Communication is critical for effective team-based care. Since the 1999 “To Err is Human” report by the Institute of Medicine, poor communication has been asso­ciated with 70% of all health care errors and near misses.1 However, just as poor communication can lead to cata­strophic outcomes, effective communication can improve the quality of care, increase patient and family satisfac­tion, and improve the morale of team members.2 Many frameworks for communication and “teaming” are uti­lized today in a variety of care settings. Interprofessional, integrated teams require clear communication strategies and protocols to facilitate communication, which may include in-person meetings, impromptu huddles, messag­ing on virtual platforms, electronic medical record docu­mentation, and protocols for connecting with community partners.3 As health systems continue to advance inte­grated models of care, communication remains a central facet of how interprofessional team members can con­currently address physical health, behavioral health, and social needs.4,5

Regardless of setting or method, it is important that teams communicate daily and consistently so that col­laboration and coordination become a routine part of the culture, making this the norm rather than the exception. The most common breakdown in communication occurs during care transitions and handoffs. In 2006 the Institute of Medicine partnered with the Agency for Healthcare Research and Quality to launch the TeamSTEPPS curricu­lum as way to create a uniform communication platform for teams.6

The TeamSTEPPS Framework

The TeamSTEPPS framework enumerates the skills needed to help teammates achieve care that is reliable, safe, patient centered, timely, equitable, and effective (IOM quality pillars). TeamSTEPPS was initially imple­mented in acute and critical care settings, but in 2015 a primary care and outpatient framework was launched.7 The updated 2023 model includes changes in health care delivery and learning methods and emphasizes active patient involvement in care.8 TeamSTEPPS is an evi­dence-based framework for optimizing team performance across the health care delivery system that is based on four skills—communication, team leadership, situation monitoring, and mutual support. Each skill alone can make an impact; however, when used together there is strong evidence of team satisfaction, reduced stress levels, and better patient outcomes.

In situations where a patient care decision warrants the attention of other team members, structured commu­nications like the CUS tool (Concerned, Uncomfortable, and Safety issue) can raise concerns without challenging other team members’ authority or expertise. For example, CUS could be used to raise awareness regarding pain management and escalate assessment needs: “I am con­cerned about Mr. Martinez, who has 10/10 abdominal pain despite the maximum pain management provided. I am uncomfortable providing additional medication and feel it is a safety issue to do so without further assessment.”

Establishing psychological safety within a team is prob­ably the most important intervention for successful team­ing.9 Another structured communication technique used in TeamSTEPPS is the SBAR (Situation, Background, Assessment, and Recommendation) tool.10 The Recommendation aspect of SBAR is often forgotten, pri­marily because of a lack of psychological safety or growth mindset, or a fear of not being able to make the “right” rec­ommendation. Strong teams take the time to build consis­tent practice and establish psychological safety amongst team members regardless of the communication strategy used. Psychological safety creates a culture where it is not only acceptable but expected for team members to watch out for each other, ask questions, and speak up without fear. Cross-monitoring is a TeamsSTEPPS tool that allows each team member to feel empowered to mutually sup­port one another.

Psychological Safety

Best practices for building psychological safety within teams and maximizing communication strategies include:

Consistent use of team huddles, briefs, debriefs, and check-ins: Allow teams to communicate and establish a plan, evaluate how an event went, or simply build the team through icebreakers. If teams are hierarchal, rotat­ing the responsibility of who leads these activities can help all team members feel empowered to contribute. Asking open-ended questions can also provide an opportunity for team members to communicate. For example, ask­ing, “What did I miss or leave out?” versus “Did I miss or leave out anything?” can encourage communication and feedback.

Solicit feedback through team meetings, one-on-one meetings with all members of the team, surveys, or quick “temperature checks” in the moment. Making feedback a daily activity rather than something that is only done when an event goes well (or doesn’t) sets a norm that feedback is a regular expectation with the purpose of helping the team grow, rather than a punishment.

Set team norms and expectations. These are made by the group and are reassessed every time a new team member arrives. Team norms should be visible (i.e., posting at the top of agendas or in a breakroom) and should be referred back to regularly. Every team has its own culture, and mak­ing these norms explicit builds trust and keeps individuals from guessing what the expectations are or feeling pun­ished when they “break a rule” they did not know existed.

Reward team members when frameworks like TeamSTEPPS are used in regular practice. This includes thanking team members for their communication and being receptive to feedback in non-defensive ways.

Implementing psychological safety within health care teams requires an emphasis on implementation and eval­uation. Despite an abundance of evidence on the impor­tance of psychological safety in how teams communicate and function, more can be done organizationally to foster improved teaming. For example, an assessment of physical space and workflows may help communication patterns and clinical functioning. Likewise, virtual mechanisms to support team interaction and consideration of organiza­tional culture can encourage collaborative environments.


Facilitating successful teaming warrants individual-level, clinical-level, and macro-level interventions. As health care systems continue to evolve, increased atten­tion to how communication can be harnessed will require sustained effort. Importantly, technology and digital aspects of health care delivery require communication that utilizes both in-person and digital approaches to col­laborative care. Furthermore, as hybrid working arrange­ments have created new challenges and opportunities for communication amongst team members and in patient interactions, communication will continue to be an inte­gral aspect of how teaming occurs and how it can advance collaborative practice.


The authors would like to acknowledge the staff and IPE direc­tors associated with the UNC Chapel Hill Office of Interprofessional Education and Practice for their educational and programmatic sup­port to advance these concepts.

The authors have no conflict of interest to report.