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AHA does not claim ownership of any content, including content incorporated by permission into AHA produced materials, created by any third party and cannot grant permission to use, distribute or otherwise reproduce such third party content. To request permission to reproduce AHA content, please click here. Corresponding author. Received 2018 Dec 7; Accepted 2019 Jun 25. The Creative Commons Public Domain Dedication waiver ( ) applies to the data made available in this article, unless otherwise stated. This article has been cited by other articles in PMC. Associated Data Data Availability Statement Data sharing is not applicable to this article as no datasets were generated or analyzed. Abstract Development and reconstruction of new healthcare facilities and spaces has the potential for latent safety threats to emerge, specifically unintentional harm that could affect actual patients once the facility opens, such as missing equipment, inefficient setup, or insufficient space for procedures. Process-orientated simulation and testing is a novel innovation in healthcare. The aim of process-orientated simulations and debriefing is to examine the process of care, rather than the outcome of care. These simulations, which take place in actual patient care settings and environments prior to occupancy, are an emerging strategy that can be used to test new environments and new healthcare facilities to ensure that the spaces created match the needs of the staff and administration, while proactively identifying latent safety threats prior to delivering patient care. In turn, these simulations can be also be used as part of the new site orientation and training plan. The aim of this paper is to examine a case study describing the use of the novel innovation of process-orientated simulations to test the opening of a new 300-bed healthcare facility. These factors are ultimately critical in the construction or redesign of any new healthcare building.https://eaitsm.org/userfiles/file/bosch-pfz-500-e-manual.xml While process-oriented simulations can include system integration simulation, process simulations focus on gaining and providing information collected from simulation sessions for individual leadership to act upon when safety issues are identified. The concept of system integration is a much broader engineering term which relates to bringing together the component of subsystems into one system that functions together. Latent safety threats are defined as unintentional harm that could affect actual patients once the facility opens, such as missing equipment, inefficient setup, or insufficient space for procedures. By only theorizing about the care delivery process, unintentional harm could affect actual patients once the facility opens. In the last decade, there has been emerging literature that looks at the use of process-oriented simulation training for the opening of new and renovated units, construction, and opening of new hospitals. In turn, these simulations could also be expanded for use as a part of the new site’s orientation and training plan. The following paper will explore a case study describing the use of process-orientated simulations to test the opening of a new 300-bed healthcare facility. Case study of simulation innovation South Health Campus (SHC) is one of the largest hospitals in Alberta, Canada, with a footprint roughly the same size as a large commercial mall. Construction began in 2007 for phase 1 for a 300-bed facility consisting of inpatient and outpatient services. The phased opening of this newly constructed acute care hospital (258 inpatient beds and 66 outpatient clinics) started in July of 2012. Final occupancy for the last clinical unit was accomplished in September 2014, at an approximate cost of 1.3 billion Canadian dollars (CAD).http://www.drupalitalia.org/node/71109 As part of this unique prospect for the opening of this new hospital, Alberta Health Services (AHS) Provincial Simulation Program, eSIM, developed a comprehensive in situ simulation project that included both clinical and non-clinical areas. In situ simulations took place in patient care settings, public spaces, support services, and administration areas in an effort to achieve the most realistic experience in evaluating the clinical environment prior to patient arrival to evaluate functionality, assess system processes, and identify areas of potential patient safety concern. Human resources In order to facilitate and coordinate simulations for the site, two positions were created: a simulation consultant with clinical background and advanced simulationist training and a simulation technician with a clinical engineering background. These dedicated resources were essential for placing simulation in the forefront for commissioning of this new space. The support of a simulation technician allowed for set up and maintenance of all equipment for simulation. The simulation consultant acted as the liaison for engaging management and leadership in using simulation as a quality assurance and training strategy. Meetings with clinicians and leadership took place 1 year prior to the phased openings. Creation of department and clinical area specific cases was completed with medical vetting for specific cases. All simulations were run by a team of simulation specialists trained in advanced debriefing techniques, alongside clinicians and physicians with expertise in their practice areas. This interactive and immersive 2-day course allowed individuals to become independent users of simulation, from scenario design, briefing, facilitating, and debriefing