Aspirations to achieve quality and safety goals in health services through simulation have led to significant investments in simulation equipment, space and faculty. However, the optimal governance and operational models through which these resources are expertly applied in health services are not known. There is growing evidence supporting ‘service’ models for simulation. In these models, simulation activities are co-designed and delivered by a team of simulation experts in partnership with health service units, specifically targeting quality and safety goals. Embedded simulation specialist teams working within these programs offer benefits not fully captured by traditional models of health education or by traditional systems for quality and safety. In this article, we explore broad and specific recommendations for establishing a simulation consultancy service within an Australian metropolitan health service. We base these recommendations on a review of current Australian practice and healthcare simulation literature, and on a specific example within a large outer metropolitan health service. The broad domains discussed include (1) governance and leadership; (2) human resources; (3) principles and planning; (4) operationalise and evaluate and (5) look to the future. The recommendations recognise that healthcare simulation is moving beyond solely addressing individual learning outcomes. The value of simulation addressing organisation and system objectives through various simulation modalities is increasingly being explored and demonstrating value. There is a growing demand for translational simulation in these contexts, and a consequent requirement for organisations to consider how simulation services can be successfully operationalised. Recommendations included in this paper are discussed and described with the intent of facilitating a deeper appreciation of the complexities associated with, and opportunities afforded by, a well-integrated simulation service.