title: Where the rubber meets the road: using FRAM to align work-as-imagined with work-as-done when implementing clinical guidelines.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors: Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, 2109, Australia. robyn.clay-williams@mq.edu.au.
authors: Robyn
authors: R
authors: Clay-Williams
authors: Centre for Quality, Region of Southern Denmark, 5500, Middelfart, Denmark. hollnagel.erik@gmail.com.
authors: Jeanette
authors: J
authors: Hounsgaard
authors: Centre for Quality, Region of Southern Denmark, 5500, Middelfart, Denmark. Jeanette.Hounsgaard@rsyd.dk.|Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark. Jeanette.Hounsgaard@rsyd.dk.
authors: Erik
authors: E
authors: Hollnagel
mesh_terms: D006801:Humans; D007362:Intensive Care Units / Q000592:standards; D008962:Models, Theoretical; D017410:Practice Guidelines as Topic; D016730:Program Development