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U.S. Air Force - Air Combat Command (ACC)


The U.S. Air Force Surgeon General (USAF SG) operates hospitals and clinics worldwide and is responsible for the full life cycle care and health of our nation’s Air Force.  Recently a patient died in an Air Force hospital due to what is believed to be deficiencies in patient safety processes and procedures.  The Air Force has been implementing TeamSTEPPS and Team-Based Health Care (TBHC) across their hospitals and clinics.  TeamSTEPPS a teamwork system designed for healthcare professionals that are focused on improving patient safety within healthcare organizations.

MainStream was engaged by the USAF SG to analyze the USAF SG’s use of TeamSTEPPS and TBHC to determine how these programs could be utilized to prevent future sentinel events and improve patient safety across the Air Force Medical Service.


MainStream deployed a small, focused, and integrated team consisting of a Business Process Improvement Specialist, a Military Process Improvement Specialist, and a Medical/Patient Safety Subject Matter Expert to assess the use of TeamSTEPPS relative to patient safety in USAF hospital facilities.  The hospital facilities assessed represented a cross section of what the Air Force believed were high, medium, and low performing hospitals. 

At these facilities, MainStream conducted an in-depth assessment of current state TeamSTEPPS approaches including whether, how and to what extent TeamSTEPPS has been adopted into the behavioral mind sets (the culture) of the Air Force medical facilities, and whether, how and to what extent safety, standards, and service has been affected by TeamSTEPPS.  In addition, dozens of personnel interviews and surveys were conducted, resulting in a sample size of roughly 29% of the total population.  Several days of additional clinical and administrative observations were made providing qualitative data in support of the survey responses.

MainStream’s findings and feedback to the medical facilities leadership included that while TeamSTEPPS training was conducted throughout the organization with retention of at least three of the tools unique to TeamSTEPPS (Huddle, 2-Challenge Rule and the use of a CUS (Concerned, Uncomfortable, Safe) word), the use of the tools were somewhat superficial.


MainStream’s near term recommendation to fully intersect TBHC and move the organization from appreciation to application was to improve the team’s understanding of how ancillary support teams (lab, pharmacy, logistics, facilities management) can enhance how TBHC is delivered and define the specific roles within that delivery system (to include defining what the ‘Team’ is in TBHC delivery).

MainStream’s longer-term recommendations include developing a culture change strategy that leverages the pervasive awareness and appreciation of TeamSTEPPS tools and aligns and deploys the change strategy through all levels of the organization.  The recommendation was made to establish measures at all levels of the organization that provide real time decision making and aid ancillary support staff gauge their contributions to the improvement agenda.  The anticipated benefits of the long-term action will align resources of all departments to the most critical areas of opportunity.

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