skills.https://domoticaaplicada.com/images/bosch-solitaire-coffee-maker-manual.pdf As part of the extensive mentorship, faculty were paired with the SHC simulation consultant and acted both as a new simulationist and as the content expert for the areas that they were supporting in the new opening of their departments. Department equipment was used for in situ simulation, and supplies that were opened were able to be re-used and repurposed for education, as all simulations took place without risk of exposure to real patients being present. The simulation training occurred as part of the orientation budget assigned to each unit, although physician participation was voluntary. Other relationships, such as the AHS Human Factors division, were consulted on an as need basis for various other projects at SHC, but did not create any additional cost for the commissioning simulations. Volunteer services provided standardized family members at no cost. Participants From a human resource perspective, new teams were being formed for all areas of this hospital. Participants in the simulation were newly hired health care providers, with varied years of experience. Challenges included large numbers of hires of out of zone, province, and country, as well as a higher proportion of new graduates, entering the workforce for the first time. Note: exact numbers include multiple participation documented for several scenarios by the same staff Procedure In situ simulation sessions were co-developed with clinicians from each area, focusing on specific patient population scenarios evaluating “Day in the Life” type activities and on responding to crises that might occur within their area. Simulations incorporated new knowledge gained during general orientation such as specifics of the building (wayfinding), equipment, and vendor training. Number of sessions run per area varied if the focus was on a system-wide exercise (Code Green Evacuation, Power Failure, and Code Red (Fire) or multiple sessions for unit orientations. See area-specific simulations—Table 1 ).http://www.festivalmarrakech.info/wp-content/plugins/formcraft/file-upload/server/content/files/1626fcbcf0fa2b---bose-manuals-lifestyle-v30.pdf No clinical support 911 response required. At the time, focus for commissioning simulations centered on the system issues versus individual performance within a medical scenario. After each simulation, debriefing and documentation of findings were collected and reviewed by leadership teams in each area to assign operational ownership and responsibility. Environmental latent safety threats identified were completed prior to opening. Human resource recommendations on team composition, roles and responsibilities, and scope of practice were brought back and further explored over the first year of opening, with subsequent simulations being run for evaluation of changes. Examples of large-scale simulation findings With the phased opening approach of various clinical units and departments, the arrival of different support and clinical teams differentiated the responses that were available to the personnel occupying the building. For example, the site did not have an active emergency department until 4 months after the opening of the ambulatory clinics. This required simulations to incorporate a community call out for 911 services as part of their emergency response plan for a patient deterioration in the building. Internally, the organization and occupying personnel had the strength as healthcare professionals to handle some first aide responses but needed to rely on external support of city emergency services. One large-scale simulation event for the diagnostic imaging department revealed that emergency medical services’ (EMS) response to the call failed to find the front entrance of the hospital. Assumptions had been made by EMS to show up at the ambulance bays in the ED, which were not functional at the time. Role clarity was also recognized for the protection services personnel as an important way-finder for EMS once they arrived on site. Further internal obstacles came once the emergency department opened, as there was no obstetrical services on site for 9 months.www.e-mogilev.com/uploads/files/911-sc-service-manual-pdf This prompted simulation training to include a potential precipitous birth. Debriefings identified a need for targeted neonatal resuscitation certification for all nursing staff and simulations surrounding other obstetrical crises such as a post-partum hemorrhage. One large-scale exercise looked at external and internal coordination of hospital and Emergency Services (Fire Department). This event involved a simulation Code Red (Fire) and simultaneous power outage. Any potential caesarean sections need to be carried out on the third level, utilizing a dedicated elevator with badge swipe access for retrieval and operation. During a Code Red event, the facility’s technology homed the elevators to the main level. The work system as designed failed during the simulation. Debriefings identified the need to be able to evacuate and transfer a laboring patient in crisis from the labor unit to the operating theatres. Discussions also poised that a similar case of cord prolapse, with a healthcare provider performing a medical intervention to maintain perfusion to the neonate, may not allow a transfer to be possible. Process changes to the organization’s care plans looked towards solutions. Purchase of evacuation sleds for patients for use on stairs was obtained. Internal tasks included a new surgical case cart for a cesarean section to be kept on the seventh floor in case a transfer was not medically