TeamSTEPPS Fundamentals Course: Module 1. Introduction
TeamSTEPPS® 2.0: Team Strategies and Tools to Enhance Performance and Patient Safety
Instructor Note: In this module, you will present information that sets the stage for the course. Most of the information can be used both in the Master Trainer course and a staff course; however, where modifications in the content may be needed, additional Instructor Notes are provided.
The Introduction module sets the stage for the entire course. It is strongly recommended that all content and activities included in this module be conducted. In subsequent modules, some activities are designated as "optional," so they may be bypassed or replaced if time is limited. For this module, the instructional time (beginning with the Objectives) requires 50 minutes. Additional time may be needed to conduct introductions and the teamwork exercise if the participant group is large.
The Introduction module includes the content provided in the outline below.
|#||Content||Page #||Approx. Time|
|1.||Faculty and Participant Introductions||5||10 mins|
|2.||Teamwork Exercise||6 - 7||12 mins|
|4.||Overview of the Master Trainer Course and Materials||9 -13||10 mins|
|5.||Sue Sheridan Video and Discussion||14 - 15||15 mins|
|6.||Barriers to Team Performance||16||2 mins|
|7.||Patient Safety Movement & Team Training||17 - 19||5 mins|
|8.||The TeamSTEPPS Framework||20 - 22||6 mins|
|9.||Characteristics of High- Performing Teams||23 - 24||3 mins|
|10.||Evidence That TeamSTEPPS Works||25||3 mins|
|11.||Applying TeamSTEPPS Exercise||26||5 mins|
Additional Resources: Below are sources of additional information you may wish to use to customize this module to your participants.
- TeamSTEPPS®: Team Strategies and Tools to Enhance Performance and Patient Safety: Published paper that provides detailed information about the development of and framework for TeamSTEPPS.
- King, H.B., Battles, J., Baker, D.P., Alonso, A., Salas, E., Webster, J., Toomey, L., & Salisbury, M. (2008). TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety. In K. Henriksen, J.B. Battles, M.A. Keyes, et al. (Eds.) Advances in patient safety: New directions and alternative approaches (Vol. 3: Performance and tools). Rockville (MD): Agency for Healthcare Research and Quality. Select for more information. (467 KB).
- DoD Patient Safety Program TeamSTEPPS Information: Provides a brief overview of TeamSTEPPS, including a brief video and an interactive TeamSTEPPS Model of Change diagram. Select for more information.
Instructor Note: At the end of each module of the Fundamentals course, participants will be asked to think about the teamwork issue they intend to address with TeamSTEPPS. It may be beneficial to encourage teams to sit together.
|Module Time: 50 minutes|
- Who is in the Room?
- Teamwork Exercise # 1
- What is Master Training?
- What Does Master Training Include?
- What Does Master Training Include? (continued)
- Master Training Materials
- Sue Sheridan Video
- Video Discussion
- Barriers to Team Performance
- Patient Safety Movement & Team Training
- What Makes Up Team Performance?
- Outcome of Team Competencies
- Characteristics of High-Performing Teams
- Evidence that TeamSTEPPS Works
- Excercise: Applying TeamSTEPPS
Welcome! Before we begin our formal agenda, we would like for everyone to know who is in the room.
We'll begin with introductions of our faculty and then facilitate participant introductions.
Instructor Note: You may wish to have faculty biographies prepared as a handout for distribution to participants.
First, facilitate introductions of the faculty who are present.
Each faculty member should share his/her name, title/role in the organization, the clinical area in which he/she works (if applicable), and experience with TeamSTEPPS.
Next, facilitate introductions of the participants.
Each participant should share his/her name, organization, title/role in his/her organization, and, if applicable, the clinical area in which he/she works. For each team of participants, at least one member should also be asked to indicate the clinical area in which they plan to implement TeamSTEPPS. If time is limited, introductions can be limited to teams, who can simply indicate their organization and area in which they plan to implement TeamSTEPPS.
