Paediatric Homecare Risk Management: An Application of Functional Resonance Analysis Method (FRAM)

Round 1

Reviewer 1 Report

Dear Editor,

Thank you for giving me an opportunity to review this manuscript. The authors describe an  Paediatric Homecare Risk Management: An Application of Functional Resonance Analysis Method (FRAM). The manuscript is well written and organized, however, there are some relevant points to be mentioned, which can contribute to the improvement of these studies. Such considerations are kindly presented thereupon.

Comments: Introduction

“The original version of the FRAM does not allow capturing temporal variations both in functional outputs and in the outcomes of the entire system. Did you encounter this issue, what remedy did you use to solve this problem?

Comments: Methods

The method section is written very briefly. It is suggested to explain more about the steps of implementing the FRAM method so that the reader does not have any ambiguity in this regard. See the article below for more information.

·         Alboghobeish, GA Shirali. Integration of functional resonance analysis with multicriteria analysis for sociotechnical systems risk management. Risk Analysis. 2022; 42(4): 882-5.

Comments: Results

What technique was used for the interview and what was their content. If possible, provide some examples.

It is unclear to reader how the difference between the work as it was done and the work as it was imagined was determined. Explain about this issue.

Additional comment:

Study Limitations were not addressed in the manuscript.

The English language of the manuscript should be revised. For example, in line 132 of page 4 (…neither reporting or…), in column 5, row 18 of table 1 (To late), correction is needed.

Author Response

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Author Response File: Author Response.docx

Reviewer 2 Report

This is a very interesting and novel study that has the potential to make a significant contribution to the literature.  The study examines a largely overlooked aspect of falls and the use of qualitative interview is  a strength and allows the researchers to obtain a real “work as done” view of incident reporting and risk assessment as it pertains to falls. 

 

Overall the manuscript is well written and organized, but there are a few substantive and some minor editorial and organizational issues that should be addressed prior to publication.  Specifically:

·         The manuscript could benefit from a critical review to ensure consistency with tenses.  At times the authors use present tense and other times it is past tense. 

·         In the “introduction’ section the authors begin with a description of the FRAM. The authors should consider begin this section with the background in Ireland with children receiving homecare and the importance of safety and risk management. The FRAM can then be presented as a unique approach to study the issue.  This reorganisation will also place the description of the FRAM closer to the methods.

·         While the use of interviews to solicit data from nurses working in homecare is ideal, it is questionable if Ground Theory (which is to generate theories) is consistent with the FRAM which is to create a visual deficit of the process/issue of interest.  If is possible that the data was used to generated a theory and then the theory was used to identify functions, but this is not clear.  It is also possible that the authors used content analysis or thematic analysis to identify the functions from the interviews.  If it is the former (use of Grounded Theory), additional information on how the emergent theory informed the development of the FRAM model is warranted.

·         In the results section (lines 103-106) it is stated that  the study is divided into 2 parts.   Yet it appears from the description of the methodology (lines 93-102) that there is only one part and the data is presented under the categories of incident reporting and assessment processes used.  If in fat there is 2 parts to the study, clarification of if/how data collection, sample, and  analysis differed in each part if warranted. 

·         If available, some description of the sample would be helpful.  Are these registered nurses?  Age? Years of experience in homecare etc

·         It is no entirely clear what is meant by induced [lines111 &  ].  Does this mean training?

·         Line 114 appears to suggest there was a code book developed to help categorize the data in NVivo.  If so, can the authors provide details on how this was developed and by whom?

·         A table or sentence about the types of questions asked during the interviews may be helpful to the reader. 

·         Figure 1 and Table 1 are excellent and are bot a strength of the manuscript.  However it isn’t clear what is meant by variability/precision and how the categories of acceptable and  imprecise were determined. If these were determined by “the management” then was it by concise?  Similar concern with Table 2. 

Author Response

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Author Response File: Author Response.docx

Reviewer 3 Report

The manuscript presents a case study of Paediatric Home Care and applies the FRAM for risk assessment. While both the application case and the methodological application have great potential, the paper must be improved significantly to present a contribution to the current body of research and a take away for the reader.

Introduction:

- the introduction should start by presenting the domain of application (paedeatric home care), the current state of knowledge in the domain and the current research gap/problem that is to be solved within the manuscript. It might help to outline concrete and concise research questions to be answered in your paper as it might create a better focus for discussion later on

- you also need to make a case for why paediatric home care is a potential domain in which the application of FRAM actual make sense . you mention among other that is it a complex system, but there is no description of home care as complex sociotechnical system to be found. 

- the description of the FRAM and earlier FRAM applications should either be presented in a seperate bakground section or maybe at least partially be integrated in the methodology seciton. I would also suggest to widen the cited literature - there are earlier applications of FRAM for risk assessment and for an overview you might wnat to have a look at the literature review on FRAM of Patriarca et al (2020) published in safety science.

Methodology:

This section lacks necessary information. The aim of the section is to enable others to understand what you have done so more information on both the actual procedure, participants and analysis is needed. It should also be possible to judge the soundness of your study and understand your methodological choices. Below some questions that can hopefully help to write a proper methodology section. Some of these may also be answered through a thorough methodological discussion in the discussion section. 

