Pocket Guide: TeamSTEPPS

Team 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
    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


Framework and Competencies

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 has five key principles. It is based on team structure and four teachable-learnable skills: Communication, Leadership, Situation Monitoring, and Mutual Support. The 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 and support quality improvement. Encircling the four skills is the team structure of the patient care team, which represents not only the patient and direct caregivers, but also those who play a supportive role within the health care delivery system.

...TeamSTEPPS is an evidence-based framework to optimize team performance across the health care delivery system.

Key Principles

Team Structure

Identification of the components of a multi-team system that must work together effectively to ensure patient safety.


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


Ability to maximize the activities of team members by ensuring that team actions are understood, changes in information are shared, and team members have the necessary resources.

Situation Monitoring

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

Mutual Support

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

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Team Structure

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

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Multi-Team System For Patient Care

Safe and efficient care involves the coordinated activities of a multi-team system.

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


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. Can you come to room 251 now?"


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"


Using 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. It includes an opportunity to ask questions, clarify, and confirm.

Examples of transitions in care include shift changes; transfer of responsibility between and among nursing assistants, nurses, nurse practitioners, physician assistants, and physicians; and patient transfers.


Strategy designed to enhance information exchange during transitions in care

I Introduction Introduce yourself and your role/job (include patient).
P Patient Name, identifiers, age, sex, location.
A Assessment Present chief complaint, vital signs, symptoms, and diagnosis.
S Situation Current status/circumstances, including code status, level of (un)certainty, recent changes, and response to treatment.
S Safety Critical lab values/reports, socioeconomic factors, allergies, and alerts (falls, isolation, etc.).
B Background Comorbidities, previous episodes, current medications, and family history.
A Actions Explain what actions were taken or are required. Provide rationale.
T Timing Level of urgency and explicit timing and prioritization of actions.
O Ownership Identify who is responsible (person/team), including patient/family members.
N Next What will happen next?
Anticipated changes?
What is the plan?
Are there contingency plans?


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

[D] Select for Text Description


Effective Team Leaders

The following are responsibilities of effective team leaders:

  • Organize the team.
  • Identify and articulate clear goals (i.e., the plan).
  • Assign tasks and responsibilities.
  • Monitor and modify the plan; communicate changes.
  • Review the team's performance; provide feedback when needed.
  • Manage and allocate resources.
  • Facilitate information sharing.
  • Encourage team members to assist one another.
  • Facilitate conflict resolution in a learning environment.
  • Model effective teamwork.

Team Events

Sharing the Plan

  • Brief—Short session prior to start to share the plan, discuss team formation, assign roles and responsibilities, establish expectations and climate, anticipate outcomes and likely contingencies.

Monitoring and Modifying the Plan

  • Huddle—Ad hoc meeting to re-establish situational awareness, reinforce plans already in place, and assess the need to adjust the plan.

Reviewing the Team's Performance

  • Debrief—Informal information exchange session designed to improve team performance and effectiveness through lessons learned and reinforcement of positive behaviors.

Brief Checklist

During the brief, the team should address the following questions:

  ___ Who is on the team?

  ___ Do all members understand and agree upon goals?

  ___ Are roles and responsibilities understood?

  ___ What is our plan of care?

  ___ What is staff and provider's availability throughout the shift?

  ___ How is workload shared among team members?

 ___  What resources are available?

Debrief Checklist

The team should address the following questions during a debrief:

  ___ Was communication clear?

  ___ Were roles and responsibilities understood?

 ___  Was situation awareness maintained?

 ___  Was workload distribution equitable?

  ___ Was task assistance requested or offered?

 ___  Were errors made or avoided?

  ___ Were resources available?

  ___ What went well?

  ___ What should improve?

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Situation Monitoring

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

[D] Select for Text Description


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 a situation to gain and maintain an understanding of what's going on around you.

Situation awareness is the state of "knowing what's going on around you."

A shared mental model results from each team member maintaining situation awareness and ensures that all team members are "on the same page."


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.

