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Introduction: Progressing the field of surgical simulation research cohesively requires organization. The purpose of this study was to establish contemporary research priorities utilizing Delphi methodology., Methods: Surgical researchers with expertise in simulation-based research were invited to submit important questions for the field according to an organized framework. Thematic analysis was used to collapse questions into unique questions. In a second round, experts rated the importance of questions. In a third round, experts re-rated the importance of questions. A prioritized agenda was then created., Results: Eighteen experts submitted 80 questions in round one, which were collapsed into 43. In the final round, experts rated the following question as the most important priority: "Does demonstrated competency in the simulation lab translate to clinical competency (OR etc.)?", Conclusions: Our systematic approach identified multiple important questions to advance the field that may guide researchers and funding agencies alike., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Analysis of the Fundamentals of Endoscopic Surgery (FES) performance exam showed higher scores for men than women. Gender differences have been reduced with task-specific practice. We assessed the effect of simulation-based mastery learning (SBML) on FES performance exam differences by gender., Methods: Forty-seven surgical trainees [29 men (m), 18 women (w)] completed a SBML curriculum and were assessed by FES. Fourteen trained on the GI Mentor 2, 18 on the Endoscopy Training System, and 15 using the Surgical Training for Endoscopic Proficiency curriculum. Performance of male and female trainees was compared., Results: On the pre-training assessment, there were large differences between genders in FES pass rates (m 77%, w 15%, p < 0.001), total scores (m 69 ± 11, w 50 ± 12; p < 0.001), and in four of five FES sub-task scores (Navigation, m 73 ± 19, w 55 ± 22, p = 0.02; Loop reduction, m 34 ± 29, w 14 ± 22, p = 0.02; Retroflexion, m 81 ± 17, w 47 ± 27, p < 0.001; Targeting, m 89 ± 10, w 66 ± 23, p = 0.002). No differences were discernible post training (Pass rate, m 100%, w 94%, p = 0.4; Total score, m 77 ± 8, w 72 ± 12, p = 0.2; Navigation, m 91 ± 13, w 80 ± 13, p = 0.009; Loop reduction, m 49 ± 26, w 46 ± 36, p = 0.7; Retroflexion, m 82 ± 18, w 81 ± 15, p = 0.9; Targeting, m 92 ± 15, w 86 ± 12, p = 0.12). Time needed to complete curricula was not discernably different by gender (m 3.8 ± 1.7 h, w 5.0 ± 2.6 h, p = 0.17)., Conclusions: Gender-based differences are nearly eliminated through task-specific SBML training. This lends further evidence to the validity argument for the FES performance exam as a measure of basic endoscopic skills.

Background: The Fundamentals of Endoscopic Surgery (FES) exam is required for American Board of Surgery certification. The purpose of this study was to develop performance standards for a simulation-based mastery learning (SBML) curriculum for the FES performance exam using the Endoscopy Training System (ETS)., Methods: Experienced endoscopists from multiple institutions and specialties performed each ETS task (scope manipulation (SM), tool targeting (TT), retroflexion (RF), loop management (LM), and mucosal inspection (MI)) with scores used to develop performance standards for a SBML training curriculum. Trainees completed the curriculum to determine feasibility, and effect on FES performance., Results: Task specific training standards were determined (SM-121sec, TT-243sec, RF-159sec, LM-261sec, MI-180-480sec, 7 polyps). Trainees required 29.5 ± 3.7 training trials over 2.75 ± 0.5 training sessions to complete the SBML curriculum. Despite high baseline FES performance, scores improved (pre 73.4 ± 7, post 78.1 ± 5.2; effect size = 0.76, p > 0.1), but this was not statistically discernable., Conclusions: This SBML curriculum was feasible and improved FES scores in a group of high performers. This curriculum should be applied to novice endoscopists to determine effectiveness for FES exam preparation., (Published by Elsevier Inc.)