It is also striking that the method you use for the risk assessment, the FRAM, is not at all described. 

·        Participants: who participated (years of experience, age, gender, current position/assignment)

·        Sampling: what sampling method did you apply to recruit participants?

·        Procedure:

o   How many items did the interview guide contain? How were they grouped according to the themes that you present? How did they correspond to the overall aim of the study?

o   How long did the interviews take? Were these conducted in person or online? Were the interviews recorded and if so how?

o   How did you conduct the analysis  and how did you derive at the functions based on the thematic analysis? Did you use your participants to confirm the functional model?

o   It is also somewhat strange that you did not apply any type of task analysis technique – while functions can be identified normally a task analysis, such as a goal-means analysis is conducted to identify potential couplings in between the functions

o   How did you build the model based on the identified functions? Which are foreground and which are background functions? How did you determine different types of variability in the functions?

o   Did you create instantiations or just the model? If so, what are the risks in doing so  

o   How did you ensure soundness in your work? E.g. trustworthiness, confirmability etc. 

Results:

The results section shows some deficiencies/misconceptions of the FRAM approach. Events and Safety can never be a function in itself as functions are activities and things that are carried out, either by human, organizations or technology. Safety is what arises, or emergeces, when functions are carried out under specific conditions. Thus you need to focus on what is actual done to guarantee safety and make that into functions, not safety in itself. 

It is important to remember that functions are activities that are carried out and that present a change in state, ie if the function is "to report" the output is report is written. This is important to consider in your model as netiher, event, safety nor decision can be a function. It therefore seems as if you are mixing acitivities and outputs throughout your results.

It is also important to consider that the functions in a model only activate couplings, thus vairability that has the potential to spread, if the functions are instantiated, ie set into a specific context. Otherwise the model produced in the FRAM software (which should be mentioned in the method section when you describe how you have built a model and identified different functions) only shows all possible connections not just those activated in a specific case. 

It is therefore recommended that the result section is reworked carefully by the authors. It might help if you actually present the results with the help of the four steps in FRAM so it becomes salient what is derived by the model (or the systme design itself) and what is described in instantiations by your respondents.

Discussion:

The discussion is very short and superficial - it remains unclear if the authors did some comparison betwee nwork as done and work as imagined and what they actually gained by using the FRAM in comparison to other methods. A discussion in relation to earlier research and why this contributes to adnvaces  in knowledge in either risk assessment methodologies or in the domain of paedriatic home care would be interesting and provide a better take away for the audience. It would also be good to read a reflection/discussion on the methodological approach chosen, what limitations the research design has and how this has been compensated.

Conclusion:

needs to be rewritten once the results and methodology have been revised. 

 

In its current form the manuscript leave more questions than it provides answers and it is not clear why the authors chose to apply FRAM and what the actual benefits of the application have been. I would really encourage a thorough re-write before a resubmission. 

Author Response

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Author Response File: Author Response.docx

Reviewer 4 Report

Congratulation  on the idea and the work done, the implementation of the method on the medical ground can significantly affect the quality of care, especially in a situation of constant shortage of nurses. It can also contribute to a better use of staff and resources.

  Suggests minor editorial changes to the abstract, and adding part such as:  introduction, purpose, methods, results and conclusions. This will make it easier not only to read, but above all to make it easier for a potential person to choose an item as interesting.

1. Main question of study: Risk assessment to home care focusing in on to aspects of risk: incident and risk assessment management.

  2. Topic: The work proposes an original approach to the subject. It was an application of a qualitative research method used in another field for medical purposes. 

3. Comparison with other publications material: There was not many similar publications, and especially in pediatrics.

4. Specific improvements regard methodology: I am not a risk management specialist. The proposed method may not be 100% original, but worth publishing. As I said before, summary should be improved. 

5. Conclusions consistent: Yes 

6. References relevant: Yes  

7. Tables and figures: They were correct, although they differ slightly from those customarily adopted in medical publications, such an approach is encountered in management publications.  Figures in particular require a description of the content not only in the text as it is now, but this does not reduce the value of the work.

 

 

 

Author Response

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Author Response File: Author Response.docx

Reviewer 5 Report

I have carefully read the article which has already had improved reviews. I believe the topic is of interest to international readers and deserves publication. However, I believe that some improvements are possible:

- I believe that the bibliography should be expanded with other articles of an international nature

- I believe that in the incident report system it should be mentioned that there are also other sources of information, for example learning from mistakes, liability cases or better medico-legal claims can be useful in this complex task, the authors could briefly mention this aspect and for example: doi: 10.1186/s12913-018-3846-7.

Author Response

Good Afternoon

Thank you for your positive review. We have taken your recommendations on and added in a section explaining more about incident reporting. Word count limitations means this could not be as extensive as I would have liked but we believe it does make the article read more easily. Referencing increased with more international scope.

 

Thank you

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

The authors have responded appropriately to previous feedback.  This is a novel study that will make an important contribution to the literature.  

Author Response

Good Afternoon

Thank you for your positive review, we have made some changes based on other reviews.

 

Thanks

Reviewer 5 Report

the authors have improved the text according to the suggestions. I think it is now publishable