Our quality and safety

We aspire to be the best, safest and most effective health and wellbeing provider there is.

To achieve this, our people must be highly skilled professionals. Our processes, practices and procedures must be evidence-based, and meet or exceed healthcare standards. And our technology must be cutting edge.

Quality Assurance Framework

    1 Safety
    Meeting the highest possible standards of safety by avoiding harm, upholding professional standards and acting responsibly.
    2Effectiveness
    Being a trusted partner to our patients, members and customers by giving them a positive and reassuring experience.
    3Experience
    Providing evidence-based health and wellbeing expertise and services that lead to excellent outcomes.

We measure our success and quality through local and national monitoring, analysis and reporting of trends and incidents.

Each month, we report on the Safety, Effectiveness and Experience aspects of quality across our organisation to our operational Boards. A detailed review is presented to the Board Quality and Safety Committee (BQSC) each quarter. These reports help us track successes and areas for further improvement, with results shared across the organisation.

Further details can be found in our 2022 Annual Report.

Clinical Governance

Good governance is the core of continuous improvement and best practice. It ensures we are meeting regulatory standards and continuously improving our services and quality of care.


Hospital ratings

All our hospitals are inspected by independent healthcare regulators to guarantee they meet their respective country's quality and safety standards.

Patient Safety Incident Response Framework

Find out how we plan to improve the way we respond to and learn from Patient Safety Incidents (PSIs) across all our hospitals over the next 12 to 18 months.

NHS patients and commissioners

A collection of information and statements regarding NHS requirements.

Annual Report

Read our 2022 Annual Report to discover how we’re building a healthier nation through our connected health and wellbeing services, and to learn about the positive actions we’re making towards a more sustainable future.

Quality Improvement Plan

To deliver the highest quality care, we must continuously improve the services and support we provide. This year, we aim to improve data quality, incident reporting, policy compliance and assurance. Find out more below.

  • Launch of new Quality Management System

    • Procurement and implementation of a new Quality Management system, Radar, which is compliant with NHS England’s ‘Learn from Patient Safety Events’ (LFPSE) framework
    • Consolidate a number of collection tools as Radar modules, including Adverse Events; Risk Management; Complaint Management; Safety Alerts; Subject Access requests/Erasure requests; Document Management Repository
    • Streamline our Quality Management processes, and ensure we are complying with the latest regulations and best practices
    • Identify areas for improvement and make datadriven decisions, using the Initiative System to provide real-time data and analytics
    • Drive data quality for safety incidents and near misses, by educating and standardising reporting to support learning.

  • Patient Safety Incident Response Framework

    • Establish Executive Lead responsible for PSIRF and focus on leadership role model initiatives.
    • Establish a Quality Lead for Patient Safety
    • Create a working group to facilitate the achievement of key elements of PSIRF: a data-driven safety culture; a clear policy and plan, with well understood learning responses to prevent and react to patient safety incidents (PSIs); a standard for engaging and involving those who experience PSIs, and strong safety leadership
    • Develop a Patient Safety Strategy to articulate our approach to patient safety across all service lines
    • Provide educational support for staff involved in patient-facing roles, including those in investigatory, engagement and involvement roles.
    • To include Health Education England’s Patient Safety Syllabus
    • Establish robust oversight structure and process to allow for local engagement and empowerment.

  • Launch of Secondary Care Professional Leadership: Assurance Network

    • Ensure appointees are highly experienced and capable of overseeing Quality Assurance in their specialism centrally, and at hospital sites
    • Ensure appointees work within a professional role on site each week, maintaining clinical expertise and credibility within their specialism
    • Ensure appointees deliver clinical development and change within the hospitals, inspiring the clinical teams directly involved in patient care
    • Ensure appointees chair and co-chair Expert Advisory Groups within the organisation, motivating the clinical talent of the MDT within the specialty
    • Ensure appointees are capable of engaging with peers and colleagues across the NHS and the independent healthcare sector, influencing policy and development of national guidelines
    • Ensure appointees are members of key professional organisational boards, keeping Nuffield Health at the forefront of strategic development within the specialism.

  • Enhanced assurance across our hospitals

    • The Hospital Quality Review (HQR) audit tool will continue to be enhanced to integrate the Specialist Quality Assurance Review tools to aid triangulation, and improve efficiency to lessen operational impact
    • Simultaneous safety surveillance data will be used consistently to proportionately assess risk and inform the future targeted programme of integrated reviews
    • Reviews will include key areas within the patient pathways, and any other areas identified through proportionate risk assessment
    • In line with the planned introduction of the CQC’s new approach to inspections, we will include themed visits or reviews which may include a particular focus on a clinical specialty or care process
    • The outcomes of 2022 site HQR will drive 2023 quality initiatives of audit and action plans, clinical documentation completion, incident management processes, duty of candour management, and risk assessment consistency.