possible. With a phased approach to opening, some sessions were overlapping with other areas, with a small impact on the simulation resources at hand, which may have affected the consistency of numbers of sessions delivered. Areas that were not listed in the table to have found specific “recommendations” might have been due to the fact that findings from simulations were small and lessons learned may have been from a staff orientation and training benefit versus a gap or latent safety threat. These findings are not exhaustive of all deficiencies revealed.www.orarestauratorisaf.it/wp-content/plugins/formcraft/file-upload/server/content/files/1626fcbdd76761---bose-manuals.pdf While these findings are specific to SHC, different institutions may learn from these themes to build their own simulations. Collaborative practice allowed new relationships to develop, not only between clinical areas but also with non-clinical areas, such as protection services, emergency disaster management, and facilities maintenance engineering. Successes included protection services personnel building on SHC’s collaborative care pillar with their team’s responses to the mental health units. They introduced a “Patient First Strategy” to decrease “hands on” patients during escalating events. Debriefings following the simulations highlighted the special skill set and training the protective services responders have for dealing with patients in crisis. Consequently, new values were gained by clinical staff through their realization that these key support services are an integral part of the larger healthcare team. Another unique unintended outcome was the lessons learned from the engagement of families (and potential patients) through simulation. Patient family-centered care members along with volunteer resources had members of the community act in the role as family and participated in debriefings, allowing them to experience how health professionals train. A practice support document guideline was developed emphasizing best practices of families as full partners in care. One volunteer stated: I feel honored to have helped these healthcare professionals out in the opening of this new hospital. It’s amazing to see that they are training together for emergencies. They listened to me as a family member when I had concerns in the debriefings. Citizen Advisory Team Council Member and Volunteer for Simulation Sustaining results Using inter-professional simulation to open the facility has resulted in a culture where simulation training has become a normal expectation for staff, educators, and management.https://gpagroup.in/wp-content/plugins/formcraft/file-upload/server/content/files/1626fcbe96311c---bose-manual-lifestyle-5.pdf These continuing sessions have reflected a more traditional use of medical simulation for intra-professional team training, staff orientations, certifications, and yearly competency assessments. Post site opening simulations from 2015 to 2018, 1336 sessions have been completed and 9352 participants have taken part in simulation activities. Lessons learned Simulation involvement in the early design and construction phase would have been a critical phase for involvement. The ability to change a space once bricks, mortar, and drywall are in place is cost prohibitive. Having to implement workarounds in a new environment is frustrating for clinicians expecting things to be done right the first time. Other institutions which plan on using simulation to test the opening of new healthcare facilities can learn from some of these lessons by initiating conversations with senior administration and infrastructure leads early on during the design and construction phase of a new hospital. Specific metrics, data points, and team evaluations were completed by area, but lacked consistency between areas and ultimately affected the ability to broadly share lessons learned for other projects. This new approach includes identifying sponsors and key stakeholders for reporting up and ownership of latent safety threats, identifying metrics and outcome reporting, so that lessons learned do not remain unheard. We have also developed post-session evaluation forms to assist in capturing findings and gaps in the system. Initial successes for this project started with a shared common goal to deliver the best patient care in a new hospital facility. Administrative leaders’ commitment was essential to ensure a portion of the new practitioners’ orientation time to the site and unit involved simulation exercises. Key stakeholders for each area helped co-design simulations and define what they needed to test and teach. Champions still continue to be drivers of site simulation education today.www.dubaimotorcycletours.com/uploaded_images/files/911-sc-owners-manual-pdf Conclusion Findings from evaluation and clinical team feedback suggested that simulation exercises were a successful method of testing new processes and systems. Simulations identified latent safety threats which would have otherwise been identified during real patient care after the facility opened. Operational readiness of a newly constructed hospital for emergency, acute, and outpatient care was successfully verified with on-site high realism simulation scenarios. Participant debriefing and survey responses identified several key issues for improvement prior to the opening day. Simulation was also recognized as an optimal training method for staff orientation into a new facility. Newly formed interdisciplinary teams came together for the first time during the simulation, allowing for analysis of team dynamics, role clarity, communication, and leadership. Acknowledgements This project could not have been accomplished without the dedicated time and effort of the eSIM South Provincial Simulation team, the South Health Campus site administration, and Clinical Educators. Both authors read and approved the final manuscript. Funding No funding was required for the development of this manuscript. Availability of data and materials Data sharing is not applicable to this article as no datasets were generated or analyzed. Ethics approval and consent to participate No ethics approval or consent was needed for this manuscript. