TeamSTEPPS® Long-Term Care Implementation Guide

TeamSTEPPS® Long-Term Care Version

Keys to success at each phase include involvement of the right people, use of information-driven decision making, and careful planning before acting. The following paragraphs provide an overview of each of the phases including goals and objectives, key actions, and recommended tools and resources.

Contents

Implementation Overview
    Shift Toward a Culture of Safety
    Phase I: Assessment
    Phase II: Planning (Action Plan), Training, and Implementation
    Phase III: Sustainment - Monitor, Coach, and Integrate
Guide to Developing a TeamSTEPPS Action Plan
    Purpose of the Guide
    Introduction
    How To Use the Guide
    Key Principles and Definitions
    The Ten Steps of Action Planning
    Step 1. Create a Change Team
    Step 2. Define the Problem, Challenge, or Opportunity for Improvement
    Step 3. Define the Aim(s) of Your TeamSTEPPS Intervention
    Step 4. Design a TeamSTEPPS Intervention
    Step 5. Develop Plan for Testing the Effectiveness of Your TeamSTEPPS Intervention
    Step 6. Develop an Implementation Plan
    Step 7. Develop a Plan for Sustained Continuous Improvement
    Step 8. Develop a Communication Plan
    Step 9. Putting It All Together: Write the TeamSTEPPS Action Plan
    Step 10. Review Your TeamSTEPPS Action Plan With Key Personnel
Action Planning Worksheets
    Step 1. Create a Change Team
    Step 2. Define the Problem, Challenge, or Opportunity for Improvement
    Step 3. Define the Aims of Your TeamSTEPPS Intervention
    Step 4. Design a TeamSTEPPS Intervention
    Step 5. Develop Plan for Testing the Effectiveness of Your TeamSTEPPS Intervention
    Step 6. Develop an Implementation Plan
    Step 7. Develop a Plan for Sustained Continuous Improvement
    Step 8. Develop a Communication Plan
The Quick Reference Guide to TeamSTEPPS Action Planning
TeamSTEPPS Action Planning At A Glance
Checklist for Root Cause Analysis
TeamSTEPPS Intervention Checklist

 

Implementation Overview

A TeamSTEPPS Initiative occurs in three continuous phases: Phase I — Assessment; Phase II — Planning, Training, & Implementation; and Phase III — Sustainment. A nursing home or work unit can shift toward a culture of safety using team tools and strategies by progressing through each of the three phases and completing the key actions within each phase. The TeamSTEPPS Initiative provides guidelines, tools, and resources for completing each phase and for gathering data necessary for progression to the next phase. Keys to success at each phase include involvement of the right people, use of information-driven decision making, and careful planning before acting. The following paragraphs provide an overview of each of the phases including goals and objectives, key actions, and recommended tools and resources.

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Shift Toward a Culture of Safety

The shift process has three phases. Phase I: Assessment. Pretraining assessment includes site assessment, culture survey and data/measures. Are these ready? If no, pass through climate improvement and return to pretraining assessment. If yes proceed to action plan and then move on to Phase II. Phase II: Planning, training and implementation. Training leads to intervention. Intervention includes testing and leads to Phase III. Phase III: Sustainment. This phase includes culture change: coach and integrate, monitor the plan, and continuous improvement. Continuous improvement includes going back to training to lead to more culture change. In short: Set the stage, decide what to do, make it happen and make it stick.

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Phase I: Assessment

Goals and Objectives: The goal of Phase I is for the nursing home (or work unit) to determine if it is ready to undertake a TeamSTEPPS Initiative. An organization is ready if it has (a) a climate conducive to change and (b) objective information to support the need for a TeamSTEPPS Intervention. A climate conducive to change is characterized by leadership and key staff members who are committed to making a change and who are willing and able to dedicate the necessary time, resources, and personnel.

Objective information supporting the need for a TeamSTEPPS Intervention could originate from a variety of sources including adverse event and near miss reports, reports of root cause analyses or failure modes and effects analyses, AHRQ Patient Safety Culture Survey, resident and staff satisfaction survey, Team Assessment Questionnaire, and site-specific process and outcome measures.

