Form #1 Form #1 Training participant questionnaire

T

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

eamSTEPPS^® Master Training Participant Web-based Questionnaire

Introduction

Thank you for accessing this questionnaire. This questionnaire is intended to obtain your perceptions of the Agency for Healthcare Research and Quality’s (AHRQ)/Department of Defense’s (DoD) National Implementation of TeamSTEPPS^® Program. You have been invited to complete this questionnaire because you were trained as a TeamSTEPPS Master Trainer under the National Implementation Program. As part of this questionnaire, you are being asked to assess the usefulness of the master training program and the concepts, tools, and strategies that make up the TeamSTEPPS curriculum. You are also being asked to indicate how you have used this material, whether at your organization or while supporting other organizations. It is important to note that this is not an evaluation of you or your progress in implementing TeamSTEPPS or your ability to share it with others. Rather, the information you provide regarding these concepts, tools, information, and resources will be used to enhance AHRQ’s repository of patient safety tools and resources, as well as future TeamSTEPPS-based initiatives. Your responses will be used to help AHRQ identify the most useful aspects of the TeamSTEPPS curriculum. Further, your responses will be used to help AHRQ identify additional support for individuals such as yourselves as you work towards improving patient safety. Your candid feedback is the only way that these enhancements can be achieved. Please note that if you do not wish to answer a specific question, you may skip it. You are, however, encouraged to respond to all questions. Please note that all of the information you provide will remain confidential and that all information collected via this questionnaire will be reported at the aggregate level to ensure the confidentiality of the participants.

Should you have any questions or comments about this questionnaire or the TeamSTEPPS evaluation effort, please do not hesitate to contact Dr. David P. Baker of the American Institutes for Research (AIR) at 202-264-0659 or [email protected]. Dr. Baker is the Practice Area Leader for all of AIR’s TeamSTEPPS work including the National Implementation Program. Additional information about the National Implementation can be found at teamstpps.ahrq.gov.

If you have concerns or questions about your rights as a participant, contact AIR’s Institutional Review Board (which is responsible for the protection of project participants) at [email protected]  toll free at 1-800-634-0797 or American Institutes for research, c/o IRB, 1000 Thomas Jefferson Street, NW, Washington, DC  20007. 

Public reporting burden for this collection of information is estimated to average 20 minutes per response, the estimated time required to complete the survey. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

Instructions

Please carefully read each question on this questionnaire. There are five primary sections:

1. Master Trainer Characteristics

2. Post-Master Training Activities

3. Facilitators and Barriers to Use of TeamSTEPPS in the Workplace

4. Outcomes of Participation in TeamSTEPPS Master Training

Note that the response scale for each question will vary from section to section. For example, in the Post-Master Training Activities section, you will be asked to respond to a given statement using a response scale wherein 1=Disagree, 2 = Neutral, and 3= Agree. By contrast, in the Transfer of Training section, you will be asked to indicate how often you have used a TeamSTEPPS tool using a response scale ranging from 1=Rarely to 4=Very Often. Please read each question carefully and make sure that you select the response you intend.

Master Trainer Characteristics (CIPP Model Variables Context and Individual Characteristics)

In this section, you are being asked to provide information about yourself, your organization, and your participation in the TeamSTEPPS Master Training program. Please answer candidly and note that your personal information will not be provided to any entity. All information will be reported to AHRQ on an aggregate level.

1. Which of the following best characterizes the organization in which you currently work? [Select one]

   1. Academic health profession program

   2. Public hospital

   3. Federal government health provider

   4. Community Hospital

   5. Children’s Hospital

   6. Critical Access Hospital

   7. Outpatient clinic

   8. Quality Improvement Organization (QIO)

   9. State health department

   10. Hospital association

   11. Patient safety center/commission

   12. Risk, Liability, Malpractice or Other Insurer

   13. Long term care facility, assisted living facility, or home health agency

   14. Regional or state-based healthcare professional association or institution

   15. Other: [Fill in the blank]

2. In what state is your organization located? [Provide drop-down menu of states]

3. What is the name of your employer facility/organization? [Fill in the blank]

4. If your facility is part of a larger healthcare system, what is the name of that larger healthcare system? [Fill in the blank]

