Pocket Guide

Team Strategies & Tools 

to Enhance Performance 

and Patient Safety
2

Table of Contents

TeamSTEPPS®

• Framework and Competencies ....4

• Key Principles...............................5

Team Structure

• Multi-Team System For Patient 

Care..............................................7

Communication

• SBAR............................................9

• Call-Out ......................................10

• Check-Back ................................11

• Handoff.......................................12

• “I PASS THE BATON” ................13

Leadership

• Effective Team Leaders..............15

• Team Events...............................16

• Brief Checklist ............................17

• Debrief Checklist ........................18
3

Table of Contents

Situation Monitoring

• Situation Monitoring Process .....20

• STEP..........................................21

• Cross-Monitoring........................23

• I’M SAFE Checklist.....................24

Mutual Support

• Task Assistance ....................... 26

• Feedback....................................27

• Advocacy and Assertion........... 28

• Two-Challenge Rule ...................29

• CUS............................................30

• DESC Script.............................31

Team Performance Observation 

Tool.....................................................32

Barriers, Tools and Strategies, 

and Outcomes....................................33

Contact Information ...........................35
4

Framework and Competencies

Team Competency Outcomes

Knowledge

 • Shared Mental Model

Attitudes

 • Mutual Trust

 • Team Orientation

Performance

 • Adaptability

 • Accuracy

 • Productivity

 • Efficiency

 • Safety

TeamSTEPPS has five key principles. It is based on 

team structure and four teachable-learnable skills: 

Communication, Leadership, Situation Monitoring, and 

Mutual Support. The arrows depict a two-way dynamic 

interplay between the four skills and the team-related 

outcomes. Interaction between the outcomes and skills 

is the basis of a team striving to deliver safe, quality care 

and support quality improvement. Encircling the four 

skills is the team structure of the patient care team, which 

represents not only the patient and direct caregivers, but 

also those who play a supportive role within the health care 

delivery system.

...TeamSTEPPS is an evidence-based framework to 

optimize team performance across the health care 

delivery system.
5

Key Principles

Team Structure

Identification of the components of a multi-team 

system that must work together effectively to ensure 

patient safety

Communication

Structured process by which information is clearly 

and accurately exchanged among team members

Leadership

Ability to maximize the activities of team members by 

ensuring that team actions are understood, changes 

in information are shared, and team members have 

the necessary resources

Situation Monitoring

Process of actively scanning and assessing 

situational elements to gain information or 

understanding, or to maintain awareness to support 

team functioning

Mutual Support

Ability to anticipate and support team members’ 

needs through accurate knowledge about their 

responsibilities and workload
Team Structure
7

Team Structure

Multi-Team System 

For Patient Care

Safe and efficient care involves 

the coordinated activities of a 

multi-team system.

ADMINISTRATION 

COORDINATING 

TEAM 

ANCILLARY

& SUPPORT

SERVICES

CORE TEAM 

CONTINGENCY 

TEAMS 

PATIENT 

MTS 
Communication
9

Communication

SBAR

A technique for communicating critical 

information that requires immediate attention 

and action concerning a patient’s condition

Situation – What is going on with the 

patient?

“I am calling about Mrs. Joseph 

in room 251. Chief complaint is 

shortness of breath of new onset.”

Background – What is the clinical 

background or context?

“Patient is a 62-year-old female postop day one from abdominal surgery. 

No prior history of cardiac or lung 

disease.”

Assessment – What do I think the 

problem is?

“Breath sounds are decreased on 

the right side with acknowledgment 

of pain. Would like to rule out 

pneumothorax.”

Recommendation and Request – What 

would I do to correct it?

“I feel strongly the patient should be 

assessed now. Can you come to room 

251 now?”
10

Communication

Call-Out

Strategy used to communicate important or 

critical information

• Informs all team members 

simultaneously during emergent 

situations

• Helps team members anticipate next 

steps

• Important to direct responsibility to 

a specific individual responsible for 

carrying out the task

Example during an incoming trauma:

Leader: “Airway status?”

Resident: “Airway clear”

Leader: “Breath sounds?”

Resident: “Breath sounds decreased 

on right”

Leader: “Blood pressure?”

Nurse: “BP is 96/62”
11

Communication

Check-Back

Using closed-loop communication to ensure 

that information conveyed by the sender is 

understood by the receiver as intended

The steps include the following:

1. Sender initiates the message

2. Receiver accepts the message and 

provides feedback

3. Sender double-checks to ensure that 

the message was received

Example:

Doctor: “Give 25 mg Benadryl IV push”

Nurse: “25 mg Benadryl IV push”

Doctor: “That’s correct”
12

Communication

Handoff

The transfer of information (along with 

authority and responsibility) during 

transitions in care across the continuum. 

