Center Team Training Success Stories

St. Charles Hospital has two critical access hospitals serving rural Central Oregon. With over 4,500 caregivers, effective communication is essential to ensure safe, high-quality care. Previous attempts to implement TeamSTEPPS were disrupted by leadership transitions and the COVID-19 pandemic. Renewed commitment in 2022 was driven by both internal data and a strategic focus on improving caregiver experience and patient outcomes.

St. Charles Health System

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Situation

In Fall 2022, leadership at St. Charles Madras and Prineville hospitals initiated the implementation of TeamSTEPPS, a program developed by AHRQ, to address variability in caregiver experience and patient safety outcomes. Employee engagement data highlighted opportunities in areas such as purpose, leadership responsiveness, feedback, well-being, autonomy and psychological safety. Concurrently, patient safety metrics revealed a need for improvement in falls with fractures, hospital-acquired pressure injuries and surgical site infections. TeamSTEPPS, with its evidence-based framework and decades of research, was selected to equip caregivers with practical tools to enhance communication, collaboration and team performance.

Actions Taken

The initiative began with 50 leaders completing the TeamSTEPPS Train-the-Trainer course. The initial rollout targeted nursing departments, focusing on foundational tools such as SBAR to improve interdisciplinary communication. Over the year, implementation expanded to ancillary and support services, introducing additional tools including briefs, huddles, debriefs and mutual support strategies.

Key implementation strategies included:

  • Monthly leadership meetings and staff engagement sessions
  • Use of process observation cards and feedback surveys
  • Sharing of success stories to reinforce learning

By year-end, 70% of nursing unit caregivers had completed at least part of all four core modules. A customized experience survey, based on the AHRQ TeamSTEPPS Teamwork Perceptions Questionnaire (TTPQ), was deployed quarterly to assess impact and guide improvements.

Results & Recommendations

Outcomes

  • Improved caregiver perceptions in key areas: role clarity and team situational awareness.
  • Enhanced communication with providers through consistent SBAR use.
  • Increased provider engagement in briefs, huddles and debriefs.
  • Reduction in patient harm:
    • Prineville: 3 falls with fractures in 2024; 0 in the first half of 2025.
    • Madras: 2 surgical site infections in 2024; 0 in the first half of 2025.

Lessons Learned

  • Offering both virtual and in-person training options increased participation.
  • Tracking attendance and learner engagement was critical for sustainability.
  • Survey participation declined over time, highlighting the need for alternative feedback mechanisms.

Next Steps

  • Continue quarterly TeamSTEPPS Fundamentals training, with annual refreshers.
  • Encourage new caregivers to participate and share success stories.
  • Expand the Council model to maintain a 75% trained workforce in each department.
  • Promote peer champions and trainers to support ongoing adoption.
  • Sustain momentum through leadership rounding, storytelling and integration into patient safety initiatives.

St. Charles Madras and Prineville remain committed to embedding TeamSTEPPS into daily practice, fostering a culture of safety, and empowering teams to deliver exceptional care through shared mental models and structured communication.

 
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