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.

Objectives The goal of sentinel event (SE) analysis is to prevent recurrence. However, the rate of SEs has remained constant over the past years. Research suggests this is in part due to the quality of recommendations. Currently, standards for the selection of recommendations are lacking. Developing a method to grade recommendations could help in both designing and selecting interventions most likely to improve patient safety. The aim of this study was to (1) develop a user-friendly method to grade recommendations and (2) assess its applicability in a large series of Dutch perioperative SE analysis reports. Methods Based on two grading methods, we developed the recommendation improvement matrix (RIM). Applicability was assessed by analysing all Dutch perioperative SE reports over a 12-month period. After which interobserver agreement was studied. Results In the RIM, two elements are crucial: whether the recommendation intervenes before or after an SE and whether it eliminates or controls the hazard. Applicability was evaluated in 115 analysis reports, encompassing 161 recommendations. Recommendation quality varied from the highest, category A, to the lowest, category D, with category A accounting for 44%, category B for 35%, category C for 2% and category D for 19% of recommendations. There was a fair interobserver agreement. Conclusion The RIM can be used to grade recommendations in SE analysis and could possibly help in both designing and selecting interventions. It is relatively simple, user-friendly and has the potential to improve patient safety. The RIM can help formulate effective and sustainable recommendations, a second key objective of the RIM is to foster and facilitate constructive dialogue among those responsible for patient safety.

Background The recurrence of sentinel events (SEs) is a persistent problem worldwide, despite repeated analyses and recommendations formulated to prevent recurrence. Research suggests this is partly attributable to the quality of the recommendations, and determining if a recommendation will be effective is not yet covered by an adequate guideline. Our objectives were to (1) develop and validate criteria for high-quality recommendations, and (2) evaluate recommendations using the criteria developed. Methods (1) Criteria were developed by experts using the bowtie method. Medical doctors then determined if the recommendations of Dutch in-hospital SE analysis reports met the criteria, after which interobserver variability was tested. (2) Researchers determined which recommendations of Dutch perioperative SE analysis reports produced from 2017 to 2018 met the criteria. Results The criteria were: (1) a recommendation needs to be well defined and clear, (2) it needs to specifically describe the intended changes, and (3) it needs to describe how it will reduce the risk or limit the consequences of a similar SE. Validation of criteria showed substantial interobserver agreement. The SE analysis reports (n=115) contained 442 recommendations, of which 64% failed to meet all criteria, and 28% of reports did not contain a single recommendation that met the criteria. Conclusion We developed and validated criteria for high-quality recommendations. The majority of recommendations did not meet our criteria. It was disconcerting to find that over a quarter of the investigations did not produce a single recommendation that met the criteria, not even in SEs with a fatal outcome. Healthcare providers have an obligation to prevent SEs, and certainly their recurrence. We anticipate that using these criteria to determine the potential of recommendations will aid in this endeavour.