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Simulation-based programs allow trainees to be progressively challenged in a systematic, learner-centered and patient-focused fashion. The design of these programs requires an understanding of the individual steps that comprise the entire surgical procedure and our ability to assess the progress of the learner. We present the results of the design and validation of performance assessment checklists for a progressive simulation-based program in cardiac surgery.Using a case study design, we videotaped 10 off-pump coronary artery bypass procedures and applied a new methodological framework to deconstruct the procedure into teachable components for which 6 simulation scenarios were developed. Individual checklists were designed and validated using the Delphi technique. An expert panel of 11 cardiac surgeons rated each checklist item by using a 5-point Likert-type scale and provided comments on the rating choice. The consistency of the experts' ratings were interpreted as consensus achieved when 70% of experts rated 3.5 or greater on the 5-point Likert-type scale for each assessment item.An in vivo workflow diagram was developed, and 6 simulation modules with progressive difficulty were selected to design an off-pump coronary artery bypass simulation-based program. The corresponding 6 assessment checklists were designed and validated. After 2 Delphi rounds, the overall average score across all checklists was 4.0, and all items were greater 3.5. The final checklists comprise between 12 and 23 items.We have demonstrated the feasibility of designing simulation-based program for complex operative procedures in a progressive fashion. The complexity at each level was given by the predefined training objectives and assessment checklists were designed and validated as content-specific assessment tools for each simulation scenario.