Section 2: Explanation and Value of the TeamSTEPPS Curriculum 

This section contains explanations and illustrations to help you better understand and appreciate the structure and importance of the TeamSTEPPS curriculum and its key concepts. If you teach this content or want additional insights into how the material can be more fully learned, you may find the instructor suggestions in section 3 helpful.

Introduction to the Curriculum

The TeamSTEPPS curriculum includes the following sections:

• Welcome Guides: The Welcome Guides are written for various TeamSTEPPS audiences. These guides are meant to provide a general understanding of what TeamSTEPPS is, and how and why it can benefit clinicians, staff, patients and their families or caregivers, and healthcare organizations. You are encouraged to read the Welcome Guide most relevant to you.
• Introduction: The Introduction (what you're currently reading) includes foundational information on why patient safety can never be taken for granted, why safety culture and effective teamwork are essential, and how TeamSTEPPS can help maximize patient safety and other desirable outcomes.
• Pocket Guide: The Pocket Guide is a quick-reference guide containing brief overviews of the key concepts and tools presented in each module.
• Instructional Modules: 
  • The TeamSTEPPS course consists of four modules: 
    • Module 1: Communication 
    • Module 2: Team Leadership
    • Module 3: Situation Monitoring
    • Module 4: Mutual Support
  • Each module is divided into three sections. 
    • Section 1, Overview of Key Concepts and Tools: Provides a quick overview of the key concepts and tools that mirrors content in the Pocket Guide. This section can provide a review of concepts covered in a past training or can help users identify information of particular interest.
    • Section 2, Explanation of Key Concepts and Tools: Provides a thorough description of the concepts and tools included in the module. This section includes textual explanations as well as alternative ways to learn about them through videos, examples, case studies, and other materials. Resources are provided that are relevant to multiple clinical settings and team member types. Each resource is labeled based on relevant clinical setting and team member type so curriculum users can identify resources they perceive as directly relevant to their situations.
    • Section 3, Teaching Introductory Material: This section provides lecture resources, rationales, and guidance for use of case studies, simulations, games, and group exercises. It is not critical for TeamSTEPPS trainees to review this section. However, people learning TeamSTEPPS independently outside of organized training courses may find instructor resources helpful to understand how tools are used and why their use is critical. 
• Implementing TeamSTEPPS: Includes implementation resources to begin and sustain the successful use of TeamSTEPPS in any healthcare setting. It is of particular relevance to those responsible for implementing TeamSTEPPS (or parts of it) in a unit or organization.

The Importance of TeamSTEPPS

The TeamSTEPPS curriculum includes several video-based stories from patients about their encounters with the healthcare system. These stories celebrate  positive experiences with high-performing teams and reflect on poorly performing teams. The video stories in the AHRQ collection include:

• A patient discussing the impact verbal and nonverbal communication had in both positive   and challenging interactions with physicians as she obtained care for a serious health condition.
• A patient describing how positive teamwork in a cardiac rehabilitation program helped restore his health and how specific communication tools such as SBAR (Situation, Background, Assessment, Recommendation) foster effective communication in time-sensitive diagnoses.
• A family caregiver sharing the value of using check-backs to ensure a shared mental model and her ability to develop a trusting relationship with her pulmonologist, despite a distressing initial encounter.

These videos have been made to enhance care safety and help the healthcare workforce cope with challenges and gain the satisfaction being part of this profession can provide. As you reflect on these and other patient stories, consider:

• What avoidable breakdowns in teamwork occurred in some of the stories?
• How did effective teamwork help protect and support patients and family caregivers?
• How does being part of low- and high-performing teams affect your own well-being and job satisfaction?

Patient harms 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:

• Frequent changes in team membership.
• Lack of attention to the central role of the patient and possibly their family or caregivers.
• Lack of time.
• Lack of information sharing.
• Hierarchy.
• Defensiveness.
• Conventional thinking.
• Varying communication styles.
• Conflict.
• Lack of coordination and followup.
• Distractions.
• Fatigue.
• Workload.
• Misinterpretation of cues.
• Lack of role clarity.

When TeamSTEPPS was created, the patient safety movement was in its infancy, and the groundbreaking Institute of Medicine (now National Academy of Medicine) report To Err Is Human¹  had only recently been released. TeamSTEPPS is now part of the ongoing patient safety movement and builds on more than 20 years of lessons learned about the key role teams play in preserving patient safety.

Teamwork is of particular importance for patients with limited English proficiency who are at higher risk of harm. Many TeamSTEPPS tools can be used to support these patients; examples are noted throughout the curriculum.

TeamSTEPPS focuses on specific skills supporting team performance. It addresses training requirements, active learning methods, human factors, and cultural shifts designed to improve quality and patient safety. Teamwork concepts are introduced that provide specific tools and strategies for improving teamwork, providing safer patient care, and reducing the stress of healthcare professionals and enhancing their job satisfaction.

This course is based on evidence derived from teams working in high-risk environments where the consequences of error are great, including aviation, the military, and nuclear power. TeamSTEPPS has evolved from more than 50 years of research and evidence in these high-risk fields and has been tailored to the healthcare environment, a high-risk, high-stakes field in which poor performance may lead to dire outcomes, including avoidable 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, an early meta-analysis published in 2008²  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 healthcare, its results demonstrated evidence that team training had a moderate positive effect on team outcomes. More-recent reviews summarized in a 2020 AHRQ report³ and in an updated evidence summary on the TeamSTEPPS website reach similar conclusions.

What Makes Up Team Performance?

