Exploring interdependencies, vulnerabilities, gaps and bridges in care transitions of patients with complex care needs using the Functional Resonance Analysis Method

doi:10.21203/rs.3.rs-2212687/v1

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Research Article

Exploring interdependencies, vulnerabilities, gaps and bridges in care transitions of patients with complex care needs using the Functional Resonance Analysis Method

https://doi.org/10.21203/rs.3.rs-2212687/v1

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Journal Publication

published 11 Aug, 2023

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Background:

Care transitions, such as a patient’s hospital discharge, are complex processes encompassing multiple interactions and requiring coordination between stakeholders. To identify potential improvement measures in care transitions for people with complex care needs, intra- and inter-organisational everyday work needs to be properly understood, including its interdependencies, vulnerabilities and gaps. The aim of this study was to map the coordination of care across healthcare and social care organisations and describe interdependencies and system variability in care transitions.

Methods:

The study was inspired by multi-method research. Data were collected through participant observations, interviews and a document review in a region of southern Sweden. The Functional Resonance Analysis Method was used to model the discharge process and visualise and analyse coordination within and between different organisations and units.

Results:

The results show that hospital discharge is a time-sensitive process with numerous couplings and interdependencies where healthcare professionals are constrained by system design and organisational boundaries. The greatest vulnerability can be found when the patient arrives at home, as maladaptation earlier in the care chain can lead to an accumulation of issues for the municipal personnel in social care working closest to the patient. The possibilities for the personnel to adapt are limited, especially at certain times of day, pushing them to make trade-offs to ensure patient safety. To counteract variability in performance of care, flexibility and adequate resources need to be ensured, to promote the possibility to respond and adjust to uncertainties.

Conclusions:

To achieve safe and secure care transitions from hospital to home, proactive work during discharge planning needs to be facilitated by improving the timing and precision in assessment and planning of patient care. Responding to unexpected events and variations requires successful adaptation and use of allocated resources during the first few days after homecoming, and a system allowing for flexibility to promote safe and personalized care.

Complexity

care transitions

hospital discharge

patient safety

resilience

Functional Resonance Analysis Method (FRAM)

Advancements in modern medicine and technology have led to new medical interventions and promoted high-quality care, creating possibilities to effectively treat acute diseases and leading to a decline in mortality and increased life expectancy (1). The advancements also lead to increased specialization and differentiation which may create gaps in communication and knowledge transfer between specialties. For patients with complex care needs, this may result in fragmentation of care as they will meet several different care providers, whether seeking care for chronic or acute conditions (2, 3). Coordinating care between different care providers is recognised as difficult (4) and is complicated by the diversity of actors and organisations involved. Due to the burden of increased chronic illness in the aging population, healthcare systems worldwide experience challenges in providing safe and efficient care to older people with complex care needs (5, 6).

Healthcare can be classified as a complex adaptive system (CAS), as its components have multiple interdependencies and work in nonlinear ways (7, 8). Complex systems have fuzzy boundaries and co-evolve with other systems (9). A CAS has intrinsic laws or principles, such as self-organisation, emergent behaviour and the capacity to learn, making it difficult to predict how its components will interact temporally in a given situation (10). This implies that the view of the horizon for each person in the system is quite limited – and the further away it is, the more unpredictable the consequences of any actions taken become. Safety problems are thus not necessarily a direct result of lacking knowledge or limited effort on the part of the healthcare professionals – rather, they are usually a result of the complexity of the system.

An illustrative example of complexity in healthcare is the multidisciplinary teamwork in coordinated discharge planning (11) and the coordination of care for older people with complex care needs. Achieving safe care transitions from hospital to home for patients with complex care needs is a complicated process requiring successful completion of a number of tasks, e.g., coordinating care with healthcare personnel outside hospital (12). The structural gaps between services and settings involved in these care transitions create safety gaps (13) and a healthcare system design with highly specialised care units may raise walls that obscure a patient’s care pathway and hide safety risks (14). In a CAS, the known and the unpredictable exist side by side. During discharge planning, this creates a need for adaptability and flexibility, where each system unit may need to relinquish some of its autonomy and favour teamwork over professional and organisational boundaries.

As outlined above, care transitions can be understood as processes in a CAS. To reflect this, care transitions can be analysed using systemic safety models that promote a focus not only on the individuals, but on the interactions between the people, the technology and the organisations involved. Systemic models aid identification and understanding of potential vulnerabilities at the system level instead of focusing on individuals as the root causes of any failure (or ‘scapegoats’) (15). However, there is often a mismatch between how work is presumed to be performed, in protocols and procedures (work-as-imagined, WAI), and how it is actually performed (work-as-done, WAD) (16, 17). When performance of tasks is adapted to changing operational conditions across organisations, such as constraints in time or resources, this leads to variability.

Poor healthcare quality is often related to the inherent complexity of the healthcare system, characterised by silos, multiple stakeholder interactions and a significant degree of performance variability within and across system levels (18–20). Care transitions, especially hospital discharges, require extensive collaboration and information exchange. Previous research indicates the hazards associated with this and the need of interventions to improve care transitions for people with complex care needs. The vulnerable exchange points in care transitions may increase both the need of healthcare services and healthcare costs (21). Understanding and improving care transitions is considered to be of major importance (22) and is an international healthcare priority (21, 23), as these are error-prone situations (24). However, one barrier to improvement is the lack of detailed understanding of how coordination of care at hospital discharge is organised, including inherent interdependencies. Therefore, it would be valuable to map the critical situations where misalignments between demands and resources may occur and where there are gaps between how work is described in procedures and how it is done in practice.

