Im concerned! How to communicate with your colleagues better (Proceedings)


Teamwork is defined by a set of interrelated knowledge, skills, and attitudes (KSAs) that facilitate coordinated, adaptive performance, improving a groups ability to meet its objectives.

Teamwork is defined by a set of interrelated knowledge, skills, and attitudes (KSAs) that facilitate coordinated, adaptive performance, improving a group's ability to meet its objectives. Both teamwork and taskwork (i.e., operational skills) are required for teams to be effective in complex environments like veterinary medical settings. However, knowledge and skill at the task level are not sufficient for success in the clinic. Teamwork depends upon the ability of each member of the team to:

  • Anticipate needs of others

  • Adjust to each other's actions and the changing environment

  • Have a shared understanding of how a plan of care should happen

In human health care, there has been significant progress in defining team requirements since the Institute of Medicine (IOM) published “To err is human” in 1999.1 This report documented as many as 98,000 preventable deaths in hospitals in the US each year due to medical errors. It is estimated that 80% of serious medical errors in human health care occur due to miscommunication among the team of caregivers. The publication of this report and the research upon which it was based led to the development of TeamSTEPPS® by the Department of Defense (DoD) and the Agency for Healthcare Research and Quality (AHRQ), which was released in 2006. In 2014, the TeamSTEPPS® program was updated to version 2.0 to streamline some of the tools and update the evidence base. The TeamSTEPPS approach leads to increased desirable teamwork and safety attitudes, as well as increased communication, teamwork behaviors, clinical process compliance, efficiency, and overall performance in a variety of medical settings.2–4 This lecture will focus on the 4 basic concepts of the TeamSTEPPS® program, leadership, communication, situation monitoring, and mutual support, as well as the knowledge, skills and attitudes necessary to achieve optimal team performance and maximize patient outcomes. We will introduce several tools that you can use in your practice to improve team dynamics and communication, reduce medical errors, and improve staff morale.

Highly functioning team members can anticipate the needs of other team members, dynamically adjust to a changing environment, and have a shared understanding of what should happen. In addition, clients should be considered part of the health care team and empowered to take an active role in patient care.

Effective leaders manage resources and facilitate team actions to ensure that all members of the team are seeking information, plan and continually refine team duties, coordinate team actions, resolve conflict among team members, and provide coaching and feedback. Leaders must balance the role of handing down solutions to problems with that of facilitating problem solving the team. By developing a shared vision with the team, facilitating coordination and collaboration, and motivating team members, effective leaders maximize the performance of each team member and improve patient care. Three communication tools can be used by team leaders to establish a supportive, collaborative environment in which each member of the team can maximally contribute to patient care: briefs, huddles, and debriefs.

A brief is a team strategy used by team leaders to share a patient care plan and encourage input from team members. During a brief, the leader forms the team, designates the role and responsibilities of each team member, establishes the climate and sets goals, and engages all members of the team in planning. During the brief, it is important that all of the following questions are answered: Who is on the core team? All members understand and agree upon the goals? Roles and responsibilities understood? Does everyone understand the plan of care? Can all team members manage additional workload? Are all necessary resources available? This simple communication tool allows the entire team to establish a shared mental model of the needs of the patient and reduces miscommunication among team members, one of the major contributors to serious medical errors.5

A huddle is used when patient status has changed or a modification to the treatment plan is needed for any reason. It's an ad hoc meeting to re-establish a shared mental model among team members, discuss critical issues, reassign resources, express concerns, and to anticipate outcomes and contingency plans. In addition to improving patient safety, the use of huddles has been shown to improve the working relationships between members of inter-professional teams.6

A debrief is a tool for team development and process improvement. It is a brief information exchange and feedback session done after a shift or a specific critical event. It is focused on identifying teamwork challenges with the goal of improved team performance and patient outcomes. The debrief is focused on answering the following questions: Was communication clear? Were roles of each team member understood? Was workload distributed effectively? Was assistance asked for and offered? Were errors made or avoided?What went well, and what could be improved?

The debrief should be informal, and all team members should be encouraged to participate. Consistent use of debriefing has been shown to increase individual and team performance and to improve patient outcomes.7,8


Leadership is an essential component of the TeamSTEPPS® approach, and is crucial for sustaining the trained behaviors and desired outcomes of the program. Ultimately, effective teams are defined by excellent communication, a shared mental model of patient status, and leadership that maximizes the performance of each team member, with the ultimate goal of improved patient care.

Situation awareness

Situation monitoring is an individual skill that involves active assessment of the clinical setting and continual scanning of the environment that allows each member of a health care team to maintain an accurate awareness and understanding of the current “situation.” It is essential that all members of the health care team maintain these monitoring activities, which contribute to team cognition. By practicing situation monitoring, the team can develop a shared mental model of any clinical situation and work as a highly effective unit in which each member is contributing maximally to patient care, unfettered by misunderstandings or conflicting assessments. Ultimately, good situation monitoring skills and a shared mental model lead to shared situation awareness, in which each member of the team is on the same page at all times.9,10

The important individual components of situation monitoring can be summarized by the acronym STEP. The table below lists each aspect of situation monitoring and examples of individual items of which all team members should remain aware. This approach can help inform the initial brief called by the team leader, and as the status of the patient changes, any member of the team may call a huddle to discuss the change and suggest alterations to the plan.