TeamSTEPPS is an evidence-based framework to optimize team performance across the healthcare delivery system. It requires clearly defined and appropriate team structure and the use of four teachable-learnable skills: Communication, Team Leadership, Situation Monitoring, and Mutual Support. The TeamSTEPPS framework reflects the connections between these four skills and how they contribute to the knowledge, attitudes, and sustained high performance needed to achieve highly reliable, safe, and effective care for every patient. While each skill alone has direct value, each also contributes to the effective use of the other skills, making every skill mutually reinforcing. 

Teams with strong communication, leadership, situation monitoring, and mutual support skills typically achieve superior outcomes, reduce stress levels, and derive more satisfaction from their work and relationships with peers as well as with patients and their families or caregivers. The interrelationships are the foundation of a strong continuous improvement model: the knowledge, skills, and performance of a team 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 achieve important team outcomes such as shared awareness about what is going on with the team and progress toward its goal. Team members are also familiar with the roles and responsibilities of their teammates.
• Attitudes: When patients, healthcare professionals, and staff work in teams in which members have strong communication, leadership, situation monitoring, and mutual support skills, team members are more likely to have a positive team orientation and enjoy working with their teammates and trust those teammates’ intentions.
• Performance: High-functioning teams will be able to adapt to changes in the care plan. Team members will know when and how to back up each other. They will be more efficient in providing care, will have a plan, and will know who is supposed to do what and how they are supposed to do it. High-performing teams will also be safer, allowing the team to more readily identify and correct errors if they occur. Adaptability, accuracy, productivity, efficiency, safety, and high reliability are hallmarks of high-functioning teams . 
• Sustainability: Supporting a strong safety culture, aligning incentives, and maintaining and reinforcing teamwork knowledge, attitudes, and performance over time will help sustain effective teamwork despite staff turnover, competing priorities, adversity, and complacency.  

No amount of teamwork can compensate for inadequate clinical or technical proficiency, chronic major staff shortages, or an overall organizational culture that does not value patient safety. However, teamwork skills can help individuals and teams cope more effectively with patient safety issues these challenges create. They can also help patients and other team members better support and encourage each other as they cope with stress and burnout in their lives. 

Characteristics of High-Performing Teams 

As a result of team competencies, teams can become high performing. High-performing teams have some common traits. They: 

• 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 individually and as a team.
• Establish and revise team goals and plans.
• Differentiate between higher and lower priorities.
• Have mechanisms for anticipating and reviewing team members’ issues. 
• Periodically assess their team’s 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 interacting with 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.
• Foster 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 abilities 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 or virtual 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.

Evidence That TeamSTEPPS Works 

Since AHRQ introduced TeamSTEPPS, considerable research has shown that the effective use of TeamSTEPPS and specific TeamSTEPPS tools can improve patient care outcomes by making care safer while achieving other benefits across a range of clinical settings. While evidence of teamwork’s importance was once viewed with considerable skepticism, extensive literature now exists establishing the importance of teamwork to patient safety, patient outcomes, and staff well-being. Available evidence shows that TeamSTEPPS trainings change knowledge, attitudes, and behaviors needed for improved communication and teamwork, thereby improving patient care.

Summaries of the impact of TeamSTEPPS include a section devoted to teamwork in an AHRQ assessment of patient safety practices⁴ and systematic reviews by Costar and Hall⁵ and Buljac-Samardzic, et al.,⁶ in 2020.

The resources section of the TeamSTEPPS website includes more-extensive reviews of relevant literature through 2021, while AHRQ's Patient Safety Network (PSNet) regularly features publications exploring these issues. Most of this research addresses communication and teamwork in the hospital setting, but many publications have explored other care settings.

While evidence of TeamSTEPPS's impact on patient safety is very clear, it is equally clear that teaching TeamSTEPPS in a healthcare organization without effective implementation and a sustained institutional commitment to a culture of safety may result in no positive impact for patients or the organization. Information about how to achieve lasting and measurable positive impacts from TeamSTEPPS is included in the implementation section (section 4) of each of the four training modules.

Notes

1. Institute of Medicine. 2000. To Err Is Human: Building a Safer Health System. Washington, DC: The National Academies Press. DOI: 10.17226/9728. Accessed April 28, 2023.
2. Salas E, DiazGranados D, Klein C, Burke CS, Stagl KC, Goodwin GF, Halpin SM. Does team training improve team performance? A meta-analysis. Hum Factors. 2008 Dec;50(6):903-33. Accessed April 28, 2023.
3. Costar D. Cross-cutting patient safety topics/practices. In: Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices. (Prepared by Abt Associates under Contract No. 233-2015-00013-I.) Rockville, MD: Agency for Healthcare Research and Quality; March 2020. Publication No. 20-0029-EF. Accessed April 28, 2023.
4. Costar D. Cross-cutting patient safety topics/practices. In: Making Healthcare Safer III: A Critical Analysis of Existing and Emerging Patient Safety Practices. (Prepared by Abt Associates under Contract No. 233-2015-00013-I). Rockville, MD: Agency for Healthcare Research and Quality; March 2020. Publication No. 20-0029-EF. Accessed April 28, 2023.
5. Costar DM, Hall KK. Improving team performance and patient safety on the job through team training and performance support tools: A systematic review. J Patient Saf. 2020;16(3S Suppl 1):S48-S56. Epub 2020/08/19. DOI: 10.1097/PTS.0000000000000746. Accessed April 28, 2023.
6. Buljac-Samardzic M, Doekhie KD, van Wijngaarden JDH. Interventions to improve team effectiveness within health care: A systematic review of the past decade. Hum Resour Health. 2020;18(1):2. Epub 2020/01/10. Accessed April 28, 2023.