Implementation Guide, Appendix B: Sample Course Evaluation Form

TeamSTEPPS® Long-Term Care Version

This guide provides an overview of the TeamSTEPPS initiative. A description of the course material, how to use it, and links to reference material on how to conduct the course, including training techniques and sample course planning tools, are provided.

 

COURSE EVALUATION

Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS)

Location: _________________________
Date:       _________________________

Rating 
Scale
(circle)
1 = Poor, inadequate, did not meet, ineffective
2 = Good, adequate, met, satisfactory, effective
3 = Excellent, more than adequate, exceeded, very effective
Session 001 Module I: Introduction – 50 minutes
Instructor NamePoorGoodExcellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation?123
To what extent did you achieve the objective(s) of this session?
   Describe the TeamSTEPPS training initiative.123
   Explain your nursing home's resident safety program.123
   Describe the impact of errors and why they occur.123
   Describe the TeamSTEPPS framework.123
   State the outcomes of the TeamSTEPPS framework.123
To what extent were the teaching methods and aids used effectively?123
Comments:
Session 002 Module II: Team Structure – 50 minutes
Instructor NamePoorGoodExcellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation?123
To what extent did you achieve the objective(s) of this session?
   Identify the characteristics of high-performing teams.123
   Discuss benefits of teamwork and structure.123
   Describe components and composition of a multiteam system (e.g., Core Team, Coordinating Team, Contingency Team, Ancillary Services, and Administration).123
   Understand what defines a team.123
   Define the roles and effectiveness of team members.123
To what extent were the teaching methods and aids used effectively?123
Comments:
Session 003 Module III: Leadership – 40 minutes
Instructor NamePoorGoodExcellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation?123
To what extent did you achieve the objective(s) of this session?
   Describe different types of team leaders.123
   Describe roles and responsibilities of an effective team leader.123
   Describe the leader’s role in resource management.123
   Describe the delegation process.123
   Describe strategies for team leaders to include team huddles and debriefs.123
   Describe how effective team leaders facilitate conflict resolution.123
   Identify the barriers, tools, strategies, and outcomes of leadership.123
To what extent were the teaching methods and aids used effectively?123
Comments:
Session 004 Module IV: Situation Monitoring – 45 minutes
Instructor NamePoorGoodExcellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation?123
To what extent did you achieve the objective(s) of this session?
   Define situation monitoring.123
   Define cross-monitoring.123
   Discuss the components of the STEP process.123
   Define situation awareness (SA) and identify conditions that undermine SA.123
   Discuss the importance of a shared mental model.123
   Discuss when to share information.123
   Recognize the barriers, tools, strategies, and outcomes of situation monitoring.123
To what extent were the teaching methods and aids used effectively?123
Comments:
Session 005 Module V: Mutual Support – 50 minutes
Instructor NamePoorGoodExcellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation?123
To what extent did you achieve the objective(s) of this session?
   Define mutual support.123
   Describe task assistance and the types of feedback.123
   Describe advocacy, assertion, and the Two-Challenge rule.123
   Discuss the "CUS" and "DESC script" techniques.123
   Discuss common approaches to conflict resolution.123
   List barriers, tools, strategies, and outcomes of mutual support.123
To what extent were the teaching methods and aids used effectively?123
Comments:
Session 006 Module VI Communication – 45 minutes
Instructor NamePoorGoodExcellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation?123
To what extent did you achieve the objective(s) of this session?
   Describe the importance of communication.123
   Recognize the connection between communication and medical error.123
   Define communication and discuss the standards of effective communication.123
   Describe strategies for information exchange.123
   Identify barriers, tools, strategies, and outcomes to communication.123
To what extent were the teaching methods and aids used effectively?123
Comments:
Session 007 Module VII: Summary-Putting It All Together – 45 minutes
Instructor NamePoorGoodExcellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation?123
To what extent did you achieve the objective(s) of this session?
   Discuss how to use the tools and strategies presented in this training.123
   Demonstrate how to appropriately apply the tools and strategies to real-life situations.123
   Practice using tools and strategies for overcoming barriers to team effectiveness.123
To what extent were the teaching methods and aids used effectively?123
Comments:
Session 008 Change Management: How to Achieve a Culture of Safety – 135 minutes
Instructor NamePoorGoodExcellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation?123
To what extent did you achieve the objective(s) of this session?
   Identify and discuss the Eight Steps of Change.123
   Describe the actions required to set the stage for change in the nursing home.123
   Identify ways to empower team members to change.123
   Discuss what is involved in creating a new culture.123
   Begin planning for the change in the nursing home.123
To what extent were the teaching methods and aids used effectively?123
Comments:
Session 009 Coaching Workshop – 65 minutes
Instructor NamePoorGoodExcellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation?123
To what extent did you achieve the objective(s) of this session?
   State how team members' knowledge, skills, and attitudes are developed.123
   Describe the characteristics of an effective coach.123
   Assess coaching strengths and areas for improvement.123
   Identify the results of good coaching.123
   Demonstrate and evaluate coaching competencies.123
   Describe how to implement a coaching strategy.123
   Demonstrate effective coaching in a role-play scenario.123
   Define the basic coaching process.123
   Discuss the characteristics of an effective coach.123
To what extent were the teaching methods and aids used effectively?123
Comments:
Session 010 Implementation Workshop- 180 minutes
Instructor NamePoorGoodExcellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation?123
To what extent did you achieve the objective(s) of this session?
   Discuss our facility or department's implementation plan.123
   Identify at least two additional members for the change team.123
   Discuss additional resources needed for implementation.123
To what extent were the teaching methods and aids used effectively?123
Comments:
Session 011 Practice Teaching Session – 330 minutes
Instructor NamePoorGoodExcellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation?123
To what extent did you achieve the objective(s) of this session?
   Demonstrate teaching one module from the TeamSTEPPS Training Course.123
   Discuss areas to improve the delivery of the content.123
To what extent were the teaching methods and aids used effectively?123
Comments:

