Standardized/Simulated Patient Program Management and Administration – Spinning Plates

Abstract

Simulated/Standardized Patient (SP) programs provide a trained cohort of SPs, expertise in SP methodology, and processes that administer SP services efficiently and cost effectively. Management in SP programs exist along a spectrum. Some programs may have one person dedicated to SP program administration while others may be headed by a dedicated manager who oversees the work of many SP educators and administrators. Regardless of size, SP programs are responsible for quality administrative and management practices, including quality planning, quality assurance, quality control, quality improvement, and SP recruiting, interviewing and on-boarding. Clearly stated policies and procedures allow an SP program to demonstrate that it meets legislated, institutional, and practice standards. They also specify approaches to meeting program goals, enable accountability to stakeholders (SPs, learner, faculty, and staff) and encourage continuous improvement (Lewis et al., Adv Simul 2:10, 2017, p 6).

We would like to acknowledge Maria Mercedes Avila, PhD, MSW University of Vermont who contributed to the section on diversity.

Appendices

Appendix 10.1 Template for Policies and Procedures

Introduction

Mission

Vision

Organizational Chart/s

What Is a Standardized/Simulated Patient?

Recommend using a standardized definition. This can be found at the Association for Standardized/simulated Patient (ASPE) website: https://www.aspeducators.org/ or in the Society of Simulation in HealthCare Dictionary https://www.ssih.org/Dictionary

A person who has been carefully coached to simulate an actual patient so accurately that the simulation cannot be detected by a skilled clinician. In performing the simulation, the SP presents the gestalt of the patient being simulated; not just the history, but the body language, the physical findings, and the emotional and personality characteristics as well (Barrows HS. Simulated (standardized/simulated) patients and other human simulations. Health Sciences Consortium; 1987).

Information for Standardized/Simulated Patients

Qualities of an Excellent Standardized/Simulated Patient

Outlining these qualities will help people figure out if they would be a good match. It also starts outlining the expectations. You could also include this in a job/position description. Here is a compilation of examples:

• Flexible work schedule: Program needs vary from month to month. Some activities are planned a year in advance; others with only a week or a day’s notice.

• Ease with people: We work with many different students in many different stages of training, so it is important to really like people and like working with students.

• Comfort with body: You need to be willing to have physical exams performed on you; often the same exams are done many times during a session.

• Comfortable “being on stage”: While you aren’t physically on a stage, you are performing a part. You are likely to perform that same part over and over again within a 4–8 hour period as each student gets a chance to interact with your case.

• Good observation skills: Because you’ll be evaluating student performance and sometimes giving the students feedback about their performance, you will need to be able to be “in role” and observing at the same time.

• Good memory: In a testing situation, you’ll need to remember what a student did or didn’t do during a 15–45 minute encounter in order to evaluate them at the end.

• Ability to provide feedback to learners

• Adaptability: We’re always updating and improving our cases and procedures, and we frequently introduce new cases. You will need to readily “relearn” things in a new way and adapt easily.

• Comfort with keyboarding skills: Basic computer (keyboarding and mouse) skills are required.

• Enjoy working with a group of people who are truly committed to making a difference in the education of our future healthcare providers, one student at a time.

What Can a Standardized/Simulated Patient Do?

Depending on where your program is, you may use SP methodology in teaching, assessment, research and/or quality improvement activities. As each of these has a different goal, it is helpful to explain what and how the SP works in each.

• 1. Teaching:

  • (a) Communication and Interpersonal Skills

  • (b) History

  • (c) Physical exam training

  • (d) Specific- Gynecology and or Male Genitalia Teaching Assessment

  • (e) Simulated participant in a mannequin simulation

  • (f) Hybrid/mixed modality simulation

  • (g) Other:

• 2. Assessment:

  • (a) Formative

  • (b) Summative

  • (c) High stakes

• 3. Research

• 4. Quality improvement

Training

Important to outline how people are trained to become SPs and trained to specific roles or purposes. You might outline general training rules in this policy and procedures and then training rules for specific activities. Here is a compilation of examples:

• As a new SP and on a yearly basis, we will review this Policy and Procedures Manual

• Training is required for specific sessions or programs. You must attend the training to perform in the program.

