Comprehensive Healthcare Simulation: Program & Center Development [1st ed.] 9783030468101, 9783030468125

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Comprehensive Healthcare Simulation Series Editors: Adam I. Levine · Samuel DeMaria Jr.

Michael A. Seropian George R. Keeler Viren N. Naik   Editors

Comprehensive Healthcare Simulation: Program & Center Development

Comprehensive Healthcare Simulation Series Editors Adam I. Levine Department of Anesthesiology Mount Sinai Medical Center New York, USA Samuel DeMaria Jr. Department of Anesthesiology Mount Sinai Medical Center New York, USA

This new series focuses on the use of simulation in healthcare education, one of the most exciting and significant innovations in healthcare teaching since Halsted put forth the paradigm of "see one, do one, teach one." Each volume focuses either on the use of simulation in teaching in a specific specialty or on a cross-cutting topic of broad interest, such as the development of a simulation center. The volumes stand alone and are also designed to complement Levine, DeMaria, Schwartz, and Sim, eds., The Comprehensive Textbook of Healthcare Simulation by providing detailed and practical guidance beyond the scope of the larger book and presenting the most up-to-date information available. Series Editors Drs. Adam I. Levine and Samuel DeMaria Jr. are affiliated with the Icahn School of Medicine at Mount Sinai, New  York, New  York, USA, home to one of the foremost simulation centers in healthcare education. Dr. Levine is widely regarded as a pioneer in the use of simulation in healthcare education. Editors of individual series volumes and their contributors are all recognized leaders in simulation-based healthcare education. More information about this series at http://www.springer.com/series/13029

Michael A. Seropian  •  George R. Keeler Viren N. Naik Editors

Comprehensive Healthcare Simulation: Program & Center Development

Editors Michael A. Seropian Department of Anesthesiology and Pediatrics Oregon Health & Science University Portland, OR USA

George R. Keeler SimResults Madison, WI USA

Viren N. Naik Department of Anesthesiology and Pain Medicine University of Ottawa Ottawa ON Canada

ISSN 2366-4479     ISSN 2366-4487 (electronic) Comprehensive Healthcare Simulation ISBN 978-3-030-46810-1    ISBN 978-3-030-46812-5 (eBook) https://doi.org/10.1007/978-3-030-46812-5 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

THINK → PLAN → INVEST → IMPLEMENT → REPEAT The global simulation community has grown exponentially through the years. This growth has been driven organically, as well as through other drivers at the workforce and regulatory levels. Simulation is more than a manikin; billions of dollars have been spent on the establishment of programs, training of instructors, and design and construction of simulation facilities. The return on the investment seems obvious to those in the simulation community; however, the return is less obvious from the view of the leadership level. To align simulation program development and implementation to best practice, the simulation community must take a deliberate approach to planning, implementation, and ultimately investing. This book is dedicated to those steps and to provide answers to questions that people may not even know need to be asked. Having programs reinvent the wheel when solutions already exist makes no sense. This book is not intended to answer all questions but rather to give readers essential and core information to be able to use as a springboard within their own programs and institutions. There are many correct ways to approach things and as such the contents should be viewed as resources to be placed in a “toolbox” to access when needed. The authors were selected for their demonstrated experience. We intentionally invited authors from the commercial and non-commercial sides of the simulation industry to contribute their perspectives and expertise. The book is entirely vendor and manufacturer agnostic. The organization of the chapters is deliberate and follows the typical steps taken as a new program is developed and implemented. The format of each chapter is intended to be to the point and brief, without losing key concepts for the sake of brevity. The authors have also offered “Pearls” based on their personal and observed experiences. If even one chapter helps a reader, then we, as editors, consider this endeavor a success. Portland, OR, USA Madison, WI, USA Ottawa, ON, Canada

Michael A. Seropian George R. Keeler Viren N. Naik

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Acknowledgment

The editors wish to thank and acknowledge all the authors who contributed to this publication. The willingness of authors to offer their time and expertise should be appreciated by the simulation community as a whole. It is important for all to remember that people do not have to contribute…. they choose to!

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Contents

Part I Business, Implementation, and Sustainability 1 Governance and Organizational Structure ��������������������������������������������   3 C. Donald Combs 2 Importance of Executive Buy-in ��������������������������������������������������������������   9 Lennox Huang 3 Establishing your Vision, Mission, and Strategy������������������������������������  15 George R. Keeler 4 Basic Business Planning����������������������������������������������������������������������������  19 Gabriel Keeler, George R. Keeler, and Teri J. Keeler 5 Implementation, Phases, and Project Management ������������������������������  25 Kristyn Gadlage and Jennifer L. Manos 6 Funding Sources and Fee Structures��������������������������������������������������������  31 Paul J. Pribaz 7 Effective Budgeting: Putting It Together ������������������������������������������������  39 Teri J. Keeler Part II Facility Design, Supporting Equipment, and Technology 8 Facility Design Part I – Process Considerations�������������������������������������  47 Michael A. Seropian 9 Facility Design Part II – Structure Considerations��������������������������������  53 Michael A. Seropian 10 Equipment Selection, Acquisition, and Maintenance ����������������������������  65 Kevin Miracle 11 Audiovisual and LMS��������������������������������������������������������������������������������  69 Lucas Huang

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Part III Curriculum and Faculty Development 12 Curriculum Integration and Development����������������������������������������������  83 Helen Levin and Adam Cheng 13 Faculty and Staff Development����������������������������������������������������������������  89 Glenn D. Posner Part IV Administration and Operations 14 Simulation Operations: An Overview������������������������������������������������������  97 Vincent J. Grant, Helen Catena, and Nicola Peiris 15 Effective Staffing, Recruitment, and HR Management�������������������������� 107 Jeffrey D. Howells 16 Policies and Procedures: Key Considerations ���������������������������������������� 115 Thomas A. Dongilli 17 Evaluation, Metrics, and Measuring ROI/VOI �������������������������������������� 123 Vicki LeBlanc Part V Marketing and Partnerships 18 Communication, Marketing Plan, and Strategy ������������������������������������ 133 Jennifer A. Calzada 19 Collaborative Partnerships: Local, Regional, National, and Global���������������������������������������������������������������������������������� 141 Viren N. Naik Index�������������������������������������������������������������������������������������������������������������������� 145

Contributors

Jennifer A. Calzada, MA, MPH  Tulane Center for Advanced Medical Simulation and Team Training, Tulane University School of Medicine, New Orleans, LA, USA Helen Catena, BA, RN  KidSIM Program, Alberta Children’s Hospital, Calgary, AB, Canada Adam Cheng, MD, FRCPC  Department of Pediatrics and Emergency Medicine, University of Calgary, Calgary, AB, Canada C.  Donald  Combs, PhD  Eastern Virginia Medical School, School of Health Professions, Norfolk, VA, USA Thomas A. Dongilli, AT, CHSOS, FSSH  Department of Anesthesia, University of Pittsburgh, WISER Center, Pittsburgh, PA, USA Kristyn Gadlage, BE  Society for Simulation in Healthcare, Dyersburg, TN, USA Vincent  J.  Grant, MD, FRCPC  Departments of Pediatrics and Emergency Medicine, University of Calgary, Calgary, AB, Canada KidSIM Program, Alberta Children’s Hospital, Calgary, AB, Canada eSIM Provincial Simulation Program, Alberta Health Services, Calgary, AB, Canada Jeffrey D. Howells, MBA, MS  Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, USA Lennox Huang, MD  Chief Medical Officer, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada Lucas  Huang, BS Washington, DC, USA

Electrical

Engineering  B-Line

Medical,

LLC,

Gabriel Keeler, BA in International Business  EvalueServe, Inc., Raleigh, NC, USA George  R.  Keeler, Madison, WI, USA

BA,

MA

English

Education,

MBA  SimResults,

Teri  J.  Keeler, BBA, Finance; CPA  Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA

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Contributors

Vicki LeBlanc, PhD  Department of Innovation in Medical Education, University of Ottawa Skills and Simulation Centre, University of Ottawa and The Ottawa Hospital, Ottawa, ON, Canada Helen  Levin, MD  Department of Pediatrics, University of Western Ontario, London, ON, Canada Jennifer  L.  Manos, RN, MSN, MBA  Society for Simulation in Healthcare, Harrison, OH, USA Kevin Miracle  Kevin Miracle Consulting, Gibsonia, PA, USA Viren  N.  Naik, MD, MEd, MBA, FRCPC  Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada Nicola  Peiris, BSc  KidSIM Program, Alberta Children’s Hospital, Calgary, AB, Canada Glenn  D.  Posner, MDCM, MEd, FRCSC  University of Ottawa & The Ottawa Hospital, Department of Obstetrics & Gynecology, Ottawa, ON, Canada Paul J. Pribaz  Business Development, Enduvo, Inc., Peoria, IL, USA Michael  A.  Seropian, MD, FRCPC, FSSH  Department of Anesthesiology and Pediatrics, Oregon Health & Science University, Portland, OR, USA

Part I Business, Implementation, and Sustainability

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Governance and Organizational Structure C. Donald Combs

Overview Governance of a simulation program refers to the structure and processes through which the program ensures it is doing the right things in the right way. The right things include ensuring: • That program activities are supportive of the mission • That activities comply with applicable laws and regulations as well as with program and organizational policies • That information and communication flows allow consistent, accurate monitoring of program activities and outcomes Governance is the way an organization polices itself. It is the process through which an organization ensures that its values, policies, and laws are known and followed by all employees. Good governance increases the accountability of an organization and helps to mitigate risks. Governance in the case of a simulation program is multifaceted, usually involving organizational policies—human resources, accounting, marketing, compliance, etc.—and program policies, curriculum design, assessment, scheduling, procurement, safe learning environment, etc. Organizational structure specifies how the roles, authority, and responsibilities are assigned, controlled, and coordinated, both within a program and across the broader organization. It also delineates how information flows between different management levels. (Most simulation programs exist within a larger organization—a university, a hospital, or a health system—and thus have at least two organizational charts, one addressing how the program fits within the larger organization and another addressing the organization of the program). C. D. Combs (*) Eastern Virginia Medical School, School of Health Professions, Norfolk, VA, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 M. A. Seropian et al. (eds.), Comprehensive Healthcare Simulation: Program & Center Development, Comprehensive Healthcare Simulation, https://doi.org/10.1007/978-3-030-46812-5_1

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Key Issues and Points It is always useful to begin with definitions. They help establish clarity about the concepts. The definitions of governance and organizational structure are as follows: • Governance Governance is the establishment of policies, and the continuous monitoring to ensure their proper implementation, by the members of the governing body of an organization. Governance includes the mechanisms required to balance the powers of the members (with the associated accountability) and their primary duty of enhancing the prosperity and viability of the organization (http://www.businessdictionary.com/definition/governance.html, n.d.). Governance is the framework of rules and practices by which a board of directors ensures accountability, fairness, and transparency in a company’s relationship with its all stakeholders (financiers, customers, management, employees, government, and the community).The corporate governance framework consists of the following: (1) explicit and implicit contracts between the company and the stakeholders for distribution of responsibilities, rights, and rewards; (2) procedures for reconciling the sometimes conflicting interests of stakeholders in accordance with their duties, privileges, and roles; and (3) procedures for proper supervision, control, and information flows to serve as a system of checks and balances (http://www.businessdictionary.com/definition/corporate-governance.html, n.d.). • Organizational Structure It is the typically hierarchical arrangement of lines of authority, communications, rights, and duties of an organization. Organizational structure determines how the roles, power, and responsibilities are assigned, controlled, and coordinated and how information flows between the different levels of management. A structure depends on the organization’s objectives and strategy. In a centralized structure, the top layer of management has most of the decision-making power and has tight control over departments and divisions. In a decentralized structure, the decision-making power is distributed, and the departments and divisions may have different degrees of independence (http://www.businessdictionary.com/ definition/organizational-structure.html, n.d.). When establishing a new program, careful attention should be paid to specifying the organizational structure. Organizational structures are primarily communication flowcharts—up, down, and lateral. Consequently, poorly conceived organizational structures will result in ineffective communication and misdirection from the mission. Well-designed organizational structures will produce efficient communication channels and encourage fast, clean decisions. Organizations can be structured by function, in the case of simulation programs, for example, the structure could reflect the education, assessment, program development, and fund-raising functions of a program; by geography, in the case of a program with multiple, independent sites; or by customers, medicine, nursing, patient safety, or risk management as examples.

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Hospital

Governing Board

Hospital CEO

Vice President Nursing

Vice President Medical Affairs

Vice President Opreations

Simulation Program

Advisory Council

Fig. 1.1  Organizational Structure 1

• Organizational Charts The organizational chart is intended to serve as a clear visual representation of the lines of authority and responsibility in the organizational structure. Three examples illustrate some of the more common charts (Figs. 1.1, 1.2, and 1.3). The first chart (Fig. 1.1) represents a simple, generic structure where the simulation program is situated in a hospital. Clearly, the governing board of the hospital sits at the top of the structure, and the hospital CEO is responsible to the Board for assuring the implementation of the policies adopted by the Board. In Chart 1, the CEO has three direct reports—vice-presidents for nursing, medical affairs, and operations. The simulation program reports to the vice-president for operations. When the simulation program is in this position, the understanding portrayed by the chart is that the simulation program activities are primarily expected to serve hospital units located within the operations’ portfolio such as patient safety, risk management, and human resources. In addition, perhaps, the program may also address education and training needs within the nursing and medical affairs divisions of the hospital. Ultimately, in this structure, the vicepresident for operations is the primary client. Usually, a simulation program will also establish an advisory council that includes representatives from the major users of the program’s activities and that provides advice concerning their needs, their suggestions for future activities of the program, and their evaluation of the effectiveness of the program. Obviously, this chart could have been drawn such that the simulation program reports through one of the other vice-presidents. The main point is that the chart should clarify how a simulation program fits into the larger hospital organization. The second chart (Fig.  1.2) illustrates how a simulation program might fit within the structure of an academic institution. In this instance, the program is

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Academic Institution

Governing Board

President

Vice President Academic Affairs

Vice President Finance

School of Nursing

Vice President Development

School of Allied Health

School of Medicine

Office of Educational Technology

Simulation Program

Advisory Council

Fig. 1.2  Organizational Structure 2

Simulation Program

Directo r

Advisary Commitee

Associate Director Standardized Patients SP Educator 1

Associate Director Simulation Technology

Simulation Techician 1

SP Educator 2 SP Educator 3

Simulation Techician 2

SP Educator 4

Fig. 1.3  Organizational Structure 3

Administrative Assistant Research coordinator

Associate Director Planning, Budget and Business Development

Medical Director

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not located within an academic discipline such as nursing, medicine, or allied health. Rather, it is identified as a unit within an office of educational technology, indicating an expectation that the program serves a variety of academic programs across the academic institution and is therefore viewed as an institutional resource. An advisory council would, in this instance, be populated with users representing the variety of academic disciplines in the institution. Obviously, the program could also be located and report primarily to an academic discipline. The main consideration is that the chart should accurately reflect the reporting responsibilities of the simulation. As in real estate, location matters—it identifies the primary focus of the simulation program. The third chart (Fig. 1.3) represents the structure within the simulation program and would usually be developed in addition to the general organizational chart. In this example, the director of the program has two functional reports— the associate directors of standardized patients and of simulation technology— and four other reports, representing the business infrastructure of the program, the clinical expertise of a medical director and an administrative assistant, and, in this example, a research coordinator. Again, an advisory council would be composed of the most important, highest-frequency users of the program’s activities. These organizational charts are illustrative and necessarily generic. The most important consideration is that the charts should clearly portray where the simulation program fits in the larger organization and how it is organized to complete its work.

