No Ordinary Dummy
The primary need to be met by "SAM" the patient simulator is training and rehearsal of rare crisis situations in a realistic setting, so an anesthesiologist can quickly recognize various patient problems and respond appropriately. An example of a rare operating room crisis is patient cardiac arrest, which may occur only every 5-10 years during an individual anesthesiologist’s career.
Product Launch of Hospital Operating Room Anesthesiology “Patient Simulator” – Simulated Anesthesiology Mannikin (SAM)
A pioneering effort in technology-based training applications for healthcare.
1. A Need for New Revenue Sources
CAE-Link (New York, Washington DC, Houston, and Silicon Valley), a business unit of Toronto-based CAE Inc., needed to diversify into new, higher-profit commercial markets to replace declining revenues from its core military and aviation training markets. Miniaturization of microchips and other technologies were enabling development of smaller and increasingly more realistic simulators. Simulation-based training was becoming more affordable for non-government users.
The CAE-Link budget for marketing services had declined from about $2 million per year to $400,000, a cut of 80%. The overall workforce had shrunk by half to about 4000. The communications staff had been reduced from 11 to 4.
At the same time, however, CAE-Link was attempting to enter several new markets, among them training for energy/ petrochemical processes, rail / locomotive, and air traffic control, distance learning, teleconferencing, and drug impairment kiosks. Trade show events had increased from 8-12 large exhibits per year to more than 40 mostly small exhibits, the majority of the increase in markets new to the company.
Marketing Services’ roles encompassed positioning strategies for all products and services, as well as tactical communications to support priority pursuits – media relations, advertising, collateral, graphic design, multimedia, events, speechwriting, public affairs, team/ partner communications, proposal development, internal communications, and investor relations.
I was Marketing Services department director, reporting to the Vice President of Marketing.
2. The Healthcare Training Opportunity
The new healthcare training market was assigned to a program manager with 30 years experience in flight simulation (Jim Herz) and a senior staff scientist (Dr. Jeff Kleinwaks). Their task was to develop a product to sell to the medical market, and generate initial sales and leads within 12-18 months sufficient to convince CAE-Link management that the product line could sustain a 20-25 percent profit margin over at least a 5-year period. They had no dedicated marketing/ sales support and received limited, sporadic assistance from specialty disciplines such as mechanical engineering.
Herz and Kleinwaks recognized that ground-up development of a new product would take too long, so through a literature search they located parallel mannikin-based research efforts at Stanford University and the University of Florida … aimed at training anesthesiologists for crisis situations in hospital operating rooms. CAE-Link negotiated with both schools, and was successful with Stanford. Florida joined forces with CAE-Link’s major competitor.
During the negotiations, Herz and Kleinwaks approached me for Marketing Services support: “How do we sell this thing?” In addition to communications efforts such as advertising, trade shows, and public relations, they wanted our advice and assistance with fundamental business development – researching the medical market, refining the simulator from a marketing perspective, developing technical documentation materials, and communicating with CAE-Link management.
The primary need to be met by the simulator was training and rehearsal of rare crisis situations in a realistic setting, so an anesthesiologist can quickly recognize various patient problems and respond appropriately. An example of a rare operating room crisis is patient cardiac arrest, which may occur only every 5-10 years during an individual anesthesiologist’s career.
The target market for the anesthesiology simulator is teaching hospitals, both in the US and internationally. There were about 400 such hospitals in the States and roughly twice that number overseas. Of those, fewer than 100 were likely purchasers, primarily those affiliated with medical colleges or Veterans Administration facilities.
The target audiences included anesthesiology practitioners and teachers who would benefit from improved skills and reduced insurance premiums, hospital administrators who approve purchase of new equipment, and insurance company risk managers who could encourage use of new training approaches which reduce risk to patients and therefore decrease malpractice lawsuits.
Based on our understanding of the Stanford and Florida simulators, we conducted a direct mail survey of medical colleges, hospital administrators, chiefs of anesthesiology, and board-certified anesthesiologists – seeking to gauge interest in an anesthesiology simulator, desired capabilities (and relative importance), and price point sensitivity. We received nearly 150 responses, a better than 20% return. In addition, we conducted focus groups with similar audiences. My role including refining the survey and focus group questions, and analyzing the feedback from business development and communications perspectives.