Instructor Note: Knowing the types of organizations, clinical areas/units, and positions/roles represented among participants will help you customize the course in a way that is most relevant to the participants. For example, you may wish to select video clips, scenarios, or your own organizational stories to align with the participants' backgrounds and/or TeamSTEPPS implementation plans. Similarly, participants will benefit from knowing about others in the room so that they can identify teams with similar issues to address or similar plans for TeamSTEPPS implementation.
|Module Time: 10 minutes|
Now that we know who is the in the room, we are going to do our first teamwork exercise.
Place the participants into groups of 4-6 members for the exercise.
Instructor Note: The activity outlined below is a teamwork exercise that involves making paper chains. Alternatives to this exercise that can easily be adapted and used are building a house of cards or working with plastic building blocks to build a tower. A second iteration of the exercise, in which the instructions change for the participants, is recommended at the beginning of the Situation Monitoring module.
Provide each team with paper, tape, and scissors. Demonstrate how to make the chains as you explain the exercise.
For this first exercise, each team will make a paper chain. To make the chains, cut the construction paper into strips; make links by taping together the ends of a strip; and then loop the next strip through it. Continue this process to make a chain. You have 2 minutes to create the longest chain. Begin!
After 2 minutes, have each group display the length of its chain. Have the groups set the first chains aside.
Starting with the groups that had the longest chains, ask each group the following questions:
- What techniques or methods did you use for working well as a team when making the chains?
- What hindered your group in working as a team?
Consider recording discussion responses on a whiteboard or flipchart. This will allow you to compare these responses to those obtained later in Teamwork Exercise #2.
Instructor Note: Where appropriate, rephrase participants' responses back to them in terms of TeamSTEPPS skills that are covered in the training. If a particular TeamSTEPPS skill is not referenced in any group's response, add it to the discussion. Suggestions for emphasizing or adding specific TeamSTEPPS skills to the discussion are listed below:
- Ask if any of the teams had designated members who agreed to take on certain roles (e.g., cutting the paper strips or taping). Ask if anyone was standing around wondering what to do because a clearly defined role was lacking.
- Ask participants what information was communicated during the task and how it affected (i.e., helped or hindered) the team's ability to perform the task.
- Point out a group in which someone assumed a leadership role and helped the team plan. If none of the groups had a member who did this, ask how this would have helped.
- Ask if anyone observed when other team members were finished cutting strips of paper or needed a piece of tape. Ask how this action affected performance.
- Point out situations in which participants helped each other, rather than simply waiting for another team member to complete a task.
The purpose of the teamwork exercise you just completed was to get your team to work together and begin to identify some of the teamwork skills that we'll discuss in this course.
The teamwork skills will be taught through a series of instructional modules. At the beginning of each module, learning objectives will be presented. After completing this first module of the course, you will be able to:
- Describe the TeamSTEPPS Master Trainer course.
- Describe the impact of errors and why they occur.
- Describe the TeamSTEPPS framework.
- State the outcomes of the TeamSTEPPS framework.
We are going to begin by discussing the Master Trainer course. After these first few slides, I will orient you to the binder you have for this course. Until then, you don't need to take notes, but I will show you in just a few minutes where you can do so for the remainder of the course.
Instructor Note: If this module is being taught to staff, you may choose to delete the first listed objective. Similarly, subsequent pages are specific to the Master Trainer course. With the exception of the list of Fundamentals modules, information about the Master Trainer course can be removed for staff training purposes.
After completing the Master Trainer course, you will be TeamSTEPPS Master Trainers who will serve as change agents in your organization.
The Master Trainer course is part of the TeamSTEPPS train-the-trainer model. It is a 2-day course that teaches the TeamSTEPPS skills, tools, and strategies; provides guidance on how to train others at your own organization; and provides information related to the implementation and sustainment of TeamSTEPPS. Today, as we are teaching you about the TeamSTEPPS skills, tools, and strategies, we hope our instruction will serve as a model for the instruction you will provide at your own organization.
It is important to remember that your role as a Master Trainer extends beyond the completion of this course. The goal is for you to take what you learn during this course and go back and do something with what you have learned. The Master Trainer, as a change agent, must serve as a leader in your organization to implement TeamSTEPPS and facilitate change.
