1. What is TeamSTEPPSTM? Evidence-Based Teamwork System
Background
What is TeamSTEPPSTM?
Evidence-Based Teamwork System
Designed to improve:
Quality
Safety
Efficiency
Practical & Adaptable
TeamSTEPPS stands for: Team Strategies and Tools to Enhance Performance and Patient Safety.
Evidence-Based Teamwork System
TeamSTEPPS is a teamwork system based on 20 years experience and lessons learned from High-Reliability Organizations (HROs) (for example, military operations, aviation, community emergency response services, and nuclear power industries). These types of organizations have been conducting extensive research on how teams work, what makes them effective and how to enhance their performance. This research is directly relevant to health care because delivering effective care requires teamwork.
Designed to Improve Team Effectiveness
TeamSTEPPS has incorporated the best practices from this research into a program to improve the quality, safety, and efficiency of health care by improving communication and other teamwork skills. These skills lead to important team outcomes like enabling the teams to:
Adapt to changing situations.
Have a shared understanding of the care plan.
Develop positive attitudes toward and appreciate the benefits of teamwork.
Provide more safe, reliable, and efficient care.
Practical and Adaptable
Designed with input from the medical community, it is an initiative that will work within the daily functioning of our organization (it is practical) and can be customized (adapted) to meet our organization’s needs.

2. FOR INSTRUCTORS This slide will not show during the presentation
TeamSTEPPS is endorsed by UNC Hospitals and this presentation highlights underlying principles and tools of teamwork that are expected in all work environments to ensure patient safety
We recognize that these tools can be applied or used in different ways, depending on the nature of the work, so please add value to this material by offering specific examples and teamwork expectations from your work area when presenting this information
If you would like to award CME/CNE credit, contact Erin Eckert in advance to complete important requirements and documentation

3. FOR INSTRUCTORS This slide will not show during the presentation
Each slide includes instructor notes to help facilitate the presentation and participant discussions
The presentation includes (optional) embedded YouTube videos
See notes section below for important instructions for using these embedded videos in your presentation
Embedded video instructions:
Using videos is optional and requires a computer with internet access, sound, and access to YouTube
Slides with embedded videos are hidden from the standard presentation and must be “unhidden” to be included
Videos are embedded versions of YouTube videos and include standard YouTube video controls.
IMPORTANT: YouTube videos may include advertising and/or show “suggested videos” at the end that are related to previous content viewed on that computer or account
Consider how presenters will be able to access and control the video controls if they are not directly controlling the slides from a laptop/desktop/mouse
We strongly recommend testing and practicing the videos and presentation in advance on the computer that will be used the day of the training
Please contact Erin Eckert if you have any questions regarding this presentation.

4. FOR INSTRUCTORS This slide will not show during the presentation
contains more information on TeamSTEPPS at UNC, including a list of TeamSTEPPS champions and trainers
Additional TeamSTEPPS training resources, videos, and case studies can be obtained free-of-charge from AHRQ at
Please contact Erin Eckert if you have any questions regarding this presentation.

5. Background
SAY:
Joint Commission data continues to demonstrate the importance of communication and teamwork to patient safety, as they are routinely identified as root causes in reported sentinel events.
We also know that there are numerous barriers to overcome to achieve our goals of team performance and effective communication in our workplaces.

6. Key Components Leadership Communication Situation Monitoring
Background
Key Components
Leadership
Communication
Situation Monitoring
Mutual Support
SAY:
TeamSTEPPS provides a set of tools and strategies that can help us overcome these barriers. There are four key components of teamwork we’ll cover in this session.
Leadership – The ability to coordinate the activities of team members by ensuring team actions are understood, changes in information are shared, and that team members have the necessary resources.
Situation monitoring – Process of actively scanning and assessing situational elements to gain information, understanding, or maintain awareness to support functioning of the team.
Mutual support – The ability to anticipate and support other team members’ needs through accurate knowledge about their responsibilities and workload.
Communication – Process by which information is clearly and accurately exchanged among team members.
Within each of these components, we’ll discuss the specific tools and strategies (identified in the yellow box at the right) that can help us achieve these outcomes.
Optional:
You’ll note that this presentation includes a few references to basketball. UNC’s former Hall of Fame Coach Dean Smith is widely regarded as one of the legends in the sport, responsible for tremendously successful teams and developing basketball teamwork practices that have since been widely adopted as standard practice in the sport and even by business leaders. We find that there are numerous parallels between his teamwork philosophies and the essential components of TeamSTEPPS.

