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Department of Defense Patient Safety Program Heidi B. King, MS, FACHE. Putting TeamSTEPPS ™ Into Practice: Integrating TeamSTEPPS ™ Into Simulation in the Military Health System (MHS). Agenda. Background-TeamSTEPPS in the MHS Where Are We? Team Resource Centers:

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Department of Defense

Patient Safety Program

Heidi B. King, MS, FACHE

Putting TeamSTEPPS™ Into Practice:

Integrating TeamSTEPPS™ Into Simulation

in the

Military Health System (MHS)

  • Background-TeamSTEPPS in the MHS
  • Where Are We?
  • Team Resource Centers:

Accelerating Practice Change

  • Where Are We Going?

…transforming healthcare through team-driven practice

in DoD and beyond…

tricare facts
    • 9.2 million eligible beneficiaries
    • 4.5 million dental enrollees
    • 65 military hospitals and 826 medical and dental clinics across the world
    • 132,700 personnel

A Week In The Life:

  • 19,600 Inpatient Admissions
  • 642,400 Outpatient Encounters (direct care)
  • 102,900 Dental Seatings
  • 2,100 Births
  • 2.2 million Prescriptions
  • 3.5 millions Claims Processed
healthcare team coordination program teamstepps is the cornerstone





Team Resource Centers: ATTC, C-STARS, National Capital Area Medical Simulation Center, & Andersen Simulation Center – MAMC, NMCP, Travis AFB

Collaboration & Outreach:

Partnering Opportunities

Marketing & Communication

Technical Expert Panel


Ongoing Efforts: Senior Leadership Engagement

TeamSTEPPS™ Training Program

Online Curriculum


L&D Longitudinal Study

NAVAIR - Teamwork Analysis Tools

Skills-based Learning

Plan, Train & Implement



Healthcare Team Coordination ProgramTeamSTEPPS™ is the cornerstone


#1 Deployment of the

HCTCP to all fixed and

combat casualty care


#2 Minimum

Establishment of Two

Centers of Excellence

#3 Expansion of the

HCTCP to include all

major medical specialties

#4 Investments in

continued research and



Promote Integration of Teamwork Principles through Optimal Use of Training, Education,

Research, and Collaborative Efforts


#1 Institutionalize team-driven care to improve patient safety

#2 Solidify Collaborative Partnerships for Safe Care

#3 Support Research Demonstration Projects



healthcare team coordination program
Healthcare Team Coordination Program
  • Promotes integration of teamwork principles into practice through training, education, research, and collaboration initiatives
    • Evidence-based teamwork intervention programs to MHS direct care facilities and combat care organizations
    • Develops and deploys tools to reduce the potential of harm to patients while delivering care
  • Establishment of Team Resource Centers (Centers of Excellence)
    • Several incorporate simulation
  • Since 2007, training incorporated higher fidelity simulation—lab and in-situ, where feasible
model for change
Model for Change


Org Level

Safety Culture



Learning Environment

“Report Card”

Leadership Level

Create a sense of urgency

Pull together a guiding coalition

Develop a change vision and strategy

Communicate for understanding and buy-in

Empower others to act

Product short-term wins

Don’t let up

Create a new culture




Improved Staff

and Patient






Decrease claims $

Individual Level

Self EfficacyTraining Motivation

Pre-training Experience

Level IV: Results


Sentinel Event





Training Transfer



Level II: Learning

Level II: Learning

Level III: Behavior


((1) Salas E & Cannon-Bowers JA. Training and retraining:

A handbook for business industry, government, and the military.

Tobias S & Fletcher JD (editors). McMillan: New York, 2000: 312-335.;

(2) Kirkpatrick, D. Model for Summative Evaluation. 1976;

(3) Kotter JP. Leading change. Boston, Massachusetts: Harvard Business School Press, 1996.)

Training Objectives



Level I: Reactions

five ways teamstepps transforms culture
Five Ways TeamSTEPPS Transforms Culture

Establishes names for team behaviors and a common language for addressing “communication” and other teamwork failures

Bridges the professional divide and levels the hierarchy

Provides ‘actions’/behaviors

Increases common mindfulness

Engages the patient

‘Acting their way into a new way of thinking’

where are we now
Where Are We Now?

