Pocket Guide: TeamSTEPPS Strategies & Tools to Enhance Performance and Patient Safety ContentsTeamSTEPPS Framework and Competencies Key PrinciplesTeam Structure Multi-Team System For Patient CareLeadership Effective Team Leaders Team Events Brief Checklist Debrief ChecklistSituation Monitoring Situation Monitoring Process Cross Monitoring STEP I'M SAFE ChecklistMutual Support Task Assistance Feedback Advocacy and Assertion Two-Challenge Rule CUS DESC Script CollaborationCommunication SBAR Call-Out Check-Back Handoff "I PASS THE BATON"Team Performance Observation ToolBarriers,Tools & Strategies, and OutcomesContact InformationTeamSTEPPS™Team Competency Outcomes[D] Select for Text DescriptionKnowledgeShared Mental ModelAttitudesMutual TrustTeam OrientationPerformanceAdaptabilityAccuracyProductivityEfficiencySafetyTeamSTEPPS is comprised of four teachable-learnable skills: Leadership, Situation Monitoring, Mutual Support, and Communication; the core of the TeamSTEPPS framework. The red arrows depict a two-way dynamic interplay between the four skills and the team-related outcomes. Interaction between the outcomes and skills is the basis of a team striving to deliver safe, quality care. Encircling the four skills is the patient care team which not only represents the patient and direct caregivers, but those who play a supportive role within the healthcare delivery system....TeamSTEPPS is an evidence-based framework to optimize team performance across the healthcare delivery system.Key PrinciplesTeam StructureDelineates fundamentals such as team size, membership, leadership, composition, identification and distribution.LeadershipAbility to coordinate the activities of team members by ensuring team actions are understood, changes in information are shared, and that team members have the necessary resources.Situation MonitoringProcess of actively scanning and assessing situational elements to gain information, understanding, or maintain awareness to support functioning of the team.Mutual SupportAbility to anticipate and support other team members' needs through accurate knowledge about their responsibilities and workload.CommunicationProcess by which information is clearly and accurately exchanged among team members.Return to ContentsTeam Structure[D] Select for Text DescriptionThe ratio of We's to I's is the best indicator of the development of a team...— Lewis B. ErgenMulti-Team System For Patient Care Return to ContentsLeadership[D] Select for Text DescriptionThe art of getting someone else to do something you want done because he wants to do it...— Dwight D. Eisenhower Effective Team LeadersOrganize the team.Articulate clear goals.Make decisions through collective input of members.Empower members to speak up and challenge, when appropriate.Actively promote and facilitate good teamwork.Skillful at conflict resolution. Team EventsPlanningBrief — Short session prior to start to discuss team formation; assign essential roles; establish expectations and climate; anticipate outcomes and likely contingencies.Problem SolvingHuddle — Ad hoc planning to reestablish situation awareness; reinforcing plans already in place; and assessing the need to adjust the plan.Process ImprovementDebrief — Informal information exchange session designed to improve team performance and effectiveness; after action review. Brief ChecklistDuring the brief, the team should address the following questions: ___ Who is on the team? ___ All members understand and agree upon goals? ___ Roles and responsibilities are understood? ___ What is our plan of care? ___ Staff and provider's availability throughout the shift? ___ Workload among team members? ___ Availability of resources? Debrief ChecklistThe team should address the following questions during a debrief: ___ Communication clear? ___ Roles and responsibilities understood? ___ Situation awareness maintained? ___ Workload distribution equitable? ___ Task assistance requested or offered? ___ Were errors made or avoided? Availability of resources? ___ What went well, what should change, what should improve?Return to ContentsSituation Monitoring[D] Select for Text DescriptionAttention to detail is one of the most important details...— Author Unknown Situation Monitoring Process Situation monitoring is the process of continually scanning and assessing what's going on around you to maintain situation awareness.Situation awareness is "knowing what is going on around you."With a shared mental model, all team members are "on the same page." Cross MonitoringAn error reduction strategy that involves:Monitoring actions of other team members.Providing a safety net within the team.Ensuring mistakes or oversights are caught quickly and easily."Watching each other's back."STEPA tool for monitoring situations in the delivery of health careComponents of Situation Monitoring: STEP√ Assess Status of Patient__ Patient History__ Vital Signs__ Medications__ Physical Exam__ Plan of Care__ Psychosocial√ Assess Level of Team Members'__ Fatigue__ Workload__ Task Performance__ Skill__ Stress√ Assess Environment__ Facility Information__ Administrative Information__ Human Resources__ Triage Acuity__ Equipment√ Assess Progress Towards Goal__ Status of Team's Patient(s)?__ Established Goals of Team?__ Tasks/Actions of Team?__ Plan Still Appropriate? I'M SAFE Checklist√ I = Illness√M = Medication√S = Stress√A = Alcohol and Drugs√F = Fatigue√E = Eating and Elimination An individual team member's responsibility...Return to ContentsMutual Support[D] Select for Text DescriptionA chain is only as strong as its weakest link...— Author UnknownTask AssistanceA form of mutual support:Team members protect each other from work overload situations.Effective teams place all offers and requests for assistance in the context of patient safety.Team members foster a climate where it is expected that assistance will be actively sought and offered.In support of patient safety, it's expected!FeedbackInformation provided for the purpose of improving team performance√Feedback should be:__ Timely — given soon after the target behavior has occurred.__ Respectful — focus on behaviors, not personal attributes.__ Specific — be specific about what behaviors need correcting.__ Directed towards improvement — provide directions for future improvement.