The challenge
Traditional capacity assessments don’t always predict real-world performance during outbreaks, leaving primary health care facilities uncertain as to how they would perform in a crisis.
The solution
Resolve to Save Lives coordinated 38 patient simulation exercises across four countries to mimic real outbreak scenarios and test whether health care workers took appropriate actions to stop the outbreak and keep themselves safe.
The impact
The simulation exercises provided valuable insights into the real-world performance of health care facilities, including those taking the correct actions and identifying gaps in others to be addressed through training and mentoring.
On a quiet Tuesday morning in Freetown, Sierra Leone, a woman arrived at Hill Station Community Health Center with a persistent cough. She had recently returned from visiting family, where her uncle had passed away from an unknown illness. Alongside her cough, she reported fever, fatigue and bloody diarrhea. As she reached into her handbag, she revealed a tissue speckled with what appeared to be blood—an unsettling moment for the health care workers assisting her on arrival.
But none of it was real. This woman wasn’t a patient—she was a trained health worker, acting out a carefully scripted role as part of a new approach for testing whether a health facility is truly ready to prevent the next epidemic. This “simulated patient” exercise is becoming a central component of Epidemic-Ready Primary Health Care (ERPHC), an initiative pioneered by Resolve to Save Lives that seeks to ensure that primary care facilities can prevent, detect and respond to outbreaks while maintaining essential health services.
What is Epidemic-Ready Primary Health Care?
An Epidemic-Ready Primary Health Care (ERPHC) system is one that can prevent, detect, and respond to outbreaks while maintaining essential health services. An ERPHC system can find cases quickly, manage them safely and cope with the increased demands they bring. Through our ERPHC initiative, we’re partnering with primary health care facilities to ensure they are “epidemic-ready”—by strengthening relationships between facilities and the communities they serve and by training and mentoring health care workers to prevent, detect, and manage outbreaks while protecting themselves and others.
“Over the last two years, we’ve been working with hundreds of health facilities across four countries to ensure every primary health facility is epidemic ready,” says Dr. Stacey Mearns, who leads the initiative. “Until now, we’ve primarily measured progress using scorecards to measure capacities. But to truly know whether a facility can handle an infectious disease threat, we need to go beyond scores. We need to simulate the real thing.”
Simulating the real thing
Mearns says that patient simulations are a logical next step from the capacity assessments her team has been using so far. Much like a mystery shopper sent to evaluate service in a retail store, the simulated patients arrive without warning—but during a scheduled visit by an ERPHC mentor, who observes and records the staff’s response. Do they wear appropriate personal protective equipment? Isolate the patient? Correctly identify symptoms? Notify surveillance teams? In short: are they epidemic ready?
At Hill Station Community Health Center, one of 80 ERPHC-supported facilities across Sierra Leone, the answer was yes. The center, which had achieved an impressive 100% on an ERPHC capacity assessment before the simulation, was selected to participate for precisely that reason—to understand how, if at all, an impressive ERPHC score translates into action.
With ICAP at Columbia University serving as the implementing partner, the team undertook months of meticulous planning to make the exercises a reality. For starters, the simulations raised important ethical considerations. Having fake patients simulate intense, Ebola-like symptoms in places where real Ebola outbreaks regularly occur, is no small thing. The team consulted ethical review boards and notified national emergency operations centers to prevent any false alarms. Above all, they worked closely with each facility to tailor their approach and ensure leadership and staff knew the exercise was coming—just not when.
Actors and the ERPHC mentors serving as assessors took part in a three-day workshop before the simulation to make sure they were prepared. In the training, participants learned how to act out the scenarios, how to progress them, when to stop them and how to facilitate a structured debrief with the facilities. Through hands-on role plays, the team rehearsed various scenarios: a collapsed health care worker, a patient in distress, a suspected case of hemorrhagic fever. The goal was to train participants to create a simulation that was as close to real life as possible.
When the simulated patient arrived at Hill Station, staff sprung into action. The patient and their caregiver were asked to wash their hands, and asked about their travel history, prompting health care workers to correctly suspect a viral hemorrhagic fever. At this point, the patient was isolated and staff donned personal protective equipment and contacted their district-level counterparts to notify the case and request an ambulance. This all happened within 20 minutes of the patient’s arrival, before the simulation was brought to a successful end.
Identifying and overcoming bottlenecks
Ultimately, these exercises seek to identify gaps between readiness capacities and real-world performance. A health care worker can be ready, but they can only respond when the system is tested. Using a simulated patient to test the system allows the team to identify and resolve important bottlenecks. Feedback sessions after each exercise have shown that health care workers find the approach useful. One participant in Sierra Leone remarked: “It felt very real, which helped us understand how we would react in a real outbreak situation.”
“Having now completed 38 exercises, we can see some patterns emerge. One recurring finding was health care workers rushing to care for the patient before protecting themselves,” says Mearns. “This is an instinct rooted in compassion, but in the context of an outbreak, it can be deadly. We saw again and again how selfless frontline workers are. They want to help, but we also have to help them—by making sure the tools and protocols are there to keep them safe.”
Even when health care workers know what to do, systemic barriers can get in the way of them taking the right actions. In many facilities, isolation areas were unavailable or lacked essential supplies. In others, meanwhile, personal protective equipment was in such short supply that health care workers couldn’t protect themselves while dealing with the simulated patients. These gaps underscore the critical importance of linking capacity assessments to real-world conditions and adapting our approach based on what we find.
That means integrating these findings into the ERPHC methodology. These learnings will inform future training and mentoring by addressing areas for improvement, ensuring we build capacity in the places that need it most. “When the next epidemic comes, it won’t check for an ERPHC score—it will test how facilities act. And thanks to exercises like this, more health facilities will be ready to respond.”