INNOVATIONS IN EDUCATION
A Multidisciplinary Teamwork Training Program: The Triad
for Optimal Patient Safety (TOPS) Experience
Niraj L. Sehgal, MD, MPH1, Michael Fox, RN2, Arpana R. Vidyarthi, MD1, Bradley A. Sharpe, MD1,
Susan Gearhart, RN2, Thomas Bookwalter, PharmD3, Jack Barker, PhD4,
Brian K. Alldredge, PharmD3, Mary A. Blegen, PhD, RN2, and Robert M. Wachter, MD1and The
Triad for Optimal Patient Safety (TOPS) Project
1Division of Hospital Medicine, University of California, San Francisco, CA, USA;2School of Nursing, University of California, San Francisco, CA,
USA;3School of Pharmacy, University of California, San Francisco, CA, USA;4, Mach One Leadership, Inc., Miami, FL, USA.
INRODUCTION: Communication and teamwork fail-
ures are a common cause of adverse events. Residency
programs, with a mandate to teach systems-based
practice, are particularly challenged to address these
AIM: To develop a multidisciplinary teamwork training
program focused on teaching teamwork behaviors and
SETTING: Internal medicine residents, hospitalists,
nurses, pharmacists, and all other staff on a designated
inpatient medical unit at an academic medical center.
PROGRAM DESCRIPTION: We developed a 4-h team-
work training program as part of the Triad for Optimal
Patient Safety (TOPS) project. Teaching strategies com-
bined didactic presentation, facilitated discussion using
a safety trigger video, and small-group scenario-based
exercises to practice effective communication skills and
team behaviors. Development, planning, implementa-
tion, delivery, and evaluation of TOPS Training was
conducted by a multidisciplinary team.
PROGRAM EVALUATION: We received 203 evaluations
with a mean overall rating for the training of 4.49±0.79
on a 1–5 scale. Participants rated the multidisciplinary
educational setting highly at 4.59±0.68.
DISCUSSION: We developed a multidisciplinary team-
work training program that was highly rated by all
participating disciplines. The key was creating a shared
forum to learn about and discuss interdisciplinary
communication and teamwork.
KEY WORDS: teamwork; communication; patient safety;
J Gen Intern Med 23(12):2053–7
© Society of General Internal Medicine 2008
Communication and teamwork failures are often cited as the
most common cause of adverse events1–5. The Joint Commission
identified communication as a critical factor in more than 65% of
reported sentinel events6. Teamwork training, which teaches
important communication skills and team behaviors, has been
proposed as a method to improve the quality and safety of care.
Current literature discussing health-care team training has
largely focused on closed environments such as emergency
departments, intensive care units, labor and delivery suites, or
operating rooms7–13. In these settings, all providers identify
with a “unit-based” environment. Most medical units, on the
other hand, have nurses who are unit-based and physicians
(and others) who are “service-based,” with patients often
housed on several geographic units.
Graduate medical education poses unique challenges to
patient safety14,15, some of which are due to poor teamwork16.
ing new core competencies (e.g., system-based practice) to
promote quality and safety, but have given little guidance on the
best educational strategies to employ17,18. Multidisciplinary
teamwork training has the potential to improve patient safety
and can help break down the traditional discipline-based silos
that contribute to communication and teamwork failures19–22.
We developed an innovative 4-h teamwork training program
targeting all providers and staff on an inpatient medical unit.
The training was part of a project called the Triad for Optimal
Patient Safety (TOPS)—a multidisciplinary and multicenter
project aiming to improve unit-based safety culture through
communication and teamwork initiatives. In this article, we
discuss the TOPS Training program, its implementation, and
PROGRAM DEVELOPMENT AND DESCRIPTION
Curriculum Working Group
We began by assembling a multidisciplinary planning team
(e.g., physicians, nurses, pharmacists) that included an
aviation expert who added insights from that industry’s
experiences with crew resource management23–28. We also
included experts in curricular development and individuals
familiar with teaching key principles of teamwork and com-
munication. Ultimately, we wanted a planning group that was
Electronic supplementary material The online version of this article
(doi:10.1007/s11606-008-0793-8) contains supplementary material,
which is available to authorized users.
Received February 19, 2008
Revised August 7, 2008
Accepted August 13, 2008
Published online October 2, 2008
committed to multidisciplinary education and had strong inter-
est, knowledge, or experience in the content matter. After
the planning team developed several overarching goals9,29–31.