Key Resources and Partners Depending on the organizational structure, the most important resources and partnerships can be found among the professions—medicine, nursing, or allied health— or among the relevant functions of the organization, education and training, patient safety, and risk management, which support the simulation program’s activities. The foundation of the structure is reflected in the organizational mission and the simulation programs’ subsidiary mission in support of the organization. Partners should be sought who, through funding or involvement in program activities, have a shared interest in the development and success of the simulation program.

Key Approaches The director of a simulation program must know what the program is expected to do before the processes for doing it can be designed. Again, the mission of the organization and program, as well as the policies and expectations of the host organization, is central to establishing a simulation program structure that facilitates activities that meet expectations.

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The director should also develop an understanding of the requirements of simulation accreditation bodies as a guide to structuring the program. The Society for Simulation in Healthcare (SSH) and the Educational Institutes Program of the American College of Surgeons (ACS) both have peer-reviewed accreditation processes, and the standards they have developed are useful guides for establishing an effective simulation program (http://www.ssih.org/Accreditation/Provisional-­ Accreditation/Standards, n.d.; https://www.facs.org/education/accreditation/aei, n.d.).They have each accredited around 100 simulation programs. Their lists of accredited centers and the center directors are good sources of advisors who can provide guidance about establishing sound governance and organizational structures.

Pearls • • • • • •

Focus on the mission. Know and engage the key stakeholders. Value must be bidirectional between the program and the users. The insights of those looking over the shoulder of the program should be valued. Do not undervalue simulation activities. Things change, so be prepared to evolve.

Key Take-Aways • • • •

Clarity of governance: know what you are supposed to do and how. Clarity of structure: know who you report to and their priorities. The mission defines what the program is expected to achieve. Governance and organizational structure must reflect the mission.

Suggested Reading and References http://www.businessdictionary.com/definition/governance.html. http://www.businessdictionary.com/definition/corporate-governance.html. http://www.businessdictionary.com/definition/organizational-structure.html. http://www.ssih.org/Accreditation/Provisional-Accreditation/Standards. https://www.facs.org/education/accreditation/aei.

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Importance of Executive Buy-in Lennox Huang

Overview Engaging leaders is a key competency for successful simulation programs and simulation leaders. Effective communication is the first step to engagement and can take many forms. Tailoring communication in both structure and content can increase the likelihood of achieving buy-in.

Key Issues and Points Engagement starts with knowing and understanding your audience. The following key points apply to both written and verbal communication. The first step for many is to identify potential decision makers and influences in an organization. In some cases, this will be relatively straightforward and can be found on an institutional org-chart. Some decision makers and influencers may not appear on organizational charts or hold official titles. Once you have identified an audience, the next step is to try and understand your audience and what they value. In design thinking, this is called “deep empathy.” Box 2.1 identifies some considerations:

L. Huang (*) Chief Medical Officer, The Hospital for Sick Children, 555 University Ave, Toronto, ON, Canada e-mail: [email protected] © Springer Nature Switzerland AG 2020 M. A. Seropian et al. (eds.), Comprehensive Healthcare Simulation: Program & Center Development, Comprehensive Healthcare Simulation, https://doi.org/10.1007/978-3-030-46812-5_2

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Box 2.1 Understanding Your Audience

• • • • •

Are they a decider or an influencer? How have they made decisions in the past? Are they in a position to make a decision now? What is important to them? Listen very carefully to what they have to say and in particular their thoughts. • Show them that you are listening. • Try to make a genuine connection based on common interests.

After identifying and understanding your potential audience, one needs to decide on your purpose/goals for communicating with your audience. Timing is important at this stage, and it is important to not to engage top-level decision makers too early or to involve them in relatively minor decisions that might be made by other leaders in an organization. Identifying the purpose behind engaging a leader or influencer is important because structuring an effective meeting with that individual starts with outlining the purpose of that meeting. Traditionally, communication of science or healthcare information starts with a hypothesis, followed by data and then the conclusions. Communicating to influence often reverses this by leading with the conclusion/impact and then building in supportive information in the form of data and stories. It’s also important to remember that verbal communication is generally inefficient, and it is better to be focus on a limited number of key points rather than overwhelming people with information (Box 2.2).

Box 2.2 Key Points

Structure your communication • Lead with the purpose. • Group ideas into threes into both rational and emotive elements. –– Stories are easier to remember than facts. –– Feelings are often remembered more than facts. –– People often need both to make a decision. • An assertion is not the same as evidence. • Try to use groups of three points. • Close with a summary and a commitment.

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Key Approaches Be Opportunistic The classic opportunistic approach to engagement comes in the form of an elevator pitch. The term arises from a coincidental meeting of individuals in an elevator and implies that the duration of contact will be less than 2 minutes. A successful elevator pitch can lead to continued conversation and potentially longer more formal meetings. Content and delivery are essential components for a pitch, and the pitch often requires considerable advance planning and practice. Common elements to elevator pitches (Box 2.3) Box 2.3 Elevator Pitches

Permission to engage • There’s something I’m working on that will really make a difference to the hospital. Can I take a minute to share it with you? Have an attention getting, catchy, impactful lede/headline. • We’ve figured out a way to improve our hand hygiene compliance by 20%. Describe no more than three key benefits to what you have to sell (how will things be different). • Improved infection control • Higher engagement • Lower staff turnover Support the benefits with stories/evidence. • For example, nurse X was telling me how much he/she looks forward to our simulation days and how none of the other hospitals in the area are doing this. (optional) Explain your role and how you’ll contribute to the success of what you have to sell. Offer and be prepared to answer questions. Get a commitment. • Could I contact your assistant so we could set up a longer meeting when it’s convenient for you?

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The classic elevator pitch is less common now that people are often accessible through email and social media. May organizations are also changing how they structure the physical workspace with leaders being placed where they can more easily interact with frontline employees. Pitches may now take the form of 140 character tweets or single images.

Tell a Story The best story is often the simplest. One example of a story structure comes from Pixar: Once upon a time there was ___. Every day, ___. One day ___. Because of that, ___. Until finally ___. When applied to simulation it might take the following form: For as long as I can remember, our approach to onboarding new clinical staff was to have them sit through a half day of power point slides. Every 6 months, our new hires gather in the auditorium to hear how our code and telecommunications systems work and how to activate our emergency response team. One day a new hire spoke up and asked whether there was a more effective way to teach this content. Because of that we explored using simulated scenarios that illustrated our hospital systems. Now new staff actively practice these skills before needing to apply them in a real scenario. Stories are often more memorable than data, and they are more likely to shift perceptions and culture. Being able to tell a story involves planning out the content, the timing, and the delivery. Stories can also be an effective way to impart feelings such as joy, anxiety, or pride. Planning a story can be as simple as writing it, or it can involve other creative techniques such as drawing. Consider using storyboarding where steps are drawn out to tell a message.

Illustrate Desirability, Feasibility, and Viability The most valuable ideas come from the intersection of these three concepts (Fig. 2.1). You should be prepared to address each of these elements when engaging decision makers and influencers. The most common pitfall is to not consider desirability from a broad perspective or to ignore the viability of a particular project. Feasibility and viability often require data and may involve significant resources. When possible, a basic business plan or model can help bring a proposal to fruition.

Use Impactful Words and Phrases The language used to communicate a pitch or story is important. Focusing on the positive is generally a good tactic as is reflecting the language used by your audience. It is also important to use names to build the connection with your audience. Some words and phrases are more likely than others to engage and persuade audiences. Examples of these are listed below:

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Fig. 2.1  Sweet spot

Desirable

Feasible Sweet Spot

Viable

• Examples of strong words/phrases: –– Because –– Imagine –– Exciting –– Transform –– Help –– Discover –– Results –– Save –– Safe –– Time –– New –– Know • Examples of building phrases: –– For this reason… –– As a result… –– Yes and… –– That’s very interesting. Can you tell me more?

Pearls 1 . Identify your target audience to influence. 2. Develop a deep understanding of their needs and values. 3. Identify your purpose in communicating with your audience. 4. Structure your communication. 5. Tell a story. 6. Use impactful words and phrases.

The Sweet Spot

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Key Take-Away Achieving executive buy-in requires communication skills, preparation and engagement. Executive buy-in is imperative for the success of any simulation program.

Suggested Reading Carnegie Associates. How to win friends & influence people in the digital age. Simon & Schuster; 2011. Carnegie D. How to win friends and influence people. Simon & Schuster/Dale Carnegie; 1936. Kelly T, Kelly D. Creative confidence: unleashing the creative potential. Crown Business; 2013. Peters T. “The wow project” (PDF). Fast Company, 24; 1999. p. 116. Pink DH. To sell is human: the surprising truth about persuading, convincing, and influencing others. Edinburgh: Canongate; 2014. Print.

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Establishing your Vision, Mission, and Strategy George R. Keeler

Overview Vision, mission, and strategy statements are essential for building an effective simulation program. They are the foundation for facility and program design, as well as the strategic business and marketing plans. Vision  An aspirational description of what an organization would like to achieve or accomplish in the mid-term or long-term future. It is intended to serve as a clear guide for choosing current and future courses of action [1]. An entity’s vision represents its place in the world and should be used as a beacon and standard for major decisions, especially those affecting direction and strategy. Example: Be a provider of high-quality and safe patient care. Mission  A written declaration of an organization’s core purpose and focus that normally remains unchanged over time. Properly crafted mission statements (1) serve as filters to separate what is important from what is not, (2) clearly state which markets will be served and how, and (3) communicate a sense of intended direction to the entire organization [1]. The mission embodies the reason for being. Example: Provide a comprehensive healthcare simulation program with focus on the healthcare teams, including patients, as well as the individual provider. A mission is different from a vision in that the former is the cause and the latter is the effect. A mission is something to be accomplished, whereas a vision is something to be pursued. Strategy  A method or plan chosen to bring about a desired future, such as achievement of a goal or solution to a problem [1]. Strategy is more about what you are G. R. Keeler (*) SimResults, Madison, WI, USA © Springer Nature Switzerland AG 2020 M. A. Seropian et al. (eds.), Comprehensive Healthcare Simulation: Program & Center Development, Comprehensive Healthcare Simulation, https://doi.org/10.1007/978-3-030-46812-5_3

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Mission Statement:

Vision Statement:

*Who we are *Who we value

*What we want to become

Strategy *How we will achieve our vision

Goals & Objectives: *How we gauge our degree of success

COMMUNICATING PURPOSE TO STAKEHOLDERS

Fig. 3.1  Vision, mission, and strategy statements

going to do, whereas tactics are the actions and activities by which a strategy is implemented. Example: Leverage relationships with department chairs and heads, as well as simulation champions to achieve buy-in for the simulation program within the organization (see Fig. 3.1).

Key Issues and Points All service lines should start by constructing a sound business plan which aligns with the strategic business plan of the larger organization. This step also holds true for simulation programs. It all starts with a business plan. And the foundation of the plan is built upon clear, compatible vision, mission, and strategy (Fig. 3.2). It is imperative for the success of a program that the vision, mission, and strategy should be well developed and documented with input from organizational leadership and key players, such as simulation champions. Buy-in from these individuals creates stakeholders in the program. Well-developed business plans add credibility to an entity and its management team. Without these three key elements, a business plan is incomplete.

Key Resources and Partners Leverage existing and potential internal stakeholders. Executive and senior leadership: These individuals and groups appreciate the need for development of a clear vision and mission. Vision and mission statements must align with the strategic direction of the organization.

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Fig. 3.2  Constructing a business plan Marketing Plans

Program Design

Vision Mission Strategy

Facility Design

Business Plans

Department chairs, heads, chiefs, and administrators: These leaders and managers are some of the most influential people for your client base. Thus, input and buy-in from them are crucial. Simulation champions and experts within the organization: This group is critical for the execution of strategy and tactics. They need to believe in and fully support the vision, mission, and strategy of the program. Business planning and analytical groups within the organization: These professional teams can be extremely helpful in developing the vision, mission, and strategy. This group can assure that both the format and content are congruent with those of the organization. External Resources Other simulation programs and simulation societies and their members offer a wealth of knowledge and experience. They can help to define the differentiators of your program and offer guidance in creating the vision, mission, and strategy of your program. Input from patients and their family members is most certainly applicable. They are part of the healthcare team. Business and simulation consultants may be extremely valuable for designing and executing surveys and assessments for your client base and in developing succinct business plans.

Key Approaches The development of vision, mission, and strategy statements is a dynamic and iterative process. Review of the organization’s annual reports, business plan, and vision and mission statements is essential. Meetings and brainstorming sessions with

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leadership and champions define and refine the details of the statements of the simulation program, thus making the statements concise and precise. Such meetings and sessions also create ownership in the program and its direction.

Pearls Clear, realistic vision, mission, and strategy statements, which are compatible with the larger organization’s plans and goals, are vital for strategic business planning. They offer direction and credibility to the program and its management. The process of developing these statements creates alliances, collaborations, and stakeholders. Although the process may seem arduous, it is well worth the journey. Vague or no statements lead to lack of direction, plans, and support. All of which are detrimental to the success of any program. Therefore, you must invest up front the time and effort to define the vision, mission, and strategy of the program. Such an investment pays great dividends.

Key Take-Away Vision, mission, and strategy are imperatives for success.

Reference 1. BusinessDictionary.com.

Suggested Reading “Building a healthcare simulation program” – METI healthcare human patient simulation conference, Tampa, February 2011. “Developing an effective and efficient marketing plan for your simulation program,” – the international meeting for simulation in healthcare, San Francisco, January 2014.

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Basic Business Planning Gabriel Keeler, George R. Keeler, and Teri J. Keeler

Overview This chapter provides an executive-level view of the purpose and key elements of an effective business plan. We begin by reviewing some common definitions, then provide details on the key components of a comprehensive business plan, and, finally, review some of the best practices for communicating the plan to leadership.

Definition of a Business Plan: What Is It? If you have been in business at any level, you have heard management discuss the need for a “plan.” So, what is it and why should you have one? And, perhaps most importantly, what comprises a successful business plan? Entrepreneur provides a comprehensive viewpoint of a business plan: A business plan is a formal written document containing business goals, the methods on how these goals can be attained, and the time frame within which these goals need to be achieved. It also describes the nature of the business, background information on the organization, the organization’s financial projections, and the strategies it intends to implement to achieve the stated targets. In its entirety, this document serves as a road map that provides direction to the business [1].

