Council of Governors Meeting

Transcription

1 Council of Governors Meeting Date: Thursday January 9 Paper Title: Performance Update Prepared by: Presented by: Paul Quick, Performance Manager Ken Wenman, Chief Executive Action: Assurance Recommendation: The Council of Governors is asked to: note further detail of the Trust s performance contained within this report and the Integrated Corporate Performance Report; and raise any questions with Non-Executive Directors. Council of Governors Meeting January 9 Page of

2 Integrated Corporate Performance Report November Page of

3 Integrated Corporate Performance Report... Introduction The Integrated Corporate Performance Report (ICPR) includes: An Executive Summary - highlights the key areas of note and interest to the Trust Board. This summary includes details of any areas of significant exception where the Trust is either off plan or below target, together with the key actions that are being taken to address under-performance; A RAG rating Dashboard - summarises the RAG ratings of the key metrics monitored by the Trust. In order to promote consistency these are ordered according to the key headings contained within the A&E (999) Operating Plan; An Information Pack the comprehensive data set includes graphs and tables covering the full list of KPIs and metrics monitored by the Trust.... A&E (999) Performance A&E Incident Numbers A&E incident numbers in November were.9% higher than those reported in November and were.% higher than the contracted volumes for November. For the year to date ( April to November ) the incidents numbers are.% higher than the equivalent period last year and.9% above contracted volumes. Page of

4 .... Whilst overall incident numbers were.% lower than the volumes reported in April to November last year, variance in the year on year movements between the CCG areas continues to be seen. Incident numbers in BANES CCG have increased by.% and are currently.% higher in Wiltshire CCG. In comparison activity in Kernow CCG is currently.% lower than the incident numbers reported last year. Activity during recent months has been close to anticipated levels, with activity averaging around, incidents per week, however towards the end of November activity volumes increased peaking at over 9, incidents for the week commencing November, peaking at over,9 incidents per day on the weekend of the and December... The Trust has forecast daily activity volumes for the busy Winter period based on previous years activity levels, and is currently anticipating a number of days where activity may rise above, incidents (including Boxing Day and New Year s day which are expected to be the peak demand periods for the Trust). Activity levels for the first week in December were in line with forecast levels as depicted in the graph below... Based on forecast activity levels the Trust has developed Winter resilience plans including scheduling of additional Operational and Hub resources across the Winter period, focussing where possible to meet the identified peaks in demand for the service. Page of

5 .. ARP Response Times Category Response times in November were again (better than) then national standards for both the mean and 9 th centile metrics for the month. The Trust remains above (worse than) the national standard for Category, and incidents. The summary of performance against the Category and response time metrics on a weekly basis from October to 9 December is included within the table below. Category Mean Response Time (Mins) Category 9 th Centile Response Time (Mins) Category Mean Response Time (Mins) Category 9 th Centile Response Time (Mins) National Standard minutes minutes minutes minutes Week Commencing Oct Oct Oct 9 Oct Nov Nov 9 Nov Nov Dec mins secs mins secs mins 9 secs 9 mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins 9 secs 9 mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins secs mins 9 secs mins secs mins secs The Trust consistently delivers performance against the Category standards, however pressures resulting from the increased activity volumes during the week commencing November (9, incidents compared to a normal activity volume of around, incidents per week) saw increases in response times to all categories of incident. The Trust has seen improvements in the response times for the most serious patients (Category patients in particular) as a result of actions taken under the Quality Performance Improvement Plans (QPIP) which commenced in /. Further improvements have been seen as a result of actions outlined in the Performance Improvement Plan and more improvements as a result of these actions are anticipated throughout the remainder of /9. Mean Category incident response times across the Trust show expected variation in the month of November, with the longest mean response time in Kernow CCG (9 mins secs) compared to the shortest time of mins secs in Swindon CCG. Mean category response times in of the CCGs were below (better than) the minute national standard. Page of

6 It is important to note that the Category incidents represent around.% of all incidents received by the Trust (equating to around to incidents per day)..% of incidents in November received a response within minutes and 9.% of Category incidents received a response within minutes. The ARP performance figures for ambulance trusts in England are included within the Information Pack to provide benchmarking of response times and the other Ambulance Quality Indicator metrics. Following improvements in recent months the Trust is now below (better than) the nationally reported average response time for Category incidents. The Trust does however remain in the lower quartile for Category and other response time metrics. It is acknowledged that some of this national variance will be due to the extremely rural nature of the South West geography. During / the Trust commissioned ORH Ltd to undertake an assessment of the response times achievable across the South West based on the current levels of funded resources and the activity volumes contracted for /9. This review included complex resource modelling and identified that there was a gap between the anticipated performance deliverable from current resources and the national performance standards. The Trust has delivered response times better than identified through the ORH modelling on some incident categories (as outlined in the table below) for the period April to October. This has been achieved through additional resourcing above the 9% target levels being delivered on a consistent basis and additional actions to improve performance particularly within the Clinical Hub as identified in the Trust Performance Improvement Plan. Response Standard ORH Identified Performance from 9% Funded Resource Cover and /9 Contract Activity Volumes Actual Performance YTD Variance Category Mean mins 9 secs mins secs + secs Category 9 th Centile mins 9 secs mins secs - min secs Category Mean mins secs mins secs - mins secs Category 9 th Centile hrs mins secs mins secs - hr mins secs Category Mean hr mins secs hr mins secs - mins secs Category 9 th Centile hrs mins secs hrs mins secs + mins secs Category 9 th Centile hrs mins secs hrs 9 mins secs + hr mins secs.... The most significant adverse variance to expected performance levels is reported for the Category (999) 9 th centile metric. Performance against this metric in November reported an improvement to hours minutes, but remains higher than the modelled achievable performance of hours minutes. This metric is challenging for the Trust as the response times are based on a smaller number of incidents (around to Category incidents per day requiring a response at scene across the whole South West). A number of key actions have been taken with a view to improving performance in Category response times during October and November. This has included revised processes for escalation in the Clinical Hub for managing any Category incident which is awaiting a response for an extended length of time and the introduction of additional operational Page of

