Editor’s note: Monika Haugstetter, MHA, MSN, RN, CPHQ, is a Health Science Administrator with AHRQ, leading AHRQ’s TeamSTEPPS® initiative. Stephen Hines, PhD, is a Senior Research Scientist at the Arbor Research Collaborative for Health. While at Abt Associates, he co-led the TeamSTEPPS 3.0 revisions in collaboration with AHRQ. We spoke with Monika and Stephen about the newly released TeamSTEPPS 3.0 curriculum.

Sarah Mossburg: Thank you both for joining us. Could you please tell us a little bit about yourselves and your interest and involvement with Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS)?

Monika Haugstetter: I am an advanced practice nurse by training with a Master of Health Administration and a Master of Science in Nursing. My professional focus has been on leading quality improvement projects. I have managed a variety of domestic and global health programs and overseen a range of patient safety initiatives. In my previous roles, I managed the development, implementation, and monitoring of clinical trainings, and I taught graduate-level nurses. At AHRQ, I serve as a program officer in the General Patient Safety Division. Throughout my career I have worked to improve communication. Therefore, when I joined AHRQ, the TeamSTEPPS program was a natural fit.

Stephen Hines: I have been involved with TeamSTEPPS since the early 2000s, including the initial TeamSTEPPS release. I was also involved with leading the AHRQ-funded National Training program and leading national conferences for TeamSTEPPS. Most recently, I was the project director and senior advisor on the TeamSTEPPS 3.0 revisions and enhancements. My PhD is in communication, and I have worked in the field of health communication for my entire career.

Sarah Mossburg: Monika, we know that AHRQ plays an important role in patient safety and sharing best practices. What is TeamSTEPPS and why did AHRQ develop it?

Monika Haugstetter: It is well-established that effective communication improves patient safety. In 2006, AHRQ, in collaboration with the Department of Defense, developed Team Strategies and Tools to Enhance Performance and Patient Safety, or TeamSTEPPS. TeamSTEPPS is a program designed for healthcare professionals. It provides tools and resources to improve communication and teamwork of healthcare teams. The program was initially implemented mainly in hospitals, and later it did spread to other healthcare settings.

Sarah Mossburg: Stephen, where and how is TeamSTEPPS used today?

Stephen Hines: As Monika said, TeamSTEPPS was initially primarily focused on the hospital setting. A number of healthcare systems decided to implement TeamSTEPPS, and those organizations were important forerunners. Some of those systems ultimately became training centers for TeamSTEPPS and shared their experiences with others. While AHRQ does not maintain a list of organizations using TeamSTEPPS, it has been introduced in many hospitals and other care settings, sometimes in response to a patient harm, and other times because of a recognition of a need to improve safety culture. TeamSTEPPS is not just a series of techniques that can be used in response to specific issues. It is a broader strategy for enhancing and reinforcing a culture of safety.

Sarah Mossburg: What impact has TeamSTEPPS had on patient safety?

Stephen Hines: Multiple studies have examined TeamSTEPPS in a variety of settings. A number of those are captured in the literature reviews on the TeamSTEPPS 3.0 website. Overall, research has found that people respond positively to TeamSTEPPS trainings. Over time, after the implementation of TeamSTEPPS within a unit or an organization, there are clear links to improvements in patient safety, organizational safety culture, and staff perceptions of communication quality within their teams.

When you implement TeamSTEPPS, you are working to implement a culture of safety, which is a long-term and all-encompassing endeavor. Culture change is more important and impactful to patient safety than any one TeamSTEPPS tool or strategy. It is less important to think about the impact of TeamSTEPPS by linking specific impacts to specific TeamSTEPPS tools; it is more important to understand that implementing TeamSTEPPS and committing to a culture of safety can improve outcomes for patients in a wide variety of settings. While most of the literature on TeamSTEPPS has focused on hospitals, positive impacts of TeamSTEPPS have been established in other care settings, including primary care, ambulatory surgery, nursing homes, and long-term care facilities.

Sarah Mossburg: We know that the new TeamSTEPPS 3.0 curriculum launched in 2023. Given that TeamSTEPPS has been widely used across many care settings, what motivated AHRQ to review and revise the previous version of TeamSTEPPS?

Monika Haugstetter: Research shows that TeamSTEPPS has significantly contributed to improving communication and teamwork among healthcare professionals and beyond. In 2020, it had been about six years since many of the TeamSTEPPS resources were last developed or revised. In the fast-paced healthcare environment, six years is a substantial amount of time. There have been monumental advancements in health information technology, as well as changes to how care is delivered, such as increased utilization of telemedicine. With a need to engage every member of the health care team, including patients and caregivers, it became apparent that the curriculum needed an update to fully support healthcare teams and continue to improve their collaboration and communication skills. The overall goals of revising TeamSTEPPS were to enhance user experience, further improve the program’s effectiveness, emphasize professionalism, and consequently increase healthcare professionals’ commitments to interdisciplinary teamwork.