5. What is your current job title? [Fill in the blank]

6. In what area did you complete your professional training? [Check all that apply]

   1. Nursing

   2. Medicine

   3. Pharmacy

   4. Public Health

   5. Health Administration

   6. Allied Health

   7. Life Science

   8. Other: [Fill in the blank]

7. How long have you served in your current role (at your current organization)? [Select one]

   1. 0-1 years

   2. 2-5 years

   3. 6-10 years

   4. 11 or more years

8. What was the reason for your participation in TeamSTEPPS Master Training? [Check all that apply]

   1. I wanted to find out more about TeamSTEPPS.

   2. I wanted to find out more about teamwork and team training in healthcare.

   3. My organization/department/unit is implementing TeamSTEPPS to improve quality of care

   4. Our health system has committed to using TeamSTEPPS to improve quality of care

   5. My organization had experienced a sentinel event or potential patient safety near miss.

   6. My organization leaders mandated our participation.

   7. We would like to introduce TeamSTEPPS in our medical or nursing education

   8. We would like to introduce TeamSTEPPS in our in-service program

   9. We are assisting a health provider organization improve patient safety We plan to use TeamSTEPPS as part of a research project

   10. Other: [Fill in the blank]

9. Where did you first learn about the TeamSTEPPS Master Training being offered through the National Implementation Program?

   1. TeamSTEPPS.ahrq.gov website

   2. Another website or web search

   3. At a conference

   4. Webinars

   5. Word of Mouth

   6. AHRQ Publications

   7. A talk given by an AIR, AHRQ, or Department of Defense (DoD) representative

   8. A talk given by a health care professional not affiliated with AIR, AHRQ, or DoD

   9. A professional newsletter or publication

   10. Other: [Fill in the blank]

10. Which of the following best represents your implementation of TeamSTEPPS since participating in master training? [Select one]

    1. I/we have implemented TeamSTEPPS concepts, tools, or strategies in my unit/department/facility/organization.

    2. I/we have supported the implementation of TeamSTEPPS concepts, tools, or strategies in organizations that we support as a QIO.

    3. I/we have supported the implementation of TeamSTEPPS concepts, tools, or strategies in organizations that we support as a hospital or health professional association.

    4. I/we have supported the implementation of TeamSTEPPS concepts, tools, or strategies in organizations that we support as teamwork consultants.

    5. I/we have supported the implementation of TeamSTEPPS concepts, tools, or strategies in organizations that we support as insurers.

    6. Other: [Fill in the blank]

11. [FOR Implementers only] Since the master training, which of the following have you accomplished? [Check all that apply]

    1. I/we have created a change team to implement TeamSTEPPS concepts, tools, or strategies in the unit/department/facility/organization.

    2. I/we have defined our teamwork problem or identified an opportunity to improve teamwork using TeamSTEPPS concepts, tools, or strategies in our unit/department/facility/organization.

    3. I/we have conducted a site assessment to define our teamwork problem or opportunity for teamwork improvement.

    4. I/we have collected data using one of AHRQ’s surveys of patient safety culture.

    5. I/we have defined the aim(s) of our TeamSTEPPS intervention.

    6. I/we have designed a formal implementation plan for our teamwork improvement intervention.

    7. I/we have created an action plan for implementation.

    8. I/we have briefed leadership and key personnel about our action plan.

    9. I/we have designed a TeamSTEPPS intervention.

    10. I/we have conducted TeamSTEPPS training for our intervention.

    11. I/we have implemented the TeamSTEPPS intervention in our unit/department/facility/organization

    12. I/we have developed a plan for testing the effectiveness of our TeamSTEPPS intervention.

    13. I/we have measured the impact of our TeamSTEPPS intervention.

    14. I/we have developed a plan for continuous sustained improvement with our teamwork improvement intervention.

    15. I/we have developed a communication plan for our teamwork improvement intervention.

12. [FOR Implementers only] Which steps in the Kotter model for Culture Change (i.e., Our Iceberg Is Melting) have you employed when implementing TeamSTEPPS? [Check all that apply]

