Simulation enters quality criteria: Switzerland takes the first step

Switzerland has included simulation among its Quality Improvement Measures, contractual tools that legally bind hospitals and health insurers. This is not a symbolic recognition: in a country that leads the World Index of Healthcare Innovation, simulation becomes a verifiable and accountable requirement. And it could become a model to use in advocacy actions.

Some news comes from a small country, just under nine million inhabitants, but with a healthcare system considered among the best in the world: Switzerland has formally recognised healthcare simulation as a quality measure. Not as an optional educational tool, not as a centre of excellence activity reserved for well-equipped facilities. As a quality improvement instrument for hospitals and clinics. A fact that, when read in the international context we operate in, takes on a very different meaning.

A mature context

Switzerland is not starting from scratch. It is a country accustomed to measuring. The measurement of hospital care quality involves several actors with complementary roles. The Federal Office of Public Health (FOPH) annually publishes medical quality indicators for acute hospitals, focused on clinical activity volumes and certain outcomes, such as mortality rates. The National Association for Quality Development in Hospitals and Clinics, instead, is a competence centre that coordinates broader national measurements on quality in hospitals and clinics, including aspects such as patient satisfaction, infections, falls, pressure injuries, and other indicators relevant to care safety.

An attentive system, organised on a cantonal basis but increasingly coordinated at the federal level. Within this ecosystem, including simulation among quality measures becomes an act with legal and contractual effects: simulation, once included in this perimeter, ceases to be a discretionary choice and becomes an expected, verifiable, accountable requirement.

But let us reflect and try to better understand the implications of this choice.

It’s not enough to believe in simulation

What “quality measure” really means

It is worth clarifying what we are talking about, because there is a substantial difference between a recommended best practice and a regulated tool. In Switzerland, the hospital quality system is built around concrete and systematic measures, the Quality Improvement Measures (MMQ). They are part of a national quality agreement that legally binds hospitals and health insurers. They are not guidelines: they are contractual requirements, related to the quality of processes and structures of hospitals and clinics, with a precise objective: to improve a specific aspect of patient safety in a given field of action. Simulation has been included in the field of action called “Quality culture”.

Each hospital and each clinic can choose which recognised MMQ to apply in their own context, but the agreement establishes how many measures must be implemented for each field of action.

Including simulation in this system is therefore not a symbolic act but becomes a genuine political act in the most technical sense of the term: it redesigns priorities, directs resources, creates measurable expectations. Simulation stops depending on the enthusiasm of the individual training officer or on the foresight of the risk manager or the medical director. It becomes structural.

This is the leap Switzerland has made. And one that other health systems will sooner or later have to face. It is only a matter of time.

In other articles we have published in this same magazine, from the Simulation Maturity Assessment Tool to the use of simulation as a clinical risk management tool, the recurring theme is always the same: simulation works (and this is by now amply demonstrated!), but it struggles to take root if it does not find an institutional anchor. A formal recognition system is that anchor. To achieve it, it is certainly useful to start from individual hospital realities, integrating simulation substantially into clinical governance models and allowing it to evolve from a predominantly educational activity into a structured process of continuous improvement of care quality and safety. This means embedding simulation into existing systems of clinical risk management, quality, training, accreditation, and performance evaluation, linking it to the strategic objectives of the organisation and not only to the initiatives of individual professionals or simulation centres.

Only when simulation is recognised as an integral part of clinical governance can it generate useful organisational evidence, produce comparable data, guide managerial decisions, and contribute concretely to continuous improvement programmes. From this perspective, formal recognition should not limit itself to certifying the existence of simulated activities, but should value their impact on processes, outcomes, safety culture, and organisational resilience.

A useful example for everyone

This Swiss move, however, does not arrive in a vacuum. In 2024, the Global Consensus Statement on Simulation-Based Practice in Healthcare was published, a unified declaration, facilitated by the European Society for Simulation in Europe (SESAM) and the American Society for Simulation in Healthcare, but drafted by representatives of 50 national and international simulation societies and networks distributed across 67 countries to support and improve the implementation of healthcare simulation. The global consensus statement identifies some clear priorities: advocacy towards policy makers, the integration of simulation into basic and post-basic curricular pathways, accessibility, the standardisation of good practices, and the development of educators.

The global consensus statement in practice is a call to action. Not only educators, not only simulation centres, but also policy makers, leaders of healthcare organisations, training institutions. A formal commitment is asked for: to recognise simulation, to fund it, to bring it to scale.

Switzerland has answered that call and has indeed recognised simulation as a quality improvement measure.

And the fact that this recognition comes from a country that consistently occupies the first position in the World Index of Healthcare Innovation and stands out for its attention to measurable quality is not irrelevant. In the narrative we must build towards decision-makers, and this is, once again, advocacy work, having a concrete benchmark, anchored to a credible system, is a strong argument that should not be underestimated. It is not a question of copying the Swiss model. Health systems are too different for uncritical transpositions. It is a question of using what Switzerland has done as a proof of concept: simulation can become an institutional instrument of the health system.

Now it is up to other European health systems, and beyond, to find a way to follow.