Be Ahead of the Game! A Systematic Review on Serious Games Aiming to Enhance Hospital Management Knowledge and Health Care Administrative Skills Acquisition

Abstract

Serious games are pedagogic tools aiming to serve educational or informative purposes by incorporating fun aspects of games with serious elements of learning. Serious games are an emerging trend in medical and nursing education since they provide the ideal opportunity to increase knowledge and enhance decision-making and problem-solving skills by actively involving learners. However, serious game initiatives on hospital management education have been given less attention. This is the first contemporary systematic review addressing the significant research gap by synthesizing existing evidence on serious games in the hospital management field, to highlight their potential in enhancing managerial and administrative skills. Robust search algorithms were implemented in Scopus and PubMed yielding 892 results. Overall, 36 serious games emerged with half of them being digital. Regarding game design, most were multiplayer games, while several required team collaboration. Serious games’ main learning target was categorized according to Katz’s three-skill approach for effective administration, including technical, interpersonal, and conceptual skills acquisition. Serious game learning activity type, teaching subject, and geographical distribution were also explored. The findings stimulate interest and increase awareness of using serious games to enhance hospital personnel’s knowledge and skills in managerial roles and administrative processes. Furthermore, the review intended to inspire academics and health care policymakers to convey administrative skills and basic management concepts to various hospital employees and health care/management students through game-based learning.

Keywords

serious games game-based learning educational games hospital administration health services management systematic review

Introduction

The daily working life of hospital executives and health care professionals assigned administrative duties and managerial roles resembles a series of game-like challenges. They should be able to determine strategies and predict outcomes similarly to chess players, develop tactics and maneuver like poker experts, and act as cooperative team players to improve organizations’ productivity and outcomes.¹ But what if game-based learning could actually be used to enhance hospital management knowledge and experiences and increase administrative skills acquisition?

Literature indeed supports that game-based learning, including serious game utilization, strongly impacts learner motivation and cognitive outcomes, making it a powerful motivation driver.² More specifically, according to a popular definition by Alvarez, serious games serve educational or informative purposes by combining serious elements of learning with playful and fun aspects of gaming, capitalizing on the innate human inclination to play but also incorporating game mechanisms into the learning experience.³ Serious games are proven to be effective pedagogical tools, especially compared with conventional educational methods,⁴ and gamification has long been used in science education to enrich the teaching experience, enhance information transfer, and increase learner involvement.⁵

Along this line, serious games and game-based learning have become a flourishing trend in health care professionals’ education.⁶ Numerous systematic reviews report on serious games being developed and implemented in the medical and nursing field,^7–9 considering they provide learners with the perfect opportunity to increase knowledge, enhance decision-making and problem-solving skills, and gain valuable practical experience in risk-free environments.^10,11 However, serious game initiatives on hospital management education have been given less attention, although it has been reported that they can be powerful training and management development tools for improving team performance, enhancing resource allocation skills, and increasing leadership abilities in hospital personnel.⁴

According to the above, within health care organizations, serious games can be seen as alternative management tools designed to address challenging administrative issues by utilizing gaming experiences to simulate realistic scenarios and reflect real-life work situations.¹² This is particularly useful considering that health care managers are frequently acting at the complex interface of conflicting objectives, such as ensuring high-quality care, promoting employee well-being, and fulfilling efficiency needs and political regulations. To this end, serious games enable health care managers and hospital executives to evaluate different decisions, experience their potential outcomes, and hence strengthen strategic planning abilities and successful decision-making processes in practice.¹⁰

The current systematic review was inspired by a previous extensive review conducted 15 years ago by Kraus and colleagues on hospital management games from an operations research perspective.¹³ This is the first contemporary systematic review to address this existing research gap by reporting on the development and implementation of digital and analog serious games in the hospital management field, to highlight the most recent serious game initiatives that can improve managerial and administrative competencies. Furthermore, apart from providing an updated and comprehensive synthesis of the state-of-the-art knowledge in the field of hospital serious games, it explores the extent of serious game digitalization and stimulates interest in using serious games to enhance hospital personnel’s knowledge and skills in managerial roles and administrative processes. The overall objective was to provide useful insights by summarizing all the available studies in the literature, to motivate academics and health care policymakers to convey administrative skills and basic management concepts to a wide variety of hospital employees and health care students through game-based learning.

Material and Methods

Literature reviews are increasingly important in navigating the expanding volume and rapid dissemination of research, enabling synthesizing and contextualizing the latest scientific developments. As the pace of publication accelerates, different types of reviews (e.g., integrative reviews, structured reviews, systematic reviews) have emerged for maintaining an up-to-date understanding of the state-of-the-art knowledge.^14,15

For the present article, a systematic literature review on studies developing and implementing serious games to enhance hospital personnel’s knowledge and skills in managerial roles and administrative processes was conducted in the PubMed and Scopus databases. The overarching research question (RQ) formed in order to guide the systematic review was: “What are the global trends in the development and implementation of serious games in hospital management over the past twenty years, in terms of format, geographic distribution, gameplay characteristics, and targeted educational objectives or skills?”

