TeamSTEPPS®, Team Strategies and Tools to Enhance Performance and Patient Safety, is an evidence-based framework to optimize team performance among health care professionals. The TeamSTEPPS training curriculum includes a comprehensive set of ready to-use tools, materials, and instructions for integrating teamwork principles successfully into the health care system. In this section, we review the facilitator and coach roles and describe our approach to training. We also present some of the communication tools that we found were critical to effective teamwork (namely, briefings, debriefings, and handoffs) and provide sample tools. Further training and coaching materials are available at the national TeamSTEPPS Web site.
The Facilitator’s Role
The facilitator should be a TeamSTEPPS Master Trainer who has primary responsibility for facilitating the training of staff in all units and for supporting coaches in early implementation of TeamSTEPPS in the units. Master Trainers have advanced teamwork training and can provide consultation to units and departments implementing teamwork, perform site assessments, and determine performance gaps. When first working with a particular unit, the facilitator should partner with a clinical team member interested in TeamSTEPPS, who can affirm and further describe findings from the readiness assessment completed earlier (described in Getting Started).
The facilitator’s role in the training process involves both working with nursing and physician leaders to schedule the training sessions and leading the sessions along with a TeamSTEPPS Master Trainer from the unit. It is advantageous to have skilled trainers from the unit co-lead the training sessions for that unit because staff members are able to relate to them, and they can provide real life examples. In addition, if the Master Trainer is also a formal unit leader, his/her active involvement in the training sessions is a visible indication of leadership support.
Following the training phase, the facilitator continues to work with the unit teams, providing process improvement support for implementation of tools and strategies (e.g., adapting the debrief form per the unit team’s specifications, providing copies of the form, and following up with the unit team after they have tried a few debriefs). It is important for the facilitator to be aware of the team dynamics in the unit, identify informal leaders and understand their level of buy-in, and be able to adapt to the environment.
At the core of the TeamSTEPPS framework are four skills: leadership, situation monitoring, mutual support, and communication. In Project TICKER, we trained all units in these four core skills through either “Ready Training,” a modification of the national AHRQ training for staff members who are new to TeamSTEPPS, or “Booster Training,” a refresher session for staff members who had been trained in TeamSTEPPS previously. The training sessions are led by two Master Trainers: the project’s TeamSTEPPS facilitator and a clinical provider in the participating unit.
The scenarios and role play exercises used in the Ready Training should be tailored to each particular clinical area and the patient population it serves. So, for example, the teamwork scenarios used during the training of the operating room would not be the same as those for the cardiac intermediate care unit. In developing the scenarios, we suggest seeking input from Master Trainers in each unit. For the Booster Training, rather than use role play, you can emphasize the importance of using tools and strategies as soon as possible. Ask participants, “What would you be comfortable trying today?”
Scheduling and staff turnover can be issues for some units being trained, so we decided to hold multiple training sessions until we had trained 85% of staff from each clinical area. We thought that reaching this critical proportion of staff trained would help ensure spread of the communication techniques to the 15% of untrained staff. Once we had documented that 85% of staff from a particular unit received the training, we considered the training phase to be complete. The facilitator then worked with unit staff to try out the tools and address structured handoffs.
Tools in Practice
In Project TICKER, we found that briefings, debriefings, and handoffs were three powerful tools for building teamwork capacity. Here we describe each of these tools and provide specific examples for how you might incorporate them into your program. Teamwork events as discussed here could be emergent situations such as codes, falls, or unplanned extubations, or they could be planned teamwork events such as morning rounds or staff meetings.
Prior to the start of a teamwork event, teams should hold a briefing. During this short planning session, teams:
- Discuss team formation,
- Assign essential roles,
- Establish expectations and climate,
- Anticipate outcomes, and
- Develop contingency plans.
The designated team leader is responsible for calling a briefing, but if the leader has not done so, anyone on the team can request one. In the briefing, the leader should empower all team members to speak up about concerns during the event and encourage the use of TeamSTEPPS skills. Documenting the discussion using a brief/debrief form can help teams with future teamwork planning and performance improvement.
Debriefings can be used after any team event—simple and routine, or complex and emergent. During a debriefing, teams recount and document key events; analyze why the event occurred; review what worked and what did not work in regards to teamwork; and discuss lessons learned and how they will alter the plan next time.
Debriefings can be structured by asking three questions:
- What went well?
- What didn’t go well?
- What could we do better next time?
Key considerations during the discussion include whether communication was clear and effective both before and during the event, whether all team members understood their roles and responsibilities, whether team members maintained situational awareness, whether the workload was efficiently and effectively distributed, whether team members asked for or offered assistance when needed, and whether errors were made or avoided.
Debriefings should be initiated by the team leader, but any member of the team should feel comfortable asking for a debriefing if the leader has not called for one. Ideally, all team members should participate in the debriefing, but if some members are not able or willing to participate, the debriefing is still valuable. During the discussion, the team leader should not assign blame or failure to an individual; mistakes should be viewed as learning opportunities. Whenever possible, a team member should document the discussion and save it for future reference using a form such as the one at the end of this section.
Project TICKER’s family advisors suggested using a debrief approach with families when a child has an unexpected cardiac event. The clinical team should find out the family’s perspective on what went well, what needed improvement, and how a similar unexpected event could be better handled in the future. This allows the clinical team to have a fuller perspective.
During a handoff, care of a patient and pertinent information about the patient’s state are transferred across the care continuum in a structured communication format. An effective handoff provides both parties with an opportunity to ask questions and clarify/confirm the transfer of responsibility and accountability.
It is important to communicate verbally and, when uncertainty exists, clear up all ambiguity before the transfer is completed. Until it is acknowledged that the handoff is understood and accepted, responsibility for the patient should not be relinquished. Handoffs are a good time to review and confirm a shared mental model for both safety and quality.
In Project TICKER, we focused specifically on handoffs that we knew needed to be improved: OR to ICU and NICU to PICU/CICU. The OR to PICU/CICU handoff tool describes the communication and steps leading up to the PICU/CICU team’s acceptance of responsibility from the anesthesia team. The NICU to PICU/CICU tools include: 1) a process flow diagram using a format known as SBARq (Situation, Background, Assessment, Recommendation, Questions) and 2) a nurse handoff/communication form with a more detailed SBARq.
The Role of the Coach
The coach’s primary role is to observe teamwork events and check in with people to find out how things are improving following TeamSTEPPS training. This coaching period is critical and helps reinforce teamwork training and sustain teamwork improvements. The best coaches are unit-based and have the skills and confidence to mentor their peers in best teamwork behavior. Some characteristics used to describe an effective coach are well-respected, positive, enthusiastic, supportive, and observant. Generally, coaches emerge during the training and early implementation phases as individuals who try the tools immediately and are respected by their peers in doing so. For Project TICKER, we asked unit leaders to help identify the coaches and recognize them in the role.
We tried coaching entire teams at the same time, but found that coaching sometimes works best on an individual level. In addition, we found that some units can be difficult to coach because of the nature of their work/the system (e.g., operating room). One coaching strategy would be to observe team events, and then provide coaching to the team leader afterward. Over time, that person will begin to serve as a champion/model for best teamwork behavior and will be able to coach others to do the same.
The UNC Health Care TeamSTEPPS Web site includes examples of coaching for each of the four skills.