Integrated Governance Report 2008 - Nuffield Health

INTEGRATED 

GOVERNANCE 

REPORT2008 

Governance 

Safety 

Infection Prevention & Control 

Training, Learning & Development 

Working/Engagement with Doctors 

Clinical Effectiveness 

Patient Focus 

Staff Health 

Designed and published by Blank Associates Design & Advertising 

www.blankassociates.com 

Nuffield Health 

40 – 44 Coombe Road 

New Malden 

Surrey 

KT3 4QF 

Telephone: 020 8329 6200 

Fax: 020 8329 6213 

www.nuffieldhealth.com 

A Registered Charity No 205533 and Company Limited by 

Guarantee Registered in England Company No 576970

02 INTEGRATED GOVERNANCE REPORT 2008 

03 

CONTENTS 

Introduction: David Mobbs...............................................................................04 

Foreword: Lord Glenarthur...............................................................................06 

Executive Summary: Dr Andrew Jones...............................................................08 

Integrated Governance Report 2008: ................................................................12 

01. Governance..............................................................................................12 

Governance Arrangements, Information Governance, 

National Health Service Litigation Authority (NHSLA) Accreditation. 

02. Safety......................................................................................................16 

Medicines Management, Health & Safety, Risk Management, 

Incident Management, Radiological Protection, Pathology, Blood Transfusion, 

Health & Safety, Decontamination Standards, Safeguarding Children 

03. Infection Prevention & Control.....................................................................28 

04. Training, Learning & Development ...............................................................34 

05. Working/Engagement with Doctors .............................................................36 

06. Clinical Effectiveness ..................................................................................38 

Care Pathways, Pre-admission Assessment, Patient Reported Outcome Measures, 

Wellbeing Assessments 

07. Patient Focus ............................................................................................42 

Patient/Client Satisfaction, Concerns & Complaints 

08. Staff Health ..............................................................................................46 

Future Direction: Dr Andrew Jones ....................................................................48 

Appendices ....................................................................................................50 

References .....................................................................................................51 

Feedback .......................................................................................................51


05 

INTRODUCTION 

It is once again a great pleasure to present our Annual Quality Report, the second 

Integrated Governance Report produced by Nuffield Health for our 2008 Annual 

General Meeting. 

When we say that “You’re in safe 

hands” it is the detail in our quality 

report that shows we really mean it. 

Our quality report now parallels the financial 

reports. As a registered Charity and an 

independent not for profit organisation, our 

primary concern is in the quality of our health 

and wellbeing services, not in giving money to 

shareholders. 2008 was a seminal year in the 

history of the UK’s largest trading Charity. The 

entities that form the Charity came under one 

umbrella as we created a leading health and 

wellbeing provider. Nuffield Hospitals, our 

name steeped in history for over 50 years, 

became Nuffield Health. 

The launch of Nuffield Health was not simply 

a change of name; it was the launch of a 

new health group and a new brand, reflecting 

our unique range of capabilities and services. 

We have built a reputation for high standards 

of care, professionalism and expertise in 

delivering healthcare. Over recent years 

we have added to this by assembling an 

impressive array of skills, talent, facilities 

and services from hospitals to health clubs. 

We were therefore delighted at the end of 

2008 to receive accreditation against the 

NHS Litigation Authority level 2 risk 

management standards for independent sector 

providers, scoring 100% in all areas. These 

risk based standards measure the process for 

the safe delivery of care. We have a depth of 

experience unrivalled by other health service 

providers; we were the first independent 

organisation to receive level 1 and are the 

only independent provider to hold level 2 

accreditation. 

We introduced our internal quality 

performance indicators during 2008, to 

ensure that we continuously challenge our 

approach to quality, safety and patient 

outcomes. The top 10 of these are published 

on www.nuffieldhealth.com as a group and 

on individual hospital basis. 

2009 will be equally challenging as we 

become the leading provider of health 

screening. Our 53 Fitness and Wellbeing 

centres are now offering Vi1 health screens 

to everyone joining who becomes a member, 

and at the end of their annual Wellbeing 

programme. No other organisation can 

combine the freedom to act solely in the 

interests of the public, with the flexibility 

to take a long term view. 

David Mobbs 

Group Chief Executive 

Nuffield Health


07 

FOREWORD 

Nuffield Health is the United Kingdom’s largest trading Charity. It combines long-held 

social values with the very best business disciplines. In this way we can maximise the 

overall benefit we generate in working to improve people’s health and by measuring 

the outcomes for our success. 

All our customers, whether patients or others 

using our facilities, are at the centre of our 

activities. They trust Nuffield Health to look 

after their needs and to help them make 

informed decisions about how to maintain 

the quality of their health. We serve over 

a million people a year and as a Board we 

ensure that they are all treated as individuals. 

Nuffield Health is independent of Government 

and, as a Charity, has no shareholders. This 

enables Nuffield Health, uniquely, to look well 

into the future at emerging requirements and 

advances towards health promotion and 

health care. Also, it allows us to reinvest any 

financial surpluses directly for the benefit of 

our customers. 

Integrated Governance is the mechanism we 

use to challenge and measure quality at every 

level. We foster an open culture to enable 

us to respond to all aspects of clinical care 

and safety, to measure performance and to 

understand, evaluate and act upon incidents 

of any kind. 

I am grateful to my fellow Governors for the 

support they give to the Board Integrated 

Governance Committee. We are conscious 

that our activities can have a direct impact 

on people’s lives. That is why care for the 

individual is at the heart of our efforts and 

will remain an essential focus of Nuffield 

Health’s strategies. 

As a Charity our success is defined 

by our ability to improve people’s 

health. As a business, our success 

is driven by our customers’ 

satisfaction with our services. 

The Lord Glenarthur DL 

Chairman of the Board 

Integrated Governance Committee


09 

EXECUTIVE SUMMARY 

Nuffield Health has embraced a “Board to Ward” culture and this quality report is 

a celebration of everything we achieved in 2008 and at the same time enabled us 

to reflect on issues from which we draw lessons. As a leading quality provider it 

is important we tell the story and learn from our shortcomings. 

We are renowned for our 

professional, friendly staff who are 

passionate about putting our users 

at the centre of everything they do. 


2008 saw the evolution of our governance 

structure to reflect the complexity of running 

Nuffield Health. Our desire to manage our 

standards enables reporting from all our local 

centres right through to the Board. We made 

additions to reinforce our focus on risk 

management, training, information 

governance and medical devices. 

Our quality reporting has increasingly been 

supported by data with internal quality 

performance indicators mapped to key 

regulatory areas. Clinical quality has been 

escalated to the top of all agendas to mirror 

financial performance. The approach to 

openness has been carried through to 

reporting the top 10 indicators for the issues 

that really matter to patients on our website 

www.nuffieldhealth.com for each hospital. 

The care standards and the safe processes for 

all areas of clinical care were extensively 

reviewed in 2008. We sought external 

verification by the NHS Litigation Authority risk 

management standards 1 for the independent 

sector and we were delighted to be 

successfully accredited against level 2 in 

December 2008. We were the first 

independent sector provider to reach level 1 

and are the only one to hold level 2, with 

compliance in all 50 areas. We additionally 

maintained our ISO 27001 2 compliance for 

information security. 

Safety 

We now have 18 months of complete data 

for risk management, complaints, and 

significant incidents on our Datix governance 

system. The number of incidents has continued 

to rise as a result of transparency and ease of 

reporting with potentially over 8500 incidents 

affecting patient and customer care across the 

organisation last year. Greater visibility means 

that we can correct near misses, learn from 

trends and proactively look at strategic risk. 

Medicines Management 

The safety of medicines management is 

second only to infection prevention and an 

area for close quality assurance. We held 

a wide ranging conference in May 2008 on 

developments in the field with Professor David 

Cousins, Head of Safe Medicine Practice at 

the National Patient Safety Agency (NPSA). 

Our training continually focuses on quality 

aspects and ensuring interventions by highly 

trained pharmacists. This ensures patient 

safety, something we were cited as having 

best practice by the Healthcare Commission’s 

publication on the Safer Management of 

Controlled Drugs in 2007 3 . 

Marlow Photographic


11 

EXECUTIVE SUMMARY 

Hospital Sterile Services Units (HSSU) 

Our Hospital Sterile Service Unit programme developed 

well with the last of our six sterilisation hubs opening to 

service our 30 hospitals. The first four units have been 

accredited against the new European Union directive 

by the Medicine and Healthcare products Regulatory 

Authority 4 and the final two are awaiting inspection. 

Nuffield Health will be amongst the first major network 

providers to reach full compliance. Our team is held in high 

regard by the Sterile Services industry as a result of this. 

Radiology 

Our attention to radiation protection was accredited by 

our external partners at St George’s Hospital. The digital 

radiology PACS NHS project has proved a technological 

challenge to complete with work progressing well. A 

£40 million radiology upgrade was completed with the 

delivery of a seventh mobile MRI and second mobile 64 

slice CT scanner. Our first mobile and ten static digital 

mammography units have been a major addition to our 

screening capability. 

Pathology 

The upgrade for our pathology centres continues to go 

well with a central Winpath computer database becoming 

fully operational. All hospitals are now using the blood 

automated release system (BARS) to meet modern 

safety criteria with successful accreditation by the 

Medicines and Healthcare Products Regulatory Agency 

(MHRA) at the first three sites to be inspected. 

Health and Safety 

With the Corporate Manslaughter and Corporate 

Homicide Act 2007 5 greater focus is now given to health 

and safety matters. Training sessions for senior managers 

and audits are prescribed throughout the group. Health 

and Safety is the main priority in the Wellbeing division. 

Taking a proactive and open stance we met the Health 

and Safety Executive with our Advisors from Quadriga. 

Enhanced automated and monitored fire systems were 

installed in all our hospitals following the lessons learnt 

from the Royal Marsden fire. Our expertise in hospitals has 

enabled us to raise the bar for our approach to managing 

the risks associated with Legionella in our swimming pool 

strategy, published in December 2008. 

Operational excellence forms part of our Wellbeing ‘smart 

leadership’, and reward for enhancing safety is as much a 

part of performance management as financial or 

customer service. We reported 43 incidents in the 

Wellbeing Division involving injury to staff or clients and 

had five significant episodes requiring serious escalation. 

Learning & Development 

Nuffield Health has appointed a Group Organisational 

Development Director to develop a senior leadership 

programme. At the same time our web based learning 

management system has been launched to allow computer 

aided induction and training in all areas, starting with 

the key mandatory areas such as child protection. 2009 

will see all our training databases and learning profiles 

migrate to a single system. A training prospectus will 

enable individuals to take control of their training needs 

and its management. 

The major training accomplishment for the year was in 

the accreditation of our 174 Wellbeing Advisors to 

undertake our Vi1 entry health screens, an important and 

complementary part of our annual Wellbeing programmes 

operated by our Fitness and Wellbeing centres. 

Infection Prevention 

Infection prevention is never far from the spotlight. We do 

not believe in gimmicks and do not stray from the scientific 

evidence. Nuffield Health continues to trust our senior 

clinical staff with everything from patient care to ward 

cleanliness. All our hospitals aim to have a trained 

infection link nurse in every department of every hospital. 

We maintain very low infection rates and in 2008 we had 

no cases of MRSA blood stream infections, one case of 

MSSA (Methicillin Sensitive Staph. aureus) and four cases 

of Clostridia difficile. In all cases the patients were 

potentially admitted with these conditions with the MSSA 

missed on screening and the C. difficile becoming evident 

during admission from elsewhere. 

We are never complacent and have adopted best in class 

hand hygiene tools 6 developed by the National Patient 

Safety Agency and in 2009 will open our doors to the 

external Patient Environment Action Team (PEAT) 

inspections 7 . 