    1. I/we set the stage and created a sense of urgency in our unit/department/facility/organization. .

    2. I/we pulled together a guiding team for our unit/department/facility/organization.

    3. I/we developed a change vision and strategy for our unit/department/facility/organization.

    4. I/we communicated for understanding and buy-in from others throughout our unit/department/facility/organization..

    5. I/we empowered others to act in our unit/department/facility/organization.

    6. I/we produced short-term wins throughout our unit/department/facility/organization.

    7. I/we did not let up as we implemented change in our unit/department/facility/organization.

    8. I/we created a new culture in our unit/department/facility/organization.

13. [FOR Implementers only] What was the goal of your TeamSTEPPS implementation [Check all that apply]

    1. To reduce the threat of medical error in our unit/department/facility/organization.

    2. To improve patient safety and quality in our unit/department/facility/organization.

    3. To improve team cohesion in our unit/department/facility/organization.

    4. To improve team leadership in our unit/department/facility/organization.

    5. To improve situation monitoring in our unit/department/facility/organization.

    6. To improve mutual support in our unit/department/facility/organization.

    7. To improve communication in our unit/department/facility/organization.

    8. To foster a just culture within our unit/department/facility/organization.

    9. Other: [Fill in the blank]

14. [FOR Facilitators only] Since the master training, which of the following have you accomplished? [Check all that apply]

1. I have trained others outside my organization on any or all of the TeamSTEPPS concepts, tools, information, and techniques.

2. I have served as a TeamSTEPPS coach facilitating the use of concepts, tools, or strategies by others outside my organization by providing guidance, observing their use, and answering questions when possible.

3. I have facilitated the use of TeamSTEPPS concepts, tools, or strategies by others outside my organization by providing guidance, observing their use, and answering questions when possible.

4. I have helped others integrate TeamSTEPPS concepts, tools, or strategies into healthcare professional education or curricula.

5. Other: [Fill in the blank]

15. Since the master training, how have you implemented the TeamSTEPPS concepts, tools, or strategies you learned?

    1. Across our health system or organization

    2. Across our facility but not the entire health system or organization

    3. Within several units/departments but not the entire facility

    4. Within our unit/department only

    5. Other: [Fill in the blank]

16. Since the master training, how have you implemented TeamSTEPPS training for others?

    1. Targeted – Unit-Based implementation focusing on the needs of one unit and tailoring training to these needs (e.g., training SBAR, Briefs, and Huddles to all staff within an Emergency Department).

    2. Targeted – Tool-Based implementation focusing on a specific problem within the organization where the same tool(s) is/are introduced across all units at one time (e.g., training only SBAR to all staff across an organization regardless of variations in specific unit needs).

    3. Transformational – Transformational implementation where a broad application of TeamSTEPPS and all its concepts, tools, and strategies is carried out across an entire organization at once (e.g, training the entire suite of TeamSTEPPS tools and strategies to all staff within an organization at once).

    4. Other: [Fill in the blank]

Post-Master Training Activities (Level III and IV)

In this section, you are being asked to report on the activities in which you have engaged since your participation in the TeamSTEPPS Master Training program. Specifically, you are being asked to consider how you have used or disseminated your knowledge about TeamSTEPPS concepts, tools, or strategies since participating in the program. You are asked to consider the following questions in the section:

[FOR Implementers Only] For each of the TeamSTEPPS concepts, tools, or strategies listed below, please answer the following questions.

