Sheri L.

Ferguson

TeamSTEPPS: Integrating Teamwork Principles Into Adult Health/Medical-Surgical Practice

n collaboration with the Health and Human Services Agency for Healthcare Research and Quality (AHRQ), the Department of Defense (DoD) Health Care Team Coordination Program (HCTCP) developed an initiative that stresses teamwork and communication among physicians, nurses, and other health care personnel to make the delivery of health care safer for all patients. The Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) principles were designed to be incorporated into the daily activities of patient care provision in an effort to reduce clinical errors, and improve patient outcomes and patient and

staff satisfaction. The TeamSTEPPS approach has met with great success in a variety of high-risk settings such as emergency departments and labor and delivery. It is now time to embrace TeamSTEPPS strategies in the medical-surgical setting.

TeamSTEPPS Goal
The goal of TeamSTEPPS is to produce highly effective medical teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients. To achieve this goal, the HCTCP will work to institutionalize team-driven care, solidify collaborative partnerships, and support research demonstration projects to improve patient safety.

Sheri L. Ferguson, MSN, MBA, MSEd, BSN, CMSRN, is a Colonel, Army Nurse Corps, and Chief, Nursing Administration, Carl R. Darnall Army Medical Center, Fort Hood, TX. She is also Medical Surgical Nursing Consultant to The Surgeon General. Disclaimer: The opinions and views expressed in this article are those of the author and do not necessarily represent those of the U.S. Army Nurse Corps, nor those of the U.S. Department of Defense. Note: Military nursing offers unique practice opportunities. Share your perspectives on your practice as a nurse in the Armed Forces with the readers of MEDSURG Nursing by submitting a manuscript in consideration for this column. Questions and submissions can be directed to the Editor, Dottie Roberts, at msjrnl@ajj.com.
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TeamSTEPPS Impact to Date

TeamSTEPPS was implemented in 2005-2007 in over 68 military treatment facilities (MTFs) worldwide. Approximately 1,500 participants have attended the train-thetrainer course, and over 22,000 continuing education (CE/CME) credits have been awarded. The train-the-trainer approach has saved the DoD $1.4 million in training and travel costs. TeamSTEPPS has been introduced in 24 peerreviewed publications and was the topic of conversation in over 10 interviews. In January 2008, the Military Health System Conference featured a 2-hour TeamSTEPPS training session for over 100 participants. TeamSTEPPS tools and strategies have been incorporated in simulation exercises and in uni-

versity curricula. It has been applied at academic institutions, including Harvard Universitys Beth Israel Deaconess Hospital and Duke University Health Systems Pediatric Intensive Care Unit. Military operational units continue to request training to enhance their ability to support any mission at a moments notice. Forward surgical teams have received training to increase the precision of care provided both on the battlefield and in the combat support hospitals in Iraq and Afghanistan. A front-page article on TeamSTEPPS in the June 1, 2007, issue of Internal Medicine News (Vol 40, No 11, www.internal medicinenews.com) confirmed the widespread attention enjoyed by TeamSTEPPS. The prestigious M. Scott Myers Award for Applied Research from The Society for Industrial and Organizational Psychology went to TeamSTEPPS in 2007.

Tools and Strategies

The TeamSTEPPS program provides tools and strategies to increase team awareness through a shared mental model (see Figure 1). It clarifies team roles and responsibilities, and creates an atmosphere of mutual trust. Cohesive teamwork will enhance performance through increased adaptability, accuracy, productivity, efficiency, and safety. The core of the TeamSTEPPS framework comprises four key principles/skills/core competencies that are integrated to foster delivery of safe, quality care as a cohesive patient care team, which includes the patient,
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Figure 1. TeamSTEPPS Teamwork Training System