It includes an opportunity to ask questions, 

clarify, and confirm.

Examples of transitions in care include 

shift changes; transfer of responsibility 

between and among nursing assistants, 

nurses, nurse practitioners, physician 

assistants, and physicians; and patient 

transfers.
13

Communication

Handoff

Strategy designed to enhance information exchange 

during transitions in care

“I PASS THE BATON”

I Introduction Introduce yourself and your 

role/job (include patient)

P Patient Name, identifiers, age, sex, 

location

A Assessment Present chief complaint, vital 

signs, symptoms, and diagnoses

S Situation

Current status/circumstances, 

including code status, level of 

(un)certainty, recent changes, 

and response to treatment

S Safety 

Concerns

Critical lab values/reports, 

socioeconomic factors, 

allergies, and alerts (falls, 

isolation, etc.)

THE

B Background

Comorbidities, previous 

episodes, current medications, 

and family history

A Actions

Explain what actions were 

taken or are required. Provide 

rationale.

T Timing

Level of urgency and explicit 

timing and prioritization of 

actions

O Ownership

Identify who is responsible 

(person/team), including 

patient/family members

N Next

What will happen next? 

Anticipated changes? What is 

the plan? Are there contingency 

plans?
Leadership
15

Leadership

Effective Team Leaders

The following are responsibilities of effective 

team leaders:

• Organize the team

• Identify and articulate clear goals (i.e., the 

plan)

• Assign tasks and responsibilities

• Monitor and modify the plan; 

communicate changes

• Review the team’s performance; provide 

feedback when needed

• Manage and allocate resources

• Facilitate information sharing

• Encourage team members to assist one 

another

• Facilitate conflict resolution in a learning 

environment

• Model effective teamwork
16

Leadership

Team Events

Sharing the Plan

• Brief - Short session prior to start to 

share the plan, discuss team formation, 

assign roles and responsibilities, establish 

expectations and climate, anticipate 

outcomes and likely contingencies

Monitoring and Modifying the Plan

• Huddle - Ad hoc meeting to re-establish 

situational awareness, reinforce plans 

already in place, and assess the need to 

adjust the plan

Reviewing the Team’s Performance

• Debrief - Informal information exchange 

session designed to improve team 

performance and effectiveness through 

lessons learned and reinforcement of 

positive behaviors
17

Leadership

Brief Checklist

During the brief, the team should address 

the following questions:

 Who is on the team?

 Do all members understand and 

agree upon goals?

 Are roles and responsibilities 

understood?

 What is our plan of care?

 What is staff and provider’s 

availability throughout the shift?

 How is workload shared among 

team members?

 What resources are available? 
18

Leadership

Debrief Checklist

The team should address the following 

questions during a debrief:

 Was communication clear?

 Were roles and responsibilities 

understood?

 Was situation awareness 

maintained?

 Was workload distribution 

equitable?

 Was task assistance requested or 

offered?

 Were errors made or avoided?

 Were resources available?

 What went well? 

 What should improve?
Situation 

Monitoring
20

Situation Monitoring

Situation Monitoring Process

Situation monitoring is the process of 

continually scanning and assessing a situation 

to gain and maintain an understanding of 

what’s going on around you.

Situation awareness is the state of “knowing 

what’s going on around you.”

A shared mental model results from each 

team member maintaining situation awareness 

and ensures that all team members are “on the 

same page.”
21

Situation Monitoring

STEP

A tool for monitoring situations in the delivery of 

health care

Components of Situation Monitoring:
22

Situation Monitoring

STEP

Tool to help assess health care situations

Status of Patient

Patient History

Vital Signs

Medications

Physical Exam

Plan of Care

Psychosocial Issues

Team Members

Fatigue

Workload

Task Performance

Skill

Stress

Environment

Facility Information

Administrative Information

Human Resources

Triage Acuity

Equipment

Progress Toward Goal

Status of Team’s Patient(s)?

Established Goals of Team?

Tasks/Actions of Team?

