From FRAM Guidelines to Reality: Incorporating Stakeholder Variability in Work-as-Done in Healthcare

Safety, vol. 11, pp. 66

Abstract

Background: The Functional Resonance Analysis Method (FRAM) analyses discrepancies between written protocols (Work-as-Imagined) and real-world practice (Work-as-Done) in healthcare. Work-as-Done is created based on multiple stakeholders, leading to variability in reported functions. No guidance exists how to manage this variability. This study examines between-stakeholder variation in Work-as-Done and its impact on differences from Work-as-Imagined in FRAM visualisations. Methods: Two FRAM studies were analysed: delirium diagnosis and treatment (1) and perioperative anticoagulant management in two hospitals (2). Heatmaps visualised between-stakeholder variability of reported functions in Work-as-Done. We assessed the impact of including only functions shared by multiple stakeholders on Work-as-Imagined versus Work-as-Done comparisons. Results: In study 1, 23 of 33 functions were shared among at least two stakeholders. In study 2, stakeholders shared 30 of 33 functions in Hospital 1 and 29 of 32 functions in Hospital 2. Including or excluding functions, e.g., only mentioned by one stakeholder, influenced the observed differences between Work-as-Imagined and Work-as-Done. Conclusions: Between-stakeholder variability in both studies influenced differences between Work-as-Imagined and Work-as-Done, which often is the starting point improving the process. Showing between-stakeholder variability in FRAM studies enhances transparency in researcher decision-making. This supports more informed analysis and discussion in process improvement efforts.

Authors 4

1. Nienke Luijcks corresponding

   Delft University of Technology

   Affiliation as printed

   Department of Safety & Security Science, Delft University of Technology, 2600 AA Delft, The Netherlands

2. Perla J. Marang‐van de Mheen

   Delft University of Technology

   Affiliation as printed

   Department of Safety & Security Science, Delft University of Technology, 2600 AA Delft, The Netherlands

3. Maarten J. van der Laan

   University Medical Center Groningen

   Affiliation as printed

   Department of Surgery, University Medical Centre Groningen, 9700 RB Groningen, The Netherlands

4. Jop Groeneweg Aachen Department of Cognitive Psychology

   Leiden University · Netherlands Organisation for Applied Scientific Research · Delft University of Technology

   Affiliation as printed

   Department of Cognitive Psychology, Leiden University, 2333 AK Leiden, The Netherlands

   Department of Safety & Security Science, Delft University of Technology, 2600 AA Delft, The Netherlands

   The Netherlands Organization for Applied Scientific Research (TNO), 2333 BE Leiden, The Netherlands