Rate the following:

The activity:

Was well organized, using the scheduled time efficiently. ____ Agree ____ Neutral ____ Disagree

Provided practical, useful information. ____ Agree ____ Neutral ____ Disagree

Kept my interest and made it easy to learn. ____ Agree ____ Neutral ____ Disagree

Was up to date in terms of current practice and issues. ____ Agree ____ Neutral ____ Disagree

Please respond to the following questions regarding disclosure of commercial support:

Were you provided disclosure of significant support or substantial financial relationships between faculty and commercial entities? ____ Yes ____ Neutral ____ No

Was bias in favor of a product present to the extent that the presentation was unbalanced or represented commercial promotion? ____ Yes ____ Neutral ____ No

If you feel any of the presentations were unbalanced, please elaborate.

What changes will you make in your practice as a result of this activity?

How can the educational aspects of this activity be improved?

What recommendations do you have for future speakers or topics?

Additional Comments:

COURSE EVALUATION for TeamSTEPPS Fundamentals and Essentials Courses

Location: ____________________________

Date: ____________________________

Please provide feedback on the TeamSTEPPS training course

Were the instructors knowledgeable, organized, & effective in their presentations?YesNoDon't Know

Comments on Instructors:

 

Now that you've completed this TeamSTEPPS course, please circle the number that best describes your ability to do the following tasks on a scale of 1 to 5 with 1 meaning "not able" and 5 meaning "very able and confident."
1. Describe the TeamSTEPPS program12345
2. Describe how medical errors affect residents and why they occur12345
3. Explain what makes a good team12345
4. Explain how teamwork benefits the residents12345
5. Describe different types of leaders and what makes a leader effective12345
6. Describe situation monitoring12345
7. Explain mutual support12345
8. Describe the Two-Challenge rule12345
9. Define CUS and when you would use it12345
10. Name two challenges to good communication12345
11. Name two TeamSTEPPS techniques that improve communication12345
12. Use TeamSTEPPS in your daily practice12345
Comments and Ideas for Future Courses

 

 

Return to Contents

Current as of November 2012
Internet Citation: Implementation Guide, Appendix B: Sample Course Evaluation Form: TeamSTEPPS® Long-Term Care Version. November 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/longtermcare/ltccrsmgmtappb.html