USING TeamSTEPPS® TO IMPROVE INTERDISCIPLINARY
COMMUNICATION & TEAMWORK IN THE OPERATING ROOM
Point of Contact: Mr. Jonathan Lubach,
Landstuhl Regional Medical Center Operating Room Data Coordinator
DSN 314-590-4348 jonathan.m.lubach.civ@mail.mil
Group Involved with the Project. Landstuhl Regional Medical Center Division of
Surgery, Perioperative Nursing Services, and Quality Management Division
MAJ Daniel Coulter, Administrative Resident
LTC Damon Baine, Preceptor
Landstuhl Regional Medical Center
16 May 2014
Executive Summary: Based on over 20 years of research, TeamSTEPPS® is an evidence-based approach to team training that can be used in any healthcare setting where teamwork and communication are critical to success such as the Operating Room (OR) or Patient Centered
Medical Home (PCMH). US Army Medical Command (MEDCOM) Operations Order
(OPORD) 11-38 directed all Medical Treatment Facilities (MTF) to implement the use of
TeamSTEPPS® in order to achieve the best clinical outcomes for their patients. In July 2013,
Landstuhl Regional Medical Center (LRMC) implemented the Surgical Services TeamSTEPPS® concepts in order to improve the surgical preoperative process and saw a significant reduction in procedure associated defects and a significant increase in OR first start rate. Through the implementation of communication concepts and tools such as a morning huddle (brief), a standardized on-line debriefing tool, and a completely trained OR staff, LRMC has set the
MEDCOM standard for improving operating room performance with the use of TeamSTEPPS®.

Objective of the Best Practice: To improve the efficiency of the surgical preoperative process utilizing the US Army Medical Command (MEDCOM) Team Strategies and Tools to Enhance
Performance and Patient Safety (TeamSTEPPS®) Surgical Services concepts at Landstuhl
Regional Medical Center (LRMC). This initiative builds on the patient safety culture, dedicated to preventing and reducing unsafe practices in the operating room environment and developing successful and effective communication and coordinated care practices to provide safe, high quality, efficient patient care.
Background: Since the early 1990’s, when the Institute of Medicine published their report To
Err is Human: Building a Safer Health System (Kohn, Corrigan, & Donaldson, 1999) patient safety has been at the forefront of discussion when it comes to high quality healthcare. The report highlighted the fact that as many as 98,000 deaths occur annually attributable to medical errors. The Department of Defense (DOD) and The Agency for Healthcare Research and
Quality (AHRQ) have been proactive in promoting and practicing patient safety initiatives, and in 2004, they developed TeamSTEPPS®. Defined by AHRQ as “an evidence-based teamwork system aimed at optimizing patient outcomes by improving communication and teamwork skills among health care professionals,” TeamSTEPPS® can be used in any healthcare setting where teamwork and communication are critical to success such the operating room (OR) or patient centered medical home (PCMH). In May 2011, MEDCOM published Operations Order
(OPORD) 11-38 (AMEDD-Wide Implementation of TeamSTEPPS®) mandating the implementation of TeamSTEPPS® in all Medical Treatment Facilities (MTF) by the end of
Fiscal Year (FY) 2011.
The Surgical Services TeamSTEPPS® concepts started as a simulation based OR training program at Madigan Army Medical Center (MAMC) in 2009. The MEDCOM adopted the principles and started a pilot program at Reynolds Army Community Hospital (RACH) - Fort
Sill, Oklahoma in 2012. LRMC was the sixth facility in MEDCOM to receive the training after
MAMC, RACH, Martin Army Community Hospital – Fort Benning, Georgia, Brian Allgood
Army Community Hospital (BAACH) – Korea, and Kimbrough Ambulatory Care Center – Fort
Meade, Maryland.
Literature Review: An extensive body of literature and research exists on teamwork, medical team training, and communication, and their impact on improving performance in healthcare settings. This is to be expected, as much of the medical care provided today is a team effort.
Porta et al. (2013) described the implementation and use of a standardized postoperative debrief tracking tool and its benefits on improving OR efficiency. This article has a direct relationship to the TeamSTEPPS® Surgical Services implemented at LRMC as the authors’ organization was the first in the MEDCOM to receive and implement it. The article highlights the factors that led to OR delays and that the use of a standardized debriefing tool and system directly led to decrease those delays.
Forse, Bramble, & McQuillan (2011) studied the impact of the use of TeamSTEPPS® on
OR performance. They had significant improvement in several areas to include staff teamwork, communication, OR first case starts, patient satisfaction, and several Surgical Quality
Improvement Program (SQIP) measures. They showed that there is statistically significant evidence that TeamSTEPPS® directly affects communication and teamwork in the OR, but also brought to light a key factor for consideration by organizations implementing TeamSTEPPS®.
While team training can be effective in improving the delivery of healthcare, sustained team