Background: Current work hour restrictions and the expansion of requirements for surgery residents has led to decreased time on high-acuity rotations such as trauma and acute care surgery. In an effort to improve resident competency, we examined the efficacy of a new team-based trauma curriculum for postgraduate year 1 (PGY1) residents., Methods: After completing required Advanced Trauma Life Support certification, PGY1s participated in a series of trauma simulations in 3-person teams from June to August. Scenarios were created to develop skills related to trauma management, teamwork, and communication. Each simulation was followed by video-based debriefing with a faculty facilitator. Clinical performance on a 1-month trauma rotation during the year was assessed by trauma faculty using a 24-item evaluation assessing management of acutely ill patients, leadership, communication, cooperation, and professionalism on a 1 (poor) to 5 (very effective) scale. Performance metrics of this intern class were compared with 2 years of previous cohorts who had not participated in any trauma-focused simulation curricula. One-way analysis of variance was used to examine differences in performance ratings across groups., Results: The 2015 intern class (n = 30) each participated in 6 scenarios during their first 2 months in residency. Trauma as intended specialty and performance on preinternship Advanced Trauma Life Support course were similar across 2013, 2014, and 2015 cohorts. Average performance on the trauma rotation was 3.55 ± 0.56 for the 2013 cohort (n = 11), 3.50 ± 0.57 for the 2014 cohort (n = 11), and 4.35 ± 0.68 for the 2015 cohort (n = 12). Post hoc analyses indicated no difference between means of the 2013 and 2014 cohort. However, the mean of the 2015 cohort was statistically significantly better than both the 2013 cohort (P < .01) and the 2014 cohort (P < .01)., Conclusion: Trauma-focused simulation improved PGY1 faculty ratings of performance in the clinical setting compared with previous cohorts with no such simulation experience. Adoption of these curricula is both feasible and beneficial., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The role of simulation-based education continues to expand exponentially. To excel in this environment as a surgical simulation leader requires unique knowledge, skills, and abilities that are different from those used in traditional clinically-based education., Methods: Leaders in surgical simulation were invited to participate as discussants in a pre-conference course offered by the Association for Surgical Education. Highlights from their discussions were recorded., Results: Recommendations were provided on topics such as building a simulation team, preparing for accreditation requirements, what to ask for during early stages of development, identifying tools and resources needed to meet educational goals, expanding surgical simulation programming, and building educational curricula., Conclusion: These recommendations provide new leaders in simulation with a unique combination of up-to-date best practices in simulation-based education, as well as valuable advice gained from lessons learned from the personal experiences of national leaders in the field of surgical simulation and education., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Although simulation is an effective method for enhancing team competencies, it is unclear how team familiarity impacts this process. We examined how team familiarity impacted team competencies., Methods: Trainees were assigned to stable or dynamic teams to participate in three simulated cases. Situation awareness (SA) data was collected through in-scenario freezes. The recorded performances were assessed for clinical effectiveness (ClinEff) and teamwork. All data are reported on a 1-100% (100% = perfect performance) scale., Results: Forty-six trainees (23 General Surgery; 23 Emergency Medicine) were randomized by specialty into stable (N = 8) or dynamic (N = 7) groups. Overall changes from Sim 1 to Sim3 were 12.2% (p < 0.01), -1.1% (ns), and 7.1% (p < 0.01) for SA, ClinEff, and Teamwork, respectively. However, improvements differed by condition, with stable teams reflecting improvements in ClinEff (15.2%; p < 0.05), whereas dynamic team ClinEff improvement (8.7%) was not significant. Both groups demonstrated improvements in teamwork (stable = 9%, p < 0.05; dynamic = 4.9%, p < 0.05)., Conclusions: Teams who continued to work together demonstrated increased improvements in clinical effectiveness and teamwork, while dynamic teams only demonstrated improvements in teamwork., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: The fundamentals of endoscopic surgery (FES) program has considerable validity evidence for its use in measuring the knowledge, skills, and abilities required for competency in