7. Leadership Skills
Organize the team
Leadership
Articulate clear goals
Skillful at conflict resolution
Empower members to speak up and challenge, when appropriate
Make decisions through collective input of members
SAY:
Team leaders must possess a set of effective skills regardless of the type of team that they lead. Team leaders should be able to effectively:
Organize the team
Articulate clear goals
Make decisions based on input of team members
Empower team members to speak up and openly challenge, when appropriate
Promote and facilitate good teamwork
Resolve conflict
Evidence also suggests that effective team leaders are responsible for:
Ensuring that team members are sharing information, monitoring situational cues, resolving conflicts, and helping each other when needed
Manage resources to ensure team performance
Facilitate team actions by communicating through informal exchange sessions
Develop norms for information sharing
Ensure that team members are aware of situational changes to plans
Suggestion for engaging participants; Ask, “Does anyone have an example of a recent experience where either you or another demonstrated these leadership skills? How did that affect the outcome?”
Actively promote and facilitate teamwork
Teams may have designated leaders or situational leaders, depending on the situation.

8. Any team member can request a brief, huddle, or debrief
Leadership
Who is on the team?
Understand & agree upon goals?
Roles & responsibilities are understood?
What is our plan for the day?
Availability of resources?
Problem solving
“Touch-base” when unexpected happens
Discuss critical issues & emerging events
Anticipate outcomes & contingencies
Assign resources
Express concerns
Celebrate teamwork success & accomplishments
What went well or as expected?
What didn’t go according to plan or as expected?
What could be done better or differently the next time?
SAY:
Leaders can request the use of these three strategies or tools that can promote teamwork; briefs, huddles and debriefs. As a team member each of you can request a brief, huddle or debrief if the leader has not thought of doing so. We’ll now spend time reviewing the components of each.
As in aviation, the briefings before flights provide the ideal forum for building a team dynamic that allows everyone to work together when carrying out both routine tasks and when tackling unexpected problems. Briefs serve the following purposes:
They clarify who will be leading the team
They open lines of communication among team members, ensuring that everyone can contribute their unique knowledge base to the task.
Protocols, responsibilities, and expected behaviors are discussed and reinforced so that possible misunderstandings are avoided
They prepare the team for the flow of the procedure, contingency plans, and the means for resolving any unusual circumstances
They convey expectations and reduce disruptive or unexpected behaviors
Huddles are ad hoc planning events that can be used to reestablish situation awareness; reinforce plans already in place: and assess the need to adjust the plan.
Debriefs provide an opportunity for teams to learn and improve in real time. To conduct a debrief after an event, a leader asks questions related to team performance, then summarizes lessons learned and sets any goals for improvement.
At UNC we’ve been using 3 simple questions to guide debriefing; “What went well, What didn’t go well, and What can we do differently next time”.
Any team member can request
a brief, huddle, or debrief

9. Leadership
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Video runs for 3:39
SAY:
This is an example of a brief in the Operating Room here at UNC. Dr. Ewend is engaging the entire team in a discussion of the plan, what to expect during the surgery, and asking for any questions or concerns so they can be addressed prior to starting the case.
OR Brief

10. Leadership
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Video runs for 2:37
SAY:
This is an example of a debrief in the Operating Room here at UNC. The entire team offers their perspective on what went well, what didn’t go well (or go according to plan), and what could be done differently in future cases.
OR Debrief

11. Communication
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Video runs for :40
German Coast Guard Video
SAY:
We often think that we’re excellent communicators, but we’ve all experienced this scenario before.

12. Communication Tools
Call-out informs all members simultaneously during team events
Check-backs use closed-loop communication to verify information
SBAR-Q provides a standardized framework for communicating about a situation or patient's condition
Communication
SAY:
Standards of communication are essential for developing teamwork and fostering a culture of patient safety. These tools help to avoid communication breakdowns that lead to patient harm.
A call-out is a tactic used to communicate critical information during a team event. Critical information called out in these situations helps the team anticipate and prepare for vital next steps in patient care. It also benefits a recorder when present during a code or emergent event.
A check-back is a closed-loop communication strategy used to verify and validate information exchanged. The strategy involves the sender initiating a message, the receiver accepting the message and confirming what was communicated, and the sender verifying that the message was received.
SBAR-Q provides a standardized framework for members of the healthcare team to communicate about a patient's condition. It provides members of the team with an easy and focused way to set expectations for what will be communicated and how. In phrasing a conversation with another member of the team, consider the following:
Situation—What is happening with the patient?
Background—What is the clinical background?
Assessment—What do I think the problem is?
Recommendation—What would I recommend?
Question – Ask the recipient if they have any questions about the information I just shared.

