Policies and Procedures. Part 7 of the 7-Part Series Dissecting the Sim Ops Standard

By: Tonya Schneidereith and Julie Poore

Previously in this series we helped you think about simulation readiness, the role of strategic planning, different ways to conceptualize staffing models,  the importance of systems management, financial considerations, and systems integration. Now, in the final blog of the series, we emphasize criterion 6 on written policies and procedures needed to support and sustain your simulation program (INACSL Standards Committee, 2017).

Policies are guiding principles, often related to the mission of the organization, that provide consistency across the organization. These may include who is responsible for administering the policy, an effective date, a review date, a rationale, and scope. Procedures, on the other hand, outline steps to support the policy. For example, an institution may have a policy statement on the roles and responsibilities required of simulation facilitators; the procedures will identify the necessary steps to hire, train, and evaluate the simulation facilitators.

Having written policies and procedures for a simulation program make for a more efficient workplace. An exemplar can be found in the Resource Library on the Society for Simulation in Healthcare’s website. These can be housed in a central location or online, so that anyone involved in simulation operations knows what to do, how to do it, or where to go. Although policies and procedures should be specific to your organization, we wanted to highlight a few areas for you to think about.

Human resources are essential areas for policies and procedures and include workload expectations, educational requirements for the role(s), competency expectations, and methods of evaluation. Requirements expected for promotion and advancement should also be included.

Data collection is an essential part of evaluation, but how are you handling the data? Policies and procedures are needed to define who has access to the data, when it will be destroyed, and who is responsible for reporting on the data. The policy for these processes should align with organization policies. For example, if there is a policy for retention of exams, then retention of simulation checklists should be similar. Who can see the checklists? Are they a permanent part of the learner’s file or are they handled differently? Similarly, do you use an A/V system and record the simulations? Consider what to do with these videos, including who can view them, how long they are stored, and when they are deleted.

Simulation programs also require clear policies and procedures on how to safely manage supplies and hazardous materials. Consider what to do with sharps containers, moulage, defibrillators, simulators, and monitors. Have safety information available for hazardous supplies and clear policies on how and where equipment is to be stored. Is your equipment located in a basement that is prone to flooding? Who is responsible for checking the space when your area is experiencing heavy rains? Do you use a pulley system for your simulators? Who is responsible for ensuring that the pulleys are working properly? All of this should be clearly outlined in your simulation policies.

However, it’s hard to cover everything that can happen in the simulated environment and sometimes policies evolve from unfortunate accidents. At one institution, a table broke and the standardized patient (SP) was injured. Because of that incident, there is now a policy placing the responsibility for equipment usability and safety on clinical engineering staff. 

Policies related to learners, in either an academic or practice setting, should also be included in the manual. Ensure that they align with the student handbook or clinical expectations. Examples include course preparation, a code of conduct, and cell phone usage.

Finally, make sure to address the logistics of your simulation program. Include processes for scheduling simulations and prioritization of requests. Consider whether outside groups will be allowed to utilize the simulation center and at what cost — including time, human resources, and anticipated income. Identify how consumables are stocked, supplied, and who is responsible for making sure that you have what you need. Have contingency policies for unanticipated events, such as weather-related closing or simulator maintenance days.

Having clear policies and procedures can be immensely helpful when you are faced with disgruntled faculty, staff, or students. They help protect the workings of the simulation program and can reinforce best practices. What advice do you have for those developing simulation policies and procedures?


INACSL Standards Committee. (2017). INACSL Standards of Best Practice: SimulationSM: Operations. Clinical Simulation in Nursing, 13, 681-687. doi:10.1016/j.ecns.2017.10.005

Leave a Reply