“SWARMing” to Improve Patient Care: A Novel Approach to Root Cause Analysis

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Article-at-a-Glance

Background

When errors occur with adverse events or near misses, root cause analysis (RCA) is the standard approach to investigate the “how” and “why” of system vulnerabilities. However, even for facilities experienced in conducting RCAs, the process can be fraught with inconsistencies; provoke discomfort for participants; and fail to lead to meaningful, focused discussions of system issues that may have contributed to events. In 2009 University of Kentucky HealthCare Lexington developed a novel rapid approach to RCAs—colloquially called “SWARMing”—to establish a consistent approach to investigate adverse or other undesirable events.

Methods

In SWARMs, which are conducted without unnecessary delay after an event, an interdisciplinary team undertakes thoughtful analysis of events reported by frontline staff. The SWARM process consist of five key steps: (1) introductory explanation of the process; (2) introduction of everyone in the room; (3) review of the facts that prompted the SWARM; (4) discussion of what happened, with investigation of the underlying systems factors; and (5) conclusion, with proposed focus areas for action and assignment of task leaders with specific deliverables and completion dates.

Results

Since its implementation, incident reporting increased by 52%—from an average of 608 incidents per month (June–December 2011) to an average of 923 per month (January–May 2014). The overall health system experienced a 37% decrease in the observed-to-expected mortality ratio—from 1.17 (October 2010) to 0.74 (April 2015).

Conclusion

SWARMs, more than an error-analysis exercise or simple RCA, represent an organizational-messaging, culture-changing, and capacity-building effort to address the challenges of creating and implementing processes that serve to promote transparency and a culture of safety.

Section snippets

Setting

Established in 1957, UK HealthCare® is the brand name for the University of Kentucky’s health care system. UKHC consists of four Lexington-area hospitals—UK Albert B. Chandler Hospital, Kentucky Children’s Hospital, Eastern State Hospital, and UK Good Samaritan Hospital—and clinics, in addition to 50 specialized clinics, 160 outreach programs, and 9,000 physicians, nurses, pharmacists, and health care workers.

Developing the SWARM Process

Before adopting the SWARM process in April 2009, RCAs were conducted by one person who

Incident Reporting and SWARMs

Since the SWARM process was implemented, incident reporting increased by 52%—from an average of 608 incidents per month (June–December 2011) to an average of 923 per month (January–May 2014), as shown in Figure 2 (page 498), in the 825-bed hospital system.

To date, UKHC has conducted more than 1,200 SWARMs, which have focused on a multitude of reported events, ranging in severity from patient falls without injuries to unanticipated death. Approximately 75% of SWARMs occurred within 16 days of

Discussion

Health services researchers and leaders from a wide variety of industries emphasize the importance of a healthy culture of safety.24., 25., 26. Originating as a reliable process in industry, the SWARM approach has also been adapted for use in health care by Williams et al.27 However, while Williams et al. focused at the hospital unit level and did not seek a broader dissemination from the start, we believe that SWARMs represent an ideal approach to RCAs both at the local-unit and system levels.

Conclusion

The systemwide acceptance of SWARMs at UKHC exemplifies how their impact extends beyond negatively perceived isolated RCAs of the past, contributing to efforts to become a learning health system instead of implementing well-intended top-down interventions, which may well result in little individual benefit and no improvement in system performance. SWARMs, we believe, provide consistent evidence of the hospital’s commitment to transparency and to a nonpunitive, systems-based approach to quality

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