TeamSTEPPS Fundamentals Course: Module 1

Evidence-Base: Introduction

TeamSTEPPS is a teamwork system developed jointly by the Department of Defense (DoD)and the Agency for Healthcare Research and Quality (AHRQ) to improve institutional collaboration and communication relating to patient safety.

Teamwork has been studied extensively over the past 30 years. Research suggests teamwork is defined by a set of interrelated knowledge, skills, and attitudes (KSAs) that facilitate coordinated, adaptive performance, supporting one's teammates, objectives, and mission.1-4 Although teamwork differs from taskwork (i.e., operational skills), both are required for teams to be effective in complex environments.5 However, knowledge and skill at the task level are not enough. Teamwork depends upon team members' ability to:

  • Anticipate needs of others.
  • Adjust to each other's actions and the changing environment.
  • Have a shared understanding of how a procedure or plan of care should happen.

In health care, there has been significant progress in defining team requirements since the release of the Institute of Medicine (IOM) report in 19996 and the early research that led to TeamSTEPPS®.7 This body of research has yielded a significant evidence base for a set of core KSA competencies that Salas and colleagues contend apply to almost all teams.8 Further, Salas, et al.'s (2008) meta-analysis on the science of team training illustrated that positive relationships exist between team training interventions like TeamSTEPPS and their associated outcomes. Importantly, such training has been found to account for 20 percent of the variance in team performance.9

The critical aspects of teamwork that must be targeted in training include: team leadership, mutual performance monitoring (i.e., situation monitoring), backup behavior (i.e., mutual support), and communication. These core skills lead to important team outcomes, such as enabling the team to adapt to changing situations, achieve compatible shared mental models among team members, and maintain a stronger orientation toward teamwork (refer to Exhibit 1).


Exhibit 1. TeamSTEPPS Skills

Teamwork Skill Definition Behavioral Examples Selected Citation
Team Leadership The ability to direct and coordinate the activities of other team members, assess team performance, assign tasks, develop team knowledge, skills, and attitudes (KSAs), motivate team members, plan and organize, and establish a positive atmosphere.
  • Facilitate team problem solving.
  • Provide performance expectations and acceptable interaction patterns.
  • Synchronize and combine individual team member contributions.
  • Seek and evaluate information that impacts team functioning.
  • Clarify team member roles.
  • Engage in preparatory meetings and feedback sessions with the team.
Cannon-Bowers, et al., 19952; Salas, et al., 200410; Barach & Weingart, 200411; Sharma, et al., 201112; Woodhead, 201113; Collins & Holton, 200414; DeRue, et al., 201115
Mutual Performance Monitoring (aka., Situation Monitoring) The ability to develop a common understanding of the team environment and apply appropriate task strategies in order to accurately monitor teammate performance.
  • Identifying mistakes and lapses in other team members actions.
  • Providing feedback regarding team member actions in order to facilitate self-correction.
McIntyre & Salas, 199516; Porter, et al., 200317; Carney, et al., 201018; Hobgood, et al., 201019
Back-up Behavior (aka., Mutual Support) The ability to anticipate other team members' needs through accurate knowledge about their responsibilities. The ability to shift workload among members to achieve balance during periods of high workload or pressure.
  • Recognition by potential back-up providers that there is a workload distribution problem involving their team.
  • Shifting of work responsibilities to underused team members
  • Completion of the whole task or parts of tasks by other team members.
Robertson, et al., 201020; McIntyre & Salas, 199516; Porter, et al., 200317
Communication The exchange of information between a sender and a receiver, irrespective of the medium.
  • Follow up with team members to ensure message was received.
  • Acknowledge that a message was received.
  • Clarifying with the sender of the message that the message received is the same as the intended message sent.
Capella, et al., 201021; Halbesleben, et al., 201122; Haskard, et al., 200923; Mayer, et al., 201124; Mesmer-Magnus & DeChurch, 200925; Robinson, et al., 201026; Shea-Lewis, 200927; McIntyre & Salas, 199516; Salas, Wilson, et al., 200828
Overall Teamwork Improvement The demonstrated improvement in teamwork across multiple teamwork skills.   Carney, et al., 201018; Capella, et al., 201021; Mayer, et al., 201124; Neily, et al., 201029; Salas, et al., 20089; Salas, et al., 200630


