MILITARY MEDICINE, 177, 7:829, 2012 The Central Simulation Committee (CSC): A Model for Centralization and Standardization of Simulation-Based Medical Education in the U.S. Army Healthcare System LTC Shad Deering, MC USA*; MAJ Taylor Sawyer, MC USA ; LTC Jeffrey Mikita, MC USA ; LTC Douglas Maurer, MC USA ; COL Bernard J. Roth, MC USA (Ret.) ; for the Central Simulation Committee ABSTRACT In this report, we describe the organizational framework, operations and current status of the Central Simulation Committee (CSC). The CSC was established in 2007 with the goals of standardizing simulation-based training in Army graduate medical education programs, assisting in redeployment training of physicians returning from war, and improving patient safety within the Army Medical Department. Presently, the CSC oversees 10 Simulation Centers, controls over 21,000 sq ft of simulation center space, and provides specialty-specific training in 14 medical specialties. In the past 2 years, CSC Simulation Centers have trained over 50,000 Army medical students, residents, physician assistants, nurses, Soldiers and DoD civilian medical personnel. We hope this report provides simulation educators within the military, and our civilian simulation colleagues, with insight into the workings of our organization and provides an example of centralized support and oversight of simulation-based medical education. INTRODUCTION The U.S. Army was one of the first organizations to adopt simulation-based training. 1,2 In 1934, after several fatal aviation accidents, the U.S. Army Air Corps purchased six Link flight simulators in an attempt to improve the competency of its pilots. 1 Based on the early success of flight simulation, in 1938, the U.S. Military purchased an additional 10,000 Link trainers. 1 Since that time, the U.S. Army has been extensively involved in simulation-based education and training. Before the 1990s, the military accounted for 80% of all modeling and simulation work. 3 Current day simulation-based training in the Army spans the continuum from unit-based simulations of maneuvers to full spectrum battle field simulations, such as that provided at the National Training Center and the Joint Readiness Training Center. 4,5 The U.S. Army has also been a driving force in the transfer of modeling and simulation technology to the medical field. During the Gulf War, Army surgeons, like COL Richard Satava, MC USA realized that many of the medical personnel under his command, many of whom were reservists recalled to active duty, had minimal experience in treating battlefield casualties. After his experiences during deployment, COL Satava returned home convinced that the same simulationbased approach to training fighter pilots should be adapted to *Uniformed Services University of Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814. Tripler Army Medical Center, 1 Jarrett White Road, Honolulu, HI 96859. Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889. Carl R. Darnall Army Medical Center, 36000 Darnall Loop, Fort Hood, TX 76544. kmadigan Army Medical Center, Fitzsimmons Drive, Tacoma, WA 98431. train military medical personnel. 6 Ultimately, the Defense Advanced Research Projects Agency and the U.S. Army Medical Research and Materiel Command initiated extensive programs to develop medical simulation technologies. Sources of simulation-based medical education in the U.S. Army today include the Army Medical Department (AMEDD) Center and School, which provides oversight of nursing simulation and policies, the Medical Simulation Training Centers (MSTC) that are responsible for all Army medic simulation training, and the Central Simulation Committee (CSC) which provides centralized oversight and support of graduate medical education (GME) simulation-based training and provides simulation-based redeployment training for physicians returning from the wars in Iraq and Afghanistan. The goals of the CSC are to create and implement standardized simulation-based curricula for resident education in the Army, provide a program for the redeployment training of physicians, and to improve patient safety throughout the AMEDD. In this report, we will describe the mission, function, administration, and accomplishments of the CSC. The format of the report follows that of the Society for Simulation in Healthcare (SSH) s Core Accreditation Standards, defined by the Council for Accreditation of Healthcare Simulation Programs. 7 This format was chosen because it includes the fundamental standards that underpin a successful simulation program. MISSION AND GOVERNANCE The mission of the CSC is to, be a worldwide leader in managing and directing multidisciplinary simulation training to enhance GME, assist in redeployment training, and improve patient safety. The vision of the CSC is to ensure that all Army providers are, trained, competent, safe, and ready to MILITARY MEDICINE, Vol. 177, July 2012 829