The capabilities ranking was matched against projected development timeframes and costs to determine the baseline product, options, and pricing.
Based in part on the survey results, CAE-Link secured license rights to a software-based drug interaction simulation (developed at the University of Washington) to incorporate into the anesthesiology patient simulator. Other “must have” capabilities suggested by the survey – such as thumb twitch – were designed into the prototype.
My approach to identifying audience characteristics and developing communications strategy and messages was to learn as much as possible about the target market – the fundamentals of anesthesiology, the interaction of doctors and nurses in the operating room environment, the personality profile of anesthesiologists, and how other companies marketed to the medical community. I read numerous magazines and research abstracts. I visited a regional hospital, gowned up, and observed several different types of live operations from inside the OR. I conducted extensive interviews with Dr. David Gaba, inventor of the Stanford simulator; Dr. Howard Schwid, University of Washington drug software developer; anesthesiologists and administrators at the regional hospital, United Health Services; and members of CAE-Link’s medical advisory board such as Dr. Warren Grundfest of Cedar-Sinai in Los Angeles.
The need for a realistic, controlled, hands-on training experience in dealing with hospital operating room crisis situations bore strong similarity to the need for airline pilots to recognize and respond to emergency flight situations such as an engine fire or loss of cabin pressure. In both situations, the patient or passengers might die if the doctor or pilot fails to react appropriately. In both cases, the scenario is rare, therefore unfamiliar, and cannot be practiced in the “real world.” Related to such crises is the specter of malpractice lawsuits, which cost anesthesiologists and their hospitals upfront as insurance premiums and in the form or extreme expense and duress in defending their actions.
CAE-Link’s founder, Edwin A. Link, had invented the first pilot simulator, and his company had dominated the flight simulation market for several decades.
The key messages to the healthcare audiences, therefore, were:
- Simulation-based training is a viable method for teaching crisis situation response, and
- Following proper procedures (documented in part by research from simulated scenarios) could lead to a decrease in malpractice lawsuits and therefore lower insurance premiums.
To reinforce these messages, we leveraged CAE-Link’s longtime experience with flight simulation, for which there were ample research studies. However, we needed to be careful not to overemphasize airlines and military experience, lest the healthcare professionals perceive CAE-Link as having little knowledge in the medical domain.
The objectives of the Patient Simulator product launch plan included:
- Develop a prototype simulator with the most desired capabilities as the baseline product – for sales demonstration purposes and to determine production unit costs and schedules.
- Launch the patient simulator before the competitor’s simulator.
- Make an early sale to a prestigious customer to enhance the credibility of the product to others in the target market.
- Make a sale to an international customer, as overseas potential was larger than the US market.
- Convince management that there was a viable long-term market for the patient simulator and related healthcare products and services.
Another objective was to help stabilize the CAE stock value on the Toronto exchange – senior management wanted the prototype simulator as the central showpiece at the annual stockholders meeting.
3. Early Adopter-Driven Communications Plan
We chose a low-key approach to the market, in part because we were concerned about generating more interest than our small team could effectively handle. We did not have the resources for high-volume follow-up (considering the multiple new and traditional markets we were supporting), nor simulator volume production capability.
The focus of our communications plan was early adopters who were comfortable with new technology and who might become ambassadors in promoting the simulation concept to their colleagues. To make a final sale, it was considered essential for prospects to witness a live demonstration of the patient simulator. The purpose of the communications materials, then, was to stimulate customer interest in seeking a demonstration.
Our communications plan was driven by three types of events:
- Development of the prototype simulator so we could shoot photos and videos, as well as demonstrate the system,
- Major anesthesiology conferences in the US and Europe, and
- The CAE Inc. Stockholders Meeting and Annual Report.
The communications budget for the patient simulator was $37,500. (This did not include salaries or travel costs, which were funded from other budgets.)
Our core plan was comprised of:
February – a “soft launch” to early adopters at the Society for Technology in Anesthesia, a group in which Dr. Gaba was very active. Also, a modest exhibit at the Risk Insurance Managers conference.
March/ April – development of artwork, photos, and text for an initial marketing brochure, technical product description, media kit, and the CAE Annual Report.