In addition, four specific RQs were developed to inform the analysis: RQ1:

How many serious games in the hospital management field have been developed and implemented in the past 20 years? Are digital serious games more common than analog serious games?

RQ2:

Are hospital management serious game initiatives distributed equally around the globe? Is any country a leader in the field?

RQ3:

What types of serious games are most commonly implemented? What are their main gameplay characteristics?

RQ4:

What are the most common educational subjects of the emerged serious games? Which hospital management skills do they most often try to enhance?

To form the search algorithms that would answer the above RQs, we investigated keywords used in relevant studies and algorithms implemented by similar review articles. Keywords focused on two main categories: (1) hospital management and health care administration-related key terms, and (2) serious games and game-based learning search terms. As a result, three robust search algorithms were implemented: two in Scopus (technical/multidisciplinary database) and one in PubMed (health-specific database). The PubMed search algorithm utilized the most relevant MeSH terms along with other common keywords. In the Scopus database, a high-precision search algorithm was first implemented utilizing four basic key terms and examining only the titles of the articles. Furthermore, a supplementary broader search algorithm was created to locate relevant studies that did not emerge from the first algorithm. The second search algorithm utilized multiple related keywords to provide a more extensive review of the literature. Search algorithms can be found in Supplementary Data (Table 1).

Table 1.

