Abstract
BackgroundEnsuring effective identification and management of sepsis is a healthcare priority in many countries. Recommendations for sepsis management in primary care have been produced, but in complex healthcare systems, an in-depth understanding of current system interactions and functioning is often essential before improvement interventions can be successfully designed and implemented. A structured participatory design approach to model a primary care system was employed to hypothesise gaps between work as intended and work delivered to inform improvement and implementation priorities for sepsis management.MethodsIn a Scottish regional health authority, multiple stakeholders were interviewed and the records of patients admitted from primary care to hospital with possible sepsis analysed. This identified the key work functions required to manage these patients successfully, the influence of system conditions (such as resource availability) and the resulting variability of function output. This information was used to model the system using the Functional Resonance Analysis Method (FRAM). The multiple stakeholder interviews also explored perspectives on system improvement needs which were subsequently themed. The FRAM model directed an expert group to reconcile improvement suggestions with current work systems and design an intervention to improve clinical management of sepsis.ResultsFourteen key system functions were identified, and a FRAM model was created. Variability was found in the output of all functions. The overall system purpose and improvement priorities were agreed. Improvement interventions were reconciled with the FRAM model of current work to understand how best to implement change, and a multi-component improvement intervention was designed.ConclusionsTraditional improvement approaches often focus on individual performance or a specific care process, rather than seeking to understand and improve overall performance in a complex system. The construction of the FRAM model facilitated an understanding of the complexity of interactions within the current system, how system conditions influence everyday sepsis management and how proposed interventions would work within the context of the current system. This directed the design of a multi-component improvement intervention that organisations could locally adapt and implement with the aim of improving overall system functioning and performance to improve sepsis management.
Highlights
Ensuring effective identification and management of sepsis is a healthcare priority in many countries
During normal working hours (8:00 am to 6:00 pm Monday to Friday), clinical assessment is arranged by General practitioner (GP) reception staff, while at other times it is arranged by NHS24
Functional Resonance Analysis Method (FRAM) model Fourteen foreground system functions were identified with description of the function and output variability outlined in Tables 4 and 5 (Fig. 1)
Summary
Ensuring effective identification and management of sepsis is a healthcare priority in many countries. A structured participatory design approach to model a primary care system was employed to hypothesise gaps between work as intended and work delivered to inform improvement and implementation priorities for sepsis management. While a significant amount has been reported about work undertaken within the hospital setting to improve sepsis management, work in primary care is at a much earlier stage but has become a national priority in Scotland [8,9,10,11]. Guidelines to aid the identification of acutely ill patients who may have sepsis in primary care have been published that recommend the use of a structured set of clinical observations to stratify the risk of sepsis including pulse, temperature, blood pressure, respiratory rate, peripheral oxygen saturation and consciousness level [10]
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