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versity curricula. It has beenapplied at academic institutions,including Harvard UniversitysBeth Israel Deaconess Hospitaland Duke University Health

Systems Pediatric Intensive CareUnit. Military operational unitscontinue to request training toenhance their ability to supportany mission at a moments notice.Forward surgical teams havereceived training to increase theprecision of care provided both onthe battlefield and in the combatsupport hospitals in Iraq andAfghanistan. A front-page articleon TeamSTEPPS in the June 1,2007, issue of Internal Medicine

News (Vol 40, No 11, www.internalmedicinenews.com) confirmed thewidespread attention enjoyed byTeamSTEPPS. The prestigious M.Scott Myers Award for Applied Re-search from The Society for In-dustrial and Organizational Psych-ology went to TeamSTEPPS in 2007.

Tools and StrategiesThe TeamSTEPPS program pro-

vides tools and strategies to in-crease team awareness through ashared mental model (see Figure 1).It clarifies team roles and re-sponsibilities, and creates anatmosphere of mutual trust. Co-hesive teamwork will enhance per-formance through increased adapt-ability, accuracy, productivity, effi-ciency, and safety. The core of theTeamSTEPPS framework comprisesfour key principles/skills/corecompetencies that are integratedto foster delivery of safe, qualitycare as a cohesive patient careteam, which includes the patient,

TeamSTEPPS: Integrating Teamwork Principles

Into Adult Health/Medical-Surgical Practice

staff satisfaction. The TeamSTEPPSapproach has met with great suc-cess in a variety of high-risk set-tings such as emergency depart-ments and labor and delivery. It is

now time to embrace TeamSTEPPSstrategies in the medical-surgicalsetting.

TeamSTEPPS GoalThe goal of TeamSTEPPS is to

produce highly effective medicalteams that optimize the use ofinformation, people, and re-sources to achieve the best clini-cal outcomes for patients. Toachieve this goal, the HCTCP willwork to institutionalize team-driv-en care, solidify collaborativepartnerships, and support re-search demonstration projects toimprove patient safety.

TeamSTEPPS Impact to DateTeamSTEPPS was implement-

ed in 2005-2007 in over 68 militarytreatment facilities (MTFs) world-wide. Approximately 1,500 partici-pants have attended the train-the-trainer course, and over 22,000continuing education (CE/CME)credits have been awarded. Thetrain-the-trainer approach hassaved the DoD $1.4 million in train-ing and travel costs. TeamSTEPPShas been introduced in 24 peer-reviewed publications and was thetopic of conversation in over 10 in-terviews. In January 2008, theMilitary Health System Conferencefeatured a 2-hour TeamSTEPPStraining session for over 100 par-ticipants. TeamSTEPPS tools andstrategies have been incorporatedin simulation exercises and in uni-

In collaboration with the Healthand Human Services Agency forHealthcare Research and Quality(AHRQ), the Department of De-fense (DoD) Health Care Team

Coordination Program (HCTCP)developed an initiative that stress-es teamwork and communicationamong physicians, nurses, andother health care personnel tomake the delivery of health caresafer for all patients. The TeamStrategies and Tools to EnhancePerformance and Patient Safety(TeamSTEPPS) principles weredesigned to be incorporated intothe daily activities of patient careprovision in an effort to reduceclinical errors, and improve pa-tient outcomes and patient and

Sheri L. Ferguson, MSN, MBA, MSEd,BSN, CMSRN, is a Colonel, Army NurseCorps, and Chief, Nursing Admini-stration, Carl R. Darnall Army MedicalCenter, Fort Hood, TX. She is alsoMedical Surgical Nursing Consultant toThe Surgeon General.

Disclaimer: The opinions and viewsexpressed in this article are those of

the author and do not necessarily rep-resent those of the U.S. Army NurseCorps, nor those of the U.S. Depart-ment of Defense.

Note: Military nursing offers uniquepractice opportunities. Share your per-spectives on your practice as a nursein the Armed Forces with the readersof MEDSURG Nursing by submitting amanuscript in consideration for thiscolumn. Questions and submissionscan be directed to the Editor, DottieRoberts, at msjrnl@ajj.com.

Sheri L. Ferguson

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direct caregivers, and those whoplay a supportive role within thehealth care delivery system. Thefour key skill areas are:1. Leadership. Involves the abili-

ty to coordinate the activitiesof team members by ensuringteam actions are understood,changes in information areshared, and team membershave the necessary resources.

