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.