Clinical governance

Our quality and safety programme

The safety of our patients, clients and staff is of paramount importance to Nuffield Health and our governance systems are guided by one key principle – that quality matters.

Nuffield Health has a track record spanning half a century. We have built a reputation for high standards of care, professionalism and expertise in delivering health services and we aim for continuous quality improvement in everything we do. When we commit to quality, our customers know we mean it.

There is an active safety and quality programme in place across all services provided by Nuffield Health and this is audited, and the outcomes monitored, at every level of the organisation. When things do not go to plan, we put them right and learn the lessons to improve future services.

The Nuffield Health Board publishes an industry-leading integrated governance report that includes the outcomes of the various elements of the safety and quality programme.

Quality and safety indicators

We have developed 81 quality performance indicators for internal use in our hospitals to check everything we do against best practice. These indicators are used voluntarily because everyone we work with recognises that quality counts and they want to continuously improve our services. Some of the indicators are driven by feedback from our customers, some represent internal or regulatory standards.

We publish the outcomes of 10 of these quality indicators on our website – as The Top 10 – these are based on what people tell us really matters to them.

Why is this information important to me?

Information about healthcare is important to ensure you get the best advice and treatment. Health is a partnership, and this can only be achieved if we share information about our services. This section is a guide that provides further information on issues that we know are important to our customers.

The indicator results for each hospital are published on each hospital’s homepage. The table below outlines the results for the overall Nuffield Health Hospital group.

Internal organisation

The board’s integrated governance committee meets at least four times a year. It is responsible for monitoring the effective operation of clinical governance throughout the group and also considers clinical and health-and-safety matters. The group medical director and senior members of staff with clinical responsibilities are in attendance at the committee’s meetings.

All our hospitals and health screening facilities in England are registered with the Care Quality Commission under the Care Standards Act 2000, amended by the Health & Social Care Act 2003 and comply with the Private & Voluntary Health Care (England) Regulations 2001.

Our hospital in Glasgow is registered with the Scottish Commission for the Regulation of Care.

Our hospitals and facilities are subject to periodic inspection by the commissions including un-announced visits and the outcomes of these inspections are published on the commissions’ websites.

How Nuffield Health works Nuffield

Health is a registered charity (number 205533) and a company limited by guarantee without share capital. We must behave like a charity, and adhere to charitable purposes, but can trade like a normal company. Our charitable status is a guarantee that any operating surpluses are reinvested for the improvement of services rather than being removed from the company as dividends, and that the assets of the trust may only ever be used for charitable purposes consistent with the wishes of the founders. Nuffield Health has a special dispensation from Companies House allowing us to avoid appending the "Ltd" generally used.

The board

Nuffield Health's strategy is determined by the board of governors, who are both directors of the company and the trustees of the charity. The governors delegate day-to-day executive authority to the group chief executive, and Nuffield Health also has unpaid non-executive members, comprised of individuals who played a significant role in the development of Nuffield Health or in healthcare generally and who hold the board to account at each annual general meeting.

Board sub-committees Executive remuneration committee The executive remuneration committee is responsible for ensuring that the group chief executive and the senior executives are, with the benefit of appropriate professional advice, properly rewarded for their individual and collective contributions to the group’s overall performance.

Nominations committee

The names of prospective governors are referred to the charity’s nominations committee which considers whether recommendations for appointment as a governor should be made to the board. The nominations committee also considers recommendations for membership of the charity, as no person may be appointed as a governor unless he or she is also a member.

Audit committee

The audit committee meets at least twice each year. A representative from each of the external and internal auditors is in attendance as are the group chief executive and group finance director. Its main duties are to assist the board in the discharge of its duties by providing independent and authoritative advice on the accuracy of financial reporting and the effectiveness of financial controls and systems. The audit committee also recommends the appointment of the external and internal auditors.

Board integrated governance committee

The board integrated governance committee meets at least four times each year. This committee is responsible for monitoring the effective operation of clinical governance throughout the group and also considers clinical and health and safety matters. The group medical director and senior members of staff with clinical responsibilities are in attendance at the committee’s meetings.