In addition to studies of how teams perform, there has been a burgeoning interest in the effectiveness of team training interventions in health care. In a recent review, more than 40 peer-reviewed articles detailing health care team training evaluations were identified.31 It is evident from these recent examinations that team training is being implemented across a wide spectrum of providers and is targeting important competencies such as communication, leadership, role clarity, and situational awareness.31 In addition to improving team performance, team training has been found to improve the use of appropriate medical technical skills in health care professionals.32

There has also been a growing body of research focused directly on the effectiveness of TeamSTEPPS. Research has shown that TeamSTEPPS leads to increases in desirable teamwork and safety attitudes, as well as increased communication, teamwork behaviors, clinical process compliance, efficiency, and overall performance in a variety of medical settings.31, 33-39


1. Baker DP, Gustafson S, Beaubien JM, et al. Medical teamwork and patient safety: the evidence-based relation. Washington, DC: American Institutes for Research; 2003.

2. Cannon-Bowers JA, Tannenbaum SI, Salas E, et al. Defining competencies and establishing team training requirements. In: Guzzo RA, Salas E, eds. Team effectiveness and decision making in organizations. San Francisco: Jossey-Bass; 1995. p. 333.

3. Salas E, Dickinson TL, Converse SA, et al. Toward an understanding of team performance and training. In: Swezey RW, Salas E, eds. Teams: their training and performance. Norwood, NJ: Ablex; 1992. p. 3.

4. Salas E, Bowers CA, Cannon-Bowers JA. Military team research: 10 years of progress. Mil Psychol 1995;7(2):55-75.

5. Morgan BB, Glickman AS, Woodward EA, et al. Measurement of team behaviors in a Navy environment. Tech. Report No. NTSC TR-86-014. Orlando, FL: Naval Training Systems Center; 1986.

6. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 1999.

7. Baker D, Salas E, King H., et al. The role of teamwork in the professional education of physicians: current status and assessment recommendations. Jt Comm J Qual Patient Saf 2005;31:185-202.

8. Salas E, Sims DE, Burke SC. Is there a "Big Five" in teamwork? Small Gr Res 2005;36(5):555-99.

9. Salas E, DiazGranados D, Klein C, et al. Does team training improve performance? A meta-analysis. Hum Factors 2008;50:903-33.

10. Salas E, Burke CS, Stagl KC. Developing teams and team leaders: strategies and principles. In: Demaree RG, Zaccaro SJ, Halpin SM, eds. Leader development for transforming organizations. Mahwah, NJ: Lawrence Erlbaum Associates; 2004. p. 325-55.

11. Barach P, Weingart M. Trauma team performance. In: Wilson W, Grande C, Hoyt, D, eds. Trauma: resuscitation, anesthesia, surgery, and critical care: New York: Dekker; 2004. p. 101-13.

12. Sharma B, Boet S, Bould D, et al. Kirkpatrick evaluation of interprofessional simulation-based education for peroperative crisis resource management. Surgical Forum Abstracts—2011 Clinical Congress. J Am Coll Surg 2011 Sep;213(3)(Suppl):S129.

13. Woodhead V. How does coaching help to support team working? A case study in the NHS. Int J Evidence-Based Coach Mentor 2011 June (Special issue 5):102-19. Available at: Accessed August 8, 2013.

14. Collins DB, Holton EF III. The effectiveness of managerial leadership development programs: a meta-analysis of studies from 1982-2001. Hum Resour Dev 2004;15:217-48.

15. DeRue DS, Nahrgang JD, Wellman N, et al. Trait and behavioral theories of leadership: a meta-analytic test of their relative validity. Pers Psychol 2011;64(1):7-52.

16. McIntyre RM, Salas E. Measuring and managing for team performance: emerging principles from complex environments. In: Guzzo RA, Salas E, eds. Team effectiveness and decision making in organizations. San Francisco: Jossey-Bass; 1995. p. 9-45.

