Participatory design of an improvement intervention for the primary care management of possible sepsis using the Functional Resonance Analysis Method

Abstract

BackgroundEnsuring effective identification and management of sepsis is a healthcare priority in many countries. Recommendations for sepsis management in primary care have been produced, but in complex healthcare systems, an in-depth understanding of current system interactions and functioning is often essential before improvement interventions can be successfully designed and implemented. A structured participatory design approach to model a primary care system was employed to hypothesise gaps between work as intended and work delivered to inform improvement and implementation priorities for sepsis management.MethodsIn a Scottish regional health authority, multiple stakeholders were interviewed and the records of patients admitted from primary care to hospital with possible sepsis analysed. This identified the key work functions required to manage these patients successfully, the influence of system conditions (such as resource availability) and the resulting variability of function output. This information was used to model the system using the Functional Resonance Analysis Method (FRAM). The multiple stakeholder interviews also explored perspectives on system improvement needs which were subsequently themed. The FRAM model directed an expert group to reconcile improvement suggestions with current work systems and design an intervention to improve clinical management of sepsis.ResultsFourteen key system functions were identified, and a FRAM model was created. Variability was found in the output of all functions. The overall system purpose and improvement priorities were agreed. Improvement interventions were reconciled with the FRAM model of current work to understand how best to implement change, and a multi-component improvement intervention was designed.ConclusionsTraditional improvement approaches often focus on individual performance or a specific care process, rather than seeking to understand and improve overall performance in a complex system. The construction of the FRAM model facilitated an understanding of the complexity of interactions within the current system, how system conditions influence everyday sepsis management and how proposed interventions would work within the context of the current system. This directed the design of a multi-component improvement intervention that organisations could locally adapt and implement with the aim of improving overall system functioning and performance to improve sepsis management.Electronic supplementary materialThe online version of this article (10.1186/s12916-018-1164-x) contains supplementary material, which is available to authorized users.

Development and application of ‘systems thinking’ principles for quality improvement

“…Alternative methods exist for modelling and understanding complex systems, such as the Functional Resonance Analysis Method,49 and a complex systems approach is used in accident models such as the Systems Theoretic Accident Modelling and Processes50 and AcciMAPs 51. These robust methods for system analysis are difficult for front-line teams to implement without specialised training 29. The principles, on the other hand, were designed with front-line healthcare workers in order to allow non-experts to be able to adopt this type of thinking to understand and improve systems.…”

“…The Safety-II approach aims to increase the number of events with a positive outcome by exploring and understanding how everyday work is done under different conditions and contexts. This can lead to a more informed appreciation of system functioning and complexity that may facilitate a deeper understanding of safety within systems 29 30…”

Double checking injectable medication administration: Does the protocol fit clinical practice?

“…To date, only a limited number of studies applied FRAM to evaluate healthcare processes (Buikstra, 2018;Clay-Williams et al, 2015;Damen et al, 2018;Laugaland et al, 2014;McNab et al, 2018;Raben et al, 2018;Ross et al, 2018). We believe FRAM is very useful for visualizing the complexity of healthcare processes, such as the double check.…”

“…This resilience results in adjusting to situations in practice (McNamara and Fealy, 2010). The number of studies that used FRAM in healthcare processes are limited (Buikstra, 2018;Clay-Williams et al, 2015;Damen et al, 2018;Laugaland et al, 2014;McNab et al, 2018;Raben et al, 2018;Ross et al, 2018). FRAM provides a unique opportunity to visualize complex processes.…”

“…By visualizing this process with FRAM and the variability in the process, we aimed to better understand factors affecting the double check process. Besides, although individual interviews are recommended for the datacollection in FRAM studies, few studies conducted group interviews as a new method (Bridges et al, 2018;McNab et al, 2018). In our study, the work-as-done model was also constructed based on group interviews.…”