When doctors and nurses can disclose and discuss errors, hospital mortality rates decline

Bocconi, Italy (May 7, 2019) - An association between hospitals' openness and mortality rates has been demonstrated for the first time in a study among 137 acute trusts in England, published yesterday in the May issue of Health Affairs. The diffusion of a culture of openness in hospitals is associated with lower hospital mortality, according to a study conducted among 137 acute trusts in England by Veronica Toffolutti (Bocconi University and London School of Hygiene & Tropical Medicine) and David Stuckler (Bocconi University) published in Health Affairs.


Hospital openness, defined as «an environment in which staff freely speak up if they see something that may negatively affect a patient and feel free to question those with more authority», has already been linked with many positive outputs, such as better patient safety or better understanding of patients' care goals, but this is the first time that an association with mortality rates has been demonstrated.

The authors linked data on hospital mortality rates with hospital openness scores for 137 acute trusts in England in the period 2012-14. They used the Summary Hospital-level Mortality Indicator (SHMI) as a measure of mortality and designed a standardized openness indicator that draws on staff surveys from the Picker Institute Europe's National Staff Survey. (An acute trust is an organization within the English NHS that includes one or more hospitals providing secondary health care services).

Two positive findings were highlighted in the study. First, fostering openness translates into lower mortality rates: a one-point increase in the standardized openness score is associated with a 6.48 percent decrease in hospital mortality rates. Second, as far England is concerned, openness is increasing: the score was 13.63 in 2012 and 16.49 in 2014.

Part of the effect is due to the higher responsiveness of open organizations: the correlation between the standardized openness indicator and the percentage of staff reporting that the trust took action after an error is very high (0.84).

«The single component of our indicator that most affects mortality rates is good hospital procedures for reporting errors, near misses, and incidents», Dr. Toffolutti says. «Moreover, as defensive medical practices could stymie openness», she continues, «preventing the blame game that holds practitioners responsible for errors, in favor of institutional responsibility, could help the shift to a greater culture of openness».

The results show that greater openness in the English NHS corresponds to improved health care quality and suggests that the reforms undertaken since 2016 - in part as a consequence of the results of the 2013 Francis Inquiry - are a step in the right direction.

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  • Veronica Toffolutti, David Stuckler, A Culture of Openness Is Associated With Lower Mortality Rates Among 137 English National Health Service Acute Trusts, in Health Affairs 38, NO. 5 (2019), DOI: 10.1377/hlthaff.2018.05303.





Bocconi University, 07.05.2019 (tB).