7 resources in key locations across the South West targeted at responding to these lower acuity incidents. This has contributed to the improvement in performance seen during November On December the Trust implemented an update to the MPDS triage system, which included a revised Dispatch Code Reference Table. Figures from the first few days following this update have indicated an increased volume of incidents being categorised as Category and this may have further impact on the Trust response times for this metric. Updates will be included within December s report. Following the release of the revised ARP guidance documentation in May the Trust is working with ORH and NHS Commissioners to refresh this modelling work undertaken during Quarter of /9 to confirm any remaining gap in resourcing levels and the expected impact of the work being undertaken and proposed within improvements plans provided in section of this report. A meeting with Commissioner and ORH to confirm the specification for this refresh of the modelling work was held during September with the work being undertaken in October and the results presented to NHS Commissioners in November. Actions to Deliver Performance Improvement To deliver performance improvements and where possible reduce the Trust response times to all categories of incident the Trust has undertaken a three phase approach: Phase One - Trust wide rota review to align rotas and fleet ratios to meet the new (increased) demand profiles and tackle inefficiencies. To ensure the right number of staff on duty at the right time in the right place. This was completed during / however the benefit of the rota changes on performance will only be fully realised when recruitment matches required establishment levels within each of the operational areas filling current vacancies within the rota patterns. Phase Two Quality Performance Improvement Plans to improve patient safety and performance by maximising resource availability. To provide additional capacity to focus on a small number of high impact actions across the Trust. QPIP Phase Sept to Dec - identified key areas of performance; QPIP Phase - focussed on further areas of performance and productivity improvements and commenced in Quarter of /. QPIP Phase commenced in June with a focus on delivering specific improvements in the ambulance Clinical Indicator metrics. This programme includes a series of focus events titled Saving Lives Together which were delivered across the Trust during September and October. Phase Three Performance Improvement Plan to address the performance gaps (after Phase and ) as per ORH analysis commenced in February and scheduled to continue throughout /9. Phase Three - Performance Improvement Plan (PIP) The Performance Improvement Plan (PIP) has been created to capture the key internal actions being undertaken by the Trust to deliver changes that will either directly or indirectly impact on the Response Times to all categories of incidents within the next months. Page of

8 The PIP does not include items that are outside of the scope direct control (eg reduction in NHS activity to the ambulance service) and does not include any items included within the Trust Transition Plans that may require additional investment from NHS Commissioners. Where possible the plan is focussed on those actions that deliver improvements in one of the key areas impacting on Response Time performance: Total Ambulance Incident Numbers; Call Answering; Call Coding and Allocation; Incident Outcomes (Hear & Treat, See & Treat, See & Convey); Call Cycle Times (Time to Scene, Time At Scene, Handover, Wrap Up); Operational Resource Hours Available. Performance against improvement trajectory that was developed during May for the Category Mean response times is provided below. As at the end of November the Trust reported a Category Mean lower (better than) the trajectory target..... However it is expected that a gap between the anticipated performance (even after these improvements) and the national performance standards for all metrics will remain as identified in the resource modelling work undertaken by ORH during /. Commissioner Action Plan and Transition Plan In addition to the Performance Improvement Plan the Trust is also committed to working with NHS Commissioners to identify joint actions which can assist the Trust in delivering the required transformational changes to further improve Response Time performance to national standard levels. These joint actions will be split into two areas: Commissioner Actions actions owned by NHS Commissioners to reduce inappropriate demand on the ambulance service and reduce areas of operational pressure (eg reductions in handover delays at acute hospitals, assistance in recruitment and retention plans); Transition Plan actions jointly owned by SWASFT and NHS Commissioners to deliver transformational change. Some of these actions may subject to investment being provided by NHS Commissioners (eg additional resources). Page of

