Team training is "huge opportunity" for safety

New approach results in dramatic changes

Better teamwork. It sounds like a simple strategy, but this goal has proved surprisingly elusive for many health care organizations.

In its 1999 report, To Err is Human: Building a Safer Health System, the Institute of Medicine (IOM) reported that medical errors cause as many as 98,000 deaths each year, and suggested that better teamwork and coordination could prevent harm to patients.

The IOM recommended that health care organizations establish team training programs for personnel in critical care areas such as emergency departments, intensive care units, and operating rooms.

In response, the TeamSTEPPS training program was developed by the Department of Defense (DoD), in collaboration with the Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS is an evidence-based teamwork system, which aims to improve patient outcomes with better communication and other teamwork skills among health care professionals, and is currently being used by more than 50 hospitals.

There is a growing body of evidence that improved teamwork directly relates to quality, according to James B. Battles, PhD, senior service fellow for patient safety at AHRQ. "We know that when we don't have good teamwork, quality of care suffers. There are lots of examples where poor coordination of care and handoffs lead to serious problems," he says. "We do believe that this is one of the major things that people can do to improve quality and safety in their institutions, but it does take a major commitment. It is hard work and requires strong leadership support."

After a series of errors resulted in the loss of a patient's baby in 2000 at Boston-based Beth Israel Deaconess Medical Center, a major reorganization of the obstetrics and gynecology unit led to a successful change of culture. "We believe that we were only able to embark on this journey as a result of being willing to confront a patient's loss and accept responsibility," says Benjamin Sachs, MD, chair of the hospital's department of obstetrics and gynecology. "Our philosophy is that health care has much to learn from the science of safety and quality developed by other industries, and that the search for quality is a never-ending journey."

Following the 2000 case, the obstetrics unit began working with the DoD and the Harvard Risk Management Foundation, the malpractice insurer for Harvard teaching hospitals, to apply the principles of Crew Resource Management (CRM), which are used to prevent errors in the military and in commercial aviation, to the field of obstetrics.

The obstetrics staff learned how to use CRM techniques to overcome poor communication and make it easier for all staff to participate in decisions about patient care. For example, doctors and nurses previously gave updates only on the patients under their care to the next shift. Now, the entire obstetrics staff are knowledgeable about all patients. Today, Beth Israel Deaconess has the lowest adverse event score of any comparable tertiary hospital reporting to the National Perinatal Information Center, a nonprofit organization that collects national data. As a direct result of the obstetrics unit's work, there are now statewide initiatives in Massachusetts, Maryland, and the District of Columbia to introduce obstetrical team training.

Outcomes data are key

SSM Health Care, a 20-hospital network based in St. Louis, is in the very early stages of implementing the TeamSTEPPS program. "We have come to the belief that teamwork training is a really important part of safety that was not easily addressed before TeamSTEPPS was developed," says Andy Kosseff, MD, the organization's medical director of system clinical improvement. "We think this is a huge opportunity for us to take."

As for many health care organizations, communication and coordination of care were significant obstacles to improving patient safety, outcomes, and satisfaction at SSM. "For that reason, one of the things we need to do is implement a more standardized and rigorous process for this, as one of the fundamental parts of our safety program," Kosseff says.

In today's hospital environment, more doctors and nurses are involved in the care of each patient, so communication and coordination of patient care is even more important than it may have been in years gone by. However, to implement TeamSTEPPS effectively is "no easy task," says Kosseff.

"We will need to prove to the people in our system that this is as important as we think it is," he says. "The literature has shown lots of benefits of teamwork training, but because it's so early on, we don't have a lot of outcome data. We will need to generate that data ourselves." Since the program is very resource-intensive, having solid data will make it much easier to obtain buy-in for a general implementation at the 20 hospitals in the health care system.

Currently, five individuals from SSM have been trained by AHRQ, including clinicians, patient safety officers, and quality professionals. "One of the things we think is key is that it should be people who have clinical backgrounds doing the training," Kosseff says. "Having a doctor and nurse team starts the modeling of the interdisciplinary teamwork, right as you are doing the teaching."

The organization is currently selecting a few units to serve as pilot sites in the typical units that teamwork training has been shown to be most valuable — obstetric units, operating rooms, and emergency departments. "By selecting pilot sites, our hope is that we can learn more about the most effective way to make this stick and work," Kosseff says. Training is expected to be completed by fall 2007, with units up and running by the end of the year.

Outcomes on the units, as well as nurse retention and safety culture assessment, will be carefully measured to demonstrate improvements. "We will try to develop some measurements that give us an indication of how successful we are," says Kosseff. "We will of course be looking at the frequency of adverse events and hoping to see these decrease."

[For more information, contact:

Andy Kosseff, MD, Medical Director of System Clinical Improvement, SSM Health Care, 477 North Lindbergh Ave., St. Louis, MO 63141. Phone: (608) 238-1337. Fax: (608) 238-0054. E-mail:

Visit the TeamSTEPPS page on-line at]