Building a safety culture takes teamwork

TeamSTEPPS trains HCWs nationwide

Dig down to the root cause of medical error and you’ll often find a lack of communication. Fixing that problem requires more than a checklist. It calls for a shift to a greater sense of teamwork.

That is the concept behind TeamSTEPPS, a program designed to build a culture of safety. While is it geared toward improving patient safety, it also boosts the work environment and employee satisfaction, says Karyn Baum, MD, MSEd, associate chair for clinical improvement at the University of Minnesota Department of Medicine in Minneapolis.

"This isn’t something that is an overnight fix, but it can really be transformative for an organization and for the people who work there," says Baum, a hospitalist who directs one of six training centers for Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS).

Pilots in a cockpit have a systematic way of sharing duties and repeating back information, and they rely on clear communication to prevent accidents. The U.S. Military Healthcare System sought to emulate that model as it designed a teamwork curriculum in 2001 to reduce medical errors in a high-stress environment.

In 2003, the Department of Defense teamed up with the federal Agency for Healthcare Research and Quality to refine the program and make the curriculum widely available. Today, it is gaining traction in hospitals; about 25% of hospitals now use TeamSTEPPS, estimates James B. Battles, PhD, social science analyst with AHRQ in Rockville, MD.

"Poor teamwork is the largest contributing factor to adverse events, bar none," says Battles, who coordinates TeamSTEPPS at AHRQ. "In virtually every incident, if you strip back the contributing factors, you’ll find poor communication and teamwork."

In fact, improving staff communication is one of the Joint Commission’s National Patient Safety Goals for 2013.

Train the trainers

Every year, AHRQ trains about 700 "master trainers," who go back to their hospitals to train their co-workers. Battles suggests hospitals send a physician and a nurse or other clinician who is not a physician.

They may come from a unit that is struggling to work together. For example, hospitals have used Team STEPPS to improve patient handoffs, teamwork in the OR, and conflict resolution. "TeamSTEPPS is a tool amongst all the other tools in our quality improvement and patient safety arsenal," says Baum.

A study of 24 hospitals that adopted TeamSTEPPS and 13 control hospitals found that implementation of the tools led to higher scores on a measure of safety culture. The more fully they followed the program, including monitoring the implementation, the greater the boost in safety culture scores.¹

TeamSTEPPS starts with some self-inspection, both in terms of the problems that will be addressed and the hospital’s readiness for change. Hospital leadership must be completely supportive, Baum says.

"It is about changing your culture," she says. "The leadership needs to be behind that. They’re the ones who set the vision and the priorities."

One core aspect of TeamSTEPPS is briefings, which typically occur at the beginning and end of each shift. They are daily "huddles," and those huddles may occur as needed during the day, as well.

"’What are the issues we all need to be aware of and what’s the game plan today?’ It literally is a huddle," says Baum. "It could last as little as a minute or as long as 15 or 20 minutes."

There may be different configurations of teams, and they all need to have strong and clear communication. A group of caregivers including the physician, nurse, nurses’ aide, and other professional staff may gather to discuss the care of a particular patient. An OR team would huddle before and after a procedure. A unit huddle may be interdisciplinary for example, including environmental services workers who need to be aware of any special disinfecting issues.

In fact, Battles encourages interdisciplinary rounding, instead of having physicians and nurses making separate rounds. "We had to break some old habits," he says.

Battles compares the model to a football game in which the coach briefs the players before they go on the field, but the players also huddle before they start a play.

There may be many analogies, but they share one commonality: teamwork works. "We know that it improves the care of the patient," says Battles. "The work environment in which people practice is also drastically improved."

[Editor’s note: More information about TeamSTEPPS is available at http://teamstepps.ahrq.gov/.]