Summary of Studies Included in the Systematic Review

Author(s)	Year	Article title	Game type	Game short description^a	Aim of the game^a
Pavillet and Dumas¹⁸	2023	The use of games as an innovative prevention method for discussing work with hospital healthcare staff	Analog	Card game (Dixit®) and board game (Concept®)	Rebuild staff bonds by encouraging work discussion and diverting conflict and tensions.
Martin¹⁹	2022	The Price Is Right: Introducing Health Care Costs Through Gameful Learning	Analog	“One-Bid game” from the show “The Price Is Right”	Increase knowledge by guessing the cost of common nursing materials and procedures.
Höffner et al.²⁰	2022	SNIK Quiz: A Multiple Choice Game About Information Management in Hospitals	Digital	Browser game with multiple-choice questions	Enhance knowledge of information management in hospitals.
Schwengel et al.²¹	2022	Influx! A game-based learning tool for in-hospital interprofessional disaster preparedness and response	Analog	Collaborative board game (Influx!)	Prepare intrahospital workers to function in teams during disasters.
Hiragi et al.²²	2022	Token Economy-Based Hospital Bed Allocation to Mitigate Information Asymmetry: Proof-of-Concept Study Through Simulation Implementation	Digital	Simulation game based on a token economy system	Improve resource management skills and human resources satisfaction.
Bacelar-Silva et al.²³	2021	Identifying and Addressing the Underlying Core Problems in Healthcare Environments: An Illustration Using an Emergency Department Game	Analog	Emergency Department (ED)—board game	Improve patient flow in the ED by making better use of the system’s existing resources.
Rahouti et al.²⁴	2021	Prototyping and Validating a Non-immersive Virtual Reality Serious Game for Healthcare Fire Safety Training	Digital	Nonimmersive virtual reality (VR) simulation game	VR-based training for health care fire safety education.
Pulido et al.²⁵	2021	Security Awareness Level Evaluation of Healthcare Participants Through Educational Games	Analog	LEGO-based designed board game	Enhance information security awareness of health care personnel.
Hiragi et al.²⁶	2020	Preliminary Evaluation of Market Mechanism-Based Bed Allocation System	Digital	Game-like simulation token system	Bed allocation applying market mechanism and human resource allocation.
Tan et al.²⁷	2020	Health$en$e™: Developing a Board Game on Value-based Healthcare Financing	Analog	Competitive board game (Health$en$e™)	Improve knowledge of health care finance by optimizing health care expenditure.
Zhang et al.²⁸	2020	Serious Gaming of Logistics Management in Pediatric Emergency Medicine	Digital	VR simulation in an ED department	Promote understanding of the logistical features of a pediatric ED.
Zhang²⁹	2019	A Serious Logistical Game of Paediatric Emergency Medicine: Proposed Scoring Mechanism and Pilot Test	Analog	Simulation-based sand table logistical board game	Practice nontechnical skills in the dynamic resource management of a pediatric ED.
Douglas et al.³⁰	2019	Gaming the system: building an online management game to spread and gather insights into the dynamics of performance management systems	Digital	Online management game	Gain an appreciation of performance management by applying metrics via different performance instruments.
Bach et al.³¹	2018	Teaching health care management with simulation games	Digital	Simulation game	Improve epidemic investigation and management knowledge.
Lovreglio et al.³²	2018	Prototyping virtual reality serious games for building earthquake preparedness: The Auckland City Hospital case study	Digital	VR simulation training game	Enhance participants’ knowledge of how to behave during and after an earthquake.
Ghazvini and Shukur³³	2018	A Serious Game for Healthcare Industry: Information Security Awareness Training Program for Hospital Universiti Kebangsaan Malaysia	Digital	Trivia computer game (InfoSecure)	Raising employees’ awareness toward information security.
Barr-Walker and Nevels³⁴	2018	Creating value through outreach in a hospital setting: a case study from Zuckerberg San Francisco General Hospital Library	Analog	Spinnable wheel—quiz	Increase staff and patients’ awareness of hospitals’ library resources and services.
Thornton Bacon et al.³⁵	2018	Enhancing Systems Thinking for Undergraduate Nursing Students Using Friday Night at the ER	Analog	Simulation-based board game (Friday Night at the ER)	Promote quality and safety of health care systems.
Vithanage et al.³⁶	2017	Game of Hospitals	Analog	Role-playing games learning sessions (Game of Hospitals)	Discussions of complex hospital clinical and administrative scenarios and their solutions.
Jantana et al.³⁷	2016	A multi-facet approach using conceptualization, application, and usability measurement for developing a financial learning system for hospitals	Digital	Business game simulation	Enhance learning of financial management in health care.
Gradel et al.³⁸	2016	Simulating the physician as healthcare manager: An innovative course to train for the manager role	Analog	Gaming simulation seminar	Increase basic knowledge of health care policy and management.
Huyghe et al.³⁹	2016	Involving End-Users in Game Based Ideation: A Case Study in Hospital Logistics	Analog	Tailor-made board game (based on Game of the Goose)	Raise awareness of using wearable technology for logistical work in hospitals.
Ruggiero⁴⁰	2016	Super Busy Hospital: wicked games that triage	Analog	Simulated gameplay sessions (Super Busy Hospital)	Force players to apply ethical thinking in decision-making for triage situations.
Cheong and Lim⁴¹	2016	Scenario-based simulation game for hospital beds capacity planning in Singapore	Digital	Scenario-based simulation game	Guide the learners through key considerations for bed capacity planning.
Chalk and Manzi⁴²	2016	The Hospital Discharge Game : A game theory-inspired workshop to encourage cooperation between health and social care organisations	Digital	Interactive workshop game (Hospital Discharge Game)	Promote whole-systems thinking within the British National Health Service among practitioners and policymakers.
Gaynor et al.⁴³	2016	Teaching EHRs security with simulation for non-technical healthcare professionals	Analog	Simulation-based role-playing game workshop	Teach complicated information technology (IT) concepts to nontechnical managers.
Shi et al.⁴⁴	2015	3D Hospital: Design and Implement Quest-Based Game Framework for Transitional Training	Digital	Role-playing game with various quests	Train participants on building work environment spatial contextual awareness.
Guérin et al.⁴⁵	2015	Change management in pharmacy: a simulation game and pharmacy leaders’ rating of 35 barriers to change	Analog	Simulation game using a negotiation-based format	Identify and rank barriers to change in a pharmacy department.
Ribeiro et al.⁴⁶	2013	Creating Awareness of Emergency Departments Healthcare Values Using a Serious Game	Digital	3D simulation game (ImPROVE)	Model the business process underlying the hospital ED and check its impacts on health care values.
Basole et al.⁴⁷	2013	Healthcare management through organizational simulation	Digital	Web‐based simulation game (Health Advisor)	Enhance health care management strategies by addressing the trade-offs between good health outcomes and health care costs.
Takemura et al.⁴⁸	2013	The Development of a Multiplayer Game for Education of Hospital Management	Digital	Networked serious game	Enhance education on hospital management and produce highly trained personnel.
Broberg and Edwards⁴⁹	2012	User-driven innovation of an outpatient department	Analog	Tabletop simulation game	Increase organization and functional layout of an outpatient department.
Bregman et al.⁵⁰	2009	An Internet-Based Simulation System for Training and Development of Regional-Healthcare-Centers Managers	Digital	Internet-based simulation game	Support the training and development of regional health care managers.
Rauner et al.⁵¹	2008	Competition under different reimbursement systems: The concept of an internet-based hospital management game	Digital	Internet-based simulation management game (COREmain hospital game)	Enhance economic and organizational decision-making to improve hospital-, regional-, and national-level policymaking.
Uhles et al.⁵²	2008	Simulation game provides financial management training	Analog	Workshop with a reality simulation game	Teach the relationships between cash flow, income statements, and balance sheets.
Levi and Bregman⁵³	2003	Simulation and management games for training command and control in emergencies	Digital	Computerized management simulation game	Increase health care system disaster preparedness and improve management control.

Game short description and aim are described according to what authors have stated in their studies (in the majority of cases).

Among the inclusion criteria set were the following: publish period from 2003 to 2023, English language, studies categorized as articles/reviews/conference papers/conference reviews/editorial doctype (in the supplementary algorithm of Scopus), and studies developing and/or implementing serious games targeting to enhance hospital management/administration knowledge and skills acquisition. The selected time horizon, spanning from 2003 to 2023, was strategically chosen to provide a comprehensive and up-to-date synthesis of the current knowledge in this field that has experienced rapid advancements over the past two decades. The PubMed and Scopus database selection was made based on their accessibility, their inclusion of high-quality peer-reviewed journals, the high-quality multidisciplinary coverage, and their standardized indexing methodologies, making them ideal sources for retrieving studies on serious games for hospital management.