care for our Soldiers and their families. This mission/vision statement was initially proposed and approved in 2008 and is reviewed and reapproved by the CSC on annual basis. The governance of the CSC consists of central and local oversight and support. Leading the CSC is the CSC Chairman, who is assisted by the CSC Administrative Staff, located at the Anderson Simulation Center in Fort Lewis, Washington. The CSC Administrative Staff includes a Chief Administrator, an Information Technology Support Technician, an Educator, and a Research Scientist. Each medical subspecialty has an assigned Simulation Specialty Advisor who sits on the CSC and reports to the Chairman. Presently, 14 medical specialties are represented on the CSC including: anesthesia, dermatology, emergency medicine, family medicine, general surgery, internal medicine, obstetrics/gynecology, orthopedics, ophthalmology, otolaryngology, pathology, pediatrics, psychology, and urology. In addition to the medical Specialty Advisors, the CSC also includes advisors from the Army Nurse Corp, the Uniformed Services University of Health Sciences, the Army MSTCs, and the Director of Medical Education from each of the 10 Military Treatment Facilities (MTFs) with CSC Simulation Centers. Members of the CSC formed and initially met in April 2007, and have thereafter attended regular, yearly CSC meetings. At the individual MTFs, members of the CSC include the Simulation Center Medical Director and the Simulation Center Administrator. Some MTFs also employ a Surgical Director and a dedicated Simulation Technician, depending on training volume, who are also CSC members. Directors of Medical Education are responsible for choosing the Medical and Surgical Simulation Directors at the MTF level. The CSC Simulation Center Director and Administrator are also members of the hospital GME Committee. An organizational chart of the CSC is provided in Figure 1. ORGANIZATION AND MANAGEMENT The concept of a central committee to oversee and support GME and redeployment simulation-based medical education throughout the AMEDD was first proposed at the Joint Services Graduate Medical Education Selection Board in November 2006. Following that presentation, a model for a Central Simulation Committee was briefed to the Office of the Army Surgeon General (OTSG) in March 2007. The model was developed to overcome several of the challenges identified by individuals at MTFs conducting simulationbased medical education at that time, which included: challenges obtaining funding to purchase simulation equipment, difficulties with program sustainment in the face of frequent duty assignment changes and deployments, lack of validated curriculum for specific subspecialties, and limited administrative support. Funding for the CSC was first approved by the OTSG in April 2007 for an initial equipment purchase of $2.88 million. Since that time, funding for the CSC has been appropriated yearly through the OTSG. The CSC currently has an estimated annual operating budget of $1.5 million. FIGURE 1. Organizational chart of the U.S. Army CSC. Uniformed Services University of Health Sciences (USUHS), Medical Simulation Training Centers (MSTC), Medical Treatment Facility (MTF). 830 MILITARY MEDICINE, Vol. 177, July 2012
At the heart of the CSC organizational framework are the CSC Simulation Administrators. These highly motivated and dedicated civilian DoD personnel provide the backbone of support in the face of frequent military staff turnover and deployments. The Simulation Administrators are responsible for the day-to-day operations of each CSC Simulation Center. They oversee all simulation training conducted in their respective Center and are responsible for directing and coordinating marketing, supply, and budget requirements. Administrative duties include the coordination and development of long and midrange plans for their Center and creation of monthly reports to the CSC on Center use. They are also responsible for acquiring, maintaining, and tracking simulation equipment/supplies, performing basic repairs to the equipment, and submitting purchase justifications for new equipment to the CSC. Administrators perform an education role by training facilitators and students on the proper use of simulation equipment and may act as proctors for simulation training. They also serve a research role by assisting with research studies conducted within their Center. Each CSC Simulation Center has a dedicated Medical Director