July 7, 2021By Lance Baily

Collection of Healthcare Simulation Policies and Procedures Manuals

Clinical simulation labs and programs tend to have a set of policies and procedures in place to help govern the use of their resources while ensuring fairness in opportunity. To help empower learners to deliver the best possible care to every patient, labs and programs must strive to promote a culture of excellence and elevated patient care. Through the development of healthcare simulation policies and procedures, facilitators are able to better position themselves and their respective facilities to meet these goals. Below are a number of programs which have implemented such standards:

The University of Vermont CSL: The University of Vermont’s The Robert Larner, M.D. College of Medicine’s Clinical Simulation Laboratory has a set of policies and procedures in place to help perfect healthcare delivery. Through innovations in clinical training, educational research and quality improvement, the university’s CSL hopes to achieve systems integration, interprofessional collaboration and value-driven healthcare. Here, policies and procedures range from budget to human resources, hours of operation, evaluation processes, research and more.

In terms of day-to-day operations, the goal is to provide a transparent scheduling process and accommodate all activities by finding room(s), time and staffing (SPs, sim specialists) that will meet the need of the activity. In doing so, academic programs with specific simulation-based graduation requirements are given top priority for CSL resources. This includes the CNHS, LCOM and some residency and fellowship programs.

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If there is a new course or a new simulation, the faculty member must schedule a meeting with the director of simulation education operations. Once the course development is underway and the resources have been identified, the faculty member will meet with the CSL scheduler with the syllabus or project plan in hand. Then, they will enter their request as tentative until the lab has all requests in for the time period. Within one month after the request window is closed, the lab will confirm by email if the faculty member’s request has been granted.

Cleveland Clinic Simulation and Advanced Skills Center Policy and Procedure Manual: The stated mission of the Cleveland Clinic is “to provide better care of the sick, investigation into their problems and further education of those who serve.” In an effort to advance the institution’s mission, further strategic goals and stay aligned with the institution’s strategic objectives, the mission statement of the SASC is to “support education and training of those who serve to foster delivery of quality patient care and safety.” This document serves to help develop a “best practice” skills program that will provide an appropriate educational setting where basic and complex procedures can be learned and practiced by healthcare professionals in all specialties prior to performing procedures of living patients.

University of Pennsylvania Policy & Procedure Manual: This Policy and Procedure Manual is not a substitute for other policies and codes, but a complement to other codes, policies and regulations held by Penn Medicine which regulate the behaviors of staff and learners of Simulation at Penn Medicine. This manual breaks down the university’s governance, complaint resolution process, quality improvement, course administration, evaluations, psychological safety and more.

University of Kentucky College of Nursing Clinical Simulation & Learning Center Policies & Procedures Manual: This CSLC is designed to help educate and facilitate patient care concepts in a simulated environment that promotes knowledge development, patient safety, skills application, clinical reasoning and evaluation. The mission of the UK CSLC is to promote “health and well-being through excellence in nursing education, research, practice and service while fostering diversity and inclusivity” in a simulation environment.

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SSH Simulation Program Policy and Procedure Manual Model Template: This procedural template was established as a revision and update of the 2012 template policy and procedure manual model for members of the SSH. This team was composed of experienced members in clinical simulation program operations, administration and management. The team was tasked to create a template for SSH members to utilize as a foundation for the creation of their own policy and procedure manual.

This manual outlines commonly accepted practices and serves as a general model for simulation programs to follow when developing their policy and procedure manual. Core topics are outlined, and each topic includes a brief description to assist in understanding the potential application. When using this template, programs should feel free to edit, add to or omit topics depending on the specific needs of their organization. The result will be a customized “Policy and Procedure Manual” addressing fundamental issues to efficiently and effectively operate a simulation program.

Healthcare Simulation Standards of Best Practice: The International Nursing Association for Clinical Simulation and Learning (INACSL) has developed the INACSL Standards of Best Practice: Simulation℠ to advance the science of simulation, share best practices and provide evidence-based guidelines for implementation and training.