Working with Doctors 

Nuffield Health works with over 6,000 of the finest 

specialists across the country. We met and discussed 

challenges and the future at a series of roadshows 

throughout the summer, hosted by David Mobbs, Group 

Chief Executive and Trish Cassidy, Chief Executive – 

Hospital Division and later in the year at a number of 

forums on orthopaedics, clinical safety and medical 

advisory committee leadership. The Nuffield Health 

approach to practice privileges has been adopted as 

a template across the independent sector celebrating 

our understanding of working in partnership. 


Win-win-wins are possible in healthcare 

High quality care is not achieved because of technology; 

it is driven by careful attention to detail and the process of 

care. Our pathway development has seen E-care modules 

published on our intranet to guide and inform our clinical 

teams. We now use standardised pre-assessment across 

all our hospitals, a win-win-win for patient, consultant and 

Nuffield Health alike. The results have swiftly quelled a 

litany of issues in medication errors, infection prevention, 

documentation, diagnostic tests and delays. This year will 

see standardised care records and we will be completing 

patient reported outcome measures in all sites by the end 

of March 2009. 

As a leading provider of health screening we celebrate the 

early identification of issues when they arise. Our Vi1 

health screens became available in our Wellbeing centres 

for the last two months of 2008 and we have already 

ensured that the 6% of clients with a potential serious issue 

have received onward care. 2009 will see us complete 

the largest number of health assessments outside the NHS. 

Clinical governance ensures that anything from our 

13,289 ECGs to 3,786 mammograms are all reviewed 

and double checked within one electronic system. 

Our audited physiotherapy pathways continue to go from 

strength to strength with the growth of our Fusion and 

Proximity partnerships ensuring that over 100,000 clients 

benefited from evidence directed therapy. 

Our approach to child standards in hospitals and child 

protection has been reviewed and updated to ensure 

industry leading compliance. Confidence comes from a 

trained paediatric nurse being with your child every step 

of the way. 

Patient & Client Focus 

Our client satisfaction scores remain world class with over 

28% of patients rating their care as simply excellent and 

68% as good, cumulatively 96% is hard to beat with over 

27,000 responses. We always look for improvement and 

we will address the 14% who need better medicine 

information and 26% who need better aftercare guidance. 

We work hard to put things right at a local level with 

1573 complaints in our hospitals, of which only 2.6% 

were not resolved with a local apology and corrective 

action. The handful of Wellbeing complaints were all 

reviewed in depth to the satisfaction of our clients. 

Staff & Public Health 

Our in house Occupational Health team continue to lead 

in ensuring that we look after our staff, complete the 

correct pre-employment health checks, address significant 

health problems when they arise, ensuring safe driver 

training is provided and when required facilitate access 

to stress counselling. 

During the year we also adopted the highest standards 

in blood borne virus screening and training in response 

to risks associated with inoculation injury. 

Summary 

Every member of our staff right across the Charity knows 

that none of these things would be possible in isolation. 

We are a giant team and I thank each and every person 

who works with us to deliver high quality, safe care, with 

good outcomes each day of the week. Our NHSLA level 

2 success is made all the more special because it is both 

an organisational and local achievement. 

Quality is evolutionary, 2009 will witness the same 

drive and attention. 

Dr Andrew Jones 

Group Medical Director


13 

01 

GOVERNANCE 

Governance Framework 

The Board Integrated Governance 

Committee (BIGC) has oversight for 

all issues relating to quality and safety 

of services across Nuffield Health. The 

Group Medical Director has executive 

responsibility in this area and chairs the 

Group Integrated Governance Committee 

(GIGC). Integrated Governance covers 

all non-financial elements of risk and 

membership of these committees together 

with a list of governance sub-committees, 

is included in Appendix 1. 

These committees review information derived from reports, 

sub-committees, clinical performance reports, risk registers, 

incident reports and clinical variance data. We manage 

a cycle of continuous improvement to reduce risk and 

enhance quality for the benefit of staff and customers alike. 

The top ten safety and quality indicators derived from the 

governance data are published on the Nuffield Health 

website for every hospital and are refreshed quarterly. 

Safety & Quality Indicators 

Indicators 

Overall patient satisfaction 

(Percentage of patients surveyed rating 

Over all Satisfaction, very good or excellent) 

Confidence and trust in 

our doctors and nurses 

(Percentage of patients surveyed who mostly 

or always have confidence and trust in 

doctors and Nurses) 

Recommendations to friends and family 

(Percentage of patients surveyed who 

would recommend or strongly recommend 

this Hospital) 

Concerns and complaints 

(Percentage of patients attending our hospitals 

who made a formal complaint) 

Cleanliness and comfort 

(Percentage surveyed rating Cleanliness 

and Comfort as satisfactory, very good 

or excellent) 

MRSA 

(Blood bacteria rate per 1000 bed days) 

Clostridium difficile 

Surgical site infection for hip replacement 

Surgical site for knee replacement 

Blood Clots 

a) Deep vein thrombosis (to be calculated in 2009) 

Table 1: Top ten safety and quality indicators 

99.4% 

98.9% 

94.6% 

0.23% 

99.6% 

0% 

4 cases 

8 cases 

8 cases 

During 2008 we reviewed, updated and re-issued over 70 Group 

Policies in compliance with the requirements of the National Health 

Litigation Authority (NHSLA) and these are now being fully embedded 

into our practices and procedures. 

Three new sub-committees of the GIGC were established during 2008 

to further support specific work activities in the following areas: 

• Group Medicines & Medical Devices 

• Group Training 

• Group Information Governance 

Quality Performance Indicators (QPIs) 

Within the Integrated Governance Report 2007, Nuffield 

Health stated our commitment to continually improve the 

safety and quality of services provided to our customers. 

To support this commitment a new framework for 

Governance reporting described as Quality Performance 

Indicators (QPIs) was introduced in 2008. 

There are 95 quality performance indicators, within the 

new framework; all are measures of safety & quality. 

The QPIs are detailed under 10 key category headings, 

reflect activity across Nuffield Health and include current 

statutory/regulatory requirements, Department of Health 

Policy, evidence based best practice and the requirements 

of compliance with Nuffield Health Policy. 

The 10 categories are: 

1: Governance 

2: Human Resources & Practice Privileges 

3: Patient & Customer Focus 

4: Safety: Infection Prevention & Control 

5: Safety: Incidents 

6: Safety: Medicines 

7: Staff/Occupational Health 

8: Clinical Outcomes 

9: Mandatory Training 

10: Legal Claims 

Each QPI has a clear definition and, where appropriate, 

this is aligned to an existing definition. For example, the 

Healthcare Commission Clinical Indicator data set. 

The main reasons for introducing this new reporting 

framework were: 

• To monitor compliance across Nuffield Health 

against current and future statutory & regulatory 

reporting requirements. 

• To improve the safety and quality agenda. There is 

a need for continuous monitoring of performance 

across the Group to enable early identification of 

non-compliance, areas requiring improvement and 

to identify best practice. This can be shared for the 

wider benefit of our users and the Group. 

• To standardise governance reporting so as to 

improve the measurement and monitoring of 

performance. 

• The need to give assurance to the Board of safety 

and quality performance across the very diverse 

range of Nuffield Health services. 

The indicators have been developed from the current 

requirements for compliance, reporting and monitoring set 

out by the various regulatory bodies including the 

Healthcare Commission (HC), NHSLA and National 

Patient Safety Agency (NPSA). 

The QPIs include the eight mandatory clinical indicators 8 

reportable to the Healthcare Commission on a quarterly 

basis and are as follows: 

• Mortality 

• Peri-operative mortality 

• Serious injury (defined in Regulation 28 

of the Private & Voluntary Healthcare 

(England) Regulations. 

• Returns to theatre 

• All unplanned transfers out 

• All unplanned re-admissions 

• All surgical site infections 

• All positive blood stream infections 

including MRSA 

Performance of hospitals continues to be carefully 

monitored and there were no significant concerns with 

the clinical performance across all eight indicators during 

2008. 

Group Risk Register 

Maintenance and review of risk registers at both local and 

Group level are now an integral part of the wider strategy 

for effective risk management. Presentation of the top ten 

(non-financial) risks together with actions being taken to 

mitigate them form part of the quality report to the Board. 

Research Governance 

A revised and updated Research Governance Policy 9 was 

issued by the Group Medical Director in 2008. The GIGC 

has the responsibility of ensuring that Nuffield Health 

facilitation of any research activity is conducted according 

to strict regulatory and research governance requirements. 

This includes receipt of the appropriate ethical committee 

approval. Table 2: Shows the research proposals ratified 

by the GIGC during 2008.


15 

01 

GOVERNANCE 

Table 2: Research and new service proposals ratified - 2008 

Project title Investigator Site 

MRgFus focused ultrasound under MRI 

guidance & conscious sedation for 

treatment of uterine fibroids 

New service delivered by local 

gynaecologists 


Derby Hospital 

The National Health Service Litigation 

Authority (NHSLA) Risk Management 

Standards 

Nuffield Health remains committed to achieving full 

compliance with the NHSLA Risk Management Standards. 

New standards for the Independent Sector (IS) were 

published by the NHSLA in April 2008, consistent with the 

standards applied to acute hospital providers in the NHS. 

Development of novel methodology for 

isolation and functional examination of 

rheumatoid and osteoarthritic joint tissue cells 

Adenosine stress CT perfusion in patients 

with and without significant coronary heart 

disease: A proof of principle study 

Biomarkers of Colorectal Carcinogenesis 

and inflammation of the Colon following 

Bariatric Surgery in Obese Individuals 

Emotional processing in healthy male 

volunteers treated with GSK424887. 

A single centre, randomised, double-blind, 

placebo-controlled parallel group study 

Pilot study of the effects of Periodic 

Acceleration (PGz) on the symptoms of 

angina and objective markers of cardiac 

perfusion 

A study assessing the role of complement 

and nitric oxide in patients with haemolytic 

anaemia including paroxysmal nocturnal 

haemoglobinuria and the underlying cause 

of these disorders 

A Long Term, Immunogenicity, Safety and 

Effectiveness study of GARDASIL (Human 

Papillomavirus [Types 6,11,16,18] 

Recombinant vaccine among adolescents 

who received GARDASIL at 9-18 years of 

age (V501-018-10) 

A multicentre, multinational randomized 

control trial of prophylactic low molecular 

weight heparin (LMWH) in high risk 

pregnant thrombophilic women. 

Dr Stephen Kilfeather (Researcher) 

Dr John Greenwood, Consultant Cardiologist 

Dr Prashant Kant, Professor Mark Hull 

Kevin Craig on behalf of P1Vital, 

on behalf of GlaxoSmithKline R&D Ltd (GSK) 

Professor U M Sivananthan 

Professor U M Sivananthan 

Dr Simon Butler-Manuel 

Dr Ian Greer 

/ Mr James Dwyer 


Newcastle-upon-Tyne Hospital 


Leeds Hospital 




The Manor Hospital Oxford 






Guildford Hospital 


York Hospital 

“ The Board & staff of 

Nuffield Health should 

be very proud of their 

considerable achievement, 

which reflects a great deal 

of effort and a strong 

commitment to risk 

management within the 

organisation “ 

Steve Walker 

Chief Executive 

NHSLA 

Further to rigorous assessment by the NHSLA in December 

2008 Nuffield Health was successful in gaining 

accreditation at level 2 of the standards. Level 2 relates to 

demonstrating the successful implementation of policy and 

Nuffield Health achieved full compliance by scoring 

50/50 across all standards. Nuffield Health is currently 

the only independent sector organisation to hold level 2 

accreditation and celebrates this very special achievement 

of 100% compliance. This success reflects well on the 

quality culture in the organisation and on its collective 

clinical achievement. We will make preparations in 2009 

for the third and highest level of accreditation, which is 

held by only 6% of hospital providers. 

Information Governance 

Nuffield Health remains fully committed to ensuring the 

protection of confidential information across the Group. 

During 2008 the Information Security Manager undertook 

a programme of audits, which resulted in no significant 

areas of information risk. 

