2018 HPRCT Conference

SWARMs allow the organization a standard process for reviewing the system when it does not perform as expected. This allows for critical information to be retained and thus immediate actions to occur while working on continuous process improvement in standard work fashion and while building and supporting a culture of safety.


Summary:
WHAT: SWARMing for Patient Safety allows the organization to review and obtain the details of an “incident”.  This being an occurrence that is not consistent with the routine operation of the hospital and outpatient areas or with the standard quality of care rendered to a particular patient.
WHY: SWARMing in real time allows the ability to get the facts and details without losing critical information.  It helps maintain a culture of safety and transparency.  This allows the organization to have a systems based approach that is standard among all associates. This allows for us to have an ability to get the appropriate immediate fix after learning the problem and identify the “5 whys” in order to plan longer term action plans.
WHO: The frontline staff is fully invested as this is a safe and respectful venue without blame.  This is appreciated from the teams and it is recognized as a venue for each team member to be heard and express their concerns.
HOW: It is a 5 step process: 1) Introduction and Review of the process, 2) Timeline of events to review the facts and identify the care delivery problems, 3) Address countermeasures and action items, 4) Assign a responsibility “R” owner for each item, including date of completion 5) Assign overall “R”.  The swarm form is completed and sent to all staff involved including risk, leadership, accreditation and safety.  Follow up is done within a week to address gaps in the action items and potential need for follow up.  The goal is to identify the correct diagnosis of the problem in order to complete action items that will actually impact the system.  All significant, sentinel or events deemed by safety to be high risk to the organization have a 60 day follow up and closure with tracking of actions.
Overall all healthcare organizations need to perform Root Causes analysis in compliance with The Joint Commission.  The method of SWARMing has been accepted by them in replacement of traditional RCAs.
Since instituting SWARMS at our organization our rates of incident reports have increased and stabilized and our sentinel and significant events have decreased annually for three years.