First, we wanted to create a program that actively engaged
every patient care discipline. To achieve this goal, we targeted
all disciplines, including nurses and pharmacists; physical,
occupational, speech, and respiratory therapists; case man-
agers and social workers; patient care assistants, unit clerks,
and custodial staff. By being inclusive, we hoped to strengthen
our overall teamwork message. On the other hand, casting the
net so broadly challenged us to design content that would
engage a diverse group of participants, particularly since most
were sharing a classroom for the first time.
Our second goal was to recognize differences among parti-
cipants in preferred learning styles. To address this, we used
diverse teaching methods, including didactic presentations,
interactive videos with facilitated discussion, and scenario-
based small-group exercises for skill practice.
Our third goal was to force our multidisciplinary audiences
to engage each other. Logistically, this required us to assemble
a cross section of disciplines for each training session. Finally,
we wanted participants to walk away with specific skills they
could incorporate into daily practice, as well as a shared
“mental model” for improving teamwork and communication.
TOPS Training Program Description
Table 1 highlights the features of our 4-h teamwork training
a TOPS Training Facilitator’s Guide (See Appendix 3 available
online) to disseminate the program to other units and hospital
sites. The basic framework (in order of presentation) involved:
1. A recognized leader – such as chief of medicine or
institutional patient safety officer – introduces the session
and shares a story about a local error, both to emphasize
the importance of the training and institutional support.
“Laying the Foundation”: a prominent unit-based clinician
presents a brief overview of safety culture, the importance
of teamwork and communication, a few local anecdotes
(e.g., unit-specific adverse events), and then sets the stage
for the rest of the program.
3. Participants then watch the compelling safety video “First, Do
No Harm”32and participate in a facilitated discussion about
howindividualsand systems contribute to medicalerrors, and
the role of communication and teamwork in those errors.
“Health-care Team Training” is the primary didactic
lecture, which builds on learnings from safety training in
aviation (Table 2 lists the skills introduced). Many of these
lectures were given by our aviation consultant (a commer-
cial pilot and psychologist), a lecture that became affec-
tionately described as the “pilot talk,” though it was
sometimes delivered by a physician or nurse.
Participants are then divided into small representative
groups from all disciplines. Facilitators guide learners
through two 45-min scenarios that apply the content to
realistic patient care situations. At pre-defined points,
facilitators prompt discussion about participants’ impres-
sions from their own perspectives. The ensuing dialog
allows groups to practice skills introduced during the
didactic lecture. By providing opportunities to practice
communication skills with members of other disciplines,
traditional differences in provider-specific communication
styles are revealed, and techniques to bridge these differ-
ences can be practiced. For example, the facilitator may
ask participants to practice the use of a structured
communication tool called SBAR (Situation, Background,
Assessment, and Recommendation)33. We provide an
actual facilitator’s script for one of our scenarios in
Appendix 2 (available online).
The program ends with the entire group reconvening. A
few minutes are spent summarizing the session’s high-
lights and probing participants for reaction. These specif-
ic, concrete responses help solidify the day’s lessons.
Course evaluations are completed.
PROGRAM IMPLEMENTATION AND ASSESSMENT
We organized six 4-h sessions, initially focused on securing
blocks of time from the Internal Medicine Residency Program,
and then assuring representation from each of the other
disciplines. Overall, we trained 225 voluntary participants,
Table 1. TOPS Training Curriculum Agenda and Objectives
Laying the foundation
◽Define patient safety culture
◽Recognize members of the health-care team
◽Understand the role teamwork and communication play in patient safety
“First, Do No Harm” video
15-min facilitated discussion
Health-care team training lecture
◽Assess the role “systems” and individuals in contributing to medical errors
◽Describe how effective communication and teamwork can mitigate patient harm
◽Define error chains
◽Identify specific communication skills and team behaviors (see Table 2)
◽Illustrate ways to translate above skills into daily practice
Two 45-min exercises
◽Practice constructing an SBAR
◽Integrate other communication skills into clinical case scenarios
◽Demonstrate how ineffective or differing communication styles impact patient care
◽Restate how to incorporate newly taught skills into daily practice
◽Discuss specific methods to improve teamwork and communication on the medical unit
◽Introduce upcoming initiatives to foster greater multidisciplinary education
Sehgal et al.: The TOPS Multidisciplinary Teamwork Training Program
including 75% of the Internal Medicine housestaff, 90% of
hospitalist attendings, 95% of nurses on our medical unit,
100% of pharmacists, 100% of case managers and social
workers, and nearly all therapists, patient care assistants,
and unit clerks. A total of 203 course evaluations were
collected at the end of the sessions (90% response rate). The
UCSF Committee on Human Research reviewed and approved
the TOPS project.