9 Performance Assurance Meeting (PAM) The Trust s Performance Assurance Meeting (PAM) oversees the delivery of the Corporate Performance Improvement Plan and the associated the performance improvement trajectory. A key purpose of PAM is to identify and support the delivery of improvements in performance and to provide the appropriate focus and challenge on items which are recognised as needing attention to ensure they are implemented. Since the last report to the Board of Directors consideration has been given to developing a proactive/forward looking approach to the agenda for PAM meetings to ensure the programme of work planned for /9 is completed. Directorates continue to provide updates to the actions within the Performance Improvement Plan, which informs the work of PAM and drives the focus for the agenda. Additional Vehicle Funding The Trust has been successful in a bid to NHS England for the funding for an additional Front Line Ambulances. This is part of a wider ambulance Fleet enhancement to help Trusts meet the new Ambulance Response Standards. These vehicles will be centrally procured and some of the may be in operational service by the end of the financial year. This compliments the Trusts bid to NHS Commissioners for additional staff and resources to meet ARP Standards as part of the Transition Plan. NHS Performance NHS Call Answering performance during November was below the national target level of 9%..% of calls were answered within seconds in Dorset (compared to.% in September and.% in October ). Call abandonment rates also increased, linked to the drop in call answering performance, and were marginally above (worse than) the target level of % at.% in November. % of Call Answered within Seconds National Average % of Call Answered within Seconds NHS Dorset National Standard Week Commencing // // 9// // // 9%.%.%.9%.9%.% 9%.% 9.%.%.%.%.... Whilst performance in the Dorset service remains below the target levels, call answering performance within NHS services have also seen some deterioration, with the national average percentage below % performance at the end of November. Due to the high level of staff attrition within the NHS service the maintenance of the required Call Taker establishment levels to meet the required rota cover has been extremely challenging. Page of

10 .. A NHS Recovery Plan has been developed internally to deliver improvements in Call Answering Performance and Clinical Resilience within the Dorset NHS service. The key actions within this plan relating to Call Answering Performance are: Recruitment of additional Call Takers to fill current vacancies in Operational rotas recruitment is being undertaken through agencies to reach a larger number of perspective staff and improve the quality of candidates received. Interviews for perspective candidates were undertaken in November with NHS Pathways training courses scheduled for successful candidates in January 9 (one for part time and one for full time staff), with a view to introducing the additional workforce into rotas during February 9. In the interim the service faces challenges leading into the Winter Period with gaps in the current rotas which will, where possible be filled by Bank and Overtime shifts. Resource Profiling look at opportunities to work with NHS staff to match resource profiles to demand patterns within the NHS service. This will include the introduction of changes to the full time Call Advisor rotas during Quarter. Productivity Improvements additional management information has been made available to assist operational managers in reviewing performance and productivity levels within the service. These tools should enable improvement opportunities to be identified and assist in performance management of staff moving forward. Abstraction Management abstraction levels within the NHS service are currently above the funded levels, with sickness levels in particular above the target of % (.% in November ). The service is providing training to managers in elements of sickness management and looking at processes to enable staff to get back to work in a timely manner where appropriate Additional actions are being undertaken to recruit new Clinicians to the service to fill gaps within the current rotas, this is more challenging due to the limited supply of individuals with the required skill set for this role. In the interim the Trust is looking at other options to provide resilience across the winter period including the use of third party Clinicians where available and appropriate. The most significant challenge continues to be maintaining the required establishment levels for both Call Takers and Clinicians within the NHS service, with staff attrition of 9% over the past months. Training courses for new Call Takers on the NHS Pathways triage system lasts weeks, plus a further period time for staff to become confident and fully productive in post after those weeks have been completed. When this extended training time is added to the recruitment period for advertising and interviews the lead time for new Call Takers is considerable and struggles, at present to meet the reported attrition rates. Due to the timeline involved in recruiting and training additional Call Takers within the NHS service, the opportunity to deliver short term improvements in NHS call answering Page 9 of

11 performance is restricted, although plans are in place as detailed in the improvement plans above Without additional capacity/resource the NHS service is therefore likely to face some difficult challenges over the winter period. Whilst every opportunity will be taken to utilise available Bank staff and overtime shifts within the service to fill the gaps within the current rota patterns, the introduction of new staff will be the catalyst for significant improvement in call answering performance. This additional resource is not anticipated until February 9. Detailed resourcing plans are submitted to NHSE on a weekly basis to advise them of the current position which includes a look forward to the end of February 9 based on current available resources. Recruitment plans will be incorporated into these forecasts when the attendees on the courses are confirmed and rota patterns established. GP Out of Hours Service Performance (GP OOH) The Quality Requirements (QR) relating to Urgent Treatment Centre appointments and Urgent Home Visits remain the greatest challenge for the Dorset GP OOH service. The Trust has not been able to deliver these standards consistently although the patient numbers outside of the target are small. However, in recent months more consistent and improved performance levels have been seen for both Treatment Centre appointments and Home Visits and the Trust delivered compliance against all QR metrics in November. In November the Dorset GP OOH service was fully compliant against the Urgent and Less Urgent Treatment Centre Appointments standards. For Urgent appointments 9.% were achieved within the hour target, compared to the target of 9%. The Trust missed the hour target on of the urgent cases in November, of which the majority are missed during the busier weekend periods. For Less Urgent Treatment Centre appointments the Trust was also compliant with 9.% of appointments completed within the hour target (.% better than the 9% target). Home Visit performance in November was also fully compliant for both Urgent and Less Urgent cases. of Urgent cases received a response within hours (9.%). For Less Urgent Visits in November the Trust was compliant with 9.99% of visits responded to within hours. Urgent Care Centre (Tiverton) Performance The primary performance measure within this contract is the hour waiting time standard. In November,, of, patients were seen within hours giving performance of 99.% against the 9% performance target. Performance above target levels has been delivered consistently since contract inception along with a local standard to triage patients within minutes. In November, 99.% of patients were triaged in minutes against a target of 9%. Page of

