Slides from the webinar on TeamSTEPPS provided by Professor George Vukotich, Ph.D. for the University of Illinois Medical School - Patient Safety Leadership Program

1. Using TeamSTEPPS® to Build a Culture of Safety in Healthcare
University of Illinois-Chicago: Patient Safety Leadership – George Vukotich, Ph.D.

2. George Vukotich, Ph.D.
- Teaching in the PSL program since 2013
- 28-Years in the Military – The last 8-years as a Health Services Administrator
- First became familiar with TeamSTEPPS at Walter Reed National Military Medical Center in 2013
- Outside of teaching, work with startup companies in areas related to innovation

3. AGENDA
- Medical Errors
- How TeamSTEPPS Works
- How You Might Implement
- TeamSTEPPS Tools
- Resources

4. TO ERR IS HUMAN
DREW ATTENTION TO THE MEDICAL ERRORS
"To Err is Human" - A patient safety documentary
Directed by Michael Eisenberg - 2018
"To Err is Human" - The book based on the study
by the Institute of Medicine - 1999
“Crossing the Quality Chasm” - by the Institute of Medicine - 2001.
A follow-up to To Err Is Human.
Crossing the Quality Chasm advocates for a fundamental redesign
of the U.S. health care system.

5. TO ERR IS HUMAN

6. CAUSES OF DEATH IN THE U.S.
CAUSES OF DEATH IN THE
UNITED STATES:
- Heart Disease: 611,000
- Cancer: 585,000
- Medical Error: 225,000
- Lung Disease: 149,000
- Suicide: 41,000
- Firearms: 34,000
- Motor Vehicles: 34,000
as a

7. A recent study by Johns Hopkins indicated Medical Errors are the third leading cause of
death in the U.S., after heart disease and cancer, causing over 250,000 deaths every year.
The authors of the Johns Hopkins study, led by Dr. Martin Makary of the Johns Hopkins
University School of Medicine, have appealed to the CDC to change the way in which it
collects data from death certificates. To date, no changes have been made.
Other studies report much higher figures, claiming the number of deaths from
medical error to be as high as 440,000.
The reason for the discrepancy is that physicians, funeral directors, coroners and
medical examiners rarely note on death certificates the human errors and system
failures involved.
IN-CONSISTENCY OF NUMBERS

8. WHY DO MEDICAL ERRORS OCCUR
- Inconsistent Schedules
- Fluctuating Workloads
- Interruptions
- Fatigue
- Failure to Follow-up
- Poor handoffs
- Ineffective Communication
- Protocol Not Being Followed
- Complacency
- Lack of Training

9. CONTRIBUTING FACTORS TO MEDICAL ERRORS

10. LIFE EXPECTANCY INCREASING

11. REGARDLESS OF THE CAUSE - MEDICAL ERRORS CAN BE DECREASED
TeamSTEPPS IS ONE TOOL THAT CAN HELP
Developed in 2005 TeamSTEPPS is a teamwork system developed jointly by the
Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ)
to improve institutional collaboration and communication relating to patient safety.
TeamSTEPPS is specifically designed as a resource for health care providers to improve
patient safety through effective communication and teamwork skills.
Team – Strategies & Tools to Enhance Performance & Patient Safety
GOAL of TeamSTEPPS: To produce highly effective medical teams that optimize the use
of information, people, and resources to achieve the best clinical outcomes for patients.

12. DRIVING FACTORS – MILITARY - HIGH RISK ENVIRONMENTS

13. LEARNING FROM – HIGH RISK ENVIRONMENTS
In one study at VA hospitals, communication
failure was the primary contributing factor in
almost 80 percent of more than 6,000 root cause
analyses of adverse events and close calls.
Other high-reliability organizations such as
aviation operations, community emergency
response systems and nuclear power industries.
All of these industries focus on mitigating risk,
accident avoidance and accident recovery,
which are crucial and applicable to health care.

