Using FRAM visualisations in quality improvement projects: identifying and testing strategies to improve anticoagulant use in the perioperative process

International Journal for Quality in Health Care, vol. 37

Abstract

BACKGROUND: To improve healthcare processes, gaining a thorough understanding of the work is important. The Functional Resonance Analysis Method (FRAM) is a method that can be used for this purpose by visualising how different steps in a process interact. However, little research is available on the use and feasibility of FRAM in quality improvement studies. Therefore, the objective of this study is to assess the feasibility of using FRAM visualisations in a quality improvement study to identify, formulate and test improvement strategies regarding anticoagulant use in the perioperative process in two Dutch University Medical Centres. METHODS: Through multiple Plan-Do-Study-Act cycles, FRAM visualisations of work-as-imagined and work-as-done were created, which were validated and discussed with healthcare professionals through focus groups. Improvement suggestions were collected as input for improvement strategies from frontline clinicians. These strategies were tested and evaluated using questionnaires and interviews. The interviews were analysed using content analysis to further explore the value of the FRAM visualisations for identifying and employing improvement strategies. RESULTS: The FRAM visualisations were perceived as confusing by professionals given their limited knowledge of FRAM, and it was time-intensive to identify possible improvements in the perioperative process. Using a simplified visualisation that showed the key FRAM information resulted in multiple improvement suggestions which were successfully tested as improvement strategies. The content analysis revealed three themes related to the use of FRAM: how care could be organised efficiently and safely, bringing stakeholders together to highlight the roles and responsibilities of professionals, and identifying how documentation of patient information is often scattered or incomplete. CONCLUSIONS: FRAM visualisations in quality improvement studies can provide valuable insights into the working process, which are also useful for formulating and testing improvement strategies. However, adjustments to the visualisations are necessary to enable professionals to participate in identifying improvement strategies.

Authors 11

1. Nienke Luijcks corresponding

   Delft University of Technology

   Affiliation as printed

   Department of Safety & Security Science, Delft University of Technology , Mekelweg 5 , Delft, 2628 CD,

   Department of Safety & Security Science, Delft University of Technology, Mekelweg 5, Delft, 2628 CD, The Netherlands

2. Annelies Visser

   Amsterdam UMC Location University of Amsterdam · Amsterdam University Medical Centers

   Affiliation as printed

   Department of Surgery, Amsterdam University Medical Centre , Meibergdreef 9 , Amsterdam, 1105 AZ,

   Amsterdam University Medical Centre, Amsterdam Department of Surgery, , The

   Department of Surgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands

   Department of Surgery, Amsterdam University Medical Centre, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands

3. Dave Anton Dongelmans

   Amsterdam Public Health · Amsterdam University Medical Centers

   Affiliation as printed

   Department of Intensive Care Medicine, Amsterdam University Medical Centre, Amsterdam Public Health (APH) , Meibergdreef 9 , Amsterdam, 1105 AZ,

   Department of Intensive Care Medicine, Amsterdam University Medical Centre, Amsterdam Public Health (APH), Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands

4. Dimmy van Dongen

   Delft University of Technology

   Affiliation as printed

   Department of Safety & Security Science, Delft University of Technology , Mekelweg 5 , Delft, 2628 CD,

   Department of Safety & Security Science, Delft University of Technology, Mekelweg 5, Delft, 2628 CD, The Netherlands

5. Erin L de Graaf

   Delft University of Technology

   Affiliation as printed

   Department of Safety & Security Science, Delft University of Technology , Mekelweg 5 , Delft, 2628 CD,

   Department of Safety & Security Science, Delft University of Technology, Mekelweg 5, Delft, 2628 CD, The Netherlands

6. Jop Groeneweg Aachen Unit of Cognitive Psychology

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

   Affiliation as printed

   Department of Safety & Security Science, Delft University of Technology , Mekelweg 5 , Delft, 2628 CD,

   TNO , Sylviusweg 71 , Leiden, 2333 BE,

   Unit of Cognitive Psychology, Leiden University , Wassenaarseweg 52 , Leiden, 2333 AK,

   Department of Safety & Security Science, Delft University of Technology, Mekelweg 5, Delft, 2628 CD, The Netherlands

   TNO, Sylviusweg 71, Leiden, 2333 BE, The Netherlands

   Unit of Cognitive Psychology, Leiden University, Wassenaarseweg 52, Leiden, 2333 AK, The Netherlands

7. Maarten J. van der Laan

   University Medical Center Groningen

   Affiliation as printed

   Department of Surgery, University Medical Centre Groningen , Hanzeplein 1 , Groningen, 9713 GZ,

   Department of Surgery, University Medical Centre Groningen, Hanzeplein 1, Groningen, 9713 GZ, The Netherlands

8. Perla J Marang-van de Mheen

   Delft University of Technology

   Affiliation as printed

   Department of Safety & Security Science, Delft University of Technology , Mekelweg 5 , Delft, 2628 CD,

   Department of Safety & Security Science, Delft University of Technology, Mekelweg 5, Delft, 2628 CD, The Netherlands

9. I Grossmann
10. Perla J. Marang‐van de Mheen

    Delft University of Technology

    Affiliation as printed

    Department of Safety & Security Science, Delft University of Technology , Mekelweg 5 , Delft, 2628 CD,

11. Vincent Jongkind