Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based patient safety program developed by The Department of Defense, the Agency for Healthcare Research and Quality, and scientific leaders that focuses on improved teamwork and communication in health care. On the basis of the science of team training and crew resource management (CRM), a comprehensive program was developed and released in 2006. The program provided tools for training, and recommended strategies to assist organizations with implementation.1
The 1999, landmark Institute of Medicine Report To Err is Human: Building a Safer Healthcare System, thrust the problem of medical errors into the national consciousness. It estimated that medical errors are the cause of up to 98,000 deaths each year, a total exceeding the number of deaths from breast cancer, AIDS, or automobile accidents. The findings sent shockwaves throughout the medical community. The widespread publicity and outcry galvanized congressional and executive branch efforts to address the problem. One of the key recommendations of the report to correct the problem was improved teamwork in health care.
More recent evidence suggests that the problems compromising patient safety are even more staggering. Previous estimates were based on a manual of review of randomly selected hospital charts now 30 years old. A study which used the Institute of Healthcare Improvement Global Trigger Tool to analyze 4 more recent studies on errors estimated that the number of deaths may be as many as 400,000 per year, with harm occurring 10 to 20 times more often.2 The impact on the health care system and the cost to society is tremendous.
There have been some advances to improve safety like the Sign Your Site initiative and the World Health Organization Surgical Safety checklist. The latter decreased morbidity and mortality in a variety of hospitals internationally.3 However, widespread implementation of the surgical safety checklist has not resulted in universal improvement in safety. Urbach and colleagues compared mortality, length of stay, rate of complications, and emergency room visits or readmissions within 30 days in 101 hospitals in Ontario, Canada before and after implementation of the safety checklist. They could not demonstrate significant improvement in any of the metrics after employing the checklist.4 They hypothesized that the checklists may have more impact with more intensive team training.
Undoubtedly preventable adverse events and quality problems persist throughout health care. Wrong site surgery, considered a “never event” by the Joint Commission, still occurs at an alarming rate of approximately 50 times per week. Retained foreign objects after surgery, another “never event” remains a problem. Hand-hygiene failures, a well-established contributor to nosocomial infections, exceed 60%. Communication failures during patient transitions, a major cause of errors, exceed 40%. Approximately 600 fires occur in the operating room each year.5
The increasing complexity of the health care system and rapidly emerging new technologies have made attempts to improve safety a continuing challenge. Patient safety experts have recognized that other industries share comparable complexity and risk, but enjoy vastly superior safety records. Examples include the commercial airline industry, the air traffic control system, aircraft carriers, and nuclear power plants. These industries are also referred to as High Reliability Organizations (HROs), which are hazardous organizations that are able to maintain records of high safety over long periods of time. Patient safety experts have scrutinized the practices of these organizations and have worked to apply them to health care to address the problems in medicine. HROs have vigorously applied principles of expert teamwork to improve working environments and safety.1
All HROs share an organizational culture of safety, where workers understand the importance of their roles, and act on an obligation to report unsafe conditions, inappropriate behaviors, and errors. Vigorous reporting and data collection allows HROs to identify system flaws early before they can result in more substantial problems. The organizations aggressively act on this information to correct problem areas, and provide feedback to employees who filed the reports. Workers hold themselves accountable for adhering to safety procedures.5
Employees accurately believe that they are members of the health care team, but the more important question is whether they are maximizing their effectiveness as team members. Effective team functioning is not necessarily intuitive, so a concerted effort is required to provide team members the knowledge, skills, and attitudes (KSAs) that workers need to elevate team functioning. The TeamSTEPPS program teaches workers the tools they need to evolve into members of high-functioning teams. Organizations pursuing team training should be committed to change with support from strong leadership and a climate for learning.6 Evidence supports the concept that team training instruction in the appropriate setting does improve teamwork in health care.1,6–10
The TeamSTEPPS initiative in the health care setting is designed to introduce the same concepts, principles, and culture into hospitals that have been successful in HROs. In fact, the underlying principles taught in training health care teams have been learned from NASA, the airline industry, and the Department of Defense (3 HRO settings). Many of the underlying principles are based on CRM. CRM was developed in the late 1970s and early 1980s in response to an increase in military and commercial aviation accidents and fatalities. Among the problems identified leading to crashes and fatalities were human errors, communication failures, leadership, and cockpit decision making. Interestingly, when one analyzes hospital sentinel events across the country, human error, leadership, and communication are among the 3 most common etiologies leading to these events. The similarities between the airline industry and the health care industry lead researchers to adapt the successful programs instituted in the airline industry to patient safety initiatives and TeamSTEPPS in the health care industry.
