Ten years ago, the Agency for Healthcare Research and Quality (AHRQ), in collaboration with the Department of Defense (DoD), released Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS), designed to serve as the national standard for team training in health care. TeamSTEPPS was the result of a multi-year research and development project jointly funded by AHRQ and DoD.(1,2) In 2006, it was unclear if health professionals would find value in TeamSTEPPS training; however, since then tens of thousands of individuals throughout the world have been trained using the program. Moreover, TeamSTEPPS stimulated research on how health care teams function, ways to improve care coordination, and the link between teamwork and clinical process and outcome measures. Today, there is little dispute about the importance of teamwork in delivering safe, quality care and the need for team training.
The purpose of this article is to provide 10 insights about team training in health care that we have learned from a decade of TeamSTEPPS. We developed these insights based on our personal involvement in the AHRQ-funded National Implementation of TeamSTEPPS and efforts throughout the DoD. We also had the privilege of meeting annually with implementers of TeamSTEPPS at the TeamSTEPPS National Meeting—originally consisting of about 30 participants in 2006 and close to 600 individuals in 2016. Finally, we implemented TeamSTEPPS in clinical settings and conducted research on how to improve patient safety through better teamwork.
Insight 1. Patient safety, care quality, and care coordination are highly related
When TeamSTEPPS launched 10 years ago, skeptics asked us to show them the evidence that TeamSTEPPS worked. Although TeamSTEPPS is evidence-based, the foundational work was conducted in domains outside of health care. Further, there was little research on the link between TeamSTEPPS and improvements in clinical process and patient outcomes.
Since 2006, research on the relationship between teamwork and patient safety has grown significantly. A recent meta-analysis of 129 studies on team training in health care found a significant association between programs like TeamSTEPPS and participant learning, training transfer, and organizational outcomes.(3) A decade of research indicates that TeamSTEPPS improves the care delivered to patients.
Insight 2. The next decade needs to tackle culture change
Despite the strides that have been made, numerous questions remain about how to best implement and sustain TeamSTEPPS tools in different clinical environments and ways to integrate teamwork principles into the delivery of care and daily practice. Even after a decade, organizations continue to struggle with organizational change initiatives. TeamSTEPPS is still considered a significant change in how health care professionals work together to deliver care. We have found that participants' knowledge about the core TeamSTEPPS tools has greatly increased since 2006, but knowledge about how to change organizational culture and sustain it has not.
Insight 3. Health professions education is embracing team training
Interprofessional education and embedding team concepts into health professions schools did not really catch fire until recently. Ten years ago, we observed an effort by Duke University and the University of North Carolina to conduct a daylong training of nursing and medical students using components of TeamSTEPPS and simulation. Around that time, we also authored an article on how to embed TeamSTEPPS in medical education.(4) Since then, interprofessional education has grown significantly. New medical schools generally include an interprofessional education component, and most schools, new and old, employ simulation. We feel that interprofessional education is foundational for improved care coordination and enhanced patient safety. While research shows that TeamSTEPPS works, it is much harder to change behaviors that are established than to teach the correct behavior from the beginning.
Insight 4. Health care reform creates new opportunities
Health care reform has brought the importance of quality to the forefront. Increasingly, service quality, patient outcomes, patient satisfaction, and resource utilization have a significant effect on provider reimbursement. While the quality of teamwork is not directly assessed in new payment models (although it is undoubtedly related to many of the outcomes that are assessed), that may well change. Opportunity now exists to validate the importance of teamwork by developing measures of how well care is coordinated. It now seems like the time is right to consider teamwork assessments as part of a hospital and provider certification and perhaps even reimbursement. In vivo simulation can allow for this kind of assessment.
Insight 5. TeamSTEPPS has no boundaries
When we launched the national implementation of TeamSTEPPS, we trained a team of researchers and providers from Australia. These individuals then customized TeamSTEPPS and applied it throughout southwest Australia with tremendous success. Since then, we know of similar efforts in Africa, Asia, Europe, South America, and the Middle East. TeamSTEPPS was studied and in 2015, recognized by the World Innovation Summit for Health as one of eight global innovations that has successfully been diffused in a relatively short period of time and achieved tangible widespread results. We have been amazed at the interest in and uptake of TeamSTEPPS abroad, especially given the wide variation in health care and national cultures. Despite these differences, we have found the core TeamSTEPPS tools and strategies—including briefs, huddles, and debriefs—to be generalizable across cultures, and the need for improved care coordination is universal.