1. Have you used each concept, tool, strategy, or resource?

2. Was each concept, tool, strategy, or resource helpful?

3. Have you implemented the concept, tool, or strategy?

4. Was each concept, tool, or strategy accepted by staff?

5. Is each concept, tool, or strategy still being used by staff?

6. What are the primary area(s) where you have implemented or used this concept, tool, strategy, or resource?

TeamSTEPPS Concept, Tool, Strategy, or Resource		1. Have you used the concept, tool, strategy, or resource? [FILTER]	2. Was the concept, tool, strategy, or resource helpful?	3. Have you implemented the concept, tool, or strategy?	4. Was the concept, tool, or strategy accepted by staff?	5. Is the concept, tool, or strategy still being used by staff?	6. What are the primary area(s) where you have implemented or used this concept, tool, strategy, or resource? [CHECK ALL THAT APPLY]
ASSESSMENT STAGE Concepts, Tools, Strategies, or Resources
Measure	AHRQ Surveys of Patient Safety Culture	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not Applicable	3 = Results were accepted 2 = Results were questioned but generally accepted 1 = Results were not accepted	4 = Every 24 months 3 = Every 18 months 2 = Every 12 months 1 = The survey will NOT be administered again	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Measure	TeamSTEPPS Team Attitude Questionnaire	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	3 = Results were accepted 2 = Results were questioned but generally accepted 1 = Results were not accepted	4 = Every 24 months 3 = Every 18 months 2 = Every 12 months 1 = The survey will NOT be administered again	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Measure	TeamSTEPPS Performance Observation Tool	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not Applicable	3 = Results were accepted 2 = Results were questioned but generally accepted 1 = Results were not accepted	4 = Every 24 months 3 = Every 18 months 2 = Every 12 months 1 = The survey will NOT be administered again	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Measure	TeamSTEPPS Readiness Assessment	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	3 = Results were accepted 2 = Results were questioned but generally accepted 1 = Results were not accepted	Not applicable	Not applicable
Resource	TeamSTEPPS Guide to Action	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	Not applicable	Not applicable	Not applicable
PLANNING, TRAINING, & IMPLEMENTATION STAGE Concepts, Tools, Strategies, or Resources
Resource	Action Planning	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	Not applicable	Not applicable	Not applicable
Resource	Implementation Guide	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	Not applicable	Not applicable	Not applicable
Concept	Cross-monitoring	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Concept	Feedback	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Concept	Advocacy & Assertion	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Concept	Collaboration	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	Briefs	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	Huddles	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	Debriefs	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	STEP Assessment	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	Two-Challenge Rule	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	CUS	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	DESC Script	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	SBAR	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	Call-out	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	Check-back	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	Handoff	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	I Pass the Baton	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Measure	TeamSTEPPS Learning Benchmarks	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	Not applicable	Not applicable	Not applicable
Resource	TeamSTEPPS Vignettes & Scenarios	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	Not applicable	Not applicable	Not applicable
Resource	TeamSTEPPS for Rapid Response Systems (RRS) Module	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	Not applicable	Not applicable	Not applicable
SUSTAINMENT STAGE Concepts, Tools, Strategies, or Resources
Concept	Coaching	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Resource	Change Management Guide	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	Not applicable	Not applicable	Not applicable

[FOR Facilitators Only] For each of the TeamSTEPPS concepts, tools, or strategies listed below, please answer the following questions.

1. Have you supported others in the use of each concept, tool, strategy, or resource?

2. Was each concept, tool, strategy, or resource helpful while supporting others in their implementation?

3. Have you supported others in the implementation of the concept, tool, or strategy?

4. Was each concept, tool, or strategy accepted by staff while supporting others in their implementation?

5. Is each concept, tool, or strategy still being used by staff?

6. What are the primary area(s) where you supported others in their implementation or use of this concept, tool, strategy, or resource?