• The training session will provide you with the following information:

  • Whether this is teaching or assessment activity.

  • The objectives of the activity

  • The type and level of student you will be seeing (year, medical, nursing student, etc.)

  • The “case” materials which include the healthcare and personal facts about the patient you are to portray.

  • A clear understanding of the checklist (if used) and how to score it.

  • A training video of the case including SP presentation if available

  • A presentation on verbal and or written feedback, if you’re required you to give feedback.

  • Expected attire: whether in hospital gown or clothes appropriate to the case

  • Logistics- day, time and location.

• The patient you are portraying may have very different answers or reactions than you would personally. You are expected to portray THAT person, not yourself.

• If at the end of the training you do not feel you are appropriate for the role or do not feel prepared to perform in that session, talk with the SPE.

• Do NOT wait until the day of the session to ask questions. You can contact the SPE by voice or email 24/7!

• You will be expected to study and know your case.

Teaching Sessions

All of us like to be clear about what is expected of us. Based on your activities, provide SPs with details they will need to do a good job.

• You will be told to arrive 15 minutes before the session formally starts. This is paid time that is built into your schedule for preparation and set up. We expect you to be ON TIME. Proctors can be reached by PHONE OR TEXT ANY TIME if you are running late and need to give us a “heads up”.

• Do not allow a faculty member to change your simulation. You have been trained from a case with the realistic physical findings, history and psychosocial problems. If the facilitator wants to change your simulation, explain your need to remain as you were initially trained and refer them to the SPE.

• However, if the faculty wants to “tune” your affect (to increase your anxiety or decrease your anxiety, for example) or your “setting” (i.e., clinic office, ER, etc.) this is appropriate. Please note this change and alert the SPE.

• If you are working with a group in a process called a “rolling roll play”, students take turns working with you. The faculty and or students can call a “time out” which is a valuable learning process for the students. When you are in a “time-out” period it is important for you to continue (i.e., facial expressions, body language, etc.). However, do NOT interact with the student or group until “time in” is called. Note: During the “time out” the faculty and or student may want to “rewind” from the beginning or another student may want to pick up where the other left off. Pay attention to the discussion in the time out and then adjust when “time in” called.

Assessment Session

• You will be told to arrive 30 minutes before the session formally starts. This is paid time that is built into your schedule for preparation and set up. We expect you to be ON TIME. Proctors can be reached by PHONE OR TEXT ANY TIME if you are running late and need to give us a “heads up”.

• Immediately upon arrival – before socializing, please:

  • First thing: Turn on and log into computer in your room. Log in to the checklist. Report any computer problems ASAP to the proctor.

  • Set up all exam equipment needed.

  • If using oto-ophthalmoscope, attach battery portion to top portion. Check to see if the battery and the bulbs in both heads are functioning.

  • Check supplies (swabs, cotton balls, tongue depressors, etc.) and fill as needed.

  • Have a sufficient number of drapes in your exam room. Put one fresh drape on the stool for each student required to perform physical exams.

  • Make sure there are cups for water available.

• Make sure that you have paper checklists (in case of a computer meltdown) and a schedule with student names. Put these out of sight before the student comes in the room. Close the cover of the computer monitor before the student enters in the room.

• Take time to discuss details of your case with other SP(s) portraying the same case.

• Breaks and time for meals or snacks may be built into a session. You may use the SP lounge during this time as long as you are back in your room before the next student encounter. Often, snacks or meals are provided, although you’re welcome to bring your own food if you prefer. We ask that you do not leave the building during this time.

• If a student assigned to your room doesn’t show up, ask the proctor what the situation is. If the proctor assures you that the student is not coming, you may then press the NO SHOW button on the computer beside the student’s name.

• If the wrong student comes into your room: If the encounter is an exam, stay in character and perform as trained. Afterward TELL THE PROCTOR IMMEDIATELY. Fill out a paper checklist and put the encounter # and student name on it.

• Papers: At the end of the session, if you haven’t used your paper checklist hand it to the proctor for use at a later date. You may recycle your schedule.

• Clean-up is crucial! Many people use the exam room for various activities. Please respect it and leave it as clean as – or cleaner than – you found it.