12 Finance and Use of Resources The Trust is assessed by NHS Improvement against the Use of Resource Metric. Under the Use of Resource Metric the best score is and the worse score is. As the Trust has not accepted its control total for /9 the highest score the Trust can achieve is a. The Trust delivered a Use of Resource Metric of at the end of November. The score of is based on the Trust not delivering against the control total derived by NHS Improvement from the Trust financial plan. The financial information is based on the eighth month of the financial year and includes the actual and year end forecast position for the Trust against the /9 Financial Plan: The Trust delivered a deficit position of 9k at the end of November. The deficit position solely reflects those unplanned costs associated with supporting operational resilience activities and is consistent with the estimated costs submitted to NHSI/E on November, for total revenue costs of,k; The Trust is awaiting confirmation on how it should claim revenue costs from NHSE and capital from NHSI; The position includes an under spend on depreciation relating to the change in vehicle life from years to years. This underspend has been recommitted through budgets to support frontline activities; The annual Cost Improvement target for /9 is,k and the Trust is forecasting delivery but recognises a risk of,k in relation to schemes that are non-recurrent in nature; The Capital Plan for /9 has been revised to,k, (this includes the successful fleet capital bid). The month eight position shows an actual of,9k compared to a plan of,k; The Trust cash position at the end of November is,9k compared to the plan of,k. This variance relates to timing differences of expenditure including capital and the impact of depreciation changes; The debtors overs 9 days past due has decreased from 9.% to.9%. The outstanding balance over 9 days has decreased from k to k, the Trust overall value of debtors has also decreased by,k due to extensive resolution work by the financial accounting team; The Trust year to date agency spend is 9k. Page of

