Sustainability in surgical practice: a collaborative call toward environmental sustainability in operating rooms.

BACKGROUND: The healthcare system plays a pivotal role in environmental sustainability, and the operating room (OR) significantly contributes to its overall carbon footprint. In response to this critical challenge, leading medical societies, government bodies, regulatory agencies, and industry stakeholders are taking measures to address healthcare sustainability and its impact on climate change. Healthcare now represents almost 20% of the US national economy and 8.5% of US carbon emissions. Internationally, healthcare represents 5% of global carbon emissions. US Healthcare is an outlier in both per capita cost, and per capita greenhouse gas emission, with almost twice per capita emissions compared to every other country in the world. METHODS: The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the European Association for Endoscopic Surgery (EAES) established the Sustainability in Surgical Practice joint task force in 2023. This collaborative effort aims to actively promote education, mitigation, and innovation, steering surgical practices toward a more sustainable future. RESULTS: Several key initiatives have included a survey of members' knowledge and awareness, a scoping review of terminology, metrics, and initiatives, and deep engagement of key stakeholders. DISCUSSION: This position paper serves as a Call to Action, proposing a series of actions to catalyze and accelerate the surgical sustainability leadership needed to respond effectively to climate change, and to lead the societal transformation towards health that our times demand.

Quality improvement in public-private partnerships in low- and middle-income countries: a systematic review.

BACKGROUND: Public-private partnerships (PPP) are often how health improvement programs are implemented in low-and-middle-income countries (LMICs). We therefore aimed to systematically review the literature about the aim and impacts of quality improvement (QI) approaches in PPP in LMICs. METHODS: We searched SCOPUS and grey literature for studies published before March 2022. One reviewer screened abstracts and full-text studies for inclusion. The study characteristics, setting, design, outcomes, and lessons learned were abstracted using a standard tool and reviewed in detail by a second author. RESULTS: We identified 9,457 citations, of which 144 met the inclusion criteria and underwent full-text abstraction. We identified five key themes for successful QI projects in LMICs: 1) leadership support and alignment with overarching priorities, 2) local ownership and engagement of frontline teams, 3) shared authentic learning across teams, 4) resilience in managing external challenges, and 5) robust data and data visualization to track progress. We found great heterogeneity in QI tools, study designs, participants, and outcome measures. Most studies had diffuse aims and poor descriptions of the intervention components and their follow-up. Few papers formally reported on actual deployment of private-sector capital, and either provided insufficient information or did not follow the formal PPP model, which involves capital investment for a explicit return on investment. Few studies discussed the response to their findings and the organizational willingness to change. CONCLUSIONS: Many of the same factors that impact the success of QI in healthcare in high-income countries are relevant for PPP in LMICs. Vague descriptions of the structure and financial arrangements of the PPPs, and the roles of public and private entities made it difficult to draw meaningful conclusions about the impacts of the organizational governance on the outcomes of QI programs in LMICs. While we found many articles in the published literature on PPP-funded QI partnerships in LMICs, there is a dire need for research that more clearly describes the intervention details, implementation challenges, contextual factors, leadership and organizational structures. These details are needed to better align incentives to support the kinds of collaboration needed for guiding accountability in advancing global health. More ownership and power needs to be shifted to local leaders and researchers to improve research equity and sustainability.

Validation of Bayesian design for broadband microslit panel absorbers using causal inference.

This paper discusses experimental validations of multilayer microslit panels (MSPs) designed via Bayesian inference to obtain both high sound absorption and wide bandwidth simultaneously. Microslit perforation in thin panels is similar to microperforated panels [Xiang, Fackler, Hou, and Schmitt (2022). J. Acoust. Soc. Am. 151(5), 3094-3103]. MSP absorbers in single-layer configurations are functioning in a limited frequency range. By stacking the MSPs in multiple layered structures, absorbing performance may be widened in frequency ranges while retaining high absorption coefficients. Besides design challenges of multiple MSPs in layered structures to fulfill a practical requirement and minimize fabrication complexity, this paper further discusses challenges in experimental validations when experimental results undesirably deviate from the initial Bayesian design. Causation analysis is applied to the validation efforts where a causal model-based inference effectively provides causal reasoning of fabrication inaccuracies. Along with the causal inference, a causal reasoning conducted in this work can guide corrections due to fabrication inaccuracies during the iterative validation process.