The aim of the study was to map coordination of care across healthcare and social care organisations and describe interdependencies and system variability in care transitions for older people with complex care needs.

Design and study setting

We conducted a qualitative study using multiple convergent data collection methods (25–27) to gather data on care transitions and then analysed the data with the Functional Resonance Analysis Method (FRAM) (28), see Fig. 1. Qualitative methods comprising document review, observations and interviews with healthcare and social care professionals (HSCPs) were used. This study focused on couplings and interdependencies in care transitions, delimited to hospital admission, in-patient care, hospital discharge and the first 72 hours at home.

[insert Fig. 1 here]

The study is part of a research project performed in collaboration with a region and municipalities in southern Sweden. The region encompasses three small to medium-sized hospitals, 40 primary care centres and twelve municipalities. Sweden has a decentralised healthcare system managed and run by regions and municipalities. The regions are responsible for primary, secondary and specialist care, while the municipalities provide healthcare and social care in nursing homes and home care services (29, 30).

The Functional Resonance Analysis Method (FRAM)

The FRAM (28, 31) offers an approach to map and visualise variability and interdependencies in complex systems and examine relationships between individual processes and elements. The FRAM has been used in numerous studies within healthcare (32), providing deeper understanding on how different components interact and drive non-linear series of actions in complex healthcare processes such as transitional care (14, 33) and hospital discharge (34, 35). In the FRAM, the discharge process can be modelled as consisting of activities that occur daily within and between organisations. The purpose of a FRAM analysis is to describe how a system should work to achieve the intended goals and to understand how potential variability can prevent this from happening or enhance functionality (28). It is first necessary to map and construct a model of the system (as in the current study) and then analyse a number of scenarios in the form of instantiations of the model (to be presented in a separate study).

In the FRAM, a function refers to the means, acts or activities that are necessary to achieve a goal or produce a certain result (28, 36). However, a function can also refer to something the organisation does, such as ‘treat patients’, or something that a technical system does automatically or after manual input. Each function is described by six aspects – Input, Output, Precondition, Resource, Control and Time (37) – as illustrated in Fig. 2.

[insert Fig. 2 here]

The output of one function interacts or ‘couples’ with other functions. In a visual representation of a FRAM model, this is illustrated by lines or ‘couplings’ connecting the functions. Functional upstream-downstream couplings create the basis for functional resonance (38), as they mean that the variability of a function may be amplified or dampened by other system functions. Internal variability relates to the nature of a function, for example bias in decision-making or assessment or the quality and effectiveness of communication in an organisation. External variability emerges from the variability of the conditions or work environment in which the function is performed, affected by unspoken norms and expectations or by organisational factors such as regulations and legal constraints. By creating a visual of the intra- and inter-organisational complexity and variability of the care transition process, the FRAM may aid discovery of potential interdependencies, vulnerabilities and gaps where discontinuities occur, thereby potentially contributing to improved patient safety.

Sampling and participants

A purposive sampling strategy was adopted (39) to recruit participants from various professions involved in care transitions from hospital to home, to maximise data variation (39). The extensive sampling enabled capture of the intra- and inter-organisational perspectives of stakeholders involved in the delivery of healthcare and social care in such transitions. The operation managers from each organisation got an introduction to the project through written and verbal information. They in turn informed their personnel. All participants were informed prior to observations and interviews and gave consent.

The sample consisted of 60 HSCPs from in-hospital care, ambulance care, primary care and municipal care. The participants had a range of professions and roles: registered nurses, physicians, care coordinators, occupational therapists, physiotherapists, aid officers, assistant nurses, ambulance nurses, as well as first-line managers. This provided a multidisciplinary and cross-stakeholder perspective on collaboration in care transitions.

Data collection and procedures

The data collection was performed as an iterative process and comprised observations, interviews and document review. It was done from June 2020 to October 2021, to achieve a comprehensive data material and understanding of the complex care transition processes. The data collection encompassed a total of 45 interviews, eleven participant observations and five meeting observations (Table 1).

[Insert Table 1 here]

Document review

First, to develop observation protocols and questions for interviews, written materials were collected by searching and accessing available documents on government websites as well as digital and printed versions used in everyday work at the units being observed. Documents included in the review were national laws, regional guidelines and local routines from in-hospital care and municipal care describing how the discharge process should be performed. The documents were analysed using document review, mapping the discharge process according to regulations and routines (i.e., WAI (38)).

Observations

To gain an understanding of how the everyday work was carried out (28), participant observations were performed (40) in multiple contexts. The researcher was present and recognisable to the participants, but not an active participant with a role in the social context, enabling observation and occasional interactions leading to a high level of involvement while maintaining detachment (40). Before meeting observations, all participants were informed and gave consent. To protect the privacy of all parties, as well as to avoid gathering sensitive information like patient data, none of the meetings were recorded. Instead, the observer wrote fieldnotes, in line with participant observation methods (40).

A semi-structured observation guide was used. It encompassed themes relevant to care transitions and hospital discharge, such as coordination, communication and information exchange. Observations were complemented with contextual inquiries to understand what was going on in the context (for example ‘Could you tell me about what you are doing there?’). These observations were performed in hospital wards (n = 6), primary care (n = 2) and community settings (n = 3) for a total of 86 hours, with personnel shadowed in their daily work. Various forms of meetings were observed, including coordination meetings, care planning meetings and discharge conversations between patients and physicians. Fieldnotes taken in association with the observations were rewritten later the same day.