Building a culture of quality and safety requires broad transformation-a tenacious commitment to achieving a sustainable effort is changing the way the Military Health System provides care and does business.

We have extraordinary success stories and continued opportunities for improvement.

how are we changing the culture
How Are We Changing the Culture?
  • Our approach*:
    • Spread: Actively disseminating best practice and knowledge about TeamSTEPPS
    • Impact: Assess TeamSTEPPS impact at several levels
    • Sustainability: Locking in the progress that sites have already made and continually build upon it

Spread, impact and sustainability take time and commitment.

*Based in part on the Institute for Healthcare Improvement (IHI) framework for helping to improve performance

spread at a glance


  • 9 Peer Reviewed Publications
  • Outcome Measures for Effective Teamwork in Inpatient Care (Technical Report)
  • #1 visited page on the DoD Patient Safety web site & #1 resource from search engine to web site
  • 16 presentations




  • Trained 36 MTFs at 50 on-site sessions
  • Created 481 trainers/coaches
  • Over 12,000 CEU/CME granted
  • Saved $1.4M in training/travel dollars (over 2 yrs)
  • Incorporated in simulation exercises
  • Integrated multi-module TS curriculum (USUHS)
  • Operation Iraqi Freedom combat support hospital implementation
  • Developing strategic communications plan for the campaign to ‘improve communication’ for safer care
  • Developed 3 online learning modules
  • Federal: AHRQ/DoD National Implementation (20 training sessions, 503 civilians TS Master Trainers)
  • 2nd Annual Technical Expert Panel (36 patient safety thought leaders in attendance)
  • South Australia Dept of Health piloted TS handoff initiative
  • Held multiple pre-conference workshops at national conferences
  • CMS 9th Scope of Work (QIOs)
  • American Association for Family Physicians (AAFP)collaboration
  • National Patient Safety Foundation toolkit
  • International Reach (Nat’l Implementation in Taiwan)
Spread At-A-Glance

Within DoD

Beyond DoD


Impact: Evaluation Plan

Level 5 – Return on Investment Was the training worth the cost?

Level 4 – Results: Did the change in behavior positively affect the organization?

Level 3 – Behavior / Training Transfer

Did the participants change their behavior on-the-job based on what they learned?

Organizational Factors

Level 2 – Learning: What skills, knowledge, or attitudes changed after training? By how much?

Level 1 – Reaction: Did the participants like the training?

What do they plan to do with what they learned?

Individual Pre-training Experiences & Attitudes

Kirkpatrick’s Model

organizational success factors
Organizational Success Factors

Supportive organizational culture & learning climate

Shared vision (leadership to frontline)

Visible leadership support

Peer and subordinate support

Reinforcement, rewards, recognition

Minimal delay between training and practice on job

On-going training – coaching, refresher, new staff

Commitment to measurement and on-going improvement

Sustainment (integration) plan

Resource availability

why can t we make this work
“Why Can’t We Make This Work?”
  • Opportunity to Perform
    • Practice, Implement, then Measure
  • Front-line Support
  • Climate of Learning
    • Progress Updates
    • Forum to Discuss
    • Train, Refresh, and Inform
  • Team Coaches
where we are going
Where We Are Going?

…Simulation is critical to changing culture, however, we are applying scientific principles, instructional design methodology with clear learning outcomes and team performance measurement tools

…only then can simulation

and practice change be aligned

mobile ob emergencies simulator
Mobile OB Emergencies Simulator

Andersen Simulation Center

mobile ob simulator
  • Created mobile platform (2006) that can accomplish the following:
    • Run simulations on actual L&D units in 20+ hospitals
    • Provide a standardized curriculum
    • Evaluate both Teamwork and Technical proficiency
    • Integrate a no-fault debriefing tool
    • Be able to monitor progress over time
    • Inexpensive (~$25K/unit); cost effective compared to average OB malpractice claim ($2.5M/claim)
mobile ob simulator17
  • Obstetric emergencies:
      • Shoulder dystocia
      • Postpartum hemorrhage
      • Eclampsia
      • Emergency cesarean section
      • Breech vaginal delivery
      • Operative vaginal delivery
      • Neonatal Resuscitation
  • Incorporates TeamSTEPPS training and evaluation tools into the scenarios and debriefing
national capital area medical simulation center ncamsc
National Capital Area Medical Simulation Center (NCAMSC)
  • Designated Team Resource Center since 2005
  • Supporting projects:
    • Team Training for Wide Area Virtual Environment
    • Fundamental Laparoscopic Surgery
    • Pediatric and OB SBT
    • Reserve Unit TeamSTEPPS