who provides supervision and support to the Simulation Administrator. The Medical Director is appointed by the Director of Medical Education of the MTF and serves for a term of at least 3 years. All Medical Directors are active duty military physicians who have completed a residency training program. The Medical Director must have at least a 0.25 full-time equivalent dedicated from their department to the Simulation Center in order to fulfill their duties. The Medical Director serves primarily in a simulation educator role, and is responsible for the promotion, oversight and development of simulation-based training initiatives at their MTF. The Medical Director is a member of the MTF s GME Committee and is responsible for providing updates to the GME Committee on their Simulation Center, as well as receiving guidance for potential areas where they may assist. Administrative duties of the Medical Director include oversight of purchasing and budgetary regulation, and reporting of training numbers back to the CSC for tracking purposes. They are also responsible for ensuring that all simulationbased research is conducted in accordance with the CSC Research Policy and local Institutional Review Board policies and procedures. The Medical Director consults with the Chairman of the CSC regarding strategic planning for coordination of simulation training with other institutions and the CSC as a whole. They also play a vital role to promote quality simulation training by expanding and improving simulation-based patient safety initiatives at their respective MTF. Each CSC Simulation Center has developed and retains a Policy and Procedure manual which includes a policy of Quality Improvement Processes, a policy of Confidentiality Procedures, and mechanisms to protect and address physical and psychological safety of individuals involved in simulation. Each CSC Simulation Center has guidelines for adherence to appropriate military, occupational and academic regulations (OSHA, IRB, etc.). Each Center also has an internal quality monitoring and improvement process in place to meet the anticipated and unanticipated needs of learners, instructors, educators, assessors, and staff. The CSC has an active program in place to train simulation educators, operators, and facilitators. Each year at the annual CSC meeting, there is a Faculty Development Day. The goals of the CSC Faculty Development Day are to allow simulation educators to become familiar with the simulation equipment available within the CSC Simulation Centers, and improving the quality of simulation-based training in the AMEDD. Prior educational topics of the CSC Faculty Development Day have included: facilitating and debriefing in simulation (2009), simulation curriculum development (2010), and simulation evaluation tool design and validation (2011). The CSC Faculty Development Day is approved for American Medical Association Physician s Recognition Award Category 1 credit through the U.S. Army Medical Command Continuing Medical Education Office. On a local level, several MTFs with CSC Simulation Centers conduct simulation educator courses on a regular basis to build and sustain internal simulation educators. The CSC is currently working to develop a standardized simulation educator course to be conducted on a regular basis at each MTF with a CSC Simulation Center. The majority of the Specialty Advisors and Medical Directors have received additional training in simulation education and theory by attending a nationally recognized medical simulation instructor course. 8 Additionally, the CSC is currently collaborating with the Uniformed Services University of the Health Sciences and the Naval Postgraduate School to create a postgraduate course in advanced medical simulation to provide further training opportunities. FACILITIES, APPLICATION, AND TECHNOLOGY The CSC currently has Simulation Centers in 10 MTFs including: San Antonio Military Medical Center (SAMMC), Carl R. Darnall Army Medical Center (CRDAMC), Eisenhower Army Medical Center (EAMC), Fort Belvoir Army Community Hospital (FBACH), Madigan Army Medical Center (MAMC), Martin Army Community Hospital (MAR- TIN), Tripler Army Medical Center (TAMC), Womack Army Medical Center (WAMC), William Beaumont Army Medical Center (WBAMC) and the Walter Reed National Military Medical Center (WRNMMC) (Fig. 2). The size of the Simulation Centers varies from 400 to 8,000 sq ft. In total, the CSC controls over 21,000 sq ft of simulation center space within the continental United States and Hawaii. Training volumes vary across the 10 centers, but in the past 2 years CSC Simulation Centers have trained over 50,000 Army medical students, residents, physician assistants, nurses, enlisted Soldiers, and DoD civilian medical personnel. A list of the size of each of these CSC Simulation Centers and the number of personnel trained in 2009 and 2010 is provided in Table I. The majority of the Simulation Centers are located MILITARY MEDICINE, Vol. 177, July 2012 831