Interviews

The knowledge gleaned from the document review was expanded through interviews with first-line managers. These interviews related to the work done at the management level and what tasks were supposed to be performed in the discharge process. The interviews were recorded, transcribed verbatim and added to the data from the document review.

To create a more in-depth view of the research problem, and to study different ways of understanding the work processes in care transitions, the observations were also complemented with individual interviews with personnel from throughout the care trajectory. The interviews were conducted on site, via telephone or via Skype/Zoom and lasted 32–75 minutes. A semi-structured interview guide was used and revised during the process, reflecting the analytical process and addressing the gaps in understanding remaining after the observations. The interviews thus offered a deeper, clarifying perspective on actions already observed. The interviews were recorded and then transcribed verbatim.

Data analysis

First, materials from the document review and interviews with managers were analysed using manifest content analysis (41), mapping WAI. The materials were coded and abstracted into categories describing the different steps in the discharge process (42).

The four-step approach described by Hollnagel (38) was applied for the analysis of WAD, preceded by a preparation step (Step 0), as follows:

Step 0: Define the purpose of the FRAM analysis.

Step 1: Identify vital functions that are required for everyday work to succeed.

Step 2: Determine and describe the system’s potential for variability.

Step 3: Identify functions that have dependencies that may affect the system.

Step 4: Propose ways to manage possible occurrences of uncontrolled performance variability.

Data analysis and creation of the FRAM model of WAD were performed through an iterative process of identifying patterns in the transcribed data and fieldnotes, to find a foundation in which existing work and communication processes could be recognised as functions. The functions were listed in a Microsoft Excel spreadsheet. For each function, as many aspects as possible were identified and described, to create an understanding of how it could be performed. Then, a preliminary chronology was drafted to position the functions in order based on their internal couplings.

Next, functions that – at an abstract level – made up the discharge process were identified. These functions were stepwise extended into a comprehensive model of everyday work in care transitions from hospital to home, visualised using the ‘FRAM Model Visualizer’ (36). The model was validated through expert audits by professionals involved in discharge processes (14), confirming the relevance of the results. Then, the potential variability of function output was assessed based on what can reasonably be expected to happen (38). The variability determines the quality of the output, which influences aspects of other functions in the system. The FRAM model was thus used to understand how variability and subsequent adjustments can affect other functions and thus the discharge process as a whole. The analysis concerned how the functions were interconnected and how this could lead to unexpected results, depending on how the outputs of each function could vary in timing (too early, on time, too late, not at all) and precision (precise, acceptable, imprecise), from the perspective of the needs of downstream functions. This step was followed by identification of functional dependencies and potential for functional resonance that could affect the system. The couplings made it possible to analyse and describe how variability of the output from one function could affect other functions, without any claims of a cause-effect perspective. Lastly, we proposed ways to deal with possible occurrences of uncontrolled performance emerging from implementation of changes that either dampened negative effects and absorbed variability or reinforced positive effects and amplified variability (43).

The results of this study are presented in five subsections. The first subsection relates to the discharge process as described in regulations and policy documents (WAI), while the three following subsections present WAD, using the FRAM steps to outline potential gaps within the care transition process. Based on the results of the analysis, measures to manage variability, risks and gaps are suggested in the final subsection.

The discharge process as described in regulations and policy documents

The document review showed that the discharge process is supposed to be achieved by eight overarching steps involving multiple stakeholders from several professions, as well as the patient and family. The steps, listed below, serve to achieve the goal of a safe and secure discharge from in-patient care:

Identify patients in need of coordinated care
Initiate coordination process
Plan and prepare for discharge
Jointly determine that the patient is fit for discharge
Facilitate the care transition
Transfer information and care responsibility from one care provider to another
Implement and perform the coordinated efforts in the home
Re-evaluate and reconsider the coordinated efforts in light of perceived needs after initiating the planned efforts

The final step of re-evaluating also includes identification of increased or altered needs for coordination, which may lead to the beginning of a new cycle of care transition.

Vital functions required for everyday work to succeed

The discharge process as performed in practice was modelled as encompassing a sizeable number of functions (n = 52), describing relevant processes and activities that occurred daily within and between different parts of the organisations, constituting WAD (example in Table 2, full list in Appendix).

[insert Table 2 here]

The comprehensive model describes WAD (Fig. 3), beginning with the function ‘Admit patient to ward’ and shows the couplings between the functions in the discharge process. Different colours show the range of actors involved in the functions. In this flow within the discharge process, the functions are clustered and follow the patient through different phases, as illustrated in Fig. 3.

[insert Fig. 3 here]

Potential variability in the system

The model reveals normal everyday changeability in the functional output, reflecting potential variability. The variability is most apparent in functions related to the planning and preparation for the care transition and the evaluation at home based on timing and precision of performance. The potential for internal variability relates to bias in assessments of what tools a patient may need on arrival at home, or whether a patient is ready for discharge. The quality of communication via digital systems can also be a factor complicating this. External variability is exemplified by the legal constraints limiting the transfer and sharing of patient information between the stakeholders involved in a care transition or by the limited personnel resources available when a patient is discharged late in the afternoon. Examples of potential variability related to timing and precision in a selection of functions are presented in Table 3.