PERFORMANCE

Leadership

Communication

Situation Monitoring

Mutual Support

KNOWLEDGE

SKILLS PAT IENT CARE TEAM

ATTITUDES

direct caregivers, and those who play a supportive role within the health care delivery system. The four key skill areas are: 1. Leadership. Involves the ability to coordinate the activities of team members by ensuring team actions are understood, changes in information are shared, and team members have the necessary resources. TeamSTEPPS tools include: Planning Brief: A short session prior to start to discuss team and establish roles. Problem solving Huddle: An ad hoc team meeting to share information and adjust plans. Process improvement Debrief: After-action review to provide feedback and improve team performance. 2. Situation Monitoring. The process by the individual of actively scanning behaviors and actions of those around him or her to assess the situation or environment. Situation monitoring fosters mutual respect and team accountability, and provides a safety net for the team and the patient. TeamSTEPPS tools include: Cross monitoring A process

3.

of monitoring the actions of other team members for the purpose of sharing the workload and reducing or avoiding errors. It ensures mistakes or oversights are caught quickly and easily. It is a way of watching each others back. Shared mental model The perception of, understanding of, or knowledge about a situation or process that is shared among team members through communication. Having team members on the same page is the desired team outcome. Mutual Support. The ability to anticipate and support other team members needs through accurate knowledge about their responsibilities and workload, mutual support protects team members from work overload situations that may reduce effectiveness and increase the risk of error. TeamSTEPPS tools include: Task assistance Team members foster a climate where it is expected that assistance will be actively sought and offered. Feedback Information for the purpose of improving team performance should be

4.

timely, respectful, specific, directed toward improvement, and considerate. Advocacy and assertion Invoked when team members viewpoints do not coincide with that of a decision maker. The team member asserts a corrective action in a firm and respectful manner. Two-challenge rule Invoked when an initial assertion is ignored. It is the team members responsibility to voice his or her concern assertively at least two times to ensure that it has been heard. The member being challenged must acknowledge the challenge; if the outcome is still not acceptable, a stronger course of action, such as notifying the supervisor, must be taken. Collaboration Achieves a mutually satisfying solution resulting in the best outcome. The patient care team (individual team members, team, and patient) all win! DESC script A constructive approach for managing and resolving conflict. Ultimately, consensus shall be reached. D Describe the specific situation. E Express your concerns about the action. S Suggest other alternatives. C Consequences should be stated. Communication. A process by which information is clearly and accurately exchanged among team members. TeamSTEPPS strategies for providing clear and accurate communication include: SBAR a technique that requires immediate attention and action concerning a patients condition. S Situation B Background A Assessment R Recommendation Call-out A strategy used to communicate important or critical information. Example: resuscitations.

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 Check-Back A process of employing closed-loop communication to ensure that information conveyed by the sender is understood by the receiver as intended. Example: all verbal orders. Handoff The transfer of information (along with authority and responsibility) during transitions in care across the continuum; to include an opportunity to ask questions, clarify, and confirm responses. Examples: shift changes, physicians transferring complete responsibility, and patient transfers.

Table 1. Resources Available

Order materials: http://www.ahrq.gov/qual/teamstepps/ Preview materials and check for updates: http://dodpatientsafety.usuhs.mil/teamstepps http://www.health.mil/

Table 2. TeamSTEPPS Citations

TeamSTEPPS Instructor Guide. [TeamSTEPPS: Team Strategies & Tools to Enhance Performance and Patient Safety; developed by the Department of Defense and published by the Agency for Healthcare Research and Quality.] AHRQ Publication No. 06-0020. Rockville (MD): Agency for Healthcare Research and Quality; September 2006. TeamSTEPPS Pocket Guide. [Team Strategies & Tools to Enhance Performance and Patient Safety; developed by the Department of Defense and published by the Agency for Healthcare Research and Quality.] AHRQ Publication No. 06-0020-2. Rockville (MD): Agency for Healthcare Research and Quality; June 2006. TeamSTEPPS Multimedia Resource Kit. [TeamSTEPPS: Team Strategies & Tools to Enhance Performance and Patient Safety; developed by the Department of Defense and published by the Agency for Healthcare Research and Quality.] AHRQ Publication No. 06-0020-3. Rockville (MD): Agency for Healthcare Research and Quality; September 2006. TeamSTEPPS Guide to Action. [TeamSTEPPS: Team Strategies & Tools to Enhance Performance and Patient Safety; developed by the Department of Defense and published by the Agency for Healthcare Research and Quality.] AHRQ Publication No. 06-0020-4. Rockville (MD): Agency for Healthcare Research and Quality; September 2006. TeamSTEPPS Poster. [TeamSTEPPS: Team Strategies & Tools to Enhance Performance and Patient Safety; developed by the Department of Defense and published by the Agency for Healthcare Research and Quality.] AHRQ Publication No. 06-0020-5.Rockville (MD): Agency for Healthcare Research and Quality; September 2006.