G. Keeler (*) Evalueserve, Inc., Raleigh, NC, USA G. R. Keeler SimResults, Madison, WI, USA T. J. Keeler Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA © Springer Nature Switzerland AG 2020 M. A. Seropian et al. (eds.), Comprehensive Healthcare Simulation: Program & Center Development, Comprehensive Healthcare Simulation, https://doi.org/10.1007/978-3-030-46812-5_4

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There is an overabundance of important information contained within a business plan. Plans may cover 1 year with an emphasis on operations, short-term actions, and budgets (these plans are usually for established enterprises); 3 years, which are usually plans for start-ups, enterprises in their infancy, or adolescence stages; and 5 years, which are usually long-term, strategic plans for a view of return on capital investment (these plans carry higher risk and more uncertainty).

Key Issues and Points Importance of a Business Plan: Why Should I Have One? As stated in its definition, the most important reason why one should have a business plan is because it serves as the well-documented road map for the enterprise. A business plan establishes guiding principles and structure, not only what you want to accomplish but also how, which is equally, if not, more important. Simply stated, countless conventional studies have demonstrated that those who document their goals and aspirations are much more likely to achieve them than those who do not – up to 1.4 times more likely according to a recent Forbes article [2]. This is the core reason why a business plan is imperative for success.

Scope of a Business Plan: What Should It Include? There are many easily available resources online and in business literature that provide outlines for business planning. These can be customized to the context of the business and preferences of the writer. For simplicity purposes, key components are listed and provided with short definitions: 1. Executive summary: Highlights the major elements of the plan and focuses management attention on items requiring decisions and support. The summary gives the basics of the plan and creates interest. 2. Introduction: Briefly describes products and the business, purpose of the plan, and markets and clients to serve. 3. Vision and mission statements: Define the nature of the business (Chapter 3). 4. Goals and objectives: State the desired future state of the business; objectives are shorter term and should be measurable. Goals are generally longer term and need to be realistic (survival, growth, share, and profitability). 5. Market size and dynamics and customer profile: Offer details on the characteristics and behavior of your prospective clients and their market segments, size and growth potential of the market segments, and what are the drivers of the segments. 6. Need/gap analysis: Summarizes the unmet needs of your clients. Address the obvious needs but especially the unmet ones, observe client processes and behaviors, and listen intently to your clients.

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7. Product/service offering(s): Details your portfolio of products and services which meet the unmet needs of your potential customers. 8. SWOT analysis: Identifies and analyzes the strengths and weaknesses of the organization (internal) and opportunities and threats of the external environment. 9. Strategy and tactics: Developed from minimizing threats and weakness, maximizing strengths, and capitalizing on opportunities. Explain how objectives are achieved. 1. Marketing and promotional plan  – How you effectively communicate to reach and educate your clients about the business. 2. Capital expenditures and investments  – Summary of key overhead and investments required to start up, operate, and grow the business. 3. Team analysis – Breakdown of the roles, skill sets, and people required to run the business effectively and efficiently from the start 4. Competition – Information on key competitors (both within the organization and externally). Includes facilities, product offerings, and their activities. 5. Positioning – What differentiates your program from others? 6. Pricing – What is the pricing strategy and structure for products offered? 7. Funding sources  – Source of funds such as grants, subsidies, department allocations, fees, sponsorships, donations, etc. 10. Financial projections [3]: Creating financial projections for a business plan is both an art and a science. It is challenging to predict your financial performance 3–5 years out, especially if you do not have historical data. Nevertheless, pro forma financial statements are a requirement of a business plan if you want engagement and buy-in from stakeholders. Key financial projections: • Sales/revenue forecast • Operating budget • Profit and loss statement • Capital budget Key tips in preparing financial statements: • Become proficient with spreadsheets or invest in a financial projection software package. • Be realistic and clearly define your key assumptions. • Prepare a 5-year projection with focus on years 1–3. • Present most likely case scenario. Have backup slide of worst case. 11. Action plan at a quarterly level: Summarizes key activities by quarter of the first year. These must be consistent with vision and mission of the plan and organization, strategy, the environment, and available resources. Rely on developed strategies and tactics. 12. Risks: • Identify key challenges, both internal and external, that may negatively impact the business. • State how to mitigate the risks. 13. Summary: Overall head and tail winds (big picture of what may hold you back and what will lead to success) and the real significant points of the plan.

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Key Resources and Partners Internal Resources Executive and senior leadership: These individuals appreciate the requirement for a business plan because they have a vested interest in the success of the organization. Dean, department chairs, and administrators: These leaders are crucial to the overall support for the simulation program from both a business planning and funding perspectives. If the healthcare system has a business development and planning group, then they may provide forms, examples, formats, financial analysis, and expertise for an effective business plan.

External Resources Other simulation programs, simulation societies, administrative healthcare associations, and their members are sources for best practices for developing an effective business plan. Some may be willing to share their plans. Business consultants may provide valuable input into the business planning process. If needed, they can also function as co-authors or editors of a plan.

Key Approaches Developing a Business Plan Based on extensive personal experience, there are a few lessons learned we want to share on how to approach writing a successful business plan: 1. Develop an outline or template of the key sections (refer to the outline above). 2. Follow a format recognizable by the readers (use one developed by the organization, if available). 3. Consult key people within your organization (see resources section). 4. Iterate. Do not expect to write everything at once. Make sure to block time over a few days or weeks to get this important activity accomplished. 5. Be precise, factual, and concise in your writing. Sometimes less is more. 6. Use tables and graphs to present information. 7. Document sources of data and information. 8. Treat a business plan as a living document. Recognize that it evolves and changes as conditions change. A plan will not be perfect in the first iteration (or ever). Continue to refer to the plan and expand key sections. Remember it is a “road map.”

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Presenting to Leadership While writing a business plan is certainly key to success, effectively presenting it to leadership is equally, if not, more critical than the written plan. Again, based on experience here are recommendations to ensure a solid presentation and a positive outcome. 1. Plan ahead. Plan for the worst, i.e., potential naysayers and in-depth, tangential, or controversial questions, and have backup slides. 2. Know as much about the audience and their individual areas of interest in the program and plan ahead of time. Acknowledge that their buy-in is a must-have to move forward. They are stakeholders, and some should have offered input to the business plan. 3. Do not assume that your audience thoroughly understands the subject matter of healthcare simulation and its benefits. You may want to clarify/define it first. 4. Prepare a written outline of the presentation. Keep it concise, precise, and on point. 5. Create text light, visually appealing slides to accompany the talk track. Do not read slides. Do not have distractive slide layouts or too many PowerPoint gimmicks such as overly creative animations. There is value in keeping things simple. 6. Practice ahead of time with peers to gain confidence and collect feedback. 7. Socialize a summary of the business plan and the agenda of the presentation to key stakeholders in advance of the meeting. 8. On the day of the presentation, clear the calendar to stay focused and avoid stress. 9. Hand out a hard copy of the presentation for people to take notes. 10. Stick to the time allotted for the presentation. Include time for questions. 11. During the presentation, ask a colleague to keep brief notes of concerns. 12. Emphasize objectives, strategy, and action plans. Go light on situational analysis. 13. Avoid introducing controversial topics requiring discussion. Manage your audience. 14. Try to postpone questions to the end of each major section or, better, to the very end of the presentation. Avoid being diverted by questions or comments that disrupt the order of your presentation. 15. If you do not know the answer to a question, confess, but follow up with “I’ll get you the answer as soon as possible.” Don’t try to provide a fabricated response. 16. Stand and deliver with confidence, enthusiasm, and commitment. You have prepared thoroughly. It is time to seize the moment! Sell your plan! 17. Leave the presentation with commitment from the audience and clarity of any follow-up required. Offer each key stakeholder an electronic and hard copy of the in-depth plan.

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Pearls • • • • • • • • • • •

Engage internal resources. Communicate, communicate, and communicate. Conduct a thorough internal and external discovery phase before writing the plan. Develop an outline. Write precisely and concisely. Be factual. Iterate the plan several times. A business plan is dynamic and, therefore, often needs to be reviewed and updated. Presentations must be well prepared and practiced, practiced, and practiced. Know your audience and prepare them in advance. Be prepared for the hard questions. Over-prepare and have backup slides. Don’t assume anything. Manage your audience and time. Sell, sell, sell the plan with confidence and conviction to achieve buy-in.

Key Take-Aways A thorough business plan serves as a well-documented road map for the enterprise. A plan establishes guiding principles and structure, not only for what you want to accomplish but also how you are going to achieve your goals. And, a well-thought-­out and complete business plan is indispensable for success. In addition, an effective presentation of the business plan to leadership is critical to “sell” the plan and achieve buy-in from key stakeholders and constituents.

References 1. Entrepreneur small business encyclopedia, 2018 edition. 2. Murphy M. Neuroscience explains why you need to write down your goals if you actually want to achieve them. Forbes Magazine, Murphy, 15 Apr 2018. 3. Richards D.  Writing a business plan  – financial projections. The Balance Small Business, Entrepreneurship, updated 13 Apr 2019.

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Implementation, Phases, and Project Management Kristyn Gadlage and Jennifer L. Manos

Overview Project management helps achieve the goals and objectives of program implementation. Project management strategies increase project success, decrease risk and costs, and help to achieve greater efficiencies and effectiveness in the execution of projects. A project has a defined beginning and end with defined scope, purpose, and allocated resources [1]. The output of a project is a set of objectives or desired outcomes that must be accomplished within given constraints. A specific budget and period of time are often two of the major constraints identified within projects. These constraints are key in helping to distinguish projects suited for project management. As an example, something that is continuous and ongoing, such as management of a staff member, would not be appropriate for utilizing project management as a tool for successful project implementation. On the contrary, a project with defined parameters (e.g., a beginning and end date and a budget) that aims at accomplishing specific objectives for the betterment of an organization or program would be an ideal scenario to implement project management tools. An example of a project within a simulation center might be to undergo the process of applying to become accredited. Project management is defined as the body of knowledge concerned with principles, techniques, and tools used in planning, controlling, monitoring, and reviewing of projects [2]. In addition, project management can further be defined as the K. Gadlage Society for Simulation in Healthcare, Dyersburg, TN, USA e-mail: [email protected] J. L. Manos (*) Society for Simulation in Healthcare, Harrison, OH, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 M. A. Seropian et al. (eds.), Comprehensive Healthcare Simulation: Program & Center Development, Comprehensive Healthcare Simulation, https://doi.org/10.1007/978-3-030-46812-5_5

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application of knowledge, skills, tools, and techniques to meet project requirements [3]. In its simplest form, a project can be defined as something that produces an output.

Key Issues and Points Projects can be considered short or long term but should be accompanied with a well-defined beginning and end. Successful project management requires: • Properly defined project group  – a group of team members that must work together who normally might not do so • Well-defined and well-outlined project life cycle that includes identification of boundaries and hurdles • Identification of sufficient resources The adherence to project management principles, methods, and strategies helps to reduce risk, decrease cost, and improve overall success rates of project implementation [4]. Having the ability to deliver projects on time and within budget can lead to greater satisfaction by key stakeholders and the ability to further develop programs and services in the future. Successful project management can serve as a bridge between strategy and results.

Key Resources and Partners Project management is a critical component to the implementation of successful projects that can have a positive influence on organization and programmatic results. However, one must implement the correct resources and partners to achieve successful project management. In short, resources and partners can be defined as: 1. Project manager  – A project manager has in-depth knowledge of key project management areas related to the following [4]: 1. Integration 2. Scope of project 3. Time 4. Cost 5. Quality 6. Procurement of resources 7. Human resource allocation 8. Communication 9. Risk management 10. Stakeholder management

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2. Internal resources include executive leadership, chief administrators, simulation champions, and business or project management teams already developed within the organization. Note, often times, that institutions have experienced project managers, such as project engineers, that may be able to provide guidance or training to help a program achieve successful project management. 3. External resources include experienced simulation programs, simulation consultant firms, and project management consultant firms that can all be utilized to meet the needs of the program. 4. Project management tools are typically defined as the software utilized to map out the project timeline, update milestones, and provide a platform of communication for the project team. Examples of these tools include but are not limited to: (a) Smartsheet (b) Basecamp (c) Workzone (d) Microsoft Project Remember, every project may require different needs and resources. While a small project may require less expertise to effectively manage a successful project management plan, a large-scale project may require the assistance from external resources (e.g., the expansion of a simulation program or the development of a new simulation program).

Key Approaches It is important to remember that there are many different approaches that can be taken to successfully manage projects. One of the most common project management approaches, known as the “traditional approach,” breaks a project down into four different phases. These four phases are commonly known as the “Life Cycle of a Project” (Fig. 5.1). The stages of the project can be modified to adapt to your specific project or organization. What’s important is that the underlying purposes behind each of the stages should be considered and implemented throughout the stages of the project life cycle.

Phase One: Project Initiation The first phase within the life cycle of a project is known as the initiation phase. Its purpose is to: • Explore the reason behind the project • Determine its feasibility • Clearly define the project goals and objectives

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Phase 1: Project Initiation

Phase 2: Project Planning

Phase 3: Project Implementation, Monitoring & Control

Phase 4: Project Close Out

Fig. 5.1  Life cycle of a project

Once a project has been determined feasible and concrete goals and objectives have been defined, the first step is to identify and assign a project manager. Once a project manager has been assigned, the first step he or she is responsible for within the initiation phase is to develop a project proposal. This proposal should: • • • •

Clearly define the scope of the project Define the project goals/objectives Describe the “feasibility” stage of the project to address project validity Include a proposed project team, budget, and timeline

Phase Two: Project Planning The planning phase is the second phase in the life cycle of the project. The project is reviewed, planned, and detailed from start to finish during this phase. The three biggest deliverables of this phase are the: • Project plan and timeline • Project budget • Project team The purpose of this phase is to develop a thorough outline of the project, which defines the time, costs, and resources associated within each of the different steps of the project. In general, this phase should begin by reviewing the list of project objectives and developing a list of activities that are needed to complete each objective.

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These activities should be as specific as possible and should be placed in chronological order. Once the activities are determined, the individual(s) (or departments) required to complete each of those activities, as well as the costs associated with each of those activities, should be defined. The individuals identified become the “project team,” and the costs determined become the project budget.

