Implementation Planning

If your organization decides that implementing part or all of the TeamSTEPPS curriculum would be of value, carefully think through how to implement and sustain what you intend to teach. Successful and sustainable implementation begins with effective implementation planning.

Basis of Implementation Planning

The TeamSTEPPS implementation steps are based on the principle of improving patient safety and quality of care by improving healthcare team processes. A team process is a series of interdependent actions that lead toward a desired endpoint. Examples of processes include admitting a patient, administering a medication, and transferring a patient from one care setting to another, which often is managed by a virtual team.

Improving a team process includes the following steps:

• Identify a recurring problem or opportunity for improvement that, if addressed, could lead to better patient safety or quality of care. An effective implementation plan must describe specifically what you want to "fix" or improve.
• Flowchart or map the process during which the targeted problem or opportunity for improvement occurs. Write down the process steps as they currently occur and identify who is doing what, when, and with which tools.
• Study the process to identify weak points where things could go wrong and lead to a recurrence of the target problem or opportunity. These weak points are called risk points.
• Design and implement interventions aimed at eliminating or reducing the impact of the risk points. The design and implementation of interventions will, in turn, prevent the targeted problem from recurring or will lead to your targeted improvements.
• Test the intervention to ensure that it did in fact eliminate or reduce the target problem or result in your targeted improvement.
• If the test shows that the intervention was successful, monitor intervention effectiveness, sustain positive process changes, and identify opportunities for further improvement.

Steps in Implementation Planning

The remainder of this section reviews the 10 steps that make up TeamSTEPPS implementation planning.

The 10 steps are:

1. Create a Change Team.
2. Define the problem, challenge, or opportunity for improvement.
3. Define the aims of your TeamSTEPPS intervention.
4. Design a TeamSTEPPS intervention.
5. Develop a plan for testing the effectiveness of your TeamSTEPPS intervention.
6. Develop an implementation plan.
7. Develop a plan for sustained continuous improvement.
8. Develop a communications plan.
9. Finalize your TeamSTEPPS implementation plan and timeline.
10. Engage key stakeholders in the creation, monitoring, and updates of your plan.

If you focus on the implementation of a single tool to address a specific concern or a smaller unit, you may simplify the process to focus on the parts directly relevant to your aims.

Step 1: Create a Change Team

Objective

Assemble a team of leaders, staff, and patients and family caregivers with the authority, expertise, credibility, motivation, and patient perspective needed to drive a TeamSTEPPS initiative.

Key Actions

1. Select a multidisciplinary Change Team.
2. Ensure representation from those most likely to be affected by the change as well as all disciplines and professions involved. Be sure to include different leadership levels, including senior leadership, clinical and technical experts, and frontline leadership. Including people from night and weekend shifts is also important.
3. Consider adding members from ancillary services such as respiratory therapy, social work, and physical and occupational therapy.
4. Ensure that at least one of the members has a thorough understanding of the parts of TeamSTEPPS that are your focus.
5. If possible, ensure that the Change Team is supported by a person with experience in performance improvement, with skills in data collection, analysis, and presentation. Such a person may function as a permanent or temporary member of the team or simply offer advice and support when needed.

Tips for Success

• Because the Change Team will focus on improving processes within its own unit, choose members with relevant clinical expertise, a suitable workplace location, credibility, and direct involvement in the processes the TeamSTEPPS intervention will affect.
• Try to ensure that all Change Team members attend your TeamSTEPPS training.
• Limit the Change Team to five or six individuals.
• Consider involving physicians, nurses, and a patient familiar with the clinical workspace.
• Be sure people on your Change Team are perceived as effective team members by others they work with. You cannot successfully implement TeamSTEPPS with a leadership team that isn't committed to its principles. Members need to fully support the practices of effective teamwork and understand a culture of safety.

Step 2: Define the Problem, Challenge, or Opportunity for Improvement

Objective

State the problem, challenge, or opportunity for improvement your TeamSTEPPS intervention will target.

Key Actions

1. Identify a problem, challenge, or opportunity, through consensus, that enhanced teamwork could improve. Also identify measurable outcomes. Strategies include:

• Reviewing unit performance and safety data as contained in incident reports, data from the AHRQ Hospital Survey on Patient Safety Culture and the TeamSTEPPS Teamwork Perceptions Questionnaire, results of staff turnover and satisfaction surveys, and site-specific process and outcome measures.
• Reviewing reports of root cause analyses and failure modes and effects analyses.
• Asking frontline staff, "What bad outcomes are waiting to happen because of breakdowns in the transfer of critical information?" "What things keep you up at night?" "What common concerns do we hear from patients?" "What is contributing to staff burnout or turnover that can be fixed by better communication and teamwork?"