FIGURE 2. The locations of the 10 current CSC medical Simulation Centers within the continental United States and Hawaii. TABLE I. CSC Simulation Centers Space and Training Volumes Current Space (sq ft) Number Trained, 2009 Number Trained, 2010 FBACH 500 1,092 1,013 MARTIN 520 713 1,496 WAMC 585 560 642 CRDAMC 780 1,523 4,731 TAMC 1,100 1,076 2,012 EAMC 1,200 3,162 5,366 SAMMC 1,750 6,262 5,967 WBAMC 2,000 1,186 2,461 WRNMMC 5,000 2,442 2,607 MAMC 8,000 6,308 5,222 Total 21,385 24,324 31,517 Tripler Army Medical Center (TAMC). within a MTF. However, some are in external facilities. The importance of having an internal Simulation Center, within the hospital, was highlighted during the planning phases for the new WRNMMC. In 2010, the Defense Health Board stated that, while coming late to medicine, simulation capability is now recognized as essential for training, competency testing of trainees, and refresher training for senior clinicians. Access to these labs in an off-site location is not adequate. This proclamation may have important implications for the design of new Army MTFs and the augmentation and redesign of existing MTFs that do not include a simulation center. Each CSC Simulation Center caters to the unique educational needs of its MTF, based on the training programs located there, and the other local Army training requirements. The majority of training courses offered within CSC Simulation Centers are for GME, involving medical residents from various specialties. A list of the GME programs supported at each MTF is provided in Table II. The residency Program Directors are responsible for the training and education of their residents. In regards to simulation-based training, the Program Directors provides the training directly or designates a well-qualified content expert in the respective field to conduct the training. Other courses conducted within the CSC Simulation Centers for physician assistant, nurses, nurse anesthetist, and Army medics are conducted by qualified content experts and clinical educators in their respective fields. All educators who conduct regular training sessions in a CSC Simulation Center are required to submit their curriculum vitae to the Center. The qualifications of all regular course providers are reviewed by the Medical Director to ensure that instructors possess the appropriate training and experience to conduct simulation training. The Simulation Center s staff are available to provide guidance and assistance to all instructors who utilize the Simulation Center. All 832 MILITARY MEDICINE, Vol. 177, July 2012
TABLE II. CSC Medical Treatment Facilities and Residency Training Programs Served Anesth Derm EM FM Gen Surg IM OB/Gyn Ortho Ophth Otol Path Peds Psych Uro FBACH X MARTIN X WAMC X X CRDAMC X X TAMC X X X X X X X EAMC X X X X X SAMMC X X X X X X X X X X X X WBAMC X X X WRNMMC X X X X X X X X X X X X X MAMC X X X X X X X X X X Anesthesia (Anesth), Dermatology (Derm), Emergency Medicine (EM), Family Medicine (FM), General Surgery (Gen Surg), Internal Medicine (IM), Obstetrics/Gynecology (OB/Gyn), Orthopedics (Ortho), Ophthalmology (Ophth), Otolaryngology (Otol), Pathology (Path), Pediatrics (Peds), Psychology (Psych), Urology (Uro). facilitators are highly encouraged to participate in the CSC Faculty Development Day or a faculty development courses at their MTF to gain additional knowledge on simulationbased medical education. Funding from the CSC is provided for several simulation facilitators to attend the yearly CSC Faculty Development Day. One of the goals of the CSC is to standardize simulationbased medical education in Army GME programs. To accomplish this, each CSC Specialty Advisor has worked to create a core group of simulation scenarios that comprise a standardized, simulation-based, educational curriculum for their respective specialty. The scenarios were chosen because of their importance for the specialty, either by way of their commonality in the field, or because of their low-frequency high-risk status. The Specialty Advisors worked with a panel of providers from their specialty to develop the initial scenarios. Efforts were made to facilitate coordination between specialties where overlap was identified, to avoid duplication, and to leverage simulation scenarios that had already been developed by one specialty for use by another specialty. Each simulation scenario follows a standardized CSC