Plan Still Appropriate?
23

Situation Monitoring

Cross-Monitoring

A harm error reduction strategy that involves:

• Monitoring actions of other team 

members

• Providing a safety net within the

team

• Ensuring that mistakes or

oversights are caught quickly and

easily

• “Watching each other’s back”
24

Situation Monitoring

I’M SAFE Checklist

I = Illness

M = Medication

S = Stress

A = Alcohol and Drugs

F = Fatigue

E = Eating and Elimination













Each team member is responsible for 

assessing his or her own safety status
Mutual Support
26

Mutual Support

Task Assistance

Helping others with tasks builds a strong 

team. Key strategies include:

• Team members protect each other 

from work overload situations

• Effective teams place all offers 

and requests for assistance in the 

context of patient safety

• Team members foster a climate 

where it is expected that 

assistance will be actively sought

and offered
27

Mutual Support

Feedback

Information provided to team members for the 

purpose of improving team performance

Feedback should be:

• Timely – given soon after the target 

behavior has occurred

• Respectful – focuses on behaviors, not 

personal attributes

• Specific – relates to a specific task or 

behavior that requires correction or 

improvement 

• Directed toward improvement – provides 

directions for future improvement

• Considerate – considers a team 

member’s feelings and delivers negative 

information with fairness and respect
28

Mutual Support

Advocacy and Assertion

Advocate for the patient

• Invoked when team members’ 

viewpoints don’t coincide with that of the 

decisionmaker

Assert a corrective action in a firm and 

respectful manner

• Make an opening

• State the concern

• State the problem (real or perceived)

• Offer a solution

• Reach agreement on next steps
29

Mutual Support

Two-Challenge Rule

Empowers all team members to “stop the line”

if they sense or discover an essential safety 

breach

When an initial assertive statement is 

ignored:

• It is your responsibility to assertively 

voice concern at least two times to 

ensure that it has been heard

• The team member being challenged 

must acknowledge that concern has 

been heard

• If the safety issue still hasn’t been 

addressed:

– Take a stronger course of action 

– Utilize supervisor or chain of 

command
30

Mutual Support

CUS

Assertive statements:

“Stop the Line”
31

Mutual Support

DESC Script

A constructive approach for managing and 

resolving conflict

D = Describe the specific situation or 

 behavior; provide concrete data

E = Express how the situation makes 

 you feel/what your concerns are

S = Suggest other alternatives and 

 seek agreement

C = Consequences should be stated in 

 terms of impact on established 

 team goals; strive for consensus
32

Mutual Support

Team Performance Observation Tool

Team Structure

Assembles team

Assigns or identifies team members’ roles and responsibilities

Holds team members accountable

Includes patients and families as part of the team

Communication

Provides brief, clear, specific, and timely information

Seeks information from all available sources

Uses check-backs to verify information that is communicated

Uses SBAR, call-outs, check-backs, and handoff techniques to 

 communicate effectively with team members

Leadership

Identifies team goals and vision

Utilizes resources efficiently to maximize team performance

Balances workload within the team

Delegates tasks or assignments, as appropriate

Conducts briefs, huddles, and debriefs

Role models teamwork behaviors

Situation Monitoring

Monitors the state of the patient

Monitors fellow team members to ensure safety and prevent 

 errors

Monitors the environment for safety and availability of resources 

 (e.g., equipment)

Monitors progress toward the goal and identifies changes that 

 could alter the care plan

Fosters communication to ensure a shared mental model

Mutual Support

Provides task-related support and assistance

Provides timely and constructive feedback to team members

Effectively advocates for the patient using the Assertive 

 Statement, Two-Challenge Rule, or CUS

Uses the Two-Challenge Rule or DESC script to resolve conflict
33

BARRIERS

• Inconsistency in Team

Membership

• Lack of Time• Lack of Information

Sharing

• Hierarchy• Defensiveness• Conventional Thinking• Complacency• Varying Communication

Styles

• Conflict• Lack of Coordination and 

Followup With Coworkers

• Distractions• Fatigue• Workload• Misinterpretation of Cues• Lack of Role Clarity

TOOLS and STRATEGIES

Communication 

• SBAR• Call-Out• Check-Back• Handoff

Leading Teams

• Brief• Huddle• Debrief 

Situation Monitoring 

• STEP• I’M SAFE

Mutual Support 

• Task Assistance• Feedback• Assertive Statement• Two-Challenge Rule • CUS• DESC Script

OUTCOMES

• Shared Mental Model• Adaptability• Team Orientation• Mutual Trust• Team Performance• Patient Safety

35

Contact Information

To learn more about TeamSTEPPS®, 

refer to the Agency for Healthcare 

Research and Quality (AHRQ) Web site: 

http://teamstepps.ahrq.gov/

and the Department of Defense Patient 

Safety Program Web site:

http://www.health.mil/dodpatientsafety/

ProductsandServices/TeamSTEPPS

Developed for the Department of Defense Patient Safety 

Program in collaboration with the Agency for Healthcare 

Research and Quality

TeamSTEPPS® 2.0 Pocket Guide
AHRQ Pub. No. 14-0001-2

Replaces AHRQ Pub. No. 06-0020-2

Revised December 2013