Nuffield Health was externally audited by ‘Lloyds Register 

Quality Assurance’ in July 2008 to measure Nuffield 

Health’s compliance with the international standard for 

information security - ISO 27001. The assessors 

reported that: 

‘There is evidence of the Information Security 

Management Systems operating across the Nuffield 

Health organisation in order to manage the security of 

patient administration and information. As a result, 

continued certification to ISO 27001 is recommended’ 

The Group Information Governance Forum has ensured 

compliance with the highest standards set by the 

Department of Health including laptop encryption and 

a confidentiality code of conduct for staff.


17 

02 

SAFETY 

Adverse Incidents 

All incidents continue to be reported by staff across Hospitals and the Wellbeing Divisions, 

using the Datix web based incident reporting system. There are plans to roll out the 

utilisation of Datix reporting across the Fitness sites during 2009, together with an upgrade 

of Datix software, which will provide enhanced reporting functions. 

Further training took place during 2008 to embed the use 

of Datix for pro-active risk management and reporting 

across the Group. 

Incidents categorised as serious (SUIs) continue to be 

immediately escalated to designated senior managers 

for prompt investigation and action to prevent the same 

incident being repeated. The benefits of Root Cause 

Analysis training carried out in 2007 are now being 

realised with more effective incident investigation. 

Table 3: 

Total number of 

incidents reported 

– 2008 

Total number of incidents: 8594 

Total Number of SUIs: 177 

2008 

SUIs 

Table 4: 

Total number of incidents reported by category – 2007 & 2008 

2007 


Access, admission, transfer, discharge 

7000 

Clinical Assessment (including diagnostics, tests & scans) 

Total number of all incidents 

6500 

6000 

5500 

5000 

4500 

4000 

3500 

3000 

2500 

2000 

1500 

1000 

500 

0 

21 SUIs 

Nuffield Diagnostic & 

Mobile Services 

3 SUIs 

Nuffield HSSU Nuffield Hospitals Nuffield Fitness 

& Wellbeing 

142 SUIs 

5 SUIs 

Blood Transfusions 

Collisions 

Communication & Consent 

Documentation 

Equipment / medical devices 

Falls, slips and trips 

Contact with a hot surface or substance 

Defects reported by Hospital 

Defects reported by HSSU 

Implementation of care 

Infection Control 

Information Security 

Infrastructure 

Injured while handling, lifting or carrying 

Drugs / Medication 

Inoculation / needlestick injury 

Other 

Other kind of Accident 

Patient Accident 

Incident involving radiation or radioactive materials 

Security 

Treatment / procedure (patients) 

0 200 400 600 800 1000 1200 1400 1600 1800 

Total number of all incidents


19 

02 SAFETY 


4500 

4000 

3500 

3000 

2500 

2000 

1500 

1000 

500 

0 

Table 5: 

Total number of incidents reported by type - 2007 & 2008 

Adverse 

events 

affecting 

patients 

2007 


Adverse 

events 

affecting 

visitors, 

contactors 

or the public 

Adverse 

events 

affecting 

staff 

Adverse 

events 

principally 

affeting the 

organisation 

Medicine 

Intervention 

HSSU Defect 

Report 

Medicines and Medical 

Devices Management 

Medicines management encompasses the entire way that 

medicines are selected, procured, delivered, prescribed 

administered and reviewed to optimise the contribution 

that medicines make to producing informed and desired 

outcomes of care. We pride ourselves that the quality, 

safety and cost-effective performance criteria by which 

we measure medicines management services allows our 

patients to put their trust in our teams. 

Medicines Management Training 

In May 2008 a group-wide Nuffield Health Medication 

Safety Conference was held with delegates from a variety 

of clinical backgrounds, including nursing, pharmacy and 

operating department practitioners to share lessons in 

medication safety. Presentations and workshop sessions 

were held with both internal and external speakers, 

including Professor David Cousins, Head of Safe 

Medication Practice and Medical Specialties at the 

National Patient Safety Agency. 

Diagram1: 

Pharmacy 

Review 

and Optimise 

Prescribing 

& selection 

Doctors 

Informed 

& desired 

outcomes 

of patient 

care 

Nurses 

Administration 

and use 


180 

160 

140 

120 

100 

80 

60 

40 

20 

0 

Table 6: 

Total number of medicine incidents and interventions reported - 2008 

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 

Total Number of 

Medication Events 

Total Number of Actual 

Medication events 

Total Number of Pharmacy 

Intervention Incidents 

From the original launch of Datix in 2007 

Nuffield Health has been committed to open 

reporting and communicating lessons learnt 

from, both incidents and near misses. 

Medicine events reported on Datix are 

amongst the highest, however, the majority 

[70% on average] are interventions that 

prevent incidents occurring. In 2007, 31% 

of medication events were actual incidents 

whereas this has dropped to 27% in 2008. 

Where trends in reporting are noted, actions 

are undertaken to disseminate lessons learnt. 

Throughout 2008 all hospitals showed improvement in 

identifying and delivering medicines management training 

locally across the multidisciplinary teams. Towards the end 

of 2008 a new system for medicines management training 

was introduced to improve the quality and reproducibility 

of training. The Nuffield Health Learning Management 

System [LMS] provides a method for delivering medicines 

management training using eLearning. In addition, the 

LMS monitors other forms of training such as classrooms 

and links to externally available material, for example 

Quality Prescribing modules from the National Prescribing 

Centre. During 2009 compliance with training 

requirements will continue to be monitored and new 

learning tools developed. 

In June and November 2008 dedicated medicines 

management training workshops were held for all the 

General Managers [GMs] of registered facilities. These 

Registered Managers also act as the Accountable Officer 

under the relevant controlled drug regulations. The training 

covers medication safety and risk management as well as 

the responsibilities of the Accountable Officer. This year’s 

workshops improved upon previous sessions by the 

introduction of GM case study presentations that provided 

a method for GMs to share lessons learnt with their peers. 

Medicines are the most 

common clinical 

intervention and are 

therefore an essential 

component of the 

pathway of care provided 

to our patients.


21 

02 SAFETY 

The Supervision and Management 

of Controlled Drugs 

In 2008 the first report into the safer management of 

controlled drugs was published by the Healthcare 

Commission which reviewed the implementation of the 

regulations following the Harold Shipman enquiry. Nuffield 

Health was cited as an example of good practice example 

within the independent sector. 

The Healthcare Commission report highlights that Nuffield 

Health has been at the forefront of sharing information with 

the Local Intelligence Networks in respect of exceptional 

occurrences with controlled drugs. We have developed 

a more open incident reporting culture. The audit 

programme for controlled drugs was improved in 2008 

and 95% of hospitals were undertaking the quarterly 

controlled drug audits in all departments. Individual issues 

prevented the 100% target being met and will be 

addressed in the first quarter of 2009. 

The Management of 

Higher Risk Medication 

The risks associated with prescribing and administering, 

medication have been highlighted by the National Patient 

Safety Agency [NPSA] in a series of alerts and we have 

been working through these requirements. All the hospitals 

have demonstrated through audit that the alerts are being 

acted upon with action plans in place. However, the 

learning from 2008 is that the multidisciplinary team 

[MDT] approach to alerts management could be improved 

in approximately half of hospitals. This will involve support 

to embed medicines MDTs and improved reporting using 

a single Document Management System [DMS]. 

A key medication safety alert 10 that was issued jointly by 

the NPSA and the National Institute for Health and Clinical 

Excellence [NICE] for action in 2008, related to the 

reconciliation of medicines for adult patients on admission 

to hospital. This alert highlighted that across the NHS there 

was significant risk to patients as they moved from primary 

care to secondary care and back to primary care in 

respect of continuity prescribing. 

Investigation of medication interventions on the Datix 

system showed that there were improvements that could 

be made to the medicine reconciliation process in Nuffield 

Health hospitals. 

In addition to responding to the specific requirements in 

the alert, these were integrated into the new pre-assessment 

pathway and introduced a standardised ‘green bag 

scheme’ to identify patients’ own medication in each 

hospital. Initial results show that since the introduction of 

the pre-assessment pathway there has been a 70% 

reduction in pre-assessment related medication events. 

The out of license use of medication is an area that 

requires a robust risk management approach and Nuffield 

Health has always been at the forefront of monitoring 

medication used in this manner. Out of license use of 

medicine is required from time to time and is covered by 

the regulations and standards of practice. However, the 

use of out of license medication must be evidence based, 

and documented. Thereafter patients must be informed. 

Over 90% of hospitals were found to be compliant against 

audit with respect to ‘off-label’ and ‘special’ use of 

medication. The need to import unlicensed medication 

on a named patient basis is monitored, but the use is very 

low [less than 0.05% of medication used] and risks are 

well managed. 

Patient Experience and Involvement 

The Patient Satisfaction Survey for hospitals has shown 

an increased response rate to the question on provision 

of information on medicines in 2008 [18351] compared 

to 2007 [12535]. In both 2007 and 2008 99% of users 

surveyed stated they were provided with written or printed 

information about medicines. However, the clarity of the 

information provided still needs to be improved as there 

has only been a 2% improvement in 2008 [20% of users 

stated ‘Not Clear’] from the 2007 position [22% of users 

stated ‘Not Clear’]. Although all users are provided with 

written information with their medication the wording of the 

question has been changed for 2009 to ensure that users 

understand what is being asked. 

Next steps – Medicines Management 

and Medical Devices 

Towards the end of 2008 the governance arrangements 

for medicines and medical devices were brought closer 

together to reflect the similar regulatory framework under 

the Medicines and Healthcare products Regulatory 

Agency [MHRA] and the close association in use of 

medicines and medical devices. The audit trail of 

medicines and the inventory and maintenance of medical 

devices show similar requirements in management and 

the approach to training will follow a similar path. 

In 2009 there will be planned changes for the pharmacy 

profession. Pharmacy will align with other professions 

with the establishment, in 2010, of a regulator which is 

separate from the professional leadership, namely the 

General Pharmaceutical Council. In advance of these 

changes a new White Paper for Pharmacy 11 was 

published in April 2008 which highlighted the opportunity 

for extending the role of pharmacy teams. Nuffield Health 

has reviewed this document against the wider strategy 

and has a planned programme of work to ensure that 

pharmacy services are standardised with a clinical focus 

for all the hospitals. This will ensure that processes are 

changed to allow pharmacy staff to better support 

colleagues in prescribing and administering medicines. 

This will produce improved outcomes for patients. 

Decontamination 

– Surgical Instruments 

The roll out programme of providing all hospitals with 

state of the art Hospital Sterile Supply Units (HSSUs) 

continued during 2008 to meet the mandatory standards 

for all hospitals to source their surgical instrument 

services from premises that are fully compliant with the 

European Medical Devices Directive (EC93/42). The 

year got off to a tremendous start when the first HSSU 

based at Wetherby was successful in achieving MHRA 

accreditation to the required standards and hence the 

Directive. This achievement allowed the HSSU to provide 

a commercial decontamination service to other hospital 

groups within the Independent Sector. 

Table 7: Represents a summary of the achievement to date 

HSSU - Site Go Live Date Accreditation 

Wetherby 21st May 2007 Yes 

Tiverton 4th February 2008 Yes 

Cambridge 5th May 2008 Yes 

Warwick 7th July 2008 Yes 

Stoke on Trent 13th October 2008 Applied for 

Eastleigh 12th January 2009 Applied for 

During 2009 the HSSU network will supply 430,000 

trays of instruments to Nuffield Health hospitals, with an 

extra 20,000 trays to other providers. It is estimated that 

this scale of processing equates to 13 million individual 

surgical instruments. 

The HSSU programme has not been without its challenges, 

despite the lessons learned from the early stages of the 

roll-out. However, when compared with similar exercises 

carried out by the NHS and private healthcare providers 

the Nuffield Health project has avoided many of the 

difficulties that have disrupted the provision of surgical 

services elsewhere, and is held in high regard by the 

Sterile Services industry. The programme will be completed 

on time and on budget and represents a total investment 

by Nuffield Health of £27M in patient safety. 