  • Change pillow cases and roll out fresh paper on exam tables.

  • Plug in scope battery.

  • Wipe water off counters.

  • Take all paperwork, training materials, pencils, clothing, and personal items with you. Double check the cupboards!

  • Place your gown in the hamper.

Learner- SP Encounter

• Remember that the focus of the encounter is the learner. Each case must be portrayed accurately to the checklist and training.

• Attire: For men: gown with underwear (briefs or boxers). For women: gown, bra (not athletic type), and underwear (bikini, hipsters, or briefs – no thongs). For any case where there is any kind of examination of the feet, there are no socks or footwear allowed. For some cases, street clothes will be appropriate; this will be covered in training.

• We are trying to make the encounter as real as possible for the student. Keep your personal belongings stashed below the sink during the encounter.

• Do not act like a “professional” patient. Do not prompt the student to pull out the footrest, or offer your arm before they ask to take your blood pressure, move gown or drape before asked, etc. REMEMBER that you are supposed to be UNFAMILIAR with your surroundings.

• We record all assessment sessions and the video and microphones stay on in between students. Don’t say or do anything that you would not want recorded.

• If you have a question on how to score something, ask the SP Educator/Proctor

Confidentiality

Confidentiality is key to the integrity of your program. Confidentiality applies to learners, SPs, case materials and more. This may a place to reference your institution FERPA and or HIPPA policies.

• 1. Learners

• 2. SPs

• 3. Case materials

Our Commitment to Your Safety

Safe work practices: At each level of an SP program, it is your responsibility to create a safe working environment.

It is our responsibility to assure that you are working in a psychologically and physically safe work environment. To that end we will,

• 1. Help faculty/staff understand the scope of SPs work and understand potential threats to physical/psychological safety. For example, when designing the flow of activity with faculty, we will consider the # of repetitions and breaks to assure reasonable expectations for SPs.

• 2. Ensure you are appropriate for the role- by making sure there is no conflict of interest, and considering your personal medical history and psychosocial history. For example, you may not want to play to case of an intimate partner violence (IPV) case if you have experienced or know someone who has experienced IPV.

• 3. Provide you with information you need to make informed decision for saying yes. We will provide you with background information on case, case specific key objectives, SP responsibilities, context (e.g., formative, summative, level of learner, placement in curriculum) and format (e.g., length of encounter, type of encounter) so you are clear about their role. You need to be clear about what physical exams they will be and how many times they will do it.

• 4. Respect your decision to decline the offer or drop out of activity if you feel you are not a good match without having to provide a reason or be concerned about offers of future work.

• 5. Once you agree to a session, we will work with you to identify any threats to your physical/psychological safety as we go through training together. We will work with you to identify potential adverse effects of role portrayal and strategies to address them. We will share any potential hazards, like use of sharps, or environmental factors, in order to mitigate risk.

• 6. Agree on the criteria and process for you and/or faculty to terminate a simulation if needed.

• 7. Monitor the simulation and respond to immediate your needs.

• 8. Schedule a debriefing and de-rolling as close to the simulation as possible.

• 9. Provide a process for you to share any post activity adverse events.

• 10. Support you, when following policies and procedures, if a complaint has been made you.

Etiquette

Working as an SP is different from other jobs. It is a good idea to layout the rules of behavior expected of an SP in role and out of role.

• No cell phone use in the exam room. Please make calls during the break (quietly in SP lounge or hall outside of lounge).

• Cell phones must be turned off or “silent” during SP sessions – even if they’re left in SP lounge.

• No conversations in the exam rooms or inner hallway while testing is in session. Please go to the SP lounge.

• When in the lounge during a testing or teaching encounter, be aware of noise level. You must keep voices at a low volume.

• No food or drink (except water) is allowed in the exam rooms.

• When in hallways or lounge, please make sure to “cover your assets”. If you’re wearing a gown that ties and is open in the back, wear a sweater on top or wear another gown as a jacket. If you’re wearing a gown that closes with Velcro or crosses over in the back, you don’t need another layer.

• While bare feet are expected in the exam rooms and acceptable in the SP lounge, you must put on footwear if leaving those areas.