TeamSTEPPS Transforms Culture

The AHRQ and DoD are engaged in an extensive awareness campaign targeted at hospitals, hospital associations, health care trade associations, professional organizations, and medical and nursing schools. As TeamSTEPPS and team training are embraced by MTFs across the military health system (MHS), they also have realized considerable growth in the private sector since their release to the public domain on November 2, 2006. The ability to export TeamSTEPPS to many different health care settings and populations is an indication that teamwork can transform the culture of an organization through a variety of different ways: 1. Establishes names for behaviors and a common language for talking about communication failures. 2. Bridges the professional divide and levels the hierarchy often seen in health care. 3. Provides teachable-learnable skills and actions to practice. 4. Increases mindfulness, or knowing what is going on around you. 5. Enlists the patient as a valued team member.

TeamSTEPPS in the MedicalSurgical Setting

Medical-surgical health care personnel often operate in silos and become frustrated because their voices and opinions are not

heard. Their priorities may be different, often causing frustration. The interdisciplinary plan of care often is difficult to orchestrate when nurses, physicians, respiratory therapists, and other health care personnel do not have a shared mental model. The tools found in TeamSTEPPS can advance culture change by providing the health care workforce with a shared simple set of words to describe critical communication behaviors. As TeamSTEPPS is spread to large numbers of health care workers, the issues that are supporting those silos begin to disappear and culture change is seeded. With a common language and focus, the introduction to a series of common behaviors gives health

care workers a way to break out of constraints of current cultures and express what they see and think more freely; the cultural outcome is collective mindfulness. Implementation across an organization is one thing; sustainability is more difficult. For a change to a shift of culture to be successful, a powerful group must lead the change, and members of that group must work together as a team. Culture change is hard work. It takes leadership commitment, time resources, and focused improvement. Medical-surgical nurses are a powerful group of professionals who, in collaboration with other health care providers, can lead that change.

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TeamSTEPPS in the Military Health System

The MHS mission is to provide optimal health services in support of the nations military mission (see Tables 1 & 2). The MHS is prepared to respond anytime, anywhere, with comprehensive medical capability to military operations, natural disasters, and humanitarian crises around the globe, and to ensure delivery of world-class health care to all DoD service members, retirees, and their families. Effective teamwork and communication are vital to the successful completion of this mission. A part of the MHS vision is to have an integrated team ready to go in harms way to meet the nations challenges at home or abroad; with the help of TeamSTEPPS, the vision has become reality. As a source of innovative education, medical training, research, technology and policy, the MHS strives to provide a bridge to peace. Dr. M. Ward Casscells, assistant secretary of Defense for Health Affairs, reported at the end of 2006 that medical teams were still saving an unbelievable 90% of soldiers wounded in battle...They did so through a commitment to making a science of performance, rather than waiting for new discoveries. And they did it under extraordinarily demanding conditions and with heroic personal sacrifices. Exceptional teamwork has resulted in the unprecedented outcomes that military health care has achieved during this most recent conflict. The MHS leadership believes such impressive results are a consequence of a culture based on innovation, service to others, and an unrelenting persistence to achieve excellence.

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