[insert Table 3 here]

Functional dependencies and potential for functional resonance

The complexity of the system becomes apparent as functional interdependencies that embody the multidisciplinary teamwork in care transitions. For example, the variability in the function ‘Execute care transition’ as performed by hospital personnel can affect the circumstances for municipal personnel to execute downstream functions, creating the basis for functional resonance.

One of the functions with the most couplings upstream and downstream is ‘Execute coordinated care at home’. The quality of the output is affected by numerous upstream functions that will amplify or dampen the variability, depending on the timing and precision of their performance. Consequently, when healthcare personnel perform coordinated care in a patient’s home, the quality of the outcome depends on the previous performance of functions in the planning and preparation for hospital discharge and care transition. When necessary, adjustments are made by municipal personnel to get the work done. If the care needs of a patient are more extensive than the assessment and planning had prepared for, the personnel will be unable to follow protocol. Instead, they must resort to using ad hoc solutions or workarounds to get the work done, which may trigger functional resonance, as the variability in output of the functions creates a suboptimal basis for downstream functions.

The functional dependencies and potential for functional resonance are here clustered into the perspectives of timing and precision.

Timing

Timing is essential within the WAD process as it may impact on both the prerequisites for and the outcomes of a care transition. If a patient is discharged from hospital while still in recovery, the course of the next few days will be dynamic. If care planning is performed too early, the patient’s status may change and no longer match the decisions made, resulting in inadequate care or a need to review these decisions:

It all depends on when in time you have the discharge or care planning. Sometimes it happens quickly and then things happen and nothing matches. Then you might even get a coordinated care plan. One of our coordinators is doing a care planning for this one gentleman today, where there has already been a care planning meeting and he wasn’t supposed to get any home care. Now he’s gotten worse and will definitely need home care. […] So it depends a bit on when in time it's done.

(Participant 25, registered nurse, municipal home care)

However, if care planning is performed too late, the personnel at the receiving end will have limited time to arrange for the arrival at home. The timing of the functions also relates to the concept of synchronisation, i.e., agreement between the sending unit and the receiving unit. The analysis revealed the importance of having time and opportunity for preparation, so that everyone is ready when the patient is discharged. This includes both social care personnel, the patient and their family:

Yeah, things move quickly once they’re … when you think that now such-and-such is done with treatment and should go home and then it’s just wham-bam…

(Participant 4, occupational therapist, municipal rehabilitation services)

Additionally, the time of day when functions are performed can have major consequences for any workarounds that must be made to gain control over a situation and resolve it in the patient’s best interest. In particular, the weekend is a vulnerable time where the personnel must use ‘firefighting’ methods to meet care demands, until more permanent solutions can be put in place:

We had one person come home on a Friday, who couldn’t get out of their wheelchair and did not have a wheelchair lift at home. And then we got a hold of … an emergency occupational therapist and physical therapist and had them bring a lift that they could borrow and use over the weekend. And then our occupational therapist and physical therapist had to come over on the Monday.

(Participant 37, assistant nurse, municipal social care)

Friday night was a time that was frequently mentioned in the narratives of the participants as a known risk factor in discharges. During evenings and weekends, resources are reduced, with limited access to decision-makers and personnel with knowledge, existing relationships with patients and insight into the care planning processes, which were performed during weekdays. At best, the personnel might have access to written documentation, but this could also be limited during weekends if secretaries had not yet had the time to transcribe the physicians’ notes into the electronic patient records.

If someone is discharged on a Friday afternoon and then there’s just temporary staff all weekend and then maybe you’ll get a message about that on Monday or something and then maybe you’ll talk it over with the regular municipal personnel. But of course things can happen over the weekend and probably do sometimes. And sometimes it’s not … sometimes it takes a long time before the patient discharge summary is transcribed and sometimes things there are missed. I think that’s a potential problem.

(Participant 22, physician in primary care)

Precision

The precision of the performed functions relates to the quantity and quality of patient care. During a hospital stay, many units and professions are involved in the process of planning for sustainable continued care at home. The findings of the study suggest that gaps occur in this process, obscuring possible problems which can surface when the patient comes home. One such gap is the fact that the social care personnel with the closest relationships to the patient are neither invited nor informed first-hand regarding care needs during the discharge process. Another illustrative example relates to information transfer: too little information about a patient leads to knowledge gaps, creating extra work to gather the missing information. This may lead to unnecessary examinations or tests or deficient care. However, too much or irrelevant information can also create problems, as important information may be obscured.

That the information is given, that it is relevant, a bit brief. If there’s too much text, you realize that you kind of lose track of what’s important. Straightforward, clear communication, with short pathways, that they aren’t too long.

(Participant 14, registered nurse, municipal home care)

As emphasised in the quotation above, effective, clear and concise communication is of utmost importance for successful care transitions. The precision of information and communication regarding relevant issues is equally important for social care personnel and when informing the patient:

The patient is just buried in information and paperwork when they are discharged from hospital, so they can’t remember what’s important. They get confused … it’s better if the important stuff is written down and then they can read it afterward.

(Participant 118, coordinator, municipal home care)

The core issue of precision in care transitions may thus emerge in the quality of information transfer and the availability, procedure and use of systems where information is stored. Availability of information in multiple systems can be considered a strength, but can also generate extra work:

Yeah, the systems are … I kind of think that you should have that information more available. There are so many different systems that you have to access to see it.