Status of the Patient Hx, Vitals, Medications, PE, Plan of Care


Team Members Fatigue, Workload, Skill Level, Stress Level


Environment Facilities, Triage Acuity, Equipment


Progress to Goal Goal of Team, Tasks/Actions to be Completed, Is the Plan Still Appropriate?






There are many ways team members can improve situation awareness and improve the ability of the team to develop a shared mental model, including sharing new information will all team members, requesting information from other members of the team, directing information explicitly to specific team members, including the client in communication about the case, maintaining a thorough and complete medical record, knowing and understanding the plan, and informing all team members when the plan has changed, ideally with a huddle.

The TeamSTEPPS® approach includes several tools to facilitate situation awareness. In general, all communication between team members should adhere to the following 4 principles of effective communication: (1) Complete: communicate all relevant information, (2) Clear: convey information that is plainly understood, (3) Brief: communicate all information concisely, (4) Timely: make information available when needed, verify its accuracy, and acknowledge the information.

Call-outs are used to communicate important or critical information to all team members simultaneously in an emergency. As a team member acquires information that is important to patient care, he or she clearly and succinctly calls out that information so that all team members can hear. This allows all team members to maintain an accurate shared mental model, and helps team members to anticipate next steps. There is strong evidence in multiple practice settings that simple tools like the call-out improve patient outcomes and team performance in varied practice settings.11,12

The check-back is a tool that uses closed-loop communication to ensure that vital information is received and understood by a specific team member. A check-back is initiated by someone with information or a request directed at a specific team member. The receiver acknowledges that the message was received and repeats back the pertinent information to ensure that the information was received accurately. The sender then verifies that the information received was correct. Proper use of the check-back is efficient way to minimize errors, and has been shown to improved patient outcomes and team performance in a number of studies.13,14

When important information must be conveyed from one member of the team to another, such as a change in patient status, the SBAR provides a framework for efficient, effective communication of that information. By using this standardized approach, essential information can be communicated quickly and concerns can be addressed efficiently. The components of an SBAR are:

  • Situation – What is going on with the patient?

  • Background – What is the relevant clinical background or context?

  • Assessment – What do you think the root problem is?

  • Recommendation – What would you suggest the team member do?

Using the SBAR approach can streamline communication of important information between members of the team and minimize misconceptions.


Transferring care of a patient from one team to another (such as from the day shift to the night shift or from one service to another) is called a handoff. Many studies have identified handoffs as major risks for medical errors, and a structured approach to handoffs is now widely advocated.15–17 The I-PASS approach has recently been developed and is associated with a 40% reduction in medical errors and significant reductions in verbal and written miscommunication rates in an initial pilot study.18 The components of an I-PASS handoff include

  • Illness Severity – categorized as (1) stable, (2) “watcher”, (3) unstable

  • Patient Summary – events leading up to admission, hospital course, ongoing assessment, plan

  • Action List – To do list, Time line and ownership

  • Situation Awareness / Contingencies – Know what's going on, plan for what might happen

  • Synthesis by Receiver – Receiver summarizes what was heard, Asks questions, Restates key action items

Mutual support

Mutual support can be thought of as the employment of “back-up behaviors” among members of a team It involves reallocating resources to a member of a team to help that team member achieve the desired goal when it is apparent that the team member is failing. At its core, mutual support is simply the concept of helping others on the team perform their tasks to optimize patient care and address team member limitations and other demands. Backup behaviors often include filling in for a team member who cannot perform a task (e.g., inexperienced, incapable, overburdened, about to make an error), helping others correct mistakes, or redistributing work to a team member who is underused.

Ultimately, mutual support in a healthcare environment is an acknowledgement that the clinical setting is frequently characterized by a high workload in combination with the requirement to efficiently complete acute, time-sensitive tasks. Demands and priorities change frequently in this setting, and mutual support provides a safety net to reduce errors, increase effectiveness, and minimize stress due to workload. Incorporation of mutual support training into health care curricula have been shown to reduce length of hospital stay by 50%, reduce hospital costs by 19%, and reduce both medical errors and mortality.19–21

Mutual Support involves three actions: (1) assisting other team membes, (2) providing and receiving feedback, and (3) assertive and advocacy behaviors when patient safety is threatened. It is essential that team members foster an environment in which these actions are not only encouraged, but are expected behaviors that become part of the culture.