• Take excellent care of all equipment. Put it away neatly as described on equipment box and place in cupboard under the sink – after EVERY session!

• Report any broken or malfunctioning equipment to SP Educator.

• If you use up or nearly use up supplies from the closet alert the SP Educator so we can order replacements & not run out at an inopportune moment.

• Many people use the exam room for various activities. Please respect it and leave it as clean as – or cleaner than – you found it.

• Help keep the SP LOUNGE clean.

  • Discard plates, food, drinks, and cups after use (right away please, not hours later).

  • If you use non-disposable cups wash them, dry them, and put them away. Do not leave them half full in the lounge. Double check this before you leave.

  • Keep clothing and personal items in your room, in your locker, or hung on hooks in the lounge. Do not leave them lying around. The chairs & sofa should be available for people to sit on.

  • Double check the SP lounge and your room before you leave!

Scheduling or how do I get to work?

For most programs, SPs are employed on a part time basis. Often times, people who work as SPs are retired, students, work a series of part time jobs etc. As such it is important for them to understand the rules of being offered work. Be as clear as you can with the process you use. For example, how will you contact them, how much time do they have to respond before the work is offered to another SP?

• SPs are contacted by email, so please check your email each day. (Occasionally SPs are contacted by phone when time is short, but that’s the exception.)

• SPs are chosen the way actors are cast in a play. Many things are considered.

  • High stakes exams or a higher level of student may require a more experienced SP.

  • Age, gender, body type, and certain physical characteristics may be specified in the case.

  • Past experience/training in a particular case.

  • Development of skills. We may assign you to a particular program so that you can learn a new set of skills.

• When we contact you about your availability for a program:

  • This is not a confirmation. You must get back to us promptly to let us know that you want to perform in this program. IF the slot has not already been filled, you will be assigned and will receive a confirmation by email.

  • Please reply promptly if you cannot work a time or case that we have requested. We need to know so that we can schedule someone else.

  • Your confirmation will include the training date and time; dates, time and name of program, and name of the trainer. YOU MUST put this information on your calendar!

  • We will contact you if we have work available for which you are suited.

• When we offer you work, you are free to decline.

• We reserve the right to not call you if

  • You miss a training or session without notifying us

  • Being repeatedly late for a trainings or session

  • Acting inappropriately or unprofessionally with a student, staff or faculty member

  • Breaking any policy of the program or the institution included in this document

  • Breaching confidentiality

  • Failing to accept the authority of the SPE, staff or faculty during a training or session

    • Adding material into the case that is not in script

    • Providing feedback that is not included in training

    • Challenging the SPE, staff or faculty

Our expectations of you

SPs are the backbone of the program. It is our obligation to provide them with a safe and respectful work environment. While these issues are covered throughout the manual, it is important to be explicit about our expectations of them and what they can expect from us

Professionalism

• You will attend all trainings and sessions that you have committed to.

• If unable to attend a training or session, you will contact the trainer AS SOON AS POSSIBLE.

• You will always arrive on time.

• You will know your case and portray your role as trained.

• You will be aware of time and be in your exam room 2–3 minutes before the beginning of each assessment.

• You will complete your work in the time allotted.

• When required, you will provide honest and objective feedback, as trained.

• If you are experiencing any difficulties or conflicts with faculty, staff, or students please address these concerns in a timely manner and in detail to an SPE or Director. For example

  • Student performance or understanding seems notably below that of classmates.

  • Student or faculty’s’ behavior appears unprofessional, offensive, or bizarre.

  • Student or faculty’s behavior feels unsafe for student or SP.

  • SP feels uncomfortable or disturbed by student or faculty behavior.

Confidentiality

• You will not discuss any other SP performance with other than the SPE or Director

• You will not discuss student performance or appearance with anyone the SPE or Director.

• You will not discuss your roles here, or share case material with anyone

• You will keep secure any case material and use it only to review before performances.

• You will not take pictures, make comments on any social media.

Your expectations of us

• To be treated with respect and consideration by the faculty, staff and students.

• To provide you with the information you need to accept or refuse a role.

• To be trained adequately for your job

• To get feedback and to be instructed as to how you can improve.