training must be practiced in order to maintain any gains made through its use.
Wolf, Way, & Stewart (2010) conducted the largest analysis of medical team training utilizing TeamSTEPPS® in the San Francisco VA Medical Center. They developed a standardized debriefing and preoperative routine which included documentation of errors and delays. Through the analysis of 4863 debriefings, they found statistically significantly improvements in a decrease in the frequency of delays, hand-off and equipment issues, and increased compliance with medication administration.
Bandari et al. (2012) set out to determine if the implementation of OR briefings and debriefings were useful in identifying defects and patient safety hazards in surgical care. Over the almost four-year study, they found that an average of 141 defects were identified per month for 6202 total defects. They gathered data in a two phases; one, which used six defect categories/codes, and another which used sixteen defect categories/codes. This was done based off the unit managers’ feedback in order to more clearly identify where the issues were generated. In the first phase, equipment and communication issues were most prevalent. In the second phase instrument issues, communication, and safety were the most identified. Results also showed that the defects were almost equally observed and noted in the initial briefing and the debriefing, highlighting the use of the tool to prevent errors that could cause harm to patients.
Salas, Wilson, Murphy, King, & Salisbury (2008) present the concept of a “threepronged” approach to teamwork in healthcare; communication, coordination, and cooperation.
Each element plays a vital role in in enhancing both patient safety and quality and are relevant to the TeamSTEPPS® concept. Of particular note they state, “Four important components should be included in communications-context, content, audience, and purpose- and all communication errors result from errors in one of those components (Salas et al., 2008, pg. 336).” Coordination is described as the ability of the team to plan and coordinate strategies, while cooperation focuses on the team’s ability to predict and anticipate the needs of each of the member’s expectations.
The article emphasizes that a blend of all three of the elements are necessary for teams to ensure the highest quality care.
Implementation Methods: The LRMC Quality Management Division (QMD) coordinated for the MEDCOM Surgical Services Simulation Train the Trainer Team to provide a three-day, onsite, surgical services based simulation-training event to LRMC identified champions and experts in their specialty in July 2013. These included personnel from all areas of the surgical services department such as surgeons, anesthesia providers, nursing staff, surgical technicians, Central
Materiel Services (CMS), and the Post-Anesthesia Care Unit (PACU). Over a six-week period, the remainder of staff personnel received the training. The focus of the training team was the practice and use of tools and strategies designed to directly impact OR performance through simulation with an emphasis on briefs and debriefs.
Immediately following the Surgical Services TeamSTEPPS® training, under the direction of the Chief, Perioperative Nursing Services (PONS) and the LRMC OR Data
Coordinator, a Root Cause Analysis (RCA) of the current process was conducted. The goal was to determine what the causes were for the lack of interdisciplinary communication and teamwork and to determine what lead to an increased number of defects before or during the surgical procedure. The RCA determined that the current process was not designed to allow communication/huddles prior to the patient being moved to the OR (with the exception of required timeouts), which increased the risk of defects or errors before or during cases. The system in place had no specific structure for team members to perform necessary perioperative

