Clay-Williams Robyn, Hounsgaard Jeanette, Hollnagel Erik
Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia.
Centre for Quality, Region of Southern Denmark, 5500, Middelfart, Denmark.
Implement Sci. 2015 Aug 29;10:125. doi: 10.1186/s13012-015-0317-y.
Uptake of guidelines in healthcare can be variable. A focus on behaviour change and other strategies to improve compliance, however, has not increased implementation success. The contribution of other factors such as clinical setting and practitioner workflow to guideline utilisation has recently been recognised. In particular, differences between work-as-imagined by those who write procedures, and work-as-done-or actually enacted-in the clinical environment, can render a guideline difficult or impossible for clinicians to follow. The Functional Resonance Analysis Method (FRAM) can be used to model workflow in the clinical setting. The aim of this study was to investigate whether FRAM can be used to identify process elements in a draft guideline that are likely to impede implementation by conflicting with current ways of working.
Draft guidelines in two intensive care units (ICU), one in Australia and one in Denmark, were modelled and analysed using FRAM. The FRAM was used to guide collaborative discussion with healthcare professionals involved in writing and implementing the guidelines and to ensure that the final instructions were compatible with other processes used in the workplace.
Processes that would have impeded implementation were discovered early, and the guidelines were modified to maintain compatibility with current work processes. Missing process elements were also identified, thereby, avoiding the confusion that would have ensued had the guideline been introduced as originally written.
Using FRAM to reconcile differences between work-as-imagined and work-as-done when implementing a guideline can reduce the need for clinicians to adjust performance and create workarounds, which may be detrimental to both safety and quality, once the guideline is introduced.
医疗保健领域对指南的采纳情况可能各不相同。然而，专注于行为改变和其他提高依从性的策略并未提高实施成功率。最近人们认识到临床环境和从业者工作流程等其他因素对指南使用的影响。特别是，编写程序的人员所设想的工作与临床环境中实际完成或实际执行的工作之间的差异，可能会使临床医生难以或无法遵循指南。功能共振分析方法（FRAM）可用于对临床环境中的工作流程进行建模。本研究的目的是调查FRAM是否可用于识别指南草案中可能因与当前工作方式冲突而阻碍实施的流程要素。
使用FRAM对澳大利亚和丹麦各一个重症监护病房（ICU）的指南草案进行建模和分析。FRAM用于指导与参与编写和实施指南的医疗保健专业人员进行协作讨论，并确保最终说明与工作场所使用的其他流程兼容。
早期发现了可能阻碍实施的流程，并对指南进行了修改，以保持与当前工作流程的兼容性。还识别出了缺失的流程要素，从而避免了按原样引入指南可能导致的混乱。
在实施指南时，使用FRAM协调设想的工作与实际完成的工作之间的差异，可以减少临床医生调整工作表现并采取变通方法的必要性，而一旦引入指南，这些变通方法可能对安全和质量都有害。