13 Appendix A: ICPR Dashboard November Clinical Quality & Patient Care Our People Operational Resources Productivity Performance Finance & Use of Resources Activity Revised Operational Rotas On the Road Establishment: were successfully implemented Category Mean and 9 th centile Establishment Lead Clinicians across the Trust as part of the response times in Nov were were. WTE below the A&E Operating Plan /. better than the national standards. funded establishment level of Performance Improvement Tiverton Urgent Care Centre,. WTE at the end of Nov Plan (PIP) for /9 has been continues to report performance CIP plans remain on target at A&E incidents were.% (improved from. developed to increase the Hear & Treat Rates are above better than 9% for the hour A&E the end of Nov, although above contract volumes in WTE in Sept ).This position availability of operational (better than) the national standard and minute triage,k is recognised as a Nov, and were.9% is forecast to improve to. resource hours. This includes average level. metrics. risk in relation to schemes that higher than the number of are non-recurrent in nature. AQI ROSC following Cardiac WTE vacancies at March 9, actions to reduce job cycle Further improvements rely on Performance against NHS incidents recorded in Nov Arrest is above (better than) but still would still be significantly times, utilise the most increasing the number of clinical KPIs, in particular the Capital Expenditure was at. the local threshold (all patients below the required levels. appropriate patient pathways, Clinicians in the Hubs through percentage of calls receiving clinical % of the YTD plan, with A&E incidents for the YTD and the Utstein Comparator Emergency Care Assistants improve efficient allocation and recruitment. input benchmarks well against other actual spend of,9k were.9% above contract Group). were. WTE above dispatch of resources and ARP response protocols have NHS Providers. compared to a plan of and were.% higher than establishment at the end of Nov removing any activity,k. The variance is due reduced the average number of Out of Hours Service performance in the number of incidents. Based on the planned inappropriate for the ambulance to an under spend against the resources arriving at scene per Dorset for Urgent and Less Urgent recorded in the equivalent attrition rates, recruitment and service where possible. Estate and HART vehicle incident. Treatment Centre Appointments period in / financial capital plans and the impact of training courses for /9 the The aim of the PIP is to deliver was complaint in Nov. year. depreciation changes. position at the end of March 9 improvement (reductions) in the Out of Hours Service performance in is forecast to be. WTE response times across the Dorset for Urgent and Less Urgent above funded establishment South West towards the national Home Visits was complaint in Nov levels. performance standards for all. response time metrics. Revised AQI clinical metrics were introduced in November, reporting against these metrics is provided in arrears and data is included within the ICPR Information Pack for reference. Thresholds for these new metrics have not yet been agreed and therefore performance is included for information as well as benchmarking data against other ambulance trusts. AQI STEMI patients receiving an appropriate care bundle is below the local threshold. AQI Stroke patients (assessed face to face) receiving an appropriate care bundle is marginally below local threshold. AQI Cardiac Arrest Survival to Discharge rate is below local threshold (all patients and the Utstein Comparator Group). Page of Time to Answer Calls is included within the new ARP metrics, with the Mean, 9 th and 99 th centile figures now reported. In Nov the Trust reported a Mean call answering time of seconds, 9 th centile of seconds and 99 th centile of seconds. All three metrics were below (better than) the national average for Nov. Recruitment plans for /9 include maintenance of both Clinician and Call Taker establishment levels at or above funded levels throughout the year. Staff Appraisals were below target levels at.% at the end of Nov. Frontline Ops and Hub appraisals were marginally below target at % and focus will be on improving this position during Quarter / of /9. The most significant challenges are within the Out of Hours and NHS services, with appraisal performance dropping to % and % respectively. To assist in future management of appraisals HR are working with Operational Managers to reprofile appraisals throughout the year to reduce peak periods for appraisal completion. 999 Sickness levels are higher than those seen in November last year at.% in Nov (.% in Nov ). Clinical Hub Sickness levels remain above the target levels, with.9% reported in Nov (.9% in Nov ). NHS Sickness levels remain a priority to address with.% sickness in Nov. The current under establishment (in line with forecast and higher abstraction levels are impacting on the ability to deliver consistent resourcing to meet the new rota schedules on a daily basis. Mitigation for the current under establishment includes overtime, agency and third party use until vacancies are filled and abstractions are managed back to planned levels. Significant improvement not expected until Feb 9. On Scene times and Wrap Up time improvements are expected as per the Performance Improvement Plan. Performance Management reports are produced on a monthly basis to assist local operational managers in benchmarking performance, identifying best practice and identifying individual outliers. Handover Delays - any operational time lost to these delays impact directly on the number of resources available. Despite the overall reduction in time lost compared to last year, local issues remain and vary on a daily basis. Action plans to improve the position at those acute hospitals with the highest (worst) time lost have been introduced. Ongoing monitoring is required to ensure these positive changes during the early part of /9 are sustained. ORH resource modelling has previously identified the challenge to deliver response time targets for Category incidents. NHS Call Abandonment rates were marginally higher (worse) than the % target Response Times for Category, and incidents were above (worse than) the national standards in Nov. It is acknowledged that ambulance trusts need to undertake operational model changes to meet the new AQI standards. NHS Call Answering performance was below 9% in Nov. The percentage of Debtors over 9 days was.9% at the end of Nov (.% in September ), above the % target level. The outstanding balance over 9 days improved to k at the end of Nov. It should be noted that a proportion of these aged debtors are subject to agreed, staged repayment plans. The Trust delivered a deficit position of 9k at the end Nov ; The deficit position solely reflects those unplanned costs associated with supporting operational resilience activities (revenue costs submitted to NHSI/E in Nov of,k). Revised rota patterns were introduced during / following extensive remodelling of operational resources. The revised rotas introduced across all areas of the Trust are designed to align operational resources to current demand patterns. The expected performance improvement will not be fully realised until the shifts are filled. The ability to fulfil the revised shift patterns on a consistent basis is linked to the delivery of funded establishment levels. There is considerable variation in CCG activity levels for the year to date. Bath & North East Somerset CCG is.9% above contract volumes and Wiltshire CCG is.% above contract volumes. At the other end of the scale Kernow CCG is.% below contract volumes.