format which was developed and agreed upon by the members of the CSC in 2007. The standardized scenario template includes learning objectives, a description of the scenario, and instructions on conducting the simulation. Each scenario includes a case flow/algorithm with branch point and completion criteria. At the end of each scenario there is an evaluation form, a list of key teaching points with critical actions to discuss in debriefing, along with references to support literature and suggested readings. All CSC simulation scenarios and specialty curricula have been internally peer reviewed by the CSC Specialty Advisor, educators within the specialty, and the CSC Educator. Some scenarios have also been externally peer reviewed through services such as MedEdPORTAL. 9 In total, the CSC currently has more than 60 simulation scenarios, many of which are used by multiple specialties. All CSC simulation scenarios and specialty curriculum are available on the internet through a secure Army Knowledge Online SharePoint. Electronic grading forms have been developed for several specialties to facilitate central data acquisition and analysis. In addition to the standardized simulation scenarios, some specialties have also developed procedural skills training modules. 10 To support the simulation curricula of the various subspecialties, each CSC Simulation Center has been provided with a number of standardized and specialty specific simulation packages. Each simulation package is comprised of a group of simulation equipment (task trainer, manikins, virtual reality trainers, etc.) to be used for a particular specialty. The simulators included in the initial simulation packages were chosen at the CSC annual meeting in 2007. At that meeting, Specialty Advisors evaluated available simulators and chose items that would support their core curriculum, provide reasonable fidelity for the assigned task, and were able to be used by multiple specialties. Once the equipment was chosen, simulation packages by specialty were created and purchased for each of the CSC Simulation Centers. This central purchasing and distribution avoided duplicate purchases and provided cost savings. Current minor equipment purchasing and distribution takes place on an ongoing basis, directed by simulation educator requests within the CSC and at the individual MTFs. The 5-year life-cycle replacement for the initial simulation packages purchased in 2007 is planned for FY 2012. At that time, new simulation packages will be purchased for each of the specialties. Simulation-based postdeployment training for military medical providers returning from the wars in Iraq and Afghanistan is provided at MTFs with CSC Simulation Centers. The same curricula and equipment used in GME are used for the redeployment training of staff physicians. An OTSG policy (09-078), published in September 2009, formalizes the process for postdeployment training. Upon return, providers are to meet with their department chair and discuss what, if any, refresher training is needed. Each provider is also contacted by the CSC and given information about the policy and sent an online survey asking about their deployment experiences both when they return and MILITARY MEDICINE, Vol. 177, July 2012 833
approximately 6 months later. Within the OTSG policy is information on what simulation-based training is available at CSC Simulation Centers and points of contact within the CSC to coordinate simulation-based postdeployment training. EVALUATION AND IMPROVEMENT Each Simulation Center is dedicated to continuous quality improvement. The quality improvement process for the CSC is designed to provide a formal ongoing process by which the CSC utilizes objective measures to monitor and evaluate the quality of services provided to its users. The Find, Organize, Clarify, Understand, Select-Plan, Do, Check and Act cycle is the framework within which the performance improvement process occurs. 11 The primary means of data acquisition for the quality improvement process for the CSC is through course evaluation forms and user feedback. Course evaluation forms are available within all CSC Simulation Centers, and all simulation educators are highly encouraged to obtain evaluations of their courses from the students. The CSC simulation administrator is responsible for collating and providing the results of the course evaluations to the course facilitator, the medical director and to the CSC. Since its inception, the CSC has been involved in numerous performance improvement activities and patient safety initiatives throughout the AMEDD. One example is the Mobile Obstetric Emergencies Simulator (MOES). 