In the fourth in a series of articles on medical simulation centers, Group Editor Marty Kauchak examines community stakeholders’ expanding interest in returns on investment for these facilities. 

During one random four week period this spring, the Halldale Group’s website reported the opening or upgrade of four healthcare simulation facilities in the US or overseas. Not to be lost on the quickening pace of new facility openings serving the healthcare community’s global learning audiences is the associated cost of these sites. A survey of the same website revealed recent, high-end investments for some new simulation centers on the order of $18 million. More common opening costs were about $7-8 million.

Investments of this magnitude during this era of increasing healthcare costs and expenditures are certain to raise the eyebrows of stakeholders of these magnificent facilities. Indeed, leaders in medical facilities’ “C-Suites” (for CEOs, CFOs and others), much like their counterparts in other high-risk sectors who invest in high-end simulation systems and centers, increasingly want to know the quantitative and qualitative returns on investment (ROI) for these appropriated funds.


One of the newest, large, private sector US medical simulation centers is at Mayo Clinic in Jacksonville, Florida. The hospital’s initial healthcare simulation program was launched in 2011 in a 2,700-sq.ft., temporary facility. This January the hospital opened the doors to a new, 9,600-sq.ft. center.

The Mayo Clinic executive leadership team and other in-house groups are aware of the broader benefits of healthcare simulation and closely monitor ROIs and associated activities – many of which are routinely recorded at their facility.

When Gene Richie, RN, the Operations Manager of the Jacksonville Simulation Center, spoke with MEdSim this May, he had just finished familiarizing one of his institution’s cardiology fellows with the function of a new endovascular simulator. The simulation subject matter expert recalled that when they were reviewing the proposed case load, the doctor identified on the simulator’s list of modules a new procedure that is being introduced at Mayo Clinic. “They had been in the planning phases for several months in preparation to perform cases of this nature,” Richie said, and continued, “The cardiology fellow stated, ‘this is almost real in terms of the way it feels when I have to move through the blood vessels and manipulate wires.’ The provider can now come over to this safe environment and practice multiple procedures without any risk to the patient.”

Mayo Clinic (with campuses in Jacksonville, Phoenix and Rochester, Minnesota) is looking beyond using simulation for building and enhancing individual skills, as reported for this cardiologist, and team skills – to the much broader challenge of gaining other ROIs from its Commitment to Safety Initiative. The program, which promotes a culture of patient safety while enhancing inter-professional communication, enables the three hospitals’ staffs to recognize a deteriorating patient and then communicate that development among team members. Richie explained one outcome. “Using key verbal queues allows staff members to focus attention to critical communication needs in a stressful environment. We’ve addressed this from many different angles including a multi-disciplinary group, which we brought into the simulation center. We were able to quantify a significant value of improving the overall competence of staff relating to listening and communication, and building confidence for moving into a real life situation.”

Mayo Clinic in Jacksonville also recorded a significant reduction in center line infection rates through the use of a simulation-enabled training course – yielding another quantifiable ROI.

The training course is part of a broader effort throughout the three Mayo Clinic facilities to have newly reporting physicians follow a proficiency checklist when performing a procedure on patients. “It’s very much like flight simulation where you have to go through the checklist to make sure you hit those appropriate key points before you actually take off,” Richie wryly noted.

Ann Mullen, MSN, ACCNS-AG, CHSE, the Program Manager at Shipley Medical Simulation Center, Newton-Wellesley Hospital, placed ROIs for her institution in perspective as she quantified the supported learning audiences. The Newton, Massachusetts-based community expert reported that in conjunction with CRICO (a provider of medical professional liability coverage, claims management and patient safety resources to its members) and their generous grants, team training programs for the Emergency Department and the Operating Room are offered for hundreds of interdisciplinary staff. “Advanced clinical skills and team training are underway for staff obstetricians and midwives. All of these programs formerly required staff to go off-site for tuition-based classes and were attended only by a fortunate few. Not only is the on-site simulation center providing opportunities to greater numbers of staff, it is more convenient, and now the entire clinical team can be included in the training for a richer experience,” she explained.