Additional investment has been made in the field of flexible 

endoscope decontamination, which cannot be undertaken 

in a location that is off-site, due to the delicate nature of 

the equipment. This area of decontamination is now under 

greater scrutiny in respect of the required standards for 

de-contamination and standards will be reviewed by the 

new Care Quality Commission during 2009.


23 

02 

SAFETY 

Radiological Protection 

Nuffield Health continues to be supported by the 

Radiological Protection Centre (RPC) based at St 

George’s Hospital, London. The 2008 annual report 

reported that: 

“Radiation protection matters 

for the Group are generally 

in good order and there is 

excellent compliance with 

regulations and guidance in 

the majority of radiology 

departments, the corporate 

structure has led to 

standardisation between 

radiology services at each 

hospital site and greater 

control over radiation 

protection policy.” 

Radiation Incidents 

There were 12 radiation incidents reported to RPC in 

2008 (compared to four in 2007). There was a mix of 

patients who had been x-rayed inappropriately, the use of 

incorrect imaging protocols, unnecessary repeat exposures 

due to lost images or equipment malfunction. It should be 

noted that the increase in incidents reported is due to our 

recommendation from RPC in the 2007 report that 

Radiology Managers/Radiation Protection Supervisors 

should report all significant radiation incidents to RPC in 

accordance with the Ionising Radiation Medical Exposure 

Regulations (IRMER) 12 . 

Radiology 

The digital picture archive project has been continuing 

throughout 2008 and 22 of our sites are fully up and 

running with another three sites in the implementation 

phase. Our mobile imaging fleet has expanded with seven 

MRI systems, two mobile CT scanners and one mobile 

full-field digital mammography system. 

Nuffield Health’s diagnostic upgrade is nearing completion 

with the installation of new equipment; this means that most 

sites now have state of the art machines which will safely 

support the business during the next 

few years. 

Table 8: Introduction of new services & equipment 

Hospital Site 

Brentwood 

Cheltenham 

Plymouth 

Taunton 

Woking 

Guildford 

Tunbridge Wells 

Wessex 

Exeter 

Cambridge 

Ipswich 

Bournemouth 

Derby 

Leeds 

New Service / equipment 

Digital mammography, 64 slice 

CT scanner, ultrasound scanner 

Digital mammography, DEXA 

bone densometry scanner 

Digital mammography, ultrasound 

Ultrasound scanner 

DEXA scanner upgrade, 

ultrasound scanner, 

DEXA scanner upgrade, 

ultrasound scanner 

Digital mammography, 

Fluoroscopy room, Dexa scanner, 

ultrasound scanner 

Fluoroscopy room, ultrasound 

scanner, CT scanner upgrade 

Mobile Image intensifier 

64 slice CT 

DEXA scanner, ultrasound scanner 

64 slice CT, ultrasound scanner, 

DEXA scanner 

64 slice CT scanner, 1.5T MRI, 

MRgFUS scanner 

64 slice CT scanner 

Pathology 

Blood Audit Release System (BARS) 

During 2008 the BAR System for automated blood 

transfusion tracking was fully implemented across all 30 

Nuffield Health hospital sites. In each laboratory the 

analyser for transfusion testing has been standardised. 

This allows consistent pre-transfusion testing at each site 

for a patient prior to release of any blood required through 

the electronic system. 

We have a ‘super user’ in every operating theatre, ward 

and outpatient area for each hospital. These super users 

have done an excellent job throughout the year in 

cascading training to hospital staff. A comprehensive 

training pack with troubleshooting guides has been 

developed by the Specialist Blood Transfusion Nurses 

to help staff overcome minor technical problems with 

the system. 

Core competencies in blood sampling and transfusion 

have also been developed and mapped against the 

National Patient Safety Agency standards, ‘Right patient, 

right blood’ 13 . 

A Group Transfusion Committee was established during 

2008 which is overseen by a consultant haematologist 

adviser and meets the current regulatory requirements for 

transfusion services. This committee meets quarterly and 

sets the strategic direction and best practice policy for the 

Group on all matters related to blood transfusion. The 

committee also monitors and takes appropriate action on 

blood stock usage and wastage of units of blood, 

throughout the Group. 

Three blood transfusion sites were successfully audited 

during the year: Woking, Warwick and Wolverhampton 

and were reported to be achieving the required level of 

safety procedures against compliance with the Medicines 

& Healthcare Products Regulatory Agency (MHRA) Blood 

Safety & Quality Regulations (2005) 14 . 

Health and Safety – Hospitals Division 

Legal Changes 

There were a limited number of legal changes introduced, 

or which took effect, during the year. 

The Corporate Manslaughter 

and Corporate Homicide Act 2007 

The Act, the full details of which were outlined in the last 

report, took effect in April 2008 and changed the 

previous legal framework in relation to corporate 

manslaughter. Under the previous system, a prosecution for 

corporate manslaughter could not be successfully brought 

against a company unless it could be shown that at least 

one very senior officer or director was individually guilty 

of conduct which constituted manslaughter. 

The Act created a new offence where a corporate 

organisation is guilty of a gross breach of a relevant duty 

of care and that breach causes the death of a person. 

An organisation is only guilty of the offence if the way in 

which its affairs are managed or organised by its senior 

management, is a substantial element of the breach. 

The duty of care extends to employees, patients, visitors 

and those providing services to the organisation and 

contractors. 

The approach already adopted within Nuffield Health of 

a clear policy framework, supported by training of relevant 

staff, monitoring and auditing of standards, creates a 

sound footing for avoiding vulnerability. The approach of 

achieving compliance with NHSLA standards is also a 

good demonstration of this policy framework being 

achieved. 

The Health and Safety Offences Act 2008 

The new Act 15 was introduced as a Private Members Bill 

and was subsequently supported by the Government 

taking effect on 16th January 2009. The Act increased the 

maximum penalty which is available for nearly all health 

and safety offences to an unlimited fine and two years 

imprisonment. 

Enforcement Authority Involvement 

HSE Involvement in Hospitals 

There have been no proactive Health and Safety Executive 

inspections undertaken within our hospitals during the year. 

This follows a very successful relationship being built in the 

past with the HSE corporately, who have been satisfied 

with the internal policies, training and auditing 

arrangements in place. There have been a very limited 

number of hospital HSE inspections during the year which 

have related to reportable incidents and these have been 

successfully handled. 

Central meetings with the HSE and attended by the 

Group Medical Director and the Managing Director of 

Quadriga (the Company’s retained health and safety 

consultants) demonstrate Nuffield Health’s commitment to 

this important area.


25 

02 

SAFETY 

Fire Authority Involvement and Fire Risk 

Assessment in Hospitals and Mobile Units 

As in previous years a small number of hospitals received 

inspections from the Fire Authority during the year, 

enforcing the requirements of the Regulatory Reform (Fire 

Safety) Order 2005 16 . Such inspections are now far more 

proactive than those undertaken under the previous 

enforcement regime and we continue to work hard to 

evolve our fire risk assessments. A more standardised risk 

assessment approach has also been developed in relation 

to the operation of mobile theatre and other units operated 

by Nuffield Health. 

Health and Safety Audit Programme 

A three year health and safety audit programme, 

undertaken by Quadriga Health & Safety Ltd, was 

completed during the year. The programme provided for 

all hospitals to be audited during the three year cycle 

and for sample audits to be undertaken within selected 

subsidiary company operations. Audits were also 

undertaken of each HSSU prior to them becoming 

operational and a post-acquisition audit was undertaken 

of Cannons. A new audit programme for the Hospitals 

Division is planned for the three year period beginning 

in 2009. 

Health and Safety Policy and 

Procedure Development 

An ongoing programme of updating and revising health 

and safety policies, procedures and guidance, forming 

part of the Group Health and Safety Manual suite of 

documents, has continued during the year. This has been 

integrated with the NHSLA work so that all revised policies 

are compliant with NHSLA requirements. 

Fire Authority Response to Automatic Alarms 

A project has been undertaken to monitor the level of false 

alarms at hospital locations to ensure these are minimised 

and meet the national standards relating to the 

acceptability of such alarm rates. 

During the year a programme of connecting fire alarm 

systems in all our hospitals to monitoring centres was 

completed. 

Health and Safety Training 

An ongoing programme of health and safety management 

training is being undertaken by Quadriga Health & Safety 

Ltd to provide a consistent approach to health and safety 

issues across the Hospitals Division. This is supplemented 

by specific health and safety training which is undertaken 

locally: 

Table 9: Training courses and the number of attendees 

(Hospitals Division) 

Training course & duration 

Significant Incidents - Fire or Fire Activations 

Number of 

attendees 

Key courses include: 

Safety for Senior Executives (one day) 19 

Managing Safety Course (five days) 12 

Other courses include: 

Permit to Work (one day) 13 

Control of Substances Hazardous to Health 77 

(COSHH) (one day) 

Risk Assessment Course (one day) 101 

Train the Trainer (one day) 18 

Health and Safety for Heads of Department (one day) 82 

Health and Safety Committee (one day) 50 

Asbestos Awareness and Management Plans 

(one day) and Asbestos Refresher Training (half day) 16 

Update Days for Health and Safety 

Coordinators (one day) 

All H&S 

coordinators 

During 2008 there were 59 fire alarm activations and 

two minor fires, one of which caused slight damage in 

a hospital kitchen. The Fire Brigade was called to 55 

of these events. On all but one of the occasions when the 

Fire Brigade was not called, the cause of the alarm was 

known and did not warrant their presence. Action has 

been taken to reiterate to staff the procedure to be 

followed in this type of incident. 

The circumstances of the two minor fires which occurred, 

were as follows: one related to a faulty portable heater 

and the other to a cooking fire. In neither case was Fire 

Brigade action needed to extinguish these fires. 

Health & Safety – Wellbeing Division 

A number of very important health and safety activities 

took place during 2008 and include the following: 

• A review of the implementation of company health 

and safety procedures for the new Nottingham 

Fitness and Wellbeing Centre. 

• Risk assessments required as a result of new 

management arrangements in five Nuffield Health 

Wellbeing swimming pool sites. 

• A review of the operational status for the 

management of two Hydrotherapy pools at 

Wessex and Bournemouth Hospitals. 

• The implementation of a revised health and safety 

management framework and procedures within 

four stand alone Wellbeing centres at Edinburgh, 

Manchester, London’s City and Queen Anne Street. 

• The ongoing development and implementation of 

shared premises agreements with Nuffield Health 

Wellbeing corporate clients and Nuffield Health 

hospital sites for health and safety responsibilities. 

• The development of management strategy and the 

implementation of the ‘Violence at Work’ section of 

the health and safety management manual. 

• The completion of Legionella risk assessments. 

• The continuation of monthly Lifeguard Training and 

Competence assessments. 

• The completion of full health & safety audits across 

all Fitness and Wellbeing sites. The necessary action 

is being taken to address the key recommendations, 

including improvement in induction training and 

enhanced lifeguard training. 

Training 

There were 311 planned Health & Safety courses 

held across the division during May – December 2008, 

as follows: 

Table 10: Health & Safety Courses (Wellbeing Division) 

Training course 

Number 

of courses 

National Pool & Life Guard Qualification 30 

First Aid at work (including paediatric) 35 

Cardiac defibrillation 76 

Cardiac defibrillation refresher 130 

Fire & evacuation 19 

Pool plant operatives 10 

Health & Safety competent persons 3 

Incident & emergency management 3 

Food Hygiene & Safety 5 

Reporting of Injuries, Diseases and 

Dangerous Occurrences Regulations 

(RIDDOR) 

Nuffield Health has a statutory requirement to report all 

accidents/incidents meeting the requirement for RIDDOR 17 

reporting. Table1: Shows the number of RIDDOR reports 

across the Group. 