17. Porter CO, Hollenbeck JR, Ilgen DR, et al. Backing up behaviors in teams: the role of personality and legitimacy of need. J Appl Psychol 2003;88(3):391-403.

18. Carney BT, Mills PD, Bagian JP, et al. Sex differences in operating room care giver perceptions of patient safety: a pilot study from the Veterans Health Administration Medical Team Training Program. Qual Saf Health Care 2010;19(2):128-31.

19. Hobgood C, Sherwood G, Frush K, et al. Teamwork training with nursing and medical students: does the method matter? Results of an interinstitutional, interdisciplinary collaboration. Qual Saf Health Care 2010;19(6):e25. Published online first: 27 April 2010.

20. Robertson B, Kaplan B, Atallah H, et al. The use of simulation and a modified TeamSTEPPS curriculum for medical and nursing student team training. Simul Healthc 2010;5(6):332-7.

21. Capella J, Smith S, Philp A, et al. Teamwork training improves the clinical care of trauma patients. J Surg Educ 2010;67:439-43.

22. Halbesleben RB, Cox KB, Hall H. Transfer of crew resource management training: a qualitative study of communication and decision making in two intensive care units. Leadersh Health Serv 2011;24(1):19-28.

23. Haskard Zolnierek KB, DiMatteo MR. Physician communication and patient adherence to treatment: a meta-analysis. Med Care 2009;47(8):826-36.

24. Mayer CM, Cluff L, Lin W, et al. Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units. Jt Comm J Qual Patient Saf 2011;37(8):365-73.

25. Mesmer-Magnus JR, DeChurch LA. Information sharing and team performance: a meta-analysis. J Appl Psychol 2009;94(2):535-46.

26. Robinson LD, Paull DE, Mazzia LM, et al. The role of the operating room nurse manager in the successful implementation of preoperative briefings and postoperative debriefings in the VHA medical team training program. J Perianesth Nurs 2010;25(5):302-6.

27. Shea-Lewis A. Teamwork: crew resource management in a community hospital. J Healthc Qual 2009;31(5):14-8.

28. Salas E, Wilson KA, Murphy CE, et al. Communicating, coordinating, and cooperating when lives depend on it: tips for teamwork. Jt Comm J Qual Patient Saf 2008;34(6):333-41.

29. Neily J, Mills PD, Young-Xu Y, et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010;304(15):1693-1700.

30. Salas E, Rosen MA, Burke CS, et al. The wisdom of collectives in organizations: an update of the teamwork competencies. In: Salas E, Goodwin GF, Burke CS, eds. Team effectiveness in complex organizations: cross-disciplinary perspectives and approaches. New York, NY: Routledge; 2006. p. 39-79.

31. Weaver SJ, Lyons R, DiazGranados D, et al. The anatomy of health care team training and the state of practice: a critical review. Acad Med 2010;85:1746-60.

32. Fransen A, van de Ven J, Merien A, et al. Effect of obstetric team training on team performance and medical technical skills: a randomized controlled trial. BJOG 2012;119(11):1387-93.

33. Buljac-Samardzic M, Dekker-van Doorn CM, van Wijngaarden JDH, et al. Interventions to improve team effectiveness: a systematic review. Health Policy 2010;94(3):183-95.

34. Capella J, Smith S, Philp A, et al. Teamwork training improves the clinical care of trauma patients. J Surg Educ 2010;67(6):439-43.

35. Deering S, Rosen M, Ludi V, et al.On the front lines of patient safety: implementation and evaluation of team training in Iraq. Jt Comm J Qual Patient Saf 2011;37(8):350-6.

36. Neily J, Mills PD, Lee P, et al. Medical team training and coaching in the Veterans Health Administration: assessment and impact on the first 32 facilities in the programme. Qual Saf Health Care 2010;19(4):360-4.

37. Paull DE, Mazzia LM, Wood SD, et al. Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program. Am J Surg 2010;200(5):620-3.

38. Salas E, Gregory M, King H. Team training can enhance patient safety—the data, the challenge ahead. Jt Comm J Qual Patient Saf 2011;37(8):339-40.

