Clinical simulation labs and programs tend to have a set of policies and procedures in place to help govern the use of their resources while ensuring fairness in opportunity. To help empower learners to deliver the best possible care to every patient, labs and programs must strive to promote a culture of excellence and elevated patient care. Through the development of healthcare simulation policies and procedures, facilitators are able to better position themselves and their respective facilities to meet these goals. This HealthySimulation.com article will explore a wide range of institutions that have published Policies and Procedures manuals, standard operating manuals, and student handbooks about healthcare and clinical simulation programs. (Editor’s Note: This article was updated September 8th, 2025).
Why are Policy and Procedure Manuals Important in Healthcare Simulation Programs?
Policy and procedure manuals in healthcare simulation programs and laboratories are essential because they act as the operational backbone of the simulation environment. They establish standards, maintain safety, ensure compliance, and provide consistency across teaching, research, and practice. These are the most important aspects that are addressed with policies and procedures.
- Standardization and Consistency: Uniform practices and reduced variability
- Safety and Risk Management: Outline safety processes to prevent harm for learners, employees, standardized participants, and equipment. This includes infection prevention, emergency procedures, and safe use of the clinical simulation equipment. Psychological safety can also be addressed in this aspect.
- Compliance and Accreditation: Provides the documentation for accreditation and endorsement while documenting the use and data required to support the healthcare simulation program.
- Operational Efficiency: Provides step-by-step instructions for workflow and requests to schedule experiential learning to improve the efficiency of skills laboratory and clinical sim set-up.
- Educational Integrity: Helps protect the rules for participation, assessment, remediation, and confidentiality. These can also help with academic dishonesty and misuse of clinical simulation data.
- Quality Improvement: Guides structured reviews and clinical updates to evaluate and improve processes in the healthcare simulation program.
- Legal and Ethical Protection: Processes for injuries, equipment misuse, and breach of confidentiality in order to act as a responsible program.
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Programs with Published Policies and Procedures Manuals, Standard Operating Manuals, and Student Learning Manuals:
- Blinn College Health Sciences Simulation Policies and Procedures
- Casper College Health Science Simulation Center Policies and Procedures
- Duke University School of Nursing Center for Nursing Discovery Policy and Procedure Manual
- Georgia College & State University – Georgia College Simulation and Translational Research Center
- Indiana University Interprofessional Simulation Center Bloomington Policy and Procedure (Joint Program School of Medicine and School of Nursing
- Lanier Technical College Simulation Center Policy and Procedure Manual
- Medical Allied Career Center, Inc. Nursing Simulation Lab Policies and Procedures Manual
- Minnesota State University Mankato Maverick Family Nursing Simulation Center Policies and Procedures Manual
- Missouri Southern State University SCICE Policy & Procedures Manual College of Health, Life Sciences & Education
- NYC Health + Hospitals Simulation Center Unit-Base (in-Situ) Simulation Manual
- Penn State Health Milton S. Hershey Medical Center Policy and Procedure Manual
- Ross University School of Medicine Simulation Institute Policies and Procedures Manual
- Saint Elizabeth University Medical Simulation Center Policies and Procedures
- Simulation at Penn Medicine Academy Hospital of the University of Pennsylvania
- South Dakota State University Standardized Patient Policy and Procedure Handbook
- Texas Tech University Health Sciences Center SiM Central
- The Grand Valley State University Interprofessional Simulation Center Policy and Procedure Manual
- The University of Rhode Island College of Nursing Nursing Skills and Simulation Lab Policy and Manual PreLicensure
- UCI Sue & Bill Gross School of Nursing Simulation Center Policy and Procedure Manual
- University of Central Florida Clinical Skills and Simulation Center Policies and Procedures Student Manual
- University of Florida Policies and Procedure Manual
- University of Florida Standards Operating Policies & Procedures
- University of Kentucky Clinical Simulation and Learning Center Policies and Procedures Manual
- University of Louisiana Lafayette College of Nursing & Health Sciences
- University of South Carolina Upstate Mary Black College of Nursing Simulation Center for Teaching Excellence: Policy and Procedure Manual
- University of Tennessee Health Sciences Center – Center for Healthcare Improvement and Patient Simulation Standard Operating Procedure Manual
- University of Wisconsin Health Clinical Simulation Program (CSP) Policy and Procedure Manual
- Victoria College Allied Health Simulation Lab Policies and Procedure Manual
- Washburn University School of Nursing Clinical Simulation and Learning Laboratory Policy and Procedure Manual
- Western Dakota Technical College Simulation Center Student Handbook
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Healthcare Simulation Program Recognition
Accreditation for healthcare simulation programs demonstrates that the program meets a high standard of quality in healthcare simulation. According to the International Society for Quality in Healthcare, accreditation is a process “in which trained external peer reviewers evaluate a health care organization’s compliance with pre-established performance standards. Endorsement of healthcare simulation programs is an assurance that a program meets the standards and requirements set forth as guidelines. Healthcare Simulation Accreditation and Endorsement are methods of external peer evaluation to determine a medical simulation program’s consistent use of the best practices and healthcare simulation standards.