14. TIP OF THE ICEBERG

15. TeamSTEPPS - IMPLEMENTATION

16. WHERE TO START – CULTURAL ASSESSMENT

17. - Communication
The effective exchange of information
among team members.
- Leadership
Assigning, coordinating, and motivating
team members for optimal performance.
- Situational Monitoring
Create common understandings and
shared mental models.
- Mutual Support
Anticipate needs and balance workloads
to support each other.
TeamSTEPPS TOOLS – BASED ON FOUR CORE SKILLS

18. TeamSTEPPS - TEAM COMPETENCY OUTCOMES
- Knowledge
- Shared mental models
- Attitudes
- Mutual Trust
- Team Orientation
- Performance
- Adaptability
- Accuracy
- Productivity
- Efficiency
- Safety

19. TeamSTEPPS TOOLS – INSTRUCTORS MANUAL
TeamSTEPPS Materials:
Implementation Guide: Detailed (PDF File, 368 KB)
Course Management Guide (PDF File, 358 KB)
Specialty Scenarios:
•Ambulatory Care (PDF File, 231 KB)
•Ancillary Services (PDF File, 261 KB)
•Med-Surg (PDF File, 241 KB)
•Dental (PDF File, 226 KB)
•Neonatal ICU (PDF File, 215 KB)
•ICU (PDF File, 225 KB)
•ED (PDF File, 251 KB)
•OR (PDF File, 258 KB)
•L&D (PDF File, 308 KB)
•Combat Care (PDF File, 265 KB)
Measurement Tools:
•Sample Course Evaluation Form (MS Word File, 159 KB)
•TeamSTEPPS Teamwork Attitudes Questionnaire (PDF File, 169 KB)
•Learning Benchmarks (PDF File, 112 KB)
•Team Performance Observation Tool (PDF File, 72 KB)
•TeamSTEPPS Teamwork Perceptions Questionnaire (PDF File, 234 KB)

20. TeamSTEPPS TOOLS – INSTRUCTORS MANUAL
Module 4: Leading Teams:
•Instructor's Guide (PDF File, 329 KB)
•Classroom Slides (PowerPoint® File, 1.88 MB)
•Evidence Base (PDF File, 206 KB)
•Briefing Exercise Sheet (PDF File, 111 KB)
•Leadership Exercise Sheet (PDF File, 96 KB)
Module 5: Situation Monitoring:
•Instructor's Guide (PDF File, 907 KB)
•Classroom Slides (PowerPoint® File, 2.24 MB)
•Evidence Base (PDF File, 203 KB)
Module 6: Mutual Support:
•Instructor's Guide (PDF File, 486 KB)
•Classroom Slides (PowerPoint® File, 1.97 MB)
•Evidence Base (PDF File, 205 KB)
Module 1: Introduction:
•Instructor's Guide (PDF File, 392 KB)
•Classroom Slides (PowerPoint® File, 1 MB)
•Evidence Base (PDF File, 232 KB)
•Implementation Worksheet (PDF File, 198
KB)
Module 2: Team Structure:
•Instructor's Guide (PDF File, 292 KB)
•Classroom Slides (PowerPoint® File, 1.44
MB)
•Evidence Base (PDF File, 294 KB)
•Multi-Team System / Teams and Teamwork
Exercise Sheet (PDF File, 151 KB)
Module 3: Communication:
•Instructor's Guide (PDF File, 329 KB)
•Classroom Slides (PowerPoint® File, 2.3
MB)
•Evidence Base (PDF File, 205 KB)

21. TeamSTEPPS TOOLS – INSTRUCTORS MANUAL
Module 7: Summary—Pulling It All Together:
•Instructor's Guide (PDF File, 267 KB)
•Classroom Slides (PowerPoint® File, 1.16 MB)
•Summary Skills Practice Exercise Sheet (PDF File,
159 KB)
Module 8: Change Management:
•Instructor's Guide (PDF File, 346 KB)
•Classroom Slides (PowerPoint® File, 1.52 MB)
Module 9: Coaching Workshop:
•Instructor's Guide (PDF File, 465 KB)
•Classroom Slides (PowerPoint® File, 1.47 MB)
•Coaching Feedback Form (PDF File, 104 KB)
•Coaching Scenarios (PDF File, 213 KB)
•Self-Assessment (PDF File, 254 KB)
Module 10: Measurement:
•Instructor's Guide (PDF File, 661 KB)
•Classroom Slides (PowerPoint® File, 530 KB)
•Evaluating TeamSTEPPS Worksheet (PDF File, 158 KB)
Module 11: Implementation Workshop:
•Instructor's Guide (PDF File, 324 KB)
•Classroom Slides (PowerPoint® File, 710 KB)
Module 12: Practice Teaching Session:
•Instructor's Guide (PDF File, 147 KB)
•Classroom Slides (PowerPoint® File, 455 KB)
•Teaching Feedback Form (PDF File, 101 KB)
Acknowledgments:
•Acknowledgments (PDF File, 37 KB)