Status of the Patient

Team Members


Progress Toward Goal

Tool to help assess health care situations


Status of Patient
__ Patient History
__ Vital Signs
__ Medications
__ Physical Exam
__ Plan of Care
__ Psychosocial Issues

Team Members
__ Fatigue
__ Workload
__ Task Performance
__ Skill
__ Stress

__ Facility Information
__ Administrative Information
__ Human Resources
__ Triage Acuity
__ Equipment

Progress Towards Goal
__ Status of Team's Patient(s)?
__ Established Goals of Team?
__ Tasks/Actions of Team?
__ Plan Still Appropriate?



A harm error reduction strategy that involves:

  • Monitoring actions of other team members.
  • Providing a safety net within the team.
  • Ensuring that mistakes or oversights are caught quickly and easily.
  • "Watching each other's back."

Situation Monitoring

Each team member is responsible for assessing his or her own safety status.


I'M SAFE Checklist

__ I = Illness
__M = Medication
__S = Stress
__ A = Alcohol and Drugs
__ F = Fatigue
__ E = Eating and Elimination

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Mutual Support

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

[D] Select for Text Description

Task Assistance

Helping others with tasks builds a strong team. Key strategies include:

  • 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.


Information provided to team members 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—relates to a specific task or behavior that requires correction or improvement.
  • Directed towards improvement—provides 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 decisionmaker.

Assert a corrective action in a firm and respectful manner

  • Make an opening.
  • State the concern.
  • State the problem (real or perceived).
  • Offer a solution.
  • Reach agreement on next steps.

Two-Challenge Rule

Empowers all team members to "stop the line" if they sense or discover an essential safety breach.

When an initial assertive statement is ignored:

  • It is your responsibility to assertively voice concern at least two times to ensure that it has been heard.
  • The team member being challenged must acknowledge that concern has been heard.
  • If the safety issue still hasn't been addressed:
    • Take a stronger course of action.
    • Utilize supervisor or chain of command.


Assertive statements:

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.

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Team Performance Observation Tool

Team Structure
Assembles team.
Assigns or identifies team members' roles and responsibilities.
Holds team members accountable.
Includes patients and families as part of the team.
Provides brief, clear, specific, and timely information.
Seeks information from all available sources.
Uses check-backs to verify information that is communicated.
Uses SBAR, call-outs, check-backs, and handoff techniques to communicate effectively with team members.
Identifies team goals and vision.
Utilizes resources efficiently to maximize team performance.
Balances workload within the team.
Delegates tasks or assignments, as appropriate.
Conducts briefs, huddles, and debriefs.
Role models teamwork behaviors.
Situation Monitoring
Monitors the state of the patient.
Monitors fellow team members to ensure safety and prevent errors.
Monitors the environment for safety and availability of resources (e.g., equipment).
Monitors progress toward the goal and identifies changes that could alter the care plan.
Fosters communication to ensure a shared mental model.
Mutual Support
Provides task-related support and assistance.
Provides timely and constructive feedback to team members.
Effectively advocates for the patient using the Assertive Statement, Two-Challenge Rule, or CUS.
Uses the Two-Challenge Rule or DESC script to resolve conflict.

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Barriers Tools & Strategies Outcomes
  • 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 Co-Workers
  • Distractions
  • Fatigue
  • Workload
  • Misinterpretation of Cues
  • Lack of Role Clarity


  • SBAR
  • Call-Out
  • Check-Back
  • Handoff

Leading Teams

  • Brief
  • Huddle
  • Debrief

Situation Monitoring

  • STEP
  • I'M SAFE

Mutual Support

  • Task Assistance
  • Feedback
  • Assertive Statement
  • Two-Challenge Rule
  • CUS
  • DESC Script
  • 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) Web site:
and the Department of Defense Patient Safety Program Web site:

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

TeamSTEPPS™ Pocket Guide—2.0

ISBN 1-58763-191-1
Revised December 2013

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Page last reviewed January 2014
Page originally created January 2014
Internet Citation: Pocket Guide: TeamSTEPPS. Content last reviewed January 2014. Agency for Healthcare Research and Quality, Rockville, MD. https://www.ahrq.gov/teamstepps/instructor/essentials/pocketguide.html
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