The TeamSTEPPS Master Trainer course takes 2 days. First, on Day 1, we will focus on the TeamSTEPPS Fundamentals course, which teaches the core teamwork skills. This course includes:
- Module 1: Introduction—Provides an overview of Master Training, TeamSTEPPS, and the science of team performance.
- Module 2: Team Structure—Defines a team and its members, including patients and their families, and describes a multi-team system, which is important in planning a TeamSTEPPS implementation.
- Module 3: Communication—Provides tools and strategies for communicating effectively through standardized information exchange strategies such as SBAR, check-back, call-out, and handoff.
- Module 4: Leading Teams—Identifies the activities conducted to effectively lead teams and the tools that support these activities, such as briefs, huddles, and debriefs.
- Module 5: Situation Monitoring—Describes the importance of team members gaining or maintaining an accurate awareness or understanding of the situation in which the team is functioning, and outcomes of situation monitoring, including a shared mental model among team members.
- Module 6: Mutual Support— Describes approaches for providing mutual support, or "backup behavior," that allows teams to become self-correcting, distribute workload effectively, provide effective feedback, and manage conflict.
- Module 7: Summary: Pulling It All Together— Provides an opportunity for participants to review and apply the TeamSTEPPS tools and strategies learned through the course.
Following the Fundamentals course, Day 2 of the Master Trainer course focuses on topics related to the implementation and sustainment of TeamSTEPPS. This includes:
- Change Management—Provides information about organizational change through Kotter's Eight Steps of Change.
- Coaching—Describes coaching, how to coach, and the role of coaching in implementing TeamSTEPPS.
- Measurement—Provides information about evaluating the success of your TeamSTEPPS implementation, including available assessment tools and resources.
- Implementation Workshop—Serves as a capstone to the course by allowing you and your team members to think through your implementation plans and strategies.
Show participants the materials as you describe them.
As part of the Master Trainer course, materials have been developed for your use and reference.
You have received a copy of the Instructor Manual. In this binder, you will find several sections of information. These sections provide the materials that we will cover during the 2-day course, as well as materials you will need to teach the TeamSTEPPS skills to others. A Table of Contents is included at the front.
- Tab A includes a Course Management Guide. In this section, you will find information about preparing for and teaching the TeamSTEPPS curriculum to others. This section includes information about the various forms of TeamSTEPPS training; checklists for training preparation and follow-through; and resources, such as a sample course agenda, a course evaluation form, and other TeamSTEPPS tools and resources.
For each part of the course, the materials include Instructor Manuals that provide instructor notes and other information, such as instructions for facilitating exercises. In addition, the course slides are provided. These can be customized—where appropriate—for use in your own organization.
- Tabs B and C include the Instructor Manuals and course slides, respectively, for the Fundamentals Course (i.e., Day 1).
- Tabs D and E include the Instructor Manuals and course slides, respectively, for the Trainer/Coach (i.e., Day 2) modules.
- Tab F includes the resources that will be discussed in the Measurement module, such as a sample course evaluation form.
- Tab G provides the curriculum acknowledgments page.
Most pages within the binder are numbered with the tab letter, followed by a module number (where relevant), and then a page number. For example, the Introduction module's Instructor Manual, which is found in Tab B and is the first module of the course, includes page numbers that begin with B-1. Some documents, such as exercise worksheets and measures, do not have page numbers, so you can easily copy and use these with your own training participants.
In addition, all of the materials used in the training are available online, including all the videos from the curriculum. Some additional videos you may wish to integrate into your training are also provided.
Several of the videos are vignettes for which an "opportunity" for improvement version and a "success" version are provided. Shorter video clips are also available to highlight the use of specific TeamSTEPPS tools and strategies. A matrix of available videos is included in the Course Management Guide (Tab A).
Other materials that we will not cover in the Master Training Course will be useful to you after the training. For example, the Essentials Course can be used for training TeamSTEPPS to staff in your organization. In addition, a set of scenarios, organized by clinical area or specialty, is available for use. These can be used to supplement your training or to develop exercises or simulations that will be most relevant to your training participants.
Instructor Note: It is helpful to demonstrate for participants how to navigate the materials online so they know where to find them.
