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 Name Poor Good Excellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation? 1 2 3
To what extent did you achieve the objective(s) of this session?
   Describe the TeamSTEPPS training initiative. 1 2 3
   Explain your nursing home's resident safety program. 1 2 3
   Describe the impact of errors and why they occur. 1 2 3
   Describe the TeamSTEPPS framework. 1 2 3
   State the outcomes of the TeamSTEPPS framework. 1 2 3
To what extent were the teaching methods and aids used effectively? 1 2 3
Comments:

Session 002 Module II: Team Structure – 50 minutes

Instructor Name Poor Good Excellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation? 1 2 3
To what extent did you achieve the objective(s) of this session?
   Identify the characteristics of high-performing teams. 1 2 3
   Discuss benefits of teamwork and structure. 1 2 3
   Describe components and composition of a multiteam system (e.g., Core Team, Coordinating Team, Contingency Team, Ancillary Services, and Administration). 1 2 3
   Understand what defines a team. 1 2 3
   Define the roles and effectiveness of team members. 1 2 3
To what extent were the teaching methods and aids used effectively? 1 2 3
Comments:

Session 003 Module III: Leadership – 40 minutes

Instructor Name Poor Good Excellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation? 1 2 3
To what extent did you achieve the objective(s) of this session?
   Describe different types of team leaders. 1 2 3
   Describe roles and responsibilities of an effective team leader. 1 2 3
   Describe the leader’s role in resource management. 1 2 3
   Describe the delegation process. 1 2 3
   Describe strategies for team leaders to include team huddles and debriefs. 1 2 3
   Describe how effective team leaders facilitate conflict resolution. 1 2 3
   Identify the barriers, tools, strategies, and outcomes of leadership. 1 2 3
To what extent were the teaching methods and aids used effectively? 1 2 3
Comments:

Session 004 Module IV: Situation Monitoring – 45 minutes

Instructor Name Poor Good Excellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation? 1 2 3
To what extent did you achieve the objective(s) of this session?
   Define situation monitoring. 1 2 3
   Define cross-monitoring. 1 2 3
   Discuss the components of the STEP process. 1 2 3
   Define situation awareness (SA) and identify conditions that undermine SA. 1 2 3
   Discuss the importance of a shared mental model. 1 2 3
   Discuss when to share information. 1 2 3
   Recognize the barriers, tools, strategies, and outcomes of situation monitoring. 1 2 3
To what extent were the teaching methods and aids used effectively? 1 2 3
Comments:

Session 005 Module V: Mutual Support – 50 minutes

Instructor Name Poor Good Excellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation? 1 2 3
To what extent did you achieve the objective(s) of this session?
   Define mutual support. 1 2 3
   Describe task assistance and the types of feedback. 1 2 3
   Describe advocacy, assertion, and the Two-Challenge rule. 1 2 3
   Discuss the "CUS" and "DESC script" techniques. 1 2 3
   Discuss common approaches to conflict resolution. 1 2 3
   List barriers, tools, strategies, and outcomes of mutual support. 1 2 3
To what extent were the teaching methods and aids used effectively? 1 2 3
Comments:

Session 006 Module VI Communication – 45 minutes

Instructor Name Poor Good Excellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation? 1 2 3
To what extent did you achieve the objective(s) of this session?
   Describe the importance of communication. 1 2 3
   Recognize the connection between communication and medical error. 1 2 3
   Define communication and discuss the standards of effective communication. 1 2 3
   Describe strategies for information exchange. 1 2 3
   Identify barriers, tools, strategies, and outcomes to communication. 1 2 3
To what extent were the teaching methods and aids used effectively? 1 2 3
Comments:

Session 007 Module VII: Summary-Putting It All Together – 45 minutes

Instructor Name Poor Good Excellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation? 1 2 3
To what extent did you achieve the objective(s) of this session?
   Discuss how to use the tools and strategies presented in this training. 1 2 3
   Demonstrate how to appropriately apply the tools and strategies to real-life situations. 1 2 3
   Practice using tools and strategies for overcoming barriers to team effectiveness. 1 2 3
To what extent were the teaching methods and aids used effectively? 1 2 3
Comments:

Session 008 Change Management: How to Achieve a Culture of Safety – 135 minutes

Instructor Name Poor Good Excellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation? 1 2 3
To what extent did you achieve the objective(s) of this session?
   Identify and discuss the Eight Steps of Change. 1 2 3
   Describe the actions required to set the stage for change in the nursing home. 1 2 3
   Identify ways to empower team members to change. 1 2 3
   Discuss what is involved in creating a new culture. 1 2 3
   Begin planning for the change in the nursing home. 1 2 3
To what extent were the teaching methods and aids used effectively? 1 2 3
Comments:

Session 009 Coaching Workshop – 65 minutes

Instructor Name Poor Good Excellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation? 1 2 3
To what extent did you achieve the objective(s) of this session?
   State how team members' knowledge, skills, and attitudes are developed. 1 2 3
   Describe the characteristics of an effective coach. 1 2 3
   Assess coaching strengths and areas for improvement. 1 2 3
   Identify the results of good coaching. 1 2 3
   Demonstrate and evaluate coaching competencies. 1 2 3
   Describe how to implement a coaching strategy. 1 2 3
   Demonstrate effective coaching in a role-play scenario. 1 2 3
   Define the basic coaching process. 1 2 3
   Discuss the characteristics of an effective coach. 1 2 3
To what extent were the teaching methods and aids used effectively? 1 2 3
Comments:

Session 010 Implementation Workshop- 180 minutes

Instructor Name Poor Good Excellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation? 1 2 3
To what extent did you achieve the objective(s) of this session?
   Discuss our facility or department's implementation plan. 1 2 3
   Identify at least two additional members for the change team. 1 2 3
   Discuss additional resources needed for implementation. 1 2 3
To what extent were the teaching methods and aids used effectively? 1 2 3
Comments:

Session 011 Practice Teaching Session – 330 minutes

Instructor Name Poor Good Excellent
To what extent was the speaker knowledgeable, organized, & effective in his/her presentation? 1 2 3
To what extent did you achieve the objective(s) of this session?
   Demonstrate teaching one module from the TeamSTEPPS Training Course. 1 2 3
   Discuss areas to improve the delivery of the content. 1 2 3
To what extent were the teaching methods and aids used effectively? 1 2 3
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? Yes No Don'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 program 1 2 3 4 5
2. Describe how medical errors affect residents and why they occur 1 2 3 4 5
3. Explain what makes a good team 1 2 3 4 5
4. Explain how teamwork benefits the residents 1 2 3 4 5
5. Describe different types of leaders and what makes a leader effective 1 2 3 4 5
6. Describe situation monitoring 1 2 3 4 5
7. Explain mutual support 1 2 3 4 5
8. Describe the Two-Challenge rule 1 2 3 4 5
9. Define CUS and when you would use it 1 2 3 4 5
10. Name two challenges to good communication 1 2 3 4 5
11. Name two TeamSTEPPS techniques that improve communication 1 2 3 4 5
12. Use TeamSTEPPS in your daily practice 1 2 3 4 5

Comments and Ideas for Future Courses

 

 

Return to Contents

Page last reviewed November 2012
Internet Citation: Implementation Guide, Appendix B: Sample Course Evaluation Form. November 2012. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/longtermcare/ltccrsmgmtappb.html