Phase Three: Project Implementation, Monitoring, and Control The third stage of the project life cycle is known as the “Implementation, Monitoring, and Control” phase; the purpose is to verify that the project outline, schedule, and budget are all being properly executed, monitored, and controlled. The project manager is responsible for overseeing this portion of the project. They should, on a frequent basis, be reviewing the project outline and ensuring that the activities associated with the project are being completed within their given start and end dates. In addition, the manager should be verifying that all costs incurred with the activities are being projected appropriately and remaining within budget. During this phase, it’s often suggested that the project manager schedules reoccurring weekly (or sometimes daily) meetings with the project team to receive activity updates. This phase is often the longest of all the phases. A proposed successful execution of this phase might be as follows: • The project manager reviews the project outline every morning for the first 15 minutes of the day. • He or she determines the project activities that are to be accomplished within the week. • The project manager then contacts the team member responsible for each of the activities to receive updates (regarding timeline, progress, costs, etc.). –– If everything is on track, no changes need to be made. –– If there is an issue with a specific activity (e.g., it’s scheduled to be completed in 3 business days but will actually take 6), the project manager would then be responsible for updating the project schedule and project budget to accommodate the changes. In addition, the project manager would be responsible for communicating the changes to all involved team members.

Phase Four: Project Closeout The final phase of the project life cycle is the closeout phase. As defined by its title, the purpose of this phase is to close out the project. The project manager is responsible for determining both when and how to implement this phase. Ultimately, the closeout phase begins once all of the project goals/objectives have been met and all

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project members agree that the goals/objectives have been met. Project closeout is often one of the shortest phases within the project. If the first three phases of the project were implemented correctly, the closeout will be relatively short. The deliverables of this phase which the project manager is responsible for include: • Project report which summarizes the project and evaluates the success of the project by reviewing how close the project stayed within its timeline and budgetary constraints. • Final budget which compares the proposed costs to the actual costs. • Team debrief with all members of the project team. This debrief should help to identify project strengths and areas of improvement for future projects. A summary of this debrief is often included in the project report.

Key Take-Away Effective project management allows for increased project success, a decrease in risk and cost, and achievement of greater efficiencies in the implementation of strategy-­driven initiatives. • • • • • • •

Have a timeline. Insist on accountability. Have individuals/teams take ownership. Monitor progress. Adapt. Accept failure but re-adjust. Perform as a team.

Resources Project management group within parent organization. Project Management Institute (www.pmi.org)

References 1. 2. 3. 4.

www.PMI.org: what is project management. 2017. BusinessDictionary.com. 2017. www.PMI.org: what is project management. 2017. The value of project management: PMI White Paper .2010.

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Funding Sources and Fee Structures Paul J. Pribaz

Overview Although people claim to understand the concept that there is no such thing as “free” when it comes to providing education, it is remarkable how troublesome it is to discuss the actual bill. This chapter will explore the how-to and, most importantly, the why of creating a robust, defensible fee structure for your simulation activities. Whether or not the actual movement of money is required at your program, your leaders will appreciate a rational approach to quantifying expenses, tracking costs, and being proactive when it comes to funding.

Key Issues and Points Rationale for Creating a Fee Structure Unless your simulation program has a single user responsible for 100% of your operating budget, it is very likely that you will be required to present pricing for your services to a variety of internal and external “customers.” Without a clear rationale for how you justify the pricing scheme, it will be difficult to solicit new users and challenging to maintain existing ones. If your program participates in any activities that are supported by taxpayer funds, there is an additional burden of complying with laws and regulations around your fee structure that, if ignored, could lead to civil or criminal consequences. In the United States, the government provides a clear road map for determining

P. J. Pribaz (*) Business Development, Enduvo, Inc., Peoria, IL, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 M. A. Seropian et al. (eds.), Comprehensive Healthcare Simulation: Program & Center Development, Comprehensive Healthcare Simulation, https://doi.org/10.1007/978-3-030-46812-5_6

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reasonable fees, and the principles behind these rules follow generally accepted accounting principles (GAAP), which make them universally applicable. Finally, a sound fee structure is a key ingredient for creating a financially sustainable enterprise. Accurate measurement of expenses and revenues creates confidence with the budget and finance professionals at your institution and also is the basis for calculating return on investment (ROI) measures for your program.

Principles for Your Fee Structure It is critical to understand the “cost of doing business,” even if your funding comes from a single source; when expenses exceed revenues, you are on an unsustainable financial path. There is a significant risk that a novice administrator could create a fee structure that does not accurately capture the true cost of operations. However, following these basic principles will ensure a solid framework that can support even the most complex of operations: • Reasonableness: Does your pricing scheme make sense when considered as a whole? Is it manageable from an administrative point of view? For example, a small program may have a single hourly rate for any simulation services; however, it would not be reasonable at a mid- or large-sized program to charge the same rate for a conference room that you might for an anatomic lab. Your fees must pass the “smell test.” • Allocability: Do your rates cover the actual costs of services and equipment that can be directly allocated to the activity? In other words, unless you have one single rate for any activity, charging the standardized patient program for costs associated with maintaining virtual reality equipment is an example of non-allocability. • Allowability: Most institutions, as well as government funders, describe certain categories of expenses that are not allowed or tightly restricted, for example, food, alcohol, first-class travel, or salary compensation above certain maximums. It is important to be attentive to these restrictions and not include them in your fee structure. • Consistent treatment in like circumstances: Although it is permissible to create tiered pricing schemes based upon the “kind” of user (e.g., the student rate for simulation is lower than the external industry rate), it is generally not allowed for the same kinds of users to be treated differently from one another. While this makes intuitive sense, the practical outcome is that costs by service category will likely need to be blended into a single rate, irrespective of the equipment or materials used.

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Identifying Your Funding Sources There are two basic types of funding: internal and external. Depending upon your program’s scope and mission, your leadership may give direction on the preferred blend of internal and external sources, as well as any longer-term objectives for financial sustainability. A key skill for a program administrator is to have a thorough understanding of how to secure both operating and capital resources. Some considerations for each type of funding are as follows: • Internal funding –– Hierarchy of your budget: do you know how your budget “rolls up” and who has authority at each level of approval? –– Annual budget process: it’s critical to understand the entire process at your institution and how to solicit help if you need it. –– Capital requests: this may or may not be aligned with the regular operating budget. Are out-of-cycle requests a possibility? How do capital requests get approved? –– Internal transfers: do other departments or units at your institution “pay” for your services? If so, how do funds get transferred? Are there allocations made to those units to cover the expense that they might generate with you, or does the funding come from a general pool? –– Duration of funding streams: often a funding commitment will expire after a certain amount of time has passed. Do you know if that is the case for any of your revenue sources and how to extend commitments? –– Sustainability: are you required to reach some level of self-sufficiency? What happens if you don’t? –– Reporting and value demonstration: what kind of metrics do your leaders seek, and are you able to gather those figures? Can the value for your program’s services be determined, and does that value impact your ability to secure additional resources? –– Intramural grants: does your institution offer competitive internal grants or other kinds of support? Are you “plugged in” to the degree that you are aware of these opportunities? • External funding –– External learners: can you solicit external participants to any of your courses? Do you have the ability to collect payment from them? –– Other institutions: would it be possible or desirable to make your simulation spaces available to learners from other local institutions or academic societies? –– Grants: are there private or public granting agencies that could be relevant to your program? Do you have the time capacity to apply for these funds? Do you have the structures in place to successfully administer and perform if you were awarded a grant? –– Philanthropy: does your institution actively solicit philanthropic support? Are the gift officers aware of your program and do they understand how to

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promote it? Are you prepared to “pitch” your simulation program to a potential donor? –– Corporate partners: does your institution allow corporate sponsorship? Could you offer space for training courses or testing programs for these companies?

Key Resources/Partners In creating your fee structure, there are two primary partners for ensuring success: • Finance and accounting: The professionals working in your institution’s central financial office are ultimately responsible for financial compliance. Identify the appropriate individuals and engage them early in the process. Invite them for a tour of your simulation facility and have a conversation about all of the new revenues you aspire to secure and the value you seek to demonstrate. It may be the most exciting meeting they’ve had all year! In all seriousness, their assistance is invaluable, and ultimately, their approval is necessary, so take advantage of any spreadsheet-crunching skills they can lend along the way. • Leadership: The level of leadership that you want to reach at your institution is the person responsible for approving your annual budget. Often these individuals are extremely busy, especially at budget time, and may have very broad administrative oversight, so it may take some time even to schedule a meeting. For political reasons, it often makes sense to work your way up through the chain of command first, and you may find yourself repeating the same message several times. However, the effort is truly worth it when this person becomes aware of the financial transparency and stewardship you demonstrate for your simulation program. This person can be a critical ally if questions ever arise about your fees and rates, and they will be well educated to support you.

Key Approaches Steps for Creating a Fee Schedule • First, determine the broad categories of service offered at your program. It may be tempting to create a space or room cost, but you’ll find that programming often happens in space it was not originally intended for. Better to conceptualize your services and what it takes to deliver them. Common activities might include “task training,” “high-fidelity simulation,” “tissue-based training,” “standardized participant,” “virtual reality,” “computer lab,” etc. • Next, decide what the relevant unit should be for each identified service. This is typically a combination of time (e.g., 1 hour), room type, and labor, which may include grouping (e.g., “1 hour of high-fidelity simulation” includes the simulation room, the debriefing room, and one simulation specialist).

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• Examine whether or not faculty or instructor time should be included in your program’s rates. This is highly variable, depending on how their time is compensated and how their employment is structured, but is certainly a significant expense. • Within each identified service, determine all of the relevant equipment that could be utilized. At this point, a spreadsheet program becomes a useful tool for tracking (e.g., Microsoft Excel or Google Sheets). Equipment should include capital items (e.g., high-fidelity simulators), room furnishings (e.g., beds, carts, monitors, medical instruments, etc.), and audio-video equipment. Your colleagues in the finance office will want to see purchase dates and prices paid for everything. Note also that institutions may have slightly different definitions of “capital” equipment, based upon a purchase price threshold that differs from place to place. • Consumables and disposables are other expense categories that become significant at busy programs. Consumables include limited-use parts for simulators and task trainers that require replacement after a defined number of uses. An example might include a synthetic skin that is cut or punctured in a particular simulation scenario. Disposables, similarly, are medical equipment like syringes, medications, or procedure kits, which typically end up discarded after a scenario. While some of this expense can be mitigated by judicious recycling, these costs end up rising in  lockstep with your overall utilization. For administrative sanity, it is strongly recommended that the overall consumable and disposable costs should be shared equally within a service category. In other words, do build the annual expense for these items into your hourly rates. • Each unit of service that is delivered requires some amount of preparation and cleanup (i.e., labor). It is important to capture all of those costs in your calculations. Thus, your “1-hour unit” of a particular simulation service as described above, might include an additional 45  minutes of labor (setup and takedown). Similarly, a piece of equipment may require 20 hours of preventative maintenance throughout the year – be sure that expense is captured in your unit of service. • The benefit of listing all of your capital equipment on a spreadsheet is that it allows you to easily calculate the allowable amount of depreciation that can be built into your baseline cost. Depreciation is a “phantom” expense, whereby you are accounting for the fact that all equipment has a finite life span and you deduct from the purchase price the annual allowance based upon the expected failure date. Also, many pieces of equipment have an annual maintenance cost associated with warranty and upkeep. • For example, if a $20,000 simulator had a useful life of 5 years, the annual depreciation expense would be $4000 ($20,000 purchase price divided by 5 years = annual depreciation allowance). The annual maintenance cost might be $2000. Therefore, if this simulator were to be in active use for 500  hours per year, each hour of its use would cost you the hourly depreciation rate plus the hourly maintenance fee, or $12 per hour ($4000 divided by 500 hours = $8, plus $2000 divided by 500 hours = $4). • The final sets of costs to keep in mind are facility and administrative costs, often called F&A or “indirect” costs. These costs include essential, though

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non-simulation, expenses that can include everything from administrative support staff and other labor to office equipment and computers, marketing expenses, rent and utilities, annual travel budget, etc. It is important to note that F&A rates are often negotiated at an institutional level, so make sure you don’t double bill for this expense! However, it is a real cost, so be sure to include it when appropriate. • At this point, you should have good visibility into all of your costs. All that remains is to calculate what the total cost of each unit of service should be in order to break even in a transaction. Typically, this breakeven rate is the rate demanded by the entities funded by the taxpayers (i.e., the government)! This should always be your “floor” price for any user, as you would be losing money if you charged less.

Alternate Fee Structures • A “quick and dirty” method to legitimately establish a service rate is to simply take your total budget expense from last year and divide it by the total number of hours that you were open. This method meets all of the principles described above and provides an accurate number for the cost of doing business. The downside is twofold: it only allows for one “service line,” and it doesn’t account for depreciation expenses. • Other proposed fee structures have significant weaknesses that are important to understand: –– The “Country Club” pricing model, where you charge an annual fee to another unit or entity for access to your simulation center. This model fails to capture allocable costs and potentially treats like users differently, since the same amount might be paid by both high and low utilizers. Another practical consequence is that schedule management can become very problematic as multiple groups may be competing for space at the same time and each has “paid” for their right to access your center. –– The so-called “Drug Dealer” pricing model, where you give away simulation services “for free” for a period of time, until the users become “hooked” and then start paying for it. This model would certainly cause an audit failure if a taxing authority (i.e., government) determined that it had paid for certain services that others had received for free, as they insist on always receiving the lowest rate provided. However, even if there were not an audit threat, the practical pitfall for this model is that you would have set a precedent that $0.00 is the cost of your services. It is politically very difficult to go up from there.

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Pearls • If your institution allows it, revenues that account for the value of depreciation can be set aside in a “piggy bank” account, which can be accessed at any time for new capital spending. • The “useful life” of a piece of simulation equipment should be set at what you really think it is. Often, financial people will tend toward a hyper-conservative number that is not reasonable (e.g., 12  years for a high-fidelity manikin). A shorter, more realistic life span will result in higher depreciation; you may need to fight for this! • When determining what multiple of expense to use to create your fee for outside entities, consider the example of the landlord of an apartment building – if there is 0% vacancy in the building, the rents are too low. In other words, if your quotes are never rejected, you may not be charging enough. That said, two or three times cost is probably a good target initially.

Key Take-Aways • Why go to all this effort to set your prices? –– One of the key benefits of having an established “federal rate” for your services, supported by your finance team and your leadership, is that it eliminates internal questions about the cost – blame it on the government! “I’m not allowed to charge less” is a terrific defense. –– A lot of effort is required to generate your cost information the first time. However, annual adjustments are relatively minor. –– Eventually, a simulation program will be asked to show its value or ROI. Cost is a key component of this calculation, so be prepared!

Suggested Reading Uniform administrative requirements for grants and agreements with institutions of higher education, hospitals, and other non-profit organizations. Retrieved 15 Apr 2017, from https:// www.gpo.gov/fdsys/granule/CFR-2012-title2-vol1/CFR-2012-title2-vol1-part215/contentdetail.html.

