1. Brady, P. Jeffrey MD, MPH
  2. Battles, James B. PhD
  3. Ricciardi, Richard PhD, NP

Article Content

IN THE MILITARY, chain of command and clearly stated instructions matter a great deal. "We follow orders or people die. It's that simple," Jack Nicholson's COL Jessup famously declared in the 1992 movie A Few Good Men. But it isn't that simple because a strong sense of team lies at the foundation. Similarly, health care depends on clear instructions-and also relies not just on individuals but also on strong teams. These interprofessional teams are composed of physicians, nurses, physician assistants, pharmacists, technicians, assistants, and many other participants. The performance of each of these contributors is critical to the endeavor's success.


Not all teams are created equal. Teams can work well together or poorly. Some have healthy, successful cultures; others are mediocre; and still others are fraught with fear, backbiting, and resentment. In every enterprise that relies on teamwork (eg, aviation, business, manufacturing, sports, the performing arts), teams that are unified, nimble, motivated, and focused on achieving the same outcome with an ingrained sense of shared accountability usually perform better than those that are not. And so it is in health care. When teams perform well, patients enjoy the benefits of organized, coordinated care that usually is of high quality. When they perform badly, patients suffer.


The Institute of Medicine, in several landmark reports, has consistently and clearly identified the importance of interprofessional teams in providing high-quality health care and, specifically, the role of nurses on those teams.1-3 In fact, we know that well-functioning teams make fewer mistakes than do individuals, especially when responsibilities are clearly delineated, members are empowered to speak up, and everyone feels responsible for and vested in the outcome.4-6 Nurses are prepared to care for the whole patient, rather than just a symptom or disease, and thus grant the health care enterprise a comprehensive perspective that benefits patients, and the Institute of Medicine has specifically recommended that opportunities for nurses to lead and diffuse collaborative improvement efforts be expanded.7 Yet, teams don't just coalesce because we want them to, and the mere imposition of a team structure does not guarantee their effectiveness. Teamwork requires the conscious, opt-in agreement by all participants to work together toward shared goals.8



Some health care organizations have needed tools and resources to achieve team goals-to go from knowing teamwork is important to actually implementing and supporting high-functioning teams. Thus, researchers led by the Agency for Healthcare Research and Quality (AHRQ) studied how teams work and how they can be employed more effectively to improve care for patients.


We started by looking to see how others do it and, among these approaches, which were applicable and adaptable to health care. We have long looked to aviation for relevant examples, particularly regarding safety.9 We also looked to the military. While they are obviously unique enterprises, the military and health care share some common features, and this is before we consider that the Department of Defense is itself an enormous health care provider. Military teams, like health care teams, often work in a high-pressure, high-intensity, life-at-risk environment. Situations can alter, often drastically, in an instant, and every participant has a stake in achieving a good outcome.


Working with our Department of Defense colleagues, we identified techniques that highly trained military units use to foster success on the ground. These were distilled into one of AHRQ's most significant contributions to improving the safety and culture of the nation's health care system: TeamSTEPPS (Team Strategies & Tools to Enhance Performance and Patient Safety), an evidence-based curriculum to improve communication and teamwork skills among health care professionals.10 TeamSTEPPS draws on core competencies that have been proven effective in the military and adapts and applies them to health care. These competencies include leadership, situation awareness and monitoring, mutual support, and communication.


TeamSTEPPS provides higher-quality, safer patient care by producing highly effective health care teams that optimize the use of information, people, and resources to achieve the best clinical outcomes for patients. It stresses accountability by increasing team awareness and clarifying team roles and responsibilities. It focuses on core principles including resolving conflicts and improving information sharing. By doing so, it eliminates barriers to quality and safety, and with modules focusing on different settings of care, it is nimble, placing an emphasis on core teamwork values that are universal in nature.



Teamwork is not simply an automatic consequence of placing people together. It is not necessarily natural or easy, especially when it requires people to make adjustments or surrender traditional authority. We have found that there are essential elements that must be in place for the health care team to succeed. These elements include the following:


* Structure: The formation of the team is critical. Communication and mutual support are important but must be housed within a framework in which team members know what to expect. In the modern military, a team is a highly skilled, highly trained unit in which each participant knows his or her role perfectly and who the team leader is.


* Accountability: Successful teams, in the military and elsewhere, possess an intense sense of accountability. Team members are accountable to each other, to their commanding officer, and to the mission. The team, working together with precision, can respond quickly and effectively and adapt to whatever situations arise.