Modern health care delivery is extremely complex. No single individual health care provider can care for their patients without the assistance of other providers or facilities. Most providers understand these limitations and recognize the necessity of working with others to successfully care for their patients. The common fallacy is that the necessity for other individuals to help care for your patients constitutes the “health care team.” The “team” is perceived simply as all of the other individuals who interact with our patients to assist them in getting well. We call for a consultation, order an imaging study, depend on a radiologist for the interpretation, perform surgery on our patients, and require the assistance of an anesthesiologist, circulating nurse, and technician to complete the procedure. In these examples, we have simply assembled a team of experts. A great example of a failure of a team of experts is seen in recent Olympic history. The 2004 US basketball team consisted of an National Basketball Association all-star team. They lost because they performed as a team of experts; each player showcased their skills, but never performed as a team member.
The most important underlying concept of TeamSTEPPS is that patient care and safety demands that everyone participating in the care of the patient, including the patient and family, have the single common goal of successfully guiding the patient and their family through their health care experience. Essentially, we are all members of the same “team” and we “win” when the patient successfully passes through their health care encounter without complications. This common goal, recognized by all team members, is what leads to successful teams. Winning necessitates the same culture and reliability as seen in HROs, and requires creating an expert team, in which everyone shares the common goal of guiding the patient through the health care experience as opposed to expertly completing their particular assigned task. Expert teams require the ability of each team member to have specific skills (tasks) necessary for the overall success of the team, but each individual needs to integrate their own area of expertise into the overall success of the team as opposed to simply addressing their individual area of expertise.
The TeamSTEPPS logo (Fig. 1) summarizes the components of successful health care teams. KSA have been found to be the foundation of successful teams in many forums outside of the health care industry. KSAs guide everyone to think like members of a unified team; imparting team philosophies of understanding and supporting all the members of the team. This allows all team members to be better able to adapt to all of the dynamic situations commonly seen in patient care and our complex health care delivery environment and ultimately improve quality and safety of the care. TeamSTEPPS training has been designed to instill the underlying philosophy of creating expert teams and to teach the skills necessary to allow everyone on the health care team to function as team members. The 4 skills required for members of the patient care team to become integrated team members are communication, leadership, situation monitoring, and mutual support. Learning these skills allows everyone to have the knowledge and attitudes that lead to improved performance and outcomes. TeamSTEPPS training teaches theses 4 skills in multidisciplinary forums, as a means of building integrated teams. The following is a brief discussion of the underlying principles and philosophy of the 4 skills. The reader is encouraged to refer to the TeamSTEPPS Web site for more detailed information (http://teamstepps.ahrq.gov).
Strong and effective leadership is imperative for a group of individuals to function as a team. Undoubtedly, communication is as important as leadership, but successful communication is a direct result of effective leadership. Successful teams are built on successful communication. Leaders come in many styles, but ultimately, leaders who are able to lead successful teams have created a working environment in which all members of the team are always able to speak up and are required to speak up. In our health care environment, the important team philosophy is that all of our teamwork is designed to provide safe and effective care. Leaders need to make every member of the team understand that their individual task is as important for successful team functioning as that of any other member of the team. TeamSTEPPS recommends regular team assembly and interaction to instill teamwork and a team philosophy. Two very effective tools are a daily brief when all of the members of the team meet to discuss the plans and challenges of the day and an end of the day debrief to discuss what went well and what can be improved in the team function. Unexplained events that occur during the day are addressed with an ad hoc huddle, during which time all involved members quickly discuss the situation and formulate a plan for its resolution.
Two common problems that undermine effective teamwork are conflicts between team members and individual team members not completing their tasks correctly. Leaders also have the responsibility to insure timely feedback to all team members to resolve these issues. Failure to address these situations invariably leaves some members of the team feeling as if they are not part of the team, destabilizing the team and teamwork.
Communication failures are very commonly identified as an underlying problem in analysis of sentinel events. No team, no business, no activity requiring >1 individual can function without effective communication. A breakdown in communication involving a member of the team, which includes the patient, their family, the physician(s), nurses, technicians, administrators, and all ancillary staff, can result in an avoidable complication. Team members need to feel comfortable speaking up and have an obligation as a team member to speak up.