The TOPS training course evaluations (see Appendix 3
available online) were designed to capture both participants’
experiences of the training and the logistics of the training
itself. Questions assessed (1) each individual session for
quality of instruction, content, and organization; (2) the
location, format, and organization of the training sessions,
including the use of a multidisciplinary group for training; (3)
whether participation would change the way “I communicate
with others” or the way “I practice”; and (4) the overall training
experience. Questions were rated on a 5-point Likert scale (1=
lowest to 5=highest). Additional open-ended questions asked
about the most common obstacles to effective teamwork, the
most, and least, useful parts of the training, how long one had
been working on our medical unit, and whether they would
recommend the training to colleagues.
Participants rated the overall training highly, with a mean of
4.49±0.79, and 99% recommended TOPS training to their peers.
Participants rated the multidisciplinary setting highly, with a
mean of 4.59±.68. By discipline, mean nurses’, pharmacists’,
and physicians’ ratings for overall training were 4.71±0.52, 4.64
±0.49, and 4.31±0.61, respectively. The differences for the
overall rating and all other aspects of the evaluation were not
statistically significant across disciplines. Participants also
reported that the training was likely to change the way they
communicate (4.37±0.71) and practice (4.31±0.56).
The most common reported obstacles to effective teamwork
reported were time, culture, and workload. These also did not
vary significantly among the disciplines. Participants’ com-
ments indicated a desire for more small-group scenarios to
foster the spontaneous cross-disciplinary discussions, high-
lighted the utility of specific communication skills (e.g., SBAR),
and expressed appreciation for how each discipline’s training
shapes their communication style. Participants also hoped for
further educational opportunities to build upon the multidis-
ciplinary TOPS Training. Several participants pointed out the
challenges of translating the learnings into practice when “not
everyone speaks the same language yet.”
to teach communication skills and team behaviors, begin
breaking down professional silos, and raise awareness about
the role these issues play in patient safety. The TOPS Training
was rated highly, and feedback from participants supported our
notion that teaching teamwork requires putting everyone—from
the doctors, nurses, and pharmacists to the social workers and
unit clerks—into the same learning environment.
We learned several lessons from our experience. First, the
“logistics” of the program often drive key aspects of the
training. Logically, our planning initially focused on creating
content and engaging our diverse audience. In the end, simply
1) Clear indication of who you are paging
2) Clear indication of the patient
and brief description of the issue
3) Your name, title, location, and callback #
4) If you need a callback or not
Figure 1. Guideline for a structured text page communication.
Table 2. Examples of TOPS Training Skills
Leadership Is there a clear leader? Is the leadership effective? Each team member can be a leader and must accept
the responsibility to ensure a safe patient outcome
Are the providers anticipating events? Does the team have a complete and updated picture of what is
happening with the patient—in the past, present, future?
Is the workload distributed appropriately and do individuals have the requisite skills? Are providers asking
for and receiving help when needed?
Is the workload distributed appropriately and are individuals being recognized for their skills? Resources
include supplies, equipment, training, and individual and group expertise
Is the plan of care clear to all team members and does everyone understand their role?
What did we do well? What could we have done better (e.g., following a code or a night on call)?
SBAR Structured communication tool for conveying critical information between providers: Situation, Background,
Assessment, and Recommendation
Common language understood by all to mean, “Stop and listen to me”: I’m Concerned, I’m Uncomfortable, and
this is a Safety issue
A non-confrontational method to actively seek information or clarification from another team member
Using assertion to get a person’s attention, express concern, state a problem, propose an action, and reach
a shared decision
Was there eye contact? Were questions asked to confirm understanding? Was there multi-tasking while listening?