endoscopy. Beginning in 2018, the American Board of Surgery will require all candidates to have taken and passed the written and performance exams in the FES program. Recent work has shown that the current ACGME/ABS required case volume may not be enough to ensure trainees pass the FES skills exam. The aim of this study was to investigate the feasibility of a simulation-based mastery-learning curriculum delivered on a novel physical simulation platform to prepare trainees to pass the FES manual skills exam., Methods: The newly developed endoscopy training system (ETS) was used as the training platform. Seventeen PGY 1 (10) and PGY 2 (7) general surgery residents completed a pre-training assessment consisting of all 5 FES tasks on the GI Mentor II. Subjects then trained to previously determined expert performance benchmarks on each of 5 ETS tasks. Once training benchmarks were reached for all tasks, a post-training assessment was performed with all 5 FES tasks., Results: Two subjects were lost to follow-up and never returned for training or post-training assessment. One additional subject failed to complete any portion of the curriculum, but did return for post-training assessment. The group had minimal endoscopy experience (median 0, range 0-67) and minimal prior simulation experience. Three trainees (17.6%) achieved a passing score on the pre-training FES assessment. Training consisted of an average of 48 ± 26 repetitions on the ETS platform distributed over 5.1 ± 2 training sessions. Seventy-one percent achieved proficiency on all 5 ETS tasks. There was dramatic improvement demonstrated on the mean post-training FES assessment when compared to pre-training (74.0 ± 8 vs. 50.4 ± 16, p < 0.0001, effect size = 2.4). The number of ETS tasks trained to proficiency correlated moderately with the score on the post-training assessment (r = 0.57, p = 0.028). Fourteen (100%) subjects who trained to proficiency on at least one ETS task passed the post-training FES manual skills exam., Conclusions: This simulation-based mastery learning curriculum using the ETS is feasible for training novices and allows for the acquisition of the technical skills required to pass the FES manual skills exam. This curriculum should be strongly considered by programs wishing to ensure that trainees are prepared for the FES exam.

Background: Ensuring the safe, effective management of patients requires efficient processes of care within a smoothly operating system in which highly reliable teams of talented, skilled health care providers are able to use the vast array of high-technology resources and intensive care techniques available. Simulation can play a unique role in exploring and improving the complex perioperative system by proactively identifying latent safety threats and mitigating their damage to ensure that all those who work in this critical health care environment can provide optimal levels of patient care., Methods: A panel of five experts from a wide range of institutions was brought together to discuss the added value of simulation-based training for improving systems-based aspects of the perioperative service line. Panelists shared the way in which simulation was demonstrated at their institutions. The themes discussed by each panel member were delineated into four avenues through which simulation-based techniques have been used., Results: Simulation-based techniques are being used in (1) testing new clinical workspaces and facilities before they open to identify potential latent conditions; (2) practicing how to identify the deteriorating patient and escalate care in an effective manner; (3) performing prospective root cause analyses to address system weaknesses leading to sentinel events; and (4) evaluating the efficiency and effectiveness of the electronic health record in the perioperative setting., Conclusion: This focused review of simulation-based interventions to test and improve components of the perioperative microsystem, which includes literature that has emerged since the panel's presentation, highlights the broad-based utility of simulation-based technologies in health care., (Copyright © 2017 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

