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5 Whys: Finding the Root Cause
When a problem presents itself, ask Why again and again until you reach the root cause.
"What Matters to You?" Conversation Guide for Improving Joy in Work
With burnout and staff turnover in health care continuing to rise at alarming rates, this resource is intended to help leaders guide conversations with colleagues about “What matters to you?” — Step 1 of the Four Steps for Leaders, described in detail in the IHI White Paper, IHI Framework for Improving Joy in Work.
Ask Me 3: Good Questions for Your Good Health
Ask Me 3® is an educational program that encourages patients and families to ask three specific questions of their providers to better understand their health conditions and what they need to do to stay healthy.
RCA2: Improving Root Cause Analyses and Actions to Prevent Harm
This document examines best practices for using root cause analysis (RCA) to improve patient safety, and includes guidelines to help health professionals standardize the RCA process and improve the way they investigate medical errors, adverse events, and near misses.
Liberation in the Exam Room: Racial Justice and Equity in Health Care
This tool is intended to be used as a starting guideline for individuals in the health care delivery context as they work to identify key areas of focus on racial justice and health equity, serving as a resource to begin conversations with teams within the organization toward developing a deeper understanding of structural racism and its impact on achieving health equity.
Optimizing a Business Case for Safe Health Care: An Integrated Approach to Safety and Finance
Team-based collaboration of safety and financial leaders is necessary to successfully create and present business cases to advance safety initiatives. This toolkit includes specific recommendations and practices for a Safety–Finance Team and provides a framework for understanding, framing, and advancing patient and workforce safety.
A driver diagram is a visual display of a team’s theory of what “drives,” or contributes to, the achievement of a project aim. This clear picture of a team’s shared view is a useful tool for communicating to a range of stakeholders where a team is testing and working.
Quality Improvement Essentials Toolkit
Download these ten essential quality improvement tools to help you with your improvement projects, continuous improvement, and quality management, whether you use the Model for Improvement, Lean, or Six Sigma.
IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events
The IHI Skilled Nursing Facility Trigger Tool for Measuring Adverse Events provides an easy-to-use method for accurately identifying adverse events (harm) and measuring the rate of adverse event incidence over time in skilled nursing facilities (SNFs).
IHI "Seven Spreadly Sins"
Improvement teams often make some common missteps when it comes to successfully sharing and spreading improvement ideas in their organizations. IHI's "Seven Spreadly Sins" infographic give teams practical tips for overcoming challenges that impede successful spread.
Improvement Project Roadmap
Improvement teams often need a roadmap for applying the science of improvement to the project management tasks associated with their improvement efforts. This step-by-step tool provides a list of essential tasks organized by five key components in all improvement efforts that team leaders, sponsors, and others can use to guide their work.
Patient Experience Data Self-Assessment
The Patient Experience Data Self-Assessment Tool and corresponding Answer Key challenges knowledge and common assumptions about what the data actually means. The tool can be used to expand your current knowledge on using patient experience data effective.
Patient Care Experience Observation Exercise
The purpose of this exercise is to learn about and understand the experience of care in your organization from the patient and family perspective, using observations of care processes to inform improvements to the care experience. The exercise may be used in any care setting.
Behavioral Health Integration Capacity Assessment Tool
This tool is designed to assist behavioral health organizations in evaluating their ability to implement integrated care (specifically processes related to three approaches to integrated care: coordinate care, co-locate care, or build primary care capacity in-house), and enable them to assess existing operational and cultural infrastructure to support greater integration.
Always Events Toolkit
Always Events are aspects of the patient experience that are so important to patients and families that health care providers must perform them consistently for every patient, every time. The toolkit supports providers in partnering with patients and family members to co-design, reliably implement, and sustain and spread Always Events to dramatically improve the care experience.
Approaches to Integrating Primary Care Services into Behavioral Health Organizations
The guide lays out a continuum of primary care and behavioral health integration, beginning with engaging individuals with severe mental illness in discussions about their physical health to full integration.
ISMP Medication Safety Best Practices
Developed with the help of leading medication safety experts, and patterned after the Joint Commission’s National Patient Safety Goals, the ISMP has issued six 2014-15 Targeted Medication Safety Best Practices for hospitals.
Quality Metric Advisor Tool
The IHI Quality Metric Advisor is a simple algorithm that assists organizations to identify and address crucial balancing measures in order to maintain and even improve clinical quality during cost-savings improvement initiatives.
Transplant Guardian Angel Always Event
The Transplant Guardian Angel program was developed to ensure that patients and families are supported through the transplant surgical process by providing them with accurate, real-time updates and clinical information, thereby reducing anxiety and increasing effective communication between care delivery teams.
MyStory Always Event
MyStory is an interprofessional effort designed to personalize the care provided to pediatric patients and transform the hospital experience for the patients and families by capturing each pediatric patient’s “story” and use the story to personalize the care provided and involve them in care planning and decision making.
"Same Page" Transitional Care Resources for Patients and Care Partners
These resources and tools were developed for patients and their caregivers or care partners to use when planning for care or during a stay in a hospital or skilled nursing facility. The goal is to support patients, their care partners, and the team of health care providers to all be “on the same page” in understanding the patient’s health and health care needs when the patient is transitioning from one setting of care to another.
Always Use Teach Back!
The Always Use Teach Back! tools can be used to confirm patient understanding of care instructions by asking patients to repeat the instructions using their own words.
PAIR Parent Mentor Program
PAIR — Parents Assisting Inspiring Reassuring — is a program created to help parents of children with cancer connect with other parents, who serve as mentors. The team at St. Jude’s developed a number of tools, including a detailed presentation about the program and tools for recruiting and onboarding mentors, matching mentors with mentees, and training mentors.
ISHAPED Patient-Centered Approach to Nurse Shift Change Bedside Report
ISHAPED (I=Introduce, S=Story, H=History, A=Assessment, P=Plan, E=Error Prevention, and D=Dialogue) focuses on making bedside shift reports more patient- and family- centered. The goal is to always include patients in the ISHAPED nursing shift-to-shift handoff process at the bedside to add an additional layer of safety by enabling the patient to communicate potential safety concerns.
SMART Discharge Protocol
The SMART Discharge Protocol (Signs, Medications, Appointments, Results, and Talk with me) was developed to improve care for patients and families and to improve the discharge process. The tools include the SMART Discharge Checklist for patients and families, FAQs for health care staff and clinicians about implementing the SMART Discharge Protocol, a presentation, and a self-learning packet.