In the first of three articles of particular interest to program administrators, Jane Kleinman, RN, MAOM, and Jeff Myers, MD, provide seven compelling questions that should be considered prior to implementing any simulation project.

Taking the right action at the right time for the right reason in the right way ensures coordinated, complete, competent safe patient care. Simple, right? Yet our learners and practitioners, all with demonstrated proficiencies and excellent test scores, often fall victim to the “practice gap”, unable to transfer what they know into what they do. Today’s healthcare environment is a rapid paced dynamic of complex care continuums without margins for any practice gap.

To help mitigate this gap there has been a rapid evolution and use of experiential learning modalities on all levels of healthcare education, often referred to as “simulation”. Unfortunately, “simulation” has become a catch-all phrase that encompasses a host of different types of experiences. Each type has its own unique needs for environment, equipment, and resources. And therein lays the crux of why implementing a “simulation program” can be so frustrating or difficult. In any given group of educators and administrators the term “simulation” has different meanings and expectations.

Whether you are developing a focused in-situ experiential learning or university level interprofessional simulation center, there are seven critical questions that must be asked and answered prior to any implementation action. The answers are inter-related and help frame the scope of the answer for the seven, subsequent questions. While not all inclusive, these questions form the basic and foundational information needed to establish your project.

Question #1 – What types of simulation are we talking about?

We have created and use the following quick reference summary guide in Table 1 that allows for different types of simulation modalities to be categorized in ways that relate to operational realities. This ensures that all levels of stakeholders are on the same page during discussions, decisions, and commitment.


Description Task training


Faculty lecture, demo,

& test


May be self paced

learning with interactive


Didactic with demonstration of pathophysiological



Faculty lecture, demo, & test


Patient Presentation:

-case study

-ad hoc progression

-course specific


May incorporate some:

-performance of tasks

-demo of tasks in


-discussion of next


Realistic 10-15 minute immersive experience designed to allow learners to put knowledge into actions in order to pro-actively identify & mitigate gaps


Faculty facilitate a standardized scenario without interrupting the learners




Realistic, dynamic,

environment & patient


Video Use May be used for

psycho-motor skill review

May be used for

psycho-motor skill review

Critical component to ensure objective review for Performance Gap identification & data analysis
# of Learners to


10-40 learners:

1-4 Faculty

10-75 learners:

1 Tech + 1-2 Faculty

6 -10 learners:

1 Tech + 1 Facilitator/Debriefer

Length of


1,4 hour/session 1,2 hour/session 2,4-8 hour sessions
Debriefing None None


Immediate targeted video review with group participants to discussion to pro-actively mitigate Performance Gaps
Equipment Static mannequin

Body part trainers

Haptic trainers

Standardized Patients


Patient care


Mid or high fidelity mannequins

Hybrid mannequin

Haptic trainers

Standardized Patients


Limited realistic

- environment

- patient equipment

- patient care supplies

Mid or high fidelity mannequin

Hybrid mannequin

Haptic trainers

Standardized Patients



- environment

- patient care equipment

- patient care supplies

Evaluation Testing/ Competency


Testing/ Competency



Performance Measures

Gap Analysis

Question #2 – Who needs to be involved ?

Identifying all possible stakeholders up front is key to creating a shared mental model. Without a shared mental model of what will be provided for the learners how, there will be competing agendas, silos of dogma, fragmented program development, limited resources, funding constraints, ad hoc utilization, and ultimately, poor outcomes.

Finding out who is doing what, who needs what, who has what and who wants what, may take some time. Cast the net wide. Think outside of your normal circle of organizational contacts. What other departments could benefit or be of benefit to yours? Who has a stake in ensuring optimum patient care? What about external clinical, business, and philanthropic relationships that could be mutually beneficial?

Identify a functional representative group that includes line personnel through key decision makers. We always like to include a “nay-sayer” for two reasons: the opportunity to allow the initially non-supportive individual to become a part of the solution, and, often that questioning voice helps push the group to better define the shared mental model.

That shared mental model, developed and therefore supported by this representative group, will be the key to both driving and holding together your program development and implementation at all levels.

Question #3 Who are the Learners and what do they need? (In tandem with# 2)

In order to know what equipment, space and types of patient encounters are needed, we need to identify our learners. Defining who the learners are by level(s) of expertise, demographics, and groups is critical to determining who needs how much of what type of simulation is required when. This ensures that planned simulation activities meet the learners’ needs and are aligned with curriculum and/or requirements. It is also very important when designing specific simulation programs desired outcomes so that the experience can be customized to the learner groups’ needs.

It is important to recognize evolving educational and regulatory mandates for provision of different types of simulation. Planning for incremental growth and utilization impacts on resources required to start, run, and grow the program must occur early.

Questions #4 – What outcomes are desired?

This is where program buy-in and sustainability are created. Alignment of specific activities with core indicators with a defined soft or hard return on investment (ROI) demonstrates needs being met. ROI is the cost of providing the experience as it relates to improved outcomes, costs or reductions elsewhere.

Get very specific with the outcome definitions. What measurable, observable, critical thinking transferred to knowledge- in- action, do we want our learners to demonstrate and gain from the experience?