"As if we are branded with the mark of Cain": stigma, guilt, and shame experienced by COVID-19 survivors in Israel - a qualitative study.

Stigma is associated with harmful health outcomes, and it fuels social and health inequalities. It can undermine social cohesion and encourage social exclusion of groups, which may contribute to secrecy about disease symptoms, avoidance of disease testing and vaccination, and further spread of a contagious illness. Stigmatization is a social process set to exclude those who are perceived to be a potential source of disease and may pose a threat to effective interpersonal and social relationships. In this qualitative study, we delved into the stigmatization experiences of twenty COVID-19 recovered patients during the COVID-19 first wave, using in-depth semi-structured interviews conducted during November 2020. Using thematic analysis, we found that the process of stigmatization was all-encompassing, from the stage of diagnosis throughout the duration of the disease and the recovery phases. On the basis of the data, we hypothesized that stigma is a significant public health concern, and effective and comprehensive interventions are needed to counteract the damaging and insidious effects during infectious disease pandemics such as COVID-19, and reduce infectious disease-related stigma. Interventions should address provision of emotional support frameworks for the victims of stigmatization and discrimination that accompany the COVID-19 pandemic and future pandemics. This study was conducted in the early days of the COVID-19 pandemic, when uncertainty about the disease was high and fear of contamination fueled high levels of stigmatization against those who became ill with Covid-19.

Implementing multidisciplinary tumor boards in oncology: a narrative review.

The healthcare industry compares unfavorably with other ultra-safe industries such as aviation and nuclear power plants, which address complexity by reducing the vulnerability of a single person and promoting teams and strong systems. A multidisciplinary tumor board (MTB) is an evidence-based organizational approach to implementing a more effective concept in oncology practice. Studies addressing the correlation between MTBs and cancer outcomes show promising results, and other potential benefits are also addressed. The objectives of this article are to define and characterize MTBs in modern oncology practice, review the current literature on MTBs effectiveness and address challenges to the implementation and maintenance of MTBs. In this commentary-type narrative review, the authors present their opinions and, whenever possible, substantiate recommendations by citing supportive literature.

Lay abstract Compared with other ultra-safe industries such as aviation and nuclear power plants, the healthcare industry operates with lower safety standards. Multidisciplinary tumor boards (MTBs) are regular meetings of various specialist doctors and other health professionals involved in cancer care to discuss cases of patients with cancer. MTBs are considered valuable tools to promote the quality of care in oncology by reducing the vulnerability of a single person and promoting teams and strong systems. Studies have shown that MTBs correlate with better treatment results, and other potential benefits are also addressed. The objectives of this paper are to define and characterize MTBs in modern oncology practice, review the current literature on MTBs and address challenges to the implementation and maintenance of MTBs. The authors substantiate their views with literature citations where possible.

Reuse of Personal Protective Equipment: Results of a Human Factors Study Using Fluorescence to Identify Self-Contamination During Donning and Doffing.