Sarah Mossburg: Stephen, as you mentioned, you led the TeamSTEPPS 3.0 updates. Can you describe the revision process?

Stephen Hines: TeamSTEPPS is a large training curriculum with at least two full days of training materials. We had to set priorities when making the revisions, and used several strategies to figure out what those priorities should be. First, we consulted a technical expert panel (TEP) that included experienced TeamSTEPPS trainers, TeamSTEPPS users, and patient advocates. We also conducted an extensive literature review. We consulted a useful literature review done as part of an AHRQ Making Healthcare Safer Report that was released in 2020 and that reviewed the literature up to that point. We also reviewed the TeamSTEPPS website to see what resources got the most attention and which got very little attention. We more extensively modified the resources that were most extensively used.

Some of the top priorities we identified included the transition to virtual teams and how changes in technology impact communication. We understood the growing presence of virtual teams in healthcare and that implementation of TeamSTEPPS can better engage patients, so those became priorities for us as we revised the curriculum. We recognized that both the healthcare workforce and the patients it supports are becoming more diverse. This diversity creates a greater potential for misunderstanding and a greater need for an understanding that patient and family caregivers may view situations differently.

Sarah Mossburg: What organizations or stakeholders were involved in the revisions?

Stephen Hines: We wanted the core technical expert panel (TEP) participants to be those familiar with TeamSTEPPS, including several representatives currently or formerly involved with the Department of Defense Health Agency, which played a major role in the development of TeamSTEPPS. We also wanted to make sure that we had representatives who were extensively involved in virtual care due to its growing importance to patient care, particularly during the pandemic. Additionally, we recognized that patients were not being treated as a part of the team itself. We included patient representatives in the TEP to gain insights on the ways healthcare professionals may treat patients as who you do things to rather than who you do things with.

Sarah Mossburg: What did you learn along the way, and how did that inform changes to TeamSTEPPS?

Stephen Hines: One thing that we learned is that people loved the TeamSTEPPS content but had challenges finding the content that they were looking for on the TeamSTEPPS website. Additionally, the initial release of TeamSTEPPS was followed by releases of TeamSTEPPS for multiple care settings focusing on multiple issues. By the time we started this revision, there were over a dozen variants of TeamSTEPPS on the website. These different versions had uniquely valuable pieces of information, but also had a lot of overlap. One major recommendation from the TEP, and one thing that made the process quite challenging, was that a single integrated version of TeamSTEPPS might be more useful and easier for users to navigate.

Sarah Mossburg: What were some challenges you faced in making that single integrated curriculum?

Stephen Hines: One challenge was in cataloging what was unique across the multiple versions of TeamSTEPPS. Across all versions, we found that the way the patient and family were discussed really needed to be changed. Including the patient as a part of the team changes a lot within the curriculum. We also encountered challenges related to language and a sensitivity to the diversity in the workforce and the patient population. We did not want to just make those changes in an introduction and then leave everything else as it was. We started off the process thinking we could just revise the parts of TeamSTEPPS needing updates and leave the rest alone. However, by the time that we finished, every piece of TeamSTEPPS was totally rewritten.

The revision process was a complex undertaking. For example, prior versions of TeamSTEPPS recommended that conflict always be addressed face-to-face. But because many teams in healthcare are virtual, that is not always possible. The new curriculum says that if you can address conflict in person, do it in person, but if you can’t, then conflict still needs to be addressed. The new curriculum explains ways in which virtual communication may introduce additional challenges, but also explains how team members can cope with these challenges as well.

Sarah Mossburg: That speaks to what Monika said earlier about AHRQ’s motivation to make a change. Eight years is a long time in the healthcare world, and it sounds like there was much that changed that necessitated this update. What materials are available through the TeamSTEPPS curriculum and where can organizations access them?

Stephen Hines: The AHRQ TeamSTEPPS website, which was reorganized with the TeamSTEPPS 3.0 release, houses the TeamSTEPPS materials. We consolidated information and eliminated duplication to make things easier to find. The website includes an updated Pocket Guide that provides a quick reference to key TeamSTEPPS concepts and tools, and includes a diagram to show how everything fits together. The Pocket Guide was redesigned to reflect the role of the patient as a core team member, as opposed to an outsider the team cares for.

There is also a section on the website with welcome guides for different kinds of users. When revising TeamSTEPPS, we found that the website is used by TeamSTEPPS trainers as well as others looking for resources or tools for their specific situation, either for individual use or for use within their team or unit.