(Participant 13, registered nurse, municipal home care)

There is an apparent gap in information transfer in the system, which can be illustrated by the case of ambulance personnel arriving at an older person’s home and trying to get the bigger picture of what the patient’s usual status was and what had been decided at hospital discharge. Access to written information was limited or non-existent, and there was difficulty getting in contact with municipal healthcare personnel with knowledge of the patient. The result was that the patient was returned to hospital and readmitted, but the solution could have been different:

It’s so hard to get information about the patient … what has been decided … I’ll look through binders and call, but I feel like I never get any information, you just stand there with your papers and wonder … So that’s what’s missing, from the side of the municipality. I mean, if you’re supposed to call one of the municipal nurses, then the person in charge will have gone home or is off or it’s in the evening or there’s no binder and there aren’t any papers and I don’t have the medical records and I don’t have anything … a care plan or whatever it is that you’re supposed to … that’s been decided, and when I’m standing there and I don’t have any idea, then maybe we’ll load up that patient and head to the emergency room. And then they’ll do something … small or, yeah, they’ll admit the patient for a night or something and then it all starts over. So you get unnecessary care and unnecessary trips for these kinds of patients.

(Participant 40, ambulance nurse)

The precision of the care planning is also a central issue. Multiple stakeholders in various professions prepare a plan of action, together with the patient and family, regarding the care efforts needed when the patient gets home. However, such planning is hypothetical, since there are limited possibilities to know what everyday life will be like for the patient after discharge:

The environment is different when you get home. The conditions are completely different.

(Participant 4, occupational therapist, municipal rehabilitation services)

To counteract this, municipal care personnel would wait a few days to let the patient get acquainted with the care efforts and aid tools and have time to recover from the hospital visit:

And then I’ll come back a day or two later and talk a bit more once they’ve settled in at home and when there’s hopefully a bit more peace and quiet […] get an idea of how things have actually gone during the first few days at home. That follow-up is valuable, I think, because then I can see quite a lot.

(Participant 1, registered nurse, municipal home care)

Management of possible instances of uncontrolled performance

The precision of functions related to the planning of resources may vary greatly. To help healthcare providers act even in uncertain conditions, their possibilities for adaptation need to be increased. Functions like ‘Execute coordinated care at home’ have several prerequisites and controls originating from the output of the function ‘Execute care transition’. However, the analysis indicates that variability in precision can be dealt with by increasing the flexibility in a patient’s home after discharge. Thus, one way to dampen the effects of functional resonance could be to increase the resources in the first few days after homecoming and perform regular and frequent reassessments, to make care adjustments flexible and accurate. This would enable adaption to the care needs that emerge during the dynamic reality of those first few days.

The timing of the care transition also affects the possibility of responding to unexpected events, as the system appears to be more vulnerable during evenings and weekends. Variability in timing can mean that the patient is discharged too early or too late, causing a ripple effect and functional resonance with consequences for downstream functions. One way of managing this could be adding prerequisites and controls for the function ‘Execute care transition’ so that the time of discharge will not be during the vulnerable periods. The downstream function ‘Execute coordinated care at home’ requires some components supplied from the hospital – such as medical information regarding the care given, medications needed during the first few days, and an updated medication list – and some components from the municipal organisation, such as availability of adapted care aids for basic mobility and ergonomic work conditions for personnel. The most critical functions in the system for monitoring and directing efforts to manage variability are ‘Co-create plan of coordinated care’, ‘Prepare care transition to home’ and ‘Execute care transition’. These three functions together constitute the grounds for the care performed at home.

The study aimed to map coordination of care across healthcare and social care organisations and describe interdependencies and system variability in care transitions among older people with complex care needs. The modelling of the discharge process reveals a complex system with numerous functional dependencies across organisations, making it almost impossible to describe and analyse this process using linear methods. Furthermore, the multidimensional aspects of patients’ care needs after hospital discharge cannot easily be planned for. Reality may differ from the plan, despite the best efforts of HSCPs. The findings relating to coordination and collaboration between different healthcare professionals and stakeholders in care transitions suggest that tasks are sometimes coordinated and sometimes not. Collaboration involving multiple individuals and teams is expected within and across organisational boundaries, even though not all individuals and teams communicate. If a healthcare team is seen as a CAS (44), healthcare professionals would need to expand the representation of the system to include anticipation of problems for others and moderation of goals, among other things. System thinking and anticipation of the consequences of processes across departments remain major challenges (45).

The findings of the study suggest that several gaps arise in the discharge process, though these are not always visible until the patient faces reality at home. Furthermore, gaps occur in the information exchange between HSCPs in the planning and performance of care transitions. The most prominent is that members of the social care personnel, who often have the most up-to-date information about a patient, are not included in the information transfer to the same extent as other parties. Instead, they are supplied with certain information fragments after the patient has returned home. Experiences of gaps in care are common, often arising from failures in communication and coordination of care (46) and interoperability of systems (47). Cross-organisational bridges may mitigate such gaps in care (48). The findings suggest that there are possibilities of creating shared documentation of a patient’s current care needs and plans. However, not all HSCPs have access to the necessary systems. Previous research indicates that sharing of patient data across systems, if performed effectively, can create the basis for safe care (49, 50), while also reducing the workload for healthcare providers (51), limiting treatment delays (52) and decreasing overall costs for the healthcare system (53).