May – participation at the European Society for Anaesthesiology, assuming availability of the prototype simulator.
June – demonstration of the prototype simulator at the CAE Inc. Stockholders Meeting; discussions with stockholders, financial analysts, and media.
July/ September – development of a marketing video featuring the prototype simulator, plus refinement of the brochure, technical product description, and other materials.
October – demonstration of the simulator at the American Society of Anesthesiologists, supported by advertising in trade journals and direct mail.
Opportunity-dependent – announcement of the 1st US sale, 1st international sale, and development of research papers by Dr. Gaba and others for scientific journals.
A critical part of the position effort was developing a product brand name. It needed to identify anesthesiology and training, of course, and during this period the term “virtual reality” was beginning to enter the vernacular. So the engineers christened the device the “Virtual Anesthesiology Training Simulation System,” and referred to it most often as “VATSS” or “the dummy.”
In order to evoke more of an emotional response to the trainer, I recommended “humanizing” the central component, the mannikin – calling him/ her “SAM,” short for Simulated Anesthesiology Mannikin.
4. Keeping Management Sold
My team and I had developed an excellent relationship with the CAE-Link Vice President of Marketing, and our consistent quality, timely delivery, and successful results had generated high confidence in our judgment.
To keep CAE-Link management sold on the product development, we provided monthly and on-demand progress reports on the status, costs, and issues of concern. Communications products such as photographs, collateral, and videos provided “emotional” support that SAM was moving toward reality. We also supported management briefings to the CAE Inc. chairman, president, and vice-presidents, as they were keenly interested in the investor publicity potential of the healthcare market.
One issue was the baseline cost of the simulator – about $250,000 – low by comparison with airline and military flight simulators costing in the millions, but perceived as high for a hospital (especially as an unproven training tool with no return on investment data yet available). The pricing strategy evolved to included encouraging consortiums of hospitals to join forces to share the costs of a single simulator, possibly setting up CAE-Link owned training centers and selling “simulator time” to users, and helping customers locate financing sources. To save time during the sales process and simplify the customer’s decision, I recommend a standard agreement and list of options with fixed prices, rather than the traditional military model of custom proposals.
5. Implementing the Tactical Plan
February – I attended the Society for Technology in Anesthesia (STA) conference in New Orleans. Herz did a “poster presentation” about SAM, which I edited and packaged, as well as coached him in responding to questions.
One of the myths that surfaced at this conference was that airline simulators cost $100 million each and pilots are forced to train at odd times such as 3 am on Saturdays. We were able to provide accurate information in an open forum, and used the feedback to adapt our communications messages.
Also at STA, we modified our strategy to incorporate partnering with vendors of related medical equipment such as operating room monitors with which SAM interfaced. Such partnering could provide no-cost loaner equipment for product development, and enabled access to industry insiders who understood healthcare customers.
One of the contacts we made at STA was a doctor from the Free University of Brussels, Belgium, who encouraged us to demonstrate SAM at the European Society of Anaesthesiologists (ESA) in May. Organizers also invited out competitor. This dialogue accelerated development of the prototype simulator and communications materials.
May – At ESA in Brussels, CAE-Link and our competitor had a side-by-side comparison demonstration which became the focal point of the conference.
In preparation for ESA, we developed the technical product description, lists of training scenarios and types of drug interactions simulated by the system, exhibit graphics, marketing brochure, and photos of SAM and other simulator components. I pre-arranged interviews with European editors.
We upstaged our competitor by announcing our 1st sale at the show – to the Free University of Brussels. An interview with International Hospital Equipment magazine resulted in a half-page article about SAM with color photo in their summer issue; more than 200 bingo-card inquiries were received from the article. Follow-up included brochures, press releases, reprints, video, and invitations to conferences and/ or demonstrations.
June – The SAM prototype (rushed back from Europe) was demonstrated at the CAE Inc. Stockholders Meeting in Toronto. The meeting was preceded by a feature on the company in Canadian Business magazine which included one of our photographs and a paragraph on the patient simulator and Brussels sale. Following the meeting, I was able to convert an inquiry about the simulator into a 7-page feature in Report on Business (Toronto Globe & Mail). We hosted the reporter and photograph at CAE-Link headquarters in Binghamton NY; I prepared Herz, Kleinwaks, and CAE president John Caldwell for the interview.