13. Situation Monitoring Actively scanning the situation & environment
Mutual respect
Accountability
Engage the patient
& family when possible
Supports cross monitoring
“Watch each other’s back”
Situation Monitoring
SAY:
Situation Monitoring is defined as the process of actively scanning behaviors and actions to assess elements of the situation or environment. It enables team members to identify the potential issues or minor deviations early enough so that they can correct and handle them before they become a problem or pose harm to the patient.
The benefits of situation monitoring are that it fosters mutual respect and team accountability, and through the process of cross-monitoring provides a safety net for both the patient and the team. Examples of situation monitoring include assessing the patient's condition, noting malfunctioning equipment, and being aware of workload spikes and stress levels among team members.
Finally, remember that you should engage the patient and/or family whenever possible.
Cross monitoring is used by fellow team members to help maintain situation awareness and prevent errors. Commonly referred to as “watching each other’s back,” it is the action of monitoring the behavior of other team members by providing feedback and keeping track of fellow team members’ behaviors to ensure that procedures are being followed appropriately. It allows team members to self-correct their actions if necessary. Cross monitoring is not a way to “spy” on other team members, rather it is a way to provide a safety net or error-prevention mechanism for the team, ensuring that mistakes or oversights are caught early. When all members of the team trust the intentions of their fellow team members, a strong sense of team orientation and a high degree of psychological safety result.
“Coaching is all about adjustments. Your game plan is only good for the first six minutes...” Roy Williams

14. Situation Monitoring The Monkey Business Illusion Situation Monitoring
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Video runs for 1:35
The “Monkey Business Illusion” shows us how easy it can be to overlook changes in the environment when we’re intently focused on a task, or anticipating a specific change/event to take place. As a team, we must always be scanned for unexpected or unforeseen events and communicating about them.
The Monkey Business Illusion

15. Shared Mental Models Shared perspective of the situation
Regularly exchange information to stay “on the same page”
Situation Monitoring
SAY:
When teams are actively scanning the environment and effectively communicating with one another, they develop a “shared mental model” about the situation. In other words, they are “on the same page” regarding the situation at hand.
As you can see in this image, failing to continually assess the situation and communicate within and among teams can lead to unintended and undesirable outcomes.

16. Shared Mental Models Shared perspective of the situation
Regularly exchange information to stay “on the same page”
Situation Monitoring
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SAY:
Having a shared mental model supports individuals with interdependent roles and responsibilities within a process or system. Understanding the bigger picture can help teams anticipate next steps or make adjustments when they see pieces of the process that aren’t working as expected.

17. Shared Mental Models Situation Monitoring
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SAY:
Does this team have a Shared Mental Model about this situation?
To prompt discussion, ask, “who should be speaking up in this situation? Have you ever experienced a situation like this on your team?”

18. Situation Monitoring The Monkey Business Illusion Situation Monitoring
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In 2016, the UNC Trauma Program developed a new resuscitation process through a series of meetings and simulated walk-throughs. Based on ATLS principles, the new process consists of four phases: 1) preparation; 2) identify and fix shock; 3) secondary survey and 4) disposition and transport.
This slide was created by UNC Trauma to help members of the resuscitation team understand their roles, but also how their roles align with and are interdependent with those of their teammates, thus enabling the team to improve their Shared Mental Model of the overall process.
The Monkey Business Illusion

19. Ferrari F-1 Perfection Situation Monitoring
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Ferrari F-1 Video
SAY:
Do you think this team has a shared mental model regarding the steps in this process and how individuals must work together to achieve the common goal? How was that developed and how do they improve?
Ferrari F-1 Perfection

20. Mutual Support Error vulnerability increases:
under stress
when fatigued
in high-task situations
Foster a climate where assistance will be actively sought and offered
SAY:
Error vulnerability is increased when people are under stress, are in high-task situations, and when they are fatigued. One of the most important concepts to remember with regard to task assistance is that assistance should be actively given and offered whenever there is a concern for patient safety related to workload. Always remember the focus should be on patient safety rather than the individual’s need or preference for task assistance. We are all vulnerable to making errors under these conditions and no one is “above” or immune from needing assistance at times.
To a certain degree, some of us have been conditioned to avoid asking for help because of the fear of suggesting lack of knowledge or confidence. Many people refuse to seek or accept assistance when overwhelmed by tasks. In support of patient safety, however, task assistance is expected. Task assistance may involve asking for assistance when overwhelmed or unsure; helping team members to perform their tasks, shifting workload by redistributing tasks to other team members, delaying/rerouting work so the overburdened member can recover, and/or filling in for overburdened team members when necessary.
Mutual Support
“There is a real strength derived from depending on one another.” Dean Smith

