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Pocket Guide: TeamSTEPPS

Strategies & Tools to Enhance Performance and Patient Safety


    Framework and Competencies
    Key Principles
Team Structure
    Multi-Team System For Patient Care
    Effective Team Leaders
    Team Events
    Brief Checklist
    Debrief Checklist
Situation Monitoring
    Situation Monitoring Process
    Cross Monitoring
    I'M SAFE Checklist
Mutual Support
    Task Assistance
    Advocacy and Assertion
    Two-Challenge Rule
    DESC Script
Team Performance Observation Tool
Barriers,Tools & Strategies, and Outcomes
Contact Information


Team Competency Outcomes

TeamSTEPPS logo. For details, go to [D] Text Description.

[D] Select for Text Description


  • Shared Mental Model


  • Mutual Trust
  • Team Orientation


  • Adaptability
  • Accuracy
  • Productivity
  • Efficiency
  • Safety

TeamSTEPPS 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 Principles

Team Structure

Delineates fundamentals such as team size, membership, leadership, composition, identification and distribution.


Ability 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 Monitoring

Process of actively scanning and assessing situational elements to gain information, understanding, or maintain awareness to support functioning of the team.

Mutual Support

Ability to anticipate and support other team members' needs through accurate knowledge about their responsibilities and workload.


Process by which information is clearly and accurately exchanged among team members.

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Team Structure

TeamSTEPPS logo. For details, go to [D] Text Description.

[D] Select for Text Description

The ratio of We's to I's is the best indicator of the development of a team...

Lewis B. Ergen

Multi-Team System For Patient Care

The team structure of the Multi-Team System For Patient Care. At the base of the system is administration. The next level is coordinating team and ancillary and support services. At the next level is the core team, which has an outside link to contingency teams. The patient is at the zenith of the system.

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TeamSTEPPS logo. For details, go to [D] Text Description.

[D] Select for Text Description

The art of getting someone else to do something you want done because he wants to do it...

Dwight D. Eisenhower

Effective Team Leaders

  • Organize 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 Events


  • Brief — Short session prior to start to discuss team formation; assign essential roles; establish expectations and climate; anticipate outcomes and likely contingencies.

Problem Solving

  • Huddle — Ad hoc planning to reestablish situation awareness; reinforcing plans already in place; and assessing the need to adjust the plan.

Process Improvement

  • Debrief — Informal information exchange session designed to improve team performance and effectiveness; after action review.

Brief Checklist

During 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 Checklist

The 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?

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Situation Monitoring

TeamSTEPPS logo. For details, go to [D] Text Description.

[D] Select for Text Description

Attention to detail is one of the most important details...

Author Unknown

Situation Monitoring Process

Circular situation monitoring process. Situation monitoring (individual skill) flows into situation awareness (individual outcome), which flows into shared mental model (team outcome), which flows back to situation monitoring (individual skill).

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 Monitoring

An 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."


A tool for monitoring situations in the delivery of health care

Components of Situation Monitoring:

Components of Situation Monitoring: Status of the patient, Team members, Environment, and Progress toward goal.


√ 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...

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Mutual Support

TeamSTEPPS logo. For details, go to [D] Text Description.

[D] Select for Text Description

A chain is only as strong as its weakest link...

Author Unknown

Task Assistance

A 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!


Information 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.

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Advocacy and Assertion

Advocate for the patient

  • Invoked when team members' viewpoints don't coincide with that of the decision maker.

Assert a corrective action in a firm and respectful manner

  • Make an opening.
  • State the concern.
  • Offer a solution.
  • Obtain an agreement.

Two-Challenge Rule

When 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.


I am Concerned! I am Uncomfortable! This is a Safety Issue! Stop the Line!

DESC Script

A constructive approach for managing and resolving conflict

D — 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.


Achieves a mutually satisfying solution resulting in the best outcome

  • Win-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"

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TeamSTEPPS logo. For details, go to [D] Text Description.

[D] Select for Text Description

Communication is the response you get from the message you sent regardless of its intent

Author Unknown


A 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?"


Strategy used to communicate important or critical information

  • Informs 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"


Process 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:

  1. Sender initiates the message
  2. Receiver accepts the message and provides feedback
  3. Sender double-checks to ensure that the message was received


Doctor:   "Give 25 mg Benadryl IV push"
Nurse:   "25 mg Benadryl IV push"
Doctor:   "That's correct"


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.

Examples of transitions in care include shift changes, physicians transferring complete responsibility, and patient transfers.


Strategy designed to enhance information exchange during transitions in care

IIntroductionIntroduce 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.).
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?


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Team Performance Observation Tool

Team Structure
Assembles team.
Establishes leader.
Identifies team goals and vision.
Assigns roles and responsibilities.
Holds team accountable.
Actively shares information.
Utilizes 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 Monitoring
Includes patient/family in communication.
Cross monitors team members.
Applies the STEP process.
Fosters communication to ensure a shared mental model.
Mutual Support
Provides 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.
Coaching 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.

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BarriersTools & StrategiesOutcomes
  • Inconsistency in Team Membership
  • Lack of time
  • Lack of Information Sharing
  • Hierarchy
  • Defensiveness
  • Conventional Thinking
  • Complacency
  • Varying Communication Styles
  • Conflict
  • Lack of Coordination and Follow-Up with
  • Distractions
  • Fatigue
  • Workload
  • Misinterpretation of Cues
  • Lack of Role Clarity
  • Brief
  • Huddle
  • Debrief
  • STEP
  • Cross Monitoring
  • Feedback
  • Advocacy and Assertion
  • Two-Challenge Rule
  • CUS
  • DESC Script
  • Collaboration
  • SBAR
  • Call-Out
  • Check-Back
  • Handoff
  • Shared Mental Model
  • Adaptability
  • Team Orientation
  • Mutual Trust
  • Team Performance
  • Patient Safety!!

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Contact Information

To learn more about TeamSTEPPS, refer to the Agency for Healthcare Research and Quality (AHRQ) website:
and the Department of Defense Patient Safety Program website:

Developed for the Department of Defense Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality

TeamSTEPPS™ Pocket Guide — 06.1

ISBN 1-58763-191-1
Revised March 2008

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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.