2. Identify the process during which the problem, challenge, or opportunity occurs by stating what the process is, who is involved, and when and where it occurs.

Tips for Success

Change Teams may want to define three or four problems or opportunities and then select the highest priority issue for the TeamSTEPPS intervention. When initiating the TeamSTEPPS intervention for the first time, begin with a solitary issue that is more likely to be successfully addressed, rather than starting with the "biggest, most complex" problem.

Look for problems or opportunities that meet the following criteria:

• The associated process occurs frequently.
• Breakdowns in team performance could result in harm to patients.
• Process change is feasible and likely within the short term.
• Ways to measure whether improvement occurs are available.

Step 3: Define the Aims of Your TeamSTEPPS Intervention

Objective

State in measurable terms what can be achieved with the TeamSTEPPS intervention: what will be achieved, who will be involved, when and where the change will occur, and how you will know something has improved.

Key Actions

1. Develop one to three measurable aims for your TeamSTEPPS intervention, and state in one or two sentences what you hope will be achieved, who will be involved, and when and where the improvements will occur. Aims should align with your defined teamwork problem or opportunity for improvement. Aims can be based on the process of the TeamSTEPPS intervention itself or on the outcomes of that intervention.

• Team process aims focus on how well or often targeted teams carry out the TeamSTEPPS intervention. For example, state, "Increase the use of presurgical briefs in the OR by 40% within 3 months of implementing some or all of the TeamSTEPPS tools. These will include the entire OR team for the targeted OR and will be conducted using a briefing checklist."
• Outcome aims focus on changes that occur because your staff carry out the intervention. These aims can be directed at changes in team performance (team outcome aims) or in clinical results (clinical outcome aims). An example of a team outcome aim is, "Increase the perception of effective use of teamwork behaviors among primary care practice staff within 6 months of implementing selected TeamSTEPPS tools. We will use the TeamSTEPPS Teamwork Perceptions Questionnaire immediately after training and 6 months post-training." An example of a clinical outcome aim is, "Increase the percentage of long-term care residents who report being given their medications on time from 85% to 100% within 4 months of the TeamSTEPPS implementation."

2. Strive to have a team process aim, a team outcome aim, and a clinical outcome aim, which is ideal (but not required). Delineating the aims becomes particularly important when testing the effectiveness of your TeamSTEPPS intervention.

Tips for Success

• Develop aims that specifically address the target problem identified during step 2.
• Put time and thought into defining the problem and the aims of your TeamSTEPPS intervention, since they are the most important steps in developing your implementation plan. The target problem and stated aims drive the development of all remaining components of the implementation plan.

Step 4: Design a TeamSTEPPS Intervention

Objective

Design a TeamSTEPPS intervention that will address your targeted problem, challenge, or opportunity for improvement and will achieve your stated aims.

Key Actions

1. Flowchart or map the process during which the target problem, challenge, or opportunity occurs. Write down the process steps as they currently occur and identify who is doing what, when, and with what tools, and where teamwork is required.
2. Identify risk points where things could go wrong and lead to a recurrence of the problem or challenge or where the opportunity for improvement could be missed.
3. Determine which TeamSTEPPS tools or strategies would work best to eliminate the process risk points.
4. Draft your TeamSTEPPS intervention. State what tools and strategies will be implemented, who will use them, when, and where.
5. Evaluate the planned TeamSTEPPS intervention for potential benefits and negative effects:

• Flowchart the redesigned process as you imagine it would look with your TeamSTEPPS intervention in place.
• Identify potential failure points in the redesigned process. Premortems are one approach to this task. How will you reduce the probability or severity of these failures?
• Identify potential benefits and negative effects of the redesigned process on units outside your workspace. How will you control potential negative effects?

Tips for Success

• Ensure that the people creating the plan will be directly involved in implementing it. Plans that the staff help create and implement are more likely to succeed than plans that seem imposed from others who do not understand the challenges staff encounter.
• Keep your initial plan simple and one you can start to implement fairly quickly. Many plans bog down in the design phase and are never implemented. It is better to start simply and add activities as needed.
• View your plan as an initial guide and not something you expect to implement as-is no matter what happens. Your plan should change as you observe staff reactions to it. If it doesn't, you may not be listening and responding to feedback as carefully as you should.

Step 5: Develop a Plan for Testing Your TeamSTEPPS Interventions

Objective

Develop a method to determine whether the planned TeamSTEPPS intervention achieved its aims. What measurements are needed to determine whether you are achieving your goal?

Key Actions

Ideally, you will test to see whether the TeamSTEPPS intervention achieved each one of the aims generated during step 3. If time and resources are limited, select only one aim for testing. Base your selection on the importance of the aim and on the feasibility of testing it. Make sure the Change Team reviews the ideas for evaluating change on each of Kirkpatrick's four levels that were suggested previously in the measurement discussion.