BACKGROUND: At least 115,000 health and care workers (HCWs) are estimated to have lost their lives to COVID-19, according to the the chief of the World Health Organization (WHO). Personal protective equipment (PPE) is the first line of defense for HCWs against infectious diseases. At the height of the pandemic, PPE supplies became scarce, necessitating reuse, which increased the occupational COVID-19 risks to HCWs. Currently, there are few robust studies addressing PPE reuse and practice variability, leaving HCWs vulnerable to accidental contamination and harm. OBJECTIVE: The objective of this study was to assess potential HCW contamination during PPE donning, doffing, and reuse. METHODS: The study included 28 active acute care physicians, nurses, and nurse practitioners that evaluated 5 simulated patients with COVID-like symptoms while donning and doffing PPE between each patient encounter. An N95 mask was contaminated with a transparent fluorescent gel applied to the outside of the N95 mask to simulate contamination that might occur during reuse. Participants were evaluated after PPE doffing for each encounter using a black light to assess for face and body contamination. RESULTS: All participants had multiple sites of contamination, predominantly on their head and neck. None of the participants were able to don and doff PPE without contaminating themselves during five consecutive simulation cycles. CONCLUSIONS: The current Centers for Disease Control and Prevention PPE guidelines for donning and doffing fall short in protecting HCWs. They do not adequately protect HCWs from contamination. There is an urgent need for PPE and workflow redesign.

Express check-in: developing a personal health record for patients admitted to hospital with medical emergencies: a mixed-method feasibility study.

BACKGROUND: Patient participation is increasingly recognized as a key component in the redesign of healthcare processes and is advocated as a means to improve patient safety. OBJECTIVE: To explore the usage of participatory engagement in patient-created and co-designed medical records for emergency admission to the hospital. METHODS: design: prospective iterative development and feasibility testing of personal health records; setting: an acute medical unit in a university-affiliated hospital; participants: patients admitted to hospital for medical emergencies; interventions: we used a design-led development of personal health record prototypes and feasibility testing of records completed by patients during the process of emergency admission. 'Express-check-in' records contained items of social history, screening questions for sepsis and acute kidney injury in addition to the patients' ideas, concerns and expectations; main outcome measures: the outcome metrics focused on feasibility and a selection of quality domains, namely effectiveness of recording relevant history, time efficiency of the documentation process, patient-centredness of resulting records and staff and patient feedback. The incidence of sepsis and acute kidney injury were used as surrogate measures for assessing the safety impact. RESULTS: The medical record prototypes were developed in an iterative fashion and tested with 100 patients, in which 39 patients were 70 or older and 25 patients were classified as clinically frail. Ninety-six per cent of the data items were completed by patients with no or minimal help from healthcare professionals. The completeness of these patient records was superior to that of the corresponding medical records in that they contained deeply held beliefs and fears, whereas concerns and expectations recorded by patients were only mirrored in a small proportion of the formal clinical records. The sepsis self-screening tool identified 68% of patients requiring treatment with antibiotics. The intervention was feasible, independent of the level of formal education and effective in frail and elderly patients with support from family and staff. The prototyped records were well received and felt to be practical by patients and staff. The staff indicated that reading the patients' documentation led to significant changes in their clinical management. CONCLUSIONS: Medical record accessibility to patients during hospital care contributes to the co-management of personal healthcare and might add critical information over and above the records compiled by healthcare professionals.

A National US Survey of Pediatric Emergency Department Coronavirus Pandemic Preparedness.

OBJECTIVE: We aim to describe the current coronavirus disease 2019 (COVID-19) preparedness efforts among a diverse set of pediatric emergency departments (PEDs) within the United States. METHODS: We conducted a prospective multicenter survey of PED medical director(s) from selected children's hospitals recruited through a long established national research network. The questionnaire was developed by physicians with expertise in pediatric emergency medicine, disaster readiness, human factors, and survey development. Thirty-five children's hospitals were identified for recruitment through an established national research network. RESULTS: We report on survey responses from 25 (71%) of 35 PEDs, of which 64% were located within academic children's hospitals. All PEDs witnessed decreases in non-COVID-19 patients, 60% had COVID-19-dedicated units, and 32% changed their unit pediatric patient age to include adult patients. All PEDs implemented changes to their staffing model, with the most common change impacting their physician staffing (80%) and triaging model (76%). All PEDs conducted training for appropriate donning and doffing of personal protective equipment (PPE), and 62% reported shortages in PPE. The majority implemented changes in the airway management protocols (84%) and cardiac arrest management in COVID patients (76%). The most common training modalities were video/teleconference (84%) and simulation-based training (72%). The most common learning objectives were team dynamics (60%), and PPE and individual procedural skills (56%). CONCLUSIONS: This national survey provides insight into PED preparedness efforts, training innovations, and practice changes implemented during the start of COVID-19 pandemic. Pediatric emergency departments implemented broad strategies including modifications to staffing, workflow, and clinical practice while using video/teleconference and simulation as preferred training modalities. Further research is needed to advance the level of preparedness and support deep learning about which preparedness actions were effective for future pandemics.