TeamSTEPPS Concept, Tool, Strategy, or Resource			1. Have you supported others in the use of each concept, tool, strategy, or resource? [FILTER]	2. Was each concept, tool, strategy, or resource helpful while supporting others in their implementation?	3. Have you supported others in the implementation of the concept, tool, or strategy?	4. Was each concept, tool, or strategy accepted by staff while supporting others in their implementation?	5. Is each concept, tool, or strategy still being used by staff?	6. What are the primary area(s) where you supported others in their implementation or use of this concept, tool, strategy, or resource? [CHECK ALL THAT APPLY]
ASSESSMENT STAGE Concepts, Tools, Strategies, or Resources
Measure	AHRQ Surveys of Patient Safety Culture		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not Applicable	3 = Results were accepted 2 = Results were questioned but generally accepted 1 = Results were not accepted	4 = Every 24 months 3 = Every 18 months 2 = Every 12 months 1 = The survey will NOT be administered again	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Measure	TeamSTEPPS Team Attitude Questionnaire		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	3 = Results were accepted 2 = Results were questioned but generally accepted 1 = Results were not accepted	4 = Every 24 months 3 = Every 18 months 2 = Every 12 months 1 = The survey will NOT be administered again	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Measure	TeamSTEPPS Performance Observation Tool		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not Applicable	3 = Results were accepted 2 = Results were questioned but generally accepted 1 = Results were not accepted	4 = Every 24 months 3 = Every 18 months 2 = Every 12 months 1 = The survey will NOT be administered again	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Measure	TeamSTEPPS Readiness Assessment		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	3 = Results were accepted 2 = Results were questioned but generally accepted 1 = Results were not accepted	Not applicable	Not applicable
Resource	TeamSTEPPS Guide to Action		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	Not applicable	Not applicable	Not applicable
PLANNING, TRAINING, & IMPLEMENTATION STAGE Concepts, Tools, Strategies, or Resources
Resource	Action Planning		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	Not applicable	Not applicable	Not applicable
Resource	Implementation Guide		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	Not applicable	Not applicable	Not applicable
Concept	Cross-monitoring		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Concept	Feedback		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Concept	Advocacy & Assertion		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Concept	Collaboration		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	Briefs		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	Huddles		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	Debriefs		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	STEP Assessment		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	Two-Challenge Rule		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	CUS		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	DESC Script		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	SBAR		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	Call-out		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	Check-back		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	Handoff		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Tool or Strategy	I Pass the Baton		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Measure	TeamSTEPPS Learning Benchmarks		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	Not applicable	Not applicable	Not applicable
Resource	TeamSTEPPS Vignettes & Scenarios		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	Not applicable	Not applicable	Not applicable
Resource	TeamSTEPPS for Rapid Response Systems (RRS) Module		1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	Not applicable	Not applicable	Not applicable
SUSTAINMENT STAGE Concepts, Tools, Strategies, or Resources
Concept		Coaching	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	1 – Yes 2 – No 3 – Don’t Know	3 = Very much accepted 2 = Somewhat accepted 1 = Not at all accepted	4 = Very often 3 = Occasionally 2 = Infrequently 1 = Rarely	1 - Many different facilities or units 2 - Medicine (nonsurgical) 3 - Surgery 4 - Obstetrics 5 - Pediatrics 6 - Emergency Dept 7 - Intensive Care Unit 8 - Psychiatry/Mental Health 9 - Rehabilitation 10 – Pharmacy 11 - Laboratory 12 - Radiology 13 - Anesthesiology 14 - Other: [Fill in the blank]
Resource		Change Management Guide	1 – Yes 2 – No 3 – Don’t Know	3 = Very helpful 2 = Somewhat helpful 1 = Not at all helpful	Not applicable	Not applicable	Not applicable	Not applicable

6. Since you attended the TeamSTEPPS master training, approximately how many persons have you trained on any of the TeamSTEPPS concepts, tools, or strategies in your organization or other organizations? [Select one]

1 = None

2 = 1-49

3 = 50-99

4 = 100-149

5 = 150-199

6 = 200-249

7 = 250-299

8 = 300-349

9 = 350-399

10 = 400-449

11 = 450-499

12 = 500 or more

6. If responded 2 – 12 on #6: What were the reasons that these individuals were trained? [Check all that apply]

1. To support health systems in enhancing patient safety initiatives

2. To support health systems in addressing a patient safety problem or need

3. To educate others, within or outside my organization, about new patient safety initiatives, policies, or processes in my organization

4. To educate others, within or outside my organization, about tools that can be used to address safety issues

5. To provide information to others, within or outside my organization, to support regulatory oversight and support of hospitals/health systems

6. Other: [Fill in the blank]

6. How many facilities are represented in approximate number of persons you have trained since attending TeamSTEPPS Master Training? [Select one]

1 = None

2 = 1 facility

3 = 2 to 5 facilities

4 = 6 to 10 facilities

5 = 11 to 15 facilities

6 = 16 to 20 facilities

7 = 21 to 25 facilities

8 = More than 25 facilities

Facilitators and Barriers to Use of TeamSTEPPS Concepts, Tools, or Strategies in the Workplace (Level III-related)

In this section, you are being asked to identify any factors (organizational or otherwise) you have encountered that facilitated the use of TeamSTEPPS concepts, tools, or strategies. Similarly, you are asked to identify any barriers you have encountered when trying to use or support others in the use of TeamSTEPPS concepts, tools, or strategies. These barriers can be organizational or individual; in either case they impede the use of TeamSTEPPS concepts, tools, or strategies.

