Introduction

Accreditation of simulation programs is a relatively new concept. Since 2010, the Society of Simulation in Healthcare (SSH) has been accrediting programs nationally and internationally. This commendation assures a simulation center’s learners, as well as to said center’s administration and stakeholders, that the center follows best practices in the creation, development, maintenance, and expansion of enterprises pertaining to simulation in healthcare. For the Society of Simulation in Healthcare (SSH), accreditation is defined as a “peer-reviewed, customized evaluation of a healthcare simulation program.” Such an evaluation aims to ensure that the program adheres to a high standard by providing quality healthcare education. To meet the requirements outlined by SSH, the applying program must apply for “Core” as well as at least one other area, including Assessment, Research, Teaching/Education, or Systems Integration.[1][2]

Function

While there are two accrediting bodies in the domain of simulation, SSH and the American College of Surgeons (ACS), the primary organization referenced here will be SSH. The ACS focuses more on domain-specific expertise in the specialty of surgery, while SSH focuses on the recognition of simulation expertise.

Ultimately, simulation centers obtain accreditation to provide value to the program and to showcase its expertise. Such validation may lead to the recruitment of better instructors, outside learners, and contracts, with the potential of increasing revenue and sustainability to the Center. Additionally, accreditation ensures that a program has a clear mission, vision, strategic plan, and formalized policies and procedures.[3][4]

Issues of Concern

 1. Creation of a complete set of policies and procedures specific to your simulation center:

We recommend that a simulation program assigns one or two “champions” to review the accreditation requirements and create the initial drafts of all required and recommended policies and procedures applicable to their simulation center.  If not pre-existing, creating a simulation-specific steering committee should merit consideration, which includes representation from the simulation center, facilitators, learners, administration, and stakeholders.  Such a steering committee would not only oversee the activities and operations of the simulation center but would also review all newly created policies and procedures for accuracy and completeness.  Such a steering committee may also serve as the integral “link” of a larger institution’s multiple levels of administrative oversight of a given simulation center.

Many organizations already adhere to a set of policies and procedures (P&Ps) and have a pre-existing mission statement applicable to their overarching institution(s).  Aligning those documents with document requirements for SSH accreditation may be difficult, as they must be complementary and non-contradictory to any organizational P&P’s.  It is often necessary to have policies and procedures specific to the simulation center only.  A simulation center steering committee is again useful in reviewing such documents and submitting them to the simulation center’s governing organization, human resources, specific stakeholders, etc.  Since this may involve multiple approving bodies, this can become time-consuming and tedious.  Such documents may also require legal and/or risk management involvement before final approval. Adequate time, well before SSH accreditation application, should be allotted to this important task.

 2. Preparation of the simulation Lab:

Sufficient time should be allowed to prepare the laboratory to meet accreditation standards, including labeling all medical equipment and medications as “for simulation use only.”  Organization and inventorying of all equipment, moulage supplies, repair tools, etc., should be demonstrated.  Although a free-standing simulation center, for example, may feel “immune” to potential confusion of “live” medications with simulation medications, etc., this has been shown not always to be the case. Consideration of signage instructing all exiting learners to check their clothing and bags for any supplies/simulation medications/medical adjuncts should be made, as well as a “drop-off” box should such items be discovered. 

Prominent display of the simulation center’s Mission and Vision statement is part of the accrediting team’s evaluation. The simulation center should attend to all safety requirements of their particular building/site, such as assuring that hallways and exits are unobstructed, building safety/entry policies and precautions have been taken, site security established, etc.

3. Consistency of message from all administrators and stakeholders:

The accreditation team will interview a broad spectrum of simulation center members, learners, and stakeholders.  In many centers, there are several levels of administrative oversight of a simulation center.  There must be consistency in expression, by all of these individuals, of the overarching mission of the simulation center, the planned future for the said center, and a well-prepared plan of financial sustainability of the center and its future potential growth.  Clear demonstration of administrative support for the simulation center and its integral role in medical education now and in the future should be clear.

4. Advice and preparation of learners to be interviewed:

Learners should not receive any pre-prepared answers to potential questions or inquiries from the accreditors. They should be instructed to be honest and forthcoming with the interviewing parties. Learners should understand that their answers are confidential and private. Learners can be advised as to areas in which the accreditors might be interested, such as perceived benefits of simulation education, maintenance of a psychologically safe environment during simulation activities, qualifications of simulation personnel and facilitators, and areas of potential improvement in the simulation education experience.  Such knowledge allows learners to better reflect on these areas of their simulation experiences and better articulate those experiences, and their recommendations, to their interviewers.

5. Documentation of staff meetings, modes of personnel communication, and team planning

The simulation center leadership should document the team dynamic in the simulation center and how the team communicates (e.g., emails, huddles, staff meetings, bulletins, etc.). Techniques used to promote staff satisfaction, well-being, and comradery should be demonstrable and well documented.  All staff meetings should have recorded minutes. If action plans have been created during staff meetings, staff should be prepared to discuss how these action plans have been enacted/addressed and what specific steps were implemented to achieve specifically identified goals.

6. Clear establishment of policies and procedures for learner/staff/facilitator complaints and/or potential breach of psychological safety:

Accreditors are consistently vigilant in assuring that all complaints, at all levels, are adequately and professionally addressed.  The simulation center should have clear guidelines of “escalating” avenues of addressing complaints dependent on either their lack of resolution at a first-line level or the seriousness of the complaint or issue. These guidelines should include specific departmental resources (such as human resources, graduate medical education office, institutional legal team, etc.) depending on the nature and seriousness of any given grievance.