The main exclusion criteria included: studies focusing on game theories without developing a serious game, studies introducing serious games aiming to enhance hospitals’ personnel care provision skills, and studies that were not retrieved in full-text form.

A three-step process was followed to screen the eligible articles. Initially, the relevance of the studies was examined according to their title. Consequently, the abstracts were screened to select studies of interest. Finally, the article’s full text was reviewed to determine the included studies. The initial screening on article titles aimed to quickly exclude articles that were clearly irrelevant to our RQ. This step helped to efficiently narrow down the pool of potential studies. The abstract screening involved a more in-depth evaluation to determine whether the study’s objectives, methods, and findings aligned with our inclusion criteria. At this stage, studies that did not meet the relevance were excluded, ensuring that only pertinent articles proceeded to the full-text review. During the full-text review, the eligibility of each article was assessed comprehensively against the predefined inclusion and exclusion criteria. This rigorous process ensured that only high-quality and relevant studies contributed to the final synthesis. Figure 1 describes the undertaken methodological steps (flow diagram according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines), which demonstrates the systematic review process per stage in numbers.¹⁶

FIG. 1.

Study selection flow diagram (according to PRISMA 2020 flow diagram for new systematic reviews, which includes searches of databases and other sources). PRISMA, Preferred Reporting Items for Systematic reviews and Meta-Analyses.

Overall, 892 articles emerged from the search algorithm, and upon removing duplicates, 810 articles were screened. After thorough review, 34 studies were finally included according to the inclusion and exclusion criteria. Furthermore, two more relevant publications were included via the backward snowballing technique. Backward snowballing technique involved reviewing the reference list of included studies to identify other relevant articles that may not have been captured through database searches.¹⁷ This method helps to mitigate publication bias and ensure comprehensive coverage of the literature.

Results

Overall, 36 studies were included in the systematic review.^18–53 The main characteristics of the identified studies (first author, publication date, title, game type, game short description, aim of the game, and reference) are listed in Table 1. The majority of them (77.8%) were published during the past decade, while altogether, more than 1700 participants were enrolled. The participants’ number was derived from 26 studies that clearly stated the participants’ sample. Enrolled participants were mostly hospital personnel and health care professionals (50.0%) or health-related students, and students in management, informatics, and other disciplines (33.3%). A 16.7% included a varied study sample of hospital personnel, academics, researchers, students, health care managers, and policymakers. To calculate the overall sample size, we excluded studies that: (1) did not provide a clear participant number^{18,19,43,50,51}; (2) enrolled hospital personnel, patients, and community members without separating the number of participants in each group³⁴; and (3) did not mention being pilot tested.^31,46,53 According to the above, the precise number of participants was estimated at 1772.

To address RQ1, “How many serious games in the hospital management field have been developed and implemented in the past 20 years? Are digital serious games more common than analog serious games?” we located and removed studies reporting on the same digital tool in more than one publication. Accordingly, one study was excluded,²⁶ and the most recent publication of the specific serious game was included.²² Furthermore, a study introducing two entirely distinct games was located.¹⁸ Therefore, we concluded that 36 serious games have been developed during the past vicennium to enhance hospital management knowledge and skills. Regarding serious game types, notably 50% of them were digital and 50% were analog. Figure 2 depicts the exact number of analog and digital games developed per triennial during the understudy period.

FIG. 2.

Number of identified serious games in digital or analog form per triennial (2003–2023).

Responding to RQ2, “Are hospital management serious game initiatives distributed equally around the globe? Is any country a leader in the field?” we categorized the studies according to their development sites. Consequently, 19 countries from 4 continents were identified. In Figure 3, the countries are depicted along with chromatic information regarding the number of published articles per country. The pioneer country in utilizing serious games for hospital management educational purposes was the United States, counting eight published articles. Also, the United Kingdom and Japan showcased a slightly increased number of publications (n = 3), while all the other countries followed with one or two relevant articles published. Analytical information on the number of studies each country yielded, along with references to those articles, can be found in Supplemental Data (Table 2).

FIG. 3.

Number of studies published on hospital management serious games per country (2003–2023).

Table 2.

Learning Activity Type Implemented by the Identified Serious Games

Learning activity type	Frequency (%)^aN = 36(100)	Studies references^bN = 36
Simulation games	22 (61.1)	22, 24, 26, 28 –32, 35, 37, 38, 40 –43, 45 –47, 49 –53
Quizzes	4 (11.1)	19, 20, 33, 34
RPGs	3 (8.3)	36, 44, 48
Board/card games	7 (19.5)	18, 21, 23, 25, 27, 39

Multiple studies reporting on the same digital tool are excluded.

Studies reporting on the same digital tool are not excluded.

RPG, role-playing game.