Background: Opportunities exist to revise the current residency selection process to capture desirable candidate competencies. We examined the extent to which components of the American College of Surgeons/Association for Surgical Education simulation-based medical student curriculum combined with a teamwork activity could be used as potential screening method., Methods: Students participated in a workshop consisting of training/evaluation of knot tying, suturing, airway management, gowning/gloving, and teamwork. Surveys were given to medical students (MS) and faculty/resident/staff (FRS) to examine their opinions about the residency screening process, the most critical competencies to assess, and the effectiveness of each station for candidate evaluation., Results: Communication (FRS, 4.86 ± .35; MS, 4.93 ± .26), leadership (FRS, 4.41 ± .80; MS, 4.5 ± .76), judgment (FRS, 4.62 ± .74; MS, 4.67 ± .62), professionalism (FRS, 4.64 ± .73; MS, 5.00 ± .00), integrity (FRS, 4.71 ± .78; MS, 4.87 ± .35), and grit/resilience (FRS, 4.71 ± .78; MS, 4.53 ± .74) were considered most valuable for candidate screening. The simulation-based curriculum for evaluation of residency candidates was rated lowest by both groups. Open response comments indicated positive perceptions of this process., Conclusions: Employing simulation to assess candidates may be most beneficial for examining nontechnical attributes. Future work should continue to explore this area., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Team mental models represent the shared understanding of team members within their relevant environment. Thus, team mental models should have a substantial impact on a team's ability to engage in purposeful and coordinated action. We sought to examine the impact of shared team mental models on team performance and to investigate if team mental models increase over time as teams continue to work together., Methods: New surgery interns were assigned randomly to 1 of 10 teams. Each team participated in one unique simulation every day for 5 days, each followed by video-based debriefing with a facilitator. Participants also completed independently a concept similarity tool validated previously in nonmedical team literature to assess team mental models. All performances were video recorded and evaluated with a scenario-specific team performance tool by a single, blinded junior surgeon under an institutional review board-approved protocol. Changes in performance and team mental models over time were assessed with paired samples t tests. Regression analysis was used to examine the extent to which team mental models predicted team performance., Results: Thirty interns (age 27; 77% men) participated in the training program. Percentage of items achieved (x¯ ± SD) on the performance evaluation was 39 ± 20, 51 ± 14, 22 ± 17, 63 ± 14, and 77 ± 25 for Days 1-5, respectively. Team mental models were 30 ± 5, 28 ± 6, 27 ± 8, 26 ± 7, and 25 ± 6 for Days 1-5 respectively, such that larger values corresponded to greater differences in team mental models. Paired sample t tests indicated that both average performance and team mental models similarity improved from the first to last day (P < .01, P < .05, respectively). Additionally, regression analyses indicated that team mental models predicted team performance on Days 2-5 (all P < .05) but not on the first day of simulations., Conclusion: These results demonstrate that greater sharing of team mental models among the teams leads to better team performance. Additionally, the increase in team mental models over time suggests that engaging in team-based simulation may catalyze the process by which surgery teams are able to develop shared knowledge., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Situational awareness (SA) describes a team's ability to perceive environmental elements, comprehend their meaning, and anticipate future events. Although SA is consistently described as a critical competency among surgical teams, there is a dearth of research identifying efficacious methods to assess and develop SA in such settings. The aim of this study was to investigate the feasibility of implementing an objective tool that has been used to measure SA in other intense and dynamic environments -the Situation Awareness Global Assessment Technique (SAGAT)-and to examine its ability to predict surgical trainee team performance., Methods: Ten team-training sessions were conducted involving 2 standardized high-fidelity trauma simulation scenarios. Teams consisted of 4 or 5 participants, and roles were randomly assigned. Team situational awareness was assessed using the SAGAT method, which involves intermittent freezes to probe trainee awareness of the situation. Team performance was assessed using the Mayo High-Performance Teamwork Scale. Hierarchical regression was used to examine SA-performance relationships for each scenario., Results: Forty-three third-year medical students participated in the training sessions. Team SA ranged from 45% to 79% and 46% to 97% for the first and second scenarios, respectively. Additionally, team SA significantly predicted team performance for both the first scenario (F(1, 42)=19.57; P<0.001; R=0.30) and second scenario (F(1,42)=26.18, P<0.001; R=0.38)., Conclusions: The SAGAT is a valid, reliable tool for assessing surgical trainee SA. Information provided by the SAGAT can help diagnose team performance problems, inform debriefing discussion points, and inform curriculum development endeavors.