The website has resources, including training slides, for people who teach TeamSTEPPS. With the TeamSTEPPS 3.0 revisions, we developed video-based training units. The videos are designed for people who may not be experts in TeamSTEPPS but want to introduce and train groups of students or colleagues on the use of TeamSTEPPS. The videos introduce new patient stories to focus on teamwork. When making the videos, we felt strongly about moving away from a tragedy-based patient story framework to stories that reflected both good and bad communication experiences of patients and family caregivers with healthcare teams. We do not want TeamSTEPPS to be implemented only after a patient has been harmed. We want it to be used proactively to prevent patient harm. Effective communication gives patients a better experience in what could be a very stressful time of their lives.

We heard from the healthcare professionals on the TEP and others whom we talked to during this process that the level of stress that healthcare workers are under, particularly during the pandemic and in the postpandemic surge, is greater than ever before. We did not want TeamSTEPPS trainings to raise those stress levels further. The goal of a training is to help people. You want to make them laugh, relax, and be able to take a breath and think about how things can be better. The way to do that is not to start off with a tragic story of a patient who was harmed. You gain more from a training if you think about it as an opportunity to make things better and to celebrate things that are going well, as opposed to adding another stressor to those that participants are already experiencing.

Sarah Mossburg: Are there any additional differences between TeamSTEPPS 3.0 and previous versions that you would like to highlight?

Monika Haugstetter: Stephen covered the differences well earlier. Dr. Craig Umscheid, the Director of the Center for Quality Improvement and Patient Safety at AHRQ, and I wrote a blog post that also discusses the differences and plans for TeamSTEPPS. Overall, the revisions to the structure and the content were equally important and equally altered. It was a significant amount of work.

Stephen Hines: Another key revision is that we acknowledged that the patient may also benefit from learning about TeamSTEPPS since they are an integral part of the healthcare team. The revised curriculum highlights tools, resources, and strategies that patients and family caregivers could use themselves. We incorporated a welcome guide specifically for patients and family caregivers to introduce them to TeamSTEPPS and offer suggestions for how they might use it.

Previously, the gold standard TeamSTEPPS training format was an extended two-day training. We received a lot of feedback that a full two-day training in healthcare is unusual these days. More frequently, TeamSTEPPS is taught in sections and in shorter trainings. TeamSTEPPS 3.0 gives guidance for teaching TeamSTEPPS both as an extended two-day training as well as guidance for what to include and what to leave out when teaching shorter (e.g., half-day) trainings. It also gives guidance for teaching elements of TeamSTEPPS in even shorter increments, such as teaching a specific concept or tool during a series of staff meetings.

The new version treats patients respectfully and inclusively and acknowledges the ways in which healthcare workers and team members need to be sensitive to the diversities that exist both within their teams and in the patients they support. The new version introduces a few new tools and training exercises designed specifically for use in virtual trainings. The video-based training modules are excellent resources for teaching important concepts in a limited time. Another benefit is the new version really encourages trainers to take a nondidactic approach to TeamSTEPPS training to make it more participatory and engaging through strategies such as discussions, dialogue exercises, and activities, as opposed to just talking through a series of slides.

Sarah Mossburg: What do organizations and trainers accustomed to using the older version of TeamSTEPPS need to know to use the new version?

Monika Haugstetter: The welcome guides are a good place to start. It is important for users to first consider what goals they want to accomplish with the training, and who the audience is. Based on that, trainers should review the curriculum in its entirety to make sure that they understand the flow and the components and adapt to their style before training others.

Sarah Mossburg: Stephen, you mentioned virtual learning and video-based training. What is the virtual learning component and how is that incorporated into the curriculum?

Stephen Hines: We recognize that many healthcare teams may be operating partially or entirely virtually, especially when teams involved in patient care span multiple care settings. It is easy to talk about how communication should happen, for example, in a surgery unit in a hospital, and who is on that team versus not on that team. It is harder to talk about communication strategies when the team consists of individuals spanning multiple settings, such as a primary care physician, specialists, a family caregiver, and long-term care facility staff. In cases like that, the team will probably never be in person. We tried to call attention to the importance of those multidisciplinary and often virtual teams because they’re frequently neglected. We also introduced some new training resources that can be used in a virtual context. I mentioned the video-based training modules, which were created and tested in a virtual setting and were very well-received. There are also some new training exercises specifically designed for virtual trainings and teams. Virtual training can be challenging. Blended trainings, where some people are in person and some are virtual, can make it easy for virtual participants to feel like they’re on the periphery. For this reason, exercises and teaching strategies that fully involve the virtual trainees are important additions to the curriculum.

Sarah Mossburg: Monika, as the AHRQ lead for TeamSTEPPS, what was your reaction to the updated version?