To answer RQ3, “What types of serious games are most commonly implemented? What are their main gameplay characteristics?” we categorized the emerging serious games into four broad groups according to the type of learning activity implemented. To this end, the categories were: (1) simulation games, (2) quizzes, (3) role-playing games, and (4) board games/card games. Several serious games presented multiple learning activity features; however, the classification was made according to the games’ predominant characteristics. For the serious game with the two publications, we included only the most recent article to avoid any overestimation. According to the results, the most common serious game type was by far simulation games (61.1%). Table 2 presents more information on the frequency and percentage per serious game learning category type, along with the relevant reference numbers. Furthermore, regarding game design features, it was estimated that 63.9% of the serious games were multiplayer games,^{18,19,21–23,25,27,29,35,36,38–40,42,43,45,49–53} while 44.4% of them^{18,21,25,29,35,36,38–40,42,45,49–53} also required teamwork-based collaboration.

To address “What are the most common educational subjects of the emerged serious games? Which hospital management skills do they most often try to enhance?” (RQ4), serious games were categorized into six broad thematic groups according to the teaching subject: (1) upper management games (52.8%), (2) financial literacy games (11.1%), (3) work organization games (8.3%), (4) information security/cybersecurity games (11.1%), (5) building information modeling games (11.1%), and (6) other (5.6%). The “upper management games” category allows the participants to make decisions and enhance top management skills by filling roles in the higher organization hierarchy. In “financial literacy games,” players enhance financial knowledge and basic accounting skills by engaging in activities including cash flow, budgeting, and expenditure optimization. “Work organization games” focus on improving daily work environment aspects, such as enhancing team building and planning workflow organization. “Information security games” aim to provide knowledge about information management, including electronic health care records and digital security. “Building information modeling games” encourage collaborative working in designing, exploring, and using buildings. Finally, serious games that did not fit into any of the above categories were included into the “others” group.

Regarding the skills that the identified serious games attempt to enhance, categories according to Katz’s three-skill approach for effective administration were created,⁵⁴ including technical (38.9%), interpersonal (5.5%), and conceptual (55.6%) skills acquisition. Technical skills include among others: financial skills, digital literacy, designing work environments, and data analysis. Interpersonal skills revolve around effective communication, human behavior understanding, and motivating and empowering others. Conceptual skills are essential for top management since they focus on viewing the organization as a whole, evaluating situations, and making important strategic decisions.⁵⁵ The majority of serious games tried to enhance multiple skills, with the most common being decision-making, strategic thinking, and team collaboration (Supplementary Data, Fig. 1). Therefore, we initially classified the games according to their main target in line with Katz’s three-skill approach but also provided a more analytical description of the different skills each game enforced, depicted as subcategories of the technical, interpersonal, and conceptual skills in Figure 4. Relevant information is summarized in Table 3 (educational subject, Katz’s three-skill categorization, analysis of skills each game tries to enforce, and game content description).

Table 3.

Summary Table of Included Studies Educational Subject, Three-Skill Approach Categorization, Targeted Skills Enforcement, and Game Content Description