Table 11: RIDDOR reports - 2008 

Division 

Number 

(2008) 

Hospitals - employees 14 

HSSU - employee 1 

Wellbeing 

Members of the public 38 

Employees 5 

Total 58


27 

02 

SAFETY 

Safeguarding Children 

Nuffield Health performs in the region of 5,000 

paediatric procedures per annum across 30 hospitals. 

To ensure that Nuffield Health keeps its younger patients 

safe and to meet the Government’s wider agenda of 

world-class services for children, young people and 

their families, as outlined in both the Children’s Plan 

2007 18 and Every Child Matters 2004 19 , a group wide 

children’s services policy was implemented in 2008. 

The policy ensures that key regulatory and legislative 

requirements are met and the child/young person’s 

welfare is firmly at the centre of the service. 

“Nuffield Health performs in 

the region of 5,000 paediatric 

procedures per annum across 

30 hospitals.” 

A multidisciplinary Paediatric National Reference Group 

was established in 2008 as an advisory group to Nuffield 

Health and supports the implementation of the policy. The 

group has representation from all Nuffield Health divisions 

and meets quarterly to ensure that key risks are identified 

and managed. Child protection training is a key agenda 

item as it impacts on all of Nuffield Health business 

activities that offer services to children. A group wide 

electronic solution for the training is scheduled for 

implementation in January 2009 which will ensure that 

all staff, as well as consultants have access to consistent, 

effective training. 

In addition to surgical and medical services, Nuffield 

Health offers a number of other services to children and 

young people as follows: 

• 2 Registered Nursery Locations 

• 44 Crèche Facilities 

• 34 Clinical Services Sites 

• 53 Consumer Fitness Locations 

• 12 Public Sector Leisure Sites


29 

03 INFECTION PREVENTION & CONTROL 

Infection rates in Nuffield 

Health hospitals remain 

extremely low, during 

2008 we published 

our “Protection from 

Infection” strategy. 

Healthcare associated infections 

(HCAIs) continue to represent 

a major risk to patient safety. 

They contribute towards suffering, 

prolonged hospital stays, mortality 

as well as increased costs. The 

national drive to prevent infection 

is to be welcomed. 

In 2008, reports of hospital 

acquired infections remained 

extremely low with one confirmed 

case of MSSA bacteraemia 

and four confirmed cases of 

Clostridium difficile. However, 

there is a continued need for 

vigilance and robust reporting 

mechanisms of all incidents of 

infection. We are mindful of the 

risks to patients from infections 

such as MRSA, Norovirus, 

Clostridium difficile and any 

other emerging antibiotic resistant 

organisms, all of which continue 

to cause outbreaks of infection 

in our communities. 

Strategy 

The focus on preventative action is necessary to ensure 

Nuffield Health is prepared to face the challenge of 

infection and maintain patient safety. In 2008, Nuffield 

Health published its Infection Prevention Strategy, 

‘Protection from Infection’ 20 which focused on a robust 

governance framework to minimise the risks of infection 

and ensure patient safety. A rigorous programme of 

prescriptive audits throughout 2008 ensured practices 

were regularly monitored and risks promptly identified. 

Overall Nuffield Health’s hospitals achieved 93% 

compliance to national infection prevention standards. 

See table 12 below. 12 Hospitals achieved the target 

of 95% compliance. 

This structured approach to audit demonstrates the 

continued commitment by Nuffield Health management 

and infection prevention staff to both monitor and improve 

infection prevention practices. This has been instrumental 

in achieving 100% compliance to the Infection Prevention 

Standards for NHSLA Level 2 inspection. 

Nuffield Health hospitals have agreed in 2009 to fully 

participate in the Patient Environment Action Team (PEAT) 

Cleanliness Inspections and in future can be ranked on 

cleanliness and benchmarked against NHS Trusts. 

Nuffield Health will also fully participate in the national 

surveillance and reporting programme of MRSA 

bacteraemia infections. This will be introduced through 

reporting via the Health Protection Agency, in the same 

way as NHS Trusts. 

From 1st April 2009 NHS Trusts and providers of NHS 

care may be required to screen all elective surgical 

patients for MRSA prior to admission. In response to this 

NHS directive the Group Infection Prevention & Control 

Committee is currently reviewing the Group Policy on 

MRSA pre-operative screening and propose to re-issue 

new guidance to all hospitals by April 2009. The 

introduction of the new pre-admission process is already 

proving to be effective in enabling compliance to our 

longstanding pre-operative screening policy. This identifies 

those patients that are either at greater risk of exposure 

to MRSA or would be at increased risk of developing 

post-operative infection. 

Effective hand washing by staff remains the single most 

effective means of prevention of infection. During 2008 

all hospitals have implemented the World Health 

Organisation (WHO) ‘my five moments’ 21 hand washing 

procedures and also utilised the National Patient Safety 

Agency’s Clean Your Hands Campaign materials. 

Bournemouth 

Brentwood 

Brighton 

Bristol 

Cambridge 

Cheltenham 

Chichester 

Derby 

Exeter 

Glasgow 

Grosvenor 

Guidford 

H Heath 

Hampshire 

Hereford 

Ipswich 

Leeds 

Leicester 

N Staffs 

N-Tyne 

Oxford 

Plymouth 

Shropshire 

Taunton 

Tees 

T Wells 

Warwick 

W’hampton 

Woking 

York 

Table 12: Hospital annual compliance scores for 

management of infection prevention during 2008 

Target 2008 

0 70.0% 75.0% 80.0% 85.0% 90.0% 95.0% 100.0%


31 

03 INFECTION PREVENTION & CONTROL 

New Legislation 

Hospital Directors of Infection Prevention and Control and 

their Infection Prevention Team will need to demonstrate 

compliance to the eleven duties imposed by the Health 

Act; Code of Practice 22 for the Prevention and control 

of healthcare associated infection by April 2010. This 

code covers all aspects of infection prevention including 

environmental cleanliness, organisational management, 

patient information, audit of practice and surveillance 

of infections. 

The challenge for 2009 is to be progressive, providing 

high quality, cost effective care in a clean, safe 

environment in which our medical colleagues want to 

work and which inspires patients’ confidence in the 

services that we provide. 

Key Achievements 

During 2008 the Nuffield Health Infection Prevention Team 

ensured that a rigorous programme for infection prevention 

and control is in place through the development and 

publication of its Strategy. 

The following Key Objectives for 2008 have been 

achieved; 

• Compliance to national regulatory requirements 

and 100% compliance to NHSLA infection 

prevention standards 

• Extremely low rates of infection – only one case 

of MSSA bloodstream infection and four cases of 

Clostridium difficile. See table 2 

• High standards of clinical practice demonstrated 

through a rigorous audit programme and an 

average compliance to infection prevention 

standards of 93%. 

Table 13: 

Nuffield Health Hospital 

Confirmed Infection Rates 

– 2008 

• Implementation of a robust governance 

framework and reporting mechanism to provide 

assurance to the Board of Governors regarding 

infection risks and the key controls implemented 

to minimise such risks. 

• Provision of an accredited training course for 

Infection Prevention Link Practitioners (IPLPs) to 

facilitate a “Board to Ward” approach in 

ensuring the infection prevention programme 

is delivered. 

• Review of Mandatory Training programme for 

Infection Prevention so that IPLPs can deliver an 

evidence based training programme for all 

healthcare workers and that such programmes 

are consistent throughout all hospitals. 

• Infection Prevention Policies have been reviewed 

and updated in line with national guidance and 

published documents. 

• The introduction of patient information leaflets 

developed for MRSA and Clostridium difficile. 

• Raised the profile of Nuffield Health through 

representation on the following; 

– Independent Healthcare Advisory 

Services (IHAS) Infection Prevention Committee, 

– Department of Health Performance 

Improvement Network meetings, 

– Infection Prevention Society working group 

[with DH] on developing Quality Improvement 

Tools to monitor infection prevention standards 

• Care is monitored and risks identified promptly 

through a rigorous audit and surveillance 

programme. 

Blood stream infections Q1 2008 Q2 2008 Q3 2008 Q4 2008 

MRSA 0 0 0 0 

MSSA 1 0 0 0 

Enterococcus/streptococcus 0 0 1 0 

Candida albicans 1 0 0 0 

Alert Organisms 

Clostridium difficile 2 1 1 0 

Tuberculosis 0 1* 0 0 

Surgical Site Infections 

Hip arthroplasty 2 3 2 1 

Knee arthroplasty 2 1 2 3 

“The challenge for 2009 is to 

keep ahead of the game, 

providing high quality, cost 

effective care in a clean, safe 

environment in which our 

medical colleagues want to work 

and which inspires patients 

confidence in the services that 

we provide.” 

*Non hospital acquired


33 

04 

TRAINING, LEARNING & DEVELOPMENT 

The responsibility for monitoring and 

planning of all group learning initiatives 

is specifically designed to facilitate 

employee skills. There is no better way to 

ensure safety than to invest in our people. 

The key activities for 2008 were to: 

01. Organise a cross-divisional 

Group Training Forum (GTF); 

02. Introduce an enterprise class Learning 

Management System (LMS) to increase 

employee access to learning and personal 

development; 

03. Deploy and monitor a mandatory learning 

roadmap; 

04. Publish a Group Training Prospectus to clearly 

set our ambitions for 2009. 

Diagram 3: GTF reporting into the Group Integrated Governance Committee 2008 

Group Training Forum 

Meeting four times a year and reporting into the Group 

Integrated Governance Committee (GIGC), see Diagram 

3, the GTF comprises of influential learning & development 

(L&D) business partners. 

The key purpose of the forum is to agree a framework 

or roadmap of Mandatory and Statutory learning. 

This is designed to address our legal and governance 

commitments. This learning exercise has been included in 

the 2009 Nuffield Health Training Prospectus. 

2009 Training Prospectus 

In addition to providing all employees with comprehensive 

access to all risk management provided by Nuffield 

Health, the prospectus will also provide an overview to 

Group L&D strategy and state the key performance 

indicators that the training forum will be assessed against. 

We monitor the success of training in terms of satisfaction, 

governance assurance, behavioural change and relevance 

of course content. 

Diagram 4: Shows how internal and external skill 

providers would work together in the first 12 weeks 

of an employee’s service, to progress the employee 

to Stage 4 and an NVQ level II award 

Group L&D Strategic Overview 

Putting Nuffield Health in the forefront of “life long 

learning” for its employees and in order to aspire to being 

the employer of choice, the prospectus for 2009 will lay 

the foundation for Nuffield Health to create a ‘Nuffield 

Health Diploma in Healthcare’. The diploma will be worth 

at least an NVQ level II (5 GCSEs), and will be flexible 

enough to be built upon by the learner pursuing higher 

awards, in or out of the workplace. 

The intention is for every new employee to enjoy an 

inclusive induction programme with constant reinforcement 

of role based skills. The classroom based learning is 

broken into smaller modular units designed to support the 

employee throughout the critical first 12 weeks of service. 

Our development in 2008 and ambition for 2009 is 

focused specifically on achieving stage 2 of our journey, 

with the core of Mandatory and Statutory delivery being 

conducted in stage 2. 

Group 

Infection 

Prevention 

Training Products taken 

from the Discovery Catalogue 

Training Products taken 

from the Connect Catalogue 

Group Datix 

Forum 

Group 

Training 

Forum 

Group 

Integrated 


Committee 

Board 

Integrated 


Committee 

Stage 1 

Engagement 

Localised 

Team 

Induction 

Stage 2 

Foundations 

Stage 3 

Consolidation 

2009 2010 and beyond 

Mandatory 

Training 

Localised 

Skill 

Management 

Stage 4 

Specialisation 

Coaching 

Others 

Technical 

Proficiency 

Group Meds 

Management, 

Medical Devices 

Committee 

Group 

Information 


Forum 

Corporate 

Orientation 

Nuffield 

Culture and 

Values 

IT Systems 

Basics 

Translate 

Learning into 

Performance 

Targeted 

Technical 

Skills 

Towards 

Leadership


35 

04 TRAINING, LEARNING & DEVELOPMENT 

The Learning Management System 

2008 witnessed the Group wide launch of the Nuffield 

Health Learning Management System (LMS). This new 

system will provide the whole business the following 

benefits: 

1. All employees will be able to view, plan and book 

classroom or online based learning 

2. Print and store certificates for courses 

3. Participate in peer forums with instant access to 

knowledge, associated learning content and 

Frequently Asked Questions. 