• To be paid for the time that you are scheduled to train and work.

• To understand that true emergencies do occur and you will not be penalized when they happen.

• To keep your status as an SP confidential unless you tell us otherwise.

• To follow up on concerns you bring forward about any aspect of the program.

Performance Feedback

In order to establish and maintain the quality of the program, it is important to outline how SPs will receive feedback on their observation of the policies and procedures and on their performance whether it is teaching or assessment. Who will do it? How often? What tools? How will the SP learn about the feedback? What happens if the SP shows a below level performance? Is there a remediation process?

You will be assessed on the following:

• Attendance

• Ability to be flexible

• Maintaining a professional and positive attitude when working with faculty, staff, students and peers

• Portrayal of case

• Checklist accuracy

• Verbal or written feedback accuracy

• Following the Policies and Procedures outlined in the document

You will meet with the SP Educator once a year to review overall performance evaluation.

You will receive immediate constructive feedback if needed.

If there is no improvement, after remediation, you may be released from the program.

SP Feedback to the Program

To maintain on ongoing quality improvement culture, it is important to provide a mechanism for SPs to provide feedback to the program. Ideally, provide a way for SPs to give feedback on training sessions, teaching and assessment sessions. They can add invaluable information that will help your program grown. Debriefing sessions following an activity, written surveys, and focus groups are a few ways to gather their input.

Logistics

Logistics. Every program is different. Think about what is important to you and them.

Compensation

SPs should be aware of how they are being compensated.

Type of Employee and Benefits if Any

Parking

Schedule for Each Event (How Many Students to be Seen, Built in Breaks etc.)

Frequently Asked Questions

Frequently asked questions. You may save time if you compile questions that SPs often ask and place here

Attestation

You will want to document that the SPs have read, understand and agree to follow the Policies and Procedures. You will want to do it when onboarding, any changes, and perhaps annually.

I___________________________________ have read, understand and agree to follow the Policies and Procedures outlined in this Standardized Patient Manual.

Signature: _____________________________________

Date: _________________________________________

Appendix 10.2 Template for SP Agreement

SP/GTA/MUTA Participation Agreement

I, ________________________________________, understand and agree to the following:

• 1. As a Standardized Patient (SP) , Gynecological Teaching Associate (GTA), or MUTA (Male Urological Teaching Associate), I am a (fill in category or employee i.e. temporary part-time.)

• 2. As a (fill in category) employee, I understand my employment (fill in what the termination policy. (i.e.…..is on an at-will basis and may be terminated at any time with or without cause and is not subject to grievance or appeal).

• 3. I understand I (am or am not eligible for benefits, paid holidays or paid time off (i.e. vacation, personal days or a cultural holiday).

• 4. If an event is cancelled, I will be notified as soon as possible and I (will or will not) be paid for that work session.

• 5. I agree to abide with (add name of parent organization if there is one and link to institutional policies and procedures). I have read, understand and agree to abide by the following (provide links to specific institutional policies and procedures that you want them to know about and agree to follow)

• 6. I will maintain a working phone number and email.

• 7. I understand that I can decline an assignment offered to me.

• 8. I will be provided with training needed to fulfill the assignment I have been offered and accepted. This includes but is not limited to training to teach communication and interpersonal skills, history taking, physical exam/point of care ultrasound, use of patient centered electronic health record, presentation skills and for learner assessment which includes portrayal, providing verbal or written feedback, and accurate completion of assessment checklist.

• 9. In my capacity as an SP, GTA, or MUTA I understand that I may be interviewed and physically examined by students or health professionals in a manner similar to that which I might experience if I were an actual patient. If I agree to become a GTA or MUTA, this includes aspects of the physical examination that are normally part of a breast and pelvic exam (for women) and genital and rectal exam (for men).

• 10. In consideration of compensation I will receive for services as a SP, GTA, or MUTA, I irrevocably and without restriction grant to (fill in your program and parent institution), its faculty and staff the right to record my name, appearance and voice and to use such for bona fide uses such as training and marketing and in the development and promulgation of educational materials (whether for profit or not) and for any use for educational purposes. If I am functioning in the GTA/MUTA role , any recording or use of name or appearance will be strictly voluntary and only occur after my consent is obtained.

