Surgery centers can employ a program called TeamSTEPPS to improve patient safety. It helps staff build communication and teamwork skills.

  • TeamSTEPPS started as a program to train helicopter pilots in the military.
  • The Agency for Healthcare Research and Quality helped develop TeamSTEPPS for healthcare professionals.
  • One of the first steps is to conduct a safety culture survey.

A safety strategy that was first developed to help military helicopter pilots has now made its way to the ASC industry. Its purpose is to improve patient safety through better communication and teamwork.

“TeamSTEPPS was borne out of work done in the Army as part of a program to train helicopter pilots,” says Bill Berry, MD, MPH, MPA, FACS, associate director and senior advisor to the executive director and chief implementation officer of Ariadne Labs in Boston. Accidents occurred from poor communication between pilots and co-pilots, he says.

This quality initiative moved to the healthcare industry as part of a collaboration between the Agency for Healthcare Research and Quality (AHRQ) and the military. It evolved into the Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) as a curriculum for healthcare, based on the same principles of teamwork and communication, Berry explains.

“It was pilot-tested in emergency departments,” he says. “It was refined there, and in the last 15 years, it has undergone further revisions.”

TeamSTEPPS is a collection of information, materials, PowerPoint slides, and training programs designed to deliver its program across all healthcare settings (https://bit.ly/2p0Ysd2). Within the past few years, the program has been launched, with AHRQ’s help, in the ASC setting to help surgery centers strengthen infection control practices and improve their use of the surgical safety checklist, Berry says.

“We helped ASCs with this training,” he adds. “It was taken seriously in about 100 surgery centers.”

There’s a perception that ASCs carry less risk than hospital operating rooms, Berry notes. “But there still is a risk, and things are moving fast, so you want to make sure you’re doing the right thing for every patient.”

In working with ASCs, Berry found that they generally employ good staff who take their jobs seriously.

“My takeaway was that the procedures done in that environment were appropriate for that type of care, and complication rates were low,” Berry says. “That doesn’t mean they can’t be better. I want to encourage them to all think about being better than they are now.”

Berry provides these details about how TeamSTEPPS works:

Conduct a safety culture survey. First, ask employees how they feel about the surgery center’s baseline safety culture. Some sample questions include: What are employees’ beliefs about safety? What are the things that are good practices to keep patients safe? What do surgeons believe about the center’s safety environment? Do employees feel safe to speak up if they see a problem?

“There’s always a gap between what the safety culture is, and how safe people feel to speak up,” Berry says. “We come from a hierarchical culture, and there are numerous cases of people knowing the wrong hand was going to be operated on or the wrong power lens was put into an eye, and they didn’t feel empowered to speak up.”

Changing a workplace culture is difficult, but not impossible, he notes.

“I’ve been in the OR since 1977, and I’ve had a lot of experiences over that long period of time,” Berry says. “I’ve watched the culture shift as the culture inside medicine is moving.”

Gender balance is changing and likely will change even more rapidly with the #MeToo movement, he says.

“I have seen behaviors by male surgeons that once were tolerated and are no longer tolerated,” Berry says. “Things are shifting. We’re trying to deal with today and maybe make a better tomorrow, but arm people with tools that let them deal with many of the realities of today,” he adds.

Encourage staff to speak up. There are some examples of ASC staff speaking up, only to be criticized by a surgeon, Berry says. “He says, ‘You’re wrong,’ and puts in the wrong lens anyway.”

These types of egregious examples highlight the problems with suppressed communication in ASCs, he adds.

“It’s a risky environment that has a very rapid pace with case turnover, so in those kinds of environments, good communication and teamwork skills are even more important,” Berry says. “They need to be encouraged, not discouraged.”

TeamSTEPPS gives people the skills to speak up and communicate when they need to.

Show outcomes to reinforce safety culture. “We have evidence out of hospitals that you can move the culture with TeamSTEPPS, and the culture is related to outcomes,” Berry says. “Measuring your culture in an ASC is part of this and can be exceptionally helpful if you see if there are gaps that you have. This will help you focus on which steps of TeamSTEPPS are helpful.”

The authors of a 2011 study of team training in operating rooms found significant improvements in the percentage of first cases on time and room turnover after adoption of the program.1

Use communication tools. There are simple exercises an ASC can perform with staff to give them a voice. One is CUS, which stands for “I’m concerned; I’m uncomfortable; This is a safety issue.” If an ASC employee sees a safety problem, the person starts by expressing concern. If this doesn’t get the surgeon’s attention, then move to expressing discomfort. As a last result, pull out the “safety issue” card.

“We encourage people in ASCs to give nurses the words that will allow gradual escalation with the surgeon,” Berry says. “Three taps on the shoulder is better than one confrontational one.”

Often, someone will jump right in to stop the unsafe action, rather than use gradual escalation. But most operating room cultures are not yet ready for the direct confrontation. So, CUS is known to work, he says.

“It doesn’t take a lot of time, and it’s doable by people without giving them a lot of training,” Berry adds. SBAR (Situation-Background-Assessment-Recommendation) is another tool that can improve communication. It refers to directing someone to state the problem, then provide brief background information about the situation. The communicator can provide analysis and options, ending with a request for action or a recommendation (http://bit.ly/2qNx0ix).

“It’s a way for nurses to communicate effectively with physicians,” Berry explains. “The entire patient stay is abbreviated, combining all the same components of a hospital stay, but shorter.”

Tools like CUS and SBAR are a shortcut that facilitates better communication within an ASC and across the care continuum.

“Suppose there’s a patient who had a hernia repair in the surgery center,” Berry offers. “The patient has moved from the OR to the recovery area, and the nurse taking care of the patient in the recovery area is a little worried because the patient is not coming along the way he should.”

The nurse calls the doctor, who is back in his office, and describes the problem. Instead of a rambling description, the nurse follows SBAR, using an outline to talk about what’s going on.

“The nurse says, ‘Let me remind you of who the patient is,’ and ‘I think you should come to see him,’” Berry says. “It’s proven to be an incredibly valuable way to cut a lot of noise out of the conversations between nurses and physicians in particular.”

Create team collaboration. “One of the things TeamSTEPPS encourages is the idea of teams working together to improve quality and safety in environments like ASCs,” Berry says. “It’s one of the things that a lot of times isn’t considered or done, and it’s really important.”

For instance, if an ASC wants to start a major quality improvement project, one person shouldn’t be responsible for the entirety of that project. The process works best if completed by a team of people working together, he explains.

“That sounds like a logical way things are done, but they’re usually not,” Berry says. “Projects are driven by single people who come up with whatever they want to come up with, in isolation.”

TeamSTEPPS advises centers to form interdisciplinary teams to improve processes, such as improving a checklist. “They can sit down with multiple perspectives, moving the work ahead,” he says. Projects will succeed when there’s communication, a leveling of the hierarchy, teamwork, and involvement by a multidisciplinary team, Berry adds.


  1. Armour Forse R, Bramble JD, McQuillan R. Team training can improve operating room performance. Surgery 2011;150:771-778.