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Service Delivery Innovation Profile

Teamwork Enhancement Program Improves Obstetric Care in a Military Hospital

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An evidence-based teamwork and communication program was implemented in the labor and delivery unit of Madigan Army Medical Center, a military hospital in Tacoma, WA. Known as Team Strategy and Tools to Enhance Performance and Patient Safety (TeamSTEPPS™), this evidence-based program is based on a set of common principles for optimizing team performance and coordination. These principles are supported by standardized, team-based communication protocols and strategies, techniques, and tools that reinforce these protocols. TeamSTEPPS™ improved time from decision to performance of cesarean section; no impact was detected on adverse maternal and/or neonatal outcomes. Evaluations of the program in other settings have demonstrated its effectiveness, including reductions in medical errors, adverse events, length of stay, and employee turnover; better adherence to evidence-based practices; and enhanced provider satisfaction.

Evidence Rating (What is this?)

Moderate: Evidence was generated through a pre-/post-implementation comparison and a two-group comparison.
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Developing Organizations

Agency for Healthcare Research and Quality; Department of Defense; Madigan Army Medical Center; TRICARE
Department of Defense (DoD) Healthcare Team Coordination Program (HCTCP), Washington, DC
Agency for Healthcare Research and Quality (AHRQ), Rockville, MD
TRICARE (Military Health Systems), Falls Church, VA
Madigan Army Medical Center, Tacoma, WAend do

Use By Other Organizations

  • TeamSTEPPS™ is widely used throughout military hospitals and is increasingly being used in for-profit and nonprofit hospitals and other health care settings across the nation. In addition, for the first time, TeamSTEPPS™ is being deployed in a combat environment by the 86th CSH TF-Baghdad at Ibn Sina Hospital, the busiest trauma hospital in Iraq. Training is also planned for other combat support hospitals in Baghdad.

Date First Implemented

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Patient Population

Gender > Female; Vulnerable Populations > Military/dependents/veterans; Womenend pp

Problem Addressed

Patient safety issues have been linked to tens of thousands of fatalities and serious injuries in hospitals across the United States, including incidents related to labor and delivery.1 One of the main causes of medical error is an organizational culture characterized by a lack of teamwork and poor communication, including misunderstandings and the failure to relay critical information.
  • Communication problems are common and lead to errors and system-wide failures: Communication problems are the leading cause of preventable patient deaths.2 Poor communication, driven by lack of a "shared mental model"3 across caregivers (i.e., the inability of staff members with varying life experiences to understand the ideas, values, multiple interpretations, and ambiguities embedded in common communications), can lead to massive system-wide failures that cause medical errors. Lack of teamwork among health care workers (due, in part, to hierarchic rather than collegial relationships) is a common cause of communication problems and is associated with one-fourth of all medical errors.2 Although error-induced maternal and neonatal morbidity and mortality are relatively uncommon, they still represent significant problems in hospitals across the nation, including military hospitals. To the extent that near-misses and errors do occur in the labor and delivery unit setting, communication problems contribute to the majority (roughly 65 percent) of them.4
  • Military hospitals experience communication and teamwork problems: Many military hospitals employ civilian staff; the very different culture of the military can make it difficult for these civilian staffers to work and communicate effectively with colleagues and patients who are in the military.
  • Military hospitals face special challenges related to pregnancy-related morbidity and mortality: Like many military hospitals, Madigan Army Medical Center was experiencing several challenges in the labor and delivery area, including an increasing birth rate due to an upsurge in troops; a spike in the rates of postcesarean emergency hysterectomies due to uncontrollable postpartum hemorrhage; high staff turnover due to physicians and nurses rotating in and out of duty; and increased use of civilian nurses and staff who were not acclimated to military culture.5

What They Did

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Description of the Innovative Activity

