Table 3. Plan-Do-Study-Act Cycles for Student and Simulated Patient Issues.

Issue (Plan)	Do	Study	Act
Student Unrealistic student expectations and poor understanding of structure of SP program	Developed and presented materials for students to describe SP program Overarching goals of the SP program and specific interactions Set the stage for students regarding the SP role	Anecdotally, students appear to have a better understanding of the SP program and expectations	Thematic analysis of course evaluations may show if there have been improvements related to the SP program from the student perspective.
Dissatisfaction among students about SP portrayal of patients	Transitioned to term ‘simulated patient’ Utilized the term “simulated patient” to remind students that these activities are designed to replicate clinical practice and SPs will react to students based communication skills	No significant differences have been identified	New SP staff member provide additional training to SPs to further improve role portrayal
Inconsistency in what information as available to students prior to the interaction such as rubrics or basic scenario descriptions	Expectations by professional year were identified Faculty deliberatively communicated what information would be provided to students and the rationale prior to interactions (e.g., P1 students are generally provided the grading rubric and basic scenario descriptions whereas P3 students may not be provided with the grading rubric in order to more closely simulate clinical practice	Anecdotally, students appear to have a better understanding of expectations in individual courses	Thematic analysis of course evaluations may show if there have been improvements related to the SP program from the student perspective.
Simulated patient Newly hired SPs relied on established SPs to gain critical information about the program	Developed SP handbook University and SP program policies and procedures including related to substance use Logistics, such as parking, where to report, dress code, and compensation Expectations related to attendance and punctuality, professionalism, realism and staying in character, confidentiality, and how to report complaints or concerns	No significant differences have been identified	New SP staff member will help to further formalize existing policies and identify the need for new policies. We aim to add the handbook to a website for SPs
Multiple changes were implemented and feedback from SPs was critical	Conducted retreat with SPs 4 hour meeting with 1-2 faculty and approximately 20 SPs to discuss the SP program and obtain constructive feedback Topics were areas of concern, such as how to provide constructive feedback and the use of electronic rubrics	SPs have responded positively to providing feedback	New SP staff member will continue to periodically meet with SPs to provide education and gather feedback

SP: simulated patient; P1: first professional year; P2: second professional year; P3: third professional year; IT: information technology