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Effective Budgeting: Putting It Together Teri J. Keeler

Overview Effective budgeting is imperative for a simulation program to remain focused on strategy and goals, as well as highlight where the program should allocate short and long-term resources (Fig. 7.1). A comprehensive budget is a financial roadmap for daily operations and future growth. It is your first tool in understanding your sources of revenue, expenses, and capital requirements. A comprehensive budget also provides a high level of accountability and oversight to measure performance and excellence. An operating budget is a detailed projection of all estimated income and expenses based on forecasted revenue during a period (usually 1 year) [1]. Recurring, day-to-­ day expenses include salaries, salary increases and bonuses, employee benefits, rent, utilities, institutional assessments, equipment maintenance, and support agreements. A capital budget is a plan for raising large and long-term sums for investment, over a period greater than the period considered under an operating budget [1]. These non-recurring, long-term expenses include equipment, technology, and property/space. Be aware of your institutional guidelines regarding capital purchases as they may vary based on dollar threshold and useful life.

T. J. Keeler (*) Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA © Springer Nature Switzerland AG 2020 M. A. Seropian et al. (eds.), Comprehensive Healthcare Simulation: Program & Center Development, Comprehensive Healthcare Simulation, https://doi.org/10.1007/978-3-030-46812-5_7

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Fig. 7.1 Effective budgeting

Comprehensive budget

Operating budget recurring income/expenses

Capital budget: non-recurring items

Key Issues & Points Considerations When Developing Your Budget  apital Versus Operating Budget C It is important to understand how your capital budget interacts with your operating budget. An increase in capital expenditures can result in an increase in the operating budget. This occurs because capital assets often require additional supplies, maintenance, and support agreements. Asset purchases are included in the capital budget while supplies, maintenance, and support agreements are included in the operating budget. Conversely, an increase in the operating budget can result in a decrease in the capital budget. It is important to keep operating costs as low as possible to ensure there is enough money available to invest in long-term assets that grow your simulation program. Return on Investment Effective (capital) budgeting considers the eventual return on investment (ROI) of an asset, technology, or property/space. Expressed usually as a percentage, ROI is a measure of profitability that indicates whether a program is using its resources in an efficient manner [1]. A simple method of measuring ROI is the payback period. When using the payback period, you should consider the time value of money and inflation for a more accurate representation of your return on investment. • Payback period – measures the time required to recover an investment or loan. Payback period (in years)  =  Initial capital investment/Annual cash flow from investment. However, the payback period does not account for the time value of money. • Time value of money – takes into consideration that money received earlier is worth more than the same amount of money received later because it could be invested to earn interest over time. • Inflation  – when inflation increases, the value of money falls, as a result projected returns are not worth as much as they appear. Your investment may only break even, or lose money when accounting for inflation.

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Another important factor to consider when assessing value is to know who the decision-makers are and what they value and expect. Value and/or return are often seen through the eyes of the beholder [2]. Capital investment decisions require a complete understanding of financial and intrinsic value.

Value Center Versus Cost Center Versus Profit Center Simulation programs are defined as cost centers or profit centers. So, how does a simulation center shift from a cost or profit center to a value center? First, you should understand the following budget concepts. A Cost Center is responsible for all of its associated costs and for ensuring adherence to its budgets [1]. A Profit Center contributes to the overall financial results of the institution. Profit centers are given responsibility to target certain percentages of the total revenue and are given adequate authority to control their costs to achieve those targets [1]. As a Value Center, a simulation program makes a financial contribution (value) to the bottom line by effectively managing all revenues and associated costs. In addition to a financial return, a simulation program can provide intrinsic value to the organization by developing curricula and instruction to support certifications, achieve quality standards and goals, and meet safety requirements, as well as other improvements and advancements for the organization.

Key Resources and Partners Internal Resources • Executive and Finance Committee: These individuals appreciate the need for an effective budget since the “Buck Stops Here!” They are equally interested in the financial bottom line and overall value to the institution. • Organizational Budgeting Team: This team provides detailed instructions and guidance, budget software training, budget templates, and analytical tools to calculate ROI and Payback. • Dean, Department Chairs, and Administrators: These leaders are crucial to the overall support for the simulation program from a financial and user perspective.

External Resources Other simulation programs, simulation societies, administrative healthcare associations, and their members are sources for best practices for developing an effective budget process. Business and simulation consultants may provide valuable input for sourcing and pricing of supplies and equipment, as well as appropriate staffing levels and space requirements.

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Guidelines

Team

Timeline

Projections

Performance

Fig. 7.2  Steps to developing an effective budget

Key Approaches Steps to Developing an Effective Budget (Fig. 7.2) Establish Guidelines The budget/planning process starts with developing goals and objectives. Goals identify the aim or end result – what the simulation program wants to achieve. These goals should already be inherent in the mission statement. Objectives help the simulation program achieve its goals – a means to an end. It is important to clarify overall institutional goals vs simulation program goals and objectives to ensure consistency with the overall mission and goals of your institution. Assemble a Budget Team Assemble a team of financial and operational staff, in a small simulation program this might be a team of one – YOU! Develop a Timeline Develop a realistic timeline for preparation, feedback, and review. The institution may have an overall budget timeline that leads to Finance Committee and Authority Board approval of a high-level institution budget. It is important that you develop an internal timeline for your simulation center budget that is consistent with the institution’s budget process. Budget Projections Identify and understand sources of revenue, operating expenses, and capital requirements so you can develop your comprehensive budget. Determine whether you will prepare your budget based on a zero-based or incremental method. Zero-based

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budgeting starts from scratch with no pre-authorized funds. Incremental budgeting, which is more traditional, reflects on historical revenue and expense trends as a basis for continuation. Document your assumptions, sources of information, and pre-approved spending levels and submit them along with your budget.

Measure Performance Measure budget performance on a monthly basis to ensure the sustainable, financial success of your simulation program. Actual vs budget reporting and return on investment are metrics used to reflect financial success. Surveys of users may solicit feedback on the non-financial, value-added success of your program.

Pearls Develop a budget that is consistent with the strategic and business plans, as well as the mission, and vision statements of the institution and your program. Align with business partners to obtain buy-in for budget assumptions and resource allocation. View yourself as a solution provider who addresses what decision-makers value.

Key Take-Away Effective budgeting is: • Paramount to the overall success of a simulation program. • Essential for strategy and meeting annual and strategic goals.

References 1. BusinessDictionary.com 2. Seropian M.  Return on investment: Society for Simulation in Healthcare, Open Forum; 21 Apr 2017.

Suggested Readings Johnston K.  Differences and similarities of capital and operational budgeting. smallbusiness. chron.com. Mullin S. Definition and examples of capital budgeting. smallbusiness.chron.com. Venkatraman N. Beyond outsourcing: managing IT resources as a value center. Sloan Manag Rev. 1997;38:3–9.

Part II Facility Design, Supporting Equipment, and Technology

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Facility Design Part I – Process Considerations Michael A. Seropian

Overview Simulation facility design is not just about the outcome, but how one gets to the desired outcome. Owners and users must accept that the end-product will never be perfect, but working to avoid common preventable errors and omissions is an important consideration. A well-defined design team, lines of communication, effective project management, cross-checks, seeking advice from others are but a few of the considerations to reaching an outcome that meets the end-users and stakeholders needs. With all this said, we remind the reader that a facility is part of a simulation program, and a spectacular facility will be meaningless without a program that is effective, efficient, and sustainable. Simulation facility design is emerging as new industry segment in the architectural, engineering, and design industry. While it is complex, many of the concepts can be borrowed from higher education, clinical settings, and education theory. Simulation facilities in healthcare seek to emulate an environment, at times clinical, to achieve objectives of the training or assessment. The infrastructure to support these facilities differs from higher education or clinical environments, in that flexibility, storage, control, and debrief space must all be considered. As is the case in all facilities, flow and adjacencies (proximity of rooms) is also an important consideration. Following a basic premise that form follows function, having a good understanding of what the facility will be used for, in as granular terms as possible, will allow the designers to develop space(s) that meet the functional needs of the end-users.

M. A. Seropian (*) Department of Anesthesiology and Pediatrics, Oregon Health & Science University, Portland, OR, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 M. A. Seropian et al. (eds.), Comprehensive Healthcare Simulation: Program & Center Development, Comprehensive Healthcare Simulation, https://doi.org/10.1007/978-3-030-46812-5_8

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Key Issues and Points Considerations When Planning Your Center Before you even begin interacting with the design team (defined later), the stakeholder(s) should clearly define their: • Mission and vision: Short term and long term –– Vision – describes the outcome (or what people see) of your mission –– Mission – describes what you want to do • Stakeholders: Who are your stakeholders (executive, faculty, staff, learners) that have a vested interest in the outcome of the project, program, or facility? –– Internal Institutions/Departments/Programs/Professions –– External Institutions • Curricular demand: Identify who the learners/user are, what is their volume and frequency of use, and what are their specific space needs. This should include all aspects of education, training, and assessment in the organization. The tricky issue here is that “we only know what we know.” It is important however to forecast what the unperceived curricular needs and growth will be 5, 10, and 15 years ahead. • Data collection and metrics: Simulation in healthcare has come to a point where it is incumbent on the stakeholder to be able to convincingly make the value proposition not only to start the project, but as the program becomes operational. Specific outcome metrics for the use of the facility should be established. Proposed outcomes define the data collection needs for the facility. It is okay if the goals change over time, but not at least defining some early can lead to underutilization, mis-utilization, lack of impact, or the inability to measure the desired outcomes or milestones. • Business planning: A business plan relates to all of the aforementioned points, and succinctly lays out what facility is needed to reach a desired outcome. Further this will help define the capital (bricks and mortar) and operating costs for the simulation program. In some instances, the business plan may not be completed prior to the start of facility design. The more it is pushed back, the greater the risk to the project not meeting its goals or having a meaningful impact (financial support model). • Budget: Funding for the project and any constraints need to be well understood before embarking on the project. Even when budget is not an issue, understanding what is expected to be spent is important to ensure efficient use of the monies. • Decision-makers: Every organization has an ultimate decision-making authority. This may be an individual or a group. This person or group should be identified and the process by which they make decisions should be well understood. • Subject matter experts (SMEs): Leverage any in-house simulation expertise. While it is often problematic to be a “prophet” in your own institution, the

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institution should clearly identify those with proven expertise. All the stakeholders, often “do not know what they do not know,” and such the SME may broaden understanding. –– Engaging/identifying external individual or groups with extensive experience building similarly sized simulation centers will help clarify and legitimize your immediate goals, and help define the foundation for building a strong and growing simulation program. • Design team selection: The selection of a design team that has experience building more than one facility and preferably many similar sized centers is important. While less experienced teams may develop a good product, they are in essence re-inventing the wheel and not taking advantage of experience and best accepted practice. –– Architects, engineers, simulation-specific consultants and program managers –– Audio Visual Consultants vs AV Integrators –– Simulation Center AV/IT specific vendors –– Simulation Specific Learning Management Solutions

Key Approaches Steps to Facility Planning and Design As the process with the design team begins it, one of the first orders of business should include governance and the user side of decision-making (see decision-­ makers above). A clear understanding of the lines of communication with and between the design team, project managers, and stakeholders should be established and documented. Beyond documentation, it should be implemented in an effective manner that does not create unnecessary barriers or points for errors and omissions. The communication strategy should be adhered to and adjusted as needed. Communication, as in all complex tasks is paramount. The design and construction process include a variety of steps from the start through the commissioning of the facility. The following are simplified interpretations of the phases that should be guided by a timeline and deliverables: • Space Programming: Space programming is where the type of spaces, their general characteristics, quantity, and special characteristics are identified. Space programming also identifies the issues related to the location of the facility which differs for new construction versus renovation. The total square footage (or square meters), key adjacencies, and general form factor are identified at this point. Square footage of the facility may be constrained by budget, location, or a combination of the two. The types and quantities of spaces should be guided by the curricular needs of the stakeholders (upon opening and 5–10  years from

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then). The programming phase is arguably one of the most important steps as this defines all the next steps. Schematic Design: Architects, engineers, and a variety of other deign professions will now try to make the pieces of the puzzle “fit.” The spaces must be located in a manner where their adjacencies to other rooms make sense (e.g., control, simulation, and debrief room). The corridors are laid out in a manner that makes flow logical and efficient. The mechanical and structural elements for the facility are defined (e.g., columns, seismic considerations, and HVAC). The final product should represent what most call the “floorplan.” Once the floor plan is established, further detail about the rooms can established. Design Development: This phase is often also called “Detail Design” or “Design Development” (DD), and for good reason. This is the phase where rooms and all spaces (from the exterior to every corridor) is given the detail that will bring the spaces to “life.” Plumbing, types of gases and associated plumbing and HVAC needs, sinks, celling/wall mounted objects, power, IT, millwork, lighting, furnishings and finishes, door size and swing, ceilings, and flooring are but a few of the details to be defined in this phase. This phase should not have much movement or change in the actual layout (schematic), but at times it may become necessary to make some adjustments. Stakeholders and SMEs alike should not be afraid to ask the design team questions in the phase as it often requires the interpretation of rather confusing information (e.g., elevations). This phase will also define any furnishings, equipment, and AV/IT needs related to the project. Construction Documents: These documents are to be used by the contractors themselves. They include the detail needed by the contractor to build the facility as specified and to relevant codes. The documents will often not include certain elements included in the DD drawings, such as furnishings and other elements that do not impact construction. The risk is that errors may occur without the context provided by these elements. Construction: This one hopefully is obvious…you get to watch your “baby” come to life. Contractors are on a schedule and often have tight project management. Frequent meetings to review progress, address questions, and identify problems are important. Be aware that changes, unless related to error of the design team or contractor, will be quite expensive and result in a change order. While the installation of a single electrical outlet may cost say $100, the same outlet as a change order may cost $300–$500 dollars. Project managers often do not like to include the users (stakeholders) in this phase for fear of imposing budget overages and unwanted delays in schedule. Commissioning: Upon substantial completion of the facility (you have the keys!), the facility, power, HVAC, and general functionality need to be tested. This testing should evolve into a punch list of items that either need to be addressed by the design team and contractors, or represent items that simply were not considered (remember it will never be perfect!). This phase is important as once commissioning is done and signed off, the contractors are pretty much done and you are on your own.

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Key Partners Owner End-user Faculty/educators/simulationists Community partners Architects Engineers

AV/IT specialists Equipment planners (for large centers) Project manager Owner representative Other consultants General contract

Pearls – Process • Establish specific timelines and key milestones for all disciplines and players. • Establish the frequency of meetings and walk throughs to help the project progress. Recall that there are milestones, such as before wall board goes up, that are all important to allow relevant parties (e.g., AV/IT) to see what is in the walls before they are boarded up. • Leverage experts that specialize in building simulation centers. • Ensure that the furniture and medical device/equipment planning and selection meet the curricular needs of your program. • Unless you are trying replicate the clinical environment exactly (not common), there is little need for many of the elements in a typical clinical environment. For example, items such as equipment booms have yet to show their value in most simulation facilities. • Purchasing at your institution should become your best friend as they can source equipment and items often at greatly discounted prices. They also can help you tie purchases to larger purchases made by your institution for further savings. • Most institutions have a surplus department, where equipment is decommissioned. This equipment may be of great value and is often FREE! • Have a good relationship with the design team! If this is not a possibility, then establish clear expectations and timelines and keep it professional at all times! • We mentioned communication before, but we will do it again…errors, omissions, and just plain frustration often can be traced back to poor communication and “siloing.” The construction industry is no different than the healthcare industry in that respect. • Flexibility, flexibility, flexibility! Things change and you don’t want to be cornered. • Assume nothing! Check and double-check. • The best design will fail with poor implementation. • Keep GREAT records during the process. Record meetings if possible and distribute minutes. • Implement a system for tight version control of key documents so everyone is working from literally off of the “same page.”

