233the task such as task difficulty and the ability to distinguish among subgroups of
target population. This ensures the appropriateness and quality of items/tasks prior
to actual use. Thereafter, assembly and evaluation of items/tasks occur where the
selected items/tasks are assembled and one or more scenarios satisfying the require-
ments of simulator specifications are chosen to undergo multistage testing or adap-
tive testing. Prior to operational or actual use, a field test of these scenarios should
be conducted using the intended target populations to assess the appropriateness of
these scenarios and robustness of the model in real educational environments.
Internal structure including generalizability of the population to use the model and
reliability of scores can also be tested.
During this phase, the interdisciplinary team of developers perform a high-level of
breakdown to delineate the choice of models, scenarios, what it has to be measured,
the method of reporting back, the method of providing feedback, the learning man-
agement platform, and connectivity to other platforms. The resulting information is
used to make a timeline for the development process and is matched with the “tech-
nology budget,” and readjustments are done when it seems necessary making sure that
the development process will be successful, timely, and within budget. A preproduc-
tion prototype that demonstrates the design is then developed prior to heading to pilot
production where optimization of the manufacturing process and component selection
occurs to optimize the cost with the potential needs. The preproduction prototype is
used for verifying the degree to which it satisfies the technical and customer’s require-
ments, and refinement is performed to fill in the identified gaps prior to starting the
business process where launching the new simulator occurs [ 8 ].
By the end of this step, it is important to document verification standards and cre-
ate user manuals and/or user guides. These should provide information about the
simulator administration in terms of user agreement, instructions to users and admin-
istrators, and sustainability and scalability and configurability of the simulator and
also describe the environmental and safety considerations. Whenever possible, it is
highly recommended to encourage compatibility and interoperability of the simula-
tor in terms of connecting with other part task trainers and transfer of data. Instructions
to simulator users and administrators have to be pretested alongside the item/test
review prior to operational use to ensure fairness for all target population. For
instance, instructions for starting a task and the task language should be the same in
case of physical simulators. On the other hand, the same hardware specifications
(e.g., memory, speed, monitor size, display resolution) and software specifications
should be consistent in the virtual reality. There has been a recent trend of federal
funding for simulation systems focused on the creation of systems with open source
and open standards. An open source/open standards physiology engine has been cre-
ated and continues to be developed [ 11 ], and an Advanced Modular Manikin plat-
form is also under development [ 12 ]. These promise to rapidly accelerate the
applications of simulation systems for surgery and other health- care fields.
Phase IV: Validation It should be noted that this phase is not separate and it is
integrated through the other three phases as validation is an “ongoing” process and
extends the content to the consequences. Therefore, it starts from the early begin-
13 Modern Theory for Development of Simulators for Surgical Education