Here’s a link to one of many stories about the “scandal” at UK hospitals in the Midlands:

http://www.guardian.co.uk/society/2013/feb/06/mid-staffordshire-report-sweeing-changes

The story says that “…up to 1,200 patients are believed to have died between January 2005 and March 2009 as a result of poor care at Stafford hospital.”

Here’s a link to the Executive Summary of the report referred to in the article:

http://www.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf

Here’s a page where you can download the entire report:

http://www.midstaffspublicinquiry.com/report

The reports are extensive and I haven’t yet been able to wade through them (many volumes and 290 recommendations).

Here’s a press conference by the Chair of the Inquiry, Robert Francis QC:

The problems reported certainly do seem shocking. The problems are obviously systemic (generic) and seem to be related to the organization. The call for culture change seems obvious, but how to change the culture will be difficult. The problem for patients is the lack of choice (there is only one NHS) so that patients can’t “vote with their feet” when the standards of care become substandard.

The popular press and political outcry is calling for increased regulation and criminal prosecution of those who violate the rules. This seems close to the standard blame game and may succeed temporarily until the increased scrutiny eventually succumbs to complacency. This seems common in organizations with a monopoly on a certain service or product.

It seems to me that competition from hospitals trying to win additional patients would be the ultimate culture change recommendation. However, it is unlikely that this approach could be taken since the UK has had a single national service for so long.

Being in the UK when the story was receiving so much press, I was constantly being asked about how one would find the root causes of patient safety relayed problems. Of course, I described how healthcare organizations in the US use TapRooT® to investigate sentinel events. In the US, patient safety is becoming a competitive advantage – a way that hospitals may compete for patients.

What does your hospital do to ensure the highest standards of patient safety? Does your root cause analysis find and fix the root causes of patient safety problems? Does your management require advanced root cause analysis and insist on the implementation of effective corrective actions to sentinel events? Can you show the improvement in patient safety through the use of advanced trending tools?

Those interested in improving patient safety should consider attending the Improving Healthcare Quality and Patient Safety Track at the 2013 Global TapRooT® Summit in Gatlinburg, TN, on March 20-22. For more Summit information see:

http://www.taproot.com//summit

And for the track’s detailed schedule, see:

http://www.taproot.com/products-services/summit/summit-schedule

and click on the button on the left for the track specific schedule.

For those in the UK, changes as great as those described will be difficult and take tremendous effort. I wish you luck but advise you that thorough advanced root cause analysis and effort will be required on a continuing basis if progress is to be made.