TeamSTEPPS tools include: Planning Brief: A shortsession prior to start to dis-cuss team and establishroles.

Problem solving Huddle:An ad hoc team meeting toshare information andadjust plans.

Process improvement Debrief: After-action reviewto provide feedback andimprove team perform-ance.

2. Situation Monitoring. The pro-cess by the individual of active-ly scanning behaviors and ac-tions of those around him orher to assess the situation orenvironment. Situation monitor-ing fosters mutual respect andteam accountability, and pro-vides a safety net for the teamand the patient. TeamSTEPPStools include: Cross monitoring A process

of monitoring the actions ofother team members for thepurpose of sharing theworkload and reducing oravoiding errors. It ensuresmistakes or oversights arecaught quickly and easily. Itis a way of watching eachothers back.

Shared mental model Theperception of, understanding

of, or knowledge about a sit-uation or process that isshared among team mem-bers through communica-tion. Having team memberson the same page is thedesired team outcome.

3. Mutual Support. The ability toanticipate and support otherteam members needs throughaccurate knowledge abouttheir responsibilities and work-load, mutual support protectsteam members from work over-

load situations that may reduceeffectiveness and increase therisk of error. TeamSTEPPS toolsinclude: Task assistance Team

members foster a climatewhere it is expected thatassistance will be activelysoughtand offered.

Feedback Information forthe purpose of improvingteam performance should be

timely, respectful, specific,directed toward improve-ment, and considerate.

Advocacy and assertion Invoked when team mem-bers viewpoints do notcoincide with that of a deci-sion maker. The team mem-ber asserts a corrective

action in a firm and respect-fulmanner. Two-challenge rule Invoked

when an initial assertion isignored. It is the team mem-bers responsibility to voicehis or her concern asser-tively at least two times toensure that it has beenheard. The member beingchallenged must acknow-ledge the challenge; if theoutcome is still not accept-able, a stronger course of

action, such as notifying thesupervisor, must be taken. Collaboration Achieves a

mutually satisfying solutionresulting in the best out-come. The patient care team(individual team members,team, and patient) all win!

DESC script A constructiveapproach for managing andresolving conflict. Ultimate-ly, consensus shall bereached. D Describe the specific

situation. E Express your concernsabout the action.

S Suggest other alterna-tives.

C Consequences shouldbe stated.

4. Communication. A process bywhich information is clearly andaccurately exchanged amongteam members. TeamSTEPPSstrategies for providing clearand accurate communicationinclude:

SBAR a technique thatrequires immediate atten-tion and action concerning apatients condition. S Situation B Background A Assessment R Recommendation

Call-out A strategy used tocommunicate important orcritical information. Exam-ple: resuscitations.

Figure 1.TeamSTEPPS Teamwork Training System

PATIENTCARE TEAM

PERFORMANCE

SKILLSKNOWLEDGE ATTITUDES

CommunicationSituationMonitoring

Leadership

MutualSupport

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Check-Back A process ofemploying closed-loop com-munication to ensure thatinformation conveyed bythe sender is understood bythe receiver as intended. Ex-ample: all verbal orders.

Handoff The transfer ofinformation (along with

authority and responsibili-ty) during transitions incare across the continuum;to include an opportunityto ask questions, clarify,and confirm responses. Ex-amples: shift changes, phy-sicians transferring com-plete responsibility, and pa-tient transfers.

TeamSTEPPS TransformsCulture

The AHRQ and DoD are

engaged in an extensive awarenesscampaign targeted at hospitals,hospital associations, health caretrade associations, professionalorganizations, and medical andnursing schools. As TeamSTEPPSand team training are embraced byMTFs across the military healthsystem (MHS), they also have real-ized considerable growth in theprivate sector since their releaseto the public domain on November2, 2006. The ability to exportTeamSTEPPS to many different

health care settings and popula-tions is an indication that team-work can transform the culture ofan organization through a varietyof different ways:1. Establishes names for behav-

iors and a common languagefor talking about communica-tion failures.

