Tool: STEP
STEP is a mnemonic tool that can help individuals monitor critical elements of a situation and the overall environment. It is suitable for use by teams supporting acutely ill patients in a hospital (e.g., an ICU patient the team hopes to wean off a ventilator as quickly as possible), for teams in long-term care settings helping residents improve physical mobility, or for teams in other care settings.
STEP encourages the monitoring of all key elements required to support patients:
Recognizing which situational elements can provide clues about impending complications or contingencies is critical for patient safety. STEP provides a framework for tracking critical elements of a situation or environment.
In an acute healthcare setting, the patient’s status requires constant monitoring. Any changes in the patient’s vital signs may require changes in the team’s actions and an urgent response. When assessing acute care patient status, consider the following:
- Patient history
- Vital signs
- Medications
- Physical exam
- Care plan
- Psychosocial condition (e.g., patient's stress level, confusion, loneliness)
- Whether the patient has limited English proficiency
In nonacute settings, patient status should be monitored regularly as well. Changes in functional status, eating and weight, cognitive status, and mood all are important for the team supporting the patient (or resident) to promptly notice and address.
STEP encourages awareness of the status of other team members on dimensions including:
- Fatigue level.
- Workload.
- Task performance.
- Skill level.
- Stress level.
Healthcare providers are just as prone to human error as the general population. Teams that recognize and maintain awareness of their individual team members’ functioning are more likely to provide constructive feedback, have a shared understanding of the situation, and lend support or assistance when needed.
The environment directly affects the quality of care delivered. The environment can change quickly and dramatically.
When it does, teams must be able to rapidly adapt. When assessing the environment, consider relevant factors such as:
- Facility information, including occupancy levels.
- Administrative information and available staff.
- Human resources.
- Triage acuity.
- Community or facility disease outbreaks.
- Equipment status.
By monitoring progress toward the team’s established goals, team members can alert the team when the care plan needs to be revised or when additional resources are needed. When assessing progress, team members need to consider the following:
- Status of the team’s patients
- Goal of the team for the patient
- Tasks/actions completed or that need to be completed
- Continued appropriateness of the patient’s care plan
Goals are established and agreed on at a team briefing. If something has changed, a huddle or followup briefing should be held to discuss how the plan needs to be modified.
Family caregivers can play a key role in this process. As they interact with the patient daily, they are often the first to observe environmental or behavioral changes. Making sure that family caregivers know what changes are of particular importance and whom to contact if a change occurs is key to ensuring that risks are quickly identified so they can be better managed.
The TeamSTEPPS curriculum now includes a video-based simulation training to illustrate the role STEP can play in fostering a shared mental model for a team that includes the patient. This training is available at: Module 3 Training Simulation Video (Full).
Applications of STEP
Here is an example of STEP drawn from an acute care hospital setting.
- Status: The respiratory therapist notes that a ventilated patient is showing a marked increase in respiratory rate, which might indicate an increased level of pain that cannot be communicated.
- Team members: The patient’s nurse is busy helping another patient.
- Environment: It is a shift change, and everyone is busy, so the respiratory therapist checks the medication record and notes that the patient is overdue for his morphine.
- Progress: The respiratory therapist notifies the oncoming nurse of their concern.
Here is an example of STEP in a primary care clinic:
- Status: A primary care physician observes that an 83-year-old patient has lost weight and appears weaker than at their prior appointment.
- Team members: Their spouse, who typically is with the patient and provides updates on the patient's status, is not present.
- Environment: It is January, there is a local influenza outbreak, and outdoor conditions are treacherous.
- Progress: The physician asks the patient about their spouse's health to understand whether changes in the spouse's condition are contributing to the observed weight loss and frailty in the patient.
TeamSTEPPS: STEP for Inpatient Medical Teams (38 seconds)
This video scenario also illustrates the use of STEP. After watching the video, think about how you would answer each of the questions below.
- How did the scenario illustrate the components of STEP?
- Even though the patient’s vital signs were normal, were there reasons for concern?