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Footnotes Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Available from: 4. O’Hara S. Planning intensive care unit design using computer simulation modeling: optimizing integration of clinical, operational, and architectural requirements. Principles for Health Care. Posner GD, Clark ML, Grant VJ. Simulation in the clinical setting: towards a standard lexicon. Available from:. 13. Geis GL, Pio B, Pendergrass TL, Moyer MR, Patterson MD. Simulation to assess the safety of new healthcare teams and new facilities. Available from: 15. Patterson MD, Geis GL, Falcone RA, LeMaster T, Wears RL. In-situ simulation: detection of safety threats and teamwork training in a high risk emergency department. Patterson, MD Blike GT, Nadkarni, VM. In-situ simulation: challenges and results. Advances in Patient Safety: New Directions and Alternative Approaches. 2008: Aug(3) Available from: 17. WorkpieceThis function is called the constant surface speed control function (SeeFor each of various types of machining (such as drilling, tapping,When a number isExamplesThis is called the tool function (SeeThis is called the tool function (See II10).For milling machining. SpindleWorkpiece. Spindle rotation. Fig. 1.6 (a) Auxiliary function. The function of specifying the on-off operations of the components ofIn general, the function isFor example, when M03 is specified, the spindle is rotated clockwiseIn the program, specify the commands in the sequence of actual toolBlock. Block. Tool movementBlockFig. 1.7 (a) Program configuration. A group of commands at each step of the sequence is called the block. The program consists of a group of blocks for a series of machining. The number for discriminating each block is called the sequenceThe block and the program have the following configurations.Nxxxxx. SequenceGxx. Xxxx.x Yxxx.x. PreparatoryDimension word. Mxx. AuxiliarySxx. TxxEnd of block. Fig. 1.7 (b) Block configuration. A block starts with a sequence number to identify the block and endsThis manual indicates the end-of-block code by; (LF in the ISO codeThe contents of the dimension word depend on the preparatoryProgram number. BlockFig. 1.7 (c) Program configuration. Normally, a program number is specified after the end-of-block (;)When machining of the same pattern appears at many portions of aThis is called theMain programThe range in which toolsMachine zero point. Motor. LimitStroke area. Besides strokes defined with limit switches, the operator can define anThis function is called stroke check (see III-6.3). LimitMachine zero point. Specify these distances. Tools cannot enter this area. The area isThe number of controlled axes used with this NC system depends onNumber of basicLathe system. MachiningControlled axes expansion (total)Basic simultaneously controlled axesSimultaneously controlled axes. Series 30i-A. Series 300i-A. Series 300is-A. Series 31i-A5. Series 310i-A5. Series 310is-A5. Series 31i-A. Series 310i-A. Series 310is-A. Series 32i-A. Series 320i-A. Series 320is-AMax. 32 axes. Max. 20 axes. Max. 9 axesMax. 24 axes. Max. 12 axes. Max. 5 axesThe move axes of machine tools are assigned names. These names areAxis names are determinedThe naming rules comply withWith complex machines, one character would become insufficient forSo, up to three characters can be used forExample)The increment system consists of the least input increment (for input)The least input incrementFive types of increment systems are available as indicated in Table 2.3IS-C, IS-D, and IS-E are optional functions. Table 2.3 (a) Increment system. Least command. Name of increment. Least input incrementThe least command increment is either metric or inch depending onFor selection between metric and inch for the least input increment, GCombined use of the inch system and the metric system is not allowed. There are functions that cannot be used between axes with differentThe maximum stroke controlled by this CNC is shown in the tableCommands that exceed the maximum stroke are not permitted. While there is an array of learning platforms on the market today, we recommend a collaborative learning system because it’s easier and faster to set up and maintain than a traditional learning management system (LMS). Learning platforms are the software you use to create, distribute, and monitor online courses. LMS tools centralize the learning process: only admins can create and distribute courses. They typically involve a lengthy and expensive course-creation process that requires special tools and extensive experience to master. Most important, LMS systems are not employee-centric. Managers can’t set learning paths, employees can’t browse courses, and team members can’t work together to create learning content. 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Make training more interesting and impactful by incorporating active learning and peer learning techniques. Keep employees interested by using active learning techniques like quizzes, games, and simulations. Use employee voices to amplify the message of interpersonal trainings.