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Key Take-Aways • Form follows function – Understand how you plan to use simulation. • Understand communication channels and establish process. • Ask questions and verify information. If you don’t understand something seek clarification. • Be engaged at all levels as your helping build your “house.”

Suggested Readings Aliner G.  The patient simulation suite; a single dedicated simulator stage surrounded by dedicated control, observing/debriefing, utility and office rooms. In: Kyle RR, Murray WB, editors. Clinical simulation. 1st ed. Burlington: Elsevier; 2008. p. 261–5. Brost B, Theiman K, Belda T, Dunn W. Creation of structure-function relationships in the design of a simulation center. In: Kyle RR, Murray WB, editors. Clinical simulation. 1st ed. Burlington: Elsevier; 2008. p. 185–99. Cook D, Hatala R, Brydges R, Zendejas B, Szoztek J, Wang A, Erwin P, Hamstra S. Technology enhanced simulation for health professions education: a systematic review and meta-analysis. J Am Med Assoc. 2011;306(9):1–11. Horley R. Simulation and skill center design. In: Riley RH, editor. Manual of simulation in healthcare. 1st ed. Oxford: Oxford University Press; 2008. p. 3–10. Kyle RR. Technological resources for clinical simulation. In: Dunn WF, editor. Simulators in critical care and beyond. Mount Prospect: SCCM Press; 2004. p. 95–113. Levine AI, DeMaria S Jr, Schwartz AD, Alan S, editors. The comprehensive textbook of healthcare simulation. 1st ed. New York: Springer; 2013. Loyd G. Issues in starting a simulation center. In: Dunn WF, editor. Simulators in critical care and beyond. Mount Prospect: SCCM Press; 2004. p. 84–90. Palaganas J, Maxworthy J, Epps C, Mancicni B, editors. Defining excellence in simulation programs. 1st ed. Philadelphia: Wolters Kluwer; 2015. Richard K, Murray B, editors. Clinical simulation: operations, engineering, and management. 1st ed. Burlington: Elsevier; 2008. Salas E, Wilson KA, Burke CS, Priest HA. Using simulation-based training to improve patient safety: what does it take? Jt Comm J Qual Patient Saf. 2005;31(7):363–71. Seropian MA. General concepts in full-scale simulation: getting started [special article]. Anesth Analg. 2003;97:1695–705. Seropian MA. Space considerations in health care simulation. In: Loyd GE, Lake CL, Greenberg RB, editors. Practical health care simulations. Philadelphia: Elsevier Mosby; 2004. p. 49–74. Seropian MA. Facility design 101 – The basics. In: Clinical simulation: operations, engineering, and management. 1st ed. Burlington: Elsevier; 2008. p. 177–84. Seropian MA, Lavey R. Design considerations for healthcare simulation facilities. Simul Healthc. 2010;6(5):338–45. Ulrich B, Mancini B, editors. Mastering simulation a handbook for success. 1st ed. Indianapolis: Sigma Theta Tau International; 2013.

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Facility Design Part II – Structure Considerations Michael A. Seropian

Overview Simulation facility design is emerging as new industry segment in the architectural, engineering, and design industry. While it is complex, many of the concepts can be borrowed from higher education, clinical settings, and education theory. Simulation facilities in healthcare seek to emulate an environment, at times clinical, that suits the desired outcomes and objectives of the training or assessment. The infrastructure to support these facilities differs from higher education or clinical environments, in that flexibility, storage, control, and debrief space must all be considered. As is the case in all facilities, flow and adjacencies (proximity of rooms) is also an important consideration. Following a basic premise that form follows function, having a good understanding of what the facility will be used for, in as granular terms as possible, will allow the designers to develop space(s) that meet the functional needs of the end-users.

Key Issues and Points General Concepts and Flow Considerations Flexibility While some centers can justify rooms that lack flexibility, the trend is moving in the other direction…toward flexibility. It is challenging to predict the specific utilization of a specific room type, but flexibility allows for maximal utilization of a given M. A. Seropian (*) Department of Anesthesiology and Pediatrics, Oregon Health & Science University, Portland, OR, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 M. A. Seropian et al. (eds.), Comprehensive Healthcare Simulation: Program & Center Development, Comprehensive Healthcare Simulation, https://doi.org/10.1007/978-3-030-46812-5_9

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room. The unintended consequences of flexibility are managing the flexibility with increased storage needs.

Adjacencies and Flow Many rooms have a natural need for proximity to another type of room. For example, we often see a control room, debrief room, and simulation room clustered together. If possible the supply/prep/support are not too far away, and if applicable the medication room needs to be in close proximity. The proximity (adjacencies) of rooms is helpful to ensure educational isolation (preventing disruption of the educational process by unrelated activities) as well as to help streamline flow of individuals in the center. Many centers have adopted an inner/outer core concept (frontstage/ backstage) that separates operation flow from learner flow. The reality is this will require more space.  oom Quantity and Size R The number of rooms and the size of the rooms will be determined by a variety of factors. Ideally curricular or other need is the primary driver so that form follows function. When needs have been determined, then volume, frequency, and capacity can all be calculated and researched. This will help determine the type of rooms, the size of those rooms (although there are other considerations as well), and the quantity of the rooms. In many circumstances, curricular need is not known. In these cases, it is best practice to bring relevant stakeholders together to forecast future need. While this may not be precise, it is far better than simply guessing. Consider: • As you calculate needs and quantity be mindful that use of specific types of rooms are often episodic with peaks and valleys. So there may be months where a specific room type may be required more than other at other times of the year. These needs should be identified as bottlenecks and addressed in the design or through curricular scheduling change. • Room size should account for the typical cohort for that room plus 20%. In cases of clinical rooms, then they should be sized appropriately for the room they are trying to emulate. As described below, there are some standard size guidelines that can be followed.

Room Types and Descriptions Room Types There are a variety of rooms that may appear in simulation facilities. They will vary in name and structure. There are some important considerations when it comes to room types: • Size (sq. ft. or sq. m) • Aspect ratio/shape

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Primary use Adjacencies Features HVAC, lighting, sound abatement Capacity

The following is a brief description of different room types. This is not intended to be exhaustive but rather share ideas and examples. Clinical Simulation Control Room • Control rooms contain the control infrastructure to control the events in the clinical simulation room. This will include AV, simulator, and IT control. This is a critical room as the scenario orchestration really emanates from this location. Standardized patient control rooms are described in a subsequent section. • Typical control rooms are immediately adjacent to the clinical simulation room with some sort of one-way class to see into the clinical simulation room. This may be a one-way mirror or through the use of a micro-porous film/membrane (Contravision® is an example). Some controversy exists whether the control room needs this one-way glass and as such not require immediate adjacency to the simulation room. The vast majority of centers use one-way glass as it affords you a visual of the whole room that cameras alone may not provide. Center with VERY robust camera systems may be able to achieve efficacy without one-way mirrors. • Control rooms may be distributed or centralized or a hybrid of the two. The more simulation rooms under the control of a single control room, the more centralized the model. As you plan at a control room consider the ratio of control rooms to simulation rooms. The range can be from 1:1 to 1:6 and beyond. As you increase the number of simulation rooms being controlled by a single room, then special accommodations for light and noise transmission must be taken into account. Moreover, flow of people in the control will be an important consideration. A centralized system certainly has the potential to reduce operations overhead but also presents some real system-level challenges. • The lighting in the control room should be dimmable as light transmission from the control room into the simulation room will occur in certain lighting conditions. • The control room should have good sound abatement and attenuation and have plenty of room for operations and faculty flow. • Ensure adequate power and IT outlets. • As a side note, some centers have advocate for elevated control rooms. The control room sits higher than the simulation room. This has its merits and we are still trying to understand whether the merits outweigh the implications. Some of the implications include a higher slab-to-slab distance, the need to meet code with ramps for people with disabilities.

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Debrief Room The typical debrief room is much like a conference room. The type of seating for this calculation should be based on learners sitting around the perimeter a table. The table need not be a single piece but preferably modular, to enhance flexibility in the room. • The aspect ratio of the room matters, as you consider where the display and white/SMART boards will be located. A rectangular shape is often preferred over a pure square. • The room should have good sound attenuation. • The display for the room must meet specifications for viewing a presentation (e.g., PowerPoint) from the back of the room. All too often displays are undersized for rooms. • The inclusion of cameras and microphones in the debrief rooms will allow teleconferencing as well as the ability to record debriefings and other activities. • As mentioned earlier, modular tables (e.g., 3  ×  6) and comfortable chairs are important for a room where participants should be comfortable. • Lighting should be dimmable to accommodate for AV playback and broadcast. • In ceiling speakers to ensure good audio playback and broadcast. • Computer and control panel to control content and display, respectively. • Different centers will do different things on the non-display wall that are available. The use of smart boards, white boards, or a writable painted surface are all options. Clinical Simulation Room In the vast majority of cases, programs cannot justify the expense of creating an exact replica of a clinical room. This also plays to the reality among experienced simulationists, that many of these additional details add little to nothing to a clinical simulation scenario. Only in cases of system testing or actual curricular need, should one consider creating an actual replica. As one walks around a hospital, it becomes clear that room sizes while varying, do not varying greatly and can be grouped: • Large (400–1,000 sq. ft.) –– Operating room (may be large in cases where large equipment such as robotics are used) –– Labor and delivery –– PACU –– Open ward • Regular (200–300 sq. ft.) –– ICU –– Medical surgical room –– ED observation room –– NICU • Small (90–150 sq. ft.) –– Outpatient clinic room –– Medication/prep room

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As part of the programming phase, we recommend that you determine how many small to large rooms you need and DO NOT label them as ICU, or PACU, etc. By avoiding labeling you dissuade the temptation to make any given room single purpose. Generally speaking, each room should be equipped with: • Gases (air, oxygen, vacuum) if applicable. • Headwalls if necessary (may be on multiple walls or extended) to enhance flexibility. Single bed versus multi-bed for example. • Sufficient power and IT. • Low-velocity HVAC. • Appropriate air flow to accommodate of oxygen (if used) and any volatile anesthetics. • Appropriate lighting. • The ability to mount patient monitors and “learner” monitors. • Cameras and microphones. • Rubber-lined flooring to attenuate sound. • Booms, OR lights, and other heavy structures should be avoided unless there is a clear case for them. They are expensive, have architectural implications, and their utility in a typical simulation environment is yet to be demonstrated. Supply/Prep/Support Room Beyond acoustics, the second most common complaint in a simulation facility is the underestimation of storage and prep space. There is no scientifically established magic number but most people benchmark 20% of net assignable sq. ft. as a standard. Going below 10% will almost certainly guarantee issues. Creative storage solutions may help make storage efficiency greater. These rooms should: • Be distributed or centralized depending on the size of the center. Recall that the distance and time to get to storage can make your personnel quite inefficient. Include flexible storage solutions. • Include large sinks (preferably double) and counter space. • Be secured. • May include washer/dryer, freezers, etc., to support center activity. Multi-purpose Room As the name would suggest, these rooms should be highly configurable. They may or may not include wall gases, but are usually flat and not on a slant. They should have modular furniture to support flexibility. The use of partitions (horizontal or vertical) with writable surfaces can be considered when dealing with larger rooms. We will often find counter space, sinks, and millwork in these rooms as well. The flooring should be consistent with the intended use. So if biologic materials or liquids are anticipated, then a laminate may be preferred over carpet. The lighting should be dimmable and zoned. Displays must accommodate for learner distance and if partitions are to be used. The room should include cameras, microphones, in ceiling speakers, and sufficient power/AV/Data floor boxes.

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Medication Room Medication rooms include some form of medical and supply dispensing units, counter space, sinks, and millwork. The room typically has cameras and microphones and services several clinical simulation rooms. As such, they are typically in proximity to these rooms. Skills Room Historically these rooms have been called nursing skills rooms, with perimeter beds and a central student seating area. As more and more professions use these spaces, it is appropriate to simply call them skill rooms. They differ from multipurpose rooms in that they typically are less flexible as they include the following: • • • • • • • • •

Perimeter beds (stretchers, med-surg bed, or exam tables) Wall gases (+/− headwall) A central seating area with tables Displays Are generally not partitionable Millwork and sinks Patient monitor mounts at each bed location Curtains or some form of separator between bed locations Laminate flooring

Standardized Patient (SP) Environments Standardized patient environments are regularly found in schools of medicine, with increasing activity in physician assistant programs, nursing, and others. They should be welcoming environments for learners as well as actors and other personnel. They are generally made up of outpatient sized rooms where specific encounters with learners occur. While manikin-based simulation can occur in these rooms, typically the use of standardized patients or embedded actors is seen. The SP environment should include a constellation of rooms that support the overall activity. • SP room – usually 90–150 sq. ft. in size and modeled after an outpatient clinic room with an exam table, chair, stool, computer, sink, millwork, and cabinets. The room typically has cameras and microphones. The addition of gases and vacuum is optional but recommend to increase flexibility of use. Similarly make the rooms manikin-compatible is recommended. Some centers have a direct view window into the room for faculty/preceptors. This is certainly an option but does have space implications. Outside the outpatient room, there is typically, a wall-­ mounted computer station to allow the learners to be briefed on the case they will encounter, as well as to allow them to enter any post-encounter notes. Larger SP rooms (e.g., 150 sq. ft.) will more likely accommodate stretchers rather than only outpatient exam tables. • SP training room  – The term standardized patient implies that the individuals (actors) are standardized to behave and perform consistently with each learner across encounters. This requires training and review. A dedicated space for this

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• • •

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will make a difference! This room may also include lockers, washrooms, and showers to allow the SPs to change and get ready for their encounters. SP lounge – The SPs are often volunteers or may be paid; however, giving them at least a basic environment to eat lunch of have a break is an important consideration. This may be combined with the SP training room. SP control room – This control room is distinct from the clinical simulation control room. In that its primary use is not to control manikins (this is still an option) but to monitor the SP simulations whether formative or summative. The control room can observe activity in the hallways, in the rooms, as well as advise learners when it is time to shift to another room. In many respects, it services to monitor and direct the flow/activity. SP debrief room – This room is no different than the prior debrief room description. While not a staple of most SP environments to date, it is emerging as a standard, to allow for pre-briefing, learner, intake, and post-encounter debriefing. SP supply/prep/support  – This environment is similar to what has previously been described but is typically smaller in that they type of equipment used in the SP environment has a smaller footprint. Educator/faculty observation room – If there is no direct vision into the SP room through one-way glass, then it is not atypical to see a dedicated room for faculty to sit and observe at a station what is occurring in any given room. It is recommended that there be a ratio of no greater than 1:3 stations to SP rooms. The concept of inner and outer core (separating learner from operations flow) is becoming more prominent in this environment but as stated previously has real implications in terms of space. This decreases the efficiency of space use but enhances flow significantly.