• 11. I may be required to assess student or health professional performance by providing both qualitative (comments) and quantitative (scores) data. I understand that I have no right, title, or interest to such assessments or data and I hereby consent to the use of such assessments or data in any analyses for research purposes. I further understand that my name will not be associated with any such research. Any research that concerns my performance as a SP, GTA, or MUTA, however, will require my informed consent to do such and will be strictly voluntary.

• 12. The program (does or does not) guarantee daily or weekly minimum or maximum number of hours of work as an SP, GTA, or MUTA.

• 13. I understand that case materials and any information related to SP, GTA, or MUTA exercises are confidential and the property of the program. I will restrict any discussion concerning such to SP staff or other participating SP, GTA, or MUTA colleagues as may be related to my position as a SP, GTA or MUTA. In no event shall I disclose any information about the program’s practices, clients, students, or an individual’s or client’s performance to any third party, including, but not limited to, through the use of social media. For purposes of the Family Education and Rights Privacy Act only (“FERPA”), I understand I am considered a school official with a legitimate educational interest with respect to access to students’ education records.

• 14. I can stop the learner encounter at any time if I am concerned about my psychological and or physical safety

• 15. If I believe I incurred an injury or developed an illness that was directly related to my work, I must contact (fill in who and how) and my SP supervisor immediately after the injury or illness, or if circumstances prevent me from immediately notifying I will provide notice as soon as circumstances permit.

• 16. I will conduct myself in an accordance with the Procedures and Policies and in an appropriate and professional manner at all times and will maintain standards including reliability, promptness, objectivity, flexibility and commitment to programs and needs.

• 17. All questions pertaining to the terms or conditions of this agreement or my rights as an employee shall be directed to (fill in who and how)

I hereby certify that I am at least 18 years old (or, if signing this on behalf of a minor, I hereby warrant I am at least 18 years old and have legal right to consent on behalf of such minor), have read this participation agreement, or it has been read to me, and that my signature constitutes acceptance of the all of the terms and conditions stated herein.

Print Name ____________________________________

Date _________________________________________

Signature _____________________________________

SP Program Representative ________________________

Appendix 10.3 Template for SP Model Agreement for Ultrasound

Standardized Patient Point of Care Ultrasound (POCUS) Model Consent

I_______________________, hereby consent to serve as a model for point of care ultrasound courses. In giving my consent, I acknowledge I have been advised as follows:

• 1. While there is no known adverse effects of diagnostic ultrasound, we try to limit the time you will be modeling.

• 2. The purpose of POCUS session is for students to learn. This is not a diagnostic ultrasound evaluation. If the faculty identify a possible finding, they will refer you to your primary care provider for follow up.

• 3. The faculty/student will put clear gel and an ultrasound probe on your abdomen, face, chest, neck, arms groin, and/or legs.

• 4. While some SPs agree to have pelvic or rectal or testicular ultrasound there is no requirement for you to participate.

• 5. You have the right to refuse any ultrasound examination or stop the session and withdraw consent for any reason and at any time.

• 6. You will alert the faculty/students immediately if you experience discomfort of any kind.

_________________    ____________________

Standardized Patient  Standardized Patient Educator

____________________________

Date

Sample Vision/Mission Statements

Parry Center for Clinical Skills and Simulation University of South Dakota Sanford School of Medicine

Vision: Advance clinical skills, patient safety, healthcare effectiveness and communication through the use of interprofessional teamwork, innovative technology and immersive training methods.

Mission: Provide evidence-based simulation and clinical training opportunities to advance the translation of education and knowledge into clinical practice. The Center offers a safe and engaging learning environment that complements the existing educational curriculum for USD medical students, residents, health professions students and faculty. https://www.usd.edu/medicine/parry-center

Simulation at Penn Medicine

Vision: Improved Patient Care through Simulation Based Teaching and the Advancement of this Education Methodology Mission

Mission: Improve patient safety and clinical outcomes by integrating medical simulation based teaching methodologies into the educational curriculum for all students, residents, attending physicians, nurses and other ancillary health care staff at the University of Pennsylvania Health.

http://www.uphs.upenn.edu/simcenter/