12 This manikin-based simulation system includes a birthing manikin and integrated software program used to display a fetal heart rate tracing. The system can be used to conduct simulation training in multiple common obstetric emergencies including shoulder dystocia, postpartum hemorrhage, and eclamptic seizure. The MOES includes a standardized curriculum, debriefing system, objective grading forms, and integrates crew resource management concepts in order to identify and address actual individual, team, and system issues that arise during training. 13 The MOES was recognized with the 2007 Patient Safety Award from TRICARE Management Activity and the CSC was given funding to propagate the program (including equipment and training) to all 54 MTFs within the Army, Navy, and Air Force that provide obstetric care. Vital to the mission of the CSC is to validate the quality of the education provided within its Simulation Centers. To date, 10% of the CSC Medical Simulation Centers have received Accreditation by the American College of Surgeons, and 20% have received Accreditation by the SSH Council for Accreditation of Healthcare Simulation Programs. Another 20% have submitted accreditation packets to the SSH and are awaiting site visits. Strategic plans for the CSC include 100% accreditation of all CSC simulation centers by the SSH by 2015. INTEGRITY As an entity within the U.S. Army, the CSC demonstrates a commitment to the highest ethical standards. All activities, communications, and relationships of CSC personnel are subject to the Department of the Army Standards of Conduct as defined by Army Regulation 600-50. In accordance with Army Regulation 600-50, all CSC personnel place loyalty to country, ethical principles, and law above private gain and other interests. The staff at each CSC Simulation Center strives to provide the best possible service to the learners and instructors utilizing their Center, and all CSC personnel appreciate the opportunity to improve the services they provide. If learners or facilitators have specific suggestions on how to improve their training exercises, they are encouraged to utilize the course evaluation forms or address it directly with their instructor. If the learner does not feel comfortable doing this, then they are encouraged to contact the Simulation Administrator, Director of Medical Simulation or the Director of Surgical Simulation (as applicable) directly. Any complaints received by the CSC are handled in a timely manner. Complaint resolutions for CSC military personnel are handled in accordance with standard military procedures. Complaint resolution for CSC civilian employees and personnel are handled in accordance with established policies for DoD civilian employees. 14 EXPANDING THE FIELD The CSC demonstrates a commitment to advance simulation education both within and outside the military. All CSC Simulation Administrators, Specialty Advisors, and Medical Directors maintain membership in the SSH. Several members are actively involved in SSH Special Interest Groups and Committees. Members of the CSC have provided numerous presentations at local, regional, national, and international conferences on the topic of simulation. To date, there have been more than 125 abstracts and platform presentations provided by members of the CSC. Several CSC Specialty Advisors and Medical Directors have received research awards at the International Meeting for Simulation in Healthcare for their work. CSC members have also received invitations to lecture and conducted workshops on simulation-based education at several national medical meetings such as the Uniformed Services Academy of Family Physician, the Army/Air Force Chapter of the American College of Physicians, and the American Academy of Pediatrics Uniformed Services Pediatric Seminar. The CSC is dedicated to improving the science of simulation, and the CSC is actively involved in simulation-based medical research. Since 2002, members of the CSC have published 40 articles in peer-reviewed journals on the subject of simulation. The majority of these are original research articles detailing the results of rigorously conducted evaluations of simulation training methodologies or the validation of simulation trainers/technologies. Additionally, members of the CSC have authored, or coauthored, several book chapters. To date, members of the CSC have received over $8.13 million in grants and external funding for simulation-based training and research. The CSC currently has several ongoing large-scale, multicenter, research projects. Nearing completion 834 MILITARY MEDICINE, Vol. 177, July 2012
