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Spenard noted that because lower-level staff shoulder considerable responsibility in nursing homes, a strictly hierarchical approach can be dangerous. Under TeamSTEPPS, a nurse's aide who notices a lapse in care, for example, would be directed to report that problem up the chain, under a "two-challenge rule" that encourages workers to voice a concern at least twice, to make sure it is acknowledged. Employees also are empowered to "stop the line" of care if they see a safety breach.
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