Similarly, the preparation of resources for learners psychologically stressed during simulation activities should exist and be well documented. Not only should there be adequate and specific resources for all learners felt to be unduly stressed or affected by a simulation event, but said learners, before all activities, should know such resources are available to them.  Stressed learners are often managed effectively and adequately by skilled facilitators in private debriefings, for example, but more formal resources such as mental health facilities/workers should be established and available for more serious learner issues.[5][6]

Curriculum Development

To obtain accreditation by SSH, a program must demonstrate two years of experience and outcomes data in the area(s) in which accreditation is sought.  Although programs may exist for more than two years, they must demonstrate an overall mission, governing structure, funding sources, strategic plan, and roles of all simulation center personnel.  

Medical Decision Making and Leadership Development

Obtaining accreditation involves understanding the leadership structure of the program (if affiliated with an institution). It is paramount to set up a form of governance specifically for the simulation program and to include all stakeholders involved. This can include the director of the program, faculty, Director of Research, Director of Finance, student representatives, hospital representatives (should the program be affiliated with any), and other persons who would benefit from the long term direction of the center.

It is well understood that the very essence of medical simulation-based education is to improve learner communication skills, develop leadership expertise, promote highly functional and efficient teamwork, and enhance medical knowledge and skills through skillfully debriefed sessions and deliberate practice.  None of these goals are easily obtainable, and all of these goals require high-level facilitator and simulation team experience and expertise.   The accreditation process is highly beneficial in creating the necessity for a simulation center to self-evaluate and critique its programs and policies and address avenues that may lead to further simulation center excellence.  Obtaining SSH accreditation often only occurs after a program has internally evaluated and optimized its learning environment and has codified its policies and principles as an educational site.[7] 

Continuing Education

The mission and goals of various simulation centers vary tremendously. They all, however, share the objective of providing ongoing training to allow participants to learn, improve, and maintain skills. Once again, the accreditation process provides each simulation site an opportunity to independently and internally review its quality of teaching and facilitating and to optimize these elements in preparation for an accreditation review. The accreditation process itself provides accreditors who are highly experienced and knowledgeable in simulation education to examine the site with a critical eye. The accreditors judge the adequacy of preparation of a given site and make expert recommendations for future improvement of a site’s activities and teaching.

Many sites also provide formal faculty development courses in skills training, simulation history and culture, debriefing techniques, and practice workshops.  In promoting and advertising such events, having obtained formal SSH accreditation lends legitimacy and an element of prestige to a simulation site and supports a site’s claims of providing high-quality, best-practice training and workshop experiences.

Clinical Significance

The significance of obtaining simulation center accreditation lies in its support of best practices in a field where such practices may be the difference in a life or death outcome. To Err is Human, a report published by the Institute of Medicine, stated that over 400,000 deaths occur annually secondary to preventable medical errors. It has been noted that the majority of the sentinel events leading to these errors fall in the domains of leadership, communication, and teamwork.  This report significantly increased the interest in medical simulation as a platform that might address these domains in a meaningful way. Hence the credibility and value of medical simulation centers are at stake. Indeed, the next vital “phase” of simulation education research shall be the demonstration of translation of skills and learning in simulation centers to real clinical sites and, hopefully, better patient outcomes. Obtaining accreditation helps to ensure the creation of valuable curricula, onboarding skilled and qualified instructors and staff, and that policies and procedures are appropriately codified and formalized.[8][9]

Pearls and Other Issues

Final “pearls” of potential questions and areas of inquiry:

• Have a very clear vision and specific plan (including financial viability and sustainability) for the future of your simulation center
• Be conversant not only on the strengths of your simulation center but self-identified areas that would benefit from improvement/modification/augmentation. Be able to outline specific plans for future development and refinement of your simulation center. 
• Be prepared to discuss plans and capabilities for simulation site emergencies (e.g., massive power failures during simulation events, catastrophic loss of computer/networking/technology capabilities, etc.).
• Be prepared to discuss the credentials and qualifications of simulation center personnel (e.g., directors, managers, simulation operations, specialists/technicians, etc.).  Be able to outline resources earmarked for staff continuing education, development, and advancement.
• Be able to discuss specific requirements and qualifications for all facilitators in the simulation center. Have specific tools for ongoing evaluation of and feedback to all facilitators (e.g., regular DASH tool evaluations, specific feedback frequency, and techniques utilized in the center, etc.). Be prepared to answer questions regarding actions taken when facilitators are found to have significant deficiencies, recurrent learner complaints, etc.)
• Accreditors are consistently interested in the annual review of all simulation center personnel. In many large institutions with general templates for regular employee review, it is clear that skills, areas of expertise, and accomplishments specific to medical simulation education may not be specifically addressed. (Some institutions, for example, have created a simulation-specific review template that we utilize, in conjunction with our larger institution’s evaluation form, in the annual review of our simulation center’s staff).
• Demonstrate how the simulation center leadership participates in and encourages staff wellness, healthy work-life balance, comradery, and effective team interaction.[10]

Enhancing Healthcare Team Outcomes

As discussed above, the medical simulation environment provides almost endless opportunities in skills training, communication development, professional and inter-professional team building, all within the confines of a safe environment conducive to such objectives. Obtaining SSH accreditation is still relatively new for simulation sites/centers, and therefore published data relating SSH accreditation with clinical outcome improvement is still largely lacking at this time. The value of simulation-based education concerning improved psychomotor skills (e.g., laparoscopic surgical skills, suturing skills, etc.) that translates to the clinical setting is becoming more abundant in the literature, but this is outside the scope of this review article topic.

The information provided in this article is mostly based on the experiences obtained preparing and obtaining SSH accreditation from gleaned experiences and contributions of a number of our colleagues from across the U.S., all of whom are experts in simulation-based medical education. Hence the evidence presented in this article is rated V: expert opinion.