is a multisite validation study of new laparoscopic nephrectomy simulator. The four MTFs that conduct GME in Pediatrics are conducting a multisite study investigating the retention of pediatrics resuscitation skills by residents. The MOES package is currently implemented at each of the 54 MTFs in the DoD that perform deliveries and training data on the device is being analyzed. Still in the protocol development stages is a large, multicenter, investigation of laparoscopic skill retention during military deployment. To encourage simulation-based research within the AMEDD, the CSC conducts a Simulation Research Forum at the annual CSC meeting. Presentations are accepted from any AMEDD personnel conducting simulation-based research. At the conclusion of the forum, the CSC grants a CSC Research Award, which includes a stipend for the winner to travel to a national meeting to present their research. The CSC also encourages MTFs to support local simulation research awards with initiatives such as the Research Day at Madigan Army Medical Center and the James W. Bass Resident Research Competition at Tripler Army Medical Center. CONCLUSION In this report, we have described the organizational framework, operations, and accomplishments of the CSC. We hope this report provides simulation educators within the military, and our civilian simulation colleagues, with insight into the workings of our organization. The CSC was established with the clear goals to implement standardized simulation-based curricula for resident education in the Army, provide a program for simulation-based redeployment training of physicians, and to improve patient safety throughout the AMEDD. Though the CSC has made great progress towards many of its goals, work remains to be done to continue to improve the quality of simulation-based training provided within the AMEDD and better define the impact this training has on patient safety. Through continuing internal efforts and increasing collaboration with academia, the CSC will work to optimize the training our centers provide and improve patient safety within and beyond the AMEDD. ACKOWLEDGMENTS The authors thank the CSC administrative staff and all the CSC simulation center administrators and technicians. It is only through your dedication and outstanding service that the CSC functions. We also thank the AMEDD directors of medical education and residency program directors for their support of medical simulation training. REFERENCES 1. Rosen KR: The history of medical simulation. J Crit Care 2008; 23: 157 66. 2. Satava RM: Historical review of surgical simulation a personal perspective. World J Surg 2008; 32: 141 8. 3. Drake J: Commercial simulation market drives industry s future growth. National defense: the business and technology magazine, 1998. Available at http://www.nationaldefensemagazine.org/index.cfm; accessed October 20, 2011. 4. National Training Center web site. Available at http://www.irwin.army.mil/pages/default.aspx; accessed October 24, 2011. 5. Joint Readiness Training Center web site. Available at http://www.jrtcpolk.army.mil/; accessed October 28, 2011. 6. Loftin B: Med School 1.0: can computer simulation aid physician training. Quest 5 2002; 5: 16 9. 7. Society for Simulation in Healthcare. Council for Accreditation of Healthcare Simulation Programs. Accreditation Standards and Measurement Criteria Program Self Study Tool. Available at ssih.org/uploads/committees/ 2011%20Self%20Study%20Tool.pdf; aaccessed February 2, 2012. 8. The Center for Medical Simulation. Comprehensive Instructor Workshop in Medical Simulation. Available at http://www.harvardmedsim. org/ims-comprehensive-workshop.php; accessed October 28, 2011. 9. Hemann B, Hall N, Mikita J: Surviving Simulated Sepsis. MedEdPORTAL, 2010. Available at http://services.aamc.org/30/mededportal/servlet/s/segment/ mededportal/?subid=8196; accessed February 2, 2012. 10. Sawyer T, Creamer K, Puntel R, et al: Pediatric Procedural Skills Training Curriculum. MedEdPORTAL, 2010. Available at http://services.aamc.org/30/mededportal/servlet/s/segment/mededportal/?subid=8094; accessed February 2, 2012. 11. McLaughlin CP, Kaluzny AD: Continuous Quality Improvement in Healthcare, Ed 3. Sunbury, MA, Jones & Bartlett Publishers, 2005. 12. Deering SH, Rosen MA, Salas E, King HB: Building team and technical competency for obstetric emergencies: the mobile obstetric emergencies simulator (MOES) system. Simul Healthc 2009; 4: 166 73. 13. Marshall D: Crew Resource Management: From Patient Safety to High Reliability, Ed 1, Littleton, CO, Safer Healthcare, 2010. 14. DoD Instruction 1400.25: DoD Civilian Personnel Management, SC1940, December 1, 2008. Available at: http://www.dtic.mil/whs/ directives/corres/html/cpm_table2.html; accessed February 2, 2012. MILITARY MEDICINE, Vol. 177, July 2012 835