Table 1

Summary of key findings

Theme	Description and examples
Reframing safety	Reframing safety occurred when Collaborative site leaders encouraged staff to discuss and think about the five dimensions (past harm, reliability, sensitivity to operations, anticipation and preparedness, integration and learning). These leaders developed strategies to share the MMSF (eg, one dimension at a time or whole Framework, modifying wording used, and who it was shared with) for local contexts. Coaching of the leaders was essential to support continued engagement, reflection and experimentation of safety dimensions. Examples: Site MMSF leaders talked about the Framework at leadership meetings within and across regional healthcare organisations to encourage people to think about the dimensions in relation to their workplace contexts, with no expected deliverables Site MMSF leaders added their own probing questions to the Framework to support the understanding and application of the dimensions by front-line healthcare workers
Framework experimentation	Sites experimented with the MMSF in different ways. Many began with the sensitivity to operations question ‘Is care safety today?’ with discussions that reflected their workplaces. Sites also frequently incorporated the Framework into existing safety activities (eg, rounds, huddles). As people became comfortable with the MMSF they began using it spontaneously and for targeted safety problems. Examples: Site MMSF leader brought safety report data back to staff to allow for informed discussions about concept of ‘reliability’ and staff came up with suggestions, for example, how to create safer surfaces to prevent falls A group used the MMSF to guide a post-mock code exercise discussion. Each dimension led to a different kind of reflection on the exercise (eg, ‘Is care safe today?’ led to discussions about the standard of care followed, having all the equipment needed, etc; The question ‘will care be safe in the future?’ led to discussions about the X-ray department and their roles during a code)
MMSF spread	Collaborative teams had both unplanned and planned spread and to a lesser degree scale-up. Examples: An MMSF team member changed jobs during the MMSF and then initiated MMSF implementation in her new unit MMSF was incorporated into the electronic medical record system that was piloted in one site and would then be disseminated across the organisation

MMSF, Measurement and Monitoring of Safety Framework.