May 10, 2019By Lance Baily

New Research Shows When Doctors and Nurses Can Disclose and Discuss Errors, Hospital Mortality Rates Decline

For the first time, a correlation between hospital openness and patient mortality rates has been demonstrated in a research article conducted among 137 acute trusts in NHS England, published earlier this month in the May issue of Health Affairs (linked below). Fabio Todesco of the Bocconi Knowledge recently wrote about the findings sharing “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.” This is crucial research to further support the utilization of teams-based communication, “black box” recording of patient engagements, and medical simulation training.


The English National Health Service (NHS) started to implement reforms in 2016 to create a culture of openness, transparency, and accountability across the entire hospital system. However, there is a debate among policy makers and researchers about whether and to what extent openness is related to significant improvements in health system performance or lower mortality rates.

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Drawing on data from 137 English acute trusts (or hospital systems) for the period 2012–14, we used multivariate regression models to test whether mortality rates, taken from the Summary Hospital-level Mortality Indicator, were lower in hospitals that had higher levels of openness among staff members, a measure derived from the NHS National Staff Survey. When we adjusted for hospital operating capacity, our results showed that a one-point increase in the standardized openness score was associated with a 6.48 percent reduction in hospital mortality rates.

These findings have important policy implications: They offer empirical evidence to support further efforts to increase openness in the English hospital system, since doing so has improved health care quality.

From Fabio of Bocconi Knowledge

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.

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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. Read the Full Bocconi Knowledge article here.

Consider our article on why “With Errors: Aviation Blames The System, Healthcare Blames the Individual” to learn more on why Healthcare needs to follow Aviation’s history when it comes to reporting errors.

Click to Purchase the Full Research Article from Health Affairs

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