1. Which of the following factors have helped you implement the TeamSTEPPS concepts, tools, or strategies in your organization or in organizations that you have supported? [Check all that apply]

Facilitators	Did you encounter this facilitator during implementation?	How important was this facilitator to the success of your TeamSTEPPS implementation?
Ample time made available to support the use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Ample resources made available to support the use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Consistent information sharing among people within the organization to support the use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Upper management support for using concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Staff willingness to use concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Unease with current practice leading to perceptions that use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Effective communication of information resulting in better understanding regarding the use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Ample coordination and follow-up with co-workers to ensure the proper use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Organizational priorities that draw attention to the use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Work sharing or shifting of staff responsibilities to support the implementation of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Consistency in team membership leading to sustained momentum in implementation or use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Commitment from the Employed Medical Staff resulting in adoption of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Commitment from the Non-Employed Medical Staff resulting in adoption of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important

2. What other factors have helped you implement TeamSTEPPS concepts, tools, or strategies since attending training? Please list all major facilitators that you have experienced.

3. Which of the following barriers have you encountered when implementing the TeamSTEPPS concepts, tools, or strategies in your organization or in organizations that you have supported? [Check all that apply]

Barriers	Did you encounter this barrier during implementation?	How important was overcoming this barrier to the success of your TeamSTEPPS implementation?
Lack of time made available to support the use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Lack of resources made available to support the use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Lack of information sharing between people within the organization to support the use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Upper management resistance to the use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Staff resistance to using the concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Comfort with the status quo leading to perceptions that the use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Conflicting information resulting in confusion about the use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Lack of coordination and follow-up with co-workers to ensure the proper use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Distractions or different organizational priorities that draw attention away from the use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Reported staff fatigue or work overload leading to inability or resistance to learning about and using concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Inconsistency in team membership leading to maintain momentum in implementation or use of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Hierarchical structure leading to resistance to learning about and using concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Staff conflict resulting in the inability to implement the concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Lack of Commitment/Engagement from the Employed Medical Staff resulting in resistance to the adoption of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important
Lack of Commitment/Engagement from the Non-Employed Medical Staff resulting in resistance to the adoption of concepts	1 = Yes 2 = No	1 = Not at all important 2 = Somewhat important 3 = Very Important

4. Please identify any other barriers to the implementation of TeamSTEPPS concepts, tools, or strategies you have encountered since attending training.

Outcomes of Master Training Participation (Level IV)

In this section, you are being asked to assess what patient safety changes have occurred in your organization or organizations you support as a result of your participation in TeamSTEPPS Master Training and your post-master training activities. These outcomes of your participation in TeamSTEPPS Master Training and your post-master training activities can range from increased awareness to changes in processes or policies. Consider all potential outcomes of your participation and post-training activities.

1. As a result of participating in the TeamSTEPPS Master Training and your post-master training activities, how have the following aspects changed at your organization?

As a result of participating in TeamSTEPPS Master Training and my post-master training patient safety activities, I have noticed that in my organization …	1 Disagree	2 Neutral	3 Agree	Does Not Apply
Team Structure
Patients and their families are considered part of the team.
There is always clear leadership during treatment of patients.
Staff has increased awareness their roles and responsibilities during treatment of patients.
Patients are valued members of the patient care team.
Staff understands their roles and responsibilities.
Leadership
Staff share a clear mental model of how the patient will be treated for his/her condition.
Staff are engaging in debriefs after patient disposition.
Staff are engaging in huddles during treatment to ensure a clear picture of treatment actions.
Staff are engaging in briefs prior to treating a patient.
Staff are held accountable for their actions.
Staff within my unit share information that enables timely decision making by the direct patient care team.
My unit makes efficient use of resources (e.g., staff, supplies, equipment, information).
My unit expects all staff, even those who are not part of the direct care team, to contribute to patient safety.
Supervisors/managers consider staff input when making decisions about patient care.
Supervisors/managers provide opportunities to discuss the unit’s performance after an event.
Supervisors/managers take time to meet with staff to develop a plan for patient care.
Supervisors/managers ensure that adequate resources (e.g., staff, supplies, equipment, information) are available.
Mutual Support
Staff are more assertive when advocating for the patient.
Staff can more easily resolve conflicts about the treatment of patients.
Staff feel more comfortable providing task assistance to their team members even if not requested.
Staff are more willing to assist others when assistance is requested.
Staff assist fellow staff during high workload.
Staff request assistance from fellow staff when they feel overwhelmed.
Situation Monitoring
Staff exchange relevant information as it becomes available.
Staff continuously scan the environment for important information.
Staff share information regarding potential complications (e.g., patient changes, bed availability).
Staff consider each other's physical and emotional status (i.e., fatigue, general health, stress, hunger).
Staff meets to reevaluate patient care goals when aspects of the situation have changed.
Staff re-route and/or delay work tasks to prevent task overload.
Staff caution each other about potentially dangerous situations.
Communication
Feedback between staff is delivered in a way that promotes positive interactions and future change.
Staff advocate for patients, even when their opinion conflicts with that of a senior member of the unit.
When staff have a concern about a patient, they challenge others until they are sure the concern has been heard.
Staff resolve their conflicts, even when the conflicts have become personal.
Information regarding patient care is explained to patients and their families in lay terms.
Staff rely on nonverbal communication to communicate their message.
Staff relay relevant information in a timely manner.
When communicating with patients, staff allow enough time for questions.
Staff use common terminology when communicating with each other.
Staff call out critical information during emergent situations.
Staff verbally verify information that they receive from one another.
Staff follow a standardized method of sharing information when handing off patients.
Staff seek information from all available sources.