Finally, a reminder that all TeamSTEPPS materials, including additional topics, such as Rapid Response, are on the Agency for Healthcare Research and Quality (AHRQ) Web site (http://teamstepps.ahrq.gov).
Now that you are oriented to the Master Trainer course and materials, it is important to understand why patient safety is so important and how teamwork can make a difference.
Play the video by selecting the director icon on the slide.
TeamSTEPPS is about improving teamwork to help prevent stories like this from happening.
|Video Time: 9:55 minutes|
Instructor Note: Ask the participants the questions below. The goal is to get the participants thinking about medical errors and teamwork and then to reframe their thoughts to align with the TeamSTEPPS skills, tools, and strategies they will learn in this course. You may wish to record responses on a flipchart or whiteboard.
- What breakdowns in teamwork did you observe in the two stories?
How can we prevent medical errors?
- If participant responses indicate a skill, tool, or strategy taught in the course, but participants use different terminology, rephrase the response back to them using the TeamSTEPPS terminology.
- If any of the participants answer negatively, focus the discussion on improvement opportunities.
Errors can occur for many reasons, and a single error can often be linked to a number of causal factors. Many obstacles also can impair an individual or team's ability to work effectively and prevent errors.
Barriers to effective team performance include:
- Inconsistency in team membership.
- Lack of time.
- Lack of information sharing.
- Conventional thinking.
- Varying communication styles.
- Lack of coordination and followup.
- Misinterpretation of cues.
- Lack of role clarity.
- Can you provide examples of how some of these barriers might play out in your clinical environment?
The patient safety movement seeks to reduce medical errors. As you can see, medical team research and training began 4 years before the onset of the patient safety movement. The integration of teamwork into health care by the Department of Defense (DoD) and forward-thinking researchers preceded the landmark Institute of Medicine (IOM) report To Err Is Human (Kohn, Corrigan, and Donaldson, 1999) and regulatory requirements.
- Emergency Department (ED) Study—A multi-year DoD research project that introduced formal teamwork training based on aviation Crew Resource Management (CRM) training concepts was applied to health care.
- MedTeams® began with a retrospective closed claim review of ED risk management cases. It was determined that 43 percent of errors resulted from problems with team coordination. In these cases, an effective team structure and caregivers trained in team behavior would have mitigated or prevented 79 percent of the identified failures.
1999 - 2001
- The IOM report was published in 1999, concluding that medical errors cause up to 98,000 deaths annually. The report drew widespread attention from the government, media, and health care profession.
- Former President Clinton established a Quality Interagency Coordination (QuIC) Task Force to develop a coordinated federal plan for reducing the number and severity of medical errors. Among the QuIC's recommendations was the widespread adoption of human factors training, such as CRM, for improving medical team performance.
- The National Defense Authorization Act of 2001 mandated that the DoD institute the Patient Safety Program and required that the DoD deploy MedTeams in at least 10 military health organizations, in different disciplines, each year.
- Joint Commission National Patient Safety Goal Requirements began in January 2003, with a strong focus on communication— with 3 of 7 National Patient Safety Goals related to communication, including "Improve communication among the health care team."
- AHRQ collaborated with the DoD to perform an independent case study of DoD and non-DoD training programs. This case study analysis included formative and summative research methods looking at strengths, weaknesses, and limitations of existing team training curricula.
- IOM released "Patient Safety: Achieving a New Standard for Care."
The 100K Lives Campaign was an initiative to engage U.S. hospitals in a commitment to implement changes in care proven to improve patient care and prevent avoidable deaths. The campaign was successful and exceeded 100K lives saved (June 2006).
This campaign enlisted thousands of hospitals across the country in a commitment to implement changes in care that have been proven to prevent avoidable deaths. The focus of the campaign included:
- Deploy Rapid Response Teams at the first sign of patient decline.
- Deliver reliable, evidence-based care for acute myocardial infarction, to prevent deaths from heart attack.
- Prevent adverse drug events.
- Prevent central line infections.
- Prevent surgical site infections.
- Prevent ventilator-associated pneumonia.