During Phase I, an initial Change Team (the group of individuals who will drive the TeamSTEPPS Initiative) is formed of leaders and key staff members. This Change Team then determines organizational readiness for a TeamSTEPPS Initiative by conducting a site assessment and reviewing available data.

Key Actions: Multiple actions occur during Phase I to assess the nursing home's readiness for a TeamSTEPPS Initiative. Teamwork experts from within or outside the nursing home may be consulted for assistance. The Guide to Developing a TeamSTEPPS Action Plan, particularly steps 1 through 3, provides additional guidance. Key actions for Phase I include:

  1. Leaders and staff members making up the initial Change Team collaborate to determine and communicate a vision for enhanced resident care team performance. Available data (e.g., adverse event and near miss reports, AHRQ Patient Safety Culture Survey, resident and staff satisfaction survey, Team Assessment Questionnaire, and site-specific process and outcome measures) are reviewed to identify opportunities for process improvement with team strategies and tools. Leaders and staff begin to cultivate ideas and collectively gain a shared focus of the opportunities for improvement within the nursing home.
    Questions to discuss include:
    • Why implement a TeamSTEPPS Initiative? Do we have any data to support the need?
    • Why now?
    • What process are we trying to fix? Who will be involved? Where will it occur?
    • What do we hope to achieve with a TeamSTEPPS Intervention?
    • How will we know that we were successful? What measures will we use?
    • How will we conduct resident care team training — initial, newcomer's, and refresher? Who will do it?
    • What resources and personnel can we allocate to this effort? Is it feasible?
    • Can we achieve our goals in a timely fashion?
    • How will we spread and maintain the change throughout key areas of the nursing home?
  2. The initial Change Team completes an internal site assessment to determine organizational readiness. They gather additional information to further answer the above questions by eliciting input from key personnel, and gathering relevant objective data.
  3. Leaders may consult with TeamSTEPPS Master Trainers to discuss a team-driven culture of safety. The site assessment provides an opportunity for leaders to gain a first-hand understanding of a teamwork change initiative and secondarily to view their role in sponsoring, evaluating, enabling, or modifying the behaviors necessary to shape and maintain the targeted behavior changes.

At the completion of Phase I, an organization decides that it IS or IS NOT ready for a TeamSTEPPS Initiative. If the Change Team determines that the nursing home IS NOT ready but believes that a TeamSTEPPS Initiative would likely benefit safety and quality of care, they should make efforts to move the organizational climate toward readiness and to collect objective data that would support the need for the initiative. If the Change Team determines that the nursing home IS ready for a TeamSTEPPS Initiative, they will document preliminary answers to the discussion questions listed above and then move on to Phase II.

Tools and Resources:

  • Guide to Developing a TeamSTEPPS Action Plan.
  • Sizing Up the Culture Exercise Sheet.
  • Measurement tools: AHRQ Patient Safety Culture Survey (Hospital Survey on Patient Safety Culture), resident, family, and staff satisfaction surveys, Team Assessment Questionnaire, Team Performance Observation Tool, and site-specific process and outcome measures.

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Phase II: Planning (Action Plan), Training, and Implementation

Goals and Objectives: The goal of Phase II is for the Change Team to develop a detailed action plan for their entire TeamSTEPPS Initiative and then to follow that plan to conduct resident care team training and to implement the TeamSTEPPS Intervention.

Key Actions: Three key actions occur during Phase II — writing a TeamSTEPPS Action Plan, conducting resident care team training, and implementing (and testing) the TeamSTEPPS Intervention.

