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.

Background
Healthcare workers (HCWs) voicing their views (speaking up) is crucial for patient safety and care quality. Yet, this is underused, especially during multidisciplinary team meetings (MDTMs), where diverse professionals collaborate to optimise patient treatment plans. Despite the benefits of open communication, HCWs face barriers such as hierarchical dynamics, time constraints and psychological risks.

Aim
This study examines factors influencing HCWs’ speaking-up behaviours in MDTMs, focusing on motivators, barriers and dynamics across disciplines.

Method
We conducted 21 semistructured interviews with MDTM participants of a gastrointestinal surgery ward, including surgeons, residents, nurses, nursing students, dieticians, ostomy nurses and physical therapists. Data were analysed collaboratively using thematic analysis.

Results
Participants are highly motivated to advocate for patients and provide optimal care. However, barriers impact speaking up during MDTMs. Three major themes were identified: (1) time pressure, (2) perception of goals and roles and (3) familiarity among team members. Structural, relational and contextual factors affect HCWs’ ability to speak up, with nurses and paramedics experiencing more hesitancy than physicians. Lack of preparation time, ambiguous objectives, no formal agenda and unfamiliarity among team members hinder contributions, leading to unbalanced input.

Conclusion
Findings support a systems-based approach to addressing barriers. Interventions should focus on clear goals, reduced time pressures and enhanced team cohesion, rather than placing the responsibility solely on individuals. For instance, adjusting meeting schedules to accommodate diverse availability improves participation across disciplines. Strengthening familiarity among team members fosters trust and lowers the perceived risks of speaking up, ensuring more balanced contributions during MDTMs.

Background
Speaking up among healthcare professionals plays an essential role in improving patient safety and quality of care, yet it remains complex and multifaceted behaviour. Despite awareness of potential risks and adverse outcomes for patients, professionals often hesitate to voice concerns due to various influencing factors. This complexity has encouraged research into the determinants of speaking-up behaviour in hospital settings. This review synthesises these factors into a multi-layered framework. It aims to provide a more comprehensive perspective on the influencing factors, which provides guidance for interventions aimed at fostering environments contributing to speaking up in hospitals.

Methods
A systematic review was conducted in November 2024, searching databases: PubMed, Scopus and Web of Science. Following PRISMA guidelines and the three stages for thematic synthesis, we developed the classification of influencing factors. Out of 1,735 articles identified articles, 413 duplicates were removed, 1,322 titles and abstracts were screened, and 152 full texts (plus six additional articles) were assessed. Ultimately, 45 articles met the inclusion criteria.

Results
The review categorised influencing factors into four categories: individual (29 articles, 64%), relational (21 articles, 47%), contextual (19 articles, 42%), and organisational (26 articles, 58%). These categories encompass motivating, hindering and trade-off factors affecting speaking up among healthcare professionals in hospitals.

Conclusions
The multi-layered framework highlights the dynamic interplay of factors influencing speaking up among healthcare professionals. A systems approach is essential for identifying barriers and enablers and designing effective speaking up interventions. This framework serves as a foundation for more focused research and practical guidance, enabling healthcare leaders to address barriers across all categories. By fostering environments that support open communication, organisations can enhance patient safety and quality of care.