Madigan Army Medical Center implemented TeamSTEPPS™ in a labor and delivery unit. This comprehensive program is based on a set of common principles for optimizing team performance and coordination. These principles are reinforced through the development of standardized, team-based communication protocols and a comprehensive set of strategies, techniques, and tools to reinforce these protocols.2 Key elements are described below.
  • Common framework and principles: The TeamSTEPPS™ program is based on a set of common principles, including the following:
    • Shared mental model that focuses on safety: A shared mental model reinforces the need for standardized communication and behavior across team members and the establishment of an organizational culture of patient safety.
    • A culture of open communication: Trust is created by establishing a culture of open communication, rewarding the reporting of one's own "near-misses" without fear of punishment, and reinforcing the importance of the team over the status of "higher-ups." Unit directors have open-door policies so that all staff members feel empowered to communicate openly.
    • Focus on performance: Teams are encouraged to constantly strive to improve performance by focusing on adaptability, accuracy, productivity, efficiency, and safety.
    • Situation monitoring: Team members are expected to remain aware of events in the unit and pass on critical information on a timely basis to help support the team, including patient status (e.g., vital signs), team members' workloads, general environmental conditions (e.g., making sure the right equipment is available, as needed), and progress toward goals.
  • Team-based structure and communication activities: Madigan Army Medical Center uses formal team structures and team-based communication activities to reinforce the notion of open communication and a focus on safety. Meetings focus on the problem and on team behaviors rather than on one person's behavior.
    • Team leaders: Team leaders are responsible for coordinating activities, sharing strategies for change, determining and allocating resources, and encouraging open and direct lines of communication.
    • Team meetings: Team meetings encourage people to share their thoughts. To improve performance and effectiveness, three types of team meetings are held at medical center units on a regular basis.
      • Briefs: These daily team meetings are brief planning conferences held at the start of the day to establish roles and responsibilities, ensure mutual understanding of directives, and establish goals. Briefs may be held at a shift change or before the start of a scheduled surgical case.
      • Huddles: These ad hoc, short team meetings are used to establish awareness of a particular situation observed by a team member; the goal is to focus on solving the immediate problem that has been identified by the team member.
      • Debriefs: These sessions are held at Madigan Army Medical Center to analyze and find solutions for both adverse events and preventive events ("good catches") that might potentially affect other patients. A review establishes whether clear communication was used and determines what errors were made or could have been avoided and/or what team behaviors led to successful outcomes. When necessary, process changes can be made promptly, often by the next day.
    • Teamwork and mutual support: Team members are taught to act as advocates for the patient, especially in situations in which they have different points of view than do clinical decisionmakers. Specific strategies include use of the "two-challenge" rule, which makes it the responsibility of the team member to assert any concerns twice to make sure that he or she is heard. Challenged team members are expected to respond appropriately. If the outcome is not acceptable, team members may "stop the line" out of concern over a safety breach. In addition, cross monitoring is used, with team members taught to constantly observe each other's behavior to ensure that mistakes or oversights are caught and corrected on a real-time basis.
  • Support tools and techniques: Madigan Army Medical Center incorporates a variety of TeamSTEPPS™ tools to enhance team performance, including the following:
    • Assessment tools: This four-component set of assessment tools is known as "STEP" (status of patient, team members, environment, and progress toward goal):
      • The patient assessment status tool provides a checklist for evaluating patient history, vital signs, medications, physical examination, plan of care, and psychosocial state.
      • The team member assessment tool offers a checklist for determining the fatigue, workload, task performance, skills, and stress of each individual worker.
      • The environment assessment tool address information about the facility, including administrative support, human resources, triage functions, and equipment.
      • The progress-toward-goal assessment tool evaluates the status of the team's patients, goals, tasks, and actions and the appropriateness of the team's plan.
    • Situation, Background, Assessment, Recommendation (SBAR) communication tool: SBAR is a standardized protocol for clear, accurate transmission of information between caregivers. Situation establishes the patient's condition; background conveys clinical background or context; assessment relays the opinion of the first caregiver; and recommendation communicates the first caregiver's suggestion to the second caregiver.
    • Other tools to improve performance and team cohesiveness: The following additional tools support the teams:
      • Team performance observation tool: Techniques for observing the functioning of the team allow every member to critically analyze each other's actions.
      • Conflict resolution methods: Tools and techniques for resolving differences and problems are shared with the team. In addition, the head of the unit or another designated individual is available to help facilitate resolution of conflicts.
      • Handoff tools: These tools are designed to enhance information exchange at transitions in care [e.g., when patients are moved from ward to ward or from operating room to intensive care unit (ICU)].