Introduction: The role of goal setting within post-simulation debriefing is not well known. This study sought to examine how inclusion of group-level goals, individual-level goals, or no goals in the debriefing process impacts teamwork., Methods: Students participated in two high-fidelity team training scenarios. Between scenarios, teams were assigned to one of three debriefing groups: jointly creating five teamwork goals for the group to achieve (group-level goals); independently creating five teamwork goals for each individual to attain (individual-level goals); or no goals. Paired-samples t tests and one-way ANOVA with post-hoc Tukey tests were used to examine performance improvements and differences between groups., Results: 86 MS3s participated in the training program across 22 groups. Percentage of items achieved on the teamwork tool from first to second scenario were 61.7±20.4 to 60.2±8.8 (no goals; ns), 59.8±14.0 to 76.8±7.0 (individual goals; p<0.01), and 62.5±9.5 to 67.0±10.0 (group goals; ns). Performance improvement in the individual goals group was significantly higher than the no goals group (p<0.05)., Conclusions: Debriefing facilitators should encourage learners to focus on creating and achieving personal goals contributing to teamwork., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Although simulation facilities are available at most teaching institutions, the number of qualified instructors and/or content experts that facilitate postsimulation debriefing is inadequate at many institutions. There remains a paucity of evidence-based data regarding several aspects of debriefing, including debriefing with a facilitator present versus teledebriefing, in which participants undergo debriefing with a facilitator providing instruction and direction from an off-site location while they observe the simulation in real-time. We conducted this study to identify the effectiveness and feasibility of teledebriefing as an alternative form of instruction., Methods: This study was conducted with emergency medicine residents randomized into either a teledebriefing or on-site debriefing group during 11 simulation training sessions implemented for a 9-month period. The primary outcome of interest was resident perception of debriefing effectiveness, as measured by the Debriefing Assessment for Simulation in Healthcare-Student Version (See Appendix, Supplemental Digital Content 1, http://links.lww.com/SIH/A282) completed at the end of every simulation session., Results: A total of 44 debriefings occurred during the study period with a total number of 246 Debriefing Assessment for Simulation in Healthcare-Student Version completed. The data revealed a statistically significant difference between the effectiveness of on-site debriefing [6.64 (0.45)] and teledebriefing [6.08 (0.57), P < 0.001]. Residents regularly evaluated both traditional debriefing and teledebriefing as "consistently effective/very good.", Conclusions: Teledebriefing was found to be rated lower than in-person debriefing but was still consistently effective. Further research is necessary to evaluate the effectiveness of teledebriefing in comparison with other alternatives. Teledebriefing potentially provides an alternative form of instruction within simulation environments for programs lacking access to expert faculty.

Background: As it addresses both technical and nontechnical skills, simulation-based training is playing an increasingly important role in surgery. In addition to the focus on skill acquisition, it is also important to ensure that surgeons are able to perform a variety of tasks in unique and challenging situations. These situations include responding to mass casualties, dealing with disease outbreaks, and preparing for wartime missions. Simulation-based training can be a valuable training modality in these situations, as it allows opportunities to practice and prepare for high-risk and often low-frequency events., Methods: During the 8th Annual Meeting of the Consortium of the American College of Surgeons-Accredited Education Institutes in March 2015, a multidisciplinary panel was assembled to discuss how simulation can be used to prepare the surgical community for such high-risk events., Conclusion: An overview of how simulation has been used to address needs in each of these situations is presented., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Simulation has been shown to improve trainee performance at the bedside and in the operating room. As the use of simulation-based training is expanded to address a host of health care challenges, its added value needs to be clearly demonstrated. Demonstrable improvements will support the expansion of infrastructure, staff, and programs within existing simulation facilities as well as the establishment of new facilities to meet growing needs and demands. Thus, organizational and institutional leaders, faculty members, and other stakeholders can be assured of the best use of existing resources and can be persuaded to make greater investments in simulation-based training for the future., Methods: A multidisciplinary panel was convened during the 8th Annual Meeting of the Consortium of the American College of Surgeons-Accredited Education Institutes (Simulation Centers) in March 2015 to discuss the added value of simulation-based training. Panelists shared the ways in which the value of simulation was demonstrated at their institutions., Conclusion: The value of simulation-based training was considered and described in terms of educational impact, patient care outcomes, and costs., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background In the past few years, there has been rapid growth in the number of simulation fellowships for physicians in the United States and Canada, with the objective of producing faculty with expertise and leadership training in medical simulation. Relatively little is known about the collective content and structure of these new fellowship opportunities. Objective We sought to identify a common set of core curricular elements among existing simulation fellowships and to obtain demographic background information on participants and leadership. Methods We designed a web-based survey and circulated it to simulation fellowship directors in the United States and Canada. The questions explored aspects of the fellowship curriculum. A grounded theory approach was used to qualitatively analyze fellowship goals and objectives. Results Of the 29 program directors surveyed, 23 responded (79%). The most commonly listed goals and objectives were to increase skills in simulation curriculum development, simulation operations and training environment setup, research, educational theory, administration, and debriefing. The majority of the responding fellowship directors (17 of 22, 77%) indicated that a set of consensus national guidelines would benefit their fellowship program. Conclusions Simulation fellowships are experiencing a period of rapid growth. Development of a common set of program guidelines is a widely shared objective among fellowship directors.