Author(s)	Game’s teaching subject	Three-skill approach categorization	Skills game enforces	Game content description^a
Pavillet and Dumas¹⁸	Work organization	Interpersonal	Communication, team collaboration, empathy	“Dixit” cards encouraged staff expression—players chose at least one card from the deck and told the others the reasons for their choices based on their professional experiences, encouraging listening and empathy.
Pavillet and Dumas¹⁸	Work organization	Interpersonal	Intercomprehension, team collaboration, communication	“Concept” makes people guess an object, a character, etc., using images on the game board. The discussion introduces professional situations that the team could encounter and that were sources of conflict.
Martin¹⁹	Financial literacy	Technical	Financial management, budgeting, delegation	“The Price Is Right” game shows four students health care items that are briefly described, and their wholesale price is given. With classmates’ help, students guess the actual cost of each item that is charged to the patient.
Höffner et al.²⁰	Information security/cybersecurity	Technical	Information security and management	“SNIK Quiz” is a multiple-choice quiz on health information management that trains basic facts, complex patterns, and connections of textbooks encoded in the Semantic Network of Information Management in Hospitals.
Schwengel et al.²¹	Upper management	Conceptual	Strategic thinking, resource management, decision-making, problem-solving, delegation, team collaboration	In “Influx!” players must cooperatively manage a mass casualty incident. Four players are assigned roles, and a facilitator monitors the game rounds where the influx of patients accelerates and resources become limited.
Hiragi et al.²²	Upper management	Conceptual	Strategic thinking, resource management (staff satisfaction), decision-making, leadership (equity)	Players act as ward managers of three inpatient wards (one each), setting a price for each illness and severity of their ward, without seeing patients admitted to other wards. A physician (computer agent) selects the cheapest ward for each patient unless the ward specialized in the patient’s illness is available.
Bacelar-Silva et al.²³	Upper management	Conceptual	Strategic planning, resource management, decision-making, problem-solving	In “ED,” one to nine players deliver care to emergency patients by making them flow through seven resources till the discharge area. A round starts by rolling a die to define patient demand that can result in different treatment plans.
Rahouti et al.²⁴	Work organization	Technical	Safety management, regulatory compliance	In this VR participants are made aware of fire doors and evacuation routes of a hospital. Among learning objectives are: using the alert button, calling the fire brigade, prioritizing and evacuating patients, etc.
Pulido et al.²⁵	Information security/cybersecurity	Technical	Information security, critical thinking, problem-solving, team collaboration	This board game simulates security incidents that put health information at risk. The game is played by a group of three to five participants who collaborate as a team to reduce security threats through critical thinking and discussion.
Tan et al.²⁷	Financial literacy	Technical	Financial management, budgeting, decision-making, strategic thinking	Each player is a financial officer who oversees a fixed budget for flowing of a certain number of patients. To win, the player needs to achieve the best value for flowing each patient through different care settings by having the least average expenditure per patient within a specific timeframe.
Zhang et al.²⁸	Upper management	Conceptual	Resource management, strategic thinking, decision-making	The player is a management nurse who plans resource allocations at runtime based on the ED to carry out a wide variety of activities.
Zhang et al.²⁹	Upper management	Conceptual	Decision-making, strategic thinking, resource management, team collaboration	The players represent inspectorates of the care production system and manage the triage station and five normal modules as parallel-functioning production units of an ED. Players collaborate to develop a resilient pediatric ED from available human resources and stretchers.
Douglas et al.³⁰	Upper management	Conceptual	Strategic planning, data analysis, decision-making	Players are hospital department managers balancing competing demands of doctors, patients, and financial officers. They use different management instruments and receive information on how these interventions affect outputs. If they fail to improve performance, they get fired.
Bach et al.³¹	Other	Conceptual	Epidemic investigation, decision-making	Players control the size of the mosquito population, number of bites per mosquito/day, and the mosquito hatch fraction. Changes in these values reflect decisions that impact yellow fever spreading indicating different health care management actions before and after the disease spreads.
Lovreglio et al.³²	Work organization	Technical	Safety management, regulatory compliance, decision-making	Players are guided through several scenarios in which they choose one or more recommended behaviors that align (or not) with the best practice. Participants are exposed to a virtual environment that allows them to act according to the best evacuation practice or to take unsafe actions.
Ghazvini and Shukur³³	Information security/cybersecurity	Technical	Information security, regulatory compliance, digital skills, decision-making	The serious game consists of eight topics, each addressing one information security issue. The player is required to answer all questions correctly for each topic to obtain a full score; otherwise he/she must replay it.
Barr-Walker and Nevels³⁴	Other	Conceptual	Strategic thinking, communication	The game utilized a spinnable wheel to ask players library-related questions. Each question was designed to promote library services, collections, and spaces entertainingly and engagingly.
Thornton Bacon et al.³⁵	Upper management	Conceptual	Strategic thinking, data analysis, problem-solving, team collaboration, decision-making, financial management	Players of “Friday Night at the ER” assume nurse leader roles to face real-life situations. Players practice handling high-stakes problems rapidly which are evaluated and scored on cost and quality outcomes based on the decisions made. Activities require collaboration and data analysis.
Vithanage et al.³⁶	Upper management	Conceptual	Problem-solving, strategic thinking, resource management, team collaboration	In “Game of Hospitals,” eight players (four doctors and four hospital administrators) negotiate over complex hospital issues. Golden stars are awarded for each problem solved according to the positive impact of the provided solution.
Jantana et al.³⁷	Financial literacy	Technical	Financial management, decision-making	The player competes a computer player as a rival user. Events feed both users and the system calculates decision-cost strategy to determine the cost of financial outcome. Final results are based on the user’s decisions.
Gradel et al.³⁸	Upper management	Conceptual	Strategic thinking, problem-solving, critical thinking, team collaboration, communication	Students are members of a hospital’s executive board and work on an existing hospital project as a group. Competition is created by forming two groups that work on the same project and present their work to each other in simulated board meetings, turning the project into a gaming battle.
Huyghe et al.³⁹	Work organization	Technical	Logistics, critical thinking, problem-solving, team collaboration	This customized “Game of the Goose” included action squares related to hospital logistics. Players were also introduced to question cards presenting problems that could be tackled using technology cards. Two teams played to allow competition but also cooperation within teams.
Ruggiero⁴⁰	Upper management	Conceptual	Strategic thinking, resource management, decision-making, ethical skills, team collaboration, communication	In “Super Busy Hospital,” player teams are given a list of people in their triage area and the amount of time and resources for each. The task is to design an optimal system for addressing all the needs within the ED.
Cheong and Lim⁴¹	Upper management	Conceptual	Strategic thinking, capacity management, problem-solving, decision-making, financial management	Player is an officer at the Ministry of Health whose task is to study current and future planned capacity of public hospitals to decide if they satisfy the growing needs. If capacity is insufficient, the player decides which hospitals will add beds and when, and in which year a new hospital should be added.
Chalk and Manzi⁴²	Upper management	Conceptual	Strategic thinking, decision-making, data analysis, team collaboration	Teams are given the roles of community and acute hospitals and are asked to make discharge decisions about patients. However, a “perverse” incentive is present in the system, and opposing teams are not allowed to communicate, which leads to increasingly “selfish” decision-making.
Gaynor et al.⁴³	Information security/cybersecurity	Technical	Digital skills, information security, regulatory compliance, decision-making	Players break into groups, and the workshop leader gives each group encryption toolkits that contain props. Attendees take the roles of different persons involved in electronically exchanging medical information. Simulation scenarios are played to demonstrate how to send health data that is private.
Shi et al.⁴⁴	Work organization	Technical	Work environment orientation, transitional training	In “3D Hospital,” the player explores the virtual hospital and locates him/her around the building using a mini-map. The player also has a clear objective in the form of a “to-do list” including various quests that encourage the player to explore the work environment based on his/her daily tasks.
Guérin et al.⁴⁵	Upper management	Conceptual	Strategic thinking, decision-making, negotiation, communication	A group of four to six players forms a pharmacy department. They are given 41 multicolored construction blocks representing 4 domains: clinical, drug distribution, research, and management. The game board has 28 block spots; they decide how many blocks of each domain form the “ideal” department.
Ribeiro et al.⁴⁶	Upper management	Conceptual	Strategic thinking, decision-making, financial management, resource management	In “ImPROVE,” the player is a department manager aiming to restructure the ED by adapting business processes inherent to the department’s functioning. The player manages different business processes utilizing an authoring business process tool using activities, decision points, etc.
Basole et al.⁴⁷	Upper management	Conceptual	Strategic thinking, data analysis, decision-making, financial management	In “Health Advisor,” players have the objective of managing a set of clients through the health care system by making various information, cost, and quality of care trade‐off decisions
Takemura et al.⁴⁸	Upper management	Conceptual	Strategic thinking, resource management, decision-making	Each player is the director of a hospital and makes management decisions under various indicators that affect the condition of the other hospitals as well as of his/her own.
Broberg and Edwards⁴⁹	Work organization	Conceptual	Strategic thinking, spatial design, team collaboration	Players designed their dream department game board using cardboard pieces representing staff members, rooms, and activities. Then they designed it in a rectangular layout. A LEGO figure was used as a patient, to showcase patient flow. Many scenarios with LEGO figures were played.
Bregman et al.⁵⁰	Upper management	Conceptual	Decision-making, strategic thinking, resource management, financial management, team collaboration	In this game, teams are Regional Healthcare Centers managers, within one specific community, and compete with each other. The simulation focuses on managerial performance, based on periodic team decisions, within the internal and external environmental context
Rauner et al.⁵¹	Upper management	Conceptual	Decision-making, strategic thinking, resource management, financial management, team collaboration	“COREmain Hospital” is a game for up to six hospitals that compete with each other. Each hospital has four players and each player is responsible for one department (management, nursing, radiology, surgery). The game trains decision-making within a team as decisions of one department affect others.
Uhles et al.⁵²	Financial literacy	Conceptual	Strategic thinking, problem-solving, financial management, decision-making, team collaboration	The six members of each team represent executives of a health care facility, working together toward financial goals. They make decisions as events take place and information becomes available, and observe the results of their actions.
Levi and Bregman⁵³	Upper management	Conceptual	Strategic thinking, decision-making, regulation compliance, team collaboration	This game first gives information by graphic interface of the event and scene and second, assesses the data gathered by the teams and the way they support managerial decisions.