Context of the Innovation

Madigan Army Medical Center is a 205-bed military hospital with an average daily census of 151. On a typical day, the hospital has 219 emergency department visits, 36 admissions, and 8 births. The facility is served by 476 officers, 593 enlisted personnel, 2,342 civilians, 303 contractors, and 300 volunteers. Of these, more than 700 are physicians and more than 1,100 are nurses. The medical center has a history of implementing teamwork-based strategies, with the goal of integrating different types of personnel, including civilians and military members, into cohesive teams focused on improving performance and safety. Pregnancy-related morbidity and mortality became a particular focus after root-cause analysis of a sentinel event revealed that better teamwork likely would have prevented the event. As noted earlier, the medical center was experiencing several challenges in the labor and delivery area, and these challenges, combined with this sentinel event, led to the decision to implement this program.

Did It Work?

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The TeamSTEPPS™ program was evaluated through (1) a cluster-randomized controlled trial that evaluated almost 29,000 deliveries at seven intervention hospitals, including Madigan Army Medical Center, and eight control hospitals; and (2) pre-/post-implementation comparisons. Only the Madigan Army Medical Center results are reported here.
Results From Madigan Army Medical Center
  • Shorter time from decision to incision for cesarean sections: In a pre-/post-comparison, one care process measure—the time from the decision to perform an immediate cesarean delivery to the time of incision—was significantly reduced after teamwork training (33.3 vs. 21.2 minutes).
  • Similar adverse outcome rates: In a two-group comparison, no differences were detected in adverse outcome index (the proportion of deliveries at 20 weeks or more of gestation in which one or more adverse maternal and/or neonatal outcomes occurred). The index in control and intervention groups at baseline was 9.4 and 9 percent, respectively. After implementation of teamwork training, the index was 7.2 and 8.3 percent, respectively. Researchers speculated that adverse outcome rate improvements might have been more likely to occur if the study period had been longer than 1 year.
Results From Other Settings
Various studies the program conducted in a variety of military and nonmilitary settings found that it resulted in an array of benefits, as noted below2:
  • Enhanced teamwork and fewer errors: Studies of emergency department staff showed improved team behaviors, enhanced staff attitudes toward teamwork, and fewer observed clinical errors.
  • Better adherence to evidence-based practices: Pre- and post-implementation comparisons showed that the percentage of patients receiving properly timed administration of preoperative prophylactic antibiotics increased from 84 to 95 percent, while the percentage of patients receiving preoperative prophylaxis for deep vein thrombosis rose from 92 to 100 percent. In addition, results show improved screening to identify patients who are too high risk for surgery.
  • Enhanced employee satisfaction and reduced turnover: The turnover rate among nurses in the operating room fell by 16 percent, whereas employee satisfaction increased 19 percent.
  • Reductions in adverse events: A labor and delivery unit saw a 50 percent decline in adverse events, whereas clinical units in another facility reduced the incidence of adverse drug events from 30 to 18 per 1,000 patient days.
  • Lower length of stay (LOS): An ICU experienced a 50 percent decline in LOS, from 2.2 to 1.1 days.
  • Better medication reconciliation: Rates of reconciliation on one unit rose from 72 to 88 percent at admission, and from 53 to 89 percent at discharge.

Evidence Rating (What is this?)

Moderate: Evidence was generated through a pre-/post-implementation comparison and a two-group comparison.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Development of guiding team: This team, made up of representatives from all parts of the organization (nursing, medical staff, administration, other staff), set the stage for organizational change by identifying key personnel to lead the implementation. Team members have the leadership and communication skills, credibility, and analytical skills necessary to both plan and promote the program.
  • Identification of physician and nurse champions: These champions model the behaviors to the staff throughout the day and during nights on call. Physician champions helped peers to overcome fears about losing control and autonomy that emerged as a result of the program. Nurse champions reassured their cohorts that the program would not add more responsibilities to their day but rather would help them to cope better, lower stress levels, and feel more empowered. Noncommissioned officer champions helped support the adoption of teamwork behaviors among the enlisted individuals.
  • Training the trainers: Trainers volunteered from different segments of the hospitals. The initial group of trainers included physicians and nurses who took the "Train-the-Trainer" program provided in the TeamSTEPPS™ materials supplied by the Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ). These volunteers then recruited and trained a cadre of trainers for all departments.
  • Training staff: Medical center personnel were trained regarding TeamSTEPPS™ principles and the use of various tools to improve communication and teamwork.