Insight 6. TeamSTEPPS flourishes when combined with simulation
In the past decade, the advancement of technology and the spread of simulation have mirrored the spread of TeamSTEPPS. Patient simulation is now relatively common in education, skills training, and recertification. Simulation has become vital for allowing teams to practice using the TeamSTEPPS tools and strategies. In the context of teamwork, fidelity of the simulation is usually less important than how the simulation scenarios are designed, which measures are employed, and how feedback is provided. Currently, three of the Regional National TeamSTEPPS Training Centers have incorporated various levels of simulation into TeamSTEPPS Master Training. In these classes, high- and low-fidelity simulations, in class participants practice using TeamSTEPPS while others observe their performance and provide skill-based feedback, are included. A decade ago, none of this was possible; but now, simulation and advancements in scenario design and teamwork measurement have become important supplements to TeamSTEPPS.
Insight 7. Physicians are advocates of teamwork
Early on, it could be argued that TeamSTEPPS was a "nursing initiative." In fact, few physicians attended TeamSTEPPS training. In the last five years, however, there has been a shift. Physicians now make up about 10% of all participants. Moreover, we have observed that physicians are also more likely to believe in the importance of teamwork and embrace the TeamSTEPPS tools and strategies. When physician leaders serve as TeamSTEPPS champions, organizations tend to achieve greater success. Early on, this was not the case. A few physicians we collaborated with during the development of TeamSTEPPS argued that concepts like "mutual performance monitoring" challenged a physician's authority. Now physicians are more supportive of teamwork, see value in TeamSTEPPS, and often are the biggest advocates for its implementation and use.
Insight 8. Spread versus depth was the right prescription
When we launched the TeamSTEPPS National Implementation project, we debated whether we should maximize the number of new Master Trainers or provide direct support to implementers. We decided to focus on training as many individuals as resources would allow. We were aided by the Centers for Medicare and Medicaid Services, which required each of its Quality Improvement Organizations to train two Master Trainers. And so, from 2008 to 2010, more than 3500 new Master Trainers were trained by AHRQ, and these early adopters trained others and implemented the tools and strategies with great success. Northwell Health, one of these early adopters, trained every single individual in their large health care system and showed significant, positive results.(5)
Insight 9. The second "P" was critical
Originally, TeamSTEPPS only contained one "P" (for "Patient Safety"). Dr. John Webster, an orthopedic surgeon involved in early planning, was adamant about including another "P" (for "performance"). His argument was that the program needed to not only be about improving patient safety but also had to drive high levels of clinical team performance. He felt this would appeal to his physician colleagues as well as hospital administration. Dr. Webster was right. We have discovered over the last 10 years that TeamSTEPPS enhances clinical team performance, which in turn improves patient safety.
Insight 10. We have been humbled and amazed by TeamSTEPPS
None of us would have imagined the level of uptake that has occurred with TeamSTEPPS. Today, we estimate that 35% of all health care workers have been exposed to TeamSTEPPS. Globally, this uptake is harder to estimate; we are always amazed when we receive a call from Europe, see a TeamSTEPPS pocket guide in Arabic, or hear about efforts to establish a training center in South America. TeamSTEPPS has taken on a life of its own, and we are humbled and overjoyed that it has proven to be such a valued patient safety resource.
In conclusion, the next decade is likely to see further growth, particularly since reimbursements will be tied to quality and safety. We feel that TeamSTEPPS will grow as organizations find that it will help them with performance, and thus reimbursement. Continued success will depend on the ongoing collaboration of researchers and implementers. We hope that both groups will continue to push the envelope regarding the importance of teamwork, team training, and patient safety.
David P. Baker, PhD Executive Vice President Center for Research, Evaluation and Implementation IMPAQ International, LLC
James B. Battles, PhD Agency for Healthcare Research and Quality (Retired) President Battles Consulting
Heidi B. King, MS Chief of Patient Safety and High Reliability Initiatives Defense Health Agency Department of Defense
1. Baker DP, Gustafson S, Salas E, Barach P, Battles JB, King H. The relation between teamwork and patient safety. In: Carayon P, ed. Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Mahwah, NJ: Lawrence Erlbaum Associates; 2006:21-37. ISBN: 9780805848854.
2. King H, Battles J, Baker DP, et al. TeamSTEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety. In: Advances in Patient Safety: New Directions and Alternative Approaches. Rockville, MD: Agency for Healthcare Research and Quality; July 2008:5-20. AHRQ Publication Nos. 080034 (1-4). [Available at]
3. Hughes AM, Gregory ME, Joseph DL, et al. Saving lives: a meta-analysis of team training in healthcare. J Appl Psychol. 2016;101:1266-1304. [go to PubMed]
4. Baker DP, Salas E, King H, Battles JB, Barach P. The role of teamwork in the professional education of physicians: current status and assessment recommendations. Jt Comm J Qual Patient Saf. 2005;31:185-202. [go to PubMed]
5. Thomas L, Galla C. Building a culture of safety through team training and engagement. BMJ Qual Saf. 2013;22:425-434. [go to PubMed]