Assisting Team Members: Acknowledgement that the veterinary healthcare environment is one of rapidly shifting workloads and demands, it is essential that all team members understand that a workplace in which assistance with tasks is actively sought and offered is a highly effective method of reducing medical errors and improving patient care. Encouraging all members of the team to check in with colleagues and to offer and ask for help will help create a culture of mutual support.

Feedback: Feedback is an essential component of improving team performance and addressing limitations of individual team members and of the overall team dynamic. Both formal, evaluative feedback, such as performance reviews and case conferences, and informal, real-time feedback, such as huddles and debriefs are needed for professional development and honing team skills.

Advocacy and Assertion: All members of the team must be comfortable advocating for the patient when their viewpoints are at odds with those of a decision maker. It is the responsibility of each team member to assert a corrective action in these cases in a firm but respectful manner. An assertive statement should be respectful and supportive of authority, but clearly assert the concern of the team member as well as the suggested alternative approach. It should be non-threatening, and include all critical information that led to the alternative conclusion reached by the team member. CUS is an acronym used to frame an assertion by a team member.

  • I am Concerned – explain the patient data that lead to your concern

  • I am Uncomfortable – explain why the data could lead to a patient safety issue

This is a Safety Issue – explain what consequences you feel could occur and your suggested plan of action



TeamSTEPPS® Homepage:

I-PASS Handoff Materials:


Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC; 1999.

Weaver SJ, Lyons R, DiazGranados D, Rosen M a, Salas E, Oglesby J, et al. The anatomy of health care team training and the state of practice: a critical review. Acad Med. 2010;85(11):1746–60.

Buljac-Samardzic M, Dekker-van Doorn CM, van Wijngaarden JDH, van Wijk KP. Interventions to improve team effectiveness: a systematic review. Health Policy. Elsevier Ireland Ltd; 2010;94(3):183–95.

Neily J, Mills PD, Lee P, Carney B, West P, Percarpio K, et al. Medical team training and coaching in the Veterans Health Administration; assessment and impact on the first 32 facilities in the programme. Qual Saf Health Care. 2010;19(4):360–4.

Lingard L, Regehr G, Orser B, Reznick R, Baker GR, Doran D, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143(1):12–7; discussion 18.

Chapman KB. Improving communication among nurses, patients, and physicians. Am J Nurs. 2009;109(11 Suppl):21–5.

Smith-Jentsch KA, Cannon-Bowers JA, Tannenbaum SI, Salas E. Guided Team Self-Correction: Impacts on Team Mental Models, Processes, and Effectiveness. Small Gr Res. 2008;39(3):303–27.

Tannenbaum SI, Cerasoli CP. Do Team and Individual Debriefs Enhance Performance? A Meta-Analysis. Hum Factors J Hum Factors Ergon Soc. 2012;55(1):231–45.

Endsley M. Theoretical underpinnings of situation awareness: a critical review. In: Endsley M, Garland D, editors. Situation awareness analysis and measurement. Mahwah, NJ: Lawrence Erlbaum Associates; 2000. p. 3–32.

Klimoski R, Mohammed S. Team Mental Model: Construct or Metaphor? J Manage. 1994;20(2):403–37.

Riley W, Davis S, Miller K, Hansen H, Sainfort F, Sweet R. Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital. Jt Comm J Qual Patient Saf. 2011;37(8):357–64.

Weaver SJ, Rosen M a, DiazGranados D, Lazzara EH, Lyons R, Salas E, et al. Does teamwork improve performance in the operating room? A multilevel evaluation. Jt Comm J Qual Patient Saf. 2010;36(3):133–42.

Mayer CM, Cluff L, Lin W-T, Willis TS, Stafford RE, Williams C, et al. Evaluating efforts to optimize TeamSTEPPS implementation in surgical and pediatric intensive care units. Jt Comm J Qual Patient Saf. 2011;37(8):365–74.

Deering S, Rosen M a, Ludi V, Munroe M, Pocrnich A, Laky C, et al. On the front lines of patient safety: implementation and evaluation of team training in Iraq. Jt Comm J Qual Patient Saf. 2011;37(8):350–6.

Gakhar B, Spencer AL. Using direct observation, formal evaluation, and an interactive curriculum to improve the sign-out practices of internal medicine interns. Acad Med. 2010;85(7):1182–8.

Clarke CM, Persaud DD. Leading clinical handover improvement: a change strategy to implement best practices in the acute care setting. J Patient Saf. 2011;7(1):11–8.

Johnson JK, Barach P. Patient care handovers: what will it take to ensure quality and safety during times of transition? Med J Aust. 2009;190(11 Suppl):S110–2.

Starmer AJ, Spector ND, Srivastava R, Allen AD, Landrigan CP, Sectish TC. I-pass, a mnemonic to standardize verbal handoffs. Pediatrics. 2012;129(2):201–4.

Pronovost P, Needham D. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725–32.

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Pronovost P, Berenholtz S, Dorman T, Lipsett PA, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003;18(2):71–5.

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