The INACSL Standards of Best Practice provides a detailed process for evaluating and improving simulation operating procedures and delivery methods that every simulation team will benefit from. Adoption of the INACSL Standards of Best Practice: Simulation demonstrates a commitment to quality and implementation of rigorous evidence-based practices in healthcare education to improve patient care by complying with practice standards.

Missouri Southern State University Simulation Center Policy & Procedures Manual: The goal of the Simulation Center for Interdisciplinary Clinical Education (SCICE) is to provide a safe learning experience that promotes successful understanding in all aspects of healthcare. The SCICE faculty and administration are here to make a student’s clinical experience educational, enlightening and serve the best interest of that student. Simulations and case scenarios are designed to help the student develop problem-solving and decision-making skills. The SCICE will attempt to include all environmental factors to make students’ learning experiences realistic and authentic.

For enhanced learning, all students are expected to come to the lab prepared. The faculty will provide students with positive feedback and debriefing of their performance, while students will self-analyze their performance and use critical thinking during the reflection process. The following guidelines maintain safety while using the SCICE. It is expected that all involved in classrooms, clinical skills and simulation activities will adhere to these guidelines. The Simulation Coordinator will update the contents of this manual as needed. All students, staff and faculty will be advised of these revisions.

Clarkson College Simulation Lab Handbook: This handbook provides definitions for terms related to clinical simulation and outlines faculty simulation lab use guidelines. For example, scheduling is done on a first-come, first-served basis via the Sim Lab-416 Calendar on Outlook Exchange. Faculty may be expected to be flexible with their simulation time. If scheduling conflicts arise, the determination of simulation use will be decided by the Simulation Lab Coordinator. Scheduling conflicts may be managed by splitting the use of the simulators or utilizing the Sorrell Center when possible. Faculty cannot use the sim lab for purposes other than high-fidelity simulations. Other topics discussed within this handbook include faculty preparedness for simulation, facilitation, student evaluation, video recording/playback and the student simulation experience expectations.

University of California Irvine Medication Education Simulation Center Policies and Procedures: UCI operates on a hierarchical organizational structure within Medical Education, School of Medicine. All strategic decisions are made by the Director in coordination with the Vice Dean for Medical Education and Dean’s office. Day-to-day operations are the responsibility of the director of operations. All scheduling is funneled through the administrative assistant to the director of operations for evaluation. Use of the simulation center, including debriefing rooms and task training rooms are by appointment only. Scheduling may be obtained by contacting the Simulation Program Office or by submitting a request online. At this time, there are no general open lab hours.

In general, any activity scheduled must contain medical simulation and/or task training to some degree. The simulation center is considered an active learning environment. Determinations are made by the Simulation Program Office. The university’s policies and procedures go on to outline other elements such as operating hours, computer use, study space, access to information and more.

Clinical Simulation Center of Las Vegas Standard Operating Procedures: The purpose of the Clinical Simulation Center of Las Vegas’ standard operating procedure is to provide a detailed, standardized operating protocol to ensure all duties of the Clinical Education Assistant are successfully performed. To ensure all duties are completed, the sim center requires attainment of all schedules and syllabi prior to each semester from the technician(s) and coordinators from each area. Additionally, this will also give a general idea of how time needs to be managed for setups, breakdowns or providing support in each area of the facility. This set of policies and procedures further includes sim control, scenario operations, lab use, equipment requests and more.

In addition to these policies and procedures, numerous other institutions offer guidance to help support their staff, facility and learners. Here are other policy outlines that may be of use to clinical simulation labs and programs throughout the world:

HealthySimulation.com also provides a comprehensive outline for healthcare simulation programs. This includes listing out a mission, contact list, stakeholder committee, confidentiality agreement, observation policies and more. Ultimately, such outlines should reflect that policies and procedures are a core requirement of accreditation programs. Additionally, a Clinical Skills Lab Coordinator Standard Operating Procedures Example and Standard Operating Procedure Guides for Simulation Technician Positions are available.

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