Credits: Chang Ha Lee

Sofia del Castillo

integrated team training
Integrated Team Training

Multidisciplinary and Forward Surgical Teams



  • Defined the team
  • Defined the chain of cmd.
  • The team leader was in charge


  • M __ mechanism
  • A __ assess GCS
  • P __ primary survey
  • F __ FAST exam
  • A __ ABG/labs
  • S __ secondary survey
  • T __ timeout/problem list
  • O __oxygen (applied oxygen)
  • X __apex apex base base (breaths)
  • Y __ yes/no (H&P)
  • G __ gauge (large bore IV)
  • E __ eyes, ears (examined eyes/ears)
  • N__nose, neck neuro check (exam)
  • V __ vital signs
  • I __ IV meds
  • T __ temperature (room)
  • A __ alert key personnel
  • L __lab results (call out)
  • S __safety
  • L __ IV line placed
  • E __ exposed patient
  • F __ Foley catheter
  • T __ temp obtained
  • R __ remove clothing
  • I __ inline stabilization
  • G __ gear collected
  • H __ hold pressure
  • T __ tubes sent to lab



























Primary Done:_______

Secondary Done:_____






  • Established a clear plan
  • Identified roles
  • Conducted rehearsal(s)




  • Performed “Call outs”
  • followed by “Echoes”.
  • Verbalized Vital Signs
  • Performed a clear
  • “hand-off”





  • Conducted an AAR
  • Discussed ways to
  • improve
  • Devised an improvement
  • plan





Subtotal= /12

Subtotal= /18

Total Score= /58

Subtotal= /28



Team Effectiveness Accelerator (TEA)

-- The Group for Organizational Effectiveness, Inc. (gOE)

-- TRICARE Mgmt Activity, DoD Patient Safety Program

-- Naval Air Warfare Center, Training Systems Division

How the TEA Works:

  • Rationale:
  • Teamwork is essential for safe and effective medical practice
  • Teams with shared understanding collaborate and perform more effectively (30+ studies)
  • Teams that debrief effectively build shared understanding and perform better (up to 40%). Unfortunately, debriefs are often not conducted or not done optimally (e.g., don’t discuss teamwork)
  • Premise: A well-designed TEA can efficiently guide teams through debriefs to enhance collaboration and performance
  • What is the Team Effectiveness Accelerator (TEA):
  • A simple-to-use web-based tool that allows a team to quickly diagnose “gaps” such as: a) disagreement about roles, priorities, etc., b) loss of situation awareness, c) inaccurate knowledge and d) lack of teamwork behaviors
  • The TEA then efficiently guides the team through a targeted debrief to rectify those gaps
  • Status of the Effort and Next Steps
  • The first TEA has been developed for use by Trauma Teams (military and civilian versions)
  • Based on thorough shared coordination requirements analysis with SMEs
  • Applicable for use with TeamSTEPPS Program
  • Will soon begin testing and provide early access
  • In the future, we will likely expand access to more institutions and develop TEAs to cover other medical domains
  • Contract Details:
  • Developed under Contract N61339-07-D-0001,“Tools for Training, Assessment, Analyses, and Debriefing of Medical Teams Performance”
  • Contact: Scott Tannenbaum, Ph.D., The Group for Organizational Effectiveness, Inc. 518.456.7738 x102;
medical team performance assessment tool mtpat

TeamSTEPPS™ is a teamwork methodology and curriculum designed to improve patient safety for health care organizations.

Scenario-based training with performance observation, assessment and post exercise team debrief provides a promising approach for building team coordination skills in the context of clinical performance.