Background: The Consortium of American College of Surgeons-Accredited Education Institutes was created to promote patient safety through the use of simulation, develop new education and technologies, identify best practices, and encourage research and collaboration., Methods: During the 7th Annual Meeting of the Consortium, leaders from a variety of specialties discussed how simulation is playing a role in the assessment of resident performance within the context of the Milestones of the Accreditation Council for Graduate Medical Education as part of the Next Accreditation System., Conclusion: This report presents experiences from several viewpoints and supports the utility of simulation for this purpose., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Error management training is an approach that encourages exposure to errors during initial skill acquisition so that learners can be equipped with important error identification, management, and metacognitive skills. The purpose of this study was to determine how an error-focused training program affected performance, retention, and transfer of central venous catheter (CVC) placement skills when compared with traditional training methodologies., Methods: Surgical interns (N = 30) participated in a 1-hour session featuring an instructional video and practice performing internal jugular (IJ) and subclavian (SC) CVC placement with guided instruction. All interns underwent baseline knowledge and skill assessment for IJ and SC (pretest) CVC placement; watched a "correct-only" (CO) or "correct + error" (CE) instructional video; practiced for 30 minutes; and were posttested on knowledge and IJ and SC CVC placement. Skill retention and transfer (femoral CVC placement) were assessed 30 days later. All skills tests (pretest, posttest, and transfer) were videorecorded and deidentified for evaluation by a single blinded instructor using a validated 17-item checklist., Results: Both the groups exhibited significant improvements (p < 0.001) in knowledge and skills after the 1-hour training program, but the increase of items achieved on the performance checklist did not differ between conditions (CO: IJ Δ = 35%, SC Δ = 29%; CE: IJ Δ = 36%, subclavian Δ = 33%). However, 1 month later, the CO group exhibited significant declines in skill retention on IJ CVC placement (from 68% at posttraining to 44% at day 30; p < 0.05) and SC CVC placement (from 63% at posttraining to 49% at day 30; p < 0.05), whereas the CE group did not have significant decreases in performance. The CE group performed significantly better on femoral CVC placement (i.e., transfer task; 62% vs 38%; p < 0.01) and on 2 of the 3 complication scenarios (p < 0.05) when compared with the CO group., Conclusions: These data indicate that incorporating error-based activities and discussions into training programs can be beneficial for skill retention and transfer., (Copyright © 2015 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The Consortium of American College of Surgeons Accredited Education Institutes (ACS-AEIs) was created to promote patient safety through the use of simulation, develop innovative education and training, advance technologies, identify best practices, and encourage research and collaboration., Methods: During the seventh annual meeting of the consortium, leaders from across the consortium who have developed institution-wide simulation centers were invited to participate in a panel to discuss their experiences and the lessons learned., Conclusion: These discussions resulted in definition of 5 key areas that need to be addressed effectively to support efforts of the ACS-AEIs., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Simulation-based training is playing an increasingly important role in surgery. However, there is insufficient discussion among the surgical specialties regarding how simulation may best be leveraged for training. There is much to be learned from one another as we all strive to meet new requirements within the context of Undergraduate Medical Education, Graduate Medical Education, and Continuing Medical Education., Method: To address this need, a panel was convened at the 6th Annual Meeting of the Consortium of the American College of Surgeons-Accredited Education Institutes consisting of key leaders in the field of simulation from 4 surgical subspecialties, namely, general surgery, orthopedic surgery, cardiothoracic surgery, urology, and otolaryngology., Conclusion: An overview of how the 5 surgical specialties are using simulation-based training to meet a wide array of educational needs for all levels of learners is presented., (Copyright © 2015 Elsevier Inc. All rights reserved.)