Stanford Medicine News Center: "Dress rehearsals ready care teams for opening day"

When the doors of the new Stanford Hospital opened early on the morning of Aug. 29, the only patients inside were volunteers playing the role of patients in an all-day dress rehearsal. Caring for them were 860 Stanford Health Care staff and School of Medicine faculty. They spent the day practicing common patient care scenarios, all part of learning how to work together, across departments, in their future workspace.

Just as actors rehearse for opening night, Stanford Hospital sent its leads through two dress rehearsals — one in July and the second in August. In all, 1,575 staff took part in a total of 164 scenarios. For each of these scripted training events, patient care and support teams walked through paths of travel, practiced new workflows, became familiar with their new environment and the location of supplies and equipment, learned how to work together and documented problems as they arose. The goal was to resolve outstanding issues before opening day so that safe processes would be maintained for every real patient care scenario. 

“The first dress rehearsal in July was transformative,” said Helen Wilmot, vice president of facilities, services and planning, whose strategy team was responsible for planning and executing the complex dress rehearsal events. “It was the first time we came together as a large group in the new hospital, and the energy was so positive.” 

Dress rehearsals are just one element of a series of synchronized activities that must occur to open a new hospital. Planning and design actually began more than five years ago with teams from every department tasked with creating new workflows for the then-unbuilt space. This planning/design phase required working with tabletop displays and cardboard sets to develop operational, staffing and training plans and to determine technology needs.  

As the hospital gets within six to 12 months of opening, the activation phase kicks in. “The work becomes more tactical as departments begin to execute their plans,” Wilmot said. Dress rehearsals are part of this activation phase.

Planning to move patients is the third step necessary to open the new hospital. Move planning takes four to five months, but moving patients will take just four to six hours, with one patient being moved to the new hospital every three to six minutes, on average.

Stabilization, a three-month period of intense scrutiny and issue identification, is the final phase required to activate the new hospital. This phase begins on patient day one, as providers and staff begin to care for real patients in the new space, with new workflows, new equipment and new technology.

Real-life scenarios

During the eight-hour dress rehearsal in July, 700 employees and faculty ran through 80 scenarios. At any given moment, 28 different scripted events were being played out in every patient care area of the hospital, from the interventional operating suites on floor 2 to the emergency department on the first floor and patient rooms on floors 4-7. In August, 875 employees ran through 84 scenarios, with 29 scenarios running simultaneously.  

These scripted, simulation-based trainings tested staff confidence in the new space. The scenarios covered common patient-care situations, but with added complexities to allow staff to troubleshoot complications. For each scenario, a host coordinator directed the team through each step, and a recorder documented issues identified by team members as they performed their typical job functions. 

In the post-anesthesia care unit on the second floor, for example, a team of nurses, physicians, laboratory personnel, imaging staff, patient experience representatives, lift specialists, respiratory therapists and patient access staff cared for an unstable patient. When the nurse called for a lift team, the first issue of the morning was identified. The wheels of the lift device were too wide to get through the patient room door. 

The “patient,” an elderly woman well prepared for her acting debut, began shivering. Together, the care team followed the detailed steps of the scenario, traveling en masse to a nearby warming drawer for a blanket and to the Omni cell, an automated medication dispensing cabinet, to retrieve a needed medication. When the nurse identified that the patient was bleeding, an order was placed for blood. Unable to control the bleed, the nurse paged the attending physician. As the patient’s condition worsened, she called a code. Throughout the scenario, the staff paused to review each step and make small adjustments to their workflows. 

“We test every step,” said Ann Cullen, MS, RN, clinical transition director for critical ambulatory care. “Anytime you move staff into a new space, they have to get familiar with the new footprint.” 

Downstairs, a team in the emergency department readied themselves for an incoming trauma victim. A 60-year-old woman with a blunt force injury from a high-speed collision was arriving by ambulance in five minutes. Treatment Bay Three was packed with trauma attending physicians, residents, nurses and observers. The team ran through their roles, identified the locations of the nearest supply cabinets, crash carts, medication Omni cells and defibrillators, and practiced operating the new overhead boom light.  

As the patient moaned in pain, the team called for a portable X-ray. When the patient was transported to the CT room, the entire entourage followed the gurney, cramming themselves into the imaging area, and then over to the elevator bays as the patient was sent to surgery. The location of supplies, crash carts and defibrillators was heavily discussed, and finding the fastest path of travel from the emergency department and CT rooms to the operating rooms above was identified as an outstanding issue. 

Fictitious patients lend a real-life quality to the role-playing, Wilmot said. “When you have a patient you’re caring for, people are used to moving a certain way to get what they need. They have muscle memory,” she said. “Dress rehearsals let teams change their muscle memory from the existing hospital to the new hopsital and adapt to their new environment.”

Future training milestones

With just two full days of cross-functional team dress rehearsals, every patient care team and department has been in the new hospital multiple times, conducting department-specific training in their new space. 

Further fine-tuning will take place this month when the Office of Emergency Management will hold a three-hour, hospital-wide mass casualty exercise. Later that same day, a facilities team will be on-site, testing all of the building’s systems — badge readers, nurse call buttons, elevator entrapments, overhead paging, pneumatic tubes. Further resolution of issues identified during dress rehearsals will be ongoing, with some teams running mini-simulations to work out final changes. An operations command center will be set up in the new hospital and will run through a final mock drill to prepare for final occupancy approval.

“We know how to do the clinical work,” said Alison Kerr, vice president of operations at Stanford Health Care. “But in the new space, with new equipment, new technology, new workflows and different disciplines working together, we have to practice so we get that operational discipline down with a high degree of reliability. We don’t ever want to get anything wrong.”

Photos by Thru Luke's Lens
First published on Stanford Medicine News Center by GRACE HAMMERSTROM.