39. Thomas L, Galla C. Building a cutlure of safety through team training and engagement. BMJ Qual Saf 2013;22(5):425-34.

Additional Resources

Adams KA, Goodwin GF, Searcy CA, et al. Development of a performance model of the medical education process. Technical report commissioned by the Association of American Medical Colleges. Washington, DC: American Institutes for Research; 2003.

Amalberti R, Auroy Y, Berwick D, et al. Five system barriers to achieving ultrasafe health care. Ann Intern Med 2005;142(9):756-65.

Baker DP, Day R, Salas E. Teamwork as an essential component of high-reliability organizations. Health Serv Res 2006;41(4 Pt 2):1576-98.

DiMeglio KS, Lucas C, Padula C, et al. Group cohesion and nurse satisfaction. J Nurs Admin 2005;35(3):110-20.

Garza M, Piver JS. Can aviation safety methods cut obstetric errors? OB/GYN Malpractice Prev 2004 Aug;11(8):57-64.

Klimoski R, Mohammed S. Team mental model: construct or metaphor? J Manage 1994;20(2):403-37.

Kotter J, Rathgeber H. Our iceberg is melting: changing and succeeding under adverse conditions. New York: St. Martin's Press; 2006.

Kozlowski SW, Gully, SM, Nason ER, et al. Developing adaptive teams: a theory of compilation and performance across levels and time. In: Ilgen DR, Pulakos ED, eds. The changing nature of performance: implications for staffing, motivation, and development. San Francisco, CA: Jossey-Bass; 1999. p. 240.

Leape LL, Berwick DM. Five years after To Err Is Human: what have we learned? JAMA 2005;293:2384-90.

Mann S, Marcus R, Sachs B. Lessons from the cockpit: how team training can reduce errors on L&D (Grand Rounds). Contemp Ob/Gyn 2006 Jan;51:34-45.

Mathieu JE, Heffner TS, Goodwin GF, et al. The influence of shared mental models on team process and performance. J Appl Psychol 2000;85(2):273-83.

Morey JC, Simon RJ, Jay GD, et al. Error reduction and performance improvement in the emergency department through formal teamwork training: evaluation results of the MedTeams project. Health Serv Res 2002;37(6):1553-81.

Morey JC, Simon R, Jay GD, et al. A transition from aviation crew resource management to hospital emergency departments: the MedTeams story. In Jensen RS. Proceedings of the 12th International Symposium on Aviation Psychology. Dayton, OH: Wright State University Press; 14 April 2003. p. 1-7.

Pisano GP, Bohmer RMJ, Edmondson AC. Organizational differences in rates of learning: evidence from the adoption of minimally invasive cardiac surgery. Manage Sci 2001;47(6):752-68.

Pronovost P, Berenholtz S, Dorman T, et al. Improving communication in the ICU using daily goals. J Crit Care 2003;18(2):71-5.

Quality Interagency Coordination Task Force. Doing what counts for patient safety: Federal actions to reduce medical errors and their impact. Report of the Quality Interagency Coordination Task Force (QuIC) To the President. Rockville, MD: Agency for Healthcare Research and Quality; 2000.

Rivers RM, Swain D, Nixon B. Using aviation safety measures to enhance patient outcomes. Assoc Oper Room Nurs 2003;77(1):158-62.

Roberts KH. Managing high reliability organizations. Calif Manage Rev 1990;32(4):101-14.

Sexton JB. Teamwork climate and postoperative sepsis in the surgical operating room. Association for Psychological Science Symposium. 27 May 2006; New York, NY.

Shapiro M, Morey J, Small S, et al. Simulation based teamwork training for emergency department staff: does it improve clinical team performance when added to an existing didactic teamwork curriculum? Qual Saf Health Care 2004;13(6):417-21.

Stout RJ, Cannon-Bowers JA, Salas E. The role of shared mental models in developing team situational awareness: implications for team training. Training Resource J 1996;2:85-116.

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Page last reviewed March 2014
Page originally created September 2012
Internet Citation: TeamSTEPPS Fundamentals Course: Module 1. Content last reviewed March 2014. Agency for Healthcare Research and Quality, Rockville, MD.