Gameplay description according to what authors have reported in their studies.

FIG. 4.

Classification of managerial skills the identified serious games try to enforce, according to Katz’s three-skills approach for leadership.

Discussion

This is the first contemporary systematic review reporting on the development and implementation of digital and analog serious games in the hospital management field. A similar-themed extensive review was conducted 15 years ago, revealing 13 hospital management games published during 1978–2008.¹³ More recent relevant reviews include a systematic review on gamification in health care management that, however, excluded articles referring to serious games, focusing solely on the application of game elements in nonplayful environments (gamification).⁵⁶ Furthermore, a systemized literature review assessed operational research and management science (ORMS) games that could be utilized in health care. Nonetheless, the review did not reveal any relevant ORMS serious games for health care but identified six games that could be adapted to serve health care purposes.⁵⁷

The current findings suggest that serious game application in the health care management field has not increased tremendously over the past years; rather, a steady increase is observed in the triennials from 2015 and onward. Noteworthy, analog serious games have become more common in the past 10 years compared with digital ones. This observation opposes the literature, which supports that the COVID-19 pandemic accelerated digital educational tools transformation, with several serious digital games being developed in various health-related disciplines.^8,58,59 This finding can be partially explained according to one of the included studies, which supports that board games increase social relatedness and enrich players’ experience, while participants (older working adults) are more familiar with board game format and assimilate the rules quicker compared with digital games.²⁷ Furthermore, the majority of the identified serious games were multiplayer games requiring team collaboration; similarly, literature supports that board games provide better opportunities for between-player discussion and allow more room for players to engage in deeper thinking, enhancing further knowledge acquisition compared with digital games.⁶⁰

Concerning the geographical distribution of the identified serious games, results indicate a moderate distribution mainly in European, North American, and Asian countries. This is consistent with a recent bibliometric analysis, which also places North America and Europe as the continents with the highest number of serious game-associated publications.⁶¹ Furthermore, according to our findings, the United States is the leader in the field, counting eight distinct serious games in the hospital management field. Indeed, literature agrees that the United States is the largest contributor to serious game development, according to several studies focusing on the health care sector or other disciplines.^11,61,62