14 Appendix B: Integrated Corporate Performance Report Information Pack November Integrated Corporate Performance Report

15 People Finance Patient Performance Quality and Governance Metrics Actual Target Var to Target PY Actual Var to PY Actual Target Var to Target PY Actual Var to PY Adverse Incidents Reported in Month 9 -,,9 -, A&E Incidents,,9.%,.9%,9,9.9%,.% Adverse Incidents Relating to Medication Administration, Prescription and Supply Errors Nov- YTD A&E Performance Metrics Cat Mean :: :: :: :: :: :: Serious Incidents Identified in Month - - Cat 9th Centile :: :: :: :: :: :: Central Alert System (CAS) Received Cat T 9th Centile :: :: :: :: :: :: Moderate Incidents Confirmed in Month Cat Mean :: :: :: :: :: :: Complaints Reported Cat 9th Centile :9: :: :9: :: :: :: PALS Reported - - Cat Mean :: :: :: :: :: :: SIRS Reported Cat 9th Centile :: :: :: :: :: :: Safeguarding Referrals,,9, 9,, Cat 9th Centile :: :: :: :9: :: :9: Actual Target Nov- Var to Target PY Actual Var to PY Actual Target YTD Var to Target PY Actual Var to PY AQI Clinical Indicators Reported in Arrears to Other Data Feeds - Monitored on a Rolling Month Basis Outcome from Cardiac Arrest - Return of Spontaneous Circulation (ROSC) at time of arrival at hospital (overall) Outcome from Cardiac Arrest - ROSC at time of arrival at hospital (Utstein Comparator Group) Outcome from Cardiac Arrest - Survival to Discharge - overall survival rate Outcome from Cardiac Arrest - Survival to Discharge - Utstein Comparator Group survival rate % of patients with a pre-hospital diagnosis of suspected STEMI confirmed on ECG receiving an appropriate care bundle % of suspected stroke or unresolved transient ischaemic attack pateints assessed face to face that received an appropriate diagnostic bundle AQI Clinical Indicators Reported in Arrears to Other Data Feeds - In Month Performance STEMI - Mean time from call to catheter insertion (hrs:mins) STEMI - 9th Centile time from call to catheter insertion (hrs:mins) Stroke - Mean time from call to hospital arrival Stroke - Median time from call to hospital arrival (hrs:mins) Stroke - 9th Centile time from call to hospital arrival (hrs:mins) Stroke - Mean time from arrival at hospital to CT scan (hrs:mins) Stroke - Median time from arrival at hospital to CT scan (hrs:mins) Stroke - 9th Centile time from arrival at hospital to CT scan (hrs:mins) Stroke - Mean time from arrival at hospital to thrombolysis (hrs:mins) Stroke - Median time from arrival at hospital to thrombolysis (hrs:mins) Stroke - 9th Centile time from arrival at hospital to thrombolysis (hrs:mins) Aug to Jul Call Answering Mean (secs) (compared to National Avg in month) - Var to Var to Actual Target PY Actual Call Answering 9th Centile (secs) (compared to National Avg) - Target PY.%.%.%.%.% Call Answering 99th Centile (Secs) (compared to National Avg) -.%.%.%.%.% Time Lost to Handover Delays Over Mins (hrs:mins) 9: : : : : :.% 9.% -.%.%.% % of Handovers in Excess of Mins.% 9.%.99%.9%.%.%.%.% -.%.% -.% Time Lost to Handover to Clear Over Mins (hrs:mins) : 9:9 : : 9: :.%.% -.% 9.9%.% % of Handover to Clear in Excess of Mins.9%.% -9.9%.%.% -.% 9.% 9.% -.% 9.%.9% Outcomes (Contract) - Hear & Treat.%.%.%.%.% -.% Jul- Outcomes (Contract) - See & Treat.%.% -.%.%.% -.% Actual Nat Avg Var to Nat Avg PY Actual Var to PY Outcomes (Contract) - See & Convey Non ED.%.% -.%.%.9% -.% : : : Outcomes (Contract) - See & Convey ED 9.9%.%.%.%.%.9% : : :9 Oct- YTD NHS, Out of Hours and Urgent Care Centre Metrics Var to Var to Var to Var to Actual Target PY Actual Actual Target PY Actual Target PY Target PY : : : NHS % of Calls Answered in Secs.% 9.% -.%.% -.9%.% 9.% -.%.% -.% : : : NHS % of Calls Abandoned.9%.%.9%.%.9%.9%.% -.%.%.% : :9 : OOH Dorset - QR Urgent Home Visits in Hrs 9.% 9.% -.9%.%.% 9.% 9.% -.%.9%.% : : : OOH Dorset - QR Less Urgent Home Visits in Hrs 9.% 9.%.% 9.%.% 9.% 9.%.% 9.9%.9% : :9 : OOH Dorset - QR Urgent TC Appointments in Hrs 9.% 9.%.%.%.% 9.% 9.% -.% 9.%.% : : : OOH Dorset - QR Less Urgent TC Appointments in Hrs 9.9% 9.%.9% 9.9%.% 9.% 9.%.% 9.%.% : : : Tiverton UCC % Triage Commenced in Mins 99.% 9.%.% 9.%.% 9.9% 9.%.9% 9.%.% : : : Tiverton UCC % Cases Completed in Hrs 99.% 9.%.% 99.% -.% 99.% 9.%.% 99.% -.% Establishment and Staff Metrics - In Month Performance Trust Total Establishment WTE A&E Lead Clinician Establishment WTE A&E Emergency Care Assistant Establishment WTE A&E Hub Total Establishment WTE NHS Total Establishment WTE OOH Dorset Total Establishment WTE Trust Total Staff Turnover % Trust Staff Sickness % Trust Staff Appraisal Completion % Nov- Nov- Var to Var to Var to Actual Target PY Actual Actual Plan Var to Plan PY Actual Target PY PY,99.,. -.,9.. Capital Service Cover ,.,. -.,.9. Liquidity Days , I&E Margin % -.%.% -.%.% -.% Variance in I&E Margin as % of Plan -.%.% -.%.% -.% Agency Spend Variance to Cap (YTD) % -9.% -9.% -.% Use of Resources Rating......%.% -.% Capital Expenditure vs Plan YTD %.% -%.9%.%.9%.9%.9% CIP vs Plan YTD % % %.%.% -.% 9.% -.% Debtors Over 9 Days %.9%.%.9% 9.% -.9% Creditors Over 9 Days %.%.% -.%.%.%

