Building a functional resonance analysis method (FRAM) in healthcare
A systematic review on how steps are reported, defined and supported by data
N.M. Luijcks (TU Delft - Safety and Security Science)
Tom Bazuin (University Medical Center Groningen)
A. Adriaensen (TU Delft - System Engineering)
Annelies Visser (Amsterdam UMC)
Dave A. Dongelmans (Universiteit van Amsterdam)
J. Groeneweg (TU Delft - Safety and Security Science)
Maarten J. van der Laan (University Medical Center Groningen)
P.J. Marang-van de Mheen (TU Delft - Safety and Security Science)
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Abstract
Objectives
The functional resonance analysis method (FRAM) is increasingly used to analyse healthcare processes. FRAM uses four steps to analyse a process and its potential variability. We systematically reviewed studies using FRAM in healthcare on how the four steps in FRAM are reported, defined and supported by data.
Design
Systematic review following the preferred reporting items for systematic reviews and meta-analyses 2020 guidelines.
Data sources
Web of Science, PubMed, Embase, Scopus, PsycINFO, Dimensions and Lens were searched up to December 2025.
Eligibility criteria for selecting studies
All peer-reviewed studies using FRAM in a healthcare context that presented a FRAM visualisation were included. The papers had to be written in English.
Data extraction and synthesis
Two independent reviewers screened titles and abstracts, and subsequently the full text of selected papers. Data was extracted reporting on the steps of FRAM, how functions were supported by data, and the functions and couplings of the visualisations.
Results
Sixty-eight papers were included, of which 20 (29%) reported at least one aspect of all four steps in FRAM. While most studies (85%) described how functions were supported by data, the methods used varied widely. Terminology was interpreted differently concerning variability, the output of variability and the effect of combined variability.
Conclusion
Most FRAM studies in healthcare do not report all steps of FRAM, and interpretations of key terms differ. FRAM studies should more clearly describe which steps of the method are conducted, and how data is collected and analysed. Refinement of FRAM guidelines, particularly on data use and terminology, would enhance consistency and comparability across studies.
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