tasks or review procedures as a group prior to a case, or in essence, that the first time there was interaction between team members was when both the team and patient were in the OR.
Because of the RCA, prioritized implementation solutions (Table 1) were yielded and a pilot plan was created to evaluate both the solutions and the implement of the solutions. Two measurable operational benefits (Reduce the defect rate by 50% and Increase on time first starts
> 90%) were identified and baseline metrics were established to determine a starting point for the measurement of the effectiveness of the utilization of the Surgical Services TeamSTEPPS® concepts. Procedure Associated Defect and Operating Room First Start data was collected starting in the 4 th
quarter of Fiscal Year (FY) 13. Prior to the adoption of the Surgical Services
TeamSTEPPS® concepts, LRMC did not collect data regarding the surgical preoperative process and defects before or during the surgical procedure. The organization did collect Operating
Room First Start data, which was used to determine the baseline metric, associated with the
Surgical Services TeamSTEPPS® implementation. For the implementation of the plan, measurements were collected monthly and reported quarterly.
At the start of the pilot plan, the initiation of a morning huddle (brief), an after case debrief for the surgical team, and the development and implementation of an online debriefing tool (Figure 1) to be completed following every case on the organization’s MEDSHARE portal prior to leaving the OR became the standard for daily operations.
Results:
Since the implementation of Surgical Services TeamSTEPPS® in the 4 th
quarter of FY13, significant progress has been made in the preoperative process. 3297 debriefs have been conducted utilizing the online debriefing tool with a compliance rate of 90.3%. In the same time, the morning “huddle” or brief prior to the start of the day compliance rate was 94.5%. The issues/trends that are noted on the debrief tracker are reported daily to the service chief for each responsible entity (i.e. Surgery, Anesthesia, Ambulatory Procedure Unit (APU), Central Materiel
Services (CMS), etc.). Furthermore, the data is reported monthly to the Chief, Division of
Surgery, and Surgical Department Chiefs, briefed at the monthly at the OR Performance Meeting and the responses are posted in the OR Break room for staff to follow-up as well as posted on the
MEDSHARE. The following are highlights from each of the three quarters since the implementation:
4 th
Quarter FY13- Table 2 shows the baseline and pilot data concerning Procedure
Associated Defects starting with the implementation during the 4 th quarter. There was an 81.99% overall improvement/decrease in Procedure Associated Defects. Additionally in the 4 th
quarter, there was a 42% increase for Operating Room First Start, and a 30% decrease in surgical delays.
This was also due in part to increased leadership emphasis on a designated time for team huddle
30 minutes prior to the start of the first case. In all, sixteen trends were identified and corrected as a result of the OR debrief and a specific debrief tool was implemented for CMS related issues and staff.
1 st Quarter FY14- There was 1125 OR debriefs completed with a 91% compliance rate and huddle compliance was 93% while Operating Room First Start improved slightly to 92%.
There was an 85% improvement with factors potentially causing surgical delays to include preoperative paperwork, labs, communication, and site verification. Five huddles identified/prevented factors for potential serious safety issues. Because of the debriefs, six trends were referred to the OR Unit Practice Council (UPC) for improvement. A modification was made to the debrief tool with the addition of a team huddle participation question to capture