1. Write an action plan using the Guide to Developing a TeamSTEPPS Action Plan.
The first step in Phase II is the development of a comprehensive TeamSTEPPS Action Plan. The action plan is a detailed report of exactly what the nursing home intends to do during their customized TeamSTEPPS Initiative. It documents the methodology for the entire initiative. It describes the Change Team; the challenge to be tackled; the TeamSTEPPS Intervention and what the Change Team hopes it will achieve; the plans for resident care team training; the plans for testing, implementing, and monitoring the intervention; and the plans for communicating and sustaining the change. A carefully developed action plan is critical to the success of a TeamSTEPPS Initiative. It establishes the strategy and focus for the entire effort and provides a "how-to guide" for each step of the Initiative. Time spent developing a detailed information-driven action plan will prevent countless wasted hours and setbacks throughout the entire improvement effort.

2. Conduct resident care team training.
The TeamSTEPPS system includes three different resident care team training curricula and a complete suite of multimedia course materials. The courses can be taught as is or modified and presented in parts based on the nursing home's specific teamwork training needs and staffing/resource infrastructure. Course instructors from within the nursing home or from outside sources may be used. The Change Team's training plan documented in their customized TeamSTEPPS Action Plan will determine which course(s) and teamwork skills will be taught, to which staff members, and by whom.

The Three TeamSTEPPS Curricula

Train-the-Trainer: 2.5 days of didactics and interactive workshops designed to create a cadre of teamwork instructors among the nursing home's staff with the skills to train and coach other staff members. Also familiarizes participants with all TeamSTEPPS materials and methodologies and prepares them to facilitate a TeamSTEPPS Initiative.
TeamSTEPPS Fundamentals: 4 to 6 hours of interactive workshops intended for direct resident care providers. Introduces attendees to the tools and strategies for improving teamwork competencies, including leadership, communication, mutual support, and situation monitoring.
TeamSTEPPS Essentials: A 1- to 2-hour condensed version of the Fundamentals Course, specifically designed for nonclinical support staff. Provides attendees with the basic tools to effectively communicate essential information.

3. Implement and test the TeamSTEPPS Intervention.
Using their TeamSTEPPS Action Plan as a guide, the Change Team implements and tests their TeamSTEPPS Intervention. TeamSTEPPS Intervention refers to the specific team strategies and tools and how they will be used to address the targeted problem, challenge, or identified opportunity. The "intervention" is therefore analogous to a "risk reduction strategy" or a "corrective action." Implementation of the intervention marks the formal launch of the TeamSTEPPS Initiative. It should be formally recognized by executive leadership and communicated as part of a continuous improvement and quality-based program. Success of the intervention, measured by improvements in resident care team performance and clinical processes and outcomes, should be rewarded by leadership and showcased throughout the nursing home.

Tools and Resources:

  • Guide to Developing a TeamSTEPPS Action Plan.
  • Measurement tools: Team Assessment Questionnaire, Team Performance Observation Tool.
  • Learning Benchmarks and site-specific process and outcome measures.
  • TeamSTEPPS Training Techniques, Sample Course Evaluation.

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Phase III: Sustainment - Monitor, Coach, and Integrate

Goals and Objectives: The goal of Phase III is to sustain and spread improvements in teamwork behavior and in associated clinical processes and outcomes resulting from the TeamSTEPPS Initiative. Specific objectives are to integrate teamwork behaviors and tools into your daily practice, monitor the ongoing effectiveness of your TeamSTEPPS Intervention, identify opportunities for continued improvement, and spread positive changes throughout the nursing home.

Key Actions: The TeamSTEPPS Action Plan written during Phase II provides the "how-to" guidelines for the key actions that occur during Phase III. Key actions include:

  1. Teamwork Coaching. Leaders, champions, and coaches continue to monitor and coach teamwork behavior among staff members.
  2. Integration. The nursing home or work unit integrates into existing normal routines and processes key features of the TeamSTEPPS Initiative such as team training, teamwork behaviors and tools, and effectiveness measures.
  3. Reinforcement and Rewards. Positive teamwork behaviors and improvements in processes and outcomes are reinforced and rewarded. Leaders, champions, and coaches provide ongoing feedback. Successes are formally recognized and showcased throughout the nursing home.
  4. Continuous Improvement. A method is established to continually measure the ongoing effectiveness of the TeamSTEPPS Intervention and to identify opportunities for further resident safety and quality improvement.
  5. Spread. A plan is developed to spread the positive changes to other workspaces demonstrating readiness for the TeamSTEPPS Initiative.