How will the outcomes be measured? The examples in Table 2 represent only a small number of possible outcome measures. The list is endless. Making the outcomes relatable to a significant problem that needs to be solved is the critical component, even if that problem is just being able to start identifying where the practice gap is.

Table 2: Examples of program outcome measures

·      Cost savings

·      Patient outcomes

·      Staff satisfaction

·      Reduction in training costs

·      Reduced length of stay

·      Improved teamwork

·      Decreased infection rate

·      Error prevention

·      Error reduction

·      Refined processes

·      Coordination across the care continuum

Question #5 – What methodology will be used?

Beware of confusing “buttonology” with methodology. Equipment vendors participate in excellent “simulation training” conferences with variable presentations, but the focus is really on how to use their technology to drive the learner experience. Methodology is how they create, present, and manage the learner experience with technology as an adjunct to cue or support the learners.

Defining the methodology for each type simulation to be used directly translates into the operational plan for learner through put, utilization, space, equipment, supplies and personnel resources necessary.

It is critical for the credibility of your program to have standardized methodology employed by all educators for each type of simulation provided. Learners will not risk demonstrating practice gaps or learning through mistakes if there is a lack of trust that defined processes are uniformly used and fairly applied.

While there are several different valid ways to run a simulation program, consistency is key. The answer to this question will drive planning for the program’s administrative structure, staffing, faculty and staff development, core operations and the operating budget.

Question #6 – What resources will be necessary to support the methodology?

Get out the calculator. Time to count up the number and size of groups and their use of simulation by hours per year, week and/or day. Those numbers determine how many personnel in what roles, how many pieces of equipment in what type of space, and even the amount and type of disposable supplies that will be necessary.

These numbers establish the operational budget for your program. Comptrollers need to know what the costs are up front and their justification. The different types of simulation require different types of personnel and equipment resources. This initial pro-forma helps define program needs and estimated operating expenses.

“Cash is King,” is a statement that describes the need for solid and accessible operating funds. Money that is tied up in an endowment, long term investment or in capital may not be accessible in the critical early stages of program development. Simulation is a resource intensive educational methodology. Not only is the equipment expensive, but the time and human capital required in developing and executing the educational experiences is significant. This all translates into needing adequate start up and sustainability funding.

Startup funding is often made in the form of an initial investment in a program by an organization, donor, or philanthropic campaign. In raising funds for “stuff”, it is easy to provide tangible benefit to the stakeholder who puts forth the investment. It is much easier to raise funds for a room to place a plaque identifying the sponsor of that space, or to a piece of equipment. It is much more difficult to put a plaque on a person.

Operating expenses for staff salary and overhead should not rely on external donations or grant funding. Both sources tend to be for the short term, leaving you with an unusable area full of equipment in the long run.

Early frank and realistic operational funding agreements among the stakeholders are essential for program survival. How will the program operations be funded? What proportions are assigned to the different stakeholders? In return for what level of access? Who is responsible for what piece of funding? And when? Make sure these decisions are secured with letters of agreement otherwise once the bill arrives it may be difficult collecting the funds.

Funding is a key area that should not be glossed over in the excitement to start a program. The time taken to finalize these details at the beginning will save a significant amount of future worry and time taken away from the educational mission of the program. There is no right or wrong answer to how funding is established, so come to whatever consensus is mutually beneficial for the stakeholders. We cannot stress enough that this key question should be answered as soon as possible in program development.

Question #7 – What are the next steps?

Now that you have answered these questions you will have a good idea of how the program will look, from the equipment and space needs, types and scope of learners and activities, staffing needs, faculty development and funding.

Dhanashri Kohok (right), resident of social and preventive medicine and internal medicine; Joel Beatty, MD, resident, social and preventive medicine. (Photo: Behling Simulation Center)
Practicing invasive skills on task trainers has been shown to decrease complications when performed on live patients. Image Credit: Behling Simulation Center.

Time to bring it all together into a functional timeline with assigned roles, responsibilities, and deadlines so that the stakeholder shared mental model is not lost and development proceeds in a focused, tangible manner.

Starting with a limited, focused, pilot program provides the grace period to gain valuable experience, work out the uncertainties, identify gaps and create efficiencies. This is an excellent way to establish a proof of concept, credibility and internal public relations to ensure full support for next level steps.

In summary:

  1. Use a clear definition of the different types of simulation and their
resources to harmonize the stakeholders’ expectations. .
  1. Establish a simulation usage plan to help develop funding for operations personnel, equipment, space, logistics, and supplies.
  1. Identify and use key representative stakeholders to create the shared mental model for program development so that resources can be optimized.
  1. Create sustainability and buy-in by linking desired outcomes to tangible problem solving that can be measured.
  1. Standardize methodology to support operations, trust, credibility, and allow for outcome measures to be obtained.
  1. Identify budget and funding details based on clearly defined utilization metrics.
  1. Create a focused timeline for activities with clear responsibilities and resources for
Accomplishment defined.

These are the foundations to build your simulation program. Make sure your beginning gets off to the right start!

About the Authors:

Jane Kleinman, RN, MAOM, is the CEO of Performance Gap Solutions, LLC and founder of Medical Simulation Design, Inc. She may be contacted at

Jeff Myers, MD, is the CEO of Fast Track Solutions, LLC and is a practicing emergency physician and emergency care consultant and educator in Buffalo, NY. He can be reached by e-mail at