2. FOR IMPLEMENTERS ONLY: As a result of participating in the TeamSTEPPS Master Training program and your post-master training activities, how have the following aspects changed at your organization?

As a result of participating in the TeamSTEPPS Master Training program and my post-master training activities, I have noticed that in my organization, …	1 Disagree	2 Neutral	3 Agree	Don’t Know
It is now easier to address the Joint Commission’s patient safety requirements
Patient satisfaction improved
Staff satisfaction has improved
There has been a reduction in the number of medication errors
It has been easier to meet our score card measures related to quality
Patient safety is viewed as a top priority of management
Our handoffs across units have improved
Staff will freely speak up if they see something that may negatively affect patient care
Staff now question the decisions or actions of those with more authority when they are concerned that the decisions or actions may negatively affect patient care
We handle a greater patient volume within the unit
Handoffs between shifts within units have improved
Patients report a high level of teamwork between doctors and nurses
We make better use of the resources within the unit (e.g., beds, supplies, staff, etc.)
Patient flow within the unit has improved
The number of patient complications occurring in our unit has dropped
The number of hospital acquired infections in the unit have dropped
The turnover rate within the unit has declined

FOR FACILITATORS ONLY: Since participating in the TeamSTEPPS Master Training program and your post-master training activities, how have the following aspects changed at the organizations you support?

Since participating in the TeamSTEPPS Master Training program and my post-master training activities, I have noticed …	1 Disagree	2 Neutral	3 Agree	Don’t Know
Healthcare providers at organizations that I support are actively doing things to improve patient safety
Positive changes in the organizational culture
The organizations evaluate the effectiveness and sustainability of the interventions/changes
Staff at these organizations have reported increased awareness about the role of teamwork in reducing the risk of hospital acquired infections.
Staff at these organizations have reported a decrease in the incidence of MRSA infections.
Staff at these organizations have attributed a reduced risk associated with medical errors to the implementation of TeamSTEPPS concepts, tools, or strategies.
Our organization has the requirements set forth by the Centers for Medicare and Medicaid Services under the 9th Scope of Work.
Patient satisfaction improved
Staff satisfaction has improved
Patient safety is viewed as a top priority of management
Handoffs across units have improved
Staff will freely speak up if they see something that may negatively affect patient care
Staff now question the decisions or actions of those with more authority when they are concerned that the decisions or actions may negatively affect patient care
A greater patient volume being handled within the unit
Handoffs between shifts within units have improved
Patients report a high level of teamwork between doctors and nurses
Resources (e.g., beds, supplies, staff, etc.) are used more efficiently
Patient flow within the unit has improved
The number of patient complications occurring in the unit has dropped
The number of hospital acquired infections in the unit have dropped
The turnover rate within the unit has declined

3. What other outcomes can you attribute to your participation in TeamSTEPPS Master Training and your post-master training activities?