Resources Used and Skills Needed

  • Staffing: Physicians, pharmacists, and nurses are needed to transmit information, provide leadership, and represent a culture of communication. They participate as part of their regular duties, so that no new staff are needed for the program.
  • Costs: The costs of the program are generally minimal, because most people participate as volunteers and/or as part of their regular duties. Training materials are available free of charge.
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Funding Sources

Madigan Army Medical Center
The development, implementation, and evaluation of TeamSTEPPS™ was funded by DoD and TRICARE. Madigan Army Medical Center covered the costs of implementation in its facility.end fs

Tools and Other Resources

A variety of materials for training instructors and personnel are available in CD/DVD and binder format from AHRQ at Examples include the following:
  • Teamwork training curricula: These three courses can be tailored to unique teamwork needs, staffing, and resource infrastructure. Modules may be taught separately or together. Materials include the following:
    • Train-the-trainer: Twenty hours of lecture and interactive training to train instructors, develop coaching skills, and facilitate TeamSTEPPS™ initiative.
    • TeamSTEPPS™ fundamentals: A 4- to 6-hour workshop describing the fundamental elements of the program.
    • TeamSTEPPS™ essentials: A 1- to 2-hour training session for nonclinical staff to provide basic tools for communication.
  • Course management guide: This guide includes information on preparing, executing, and sustaining TeamSTEPPS™.
  • Multimedia course materials: These include a DVD/CD with presentation slides and video modules.
  • TeamSTEPPS™ implementation guide: This guide provides how-to information and actions related to program design, implementation, monitoring, and maintenance.
  • Measurement tools: A battery of ready-to-use tools are available to assess the effectiveness of the program. Guidance is also provided on how to select tools, develop metrics, and evaluate data.

Adoption Considerations

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Getting Started with This Innovation

  • Obtain pertinent organizational data to evaluate the state of the facility in terms of quality and safety, patient satisfaction, and nurse and physician satisfaction: Evaluate the types of medical errors and "good catches," along with "accidents," and "events" that may have been only informally reported. Several tools, available through the DoD/AHRQ, can assist, including the Hospital Survey on Patient Safety Culture, Team Assessment Questionnaire, and incident reports. Once the analysis is complete, determine whether implementation of the program is reasonable given the current state of resources, information infrastructure, commitment to excellence, and leadership support.
  • Use champions to promote the program: Promote the program by having champions emphasize the role of communication failures as the leading cause of preventable death and the potential for cost savings through reduced medical errors (which administrators will likely find intriguing). Some surgeons and other physicians at Madigan Army Medical Center were initially resistant to the program. Physician champions shared information about the program, including how it works and evidence of its success, which helped to reduce others' concerns about a loss of autonomy or authority among these physicians.
  • Create a sense of urgency regarding the need for improvement in teamwork: Sharing data on the magnitude of the current safety problem can assist with this task.
  • Establish goals: Establish clear goals and objectives related to clinical outcomes, staff and patient satisfaction, and patient and provider safety.
  • Select a unit for a pilot test: The unit should be small and stable enough to train all team members in a short time. Starting small and using the tools provided in TeamSTEPPS™ training manuals increases the probability of successful implementation.

Sustaining This Innovation

  • Use pilot unit success to promote the spread of the program throughout the organization: Begin the scaling-up process by targeting units that are logically and physically close to the pilot unit.
  • Hold meetings and conferences: Hold twice-daily meetings for multiunit charge nurses to communicate critical information. Hold weekly multidisciplinary unit conferences to provide opportunities to share lessons learned.
  • Celebrate and reward success: Success is infectious and helps to sustain the innovation within and across units. Acknowledge team members who show understanding.
  • Plan the next training session as soon as the current one is finished: If dates are not set, the next wave of training may not happen.
  • Hold maintenance sessions twice a year: These condensed training classes act as refreshers and reinforce the mission and vision of the institution.
  • Plan annual training: Plan annual "sustainment training" so that teamwork and TeamSTEPPS™ principles are maintained during periods of staff turnover and so that the process is institutionalized at all levels.
  • Keep leaders involved and committed: Leaders can indoctrinate new hires and inform them that the hospital "no longer does business the old way." Leaders can also direct new hires to training and follow up on their progress.
  • Establish a committed team of trainers: A cadre of highly trained volunteer instructors serves to reinforce the message to coworkers during classes.
  • Hold learning sessions: Quarterly morbidity and mortality conferences have been transformed into active learning sessions that incorporate TeamSTEPPS™ strategies to integrate improvements and creative solutions.
  • Make policy changes on an ongoing, immediate basis: At Madigan Army Medical Center, lessons learned from an event are quickly distributed via e-mail to team members, including the establishment of new policies.
  • Recognize the need for patients to feel empowered and responsible for their own health: The medical center's patient initiative program, Patient and Family Join the Team, addresses The Joint Commission's Patient Safety Goal Number 13, which urges providers to encourage patients to safeguard their health.
  • Use conflict resolution tools and techniques: The medical center found that these resources promoted better relationships between individuals who had been experiencing conflicts in the past.