4. Run reports for individual learning, Group wide 

risk management training, and professional 

development. 

5. Find and print handouts and other learning 

& development based documents 

6. Courses can be found using a graphic calendar, 

keyword search or by browsing a picture based 

course catalogue 

7. Based on indicators the LMS can alert, via email, 

key governance employees to a reduction in 

compliance of risk management training 

8. Based on role, new employees will be 

automatically allocated all their Mandatory and 

Statutory risk management training and then 

attendance is automatically monitored by the LMS 

Diagram 5 

Automatic 

designation of 

training based 

on Role 

Classroom 

and Online 

Course 

Scheduling 

LMS 

Personal 

Development 

Plans 

Fitness & Wellbeing Innovation 

2008 witnessed the Group wide launch of the Nuffield 

Health Learning Management System (LMS). This new 

system will provide the whole business the following 

benefits: 

• Our Corporate Wellbeing Advisors are now 

required to attain a First Aid course at Work (FAW). 

• We have introduced an annual respiratory 

training programme for our physiotherapists to 

ensure training refreshers each year. 

• The Fitness & Wellbeing sector has introduced an 

additional health and safety trainer in 2008 so 

that a greater level of health and safety training is 

delivered internally to ensure continued quality 

standards. 

• Our Senior Wellbeing Advisors completed 

a structured training programme followed by 

15 practise Vi1 Health Assessments and a 

competency sign off by the Professional Head 

of Fitness. 

• Our Wellbeing Advisors completed a two day 

training course including an initial safety approval 

followed by 15 Vi1 Health Assessment practices 

and a competency approval. 174 Wellbeing 

Advisors have completed training. 

• A continuing programme of Wellbeing Advisor 

training is scheduled to operate throughout 2009. 

A Senior Wellbeing Advisor ‘Grow Our Own’ 

programme will be designed and implemented 

in 2009 to train Senior Wellbeing Advisor 

designates. 

• A programme of continuing professional 

development will be designed and implemented 

for all Wellbeing Advisors and Senior Wellbeing 

Advisors in 2009 following the same industry 

beating model we have used for physiotherapy 

and physiology. 

“All employees will 

be able to view, plan 

and book classroom 

or online based learning” 

Mandatory 

Training 

IT Training 

Clinical 

Training


37 

05 WORKING WITH DOCTORS 

Doctor Engagement is an integral part 

of the day to day management of the 

hospitals and there is a central team 

whose function is to support and advise 

the hospitals and operational managers. 

The central programme for doctor 

engagement in 2008 comprised two 

elements: 

•Operational Management and 

clinical and corporate governance. 

•Development of new ways of 

working with consultants in 

partnership. 

At the end of the 

2008 Nuffield Health 

introduced Practice 

Privileges Plus (PP + ), 

a new and innovative 

model for working in 

partnership with our 

Consultants 

Operational Management 

Healthcare is constantly changing and evolving. 

Governance monitors that change to ensure safe and 

effective care delivery. Independent healthcare is no 

different. 

Practising Privileges 

In 2008 Nuffield Health reviewed the way practising 

privileges (PPs) licences are administered and managed 

within hospitals. This review identified the need to update 

both the policy and the administration process. There is a 

project underway to centralise the administration of PPs, 

and reduce the burden on the Consultants who currently 

have to provide the same information to each hospital at 

which they practice. 

This database, whilst held centrally, is managed locally 

and will allow for central monitoring on compliance with 

many mandatory and local requirements; for example – 

Criminal Records Bureau (CRB) clearance, data protection 

registration, clinical audit data and whole practice 

appraisal. This will make it much easier for Nuffield Health 

to provide consultants with information they require for 

whole practice appraisal, and re-licensing and 

revalidation when it is introduced by the General Medical 

Council (GMC) in 2009. 

The early stages of work are underway to enable 

information on the database to be linked into the Nuffield 

Health website for patients to view the profile and agreed 

data of a consultant to whom they have been referred. 

The practising privileges policy has been reviewed and 

the new version is currently out for consultation and 

implementation during 2009. Nuffield Health is 

participating in a working group set up by the 

Independent Healthcare Advisory Services, and chaired 

by Dr Andrew Jones, Group Medical Director of Nuffield 

Health, to review Practising Privileges across the 

independent sector and recommend a framework for 

policy development. Nuffield Health has been instrumental 

in developing that framework and the new practising 

privileges policy will reflect that work. 

Reviews 

The Doctor Engagement team has undertaken several 

reviews in response to requests from consultants. 

• The requirements for CRB clearance have been 

reviewed and confirmation obtained that CRB 

clearances are not transferable outside Nuffield 

Health. Consultants are unable to use clearances 

obtained elsewhere, or in turn to use their Nuffield 

Health clearance somewhere else. An advice paper 

regarding the introduction of the Independent 

Safeguarding Authority and the requirement for 

people working with children and vulnerable adults 

to register with them in 2009 is being developed 

and will be issued in early 2009. 

• There was a review of consultants’ registration on 

the GMC specialist register. This identified a small 

number of consultants who were not on a register, 

and Nuffield Health met the GMC to discuss 

future registration. With the introduction of the 

re-licensing and revalidation programme in 2009, 

those consultants who are not currently on the 

specialist register and who have been tied up in 

the PMETB application system should be able to 

register later this year. 

• A review of the data protection requirements for 

consultants was undertaken and guidance issued 

that all consultants engaged in delivering care in 

the independent sector should be registered as 

data controllers with the Information 

Commissioners Office. This is now a requirement 

for maintaining practising privileges within 

Nuffield Health. 

• Consultants’ compliance with policies and 

procedures within Nuffield Health was reviewed 

and Nuffield Health reissued the Consultants 

handbook which gives requirements, brief details 

and the location of all policies and procedures 

that apply to Consultants. It is an aide memoire 

and ensures all consultants are aware of the Care 

Standards Act, the National Minimum Standards 

and the personal requirements and responsibilities 

that arise from them. 

Partnership with Consultants 

The last year has seen a focus on improving 

communication with consultants. This happened in several 

ways; with the Group Chief Executive roadshows when 

David Mobbs and Trish Cassidy visited all parts of the 

country and met with consultants; with conferences for the 

Medical Advisory Committee Chairs, the Designated 

Consultants who advise on Clinical Governance, and 

Orthopaedic representatives. And with ‘Future Thinking’ 

our regular newsletter for consultants. It has culminated in 

the introduction of Practice Privileges Plus (PP + ), a new way 

of working with consultants that rewards loyalty and 

business growth, and concentrates on developing the 

relationship into one of partnership working. 

Each focused on the quality of care within Nuffield Health, 

although in slightly different ways. 

The Medical Advisory Committee Chairs’ conference 

was entitled ‘Quality Counts’. It discussed two questions 

in depth ‘Has quality made a difference?’ focusing on the 

last year in Nuffield Health and ‘How will quality matter 

in the future?’ looking at how quality will be measured 

and delivered in the future. 

The meeting agenda also covered the changes in 

re-licensing and revalidation; and the role of Medical 

Advisory Committees within Nuffield Health. 

The Designated Consultant forum also entitled ‘Quality 

Counts’, focused on reporting the clinical governance data 

from the last year and risk in the Healthcare workplace. 

There were workshops to discuss different scenarios, and 

a discussion about the role of the designated consultant. 

The Orthopaedic Consultants’ conference also had quality 

as a key theme running throughout the day. It asked the 

question – How does quality affect the orthopaedic 

market?, and focused on Nuffield Health’s approach 

to quality in orthopaedic care, looking at last year’s 

outcomes and future quality management. 

At the end of the 2008 Nuffield Health introduced its 

new and innovative model for working in partnership 

with Consultants which commenced on 1st January 2009. 

PP + rewards consultants for their loyalty and for increasing 

activity with Nuffield Health. It also creates a partnership 

that develops patient pathways and aims to improve 

patient care.


39 

06CLINICAL EFFECTIVENESS 

Last year an effective change 

management programme was 

implemented for pathway improvement 

at Nuffield Health. Coupled with 

engaging key staff, our approach aims 

to deliver excellence in care and a 

supportive cultural change in the 

pathways through the processes our 

clinical teams use to deliver care. 

Prioritising Care Pathway Development 

Our agreed definition of a care pathway is as follows: 

‘The way, in which we 

deliver care (clinical 

processes) across the whole 

patient journey, supported 

by the documentation where 

we record care given’. 

There is a clear imperative to improve the quality of our 

services, and all our staff can relate to this opportunity in 

standardising to achieve the best levels of service that can 

be offered. 

Pathway selection has been based on realising a 

combination of delivering safe and effective care, enhancing 

the patient experience and negating risk. Taking a systems 

approach, and analysing previous lessons learned we 

started with the fulcrum for the admissions process to develop 

the pre-assessment pathway. 

Number of reported incidents 

25 

20 

15 

10 

5 

0 

Table 14: 

Analysis of reported incidents related to pre-assessment 

(pre & post new pre-assessment system roll out) 

Oct. 07 

Medicine 

Management 

Infection 

Prevention 

Oct. 08 

Documentation 

Incidents 

Diagnostic 

Tests 

Category of reported incidents 

Process 

Incidents 

Lessons Learnt 

Our people are the key factor in the successful 

management of change. Excellence in care can be 

achieved when they understand the drivers for change 

and are fully engaged in its design and implementation. 

They also feel well supported in bringing about the 

improvements to patient care. The approach for preassessment 

re-engineering was inclusive of all key 

stakeholders and these principles will be adopted and 

refined for future pathway development: 

• Develop the product from a patient perspective 

• Adopt an inclusive approach from all professional 

groups to the design of the pathway 

• Underpin the pathway with evidence 

• Identify a hospital lead to champion the pathway 

and gain acceptance from Consultant groups 

• Engage the full support of the hospital senior 

management team to drive the implementation 

of the pathway 

• Support sites with implementation tools and 

regular update support strategies 

Driving the Changes 

Adopting a project management framework the key 

elements required to deliver an effective pre-assessment 

system were broken down into work streams. Senior staff 

from across the clinical community were identified to take 

these work streams forward through established working 

groups with input from Matrons and Pre-Assessment 

Nurses. Anaesthetists from different hospitals were also 

consulted. 

Implementing this change through pathway development 

highlighted the need to engage people from different 

functions and at different levels in the Group’s hierarchy. 

As a result of this work there has been a positive shift in 

our values towards our aspirations as an innovative and 

enterprising organisation. 

Pre-assessment Success 

Diagram 5: 

Pathway Framework 

New Services 

Identified 

Evidence based 

knowledge support tool 

Implementation 

Methodolgy 

SAFE 

CARE 

Consistent care 

documentation 

Care Record 

Outcome Measures 

We can now demonstrate an 80% reduction in incidents 

related to patient pre-assessment through analysis of 

reported incidents. The benefits have been wide ranging. 

These include a reduction in medication incidents, 

compliance with infection prevention policies, the use of 

standardised documents which ensure completion of tests 

and reduction of admission delays. 

Principles & methodology 

of design


41 

06CLINICAL EFFECTIVENESS 

Physiotherapy Treatment Pathways 

Our evidence based physiotherapy pathways continue 

to use the latest technical evidence. These have proved 

to be an extremely reliable clinical auditing tool to 

demonstrate consistency and reliability in identifying 

clinical results. Consideration is being given to the 

publication of our pathways by the Chartered Society of 

Physiotherapy (CSP) to cement our professional profile 

within the professional field of Physiotherapy. 