Surgical Skills The field of procedural and surgical skills is ever growing with an acknowledgment that simulation on a cadaver or live animal is superior to many of the virtual reality modalities available. Depending on the country, there are strict regulations related to cadaveric and animal use. The surgical skills lab environment is unique in many ways: • Main surgical/procedural room – This is often an open space with multiple stations for cadaveric or animal based procedures. –– The typical space for each station varies from 100 to 150  sq.  ft. with sufficient circulation space around each station. –– The station includes an operative table, surgical tables, instrument booms, and surgical lights. –– In the case of animal-based procedures, a ventilator or anesthesia machine is also required. –– The floor is laminate and waterproof. –– Master station – within the main surgical/procedural room, it is best practice to have a master station that can broadcast what the educator is doing to each station.

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–– Each station has HD cameras for recording a broadcast as well as displays for playback of content and visualization related to laparoscopic procedures. –– The room should be appropriately ventilated to meet national, regional, and local regulations and codes. Support – There are several types of support rooms for this type of environment: –– Cadaveric storage – This includes appropriate secure cooling structures and a clear pathway to accept and return the cadavers or cadaveric parts. –– Animal storage/holding – Depending on the accreditation of the center, it may or may not have an animal holding area. In the case where it does not, the animals are transported to the facility, anesthetized, and then picked up by a service provider. There are real regulations around how long an animal may be in a facility before a holding area is required. –– Abattoir – Some facilities that engage in animal- based skills training have areas where the animals can be euthanized and often cremated. –– Sterile processing  – The surgical equipment should be sterilized/cleaned appropriately, although the standards differ from sterilization needs related to live human use. –– Storage equipment and supplies  – This area holds consumable supplies as well as sterile equipment. Surgical skills control room – Much like the SP control room, this room functions to observe, record, and broadcast information. Debrief room – The use of debrief rooms is becoming increasingly popular to review content before and after the event. The rooms should be sized to accommodate the typical cohort size of _ 20%. Lecture hall – Many institutions have lecture halls that are tiered. This may or may not be of benefit versus a flat multi-purpose room with good projection capabilities. Reception – A dedicated reception area id an important consideration to control flow in and out of the surgical skills environment. Lockers/change rooms – The surgical skills environment should include a change and locker area with shower facilities. It should be secure and gender specific. The area should include hampers for soiled clothing and a clean scrub dispenser of some sort. Soiled utility – There will be linens and scrubs that should be isolated and that will require cleaning by appropriate services. Lounge – Depending on the purpose of the center, many centers will include a participant lounge. This mainly occurs in facilities where there is a significant revenue motivation of bringing outside industry to use the facility.

Special Room Types • AV server rooms – Depending on the size of the center of the AV design topography, the need for AV server rooms (potentially on each floor) is an important consideration. These rooms have specialized power and heat considerations with HVAC built to accommodate the anticipated heat load of the housed servers. These rooms are usually secured.

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• MDF/IDF – These rooms are an essential part of any building in that they house the data and telephony solutions. They are usually stacked (aligned) from floor to floor. • Janitorial room – The need for a janitor’s closet will depend on the size of your center; however, it is an important consideration for maintenance of your space. • Gas tank storage – Centers that use oxygen will need to consider a location for tie-in and storage of tanks large enough to supply the center. The number and size of the tanks can be calculated, and this will determine the room size. • Maintenance support room – This type of room is emerging in importance as a space dedicated to maintenance and support of equipment. As warranties continue to skyrocket in price, good maintenance and support become critical. • Office – Planner must accommodate for the need for office space of fulltime and casual personnel. The distribution of the office should be such that, the spaces are not so far that their use becomes impractical. • Reception – While this seems like a luxury, it is important to have a reception space with either a receptionist or good wayfinding signage to promote security and good flow within the center. This is also the point where a first impression is made upon entry and as such consider the space to include a “WOW” factor for potential donors. • Lounge – If you have the luxury of space, then you likely have a greater number of personnel. The need for a lounge with adequate seating, tables, a refrigerator, dishwasher, microwave, etc., becomes a real consideration. • Admin support – Unlike the support space described earlier, this space is purely for storage of administrative supplies and the housing of equipment such as copiers. In tighter facilities, this space can be included in the other support space. • Locker/change rooms – If you have the luxury of space, the presence of locker and change space is often appreciated. There are certain circumstances where this is not optional, such as in cadaveric or animal surgical labs. • Laundry – Depending on the size of your center, a soiled utility and laundry area may be of use. Many centers will include washers/dryers/in their support areas to manage linens, etc. If your organization uses a laundry service and supply provide, then that is likely a reasonable option to explore. Keep in mind that unique clothing may not return from a hospital or outsourced laundering service.

Miscellaneous Planning/Design Considerations The following are important items and considerations: • Remember to order appropriately specified and applicable office computers, debriefing computers, simulator controls, and tablets. • If relevant to your program, sit with the design team to allow for power and gas failure simulations. This will require specific design features that would otherwise not be included. Be sure to alert the design team and engineers and be very precise of what you desire. Consideration with respect to lighting, outlets that are red (emergency) versus white must all be addressed.

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• The selection of simulation equipment should occur with enough lead time for bidding (if needed), purchasing, manufacturing, shipping, and commissioning. The equipment should reflect the curricular needs of the program and end-users. The most expensive simulators are not always the best. Don’t forget the warranty (if you can afford it). • Technology selection is also an important consideration. Think about the future and not the past if possible. There are many emerging technologies that will make current technologies obsolete. This is not to suggest that only leading edge technology be used, but rather to plan for what the future looks like. • Determine what gases will be used as they have implications on plumbing and HVAC. The use of oxygen has specific regulations to ensure that the space does not represent and explosive hazard with an oxygen-enriched environment. Similarly, the use of the gases on actual people, such as standardized patients or embedded actors, may require medical grade plumbing (big cost increase). Volatile anesthetic gases will have specific HVAC and scavenging requirements. AV/IT infrastructure is important and quite unique in simulation (for a variety of reasons). Helping the IT consultants understand simulation will help prevent an infrastructure that does not support your needs. Important components/considerations include the following: • Network infrastructure design that follows established best practices. • Wired and wireless infrastructure. • Virtual local area networks (VLANs), remote access via VPN, interfacing with your institution network, and interfacing with your clinical partners (hospitals/ outpatient). • AV/IT have definable power requirements, heat load requirements, server space and location requirements, and HVAC and access considerations. • IP technology (pros/cons), baseband technology (pros/cons), everything HD (pros/cons). • Considerations related to expense (HD, quantity, capture, etc.). • Room-specific AV and connectivity considerations. • Low voltage, capture, and connectivity needs related to simulation. • Simulator specific considerations (Manikin/VR). • Medical equipment IT and AV capture requirements (Simulated/Real). • Flexibility.

Key Partners Owner End-user Faculty/educators/simulationists Community partners Architects Engineers

AV/IT specialists Equipment planners (for large centers) Project manager Owner representative Other consultants General Contractor

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Pearls – Structure • There is no ACTUAL benchmark for the amount of storage in any given facility. Suffice to say that most people complain they do not have enough. Our experience is that 20% of net assignable square footage is a safe bet with efficient storage solutions. As you approach 10% and below, start to prepare for those stretchers lining your corridors…there goes your beautiful new facility! • Ensure that the mechanical and HVAC is appropriate for the space (air exchange rate, low noise, etc.). • Plan for sound  – where you have low ambient noise, minimal propagation between walls, and good sound attenuation. Sound attenuation is critical. Strategies such as acoustically shielded ceiling tiles, slab-to-slab walls, rubbershielded flooring are but some of the strategies to attenuate sound. • Plan your lighting to ensure that you use the correct type of lighting, color, and controls (dimmers, motion-activated, regular switch, etc.). • Remember to account for “Special Features” that provide a “Wow” factor for your center. Don’t forget the all-important donor wall if you are so fortunate to have donors associated with your project. • Use modular furniture where possible, as large furniture may limit the flexibility of any given room. • When using one-way glass or glass coated with a micro-pore film, ensure that light transmission from the control room TO the simulation room is mitigated. Remember your lights, computers and personal devices all emit light! • Flexibility, flexibility, flexibility! Things change and you don’t want to be cornered. • Assume nothing! Check and double-check.

Key Take-Aways • • • •

Flexibility is the dominant concept in design currently. Make a checklist of things to verify and check. Storage is the most frequent oversight. If you have seen one simulation center…you have seen one simulation center. • Ask questions. The people hired to design and build are happy to answer. • Seek advice from people who may have more experience. Sometimes we don’t know what we don’t know.

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Suggested Readings Aliner G.  The patient simulation suite; a single dedicated simulator stage surrounded by dedicated control, observing/debriefing, utility and office rooms. In: Kyle RR, Murray WB, editors. Clinical simulation. 1st ed. Burlington: Elsevier; 2008. p. 261–5. Brost B, Theiman K, Belda T, Dunn W. Creation of structure-function relationships in the design of a simulation center. In: Kyle RR, Murray WB, editors. Clinical simulation. 1st ed. Burlington: Elsevier; 2008. p. 185–99. Cook D, Hatala R, Brydges R, Zendejas B, Szoztek J, Wang A, Erwin P, Hamstra S. Technology enhanced simulation for health professions education: a systematic review and meta-analysis. J Am Med Assoc. 2011;306(9):1–11. Horley R. Simulation and skill center design. In: Riley RH, editor. Manual of simulation in healthcare. 1st ed. Oxford: Oxford University Press; 2008. p. 3–10. Kyle RR. Technological resources for clinical simulation. In: Dunn WF, editor. Simulators in critical care and beyond. Mount Prospect: SCCM Press; 2004. p. 95–113. Levine AI, DeMaria S Jr, Schwartz AD, Alan S, editors. The comprehensive textbook of healthcare simulation. 1st ed. New York: Springer; 2013. Loyd G. Issues in starting a simulation center. In: Dunn WF, editor. Simulators in critical care and beyond. Mount Prospect: SCCM Press; 2004. p. 84–90. Palaganas J, Maxworthy J, Epps C, Mancicni B, editors. Defining excellence in simulation programs. 1st ed. Philadelphia: Wolters Kluwer; 2015. Richard K, Murray B, editors. Clinical simulation: operations, engineering, and management. 1st ed. Burlington: Elsevier; 2008. Salas E, Wilson KA, Burke CS, Priest HA. Using simulation-based training to improve patient safety: what does it take? Jt Comm J Qual Patient Saf. 2005;31(7):363–71. Seropian MA. General concepts in full-scale simulation: getting started [special article]. Anesth Analg. 2003;97:1695–705. Seropian MA. Space considerations in health care simulation. In: Loyd GE, Lake CL, Greenberg R, editors. Practical health care simulations. Philadelphia: Elsevier Mosby; 2004. p. 49–74. Seropian M. Facility design 101 – The basics. In: Clinical simulation: operations, engineering, and management. 1st ed. Burlington: Elsevier; 2008. p. 177–84. Seropian MA, Lavey R. Design considerations for healthcare simulation facilities. Simul Healthc. 2010;6(5):338–45. Ulrich B, Mancini B, editors. Mastering simulation a handbook for success. 1st ed. Indianapolis: Sigma Theta Tau International; 2013.

Equipment Selection, Acquisition, and Maintenance

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Kevin Miracle

Overview It has been said that money can make or break a program! One of the main impacts on the finances of a program, and a key driver on the impact on the ROI, is proper equipment selection and maintenance of the equipment. Understanding the needs of the program in concert with the goals and objectives of the program is crucial. Once the equipment is acquired, the staff will need to be trained to properly operate the technology, to maintain the technology, and how to troubleshoot equipment issues when encountered.

Key Issues and Points The equipment used in simulation centers ranges from low technology partial task trainer, to high technology/high fidelity patient simulators. There are multiple factors that need to be considered related to equipment selection and maintenance that need to be considered. These points include the following: • Matching needed equipment to the educational goals of the courses. • How many, and what types of equipment should be obtained, and when. • Is the simulator software compatible with the organizations information technology systems? • If adding additional simulators, does the new system/s integrate with the AVS system? • When should a maintenance agreement/warranty be purchased and/or extended?

K. Miracle (*) Kevin Miracle Consulting, Gibsonia, PA, USA © Springer Nature Switzerland AG 2020 M. A. Seropian et al. (eds.), Comprehensive Healthcare Simulation: Program & Center Development, Comprehensive Healthcare Simulation, https://doi.org/10.1007/978-3-030-46812-5_10

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• Utilizing the equipment manufacturer for service/repairs versus performing them with center - staff. When it is time to acquire the equipment, it is recommended to collaborate with the finance and purchasing departments in your organization to determine the best approach to obtain the items. There are a few options that can be considered. These include the following: • Outright purchase of the technology – converting cash to an asset on your balance sheet. • Long-term leasing – allows the center to keep the equipment long term while conserving cash on hand. • Renting the equipment – if the need is short term, it may be more beneficial to rent the equipment for a specified period of time. • Fleet management – this program offers the tax benefits of renting, with the customization capabilities of buying or leasing. Many organizations will not rent or lease equipment.  Thus, it is important to verify your organizations position when it comes to these options.

Key Resources and Partners It is suggested that the simulation center establish relationships with the various simulation equipment manufacturers, and learn as much as possible about the technologies offered. The vendors will help you determine what the best solution is for your need. Keep in mind, the vendor wants to sell equipment, therefore evaluate several different solutions, and don’t purchase the first product evaluated. There are various schools of thought related to purchasing and/or continuing with an extended warranty. Does your simulation center have access to biomedical service department? Are your staff members trained to troubleshoot and then perform the necessary repairs? Will you be able to purchase the parts? New technology can be difficult to maintain, and hard to repair, resulting in the need for service contracts. Through the development of a professional relationship with the sales representatives of the simulation companies that you wish to work with, they will better understand your needs, expectations, and limitations, and collaborate with your center’s best intentions. When it comes to maintaining your technology, your sales representative should be able to provide you with preventive maintenance checklists that can be utilized to check functionality. If the sales representative cannot provide that documentation, frequently it can be found on the manufacturer’s website. While it may take some investigative work to find and create the checklists, a customized document can be created specific to your organization’s equipment.

