Turn Stafford anger into action, says Obama adviser
The man leading a review of patient safety in the NHS has said he wants to turn the anger over the Stafford hospital scandal into action.
Don Berwick, a former health adviser to President Obama, has been commissioned by the government to introduce a "zero-harm culture" into English hospitals.
He will report back on his initial findings by July.
Many of the Stafford families are still calling for the resignation of the chief executive of the NHS.
Speaking exclusively to the BBC for the first time since his appointment, Prof Berwick said he fully understood the anger of those who had lost relatives at Stafford hospital between 2005 and 2008, having read their accounts.
"To think so much injury was done that really should not have been done. It's very sad and that's what I feel."
But he refused to be drawn on the call from their campaign group Cure the NHS for David Nicholson the chief executive of the NHS to resign, simply commenting that leadership would be a key element in any culture change.
"My heart bleeds for these patients and families - I would say to them I know you're angry, I'm angry too - and yes proper inquiries and accountability of course we need to provide that.
"But we need to remember the best testimonial to the suffering of you and your family would be a healed and better NHS in the future. "
The Institute for Healthcare Improvement in Boston, which he founded, conducted an earlier internal review for the NHS.
Released under a freedom of information request in 2010, it found a "shame and blame" culture in the NHS in England, which got in the way of improving quality of care.
Asked by the BBC about the scepticism another initiative might face, Prof Berwick said if he had the chance to speak to a nurse he would say: "I know you want to do well. I know that top of your mind is doing the right thing for your patient every single moment.
"The hassles that get in your way, the pressures of nonsense, the waste in your work, the hurdles that you're made to climb over, the machines that don't work, the space that's poorly designed, the uncleanliness that surrounds you. These are all in your way. Let's get them out of it."
The idea of trying to create a zero-harm culture has come out of a global recognition that some patients needlessly suffer or die in hospital because of errors.
It uses experience from industries such as aviation where attempts are made to design systems which reduce the chance of mistakes.
The NHS in England has already drawn extensively on such thinking to reduce errors in operating theatres and levels of hospital-acquired infections such as MRSA.
At its most basic, it can mean the use of checklists before surgery.
Scotland has based its patient safety programme on collaboration with the Boston-based Institute for Health Improvement (IHI) co-founded by Don Berwick.
Professor Jason Leitch, clinical director of the quality unit in Scotland, said this had contributed to a fall of 12.4% in hospital death rates since 2008. Prof Leitch will be on the expert panel working with Don Berwick to advise the NHS in England.
He said having a high degree of local flexibility had allowed staff in many cases to decide how to improve safety in their own hospitals.
For patients, the most visible part of the programme is the information on issues such as the number of falls or infections displayed on all Scottish hospital wards.
The Scottish approach has attracted attention from other countries such as Denmark, which has set up a similar patient safety programme.