The consequences of poor leadership and communication can be readily understood in the surgical treatment of an adolescent child with a both bones fracture of the forearm. The individual preparing the tray with the implants notices an inadequate number of 14-mm screws but assumes that 4 should be plenty. The anesthesiologist notices contamination of the instrument table by the fluoroscopy machine, but because she is not a part of the surgical team fails to speak up. The scrub tech assisting the surgeon notices the counter sink is missing. He has never seen it used before, and is afraid to speak up because the surgeon is frequently abusive, so he does not let the circulating nurse know. The 16-year-old patient develops numbness in her fingers the night after surgery, but does not speak up because she is shy and no one asked her if she had numbness. Three weeks after the procedure the wound begins to drain. The family is not concerned because it drained 2 days after surgery and the surgeon advised that the drainage was normal. In each one of these instances, the lack of understanding of individual team members, because of a lack of communication/understanding of the importance of speaking up to report these observations could potentially lead to serious and avoidable complications.
An integral component of teamwork and building an expert team is situation monitoring. This is a skill in which all members of the team remain fully cognizant of everything that is occurring during the process of guiding a patient through a successful health care encounter. It requires that all members of the team are aware of how they are functioning as individuals and how other members of the team are functioning. TeamSTEPPS describes a four S-T-E-P process in situation monitoring: knowing the Status of the patient, knowing what Team members are available to address the situation, Environmental concerns including the urgency of the situation, equipment availability, facility concerns all of which create an awareness by all team members of the Progress toward the goal. When all members of the team are constantly aware of the situation and factors affecting the progress toward the goal, everyone can respond appropriately in real time to both prevent and address preventable errors. This creates what is referred to as situational awareness in CRM and leads to a shared mental model.
The integration of leadership, communication, and situation monitoring creates the skill of mutual support. Mutual support is truly what creates successful teams and improves safety. In an environment of mutual support, all members of the team are available, when necessary, to help each other, complete the necessary tasks for the team to “win,” that is, successful union of the both bones fracture without complications.
Professional barriers are broken down permitting everyone to contribute, within the limits of their ability and knowledge, to reach the final goal. TeamSTEPPS specifically promotes task assistance, in which one member of a team may assist another member who is overwhelmed. In addition, everyone on the team understands that personality conflicts arise and that human errors occur. These problems need to be immediately identified and addressed through timely feedback and conflict resolution. TeamSTEPPS teaches skills and techniques to facilitate conflict resolution. Finally, in an environment of mutual support, everyone will immediately speak up to prevent an impending error or complication from occurring.
Evidence supporting the efficacy of team training continues to grow. Widespread implementation of team training in the Veteran’s Administration Hospital System has demonstrated its value. Neily et al11 studied annual surgical mortality rates before and after implementation of medical team training and demonstrated a 18% reduction at facilities that completed team training. Young-Xu et al10 found a statistically significant reduction in surgical morbidity after team training, including surgical site infections.
Barriers to implementation remain a challenge. Hospitals must be fully committed to the program, which includes the considerable expense required for an institution to provide teamwork training for all of its employees. Surgeons pose a formidable barrier as well. Surgeons are accustomed to their own routines and generally provide expert care. Because problems occur infrequently, they fail to see a compelling reason to change. To completely embrace the program, however, requires a cultural change throughout the institution. Cultural change requires dedication, persistent effort, and leadership from the highest levels of the organization. Physician and nursing champions cannot coordinate and advance the agenda without the complete, enthusiastic support from individuals with more authority.
Researchers have identified 7 factors that are essential for successful implementation of a team training program. The health care entity must (1) align team training objectives and safety aims with organizational goals; (2) provide organizational support for the team training effort; (3) engage leaders to promote the initiative on the frontline; (4) prepare the environment and trainees for training; (5) ensure required time commitment and resources are available; (6) facilitate application of the acquired skills on the job; and (7) measure the effectiveness of the effort.6
The current levels of errors and harm that are routine in health care would never be tolerated in any other industry. All health care providers must avoid complacency and acceptance of the current standards. The principles of teamwork that have succeeded in other industries can be applied to health care with success. To reach the next level of patient safety and outcomes, every member of the health care team has to evolve from being simply an expert caregiver to being a member of an expert team.
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