Testing does not need to be complicated. Basic performance improvement trending and tracking methods generally suffice. For each aim you select, create a testing method by performing the following key actions:

1. Identify who on your Change Team will be responsible for data collection, analysis, and presentation (generation of graphs and charts). Consider recruiting data analysis staff to help the Change Team.
2. Identify a measure and define target ranges for that measure.
3. Measure before and after you implement TeamSTEPPS to see whether the desired changes occurred.

Tips for Success

• Keep it simple. Select one solid measure for each aim.
• If your Change Team uses any patient data, ensure that your plan adheres to all patient rights and privacy laws and regulations. Check with the responsible person or group in your organization about your plans if you are unsure.
• Use existing data sources whenever possible. Most healthcare settings routinely collect significant amounts of data required for institutional reports. Determine what data your facility or workspace already collects that you may be able to use.

Step 6: Develop an Implementation Plan

Objective

Develop a plan for training your staff on the TeamSTEPPS tools and strategies you plan to implement, and develop a plan for putting your TeamSTEPPS intervention into place.

Key Actions

1. Determine the specific TeamSTEPPS tools you have identified for your intervention. Be focused and specific to facilitate the training process.
2. Determine the staff members within a targeted unit or department who need to be trained and identify their specific training needs.
3. Identify the instructors for each audience.
4. Develop a training plan for each audience, including:

• Who will attend the training sessions.
• What specific TeamSTEPPS tools you will teach.
• When the training sessions will occur and for how long.
• Where the sessions will occur.
• How you will train (modality, such as virtual, in person, or blended; and method of training, tools, and supplies).
• Logistics such as schedules, equipment, impact of training on other operations, additional required resources, and notification of trainees and other key stakeholders.

5. Determine how you will reinforce the initial training. Knowledge, attitudes, and behaviors all require review and positive reinforcement to be sustained. Unit or organization staff also change regularly. To achieve sustainable improvements, include reinforcement and refresher trainings as part of your plan.
6. Create your training timelines. Include time for developing your materials and managing team communication and logistics.
7. Determine whether and how members of the unit will be equipped to coach peers and help sustain your implementation plan. If you plan to use formal coaches, consider:

• How many are needed.
• When and how they will be trained.
• How they will be used, including expectations for the role.

Tips for Success

• View implementation as an ongoing process, not a one-time event. While the initial training is critical, how you follow up and reinforce this training is just as essential.
• Model the behaviors you want staff to adopt. If members of the Change Team demonstrate their support for, and use of, tools and concepts you've taught, success is more likely.
• Listen, observe, and adapt. It's rare for implementation plans to succeed exactly as planned. A changed plan based on direct and indirect feedback your Change Team receives is much better than an unchanged plan that doesn't succeed.

Step 7: Develop a Sustainability Plan

Objective

Develop a sustainability plan for your TeamSTEPPS intervention that will proactively reinforce and maintain knowledge, attitudes, and behaviors and allow you to see whether the efforts are effective in meeting the aims.

Key Actions

1. Assume that your efforts to produce change will not last unless they continue to be monitored and reinforced. Most organizational initiatives are short term and have few lasting effects. Staff recognize this situation and can readily dismiss TeamSTEPPS as another "flavor of the month" that will go away like many prior initiatives. The only way to prevent a TeamSTEPPS implementation from losing momentum is by proactively reinforcing TeamSTEPPS on a regular basis. Use data to show improvements in patient outcomes, and leverage the power of stories from staff and patients to help team members see the real-world impact of their efforts.
2. Embed TeamSTEPPS concepts and tools into ongoing organizational processes and activities. If you make TeamSTEPPS HOW you do all your work, you can embed it into your culture. If it stays separate, it is less likely to be sustained. You can achieve this goal through:

• Conducting short refreshers in staff meetings.
• Celebrating successful uses of TeamSTEPPS tools that prevented a patient harm or made a team more efficient and satisfied.
• Providing spot bonuses related to TeamSTEPPS use.
• Incorporating TeamSTEPPS tools or concepts into orientation activities.
• Getting patients and family caregivers involved to reinforce their inclusion in teams providing them care. Module 4's discussion of mutual support includes concrete recommendations for involving patients and family caregivers. Sharing dashboards or other data with them is also recommended.

3. Measure and monitor the process and outcome changes you've targeted. Key approaches include determining:

• Measures and target outcomes.
• Data source or sources (e.g., existing quality improvement database).
• Methods for data collection.
• Methods for data analysis and interpretation.
• Needed resources (money, time, equipment, personnel, expertise).
• People responsible for implementation and oversight.