As regards the issues of timing in the discharge process, the study shows that the time of day when the patient is discharged strongly affects the ability of personnel to deal with unexpected situations. Friday afternoons are mentioned as a particularly vulnerable time for discharge of people with complex care needs. This is in line with previous studies suggesting that the time of day when a patient is considered medically fit sets temporal conditions and time pressures for subsequent actions (54). Decisions later in the day were associated with increased time pressure and variability, thus affecting precision. Other studies indicate that the time between the decision on discharge and the care transition is a potential barrier to information sharing, as time constraints lead to greater time pressure, increased performance demands and decreased flexibility (55). Complex systems are resilient when they have diversity, as different professionals deploy different behaviours to respond to actions and situations based on their own perspectives and the construction of evidence by others (56). However, according to complexity theory, a system can never be fully described or fully controlled (57). This creates challenges in care transitions since the findings suggest many interdependencies between the actors involved, meaning that they depend on each other and on collaboration. Rasmussen (58) emphasises how circumstances may not be under the control of any one person, and that there may be systematic but unseen traps set by upstream decisions.

As healthcare professionals often lack insight and knowledge of each other’s areas, it is difficult to plan, prepare and facilitate care transitions as suggested in WAI and described in regulations and policy. Instead, tasks are performed from each person’s own perspective and from what they believe the relevant party needs. In a complex system like healthcare, WAD is always different from WAI (38, 59–61), though a large discrepancy between WAI and WAD is an indicator of brittleness in the system (62). However, understanding why deviations occur is fundamental to improving patient safety (62, 63). According to ‘the dynamic safety model’ (64), differing demands may pressure professionals to ‘flirt with the margin’, as increased expectations of performance results or limitations of resources push the operating point beyond the realm of safety, which increases the risk of adverse events. In the findings, the system design appears to create limitations that lead to the use of ‘workarounds’ in order to manage certain tasks in time and reconcile WAI and WAD (65). The process mapped in WAD works because individuals go beyond their responsibilities and do more than expected to manage the negative effects of variability. Reasons suggested for why WAD differs from WAI are the complex work requirements, the need to manage working relationships and the need to maintain efficiency (66). The findings thus show that the discharge process in WAI is not adapted to the current healthcare system design given existing staffing levels, structures and information systems.

Limitations

Care transitions for older people with complex care needs involve multiple stakeholders and a diversity of professionals and organisations, making the study of this system almost overwhelming. Thus, future studies should examine separate or integrated parts of the care transition process with multiple methods, to obtain both deeper and wider knowledge.

A key strength of this study was inclusion of multiple perspectives across a variety of healthcare settings to explore how different clinical teams successfully support care transitions. However, the heterogeneous sample may have limited our ability to achieve theoretical saturation. On the other hand, we were not looking for a representative sample, but one that encompassed the participants with the knowledge, skills and expertise to answer the research question (67). Multiple data collection methods were used as triangulation enables qualitative researchers to study relatively complex entities or phenomena in a holistic way (25). The study was performed over the course of more than a year. The number of participants is related to concerns about the richness and thickness of the data (67), thus, the large amount of material represents a strength in this study.

As described in this study, existing sequential approaches to studying care transitions are inadequate to capture the complexity of multi-disciplinary functions that are performed simultaneously. A study aiming to describe the interaction, work processes, adjustments and resilience in care transitions needs to take these intricacies into account, for example through the use of complexity perspectives (68). Therefore, the FRAM was used to visualise the intra- and inter-organisational complexity of the discharge process for patients with complex care needs. Constructing the FRAM model is a trade-off between showing all the related functions and achieving a usable and understandable model. All models of reality can be considered trade-offs. Due to the scale of the transitional care system, we had to model the functions at a high level of abstraction, which may have led to loss of meaning in some functional activities. Thus, variability may not have been modelled reliably. However, detailed the presented FRAM model is, it may be lacking some perspectives from the complete picture of the discharge process. To mitigate this, the model was checked for sense by professionals with experience of working with older people with complex care needs and the care transitions involved. This expert audit was performed to increase ecological validity.

Furthermore, the focus has been on the professionals and functions conceived to be relevant in the discharge process, based upon results from pilot interviews. Accordingly, limitations have been introduced by selecting and pursuing activities performed by certain roles. This study was performed in a single region of southern Sweden. Future studies should be performed in other settings to elucidate whether the phenomena may be transferred. As regards data collection in the hospital environment, the sampling was limited to medicine and geriatric wards, aiming to gather data that were general across the different geographical locations. Thus, orthopaedic and surgical wards were excluded from the study. The study aimed at mapping and describing intra- and inter-organisational processes with a focus on coordination and collaboration between different professionals and stakeholders. This study contributed to increased understanding of the system of hospital discharge and care transitions from the perspective of healthcare professionals. It did not include patients, family or informal caregivers. We want to emphasise the importance of including patients and families in future studies (14, 69). Lastly, the study offered a thick description of a process that normally remains covered and thus enabled potential development of new guidelines.