Non-pharmaceutical Interventions and the Infodemic on Twitter: Lessons Learned from Italy during the Covid-19 Pandemic.

The COVID-19 pandemic changed expectations for information dissemination and use around the globe, challenging accepted models of communications, leadership, and social systems. We explore how social media discourse about COVID-19 in Italy was affected by the rapid spread of the virus, and how themes in postings changed with the adoption of social distancing measures and non-pharmaceutical interventions (NPI). We used topic modeling and social network analysis to highlight critical dimensions of conversations around COVID-19: 1) topics in social media postings about the Coronavirus; 2) the scope and reach of social networks; and 3) changes in social media content as the nation moved from partial to full social distancing. Twitter messages sent in Italy between February 11th and March 10th, 2020. 74,306 Tweets sent by institutions, news sources, elected officials, scientists and social media influencers. Messages were retweeted more than 1.2 million times globally. Non-parametric chi-square statistic with residual analysis to identify categories, chi-square test for linear trend, and Social Network Graphing. The first phase of the pandemic was dominated by social media influencers, followed by a focus on the economic consequences of the virus and placing blame on immigrants. As the crisis deepened, science-based themes began to predominate, with a focus on reducing the spread of the virus through physical distancing and business closures Our findings highlight the importance of messaging in social media in gaining the public's trust and engagement during a pandemic. This requires credible scientific voices to garner public support for effective mitigation. Fighting the spread of an infectious disease goes hand in hand with stemming the dissemination of lies, bad science, and misdirection.

Patterns in medication incidents: A 10-yr experience of a cross-national anaesthesia incident reporting system.

BACKGROUND: Medication-related adverse events (MRE) in anaesthesia care are frequent and require a deeper understanding if we are to prevent medication harm. METHODS: We searched for reported MRE from the Spanish Anaesthesia Incident Reporting System (SENSAR) database over a 10-yr period. SENSAR is a cross-national, multicentre system focused on perioperative and critical care. A descriptive analysis of independent variables, phase of medication process, type of MRE, and medication group involved, and their relationships with morbidity was conducted. RESULTS: A total of 1970 MRE were identified from 7072 reported incidents. Patient harm was reported in 31% of the MRE. The administration phase was more frequent (42%) and showed the highest harm rate (44%) compared with other medication process phases. The most frequent types of MRE were wrong treatment regimen and wrong medication (55% of cases). The medication groups most commonly reported were those that alter haemostasis (18%), vasoconstrictor agents (13%), and opioids (10%). Vasoconstrictor agents, benzodiazepines, and neuromuscular blocking agents were the medication groups involved in patient harm four-fold more, and opioids three-fold more, than medications that alter haemostasis. The 1970 incidents were investigated and led to implementation of 4223 local corrective patient safety and quality improvement measures. CONCLUSIONS: Patient harm in the perioperative setting from medications remains a major issue for patients, hospital leaders, and clinicians. We found patterns and specific causes that can be mitigated through proven systems solutions, and should be taken into consideration in designing sustainable solutions for safe perioperative care. CLINICAL TRIAL REGISTRATION: NCT03615898.