Use By Other Organizations

  • TeamSTEPPS™ is widely used throughout military hospitals and is increasingly being used in for-profit and nonprofit hospitals and other health care settings across the nation. In addition, for the first time, TeamSTEPPS™ is being deployed in a combat environment by the 86th CSH TF-Baghdad at Ibn Sina Hospital, the busiest trauma hospital in Iraq. Training is also planned for other combat support hospitals in Baghdad.

Additional Considerations

TeamSTEPPS™ was awarded the 2007 M. Scott Myers Award for Applied Research in the Workplace from The Society for Industrial and Organizational Psychology.

More Information

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Contact the Innovator

Peter G. Napolitano, MD
Colonel, MC, USA
Director, Maternal-Fetal Medicine Fellowship MCHJ-CLG-M (Attn: COL Napolitano ADC/3-North)
Department OBGYN
Madigan Army Medical Center
Tacoma, WA 98431
Phone: (253) 968-2417/6023
DSN: (782) 2417/6023
Fax: (253) 968-5518

TRICARE Management Activity
Military Health System
Skyline 5, Suite 810 5111 Leesburg Pike
Falls Church, VA 22041-3206

Innovator Disclosures

Dr. Napolitano has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Baker DP, Beaubien JM, Holtzman AK. DoD medical team training programs: an independent case study analysis. (Prepared by the American Institutes for Research Under Contract No, 282-98-0029, Task Order No. 54) Rockville, MD: Agency for Healthcare Research and Quality; May 2006. AHRQ Publication No. 06-0001, March 2006.

TeamSTEPPS™: Creating a safety net for your healthcare organization: guide to action. June 2008. Available at:

AHRQ, Tricare. Team STEPPS: Strategies and tools to enhance performance and patient safety. DVD/CD. Curriculum kit disk wallet AHRQ publication number 06-0020-3.

Henriksen K et al. (eds). Advances in patient safety: from research to implementation. Vol. 3, Concepts and methodology. AHRQ Publication No. 05-0021-3. Rockville, MD: Agency for Healthcare Research and Quality; Feb 2005, p. 425-35. Available at:

Nielsen PE, Goldman S, Mann DE, et al. Effects of teamwork training on adverse outcomes and process of care in labor and delivery: a randomized controlled trial. Obstet Gynecol. 2007;109(1):48-55. [PubMed]

Williams L, Morrow B, Shulman H, et al. Pregnancy risk assessment monitoring system (PRAMS) 2002 Surveillance report. Atlanta, GA: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention; 2006.


1 Williams L, Morrow B, Shulman H, et al. Pregnancy risk assessment monitoring system (PRAMS) 2002 Surveillance report. Atlanta, GA: Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention; 2006.
2 TeamSTEPPS™: Creating a safety net for your healthcare organization: guide to action. June 2008. Available at:

3 Haig KM, Sutton S, Whittington J. SBAR: a shared mental model for improving communication between clinicians. J Qual Patient Saf. 2006;32(3):167-75. [PubMed]
4 Mahlmeister RL. Best practices in perinatal care: reporting "near misses" and "good catches" as a risk reduction strategy. J Perinat Neonatal Nurs. 2006;20(3):197-9. [PubMed]
5 Telephone interview with PG Napolitano, May 23, 2008.
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: November 10, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 23, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: October 16, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.