Implementation Guide, Appendix B: Sample Course Evaluation Form
TeamSTEPPS® Long-Term Care Version
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
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