"Do You Know What I Know?": How Communication Norms and Recipient Design Shape the Content and Effectiveness of Patient Handoffs.

BACKGROUND: Poor communication during end-of-shift transfers of care (handoffs) is associated with safety risks and patient harm. Despite the common perception that handoffs are largely a one-way transfer of information, researchers have documented that they are complex interactions, guided by implicit social norms and mental frameworks. OBJECTIVES: We investigated communication strategies that resident physicians report deploying to tailor information during face-to-face handoffs that are often based on their implicit inferences about the perceived information needs and potential harm to patients. METHODS/PARTICIPANTS: We interviewed 35 residents in Medicine and Surgery wards at three VA Medical Centers (VAMCs). MAIN MEASURES: We conducted qualitative interviews using audio-recorded semi-structured cognitive task interviews. KEY RESULTS: The effectiveness of handoff communication depends upon three factors: receiver characteristics, type of shift, and patient's condition and perceived acuity. Receiver characteristics, including subjective perceptions about an incoming resident's training or ability levels and their assumed preferences for information (e.g., detailed/comprehensive vs. minimal/"big picture"), influenced content shared during handoffs. Residents handing off to the night team provided more information about patients' medical histories and care plans than residents handing off to the day team, and higher patient acuity merited more detailed information and the medical service(s) involved dictated the types of information conveyed. CONCLUSIONS: We found that handoff communication involves a complex combination of socio-technical information where residents balance relational factors against content and risk. It is not a mechanistic process of merely transferring clinical data but rather is based on learned habits of communication that are context-sensitive and variable, what we refer to as "recipient design." Interventions should focus on raising awareness of times when information is omitted, customized, or expanded based on implicit judgments, the emerging threats such judgments pose to patient care and quality, and the competencies needed to be more explicit in handoff interactions.

"Workin' on Our Night Moves": How Residents Prepare for Shift Handoffs.

BACKGROUND: Poor-quality handoffs have been associated with serious patient consequences. Researchers and educators have answered the call with efforts to increase system safety and resilience by supporting handoffs using increased communication standardization. The focus on strategies for formalizing the content and delivery of patient handoffs has considerable intuitive appeal; however, broader conceptual framing is required to both improve the process and develop and implement effective measures of handoff quality. METHODS: Cognitive task interviews were conducted with internal medicine and surgery residents at three geographically diverse US Department of Veterans Affairs medical centers. Thirty-five residents participated in semistructured interviews using a recent handoff as a prompt for in-depth discussion of goals, strategies, and information needs. Transcribed interview data were analyzed using thematic analysis. RESULTS: Six cognitive tasks emerged during handoff preparation: (1) communicating status and care plan for each patient; (2) specifying tasks for the incoming night shift; (3) anticipating questions and problems likely to arise during the night shift; (4) streamlining patient care task load for the incoming resident; (5) prioritizing problems by acuity across the patient census, and (6) ensuring accurate and current documentation. CONCLUSION: Our study advances the understanding of the influence of the cognitive tasks residents engage in as they prepare to hand off patients from day shift to night shift. Cognitive preparation for the handoff includes activities critical to effective coordination yet easily overlooked because they are not readily observable. The cognitive activities identified point to strategies for cognitive support via improved technology, organizational interventions, and enhanced training.

Content counts, but context makes the difference in developing expertise: a qualitative study of how residents learn end of shift handoffs.