Regarding the most common learning activity type, simulation serious games have the lion’s share. Especially, virtual simulation usage has globally increased in the past years since it is proven to improve learners’ experience at all educational levels, subjects, and contexts.⁶³ Simulation games utilize reality-based scenarios with action-oriented activities,⁶⁴ resulting in powerful educational tools for promoting teamwork and collaboration,^65,66 but also aid in mastering managerial and leadership skills, such as complex and dynamic decision-making.^67,68 To this end, a systematic review of different serious game genres identified, justifiably, simulations as the most prominent serious game genre.⁶⁸

As regards the most common subject among the identified serious games, upper management skills-themed games were the most predominant. This was expected since this category incorporates a wide range of important managerial and administrative duties including strategic planning, decision-making, and resource management allocation, which are key skills for all successful hospital executives. However, important game subjects such as financial literacy and information security games also emerged. Several members with higher administrative roles in hospitals are doctors or nurses, which creates a difficulty to understand complicated financial processes; thus, providing financial lessons in the form of serious games is considered rather helpful.³⁷ Additionally, data security is a complex concept for many health care managers; therefore, basic training on understanding data encryption and health care record privacy is considered crucial.⁴³

Finally, Katz’s three-skill approach theory⁵⁴ was embarked to classify the basic skills categories that the identified serious games tried to enhance. In an eminent article published in 1955, Katz introduced the necessary “manager skills” based on three categories: technical, interpersonal, and conceptual skills.⁶⁹ Interpersonal skills are important at every management level, technical skills are most important at lower and middle management levels, and conceptual skills are most important at the top management level.⁷⁰ We chose to incorporate the specific theoretical model since it is widely accepted by the scientific community and could incorporate perfectly all the individual subcategory skills within its main three-skill classification.

Summarizing, the literature supports that today’s management education needs to exceed traditional teaching models.⁷¹ This document offers a coherent literature review on multiple serious games being developed regarding different educational subjects, targeting diverse populations, and enhancing several different managerial skills. This systematic review could serve as inspiration and guidance both for academics and health care stakeholders for including innovative serious games as part of hospital management training programs either at the postgraduate level or for lifelong training of hospital personnel. More specifically, academic institutions can leverage these innovative serious games to enrich their curricula, making learning more engaging and practical for students who are preparing for administrative roles in health care. Hospitals and other health care organizations can incorporate these educational tools into their training programs to ensure staff development of critical managerial competencies in an affordable, enjoyable, and interactive manner, ultimately leading to improved operational efficiency and patient care quality. For hospital personnel, serious games offer an easily accessible way to continuous learning and skills improvement, adapt to evolving challenges, and stay current with best practices, while simultaneously fostering team cohesion and enhancing their overall daily working life.

Furthermore, health care policymakers can greatly benefit by supporting the integration of serious games into ongoing educational and professional development initiatives, recognizing their potential to standardize and elevate health care managers’ competencies. Overall, the adoption of serious games tailored to specific stakeholder needs can foster a more competent, adaptable, and innovative health care management workforce, positively impacting organizational performance and patient outcomes.

Limitations

A potential limitation lies within selection bias; “serious games” is a relevantly old term (1970) that became popular over the past 15 years. However, only 13 of the included articles utilized the term “serious game” within their text. Therefore, multiple robust search algorithms were created including a wide range of relevant keywords to minimize the risk of misidentifying relevant studies. Furthermore, another limitation lies within the classification of “learning activity types” and “game’s teaching subject” categories. Their classification has a scientific basis; however, due to the heterogeneity of the reported information, we improvised to a certain extent to be able to report the data in more homogenous categories.

Conclusions

Serious games have conquered many scientific fields, and although in hospital management education the advances are rather modest, there are plenty of opportunities and benefits that learners could reap. This article can be perceived as a useful guideline for those who want to lead the way for more synchronous, fun, and engaging learning experiences as it provides a wide spectrum of distinguished serious games that could be exploited by academics, hospital managers, and health care policymakers to enhance hospital management knowledge and health care administrative skills acquisition to create more successful and high-performing hospital executives. Future research should launch a discussion regarding the approval of health-related serious games by an official authority body. The need is more imperative regarding serious games implemented for patients’ disease management.⁷² However, the entire health care community could greatly benefit from the establishment of such an authority with the task of certifying health care–related serious game applications.

Authors’ Contributions

V.E.C.: Conceptualization (lead), methodology (lead), formal analysis (lead), investigation (lead), writing original draft (lead), and writing—reviewing and editing (equal). C.P.: Methodology (supporting), formal analysis (supporting), and writing—reviewing and editing (equal). N.V.: Methodology (supporting), formal analysis (supporting), and writing—reviewing and editing (equal). J.F.: Conceptualization (supporting), methodology (supporting), formal analysis (supporting) writing—reviewing and editing (equal), and supervision (lead).

Footnotes

Acknowledgment

Dimitra Sifaki-Pistolla is acknowledged for her support in preparing the world diagram.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this study.

Supplemental Material

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