Policy and procedure manuals are critical in healthcare simulation because they promote safety, consistency, compliance, efficiency, and accountability, and uphold the educational mission of the lab. They form the “rulebook” that keeps clinical simulations realistic yet controlled, safe, and effective.
- The Society for Simulation in Healthcare offers a template for Policies and Procedures.
- Avkin offers a guide to craft a comprehensive policy and procedure handbook for standardized patient programs.
- Healthcare Simulation Standards are designed to incorporate best practices into a healthcare simulation program.
- If you have resources or would like to share your policy and procedures manual with the simulation community, please contact support@healthysimulation.com
Learn More About Healthcare Simulation Accreditations and Endorsement Programs!
Additional Resources for Clinical Simulation Policy and Procedure Manuals:
Clinical simulation labs and programs tend to have a set of policies and procedures in place to help govern the use of their resources while ensuring fairness in opportunity. To help empower learners to deliver the best possible care to every patient, labs and programs must strive to promote a culture of excellence and elevated patient care. Through the development of healthcare simulation policies and procedures, facilitators are able to better position themselves and their respective facilities to meet these goals. Below are a number of programs which have implemented such standards:
University of Pennsylvania Policy & Procedure Manual: This Policy and Procedure Manual is not a substitute for other policies and codes, but a complement to other codes, policies and regulations held by Penn Medicine which regulate the behaviors of staff and learners of Simulation at Penn Medicine. This manual breaks down the university’s governance, complaint resolution process, quality improvement, course administration, evaluations, psychological safety and more.
SSH Simulation Program Policy and Procedure Manual Model Template: This procedural template was established as a revision and update of the 2012 template policy and procedure manual model for members of the SSH. This team was composed of experienced members in clinical simulation program operations, administration and management. The team was tasked to create a template for SSH members to utilize as a foundation for the creation of their own policy and procedure manual.
This manual outlines commonly accepted practices and serves as a general model for simulation programs to follow when developing their policy and procedure manual. Core topics are outlined, and each topic includes a brief description to assist in understanding the potential application. When using this template, programs should feel free to edit, add to or omit topics depending on the specific needs of their organization. The result will be a customized “Policy and Procedure Manual” addressing fundamental issues to efficiently and effectively operate a simulation program.
University of California Irvine Medication Education Simulation Center Policies and Procedures: UCI operates on a hierarchical organizational structure within Medical Education, School of Medicine. All strategic decisions are made by the Director in coordination with the Vice Dean for Medical Education and Dean’s office. Day-to-day operations are the responsibility of the director of operations. All scheduling is funneled through the administrative assistant to the director of operations for evaluation. Use of the simulation center, including debriefing rooms and task training rooms are by appointment only. Scheduling may be obtained by contacting the Simulation Program Office or by submitting a request online. At this time, there are no general open lab hours. In general, any activity scheduled must contain medical simulation and/or task training to some degree. The simulation center is considered an active learning environment. Determinations are made by the Simulation Program Office. The university’s policies and procedures go on to outline other elements such as operating hours, computer use, study space, access to information and more.
Clinical Simulation Center of Las Vegas Standard Operating Procedures: The purpose of the Clinical Simulation Center of Las Vegas’ standard operating procedure is to provide a detailed, standardized operating protocol to ensure all duties of the Clinical Education Assistant are successfully performed. To ensure all duties are completed, the sim center requires attainment of all schedules and syllabi prior to each semester from the technician(s) and coordinators from each area. Additionally, this will also give a general idea of how time needs to be managed for setups, breakdowns or providing support in each area of the facility. This set of policies and procedures further includes sim control, scenario operations, lab use, equipment requests and more.
In addition to these policies and procedures, numerous other institutions offer guidance to help support their staff, facility and learners. Here are other policy outlines that may be of use to clinical simulation labs and programs throughout the world:
- University of Louisiana at Lafayette Department of Nursing Simulation Program Policy and Procedure Manual
- Maverick Family Nursing Simulation Center Policies and Procedures Manual
- Penn State Health Milton S. Hershey Medical Center Clinical Simulation Center Policy and Procedure Manual
- Victoria College Simulation Lab Policies and Procedure Manual
- Georgia College Simulation and Translational Research Center Policy and Procedure Manual
HealthySimulation.com also provides a comprehensive outline for healthcare simulation programs. This includes listing out a mission, contact list, stakeholder committee, confidentiality agreement, observation policies and more. Ultimately, such outlines should reflect that policies and procedures are a core requirement of accreditation programs. Additionally, a Clinical Skills Lab Coordinator Standard Operating Procedures Example and Standard Operating Procedure Guides for Simulation Technician Positions are available.