ROIs also have the attention of stakeholders of simulation centers at academic institutions, including community colleges.

The Allied Health Simulation Center at Ozarks Technical Community College is a multi-disciplinary, inter-professional Center that provides high-fidelity education experience to 12 different Allied Health Programs.

The facility became operational this February.

The 2,000 square foot Center provides multiple learning environments including a medical-surgical suite, a trauma and intensive care suite, a labor and delivery suite, a residential suite, and a debriefing space.

Shipley Medical Simulation Center and CRICO offers team training programs for the Emergency Department and the Operating Room. Image Credit: Shipley Medical Simulation Center, Newton-Wellesley Hospital
Shipley Medical Simulation Center and CRICO offers team training programs for the Emergency Department and the Operating Room. Image Credit: Shipley Medical Simulation Center, Newton-Wellesley Hospital

The Simulation Center also partners with local hospitals and the Missouri National Guard to deliver continuing education experiences.

Joel Doepker, the College’s Director of Communications and Marketing, told MEdSim the Simulation Center operates independently through student tuition and grant resources. The Ozarks Technical Community College is expecting a mix of qualitative and quantitative ROIs from the investments in the Center.

“Although our Allied Health programs are already in high demand within the community, the Center provides an additional learning experience that students may not be able to receive at other colleges or universities within the state. The return on investment is anticipated to come from additional students desiring to complete their healthcare education at Ozarks Technical Community College thus increasing general education enrollment and more qualified applicants for each program. The Simulation Center can be used as a purposeful clinical site, thus alleviating the burden of securing high demand areas for student experiences and lowering the student to teacher ratio,” Doepker said.

Of particular note, the Center has recently developed a fee-for-usage strategy that will provide another ROI.

Returns on investment are not the exclusive domain of the private sector.

The Naval Hospital Bremerton (NHB) (Washington)’s Simulation Center is capable of simulating most facets of Advanced Cardiac Life Support (ACLS), Pediatric Advanced Life Support, Neonatal Resuscitation Program, Advanced Trauma Life Support, and Childbirth, Pre-and Post-Partum conditions.

Shipley Medical Simulation Center, Newton-Wellesley Hospital. Image Credit: Shipley Medical Simulation Center, Newton- Wellesley Hospital
Shipley Medical Simulation Center, Newton-Wellesley Hospital. Image Credit: Shipley Medical Simulation Center, Newton- Wellesley Hospital

NHB training that utilizes simulations range from American Hospital Association-certified ACLS and Basic Life Support courses, to training on how to identify myocardial infarcts (heart attacks) or the proper placement of tourniquets. “We can even do certain procedures such as broncoscopies and endoscopies,” Stutz explained. In a much broader context, the Simulation Center delivers a wide range of training. Some skills that are often sought after include: suturing, birthing drills, intubations, inserting nasogastric tubes, central line insertions using sonosites, and many more.

Even in this era of constrained Department of Defense resources NHB continues to invest in learning technologies. Douglas Stutz, the hospital’s Public Affairs Officer, noted, “We have recently added three of the most advanced simulators on the market; these pediatric, neonatal and adult simulators are now (or will be soon) installed and ready for training.” These investments support NHB's Simulation Center's mission, keeping it on course to develop and maintain the skills of our healthcare staff and become the go-to source of skills development for regionally based military personnel

The naval hospital’s rich mix of simulation devices help deliver diverse ROIs.

Stutz’s short list of cost-savings and other quantitative advantages, and qualitative benefits is familiar to MEdSim’s readers in the private sector: streamlining training for doctors, nurses, Navy corpsman and medical/nursing students; providing medical personnel with the ability to practice, and then practice some more, and see the physiological results without risking real-life patients; verifying and validating student retention of material taught during certification programs and providing realistic training to test certification requirements.