- The Patient Safety and Quality Improvement Act was signed, requiring the Department of Health and Human Services to establish a process for the voluntary and confidential reporting of medical errors to patient safety organizations.
- The TeamSTEPPS pilot curriculum was developed and extensively field tested in 19 training sessions throughout DoD hospitals and clinics. More than 440 physicians, nurses, and technicians became instructors in 2005, with more than 5,000 participants trained by these instructors.
2006 - 2007
- In 2006, AHRQ released TeamSTEPPS into the public domain, allowing access to medical team training on skills, tools, and strategies to any interested organization.
- In 2007, AHRQ expanded its support of TeamSTEPPS by launching the National Implementation Program. This program provides an infrastructure to TeamSTEPPS through Regional Training Centers and organized Master Trainer courses.
- TeamSTEPPS was required under the Quality Improvement Organization (QIO) 9th Scope of Work. This supported the use of TeamSTEPPS by hospitals to address methicillin-resistant Staphylococcus aureus (MRSA) and required QIOs to use the Regional Training Centers to have individuals trained as Master Trainers.
- AHRQ began to support the National Implementation of the Comprehensive Unit-based Safety Program (CUSP) to reduce central line-associated bloodstream infections (CLABSIs). The success of this effort would lead to the development and deployment of similar interventions to address other infection types, such as catheter-associated urinary tract infections (CAUTIs), surgical site infections (SSIs), and ventilator-associated pneumonia (VAP).
- The Centers for Medicare & Medicaid Services (CMS) initiated the Partnership for Patients national campaign to reduce hospital-acquired conditions (HACs) by 40 percent and hospital readmissions by 20 percent in 3 years.
TeamSTEPPS is now part of the ongoing patient safety movement.
TeamSTEPPS focuses on specific skills supporting team performance principles, including training requirements, behavioral methods, human factors, and cultural change designed to improve quality and patient safety.
Teamwork concepts are introduced that provide specific tools and strategies for improving communication and teamwork, reducing chance of error, and providing safer patient care.
This course is based on evidence derived from teams working in high-risk environments; that is, those where the consequences of error are great.
More than 30 years of research and evidence have been accumulated on teams and team performance in diverse areas, such as aviation, the military, nuclear power, health care, business, and industry. TeamSTEPPS has evolved from research in these high-risk fields to the health care environment, a high-risk, high-stakes environment in which poor performance may lead to serious consequences or death.
Based on research, we know what defines a team, what teamwork requires, how to train team members, and how to manage team performance. Researchers have linked team training programs to improved attitudes, increased knowledge, and improved behavioral skills. For example, a meta-analysis published in 2008 (Salas, et al., 2008) included a comprehensive search of team training literature from 1955 through 2007 and examined more than 300 empirical articles. Although this meta-analysis was not specific to team training in health care, its results demonstrated evidence that team training had a moderate, positive effect on team outcomes.
We will look at some TeamSTEPPS-specific evidence later in the module.
TeamSTEPPS is built upon an evidence-based framework composed of four teachable, learnable skills: communication, leadership, situation monitoring, and mutual support. This framework forms the core of the TeamSTEPPS model. The red arrows depict a two-way dynamic interplay between the four core skills and the team-related outcomes of enhanced knowledge, positive attitudes, and exceptional performance.
Encircling the four skills is 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.
Team members with strong communication, leadership, situation monitoring, and mutual support skills typically yield important team outcomes. The interrelationships are the foundation of a strong continuous improvement model: The knowledge, skills, and attitudes of teamwork will complement clinical excellence and improve patient outcomes, because teams will use feedback cycles and clearly defined tools to communicate, plan, and deliver better quality care.
- Knowledge: Teams whose members have strong communication, leadership, situation monitoring, and mutual support capabilities yield important team outcomes such as shared awareness about what is going on with the team and progress toward its goal. Team members will also be familiar with the roles and responsibilities of their teammates.
- Attitudes: When you work in teams in which the members have good communication, leadership, situation monitoring, and mutual support skills, team members are more likely to have a positive experience; you will enjoy working in teams and trust the intentions of your teammates.