__ Considerate — consider a team member's feelings and deliver negative information with fairness and respect.Return to ContentsAdvocacy and AssertionAdvocate for the patientInvoked when team members' viewpoints don't coincide with that of the decision maker.Assert a corrective action in a firm and respectful mannerMake an opening.State the concern.Offer a solution.Obtain an agreement.Two-Challenge RuleWhen an initial assertion is ignored:It is your responsibility to assertively voice concern at least two times to ensure it has been heard.The team member being challenged must acknowledge.If the outcome is still not acceptable: Take a stronger course of action.Utilize supervisor or chain of command.Empowers all team members to "stop the line" if they sense or discover an essential safety breach.CUS DESC ScriptA constructive approach for managing and resolving conflictD — Describe the specific situation or behavior; provide concrete data.E — Express how the situation makes you feel/what your concerns are.S — Suggest other alternatives and seek agreement.C — Consequences should be stated in terms of impact on established team goals; strive for consensus.CollaborationAchieves a mutually satisfying solution resulting in the best outcomeWin-Win-Win for Patient Care Team (includes the patient, team members, and team.)Commitment to a common mission.Meet goals without compromising relationships."True collaboration is a process, not an event"Return to ContentsCommunication[D] Select for Text DescriptionCommunication is the response you get from the message you sent regardless of its intent— Author UnknownSBARA technique for communicating critical information that requires immediate attention and action concerning a patient's condition.Situation — What is going on with the patient?"I am calling about Mrs. Joseph in room 251. Chief complaint is shortness of breath of new onset."Background — What is the clinical background or context?"Patient is a 62 year old female post-op day one from abdominal surgery. No prior history of cardiac or lung disease."Assessment — What do I think the problem is?"Breath sounds are decreased on the right side with acknowledgement of pain. Would like to rule-out pneumothorax."Recommendation and Request — What would I do to correct it?"I feel strongly the patient should be assessed now. Are you available to come in?"Call-OutStrategy used to communicate important or critical informationInforms all team members simultaneously during emergent situations.Helps team members anticipate next steps.Important to direct responsibility to a specific individual responsible for carrying out the task.Example during an incoming trauma:Leader: "Airway status?"Resident: "Airway clear"Leader: "Breath sounds?"Resident: "Breath sounds decreased on right"Leader: "Blood pressure?"Nurse: "BP is 96/62"Check-BackProcess of employing closed-loop communication to ensure that information conveyed by the sender is understood by the receiver as intended.The steps include the following:Sender initiates the messageReceiver accepts the message and provides feedbackSender double-checks to ensure that the message was receivedExample:Doctor: "Give 25 mg Benadryl IV push"Nurse: "25 mg Benadryl IV push"Doctor: "That's correct"HandoffThe 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.Examples of transitions in care include shift changes, physicians transferring complete responsibility, and patient transfers.HandoffStrategy designed to enhance information exchange during transitions in careStepDescriptionIIntroductionIntroduce yourself and your role/job (include patient).PPatientIdentifiers, age, sex, location.AAssessmentPresent chief complaint, vital signs, symptoms, and diagnosis.SSituationCurrent status/circumstances, including code status, level of uncertainty, recent changes, and response to treatment.SSafetyCritical lab values/reports, socio-economic factors, allergies, and alerts (falls, isolation, etc.).THE BBackgroundCo-morbidities, previous episodes, current medications, and family history.AActionsWhat actions were taken or are required? Provide brief rationale.TTimingLevel of urgency and explicit timing and prioritization of actions.OOwnershipWho is responsible (person/team) including patient/family?NNextWhat will happen next?Anticipated changes?What is the plan?Are there contingency plans? Return to ContentsTeam Performance Observation ToolTeam StructureAssembles team.Establishes leader.Identifies team goals and vision.Assigns roles and responsibilities.Holds team accountable.Actively shares information.LeadershipUtilizes resources to maximize performance.Balances workload within the team.Delegates tasks or assignments, as appropriate.Conducts briefs, huddles, and debriefs.Empowers team to speak freely and ask questions.Situation MonitoringIncludes patient/family in communication.Cross monitors team members.Applies the STEP process.Fosters communication to ensure a shared mental model.Mutual SupportProvides task-related support.Provides timely and constructive feedback.Effectively advocates for the patient.Uses the Two-Challenge rule, CUS, and DESC script to resolve conflict.Collaborates with team.CommunicationCoaching feedback routinely provided to team members when appropriate.Provides brief, clear, specific, and timely information.Seeks information from all available sources.Verifies information that is communicated.Uses SBAR, call-outs, check-backs, and handoff techniques.Return to Contents BarriersTools & StrategiesOutcomesInconsistency in Team MembershipLack of timeLack of Information SharingHierarchyDefensivenessConventional ThinkingComplacencyVarying Communication StylesConflictLack of Coordination and Follow-Up withCo-WorkersDistractionsFatigueWorkloadMisinterpretation of CuesLack of Role ClarityBriefHuddleDebriefSTEPCross MonitoringFeedbackAdvocacy and AssertionTwo-Challenge RuleCUSDESC ScriptCollaborationSBARCall-OutCheck-BackHandoffShared Mental ModelAdaptabilityTeam OrientationMutual TrustTeam PerformancePatient Safety!!Return to ContentsContact InformationTo learn more about TeamSTEPPS, refer to the Agency for Healthcare Research and Quality (AHRQ) website:http://teamstepps.ahrq.gov/and the Department of Defense Patient Safety Program website:http://dodpatientsafety.usuhs.mil/teamsteppsDeveloped for the Department of Defense Patient Safety Program in collaboration with the Agency for Healthcare Research and QualityTeamSTEPPS™ Pocket Guide — 06.1ISBN 1-58763-191-1Revised March 2008Return to Contents Current as of November 2008 Internet Citation: Pocket Guide: TeamSTEPPS: Strategies & Tools to Enhance Performance and Patient Safety. November 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/essentials/pocketguide.html
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