Scenario design and measurement best practices include constructing scenario events and performance measures around specific training objectives and then structuring debrief around these objectives and events.

What is MTPAT?

A software application that provides capabilities to support evaluation, debrief, and analysis of healthcare team performance in training and operational environments.

An architecture to support an event based training and assessment approach where assessment items are linked to scenario events.

Integrates the TeamSTEPPS™ principles and skills so that military and civilian medical teams can rapidly record, assess, and analyze teamwork performance evidence and provide timely feedback and debrief.

Supports coordinated evaluation of technical and teamwork skills.

Ultimately, MTPAT can provide an evidence base from which medical teams can measure and continually improve their performance, thereby reducing medical errors and improving patient safety.

Current Status

MTPAT prototyped for Trauma and Labor & Delivery.

Events and assessment item content developed for Trauma and Labor and Delivery domains based on document analysis, observations and interviews with subject matter experts.

Testing and review in progress with participant facilities

Medical Team Performance Assessment Tool (MTPAT)


  • Alion Science and Technology
  • American Institutes for Research
  • TRICARE Mgmt Activity, DoD Patient Safety Program
  • Naval Air Warfare Center, Training Systems Division
  • Contract Details:
  • Developed under Contract N61339-07-D-0001,“Tools for Training, Assessment, Analyses, and Debriefing of Medical Teams Performance”
  • Contact: Tom Carolan, Ph.D., Alion Science and Technology. 517.347.6117;
simulation as a training strategy
Simulation As A Training Strategy
  • Establish the vision, goals and objectives
  • Determine the model
    • In-center
    • In-situ
  • Establish the needed resources
    • Simulation Center
      • Staff - clear vision, roles & responsibilities
      • Equipment
    • Participating department
      • Clear vision and expectations for participation
      • Staff release time
  • Develop event-based scenarios
  • Expect results
  • Debrief and educate on awareness
understanding teams
Understanding Teams

Determine the performance outcomes you expect to see, then:

  • Develop learning outcomes
  • Train teamwork competencies
  • Define and determine diagnostic measures
needed links in simulation based team training
Needed Links in Simulation-Based Team Training…

Rosen et al, 2008

Tasks & KSAs


Scenarios &Events




understanding performance
Understanding Performance
  • The behaviors sought should drive the simulation goals
    • Select measurement tools based on goals of simulation/assessment criteria
    • Measure what is important, not what is easy
  • Performance Observation Tools
    • SMARTER Approach (Simulation Module for Assessment of Resident Targeted Event Responses)
    • Communication and Teamwork Skills (CATS)
    • Others
smarter team
  • Focus on teaching points
  • Define specific learning objectives
  • Choose clinical context to frame scenario development
  • Develop set of targeted KSA’s to capture pre-defined learning objectives and core competencies
  • Craft scenario to ensure team members have opportunity to display targeted KSA’s
  • Define set of targeted responses
  • Create diagnostic measurement tools
  • Create scenario script

Rosen, et al

understanding debriefing
Understanding Debriefing
  • Center debriefing around the chosen teaching points e.g. “Did the leader
    • Specify the goals to the team?”
    • Coordinate team efforts?”
    • Cross-monitor team members?”
    • Resolve conflict?”
  • Focus discussion on communications and interactions with team members
  • Keep discussion focused on team behaviors, minimize clinical discussions use scenarios that
    • Stress rapid team responses and coordination of care
    • Straightforward diagnoses with clear and easily determined treatment
  • Simulation-Based Training for Patient Safety: 10 Principles That Matter (Salas et al, 2008)
  • Measuring Team Performance in Simulated-Based Training: Adopting Best Practices for Healthcare (Rosen et al, 2008)
  • SMARTER-Team: Adapting Event-based Tools for Simulation-based Training in Healthcare (Rosen et al, 2008)
  • Promoting Teamwork: An Event-based Approach to Simulation-based Teamwork for Emergency Medicine Residents (Rosen et al, 2008)
  • Does Team Training Work? Principles for Healthcare (Salas et al, 2008)
for more information
For More Information