Patient Reported Outcome Measures 

The quality equation involves a number of factors, namely 

satisfaction, clinical variation and process measures of 

best practice. The UK health system will be amongst the 

first in the world to systematically use patient reported 

outcomes to add to this data. Nuffield Health has 

successfully piloted the collection of Patient Reported 

Outcome Measures (PROMS) and is on track to roll this 

out to all of its 30 hospitals by March 2009. 

This quality project is part of a pathway approach and 

pre-assessment project to improve the patient journey. 

Outcomes will be used to inform patient feedback to 

ensure that hospitals are truly focused on patient care; as 

an early warning governance tool to assist clinical team 

follow-up; to provide variance data to the pathway of 

care; and to add data to clinical performance for the 

purposes of clinical appraisal. 

Nuffield Health has worked closely with its clinical staff 

on the implementation of outcome measures and has 

identified some key lessons learnt. These are: 

• Systematised collection by design. Nuffield Health 

introduced PROMs through the pre-assessment 

of patients, by posting a questionnaire with the 

admission documentation. On admission, a 

completed questionnaire if it had been received will 

be entered in care records. The outcome measure 

has become integral to the care pathway; 

• Support local implementation. Matrons lead the 

change through project groups. A ‘must do’ 

document shows progress on key tasks and 

weekly conference calls offer central support. 

Consultants were involved in the project early on 

since Nuffield Health was keen to see PROMs 

implemented in partnership with them. Clinical 

leadership is crucial to ensure local cooperation; 

• Reduce the burden on frontline staff and patients 

where possible. Nuffield Health uses unique 

patient ID on forms. This avoids the need for 

patients to handwrite their personal details and 

assists with the centralised follow-up and analysis 

of PROMs data. 

PROMs will be a key part in our governance mechanisms 

to build in quality and the resulting information will ensure 

that Nuffield Health develops care pathways that achieve 

the best possible results for the patients. 


Fitness & Wellbeing 

Welcome to a smarter way of taking 

care of your health 

The transition from Cannons to Fitness and Wellbeing 

has been underpinned by quality initiatives from Nuffield 

Health Wellbeing division. 

In 2008 we successfully; 

• Removed all sun beds 

• Accredited all physiotherapists working in our 

Fusion network 

• Trained new Senior Wellbeing Advisors to work 

in every centre 

• Reconfigured the centres to deliver and introduce 

the new Vi1 health assessment 

• Introduced new branding, language and client 

health information 

• Introduced improved cleaning and towel 

arrangements 

In 2009 we intend extending a range of practitioners, 

Wellbeing services across the centres and create services 

to look after people with specific health problems. 

Our 53 Fitness and Wellbeing centres perform around 

5,000 Vi1 complementary health screens each month at 

the start and end of a Wellbeing programme. As in all 

other areas of the Charity these checks are continuously 

quality assured to ensure nothing is missed. This 

programme commenced in October 2008 for our 

144,000 clients and each month around 6% have 

problems such as high blood pressure, raised cholesterol 

or diabetes which are then investigated. 

Each assessment considers the issues around cardiac risk 

and also fitness to exercise. Results are discussed in 

a supportive manner with the client setting their own 

behavioural change goals with supporting information. 

Health Screening 

In 2008, we continued to be the second largest provider 

of health assessment outside the NHS. What makes us 

different is the detail that underpins the screening. 

13,289 ECGs were conducted including resting and 

stress tests. 1240 of these showed abnormal findings 

(9.3% of total), 137 had urgent results showing ischaemia, 

arrhythmia or other abnormalities. We undertook 3,786 

mammograms, of these 234 required further investigation 

(6.1% of total) and 23 were classified as urgent. Male 

patients consented to 6,276 prostate blood tests (PSA) 

with 189 needing further review (3.0% of total) of which 

38 patients were identified as being urgent. Female 

screening included 5,725 smears tests with 288 showing 

an abnormality (5.0% of total), 26 showed a clear marker 

for onward investigation (severe dyskaryosis). One patient 

required very urgent action. 54 patients had a marker of 

milder (mild dyskaryosis) change with interim follow-up 

arrangements being made. 207 inadequate smears 

(3.6%) were repeated, well within national guidelines 

of 7%. 

We conduct high level audits of all results to ensure that 

no stone goes unturned and that all important results are 

acted upon.


43 

07 PATIENT & CLIENT FOCUS 

“Nuffield Health 

continues to maintain the 

highest levels of customer 

satisfaction experienced 

by MSB Consultancy in 

21 years of undertaking 

this type of research 

internationally with 96 % 

of respondents rating 

their experience as 

‘good’ or ‘excellent’ 

with the same very high 

proportion stating that 

they would recommend 

Nuffield Health to 

friends or family, these 

are enviable ratings.” 

Don Porter 

Managing Director 

MSB Consultancy services 

Client Focus – 

Wellbeing Division 

Overall the balance of feedback has been good with 

clients recognising that the provision of a health 

assessment is a valuable stage in their client journey 

and that the assessment is educational and 

empowering. 

• Other clients providing feedback have felt that 

the advice relating to the increased risk of incidents 

while exercising is overly conservative. The 

Algorithm Generating Advice was developed 

following industry best practise and so it is felt that 

this was sound. We will however monitor feedback 

and outcomes to determine whether the Algorithm 

Advice should be amended. 

Table 15: 

Responses to patient 

survey questions 

- 2007 & 2008 

Patient Satisfaction Survey 

– Hospitals Division 

All patients attending a Nuffield Health Hospital either as 

an inpatient or day case are encouraged to complete a 

detailed questionnaire to provide feedback and rate their 

experience of the hospitals services. See table 15 for 

responses. 

The Patient Satisfaction Survey for 2008 revealed that 

96% of all patients rated their overall satisfaction as ‘good’ 

(28%) or ‘excellent’ (68%) with all Nuffield Health hospitals 

achieving at least a 91% (up 1% on 2007) overall 

satisfaction rating. 

The independent analysis of the questionnaires, conducted 

by MSB Consultancy, also showed that patients would 

‘strongly recommend’ (66% of patients - up 1% on 2007) or 

‘recommend’ (30%) the hospitals to their friends and family 

and that none (0%) would oppose a recommendation. 

The anonymous questionnaire allows all patients the 

opportunity to feed back and rate their experience across 

the patient journey. In total over 27,000 questionnaires 

were returned, 9,000 more than in 2007. 

The survey has also identified three areas of opportunity 

for improvement as follows: 

• Clarity of written or printed information about 

medicines 

• Providing all patients with written instructions and 

information about what they should or should not 

do after leaving hospital. 

• Choice of admission dates 

2007 2008 

Admissions process rated as very organised 84% 85% 

Comfort & facilities rated excellent/very good 91% 91% 

Cleanliness rated excellent/very good 95% 94% 

Confidence in Doctors, mostly/always 100% 100% 

Confidence & trust in nurses, mostly/always 98% 98% 

Involved in decisions, adequately/very involved 94% 94% 

Kept informed about care & treatment 97% 97% 

Clear explanation of risks & benefits 99% 99% 

Printed materials, coming in to hospital useful 95% 95% 

Explanation of complications, clear/very clear 96% 96% 

Point of contact given, at point of discharge 84% 84% 

Privacy & dignity always respected 93% 94% 

Explanation of outcome of procedure clear/very clear 96% 97%


45 

07 PATIENT & CLIENT FOCUS 

Complaints 

Fitness & Wellbeing 

There were only two significant written complaints from 

Fitness clients: 

• One client felt that the assessment was too 

structured and did not consider her complicated 

health history and also that the advisor completing 

the assessment was not welcoming and lacked 

empathy. 

• The second formal complaint was from a client 

who felt that we had overstated the significance 

of some previous health history and felt that our 

advice to undertake modified exercise as a 

consequence of her reported musculoskeletal 

history was too conservative. 

Physiotherapy 

There were three formal complaints in 2008 as follows: 

• Patient suffered Deep Vein Thrombosis (DVT) and 

subsequent Pulmonary Embolism. The DVT was not 

identified by the Physiotherapist. 

• Patient suffered patella fracture post-operatively 

and complained that the Physiotherapist acted 

inappropriately and caused his injury. 

A complaint was also lodged with the Health 

Professions Council, which was subsequently 

rejected as unsubstantiated. 

• Patient complained that a Physiotherapist had 

delayed the healing of his shoulder postoperatively, 

an assumption given credence by 

his consultant and the hospital Matron, despite 

a full report stating the contrary. 

All of these complaints were fully investigated and the 

Physiotherapist in each case was not found to have acted 

in an unsafe manner, or inappropriately. However 

complaints are always taken very seriously and there are 

learning points to share to enhance best practice. 

Hospitals Division 

All complaints from patients and clients are taken seriously, 

thoroughly investigated and, where required, appropriate 

action taken. Our main aim is to resolve the complaints 

raised by our users and learn from them to enable 

continuous quality improvement. 

During 2008 the Group complaints policy was reviewed 

and re-issued together with a new version of the 

complaints leaflet for patients. The policy and leaflet reflect 

our commitment to being open and honest with those who 

raise a complaint. 

A number of events took place in 2008 to help staff 

effectively manage the complaints process. These included 

training provided to Hospital General Managers and a 

Matrons leadership programme commissioned in 2008 

aimed at ‘Inspiring Excellence in Customer Service’. 

A key theme of the leadership programme was centred on 

managing the user’s expectations. Recognising that 

no service provider will achieve excellence 100% of the 

time, the complaints management aspect of the 

programme focused on service recovery. Teams have been 

actively encouraged to take ownership of problems and 

achieve quick and efficient resolution minimising escalation 

of complaints. 

A number of projects are underway from the leadership 

programme to ensure teams continue to value the 

importance of patient excellence in the achievement of 

Nuffield Health’s vision for the future. 

The Hospitals complaints data reported in 2008, includes 

reports from diagnostics.See table 16: 

Table 16: 

Number of formal complaints received - 2007 & 2008 

Stage of Complaint 2007 2008 

1 local resolution at the 1450 1573 

individual hospital/facility 

2 Escalated for 32 (2.24%) 38 (2.4%) 

Director’s review 

3 External Adjudication 8 (0.5%) 3 (0.2%) 

The total number of complaints received in 2008 equates 

to less than 1% of all inpatient and day case visits. 

The numbers of complaints being escalated for external 

adjudication have been reduced. We believe this to be 

as a direct result of improved management of complaint 

reviews at Level 2. 

To enable analysis and continuous improvement all 

complaints are reviewed and categorised into key 

performance areas, such as clinical care, admission 

and discharge arrangements, patient billing process, 

communication and information, hotel services etc. 

Table 17: 

Top five reasons for complaints (Hospitals) 

29% Concerns related to clinical care 

17% Communication/information 

15% Finance & billing 

9% Hotel services 

11% Attitude 

“Our main aim is to resolve 

the complaints raised by our 

customers and learn from 

them to enable continuous 

quality improvement.”


47 

08 

STAFF & PUBLIC HEALTH 

Occupational Health 

Occupational Health (OH) is concerned with protecting 

and promoting the health of staff at work and aims to 

balance the needs of individuals whilst supporting 

managers in meeting their obligations under Health and 

Safety Law, Employment Law and the requirements of the 

Care Standards Act 23 

OH services are provided to all divisions within Nuffield 

Health and are also extended to other business partners. 

Currently 24 hospitals and all HSSU units receive services 

from Nuffield Health OH nurses. Where internal services 

are not a viable option, these are obtained from third 

party providers. These include two independent OH 

practitioners and four NHS Trusts. There is scope to 

provide an internal service to two more hospitals during 

2009. We seek external guidance from a Consultant in 

Occupational Medicine to provide additional specialist 

support to the team. 