- Performance: You'll be able to adapt to changes in the care plan. Team members will know when and how to back up each other. You'll be more efficient in providing care; you will have a plan, and you will know who is supposed to do what, and how they are supposed to do it. Finally, your team will be safer, allowing the team to more readily identify and correct errors, if they occur.
No amount of teamwork can compensate for clinical/technical proficiency. The foundation of teamwork builds on technical proficiency and protocol compliance.
As a result of team competencies, teams can become high performing. During this training, we will touch on the many interrelated aspects of high-performing teams. Generally speaking, high-performing teams have some common traits.
- Have members with clear roles and responsibilities.
Have members with a clear, valued, and shared vision:
- A common purpose.
- An engaging purpose.
- A leader who promotes the vision with the appropriate level of detail.
- Have a shared mental model.
- Optimize resources.
- Have strong team leadership.
- Engage in a regular discipline of feedback:
- Regularly provide feedback to one another and as a team.
- Establish and revise team goals and plans.
- Differentiate between higher and lower priorities.
- Have mechanisms for anticipating and reviewing issues of team members.
- Periodically diagnose team effectiveness, including its results, processes, and vitality (including morale, energy, and retention).
Develop a strong sense of collective trust, team identity, and confidence:
- Manage conflict by effectively confronting one another.
- Have a strong sense of team orientation.
- Trust other team members' intentions.
- Believe strongly in the team's collective ability to succeed.
- Develop collective efficacy.
- Have a high degree of psychological safety.
Create mechanisms to cooperate, coordinate, and generate ongoing collaboration:
- Identify teamwork and task requirements.
- Ensure that the team has the right mix of competencies through staffing and development.
- Distribute and assign work thoughtfully.
- Consciously integrate new team members.
- Involve the right people in decisions in a flexible manner.
- Examine and adjust the team's physical workplace to optimize communication and coordination.
Manage and optimize performance outcomes:
- Communicate often and at the right time to ensure that fellow team members have the information they need in order to contribute.
- Use closed-loop communication.
- Learn from each performance outcome.
- Continually strive to learn.
In the last few slides, we have described the TeamSTEPPS framework and the outcomes of team competencies. We have also reviewed characteristics of high-performing teams. While this information is critical to understanding the basis of TeamSTEPPS, how do we know that any of this works?
We have already noted the work that Salas and colleagues published in 2008, which showed that team training had a positive effect on team outcomes. But what about TeamSTEPPS in particular? Does it lead to the outcomes we have described?
Evidence has shown that TeamSTEPPS training does produce these outcomes in health care organizations. Here are some examples:
- Capella and colleagues (2010) found that trauma resuscitation team performance improved across all teamwork skills after TeamSTEPPS training. Further, following TeamSTEPPS training, times from patient arrival to CT scan, intubation, and arrival to the operating room were all significantly decreased. TeamSTEPPS improved the team's performance, which improved these critical aspects of patient care in the trauma bay.
- Thomas and Galla (2013) describe a systemwide implementation of TeamSTEPPS that involved providing TeamSTEPPS training to more than 30,000 employees across several hospitals, long-term care centers, and outpatient areas. They found an increase in scores on the Hospital Survey on Patient Safety Culture from pre-TeamSTEPPS implementation to post-implementation. This work suggests an important link between team training and organizational outcomes.
These proven results, expert consensus, and anecdotal results indicate that TeamSTEPPS does contribute to positive outcomes. In addition, new research is emerging regularly, allowing the evidence base for TeamSTEPPS to continue to grow.
Instructor Note: This slide is intended for the Master Training course only. The previous slide should be the last one shown to staff participants at your organization.
Provide each participant with a copy of the TeamSTEPPS Implementation Worksheet.
At the end of each of the modules taught today, you will be asked to think through questions about the specific teamwork issue that you plan to address with TeamSTEPPS at your facility or organization. The questions you will be asked to think through will prepare you for planning your TeamSTEPPS implementation, which we will also spend time focusing on in the Implementation Planning Workshop.
To begin, go to the first question on the Implementation Worksheet you just received. Take a moment to document the specific patient safety issue in your facility or organization that is linked to a problem with teamwork.
Ask a few individuals to report on their identified teamwork issue.