21. Mutual Support Mutual Support
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In a true team, there can be no individual success if the team doesn’t accomplish its goals. We must all support each other if we are to achieve our shared goal of safe and effective patient care.
Mutual Support

22. Advocacy and Assertion
Assert a corrective action in a firm and respectful manner
Advocate for the patient
Use CUS words when appropriate!
Concerned, Uncomfortable, Safety issue
“Two Challenge Rule”
Be persistent and seek help if needed
SAY:
Advocacy and assertion interventions are invoked when a team member’s viewpoint does not coincide with that of a decision maker. You should respectfully advocate for the patient even when your viewpoint is unpopular, is in opposition to another person's view, or questions authority. You should be persistent and persuasive, providing evidence or data for your concerns.
Using the CUS technique provides another framework for conflict resolution, advocacy, and mutual support. “CUS” and other signal phrases are designed to catch people’s attention. When they are spoken, all team members will understand clearly not only the issue but also the magnitude of the issue.
First, state your concern, then state why you are uncomfortable.
If the conflict is not resolved, state that there is a safety issue and discuss. If the safety issue is not acknowledged, a supervisor should be notified.
It is important to voice your concern by advocating and asserting your statement at least twice if the initial assertion is ignored (thus the name, “Two-Challenge rule”). This tactic ensures that an expressed concern has been heard, understood, and acknowledged. If after two attempts the concern is still disregarded, but the member believes patient or staff safety is or may be severely compromised, the Two-Challenge rule mandates taking a stronger course of action or using a supervisor or chain of command.
Mutual Support

23. Advocacy and Assertion
Empower all team members to “stop the line” for safety
If you are challenged:
Pause what you’re doing
Listen and take the concern seriously
Work to address the concern
Preventing errors protects the patient and the team
SAY:
We want every member of the team to feel empowered to speak up using these techniques to “stop the line” and prevent actions that could lead to patient harm. This is an action that should never be taken lightly, but requires immediate cessation of the process to resolve the safety issue.
If you personally are challenged by a team member, it is your responsibility to acknowledge the concerns instead of ignoring the person.
Remember – if someone says these words to you, pause what you’re doing and listen/take the concern seriously.
We all share responsibility for preventing actions that could lead to patient harm. Being a part of a team means that we also share responsibility for protecting each other from making these kinds of mistakes. Speaking up is a form of mutual support and we should all appreciate anyone willing to help us in this manner, even if it feels uncomfortable or embarrassing in the moment.
Suggestion for engaging participants; Ask, “ What’s the worst that can happen if you don’t speak up? “ “What makes speaking up uncomfortable?” “Will speaking up always get the response you are hoping for, if not what do you do?”
Mutual Support

24. SAY:
The best teams know that teamwork requires trust, hard work, lots of practice, and a commitment to continuous improvement. Teams that practice these TeamSTEPPS tools and strategies will be well-equipped to:
Adapt to changing situations
Have a shared understanding of the care plan.
Develop positive attitudes toward and appreciate the benefits of teamwork.
Provide more safe, reliable, and efficient care.
Optional:
The Hall of Fame Coach of the UNC Tar Heels, Dean Smith explained his teamwork philosophy (Play Hard, Play Smart, Play Together) in a story from his book, “The Carolina Way: Leadership Lessons from a Life in Coaching.”
When asked by a fellow coach, “How do you teach your team not to ever give up?,” Coach Smith once said:
“We try to execute well on each possession and fall back on our philosophy of playing hard, playing together, and playing smart. We always believe we have a chance if we do those things.”
We believe that the “Carolina Way” can also describe how we approach teamwork in our healthcare teams.

25. Team Resilience Mutual Support
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SAY:
Resilience is often described as the ability to “bounce back” after difficulty. Although not officially one of the TeamSTEPPS tools or strategies, there are times that your work will be difficult or demanding and we should consider how teamwork can influence our ability to handle these situations. While we typically discuss resilience as something that individuals build for themselves, when we look at the five components of how individuals can boost their resilience, we see a few areas with potential connections to teamwork.
Individuals can build resilience through relationships – we spend a lot of time together at work! Supporting each other and regularly showing appreciation can be very powerful.
Self-care is also extremely important, but can sometimes be difficult to practice if others don’t have your back. When you take care of someone’s patient so they can get a lunch break, or give someone permission to step away for some fresh air or a cup of coffee, you are letting them practice self-care that will enable them to perform more effectively and replenish their energy, attention, or emotions. Teams can help by role modeling their own self-care practices, encouraging individuals to practice self-care, and removing barriers to this practice by offering task assistance and mutual support.
Mutual Support