IHI recently released a white paper called “Sustaining Improvement”. A great case study is included in the Appendix from Saskatchewan Health Quality Council, who uses a tool called SAFER to help front-line staff consistently improve patient safety:
Stop: Stop if staff see anything unsafe.
Assess: Assess the situation. Ask for support from other staff, supervisors, or leaders.
Fix: Fix the unsafe situation if they can.
Escalate: If they cannot fix the situation, escalate the concern to the next person in the chain of command.
Report: Report unsafe situations, environments, and practices, including “near misses” and incidents resulting in harm to patients or staff.