16 Ambulance Response Programme (ARP) The Trust has participated in the Ambulance Response Programme (ARP) trial since April. The Secretary of State for Health announced on July that the three tests of ARP have been met as follows: There is clear clinical consensus that the proposed changes will be beneficial to patient outcomes as a whole and will act to reduce overall clinical risk in the system; There is evidence from the analysis of existing data and pilots that the proposed changes will have the intended benefits and is safe for patients; There is an associated increase in operational efficiency. The aim is to reduce the average number of vehicles allocated to each 999 call and the ambulance utilisation rate. Further information on the Ambulance Response Programme, the new ambulance standards and a copy of Sheffield University s report on ARP can be found on the NHS England website: NHS England has also developed a guide to the new Ambulance Standards, which outline the purpose of ARP and the new ambulance standards that have been introduced. A copy of this easy read document can be found on the NHS England website: New standards, indicators and measures have been introduced through the ARP for publication in the NHS England Ambulance Quality Indicators (AQI). A technical guidance document issued in August (and updated in September ) has been developed to ensure that all aspects of ambulance performance are measured accurately and consistently. All ambulance trusts in England were required to commence reporting against the new standards by November. Compliance against the new standards is expected from April. Until then the standards proposed are to be used for monitoring purposes only to enable ambulance trusts to update their operating models to deliver the new performance standards. SWASFT implemented the new response time reporting standards required for ARP v. with effect from November. This report therefore includes data in relation to the old metrics up to and including November and reporting on the new metrics with effect from November. The new performance standards against which the Trust will be monitored are outlined in the table below: Category National Standard How long does the ambulance service have to make a decision? Category Category Category Category minutes The earliest of: Mean response time The problem being identified; An ambulance response being dispatched; minutes seconds from the call being connected. 9 th centile response time minutes The earliest of: Mean response time The problem being identified; An ambulance response being dispatched; minutes seconds from the call being connected. 9 th centile response time minutes The earliest of: Mean response time The problem being identified; minutes An ambulance response being dispatched; 9th centile response time seconds from the call being connected. The earliest of: The problem being identified; minutes An ambulance response being dispatched; 9th centile response time seconds from the call being connected. Integrated Corporate Performance Report

17 ARP. Performance Metrics -Response Times Target/ KPI YTD Category Response Time - Mean (hrs:mins:secs) Category Response Time - 9th Percentile (hrs:mins:secs) Category (Transport) Response Time - 9th Percentile (hrs:mins:secs) Category Response Time - Mean (hrs:mins:secs) Category Response Time - 9th Percentile (hrs:mins:secs) Category Response Time - Mean (hrs:mins:secs) Category Response Time - 9th Percentile (hrs:mins:secs) Category (999) Response Time - Mean (hrs:mins:secs) Category (999) Response Time - 9th Percentile (hrs:mins:secs) :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: n/a :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :: :: :9: :9: :: :: :: :: :: :: :: :: :: :: ARP. - Category Response Time (hrs:mins:secs) :: :: :: :: :: :: :: :: :: :: :: :: ARP. - Category Response Time (hrs:mins:secs) :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: ARP. - Category Response Time (hrs:mins:secs) ARP. - Category (999) Response Time (hrs:mins:secs) :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: Integrated Corporate Performance Report

18 ARP. Performance Metrics - Category Mean Response Times by CCG Bath & North East Somerset CCG Bristol, North Somerset & South Gloucestershire CCG Dorset CCG Gloucestershire CCG Kernow CCG NEW Devon CCG Somerset CCG South Devon & Torbay CCG Swindon CCG Wiltshire CCG Trust Total Target/ KPI YTD :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :9: :9: :9: :: :9: :9: :: :9: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: ARP. Performance Metrics - Category 9th Percentile Response Times by CCG Bath & North East Somerset CCG Bristol, North Somerset & South Gloucestershire CCG Dorset CCG Gloucestershire CCG Kernow CCG NEW Devon CCG Somerset CCG South Devon & Torbay CCG Swindon CCG Wiltshire CCG Trust Total :: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :9: :9: :9: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: Category - Mean Response Times by CCG - Current Month Category - 9th Percentile Response Times by CCG - Current Month Trust Total :: Trust Total :: Wiltshire CCG :: Wiltshire CCG :: Swindon CCG :: Swindon CCG :: South Devon & Torbay CCG :: South Devon & Torbay CCG :: Somerset CCG :: Somerset CCG :: NEW Devon CCG :: NEW Devon CCG :: Kernow CCG :9: Kernow CCG :: Gloucestershire CCG :: Gloucestershire CCG :: Dorset CCG :: Dorset CCG :: Bristol, North Somerset & South Gloucestershire CCG :: Bristol, North Somerset & South Gloucestershire CCG :: Bath & North East Somerset CCG :: :: :: :: :: :: :: Bath & North East Somerset CCG :: :: :: :: :: :: :: :: :: :: :: Integrated Corporate Performance Report