Tips for Success

• Integrate your TeamSTEPPS intervention into existing processes for long-term sustainability. Make it part of your unit's normal daily routines.
• Publicize your successes. Examples include displaying large wall charts in your workspace showing positive performance trends; writing articles in local publications and medical journals; and giving presentations on your results at staff meetings. Develop standardized procedures for integrating newly hired staff.

Step 8: Develop a Communications Plan

Objective

Use communication strategies targeting stakeholders to generate initial and ongoing support for the TeamSTEPPS initiative and promote the maintenance and spread of positive changes.

Key Actions

1. Identify the stakeholders for the communications plan. Many stakeholders were probably identified in earlier planning steps and some will already be on the Change Team. The communications plan stakeholders are people or groups whose support will be important for achieving the aims of your intervention and for maintaining positive changes. They may be patient advocates, organization leaders, frontline leaders, staff directly involved in the intervention, patients, support staff, and other units affected by the intervention.
2. Once stakeholders are identified, develop a communications plan, including:

• Goals for communication with each group. What do you want to achieve?
• Who will receive the information?
• What information will you communicate?
• When and how often will you communicate?
• How will you communicate (e.g., reports, presentations, emails)?

3. Identify a person on the Change Team who will be responsible for implementation and oversight of the communications plan.

Tips for Success

• Keep the plan as simple as possible. If time or resources are limited to implement a complex plan, a simple plan will be more realistic and successful.
• Stay focused on your goals for communication with each stakeholder group. Keep asking, "What do I hope to accomplish for the initiative (e.g., buy-in, resources, participation) by communicating with this group?" The goals will drive the development of your communications plan.

Step 9: Finalize Your TeamSTEPPS Implementation Plan and Timeline

Objective

Finalize your written implementation plan, based on steps 1 through 8, that will function as your "How-To Guide" for every component of your TeamSTEPPS initiative.

Key Actions

If you completed the activities in steps 1 through 8, you have already written your TeamSTEPPS implementation plan. Review the plan to be sure it includes the following elements:

1. Identification of the Change Team
2. Identification of the problem, challenge, or opportunity for improvement that will be the focus of the TeamSTEPPS initiative
3. Stated aims of the TeamSTEPPS intervention
4. Detailed description of the TeamSTEPPS intervention
5. A plan for testing the effectiveness of the TeamSTEPPS intervention
6. An implementation plan for both medical team training and the TeamSTEPPS intervention
7. A monitoring plan for ongoing assessment of the effectiveness of the TeamSTEPPS intervention
8. A communications plan to generate support for the TeamSTEPPS initiative, to keep major stakeholders informed of progress, and to maintain and spread positive changes
9. Timelines
10. Required resources

Tips for Success

• If your organization uses standard approaches for developing implementation plans, incorporate the contents of steps 1-8 into that approach. This standard plan will be easier for staff and leadership to understand and will reinforce your efforts to embed TeamSTEPPS into existing work processes and organizational norms.
• If the plan seems too long or complex, it almost certainly is. A simpler plan that's more realistic and achievable is a better plan.
• Regularly review and modify your plan as needed. Plans often need to change. That is inevitable and not a planning failure.
• Don't get bogged down in details of later steps in your plan. Work out the details for initial steps because those are more important. You can adjust later steps in the future in time for them to be successfully implemented.
• Everyone is busy, so set a realistic timeline. (It will be difficult to work through all steps in one meeting.) Consider developing a 30-, 60-, or 90-day timeline and have deliverables that are achievable for the Change Team.

Step 10: Engage Key Stakeholders in the Creation, Monitoring, and Updates of Your Plan

Objective

Generate and sustain the support and ideas of key stakeholders and involve them in solving implementation challenges.

Key Actions

1. Review the previously identified stakeholders to target those who could contribute significantly to the implementation plan. Consider patients and family caregivers or a member of your organization's patient and family advisory council, organization leaders, frontline leaders, people directly involved in the intervention, and personnel with special expertise such as facility data analysts.
2. Involve these key stakeholders in the development, review, and updating of your implementation plan. Some of these should be on your Change Team throughout. Specifically request the help of these stakeholders in understanding challenges and developing ways to overcome them.
3. Share data on process and outcome changes with key stakeholders on a regular basis. Doing so increases accountability and may identify solutions to challenges that are preventing targeted improvements.

Tips for Success

• Actively involve patients in these discussions. Patient inclusion will reinforce the central aim of TeamSTEPPS, which is to keep them safe. Patients also have a perspective that's often overlooked and that can identify solutions staff may not have considered.
• Make stakeholder input easy and worthwhile. Stakeholders are busy, potentially experiencing burnout, and often have more responsibilities than time. Scheduling frequent or extended meetings may be counterproductive. If stakeholder input is elicited efficiently in forums they are already attending (e.g., staff meetings, grand rounds), they are more likely to stay engaged.