Implications for practice

This study provides a map of the most prominent gaps and vulnerabilities in the care transition process indicating where special attention to communication and coordination is needed. The findings show the importance of consensus in the care planning process and that all relevant information is collected, distributed and made available to the parties involved in the decision process and particularly in patient care at home. Reinforcing the ability to bridge gaps may improve safety (70). However, the possibility of bridging the gaps depends on both access to information and inclusion in the process. During the hospital stay, possible problems or issues waiting at home do not always surface, making the planning of care at home a hypothetical reality, left for municipal personnel to deal with after discharge. To achieve a safe and secure discharge and subsequent care at home, proactive work during the discharge planning process needs to be facilitated. This may be done by increasing precision in the assessment and planning of a patient’s care. Since this is a time-sensitive process, considerations need to be made as to at what time and on what day of the week the discharge will be performed, so the variable demands can be dealt with accordingly. It could be useful to have a clear definition of what a secure discharge for patients with complex care needs should be, and what parameters need to be fulfilled. If security is intentionally created, the discharge process can proceed and perform successfully. Furthermore, to ensure the ability to respond to unexpected events and variations by adapting care efforts at home, more resources should be allocated in the first few days after homecoming, as this would enable flexibility and increase patient safety. By promoting insight and knowledge of other HSCPs’ areas and creating the basis for a resilient organisation with HSCPs that anticipate and adapt by going outside their boundaries, we could increase the possibility of safely bridging the gaps in the system.

In this study, we mapped hospital discharge as a process, which revealed couplings and interdependencies outlining an exchange of information between various individuals, teams and organisations. This exchange of information was performed in a complex system characterised by little or no control. Limited access to patient information created barriers to safe and coordinated care. The most vulnerable point was when a patient arrived at home, since the multifaceted needs were difficult to predict and plan for. To increase patient safety, variability and the possibility of adaptations in the system should not be stifled – instead, the system needs to allow flexibility and promote the availability of the resources needed. Healthcare professionals need to anticipate and adapt to expect the unexpected when an older person arrives at home. This could be promoted by allowing for flexible resource allocation to deal with variability and enable adaptations. This study can be considered as part of the groundwork in understanding how coordinated care is designed and managed in care transitions. It can serve as input to future studies regarding the development of guidelines and training, as well as multidisciplinary simulations to strengthen intra- and inter-organisational collaboration and cooperation with the aim of reducing the gaps in care for people with complex care needs.

CAS

Complex adaptive system

FRAM

Functional Resonance Analysis Method

HSCP

Healthcare and social care professional

WAD

Work-as-done

WAI

Work-as-imagined

Ethics approval and consent to participate

The study was approved by the Swedish Ethical Review Authority (Registration number 2020-01219). Information contained in the study was processed in accordance with the EU General Data Protection Regulation (71). No sensitive personal information was collected. The study has adhered to the ethical guidelines of the Helsinki Declaration (72) concerning requirements on information, consent, confidentiality and use. All participants gave fully informed, written consent.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and analysed in the current study are not publicly available, to protect the privacy of the participants. Qualitative interview transcripts could be used to identify participants and cannot be shared publicly as per the Research Ethics Board’s guidelines.

Competing interests

No competing interests have been declared by the authors.

Funding

The overarching project that this study is a part of was funded by the Kamprad Foundation. The funding body had no input into design, conduct or reporting of the results.

Authors’ contributions

Design: ATH and ME. Data collection: ATH. Analysis: ATH, ME and GP. All authors have had a significant part in drafting and revising the article for important intellectual content.

Corresponding author

Ann-Therese Hedqvist.

Acknowledgements

We thank Emelie Ingvarsson, PhD student, for her assistance in data collection. We would also like to thank the participating healthcare and social care professionals, who made this study possible.

Authors’ information / Affiliations

Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
Ann-Therese Hedqvist and Mirjam Ekstedt

Ambulance Service, Region Kalmar, Västervik, Sweden
Ann-Therese Hedqvist

Centre of Interprofessional Collaboration within Emergency Care (CICE)

Department of Health and Caring Sciences, Linnaeus University, Sweden
Ann-Therese Hedqvist

Swedish National Road and Transport Research Institute, Linköping, Sweden
Gesa Praetorius

Training and Assessment Research Group (TARG), Borre, Norway
Gesa Praetorius

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Table 1. Data collection and participants

1a)

Data collection		n
Interviews		45
Participant observations		11
Meeting observations:		5
	Coordination meeting	2
	Care planning meeting	2
	Discharge conversation	1

1b)

				Occurrences in
Participants			n (60)	Interviews (45)	Participant observations (11)	Meeting observations (24)
Medical and geriatric hospital wards			(12)	(7)	(6)	(12)
	Registered nurse		5	2	4	3
	Care coordinator		4	4	2	4
	Physician		3	2		1
Ambulance care			(5)	(5)
		Ambulance nurse	5	5
Primary care			(8)	(3)	(2)	(2)
	Care coordinator		6	3	2	4
	Physician		2	2
Municipal care			(35)	(27)	(3)	(14)
	Occupational therapist		5	4		2
	Physiotherapist		6	4		3
	Registered nurse		8	7		2
	Aid officer		5	2		4
	Care coordinator		5	4	3	3
	Assistant nurse		4	4
	First-line manager		2	2

Table 2. Aspects of the function ‘Initiate planning of coordinated care’ in the FRAM model

Aspect	Description	Example
Input	That which starts the function. Link to previous/upstream functions. What a function uses to produce the output	Need of coordinated care
Outputs	The result of a function. Constitutes links to subsequent/downstream functions	Initiated coordination
Precondition	Conditions that should be satisfied for a function to be executed	Consent from patient
Resource	What is needed or consumed to execute a function	Care contact
Control	What regulates or monitors a function	Policies for coordinated care
Time	Temporal constraints and requirements affecting the function	Within 24 hours