* Patient-centeredness: The military defines "objective" as "the clearly defined, decisive, and attainable goal toward which every operation is directed."11 The "goal toward which every operation is directed" in health care can sometimes be unclear, because it can shift depending on circumstances. For instance, a 25-year-old athlete being treated for a knee injury may have a different expectation than an elderly patient with cancer who has been determined to be terminally ill. Successful teams understand this and work to provide high-quality, patient-centered care to meet or exceed the objective.



The foundation that supports all of these elements is culture. Sometimes a shift in culture is necessary to establish a healthy and successful team. This task is often challenging, but we know where to start. Culture is both measurable and modifiable. The AHRQ has created a series of surveys designed to help health care organizations assess the culture of safety in their institutions. Originally developed in 2004 for hospitals, AHRQ Surveys on Patient Safety Culture12 are now available for medical offices, nursing homes, and community pharmacies. Together, the patient safety culture surveys and TeamSTEPPS are being used by health care organizations to examine each step of their health care delivery process to ensure that it is patient-centered and mission-driven.



Much as our colleagues in the military are unremittingly focused on the composition and performance of the team, they never forget why the team is assembled in the first place. It is the objective, the mission, and so must we in health care remain fixated on our mission. Our interprofessional health care team must include physicians, nurses, pharmacists, technicians, and a host of other participants. But it is important to remember the real mission is providing safe, effective, patient-centered care.


Patient-centeredness has long been a goal of quality care.2 Research shows that when patients are engaged in their health care, it can lead to measurable improvements in safety and quality. But patients' voices sometimes are not heard. Clinicians feel rushed during their interactions with patients. Patients themselves feel rushed and sometimes intimidated. Language and cultural barriers emerge, and patients' role in their own care can be unclear or, worse, undervalued.


That is why taking the time to engage patients and families and including them as a part of the health care team are so important. This may seem like yet another demand on already overwhelmed clinicians, but there are resources that can help guide these efforts. To promote stronger engagement, the AHRQ developed the Guide to Patient and Family Engagement in Hospital Quality and Safety, a tested, evidence-based resource to help hospitals work as partners with patients and families to improve quality and safety.13 Believing that asking questions often leads to the answers that help people get better care, we developed "Questions Are the Answer" materials that encourage patients to ask questions and to empower them to ask those questions until they understand the answer.14


Thus, we encourage you to use TeamSTEPPS as an opportunity to examine the degree to which your nursing practice supports team-based care methods. Are lines of communication clear? Are roles well defined? Are team members accountable to each other? As part of this, we urge you to think carefully about how your team is composed and how that composition supports safe, high-quality care. Is the patient at the center of your health care team? If not, why not?


As health care continues to evolve, team-based care is becoming increasingly important. We see this trend in several arenas, including care for chronically ill patients through multispecialty teams or care by an interprofessional team in a primary care office. TeamSTEPPS provides the foundation to prepare clinicians for this work environment. Include your patient as a key member of your team. Remember the mission, focus on it ceaselessly, and never forget that a team cannot succeed unless every member is motivated to achieve the same goal: the best possible outcome for the patient, in concordance with his or her values, every time.




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3. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press, Institute of Medicine; 2010. [Context Link]


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6. Sims DE, Salas E, Burke SC. Is there a "big five" in teamwork? Paper presented at: 19th annual meeting of the Society for Industrial and Organizational Psychology; 2004; Chicago, IL. [Context Link]


7. Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press, Institute of Medicine; 2010. [Context Link]


8. Baker DP, Gustafson S, Beaubien JM, et al. Medical team training programs in health care. In: Henriksen K, Battles JB, Marks ES, et al., eds. Advances in Patient Safety: From Research to Implementation (Volume 4: Programs, Tools, and Products). Rockville, MD: Agency for Healthcare Research and Quality; 2005. Accessed July 2014. [Context Link]


9. Rutherford W. Aviation safety: a model for health care? Qual Saf Health Care. 2003;12(3):162-163. [Context Link]


10. TeamSTEPPS National Implementation. Accessed September 20, 2014. [Context Link]


11. Military Terms and Definitions. Accessed August 2014. [Context Link]


12. Surveys on Patient Safety Culture. Rockville, MD: Agency for Healthcare Research and Quality; 2014. Accessed August 1, 2014. [Context Link]


13. Guide to Patient and Family Engagement in Hospital Quality and Safety. Rockville, MD: Agency for Healthcare Research and Quality; 2013. Accessed August 1, 2014. [Context Link]


14. Questions to Ask Your Doctor: Questions Are the Answer. Rockville, MD. Agency for Healthcare Research and Quality; 2012. Accessed August 1, 2014. [Context Link]