2. Bridges the professional divideand levels the hierarchy oftenseen in health care.

3. Provides teachable-learnableskills and actions to practice.

4. Increases mindfulness, orknowing what is going onaround you.

5. Enlists the patient as a valuedteam member.

TeamSTEPPS in the Medical-Surgical Setting

Medical-surgical health carepersonnel often operate in silosand become frustrated becausetheir voices and opinions are not

heard. Their priorities may be dif-ferent, often causing frustration.The interdisciplinary plan of careoften is difficult to orchestratewhen nurses, physicians, respira-tory therapists, and other healthcare personnel do not have ashared mental model. The toolsfound in TeamSTEPPS can advance

culture change by providing thehealth care workforce with ashared simple set of words todescribe critical communicationbehaviors. As TeamSTEPPS isspread to large numbers of healthcare workers, the issues that aresupporting those silos begin to dis-appear and culture change is seed-ed. With a common language andfocus, the introduction to a seriesof common behaviors gives health

care workers a way to break out ofconstraints of current cultures andexpress what they see and thinkmore freely; the cultural outcomeis collective mindfulness.

Implementation across anorganization is one thing; sustain-ability is more difficult. For achange to a shift of culture to be

successful, a powerful group mustlead the change, and members ofthat group must work together as ateam. Culture change is hard work.It takes leadership commitment,time resources, and focused im-provement. Medical-surgical nurs-es are a powerful group of profes-sionals who, in collaboration withother health care providers, canlead that change.

Order materials:http://www.ahrq.gov/qual/teamstepps/

Preview materials and check for updates:http://dodpatientsafety.usuhs.mil/teamstepps

http://www.health.mil/

Table 1.Resources Available

TeamSTEPPS Instructor Guide. [TeamSTEPPS: Team Strategies & Tools toEnhance Performance and Patient Safety; developed by the Department ofDefense and published by the Agency for Healthcare Research and Quality.]AHRQ Publication No. 06-0020. Rockville (MD): Agency for Healthcare Researchand Quality; September 2006.

TeamSTEPPS Pocket Guide. [Team Strategies & Tools to Enhance Performanceand Patient Safety; developed by the Department of Defense and published by theAgency for Healthcare Research and Quality.] AHRQ Publication No. 06-0020-2.Rockville (MD): Agency for Healthcare Research and Quality; June 2006.

TeamSTEPPS Multimedia Resource Kit. [TeamSTEPPS: Team Strategies &Tools to Enhance Performance and Patient Safety; developed by the Departmentof Defense and published by the Agency for Healthcare Research and Quality.]AHRQ Publication No.06-0020-3. Rockville (MD): Agency for Healthcare Researchand Quality; September 2006.

TeamSTEPPS Guide to Action. [TeamSTEPPS: Team Strategies & Tools toEnhance Performance and Patient Safety; developed by the Department ofDefense and published by the Agency for Healthcare Research and Quality.]AHRQ Publication No.06-0020-4. Rockville (MD): Agency for Healthcare Researchand Quality; September 2006.

TeamSTEPPS Poster. [TeamSTEPPS: Team Strategies & Tools to EnhancePerformance and Patient Safety; developed by the Department of Defense andpublished by the Agency for Healthcare Research and Quality.] AHRQ PublicationNo. 06-0020-5.Rockville (MD): Agency for Healthcare Research and Quality;

September 2006.

Table 2.TeamSTEPPS Citations

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TeamSTEPPS in the Military Health SystemThe MHS mission is to provide optimal health

services in support of the nations military mission(see Tables 1 & 2). The MHS is prepared to respondanytime, anywhere, with comprehensive medicalcapability to military operations, natural disasters,and humanitarian crises around the globe, and toensure delivery of world-class health care to all DoDservice members, retirees, and their families. Effective

teamwork and communication are vital to the success-ful completion of this mission. A part of the MHS visionis to have an integrated team ready to go in harms wayto meet the nations challenges at home or abroad; withthe help of TeamSTEPPS, the vision has become reali-ty. As a source of innovative education, medical train-ing, research, technology and policy, the MHS strivesto provide a bridge to peace. Dr. M. Ward Casscells,assistant secretary of Defense for Health Affairs,reported at the end of 2006 that medical teams werestill saving an unbelievable 90% of soldiers woundedin battle...They did so through a commitment to mak-ing a science of performance, rather than waiting fornew discoveries. And they did it under extraordinari-

ly demanding conditions and with heroic personalsacrifices. Exceptional teamwork has resulted in theunprecedented outcomes that military health carehas achieved during this most recent conflict. TheMHS leadership believes such impressive results are aconsequence of a culture based on innovation, serviceto others, and an unrelenting persistence to achieveexcellence.

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