BACKGROUND: Handoff education is both formal and informal and varies widely across medical school and residency training programs. Despite many efforts to improve clinical handoffs, little evidence has shown meaningful improvement. The objective of this study was to identify residents' perspectives and develop a deeper understanding on the necessary training to conduct safe and effective patient handoffs. METHODS: A qualitative study focused on the analysis of cognitive task interviews targeting end-of-shift handoff experiences with 35 residents from three geographically dispersed VA facilities. The interview data were analyzed using an iterative, consensus-based team approach. Researchers discussed and agreed on code definitions and corresponding case examples. Grounded theory was used to analyze the transcripts. RESULTS: Although some residents report receiving formal training in conducting handoffs (e.g., medical school coursework, resident boot camp/workshops, and handoff debriefing), many residents reported that they were only partially prepared for enacting them as interns. Experiential, practice-based learning (i.e., giving handoffs, covering night shift to match common issues to handoff content) was identified as the most suited and beneficial for delivering effective handoff training. Six skills were described as critical to learning effective handoffs: identifying pertinent information, providing anticipatory guidance, applying acquired clinical knowledge, being concise, incorporating delivery strategies, and appreciating the styles/preferences of handoff recipients. CONCLUSIONS: Residents identified the immersive performance and the experience of covering night shifts as the most important aspects of learning to execute effective handoffs. Formal education alone can miss the critical role of real-time sense-making throughout the process of handing off from one trainee to another. Interventions targeting senior resident mentoring and night shift could positively influence the cognitive and performance capacity for safe, effective handoffs.

Crisis checklists for in-hospital emergencies: expert consensus, simulation testing and recommendations for a template determined by a multi-institutional and multi-disciplinary learning collaborative.

BACKGROUND: 'Failure to rescue' of hospitalized patients with deteriorating physiology on general wards is caused by a complex array of organisational, technical and cultural failures including a lack of standardized team and individual expected responses and actions. The aim of this study using a learning collaborative method was to develop consensus recomendations on the utility and effectiveness of checklists as training and operational tools to assist in improving the skills of general ward staff on the effective rescue of patients with abnormal physiology. METHODS: A scoping study of the literature was followed by a multi-institutional and multi-disciplinary international learning collaborative. We sought to achieve a consensus on procedures and clinical simulation technology to determine the requirements, develop and test a safe using a checklist template that is rapidly accessible to assist in emergency management of common events for general ward use. RESULTS: Safety considerations about deteriorating patients were agreed upon and summarized. A consensus was achieved among an international group of experts on currently available checklist formats performing poorly in simulation testing as first responders in general ward clinical crises. The Crisis Checklist Collaborative ratified a consensus template for a general ward checklist that provides a list of issues for first responders to address (i.e. 'Check In'), a list of prompts regarding common omissions (i.e. 'Stop & Think'), and, a list of items required for the safe "handover" of patients that remain on the general ward (i.e. 'Check Out'). Simulation usability assessment of the template demonstrated feasibility for clinical management of deteriorating patients. CONCLUSIONS: Emergency checklists custom-designed for general ward patients have the potential to guide the treatment speed and reliability of responses for emergency management of patients with abnormal physiology while minimizing the risk of adverse events. Interventional trials are needed.

A qualitative study of patient experiences of decentralized acute healthcare services.

OBJECTIVE: Municipality acute wards (MAWs) have recently been launched in Norway as an alternative to hospitalizations, and are aimed at providing treatment for patients who otherwise would have been hospitalized. The objective of this study was to explore how patients normally admitted to hospitals perceived the quality and safety of treatment in MAWs. DESIGN: The study had a qualitative design. Thematic analysis was used to analyze the data. SETTING: The study was conducted in a county in south-eastern Norway and included five different MAWs. PATIENTS: Semi-structured interviews were conducted with 27 participants who had required acute health care and who had been discharged from the five MAWs. RESULTS: Three subthemes were identified that related to the overarching theme of hospital-like standards ("almost a hospital, but…"), namely (a) treatment and competence, (b) location and physical environment, and (c) adequate time for care. Participants reported the treatment to be comparable to hospital care, but they also experienced limitations. Participants spoke positively about MAW personnel and the advantages of having a single patient room, a calm environment, and proximity to home. CONCLUSIONS: Participants felt safe when treated at MAWs, even though they realized that the diagnostic services were not similar to that in hospitals. Geographical proximity, treatment facilities and time for care positively distinguished MAWs from hospitals, while the lack of diagnostic resources was stressed as a limitation. Key points Municipality acute wards (MAWs) have been implemented across Norway. Research on patient perspectives on the decentralization of acute healthcare in MAWs is lacking. • Patients perceive decentralized acute healthcare and treatment as being comparable to the quality they would have expected in hospitals. • Geographical proximity, a home-like atmosphere and time for care were aspects stressed as positive features of the decentralized services. • Lack of diagnostic resources was seen as a limitation.