daily participation and gain reportable data.
2 nd
Quarter FY14- This quarter seemed to yield the slight gains and losses in some areas while producing the greatest amount of actionable data since implementation. Huddle participation increased to 96% while OR debrief compliance and Operating Room First Start dipped slightly to 89.9% and 90.6% respectively. Actionable data included four critical instrument sets identified as high use, data was used to justify the procurement of additional sets, and eight huddles identified and prevented factors for potential serious safety issues prior to surgery. Debriefs generated eighteen additional opportunities for improvement to the OR UPC, topics comprised of ideas to improve OR performance and turnover time (two of the six
MEDCOM 3SL metrics). The OR debriefs highlighted an increase of trends in preoperative issues that caused delays which led to the creation of a debrief tool for the APU to track and rectify issues with the clinics and support services. The data gathered through the tool for the
APU will be analyzed to determine if there are certain areas for future process improvement.
Staff satisfaction, particularly among the surgeons and OR, remains high and the organization continues to receive positive comments on the use of OR debriefs and the effective use of the Surgical Services TeamSTEPPS® concepts. During the organization’s recent Joint
Commission survey, Surgical Services TeamSTEPPS® served as the primary topic during the
Data Management Tracer presented to the survey team. The LRMC staff continues to receive praise on its practices and the results gained through implantation from the MEDCOM Patient
Safety Office. The Operating Room Data Coordinator and Project Manager of LRMC’s Surgical
Services TeamSTEPPS® implementation has been asked by MEDCOM to give a ten minute speech on the program’s success at the 2014 TeamSTEPPS National Conference in June 2014.
Conclusion:
While it has only been nine months since its implementation, it is clear to see the benefits of utilizing the Surgical Services TeamSTEPPS® concepts from both the patient safety and performance points of view. Because the OR is a complex, high-risk, high-stress environment, it is susceptible to errors with the greatest being severe harm and even death. The program as adopted by LRMC has an unmistakable impact on safe, high quality care. The process is replicable and is currently available to any organization within the MEDCOM; however, the goals and expectations must be realistic. The results achieved from the Surgical Services
TeamSTEPPS® training are only as strong as the effort of applying the concepts to the organization. To achieve the greatest results, there has to be support from the leadership and buy-in from the staff. The only way to ensure continued success and maintain desired outcomes is to sustain the emphasis on training and build upon the gains achieved. The use of the debriefing tool will provide data for future analysis and continuous process improvement.

Appendix
Table 1. LRMC Surgical Services TeamSTEPPS® Goals and Prioritized Solutions
Train staff on TeamSTEPPS® concepts
Conduct training with various scenarios
Designate specific time & centralized location for team huddles
Conduct and document a post-operative debrief after each case
Review debriefs and distribute issues to responsible Department Chief
Report issues and follow-up responses at the monthly OR Performance Meeting
Track compliancy of huddles and debriefs
Identify trends and submit for possible Process/Performance Improvement opportunity
Report highlights and statistics to OTSG quarterly
Table 2. Changes in Procedure Associated Defects in 4th Quarter FY 13* (July-September 2013)
Procedure Associated Defect
Baseline Occurrences
N= 272
Pilot Occurrences
N= 49
% Improvement
Surgeon Unavailable
Site Verification Marking
Consent Issue / H&P
No/Difficult IV
Incomplete Paperwork
Lab/EKG Pending
HCG Pending
Communication Between Any Party
Not in APU on Time
Medical Issue on Surgery Day
27
26
18
11
10
45
40
34
32
29
11
3
4
4
2
6
5
8
3
3
86.7%
87.5%
76.5%
90.6%
89.7%
85.2%
84.6%
88.9%
0.0%
70.0%
* Overall Improvement 81.99%

Figure 1. Screen shot of online debrief tool utilized on LRMC MEDSHARE.

References
Bandari, J., Schumacher, K., Simon, M., Cameron, D., Goeschel, C., Holzmueller, C., Makary,
M., Welsh, R., & Berenholtz, S. (2012). Surfacing safety hazards using standardized operating room briefings and debriefings at a large regional medical center. Joint
Commission Journal on Quality and Patient Safety , 38 (4), 154-160.
Forse, R. A., Bramble, J. D., & McQuillan, R. (2011). Team training can improve operating room performance. Surgery , 150 (4), 771-778.
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: building a safer health system (Vol. 627). National Academies Press.
Porta, C. R., Foster, A., Causey, M. W., Cordier, P., Ozbirn, R., Bolt, S., Allison, D., & Rush, R.
(2013). Operating room efficiency improvement after implementation of a postoperative team assessment. Journal of Surgical Research , 180 (1), 15-20.
Salas, E., Wilson, K. A., Murphy, C. E., King, H., & Salisbury, M. (2008). Communicating, coordinating, and cooperating when lives depend on it: tips for teamwork. Joint
Commission Journal on Quality and Patient Safety , 34 (6), 333-341.
Wolf, F. A., Way, L. W., & Stewart, L. (2010). The efficacy of medical team training: improved team performance and decreased operating room delays: a detailed analysis of 4863 cases. Annals of Surgery , 252 (3), 477-485.