Times when direct communication is required: at admission, during a change in clinical condition, at discharge, or
at time of handoff
Sehgal et al.: The TOPS Multidisciplinary Teamwork Training Program
finding the appropriate space and time, while balancing the
clinical and administrative schedules of people in disciplines
that work different shifts, days, or rotations, was critical,
requiring careful planning and coordination. We also found
that non-clinical participants (e.g., unit clerks and custodial
staff), whose engagement we worried about the most (particu-
larly for clinical scenarios), were in fact among the most
engaged, largely due to feeling acknowledged and included as
part of the “health-care team.” Though we made training
voluntary, we believe that leadership within all disciplines
must mandate the training and help create time for it in
people’s schedules. The perfect training program will fail if the
participants lack “protected time” to fully engage, free of
responsibilities such as answering pages. It will also fail if the
audience does not include diverse disciplines, since the
curriculum and training depend on spontaneous, cross-disci-
plinary dialogues and the entire thrust of the training is to
break down professional silos.
Second, a multidisciplinary planning and teaching team is
critical, both to help shape content and deliver it. Each
discipline carries its own educational traditions, and the
cross-disciplinary discussions can deteriorate into tense
exchanges if the sessions are not skillfully facilitated. Further-
more, the role modeling—of having a physician and nurse, for
example, co-lead or jointly facilitate a small-group discussion—
addresses the very hierarchy we aimed to flatten. In addition, it
was striking, and frankly unanticipated, that many partici-
pants shared how the challenges in communication and
teamwork between disciplines mirror those that exist within
their own discipline. For example, the case managers stated
that the training changed the way they communicate with
each other as much as they did with the other disciplines. This
important learning came from the training experience itself.
Finally, an educational program focused on communication
and teamwork skills must be coupled with operational activ-
ities (“putting the skills into practice”) to foster use of new
skills and change behavior. Such activities might be the
concept of “Critical Conversations” highlighted in Table 2 or
creating structured mechanisms to send text paging commu-
nications (Fig. 1). Regardless of the method, a similar effort to
hardwire or integrate new communication skills into existing
processes, such as handoffs34–35, provides an important
opportunity for reinforcement.
Teamwork is essential to delivering high quality and safe care.
Our program was motivated by a belief that improving teamwork
required bringing the different disciplines together for a shared
educational experience. It would be a mistake to expect that a
single training session (a “one and done”) could change behavior.
consultants to deliver a teamwork and communication curricu-
lum. A multidisciplinary teamwork training program must be
viewed as a tool (rather than a solution) and a start (rather than
the end) of a locally owned program.
In summary, we created a novel multidisciplinary teamwork
training program, the success of which depended on multidis-
ciplinary planning, implementation, and participation. The
program was highly rated by participants, and the multidisci-
plinary setting was particularly valued. The next steps moving
forward would be a more robust evaluation of the effectiveness
of multidisciplinary educational programs in changing beha-
viors and clinical practice at the bedside36. We hope our
curriculum and materials will stimulate continued interest in
shifting education away from existing silos and towards shared
understanding of the communication and teamwork that
Acknowledgements: We thank the Gordon and Betty Moore
Foundation for their active support and funding of the TOPS project.
We also thank our wonderful collaborators at El Camino Hospital in
Mountain View, CA (including Suann Schutt, Michael Podlone, Phil
Strong, and Sara Mills) and Kaiser Permanente in San Francisco, CA
(including Rachel Mueller, Clarissa Johnson, Paul Preston, and Lynn
Paulsen) for their contributions to the TOPS Training Program and
implementing local versions on their respective medical units. We’re
grateful for the support we received to conduct TOPS Training from
UCSF Medical Center and the UCSF Internal Medicine Residency
Program leadership. Finally, we thank Terrie Evans for her role as
TOPS Project Coordinator in orchestrating the successful delivery of
the TOPS Training Program sessions. The TOPS Training program
was presented as a poster presentation (2006) and workshop
(2007) at the Society of General Internal Medicine Annual Meeting.
Conflict of Interest: Jack Barker was employed as a consultant
from Mach One Leadership, Inc., to contribute experience and
expertise in developing and teaching teamwork training. There are
no other conflicts of interest to report for the remaining authors.
Corresponding Author: Niraj L. Sehgal, MD, MPH; Division of
Hospital Medicine, University of California, 533 Parnassus Avenue,
Box 0131, San Francisco, CA 94143, USA (e-mail: nirajs@medicine.
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