A systematic review of hospital accreditation: the challenges of measuring complex intervention effects.

BACKGROUND: The increased international focus on improving patient outcomes, safety and quality of care has led stakeholders, policy makers and healthcare provider organizations to adopt standardized processes for evaluating healthcare organizations. Accreditation and certification have been proposed as interventions to support patient safety and high quality healthcare. Guidelines recommend accreditation but are cautious about the evidence, judged as inconclusive. The push for accreditation continues despite sparse evidence to support its efficiency or effectiveness. METHODS: We searched MEDLINE, EMBASE and The Cochrane Library using Medical Subject Headings (MeSH) indexes and keyword searches in any language. Studies were assessed using the Cochrane Risk of Bias Tool and AMSTAR framework. 915 abstracts were screened and 20 papers were reviewed in full in January 2013. Inclusion criteria included studies addressing the effect of hospital accreditation and certification using systematic reviews, randomized controlled trials, observational studies with a control group, or interrupted time series. Outcomes included both clinical outcomes and process measures. An updated literature search in July 2014 identified no new studies. RESULTS: The literature review uncovered three systematic reviews and one randomized controlled trial. The lone study assessed the effects of accreditation on hospital outcomes and reported inconsistent results. Excluded studies were reviewed and their findings summarized. CONCLUSION: Accreditation continues to grow internationally but due to scant evidence, no conclusions could be reached to support its effectiveness. Our review did not find evidence to support accreditation and certification of hospitals being linked to measurable changes in quality of care as measured by quality metrics and standards. Most studies did not report intervention context, implementation, or cost. This might reflect the challenges in assessing complex, heterogeneous interventions such as accreditation and certification. It is also may be magnified by the impact of how accreditation is managed and executed, and the varied financial and organizational healthcare constraints. The strategies hospitals should impelment to improve patient safety and organizational outcomes related to accreditation and certification components remains unclear.

Expertise in medicine: using the expert performance approach to improve simulation training.

CONTEXT: We critically review how medical education can benefit from systematic use of the expert performance approach as a framework for measuring and enhancing clinical practice. We discuss how the expert performance approach can be used to better understand the mechanisms underpinning superior performance among health care providers and how the framework can be applied to create simulated learning environments that present increased opportunities to engage in deliberate practice. EXPERT PERFORMANCE APPROACH: The expert performance approach is a systematic, evidence-based framework for measuring and analysing superior performance. It has been applied in a variety of domains, but has so far been relatively neglected in medicine and health care. Here we outline the framework and demonstrate how it can be effectively applied to medical education. DELIBERATE PRACTICE: Deliberate practice is defined as a structured and reflective activity, which is designed to develop a critical aspect of performance. Deliberate practice provides an opportunity for error detection and correction, repetition, access to feedback and requires maximal effort, complete concentration and full attention. We provide guidance on how to structure simulated learning environments to encourage the accumulation of deliberate practice. CONCLUSIONS: We highlight the role of simulation-based training in conjunction with deliberate practice activities such as reflection, rehearsal, trial-and-error learning and feedback in improving the quality of patient care. We argue that the development of expertise in health care is directly related to the systematic identification and improvement of quantifiable performance metrics. In order to optimise the training of expert health care providers, advances in simulation technology need to be coupled with effective instructional systems design, with the latter being strongly guided by empirical research from the learning and cognitive sciences.