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Empowering Sustained Patient Safety: The Benefits of Combining Top-down and Bottom-up Approaches

Stewart, Greg L. PhD; Manges, Kirstin A. RN; Ward, Marcia M. PhD

doi: 10.1097/NCQ.0000000000000103

Implementation of TeamSTEPPS for improving patient safety is examined via descriptive qualitative analysis of semistructured interviews with 21 informants at 12 hospitals. Implementation approaches fit 3 strategies: top-down, bottom-up, and combination. The top-down approach failed to develop enough commitment to spread implementation. The bottom-up approach was unable to marshal the resources necessary to spread implementation. Combining top-down and bottom-up processes best facilitated the implementation and spread of the TeamSTEPPS safety initiative.

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Tippie College of Business (Dr Stewart), College of Nursing (Ms Manges), and College of Public Health (Dr Ward), The University of Iowa, Iowa City.

Correspondence: Greg L. Stewart, PhD, Tippie College of Business, The University of Iowa, S384 John Pappajohn Business Bldg, Iowa City, IA 52242 (

This research was supported by grant number R18HS018396 from the Agency for Healthcare Research and Quality (AHRQ). The content is solely the responsibility of the authors and does not necessarily represent the official views of the AHRQ.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (

Accepted for publication: September 27, 2014

Published ahead of print: December 4, 2014

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