July/ August – The video needed to answer top-level questions for customer decision-makers about the value of simulation-based training. It also required sufficient detail to entice technically astute anesthesiologists to request a personal demonstration. I wrote the script, arranged for filming at the regional hospital, recruited and coached the actors, directed filming, and supervised editing the production studio.
August – We announced the first US sale to arguably the most prestigious customer possible – Harvard Medical School and its five affiliated hospitals in Boston. Approval of the press release language was one of the more challenging aspects of the communications campaign; Harvard is understandably sensitive about how their name is used, and the doctors, administrators, and communicators at each of the hospitals had diverse opinions on how to represent this 1st simulation-based training center.
At the request of a UK annual publication on medical technology, I wrote a feature for Dr. Kleinwaks’ byline. I also generated feature coverage in the local Binghamton newspaper and CBS-affiliate television station; these served primarily to boost CAE-Link employee morale.
October – We exhibited at the American Society of Anesthesiologists (ASA) convention in Washington DC, but limited demonstrations of SAM to invited guests in a hotel suite co-sponsored by one of our equipment partners. The exclusivity was in part to devote more time to qualified prospects and medical editors and to prevent the competition from viewing new simulator features developed since Brussels.
With our initial sales goals achieved and production timeframes better understood, we initiated advertising in trade journals such as Anesthesiology, Anesthesiology News, and Medical Technology. I wrote the ads and directed design and production. Their purpose was to raise awareness of the SAM’s availability and stimulate inquiries through offers of the videotape in NTSC and PAL formats.
I also initiated contacts with network news and newsmagazine medical segment producers, resulting in a feature on NBC TV’s Dateline.
6. All Plan Objectives Met
Here’s how our results aligned with the product plan objectives:
- The prototype simulator was developed a month ahead of schedule, production issues addressed, and baseline product and options priced;
- SAM was publicly launched simultaneous with the competing simulator in a manner that verified our technical superiority;
- Our 1st sale to an international customer was announced at product launch;
- Our 1st US sale was to one of the most visible and credible medical teaching centers – Harvard;
- Management continued to support development of the initial product and extensions -- such as a maternity model simulating mother and child, as well as a laparoscopy training model.
In addition, professional medical journal articles by Dr. Gaba, Dr. Schwid, Dr. Jeffrey Cooper of Harvard, and others were published in Anesthesiology. The following year, Dr. Gaba and two colleagues published a book, Anesthesia Crisis Management. Dr. Gaba was elected secretary of the Anesthesia Patient Safety Foundation, and Dr. Cooper was elected Chair of the Scientific Evaluation committee.
When CAE sold the Link business two years later, the Toronto company retained the patient simulator product line. At that point, there were 35 sales of SAM – several in Japan, four in Germany, four in Canada, three in Australia, Spain, Argentina, and the US.
Today there are hundreds of patient simulators in use worldwide. Dr. Gaba still looms large as editor-in-chief of the field’s first peer-reviewed journal – Simulation in Healthcare – and as Director of the Center for Immersive and Simulation-based Learning at Stanford University School of Medicine. He is a founding member of the Society for Simulation in Healthcare (SSH), which has about 2000 members.
Adapting information gleaned from the survey, focus groups, first-hand observations, and discussions with professionals from the target audiences, we were able to successfully bridge from our vast experience in the flight simulation community – indeed, the doctors’ psychological profile is very similar to fighter pilots. We were also able to leverage Dr. Gaba’s research to address training validity questions, and use the Brussels and Harvard endorsements to open doors and reduce skepticism.
Having a direct competitor with high credibility actually helped break down barriers to initiating a new market category. It shaped the dialogue more in the direction of “Which simulator is better?” rather than “Why do I need a simulator?”
One of the best decisions was the “SAM” nickname, providing a “high touch” shorthand to the high-tech simulator system. Management, employees, reporters, and customers all readily adopted the term, speaking almost affectionately of what was originally referred to as “the dummy.”
From a personal perspective, it is highly gratifying to have played a key role in launching a successful product in a pioneering market – improving healthcare and saving lives around the world.