Third evaluation of the National Patient Safety Program in Dutch hospitals: A Safety-II approach using FRAM analysis

Within this research project, we will examine the effect of the Functional Resonance Analysis Method (FRAM) as an intervention to help healthcare professionals gain visual insight into three healthcare processes: screening frailty of older patients, double checking injectable medication administration and performing medication reconciliation at discharge. For each process, we will first map out how the process would ideally be performed (work-as-imagined) based on guidelines. Secondly, we will interview healthcare professionals involved in the process to determine how the processes are done in practice (work-as-done). During a feedback meeting with healthcare professionals from each participating ward, the work-as-done model versus the work-as-imagined model will be discussed. Healthcare professionals will be invited to explore the findings and discuss the causes and implications for their workflow. During this feedback meeting, the main focus will be on organizational learning, rather than (non-)adherence to guidelines. The FRAM intervention aims to help healthcare professionals to gain more insight into the variability in these particular healthcare processes. Nursing wards of internal medicine, surgery, cardiology and orthopedics and ICUs from 19 Dutch hospitals will be included in the study. We will use a stepped wedge design, allowing all participating wards to eventually be exposed to the intervention. The primary outcomes are 1)an evaluation of the different care processes by comparing the Work-as-Done vs. the Work-As-Imagined, 2) a qualitative description of whether the intervention has provided healthcare professionals with more insight into the healthcare processes and whether team reflection has stimulated behavioral change among healthcare professionals and substantive changes in the process, and 3) a quantitative description of team learning and behavior change by quantifying the proposed and implemented changes of the care process and protocols. The secondary outcomes will provide quantitative insight into the effects of the intervention on daily practice. These outcomes are employee resilience, compliance with several safety indicators (SIs) related to the observed healthcare processes and a process evaluation.

By using FRAM, healthcare professionals will gain more insight into the variability of the healthcare processes, which leads to improved compliance with the selected safety indicators.

A stepped wedge design will be used, meaning that every two months two to three wards per theme will receive the intervention. After ten months, all wards will have received the intervention. Employee resilience will be measured at baseline level and at the end of the data collection period. The safety indicators will be collected every two months in all participating wards.

The FRAM intervention includes:
- FRAM interviews with healthcare professionals,
- a feedback meeting with healthcare providers of the participating ward to discuss WAI and WAD,
- an interview with the contact person of each ward to evaluate the implementation process of the FRAM.