NHB’s Stutz noted the greatest cost savings in terms of ROIs would be that of time –closely mirroring the insights of Shipley Medical Simulation Center’s Mullen. Stutz pointed out that training time at the NHB Simulation Center is more efficient. “Training periods are compressed to the actual training event and time is not spent on scenario development, travel, setup, and/or clean-up. Trainees have a quicker return in that the Simulation Center has training scenarios set up so that clinicians can show up ready to train and then return immediately to normal patient care duties upon completion of training,” he said. And finally, travel is mitigated in that the simulators are located in centralized areas and also have the capability to be mobile so that training can take place in work center of providers.

Senior Leadership Interest in ROIs

Other qualitative and quantitative ROIs monitored by community leaders include learner hours, volume of activity at the center and the departments that use the center. Mayo’s Richie noted that his CEO “Dr. [William] Rupp remains abreast of department utilization. He wants to make certain staff are availing themselves in the use of the center because he understands the value of practicing in a safe environment and improving the quality of their skills prior to transferring them to the hospital environment,” Richie added

Richie said that as Mayo’s leaders are “monitoring our metrics and activities – returns on investment – and as we feel compressed for space, we can go back and talk about expanding to a commitment of 18,000 sq. ft. in total.”

Shipley Medical Simulation Center’s Mullen said her center has been open for just over two years and it has been fortunate to receive significant foundation and grant monies for development, construction and initial operations. Early on, Mullen and her staff have established a culture of accountability and transparency for their leadership about the center’s activities. “From the beginning, we have provided hospital leaders with information about our contribution to the hospital’s goals. We collect the following data to illustrate the program's success: class attendance, number of instructors trained, and hours of instruction. We also conduct post-course evaluations asking Simulation Center participants to share a behavior or practice that they intend to change based on the learning, in addition to standard survey questions,” Mullen explained.

Of special note, to date, the Simulation Center has not expended any operational dollars. In its current state of rapid growth in programs, sessions, faculty and attendance, accurate cost analysis is not yet possible. Mullen did point out that her office has been able to provide educational opportunities specific to simulation that greatly benefit the Hospital’s clinical programs and provide possible liability insurance discounts for some clinician groups.

That simulation activity may offer ROIs to the insurance sector and its policy holders is a powerful notion – one that is often discreetly mentioned and always off-the-record, on conference exhibition floors and in break-out sessions, and in other community settings.

MEdSim attempted to engage several healthcare practitioner insurance providers on the record for this article. Mary G. Gregg, MD, FACS, MHA, the Chief Medical Officer, SVP, at MagMutual Insurance Company, was the only leader in this sector who accepted our invitation to discuss the topic.

For its part, MagMutual Insurance Company is a mutually physician owned, medical liability company covering 17,500 physicians.

The Atlanta-based corporate leader and her company fully understand the opportunities offered by simulation. Some of the company’s expectations from ROIs in medical simulation centers include improvements in safety, decreased risk and, as significant, decreased claims and liabilities.

“Simulation can be used in almost every segment of the health care field including the practice of medicine as well as the creation of safe healthcare systems and design of ongoing assessments,” Gregg emphasized.

And while MagMutual Insurance Company has not yet made any investments in medical simulation centers, “plans are in the works,” Gregg told MEdSim. She continued, “We see simulation as a means to improve safety and change the culture of medical education.”

On the Horizon

The Naval Hospital Bremerton is also taking its entire ROI construct to a higher plateau.

In one instance, the naval facility’s Simulation Center is in the process of developing a system for the collection of training metrics. The collection of this performance data will be used for trend analysis and improvement of the training system and curriculum to address areas identified through trend analysis. Continuous “Needs Assessment” in the form of training critiques has been developed in order to continuously assess and improve the Simulator Center.

Stutz added “The program TEAMSTEPPS, which is a teamwork system that offers a powerful solution to improving collaboration and communication within the institution, is being incorporated into scenarios in order to enhance communication between team members.”