22. Set the Stage
1. Create a sense of urgency.
2. Build the guiding team.
Decide What to Do
3. Develop a change vision and strategy.
Make it Happen
4. Communicate for understanding and buy in.
5. Empower others to act.
6. Produce short-term wins.
7. Don’t let up.
Make it Stick
8. Create a new culture.
The 8 Steps of Change
TeamSTEPPS – SETTING THE STAGE FOR CHANGE

23. TeamSTEPPS – TEAMWORK

24. TeamSTEPPS – TEAMWORK

25. TeamSTEPPS – TEAMWORK

26. TeamSTEPPS CURRICULUM

27. TeamSTEPPS IMPLEMENTATION

28. TeamSTEPPS – Putting the Pieces Together

29. TeamSTEPPS – Creating a Culture of Safety

30. Designed to help develop and deploy customized plans to train staff in teamwork skills and lead a medical teamwork
improvement initiatives
TeamSTEPPS 2.0 includes several significant changes:
A measurement module has been added that provides information about how to measure the impact of TeamSTEPPS and the
available tools to support evaluation.
The communication module has been moved up in the order of instruction to better align with the emphasis on communicating
early and often to improve teamwork.
The course management guide has been updated to include TeamSTEPPS modules and versions that have been added for the
user's reference.
There are supplemental versions of TeamSTEPPS that are focused on working in the environments of primary care offices and
long-term care environments. In addition, there is a module on "Enhancing Safety for Patients with Limited English Proficiency."
Training Curricula & Ready-to-Use Materials
For health care organizations that are interested in implementing TeamSTEPPS, numerous training curricula and ready-to-use
materials are available. Visit the Agency for Healthcare Research and Quality web site
TeamSTEPPS 2.0 – UPDATE AND RELEASED BY AHRQ 2014

31. TeamSTEPPS - TIMELINE

32. TeamSTEPPS – Growing as Individuals Transition from
Military to Civilian Careers

33. TeamSTEPPS – Contributing to the Patient Safety
Improvement Process

34. NATIONAL PATIENT SAFETY FOUNDATION
RECOMMENDATIONS
1. Create a culture of safety.
2. Create a centralized and coordinated approach to patient safety.
3. Create a common set of safety metrics that reflect meaningful
outcomes.
4. Prioritize funding for research in patient safety and
implementation science.
5. Address safety across the entire care continuum.
6. Support the health care workforce.
7. Partner with patients and families for the safest care.
8. Ensure that technology is safe and optimized to improve patient
safety.

35. Advances in Patient Safety - New Directions and Alternative Approaches:
https://www.ncbi.nlm.nih.gov/books/NBK43686/
Agency for Healthcare Research and Quality:
https://www.ahrq.gov/teamstepps/instructor/index.html
DOD Patient Safety Resources:
https://www.onlineregistrationcenter.com/register/222/page1.asp?m=250&c=5364
Improving Patient SafetyCulture Through Teamwork and Communication:
https://www.aha.org/system/files/2018-01/2015_teamstepps_FINAL.pdf
TeamSTEPPS Guide to Action:
https://www.onlineregistrationcenter.com/company_images/347/TeamSTEPPS_GuideToAction.pdf
TeamSTEPPS Instructors Manual:
https://www.ahrq.gov/teamstepps/instructor/printver/index.html
TeamSTEPPS – RESOURCES

36. QUESTIONS