Tools and Resources:

  • Measurement Tools: AHRQ Patient Safety Culture Survey, resident and staff satisfaction surveys, Team Assessment Questionnaire, Team Performance Observation Tool, and site-specific process and outcome measures.
  • Guide to Developing a TeamSTEPPS Action Plan.
  • Massoud MR, et al. A Framework for Spread: From Local Improvements to System-wide Change. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement; 2006. (Available at www.IHI.org)
  • 100,000 Lives Campaign. Running a Successful Campaign in Your Hospital, How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2006. (Available at www.IHI.org)
  • 100,000 Lives Campaign. Getting Started Kit: Sustainability and Spread, How-to Guide. Cambridge, MA: Institute for Healthcare Improvement; 2006. (Available at www.IHI.org)

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Guide to Developing a TeamSTEPPS Action Plan

Purpose of the Guide

The purpose of the guide is to provide nursing homes with an easy-to-use but comprehensive tool for developing an evidence-based TeamSTEPPS Action Plan. The intent is for the Change Team (the group of individuals who will drive the TeamSTEPPS Initiative) to write their action plan by working through each of the 10 steps and then to use it as a "how-to guide" for putting their TeamSTEPPS Initiative into place. The guide is a recommended strategy, not a requirement. However, for those nursing homes that are Joint Commission accredited, the 10 steps do address Joint Commission requirements so that facilities may also use the guide to develop TeamSTEPPS Action Plans in response to sentinel events.

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Introduction

The TeamSTEPPS Action Plan is a detailed written report of exactly what the nursing home intends to do during their TeamSTEPPS Initiative. It documents the methodology for the entire initiative. Box 1 lists the elements of a comprehensive TeamSTEPPS Action Plan.

 

Box 1. Elements of a Comprehensive TeamSTEPPS Action Plan

  • Identification of the Change Team, the group of key leaders and staff members who will make the TeamSTEPPS Initiative happen.
  • Identification of the specific problem, challenge, or opportunity for improvement that will be the target of the TeamSTEPPS Initiative.
  • Stated aims of the TeamSTEPPS Intervention.*
  • Detailed description of the TeamSTEPPS Intervention, the team strategies and tools and how they will be used to correct the problem (or make improvements). Interventions are also known as risk reduction strategies, corrective actions, and improvement actions.*
  • A plan for testing the effectiveness of the TeamSTEPPS Intervention, including measures, methodologies, target outcome ranges, and pilot testing as appropriate.*
  • An implementation plan for the TeamSTEPPS Intervention including implementation date and identification of person(s) responsible for implementation and oversight.*
  • A monitoring plan for ongoing assessment of the effectiveness of the TeamSTEPPS Intervention.*
  • A communication plan to generate support for the TeamSTEPPS Initiative, to keep major stakeholders informed of progress, and to maintain and spread positive changes.
  • Timelines.*

 

Note: The (*) denotes components of an action plan required by The Joint Commission when the action plan is generated in response to a sentinel event. (Reference: The Joint Commission. Root Cause Analysis in Health Care: Tools and Techniques, 2nd ed. Oakbrook Terrace, IL: Joint Commission Resources; 2003.)

A carefully developed action plan is critical to the success of a TeamSTEPPS Initiative. It establishes the strategy and focus for the entire effort and provides a "how-to guide" for each step of the Initiative. Time spent developing a detailed information-driven action plan will prevent countless wasted hours and setbacks throughout the improvement effort.

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How To Use the Guide

The guide is a tool for developing a comprehensive, evidence-based TeamSTEPPS Action Plan. It consists of a series of 10 steps (go to Box 2), each presented with an objective, key actions for step completion, recommended tools and resources, tips for success, and a worksheet. Users should work their way through each of the 10 steps in sequence, addressing the key actions and completing the worksheets. The worksheets are designed to assist users through each of the 10 steps, and once completed, to function as the Change Team's written TeamSTEPPS Action Plan.