Service Provision 

OH activity is driven by occupational demands and hazards. 

Clinical settings generally require greater OH input and all 

hospitals and HSSU units have regular OH nurse site visits. 

Staff not based within a hospital who need an OH 

appointment are usually seen at the Nuffield Health hospital 

nearest to where they work or live. 

The range of services provided are described in the OH 

Operational Plan and include pre-employment screening, 

immunisation programmes, statutory health surveillance and 

sickness absence management. 

Blood Borne Viruses & Inoculation Injuries 

The risk of blood borne virus transmission is a significant 

occupational hazard for those exposed to blood and body 

fluids in the course of their work. Exposure occurs through 

needle stick injuries, cuts sustained whilst using or cleaning 

surgical equipment or through blood splashes to mucous 

membranes. There is a robust hepatitis B vaccination 

programme in place and this remains a key focus for local 

OH nurses. There are currently no vaccines available 

against Hepatitis C or HIV: the prompt management of 

needle stick injuries is therefore essential to minimise the 

risks of transmission. 

Table 18: 

Total number of inoculation injuries reported - 2007 & 2008 

Year Inoculation Splash Hospitals Total 

Injuries Injuries Reporting Incidents 

2008 144 10 30 154 

2007 109 3 36 112 

Table 19: 

Top ten causes of inoculation injuries 

Cause 

Number 

Suturing 23 

Other 19 

Cutting 15 

Intramuscular injections 11 

Unknown 8 

Cannulation 5 

Venepuncture 4 

Finger/heel stick 3 

Elecrocautery 2 

Drilling 2 

Blood Borne Viruses 

– Infected Health Care Workers 

Patients may be put at risk if a health care worker (HCW) is 

infected with a blood borne virus and carries out exposure 

prone procedures (EPP). Staff classified as EPP workers 

include surgeons, first assistants, scrub nurses, operating 

department practitioners, dentists and dental hygienists. 

In 2007 a Nuffield Health healthcare worker reported to 

OH when they were diagnosed as HIV positive. The Health 

Protection Agency (HPA) was informed and detailed risk 

assessments were completed with no cases of transmission 

identified. We worked openly with the Department of Health 

UK Advisory Panel for Blood Borne Viruses to allow an 

independent assessment to be made. 

This is the third time such an incident has occurred in 

Nuffield Health over the last eight years. In view of the small 

but significant risk to patients from such incidents, the blood 

borne virus screening policy has been revised. From March 

2009 all EPP staff applying to work within Nuffield Health 

for the first time will be required to provide evidence of their 

HIV, Hepatitis B and Hepatitis C status. 

Stress Management 

- Employee Assistance Programme 

In June 2008, in support of the stress management policy 

and in order to provide access to timely, reliable and 

confidential support for staff an employee assistance 

programme (EAP) was introduced. The EAP service is 

available 24 hours a day, seven days a week and is open 

to staff and their immediate family. 

The following telephone services are now available: 

• Counselling – emotional/psychological 

• Legal 

• Financial/debt 

• Citizens Advice Bureau style information services 

Driving at Work 

Driving at work is an occupational hazard which is being 

giving increasing prominence and companies are expected 

to assess the risks associated with driving at work and 

provide suitable control measures to reduce risks. 

For the last three years the Hospitals Division has worked in 

partnership with DriveTech a driving at work, risk 

management and driver training company. All staff in receipt 

of a car allowance or company car who drive regularly on 

company business are included in the risk assessment 

process. This involves completing an on line risk assessment 

with follow up control measures such as on-road training or 

attending a safe driving workshop, depending on the risk 

rating. No further follow up is required for low risk drivers. 

Most drivers within the Hospital Division have now been 

through the programme and the programme is at the 

‘maintenance’ stage with activity focused around new drivers 

joining the company. The process is now managed by 

Human Resources as part of the induction for new company 

car drivers. Whilst some staff are initially sceptical about the 

driving at work programme, all those who have completed 

a workshop or on road training have rated it highly and 

found it useful. 

Drivers for HSSU and mobile diagnostic services have a 

different driver programme in place to meet the specific 

needs of lorry drivers. 

Policy Development and Renewal 

During 2008 the following policies and procedures have 

been reviewed and re-issued: 

• Health Surveillance 

• Stress Management 

• Stressful and Traumatic Incidents 

• Inoculation Injury Management 

• Violence and Aggression 

• Testing Patients for Blood Borne Viruses 

• Sickness Absence Management 

Training staff in the prevention and management of needle 

stick injuries, to include the process for testing patients for 

blood borne viruses has been a key focus in 2008 with 

101 staff from 20 hospitals attending training. Further 

courses are planned for 2009. 

The Group Infection Prevention & Control Committee has 

recommended that all Wellbeing Advisors performing 

health assessments on clients that involve finger prick 

blood sampling must be offered a course of Hepatitis B 

vaccination, followed up by testing to assess immunity 

response. 

In addition to the telephone services, staff can view a wide 

range of information using the on line service.


49 

FUTURE DIRECTION 

By Dr Andrew Jones 

Group Medical Director 

Quality will never be a single 

measure; we recognise the 

combination of satisfaction scores, 

safe processes, clinical variation 

and outcome measures. 

Last year witnessed the creation of Nuffield Health as we embarked on a journey 

to meet the needs of the health consumer across the landscape recognising the 

importance from wellbeing to hospital care. 2008 allowed the enabling work to create 

an enhanced consumer experience, with high quality and safe services, investment in 

key infrastructure and completion of the diagnostic modernisation programme. 

In this 2008 quality report we hope to have 

demonstrated our ongoing commitment to high 

quality and safe services that deliver good 

outcomes of care. Our approach to clinical 

leadership and “Board to Ward” oversight has 

led to real benefits in open and transparent 

reporting of issues and a cohesive 

understanding of strategic risk management. 

Local clinical leadership will be as important 

to us going forward as it has been in the past. 

Our approach to quality has put us in good 

standing for the “High Quality Healthcare 24 for 

All” review by Lord Darzi in July 2008 and for 

the preparations for the creation of the Care 

Quality Commission as the gatekeeper across 

health and social care. This year will also see 

all Doctors issued with a licence to practice 

by the General Medical Council and we will 

play our part in contributing to revalidation 

ensuring we continue to work with the very 

best specialists. 

Health and wellbeing will increasingly be 

supported by good information. There will be 

no simple formula to measure quality and we 

will take a balanced approach to the use of 

patient satisfaction scores, risk based safety 

processes, clinical variation and patient 

reported outcome measures. Our top 10 

quality indicators are published by individual 

hospital on www.nuffieldhealth.com, and 

we will benchmark and collaborate with 

information providers to allow the health 

consumer information to guide health decisions 

against their needs. 

Added value will be as important in 

healthcare for 2009 as to the wider economic 

climate. Our pathways will continue to evolve, 

enhancing the benefits of pre-assessment, 

pre-surgical exercise programmes and 

extended physiotherapy and fitness recovery 

for major undertakings such as joint 

replacement. High quality healthcare will 

increasingly need to demonstrate the benefits 

and efficiencies for good long term outcomes, 

the avoidance of complications and the return 

on early preventative programmes. 

In difficult times the first casualty is usually 

training. Nuffield Health uses evidence as 

a guiding principle and smart organisations 

invest in regulatory and leadership training 

through good times and bad. Our learning 

management system became a green shoot 

at the end of 2008. 2009 will see the project 

develop to ensure that all our people engage 

in frequent online learning, to reinforce our 

passion and care and also to reinforce our 

independence and enterprise.


51 

APPENDIX 1 

MEMBERSHIP OF 

GOVERNANCE COMMITTEES 

Membership of the Board 

Integrated Governance Committee 

The Lord Glenarthur (Chairman) 

Mr Michael Smith 

Mr Christopher Tetley 

Ms Jane Wesson 

GOVERNANCE 

SUB-COMMITTEES 

Governor 

Governor 

Governor 

Governor 

Sub – Committees of the 

Group Integrated Governance Committee 

Group Infection Prevention Committee 

Group Medicines & Medical Devices Committee 

Group Training Forum 

Group Risk Management (Datix) Forum 

Group Information Governance Forum 

Group Blood Transfusion Committee 

Group Radiation Protection Committee 

Group Pathology Governance Committee 

Membership of the Group 

Integrated Governance Committee 

Dr Andrew Jones (Chair) Group Medical Director 

Su Barnett 

Group Governance 

Manager 

Ian Clements 

Karen Harrowing 

Stephen Outhwaite 

Ian Slonim 

Andrea Paterson 

Duncan Roper 

Gary Birney 

Gail Thomson 

Sue Millward 

Managing Director of 

Quadriga Health 

& Safety Ltd 

Group Chief Pharmacist 

Group Property Director 

Group Procurement & 

Supply Chain Director 

Group Occupational 

Health Manager 

General Manager HSSU 

Human Resources Director 

– Hospitals Division 

Hospitals Governance 

Manager 

Group – Consultant Infection 

Prevention Nurse Manager 

Dr Sarah Dauncey Medical Director – 

Wellbeing Division 

Harvey Seale 

Linda Tomlinson 

Jon Wood 

Annette Sparks 

Kathryn Vincent 

Edward Parkes 

Linda Ncube 

Sarah Geraghty 

(Secretary) 

Group Learning & 

Development Manager 

Group Radiology Manager 

Group IT Director 

Clinical Performance 

Manager 

Assistant Company Solicitor 

Outcomes Manager 

Group Integrated 

Governance Assistant 

PA to Group Medical 

Director 

REFERENCES: 

1. The National Health Service Litigation Authority, Acute 

Risk Management Standards (Independent Sector) 

April 2008 

2. ISO 27001 (Information Security). 

3. The Safer management of Controlled Drugs, 

Healthcare Commission Annual report, 2007 

4. The Medical Devices Directive, 93/42, European 

Community Directive 

5. Corporate Manslaughter and Corporate Homicide 

Act, 2007 

6. National Patient Safety Agency, Clean your hands 

campaign,2008 

7. National Patient Safety Agency, Patient Environment 

Action Team, 2006 

8. Submission and use of Performance indicators, 

Guidance for providers of acute hospital services in 

the independent sector, Healthcare Commission, 

2007 

9. Nuffield Health, Research Governance Policy, 2008 

10. National Patient Safety Agency/National Institute for 

Health and Clinical Excellence, Guidance to improve 

Medicines reconciliation, 2007 

11. Pharmacy in England, building on strengths-delivering 

the future, White paper for Pharmacy, 2008 

FEEDBACK 

We would be very pleased to receive 

feedback on any aspect of this report 

or answer any questions that the report 

raises for you. 

12. The Ionising Radiation (Medical Exposure) 

Regulations, IRMER, 2000 

13. National Patient Safety Agency, Right Patient Right 

Blood, Advice for safer blood transfusions, 2006 

14. The Blood Safety and Quality Regulations, 2005 

15. The Health and Safety Offences Act, 2008 

16. The Regulatory Reform (fire safety) order, 2005 

17. Reporting of Injuries, Diseases and Dangerous 

Occurrences Regulations, (RIDDOR) 1995 

18. The Children’s Plan, Building Brighter futures, 2007 

19. Every Child Matters, 2003 

20. Nuffield Health, Infection Prevention and Control 

Strategy, Protection from Infection, 2008 

21. World Health Organisation, my five moments for 

hand hygiene, 2008 

22. The Health Act, Code of Practice for the prevention 

and Control of healthcare associated infections, 

Department of Health, 2008 

23. Care Standards Act 2000 

24. High Quality Care for all, 

Department of Health, 2008 

Please send your feedback to: 

Su Barnett 

Group Governance Manager 


40 – 44 Coombe Road 

New Malden 

Surrey 

KT3 4QF 

e-mail: su.barnett@nuffieldhealth.com 

Telephone: 020 8329 6363

Integrated Governance Report 2008 - Nuffield Health

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