Monika Haugstetter: AHRQ is very pleased with the final product. As Stephen mentioned, the path to that product was bumpy at times. There were challenges, including the amount of content to be revised and coordination of revisions across all components. I think that the outcome is wonderful, and a few of my favorite additions are the patient safety videos and the video simulation trainings. The entire curriculum and the website work very well, and the navigation, which was tricky at times in the past, is now streamlined. Overall, it is a great success.

Stephen Hines: Ultimately, the value of TeamSTEPPS is not in the curriculum itself, but in how people use the curriculum. The revisions are designed to make TeamSTEPPS more accessible to all team members. The revised website and curriculum provide value to experienced trainers, people thinking about becoming a TeamSTEPPS trainer, healthcare professionals looking for solutions to issues within their teams, and healthcare professionals looking to implement or reinforce a culture of safety. It’s not easy to be a good TeamSTEPPS trainer, and it’s not easy to implement and sustain TeamSTEPPS. We emphasize sustainability a bit more in the new version. It’s one thing to implement TeamSTEPPS, and another to sustain it. The revisions aim to make it easier for people to get value out of TeamSTEPPS, but ultimately, it is on the teams and trainers and organizations to put in the work to implement TeamSTEPPS and reach the goal of sustaining a culture of safety.

Sarah Mossburg: What feedback have you heard from the field regarding the new version of TeamSTEPPS?

Monika Haugstetter: The reaction to the updated TeamSTEPPS has been overwhelmingly positive. The revisions to TeamSTEPPS 3.0 are still relatively new, and there are no examples of the impact just yet. However, I regularly receive messages from the field about how much folks appreciate the augmentations to the program, as well as requests for permission to adapt the new tools and practices to their specific situations. That, to me, shows great enthusiasm and interest in TeamSTEPPS 3.0.

AHRQ has an implementation and evaluation contract in place to promote and evaluate the new program. Through this contract, 115 organizations throughout the country will be selected and trained on TeamSTEPPS 3.0. After the implementation, the impact will be evaluated at three- and six-month intervals. The results of that evaluation could be available as early as the end of 2024.

Sarah Mossburg: What do you both see as the future for TeamSTEPPS?

Monika Haugstetter: Promoting TeamSTEPPS 3.0 is the top priority in the immediate future. Aside from training large medical centers and hospitals, a big emphasis will be put on training in various ambulatory settings, rural healthcare facilities, and preprofessional schools such as nursing and medical schools. If we can begin the training in schools and folks can embrace the tools and the resources from the start, then the training will have a huge impact on how they do their job in the future and how TeamSTEPPS can impact patient safety. Beyond that, AHRQ has tentative plans for a few more modifications and additions to the website. Furthermore, we encourage anyone from the field who is interested in evaluating TeamSTEPPS for its effectiveness to apply for grant funding.

Stephen Hines: I think that today, there is a broader recognition of what constitutes patient safety issues than there was 20 years ago. Diagnostic error is an emerging issue that harms a lot of people. Due to its importance, the only other version of TeamSTEPPS retained on the website focuses on that particular issue. Diagnostic errors are seen frequently with virtual teams where a diagnosis isn’t communicated quickly enough, or something falls through the cracks. I think part of the future of TeamSTEPPS is broadening the ways in which TeamSTEPPS can be used and the kinds of patient safety issues for which TeamSTEPPS is relevant. Monika has been leading AHRQ’s efforts in the diagnostic error realm, so I know that that’s a topic that’s of importance to them.

Monika Haugstetter: I agree; since diagnostic safety is a top priority for AHRQ, the TeamSTEPPS for diagnostic safety is just as critical. It is part of the curriculum, and it has a prominent place on the website as well. In the contract that I mentioned, the implementation of the Diagnosis Improvement Course will occur alongside the TeamSTEPPS 3.0 curriculum. The Diagnosis Improvement Course will be part of the evaluation as well.

Sarah Mossburg: Is there anything we haven’t discussed today that either of you would like to share?

Monika Haugstetter: The process of updating TeamSTEPPS was a team effort with many contributors, and the final product is exceptional. AHRQ appreciates all stakeholder contributions to this work. We will only know the true impact of the revised curriculum once people really start using it. There was also a TeamSTEPPS video challenge that sought innovators to develop new TeamSTEPPS videos for communication and collaboration among healthcare teams. Five winners produced six new videos. You can visit the AHRQ challenge or TeamSTEPPS video collection sites to learn about the winning organizations and the videos they created.

Stephen Hines: To add to that, the TeamSTEPPS website includes an acknowledgments section for individuals and organizations involved in the revisions process. We’d like to thank all those involved for their dedicated and thoughtful contributions.

Sarah Mossburg: Thank you both for talking with us today. This has been a really interesting conversation.