Abbreviation: SDH, social determinants of health.

PDSA cycles were used to refine and improve acceptability and feasibility of the cases. For example, after piloting a new case in a single simulation session, feedback was sought about the SDH portion within the case and the debrief from the trainees and facilitator. Recommendations such as changing the way an SDH topic was woven into the scenario and the desire for abridged resources for the facilitator informed improvements in both case development and resource provision prior to wider implementation.

Study of the interventions

This work follows the SQUIRE 2.0 reporting guidelines. ⁷ We evaluated data for signals of nonrandom change using standard control chart rules (shift, trend, number of runs). ⁸

At the conclusion of each simulation session, participants received a standard feedback form to ensure that educational objectives were met (Supplemental Figure S2). If there was an SDH objective in the simulation session, specific prompts asked about the learner's acceptability of the SDH portion of the simulation. A 4‐point Likert scale was used to assess agreement with statements assessing acceptability with responses ranging from strongly agree to strongly disagree. Descriptive data are reported.

Data analysis

We tracked the percentage of monthly cases (n = 4–5) that incorporated SDH objectives with a statistical process control p‐chart, utilizing QI Macros for Excel (KnowWare International, Inc.). Upper and lower control limits were specified around the center line. Standard rules for control chart interpretation (e.g., shift of eight consecutive monthly data points to one side of the center line) were used to evaluate for special cause variation or unexpected variation due to identifiable changes in a process. ⁹ This quality improvement work was exempted from formal review by our institutional review board.

RESULTS

We started the work in November 2020, with formal and regular integration into the resident simulation curriculum in August 2021. Evidence of special cause variation with a shift in the center line, reflecting eight data points to one side of the center line, was identified beginning on July 31, 2021, with the average percentage of simulations that included SDH objectives increasing from 5% to 57% (Supplemental Figure S3). Out of the estimated 200 participants in the study period, 76 participants completed a postsimulation survey for a response rate of 38%. Fifty‐seven of those who completed the survey answered “yes” to having SDH objectives included in their simulation. Of those 57, 54 (95%) agreed or strongly agreed with the following two statements: (1) incorporating an SDH objective in today's simulation meets my approval and (2) I welcome the addition of SDH topics in our simulation cases.

DISCUSSION

In this study, we used the Model for Improvement to integrate SDH objectives into emergency medical scenarios in a longitudinal resident simulation curriculum in a way that was acceptable to trainees. Quality improvement methodology facilitated the application of changes through the examination of existing processes, identification of possible barriers, and testing and implementing changes that resulted in a systematic curricular change. ⁷

A recent systematic review demonstrated that most simulation curricula addressing SDH focus on one‐time events and often address the SDH as the focus of the simulation. ⁶ In contrast, we developed a wide variety of SDH objectives that could be paired with most emergency medical scenarios to represent real‐life patient interactions and provide a feasible longitudinal curriculum. Learners also had the opportunity to repeat the same SDH objectives but paired with different medical scenarios, allowing them to solidify and apply the learned principles in a more realistic way. Integration of SDH education within a longitudinal curriculum may lead to improved retention of skills that may be translated to improvements in patient care. ⁵

Furthermore, simulation may allow a safe learning environment for learners to practice holistic care. ¹ , ⁵ During the discussion of potentially sensitive topics during the simulations with SDH topics, our team stressed the importance of psychological safety or when participants feel comfort in speaking up, sharing thoughts, and asking for help without concern for retribution or embarrassment. ¹⁰ Prebriefs, clear objectives for participants, and opportunities to reflect on actions and feelings during the debriefing are best practices to promote psychological safety, especially when participants may have had past experiences that influence their reflections on the objectives. ⁶ , ¹⁰ , ¹¹ , ¹²

In our curriculum, best practices, such as facilitator prebriefs and provision of evidenced‐based resources to prepare facilitators to lead a simulation and debrief, enabled integration of SDH objectives and increased feasibility of simulation performance. The addition of content expert review of each case, as well as co‐debriefing when possible, may have helped to further reduce stereotypes and address implicit biases during simulations. Iterative feedback from participants and facilitators will continue to inform the maintenance of psychological safety as the curriculum is refined. Continued program leadership commitment may further increase sustainability of the curriculum.

LIMITATIONS

We identified at least five limitations to this study. First, due to challenges such as limited funding, the actors and mannequins did not always reflect the diversity of the patients in the scenarios. Second, the curriculum was implemented for one group of learners and facilitators at one institution. However, by the end of the study period, dissemination had occurred to various learning settings. Third, we did not examine the impact of simulation setting on trainee acceptance of the curriculum. It is possible that incorporating SDH may be more acceptable in inpatient settings, where rapport with a family may be established, compared with ED settings. Fourth, not only was it difficult to track total number of participants, as not everyone signed in, but also not all participants completed the survey to assess acceptability, introducing the potential for nonresponse bias. Finally, the effectiveness of the curriculum in changing provider behaviors and improving patient‐level outcomes was not assessed.

CONCLUSIONS

The development and implementation of a longitudinal curriculum that provides trainees with the tools to be more culturally aware in simulated practice were both feasible and acceptable. Given this work focused on implementing effective practices, next steps include examining knowledge acquisition and skill development, dissemination to additional learners, and examining sustainability in practice.

AUTHOR CONTRIBUTIONS

Megan Feick participated in the conception and design of the study, analysis and interpretation of data, and in drafting the article and revising it critically for important intellectual content in the manuscript. Gunjan Tiyyagura participated in the conception and design of the study, acquisition of data, analysis and interpretation of data, and drafting the article and revising it critically for important intellectual content. Ammarah U. Iqbal helped design and conceptualize the study and participated in data analysis. Henna Boolchandani, Gauthami Soma, Lindsay Johnston, Sarah Kandil, Alexis Cordone, and Marc Auerbach conceptualized and designed the study. Marc Auerbach also coordinated and supervised data collection. All authors reviewed and revised the manuscript.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

Supporting information

Figure S1.

Figure S2.

Figure S3.

Table S1.

Feick M, Iqbal AU, Boolchandani H, et al. A quality improvement approach to integrating social determinants of health objectives into pediatric simulation. AEM Educ Train. 2023;7:e10910. doi: 10.1002/aet2.10910