Table 3. Examples of potential for variability

Function	Output	Potential for variability		Expressions of variability
Function	Output	Timing	Precision	Expressions of variability
Initiate planning of coordinated care	Initiated care coordination process	Too early		Input possibly missed, risk of lacking information for correct decision
		On time		No effect or possible damping of further variability
		Too late / Omission		Delayed or non-initiation of coordination may mean delaying the case or other healthcare providers being given a very short time to communicate and plan.
			Precise	Possible damping of further variability
			Acceptable	No effect
			Imprecise	Misjudging the need for coordinated care (the patient is excluded from the subsequent process and discharged without intervention)
Co-create plan of coordinated care	Agreed upon plan for care at home	Too early		A care plan created too early in the patient’s hospital care risk becoming imprecise due to the dynamic conditions of recovery. Depending on the status of the patient, the care plan may need to be re-created.
		On time		Possible damping of further variability
		Too late / omission		Delayed or non-initiation of coordinated care plan may mean delaying the case or other healthcare providers being given a very short time to communicate and plan.
			Precise	Possible damping of variability as a precise care plan will aid in situations that may arise downstream
			Acceptable	No effect or increased variability due to ambiguity
			Imprecise	Incorrect depiction of current care efforts and aid tools at home may misrepresent the support available to the patient when discharged.
Prepare care transition to home	Patient ready to go home	Too early		Increased variability as the patient may not be ready for discharge or the preparations made will not be relevant, the function may need to be repeated

		On time		Possible damping of further variability
		Too late / omission		Ad hoc solutions are used to prepare the patient with limited time
			Precise	Possible damping of variability
			Acceptable	Increases variability downstream to compensate for flaws in preparation
			Imprecise	In lack of accurate preparation, the correct medications, adapted aid tools or care efforts will not be available when the patient comes home. The municipal staff will then need to devote considerable time to try to solve this, taking time from other patients and assignments.
Execute care transition	Patient goes home	Too early		The discharge of a patient frees up a hospital bed, making it available to a new patient. However, when a patient is discharged prematurely, the patient may not actually be ready for discharge increasing the workload for the home care personnel with the risk of readmissions if the situation becomes untenable in the home.
		On time		Possible damping of variability
		Too late		A discharge late in the afternoon presses the home care personnel to receive the patient with less personnel on duty and limited availability to contact managers in need of added resources.
		Omission		May contribute to resource issues in the hospital ward if the patient could have been discharged successfully but is now occupying a hospital bed
			Precise	Possible damping of variability
			Acceptable	No effect
			Imprecise	Increased variability in downstream functions to compensate for missed aspects
Execute coordinated care at home	Execution of efforts in home according to plan	Too early		-
		On time		Dampening of variability
		Too late		Delayed activity affecting the care of the patient, ad hoc solutions
		Omission		Ad hoc solutions or potential omitted care of the patient
			Precise	Possible dampening of variability
			Acceptable	No effect
			Imprecise	If the preparation of care efforts does not correspond to the actual needs, it may mean a lack of care and social support for the patient and "firefighting" by the various actors to solve this.
Monitor and evaluate care efforts at home	Assessment of efforts in home according to plan	Too early		If the follow-up occurs too early, the patient has not had time to settle at home or to know what works and what does not.
		On time		Dampening of variability, promoting a safe and secure care adapted to the patient’s care needs
		Too late / Omission		If it takes too long or the evaluation is omitted, there may emerge urgent needs or problems due to the care measures not being adapted to the current care needs and resources.
			Precise	Dampening of variability
			Acceptable	No effect
			Imprecise	Increased variability
Handle needs with available resources	Adequate care efforts in home	Too early		Increased variability, possibility of missing actual care needs
		On time		Dampening of variability, promoting a safe and secure care adapted to the patient’s care needs
		Too late		Increased variability
		Omission		Increased variability
			Precise	Dampening of variability
			Acceptable	No effect
			Imprecise	Timing of and variability in upstream functions determines the availability of resources for the patient. Depending on the day of the week and the time of day, the resulting needs can be handled either at short notice, with a large amount of effort or not at all. May result in a readmission in hospital when all options are exhausted at home.

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Exploring interdependencies, vulnerabilities, gaps and bridges in care transitions of patients with complex care needs using the Functional Resonance Analysis Method

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Abstract

Background:

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Background

Methods

Design and study setting

The Functional Resonance Analysis Method (FRAM)

Sampling and participants

Data collection and procedures

Document review

Observations

Interviews

Data analysis

Results

The discharge process as described in regulations and policy documents

Vital functions required for everyday work to succeed

Potential variability in the system

Functional dependencies and potential for functional resonance

Timing

(Participant 25, registered nurse, municipal home care)

(Participant 4, occupational therapist, municipal rehabilitation services)

(Participant 37, assistant nurse, municipal social care)

(Participant 22, physician in primary care)

Precision

(Participant 14, registered nurse, municipal home care)

(Participant 118, coordinator, municipal home care)

(Participant 13, registered nurse, municipal home care)

(Participant 40, ambulance nurse)

(Participant 4, occupational therapist, municipal rehabilitation services)

(Participant 1, registered nurse, municipal home care)

Discussion

Conclusions

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors’ contributions

Corresponding author

Acknowledgements

Authors’ information / Affiliations

References

Tables

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