The primary focus of the guide is on TeamSTEPPS Initiatives that will be implemented within the Change Team's own clinical workspace. However, the guide may be modified for different applications, based on user needs.

 

Box 2. Ten Steps to Developing a TeamSTEPPS Action Plan

  1. Create a Change Team.
  2. Define the problem, challenge, or opportunity for improvement.
  3. Define the aims of your TeamSTEPPS Intervention.
  4. Design a TeamSTEPPS Intervention.
  5. Develop a plan for testing the effectiveness of your TeamSTEPPS Intervention.
  6. Develop an implementation plan for resident care team training and for the Intervention.
  7. Develop a plan for sustained continuous improvement.
  8. Develop a communication plan.
  9. Putting it all together - Write the TeamSTEPPS Action Plan.
  10. Review your TeamSTEPPS Action Plan with key personnel, and modify according to input.

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Key Principles and Definitions

Process Improvement. The guide is based on the principle of improving resident safety and quality of care by improving health care processes. A process is a series of actions toward a desired endpoint. Examples of processes include (a) admitting a resident, (b) administering a medication, and (c) transferring a resident from one unit to another. The process improvement method includes the following steps:

  • Identify a recurring problem or opportunity for improvement, that if addressed, could lead to better resident safety or quality of care. What is it specifically that you want to "fix" or improve?
  • Flowchart or map the process during which the targeted problem or opportunity for improvement occurs — write down the process steps as they currently occur and identify who is doing what, when, and with what tools.
  • Study the process to identify weak points where things could go wrong and lead to a recurrence of the target problem or opportunity. These weak points are called risk points.
  • Design and implement interventions aimed at eliminating or reducing the impact of the risk points. This in turn will prevent the targeted problem from recurring (or lead to your targeted improvements).
  • Test the intervention to ensure that it did in fact eliminate or reduce the target problem (or result in your targeted improvement).
  • If the test shows that the intervention was successful, monitor intervention effectiveness, sustain positive process changes, and identify opportunities for further improvement.

Resident Care Teamwork. The TeamSTEPPS Initiative focuses specifically on improving processes by designing and implementing interventions that enhance resident care team performance. The primary goal of resident care teamwork is to optimize the timely and effective use of information, skills, and resources by teams of health care providers for the purpose of enhancing the quality and safety of resident care. Specifically, resident care teamwork aims to ensure that the RIGHT INFORMATION is provided to the RIGHT PERSON(S) at the RIGHT TIME resulting in the RIGHT ACTION(S). To meet that aim, resident care teams require optimal:

  • Team Structure: composition, size, distribution - the right people with the right skills in the right place.
  • Leadership: ability to coordinate, resource, and facilitate optimal team performance.
  • Awareness: clear understanding at all times of team goals, of task responsibilities, and of situational information critical to goal achievement, such as status of resident, of self, of team members, of operating environment, and of progress toward the goal—having the right information at the right time.
  • Team Skills: (a) Situation Monitoring: ability to continually gather and assess situational information to maintain awareness; (b) Mutual Support: ability to provide timely mutual support/back-up, both verbal and task-related, to team members; (c) Communication: ability to exchange information among team members—gathering and communicating the right information at the right time to the right person(s) resulting in the right actions.

Team STEPPS Initiative vs. TeamSTEPPS Intervention. When used in this guide, TeamSTEPPS Initiative refers to the resident care teamwork improvement effort in its entirety, from identifying the Change Team through the sustainment phase. TeamSTEPPS Intervention refers to the specific team strategies and tools and how they will be used to address the targeted problem, challenge, or opportunity for improvement.

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Page last reviewed October 2008
Internet Citation: TeamSTEPPS® Long-Term Care Implementation Guide: TeamSTEPPS® Long-Term Care Version. October 2008. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/longtermcare/implement/implguide.html