Using swarm intelligence to boost the root cause analysis process and enhance patient safety.

In an effort to strengthen patient safety, leadership at the University of Kentucky HealthCare (UKHC) decided to replace its traditional approach to root cause analysis (RCA) with a process based on swarm intelligence, a concept borrowed from other industries. Under this process, when a problem or error is identified, staff quickly hold a swarm--a meeting in which all those involved in the incident or problem quickly evaluate why the issue occurred and identify potential solutions for implementation. A pillar of the swarm concept is a mandate that there be no punishments or finger-pointing during the swarms. The idea is to encourage staff to be forthcoming to achieve effective solutions. Typically, swarms last for one hour and result in action plans designed to correct problems or deficiencies within a specific period of time. The ED was one of the first areas where UKHC applied swarms. For example, hospital administrators note that the approach has been used to address issues involving patient flow, triage protocols, assessments, overcrowding, and boarding. After seven years, incident reporting at UKHC has increased by 52%, and the health system has experienced a 37% decrease in the observed-to-expected mortality ratio.