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Key Approaches In determining what types of equipment to purchase, it is essential that you meet with the course directors/facilitators to understand the educational objectives of their courses. This conversation allows you to determine what are the desired expectations of the equipment and, can the skills/tasks be accomplished using a task trainer in leiu of a full simulator. Once the needs are determined, conduct a thorough web review of the equipment manufacturers and conduct a preliminary review of equipment  capabilities; then match the equipment to the needs identified. Invite the vendors to provide an onsite demonstration of the selected trainers/simulators and invite the course directors to participate. Part of the vendor presentation should cover what additional technology is needed to conduct the training programs, equipment warranty coverage, and common maintenance issues. Ask for a list of simulation programs currently using the technology so that you can contact them to discuss the product’s performance and any issues. It is also important to include your information technology team to understand the potential to integrate into existing information systems. Maintenance of the simulation equipment can be challenging. As the level of fidelity increases, the ability to perform repairs becomes more difficult. This is often due to the increasing utilization of electronics that can go bad, and be difficult to identify. You may be able to troubleshoot issues with the manufacturers’/vendors’ technical support teams over the telephone or through remote access; however, the actual repair may require the equipment to be shipped to the manufacturer for repairs. This results in the loss of the technology for an undefined period of time, as well as incurring shipping costs, in addition to the cost of the repairs. Performing routine maintenance on a monthly basis will help prolong the useful life of equipment. This is also helpful in identifying problem trends in anticipation of future service and repairs. Track the preventive maintenance checks, as well as problems identified to assist with repair budget management.  Monthly preventitive maintenance schedules and checklists are well worth the effort and result in cost savings in the long run.

Pearls Do not try to fit the preverbal square peg into the round hole. • Be specific when obtaining quotes for equipment, don’t let the sales representative quote what they feel is best. That is your decision, and your budget. • Do not allow yourself to be convinced to purchase equipment that you do not want, or need. • Conduct monthly (at a minimum) preventive maintenance checks on the technology to verify functionality. This will prolong the life of the equipment. • Verify that any repairs being performed by your organization do not void any warranties, if a warranty was purchased. Routine maintenance is one thing, repairs are another.

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• Do your best to limit “ink pens and markers” being used near the simulation equipment. Do not set printed or photocopied documents, text side down as the ink will transfer to the skin of the simulator. While it is not impossible to remove, it can be time consuming.

Key Take-Aways • The technology being considered for purchase must match the needs of the program. • The need for the technology must be tied directly to the educational goals and objectives of the course. • Ensure that all technology is compatible with your organizations’/systems’ IT infrastructure. As an example, some simulation software programs are not intended to operate on an organizational network platform. • Maintain your equipment. Clean/disinfect the equipment. With many people laying their hands on the equipment, it will quickly become as infectious as the local playground.

Suggested Reading Fatah AA, Barrett JA, Arcilesi RD Jr, et  al. Guide for the selection of communication equipment for emergency first responders. NIJ Guide 104-00, Volume I. Washington, DC: National Institute of Justice; February 2002. Levine AI, DeMaria S Jr, Schwatrz SD, Sim AJ.  The comprehensive textbook of simulation. New York: Springer; 2013. Pellegrino L, Reed L. Simulation centers: selection and tips from the field. Hollis: Farm Design, Inc; 2013. Soyring Consulting. How to maintain your medical equipment and cut costs. 2013. http://www. soyringconsulting.com/newsletter/how-to-maintain-your-medical-equipment-and-cut-costs. Why Maintain Equipment. https://www.nibusinessinfo.co.uk/content/equipment-maintenanceand-checks-safety.

Audiovisual and LMS

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Lucas Huang

Overview This chapter will focus on the (non-simulator) technology infrastructure that your simulation program will depend upon to function effectively. Ease of management, flexibility, scalability, and accessibility are critical to properly support expansion and growth. There are three core technology areas: • Audiovisual (cameras, microphones, device capture, large displays) • Information Technologies –– PC (debriefing, video distribution, staff support, faculty support) –– Mobile Devices (collaborative screen sharing) –– Networks (AV, wired, wireless, vpn) –– Data (centralized portals, redundancy, backups, access) • Learning Management Systems (managing your simulation activity) These technologies have significant interdependencies that are commonly supplied by different groups, so it is important to understand how the technologies layer upon each other to deliver the necessary functionality and make sure there is coordination between the various suppliers (external and internal).

L. Huang (*) B-Line Medical, LLC, Washington, DC, USA e-mail: [email protected] © Springer Nature Switzerland AG 2020 M. A. Seropian et al. (eds.), Comprehensive Healthcare Simulation: Program & Center Development, Comprehensive Healthcare Simulation, https://doi.org/10.1007/978-3-030-46812-5_11

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Key Issues and Points (Fig. 11.1) • AV – Audiovisual infrastructure –– Driven by LMS –– Monitored/adjusted by staff –– Communications via IT • IT – Connectivity/authentication –– Provisions bandwidth –– Manages PC platforms –– Security/storage for LMS • LMS – Core functionality –– Accessibility by learners –– Accessibility by faculty –– Managed by staff –– Cloud usage The below diagram is simplified, but should put into context why a good LMS is a core foundational element. Keep in mind, while staff typically access the LMS at the simulation centers, faculty and learners spend the majority of their time accessing the system from somewhere else within your institution’s network, remotely from home or the nearby coffee shop, or from clinical environments that can have some challenging accessibility restrictions.

AV: Capture & display infrastructure (control) Cameras

Mics

Screens

IT: Connectivity and authentication Network

Computers

Storage

LMS: Manage content and accessibility Capture

Staff

Debrief

Faculty

Assess

Learners

Manage OSCE’s/Sim activity Schedule events/resources

Teach/interact with learners Review/assess/research

Sign up for events Fully engage in Sim activities

Manage content Support faculty

Track performance/remediate Monitor/adjust curriculum

Peer assess/reflective review Manage their portfolio

Fig. 11.1  Interdependency diagram

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From a big picture perspective, the selected LMS and IT should be leveraged to aggregate and manage activities from the various institution simulation silos and include InSitu activities within the clinical environments. One of the keys to learner retention of training is “high frequency, low dose” but it needs to be easily accessible, easy to execute, effective, and minimize time away from clinical care (paid/unpaid time away for patient care).

Key Approaches Step 1 – Pick an LMS This will set the foundation for your program and its capabilities. • Functionality (really spend time understanding the needs  – short term and long term) –– Recording and live streaming of your simulation activities • What operational environments will you be simulating? –– Trauma, ED, OR, IR, LDR –– ICU, NICU, PICU –– Outpatient • Integrate clinical technologies to reflect operational environment. –– Patient monitor/anesthesia/ventilators –– Electronic medical records –– Medication delivery –– Ultrasound, airway cameras, surgical cameras, Fluoroscopy • Do you want to support peer streaming and assessment (effective in learner rotations, cycling roles, and usually via nearby observation)? • Live assessments (checklist and annotations, locally and remotely)? • Pre/post assessments (before/after simulation activity)? (Fig. 11.2) –– Debriefing (done immediately after by trained individuals has greater impact) • Will the LMS help or hinder the way your faculty like to interact with learners? Source types Video Digital media Audio Data

Ultrasound capture

Surgical camera Simulator data

Camera 2

Patient monitor Airway camera

Simulation Recording

Faculty #1 assessments Microphone 1

Bandwidth Heavy Moderate Light

Faculty #2 assessments Camera 3 Electronic medical record Peer assessments

Medication dispenser Camera 1

Microphone 2 Faculty annotations

Fig. 11.2  Elements that go into a simulation recording

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• Ability to start a recording, be in the room with learners, tag areas of discussion, either from the adjacent control room or on mobile devices. • Ability to leverage video effectively in the debrief (jumping to tagged events) (Figs. 11.3 and 11.4). –– Management of OSCE’s (Objective, Structured, Clinical Examinations) • Setting up to run (how difficult is the system to set up and run) –– Door notes, faculty evaluations, SP checklists, learner SOAP –– Exam timing, ability to record multi-segments, auto rotate –– Scheduling of resources, SP training/assignments, learner assignment

Simulation

Debrief

Move

Debrief

Start/Stop annotate

Fig. 11.3  Traditional flow: simulation activity ⟶ Review in debrief room (Learners Faculty move to debrief room)

Simulation

Debrief

Simulation

Debrief

Simulation

Debrief

Simulation

and

Debrief

Debrief

Start/Stop annotate

Fig. 11.4  Rapid cycle deliberate practice flow: Sim/debrief 3–5 cycles in room (Learners Faculty stay in the Sim room)

and

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12'-0"

10'-0"

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Faculty/QA Assessment

Exam Room (10' x 12')

Proctor Station Exam Management

Multi-Room cycle –Door notes, Learner/SP encounter, Learner SOAP, SP checklist, Faculty/QA assessments Exam Exa x m Room

Exam Exa x m Room

Exam Exa x m Room

Exam Exa x m Room

(10' x 12')

(10' x 12')

(10' x 12')

(10' x 12')

Exam Room (10' x 12')

Learner/SP Encounter

3'-0"

Door Note

SP

SOAP Note

Fig. 11.5  Example OSCE room layout (usually 12 rooms) – Patient exam rooms, double circulation with learner corridor and faculty/SP corridor, unique case in each room

• • • •

Managing day of the event (how does it handle missing learners/SPs) Aggregation of data (reports day of and remediation targets for faculty) Linking multiple sites (same content) Reflection of credentialing body exam process (varies by country and discipline) (Fig. 11.5) –– Management of large events • Support faculty training needs • Determine availability of space and resources (simulators, techs, time) • Ability to assign or auto-enroll to learners • Ability to communicate to learner and support staff for the event easily • Learner remediation identification and communication –– Learner management • Single sign on (avoid assigning passwords to learners, use LDAP) • Portfolios to track progress and time they have spent in simulation • Single Sign ON support (Integration via LDAP) –– Faculty resources • Ability for faculty to easily perform assessments • Ability for faculty to collaborate and adjust pass/fail criteria • Ability for the system to quickly identify borderline learners • Ability for the system to highlight individual learner deficiencies • Ability to support faculty’s ability to conduct meaningful research • Ability to support faculty’s ability to present exemplar cases • Selection Process –– Do the due diligence up front before any decision on the AV infrastructure. • Create a small team to help you make your decisions. –– It is often important to consider politics when creating the team. –– Make sure they are the right complement of individuals. • See pictures of simulation centers they have helped develop or create. –– Is it an example of what you want your center to look like? –– Is there functionality there you need to include in your needs? • Talk to others who have gone through the process. –– Did the process give them the best solution? –– Did pricing force them to compromise? • Talk with end users who have extensively used multiple systems.

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–– Strengths and weaknesses of each system. –– What is their rationale for what they like? • Understand what makes the lives of users easier or harder. –– Reliability (checklists electronic in system or bypassed to paper). –– Reports (analytics out of the box, ease of setup and retrieving). –– Access (do faculty find the system easy access and use). –– Can you run a comparison (side by side)? • Simulator Integration. –– Capture of patient monitor –– Import of data from simulator event and metric logs • Ease of setup • Reliability • Capture of medical devices. –– EMR, ultrasound, airway cameras, surgical camera, flouro –– Ease of setup and quality of capture create realistic environments –– Ability to do this Insitu (critical for growth and expansion) RFPs are a common tool; if properly structured they can be very helpful in helping select the best solution for your center. • RFPs are not foolproof, as some responders may misrepresent their capabilities to meet a requirement. • Make sure that the procurement team is aware that pricing cannot be the deciding factor, that although a heavy influence, your committee must make the final decision as to the best solution for your program, which may not be the lowest price bidder. • Use the process to narrow your responders, get onsite presentations, and require short term loans of gear to enable your team to properly evaluate the capabilities of the respective systems. • Visit other centers and ask questions –– Once selected, leverage their expertise. • They will have the extensive experience helping design simulation centers. • Have them work with the architects. • You may consider involving them in the AV integrator selection process. • Some LMS systems do their own AV work, which logistically is easier, but the quality of execution may be an issue.

Step 2 – Involve Your Institution’s IT Leadership • Let the IT leadership help you to design your flexible scalable network topology –– Having leadership support is critical for long-term sustainability. –– Leverage their IT expertise to clearly define roles and responsibilities and have their network architects help structure the implementation for growth both near term and long term. –– Key areas to focus are network topology, bandwidth, storage, remote access both outside the simulation centers and external to the institution network, and the selection and management of computers/servers.

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• Network topology –– Private VLAN for Video…is your LMS in the Cloud or on premise? • Locally contained, encoded video distribution stays within the center • Manage local access when appropriate –– Private VLAN for data, simulator manufacturers may require their own segment. –– Connectivity to the data center (central archiving and central portal). –– Firewalls to control access and secure data. –– Who will install (will this be by the AV integrator, your IT team, or construction)? –– Who will manage (will this be AV integrator or IT team) (Fig. 11.6)? • Bandwidth and storage –– This is highly dependent on the camera you select and the resolution you want to record and archive. While video recording at 1080p or even 4K are beautiful to look at, they are exceptionally bandwidth intensive and can be cost prohibitive to maintain. –– SD (640 × 480) does not look good when projected on a large screen. –– HD (720, 1080, 4K, 8K) requires (4×, 8×, 27×, 108×) bandwidth respectively. –– Typically anything above SD (even 800  ×  600) will meet the needs of simulation. –– Also keep in mind that, these days, lots of access is wireless, so plan accordingly. –– Note: Depending on the Cloud implementation of the LMS, this may be a non-­ issue where video streaming may automatically adapt for end-user bandwidth limitations.

Internet (Remote access to LMS)

LMS – Cloud optimized Load balancing

Data security

Video processing

VPN

User security

Replication service

Dynamic streaming

Data center (LMS)

SimCente SimCente Sim center rr Network (educational)

SSO

SSO

Hospital Hospital Hospital Network Network (clinical)

Typical – On-premise topology

SimCente SimCente Simrcenter r Network (educational)

Hospital Hospital Hospital Network Network (clinical)

Typical – Cloud topology (verify cloud implementation)

Fig. 11.6  Network topologies: on-premise vs. cloud (determine pros and cons)

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• Computer topology and management –– IP cameras have integrated hardware encoders to compress the HD video feeds into something that is relatively lightweight to not negatively impact the network. These devices are designed to encode 24 × 7 and do a great job. –– PCs and mobile devices need to use software to decode each video stream, and that requires processing power. –– Latency – the time it takes the video camera to encode the stream, send it to the far side (to the person remotely viewing), and the playback computer to decode the stream and show it on the screen can range anywhere from 200 ms to several seconds. • If your playback device does not have enough processing power, you will see significant degradation in performance. • If your network does not have the necessary bandwidth to transmit the video streams fast enough, you will see significant degradations in performance. • If your firewall restricts bandwidth, you may run into situations where too many users will cause significant degradation in performance (Fig. 11.7). • Access control plan for this through your institution’s infrastructure –– Single Sign-on • You do not want to support assigning and reminding learners of their passwords. • Make sure your IT is working with the LMS provider to implement this. • LDAP and Active Directory integration are the most common protocols to support single sign-on integration. • Newer authentication models are evolving including Shibboleth and Sabre, but your LMS may not support these authentication models. –– Guest Access • You will always have guest users (third parties that want to use your center and are not within your institution’s authentication system). • Be sure your LMS supports this and can provision guest access so you can properly bill them.

AV - Selection (