The top-ranking health official from the United Kingdom, where a hospital’s neglect and abuse of patients resulted in as many as 1,200 patient deaths over four years, has chosen Virginia Mason Medical Center as a model in his quest to change the National Health Service’s (NHS) hospital culture.
Britain’s Secretary of State for Health, Jeremy Hunt, in a speech at Virginia Mason on Wednesday morning, talked of how his nation has been rocked by “appalling cruelty and neglect” in the Mid Staffordshire hospital system and “failings in care” later uncovered in other hospitals.
His plan includes a “Duty of Candour,” which will require hospitals to notify patients when severe or moderate harm occurs and to apologize.
“This will help to make English NHS hospitals amongst the most open and transparent in the world and mark the start of a transformation in our safety culture,” Hunt said.
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He said he has been inspired by Virginia Mason, which faced “deep tragedy” with a 2004 operating-room error that took the life of a patient, 69-year-old Mary McClinton, but used the event and its broad impact on all concerned to create a new culture of transparency and patient safety.
“Just as Mrs. McClinton’s death was a turning point for this one hospital, I want to make Mid Staffs a turning point for an entire health economy,” he said.
McClinton, a mother of four and an advocate for the disadvantaged, died after she was injected with antiseptic fluid instead of a harmless dye.
In the wake of that mistake, the hospital’s top officials pledged to openly and honestly admit errors and to begin creating a culture where workers seeing something amiss are not afraid to speak out — “to stop the line,” in the production-system parlance Virginia Mason has embraced.
As part of that shift, Virginia Mason said that instead of blaming individual workers, it would focus attention on learning where its systems, which should prevent the inevitable human errors, went wrong, and on continually improving them.
In Britain, an independent inquiry into events in the Mid Staffordshire system from 2005 to 2009 found that the safety of sick and dying patients was routinely neglected and that some patients were subjected to inhumane treatment, bullying and abuse.
In some of the worst examples reported, elderly patients were left lying in their own excrement and were forced to drink water from vases. Reports of filthy conditions surfaced, and conditions at the hospital fueled dueling accusations by warring political factions and calls for privatization.
Later reports implicated other hospitals, saying that 10 percent failed to meet even basic standards.
Prime Minister David Cameron turned to U.S. patient-safety expert, Dr. Donald Berwick, former head of the Centers for Medicare & Medicaid Services and co-founder of the Institute for Healthcare Improvement in Boston.
In a report released last year, Berwick counseled the government to abandon blame and instead listen to patients and their caregivers, create a “culture of learning” and transparency, and put quality and safety of patient care above all other aims for the NHS.
Hunt chose to use the Seattle speech to announce details of a three-year plan for the NHS that he said would improve both patient safety and the bottom line.
The NHS, which includes 260 hospitals and 1.3 million staff members, would become, according to Hunt, “the safest health-care system anywhere in the world.”
To do that, his plan includes both carrots and sticks.
Hospitals will be asked to participate in a “Sign up to Safety” program, setting out publicly their plans to reduce avoidable harm, such as medication errors, bedsores and falls. And the country’s national body that indemnifies NHS hospitals against lawsuits, he said, would allow hospitals that successfully put such plans into practice to reduce their insurance premiums.
Safer care saves money, noted Hunt.
Although bad accidents have transformed other industries, Hunt said, the health-care sector has been strangely resistant to change.
Hunt also spoke Wednesday of how avoidable safety failures in health care are too often accepted as unavoidable,
“even though they would be intolerable in other contexts.”
A first step, he said, will be for Britain to collect safety data more reliably. By June, the public will be able to compare hospitals on a range of safety indicators — by ward level — in a “How Safe is my Hospital” tool posted on the NHS Choices website.
Carol M. Ostrom: firstname.lastname@example.org or 206-464-2249. On Twitter @costrom