19 ARP. Performance Metrics - Category Mean Response Times by CCG Bath & North East Somerset CCG Bristol, North Somerset & South Gloucestershire CCG Dorset CCG Gloucestershire CCG Kernow CCG NEW Devon CCG Somerset CCG South Devon & Torbay CCG Swindon CCG Wiltshire CCG Trust Total Target/ KPI YTD :: :9: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: ARP. Performance Metrics - Category 9th Percentile Response Times by CCG Bath & North East Somerset CCG Bristol, North Somerset & South Gloucestershire CCG Dorset CCG Gloucestershire CCG Kernow CCG NEW Devon CCG Somerset CCG South Devon & Torbay CCG Swindon CCG Wiltshire CCG Trust Total :: :: :: :: :: :9: :9: :: :: :: :: :9: :: :: :: :: :: :9: :: :: :: :: :: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :: :: :: :: :: :: :9: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :9: Category - Mean Response Times by CCG - Current Month Category - 9th Percentile Response Times by CCG - Current Month Trust Total :: Trust Total :9: Wiltshire CCG :: Wiltshire CCG :: Swindon CCG :: Swindon CCG :: South Devon & Torbay CCG :: South Devon & Torbay CCG :9: Somerset CCG :: Somerset CCG :: NEW Devon CCG :: NEW Devon CCG :: Kernow CCG :: Kernow CCG :: Gloucestershire CCG :: Gloucestershire CCG :: Dorset CCG :: Dorset CCG :9: Bristol, North Somerset & South Gloucestershire CCG :: Bristol, North Somerset & South Gloucestershire CCG :9: Bath & North East Somerset CCG :: Bath & North East Somerset CCG :: :: :: :: :: :: :: :: :: :: :: :: :: Integrated Corporate Performance Report

20 ARP. Performance Metrics - Category Mean Response Times by CCG Bath & North East Somerset CCG Bristol, North Somerset & South Gloucestershire CCG Dorset CCG Gloucestershire CCG Kernow CCG NEW Devon CCG Somerset CCG South Devon & Torbay CCG Swindon CCG Wiltshire CCG Trust Total Target/ KPI YTD :: :: :: :: :: :: :: :9: :: :: :: :: :9: :: :: :: :: :: :9: :: :: :: :: :: :: :9: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :: :9: :: :9: :: :9: :: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: ARP. Performance Metrics - Category 9th Percentile Response Times by CCG Bath & North East Somerset CCG Bristol, North Somerset & South Gloucestershire CCG Dorset CCG Gloucestershire CCG Kernow CCG NEW Devon CCG Somerset CCG South Devon & Torbay CCG Swindon CCG Wiltshire CCG Trust Total :: :: :: :: :9: :: :: :: :: :: :: :: :9: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :: :: :: :: :: :9: :: :: :: :: :9: :: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :9: :: :: :: :: :: :: :: :: :9: :: :: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: Category - Mean Response Times by CCG - Current Month Category - 9th Percentile Response Times by CCG - Current Month Trust Total :: Trust Total :: Wiltshire CCG :: Wiltshire CCG :9: Swindon CCG :: Swindon CCG :: South Devon & Torbay CCG :9: South Devon & Torbay CCG :: Somerset CCG :9: Somerset CCG :: NEW Devon CCG :: NEW Devon CCG :: Kernow CCG :: Kernow CCG :: Gloucestershire CCG :: Gloucestershire CCG :: Dorset CCG :: Dorset CCG :: Bristol, North Somerset & South Gloucestershire CCG :: Bristol, North Somerset & South Gloucestershire CCG :: Bath & North East Somerset CCG :: Bath & North East Somerset CCG :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: Integrated Corporate Performance Report

21 Target/ KPI ARP. Performance Metrics - Category 9th Percentile Response Times by CCG Bath & North East Somerset CCG Bristol, North Somerset & South Gloucestershire CCG Dorset CCG Gloucestershire CCG Kernow CCG NEW Devon CCG Somerset CCG South Devon & Torbay CCG Swindon CCG Wiltshire CCG Trust Total ARP. Performance Metrics - Category (Transport) 9th Percentile Response Times by CCG YTD :: :: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :: 9:: :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :: :9: :: :: :: :: :: :9: :9: :: Bath & North East Somerset CCG Bristol, North Somerset & South Gloucestershire CCG Dorset CCG Gloucestershire CCG Kernow CCG NEW Devon CCG Somerset CCG South Devon & Torbay CCG Swindon CCG Wiltshire CCG Trust Total :: :: :: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :: :: :: :: :: :9: :9: :9: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: :: :: :: :: :: :: :: :: :: :: :: :9: :: :: Category - 9th Percentile Response Times by CCG - Current Month Category (T) - 9th Percentile Response Times by CCG - Current Month Trust Total :: Trust Total :: Wiltshire CCG :: Wiltshire CCG :: Swindon CCG :: Swindon CCG :: South Devon & Torbay CCG :: South Devon & Torbay CCG :: Somerset CCG :: Somerset CCG :: NEW Devon CCG :: NEW Devon CCG :: Kernow CCG :: Kernow CCG :: Gloucestershire CCG :: Gloucestershire CCG :9: Dorset CCG :: Dorset CCG :: Bristol, North Somerset & South Gloucestershire CCG :: Bristol, North Somerset & South Gloucestershire CCG :: Bath & North East Somerset CCG :: Bath & North East Somerset CCG :: :: :: :: :: :: :: :: :: :: 9:: :: :: :: :: :: Integrated Corporate Performance Report

22 Ambulance Quality Indicators. Metrics - National Benchmarking Category - Mean Response Time (Mins) Category - 9th Percentile Reponse Time (Mins) Category (Transport) Response Time - 9th Percentile (minutes) Category - Mean Response Time (Mins) Category - 9th Percentile Response Time (Mins) Category Response Time - Mean (minutes) Category - 9th Percentrile Reponse Time (Mins) Category (999) - 9th Percentile Response Time (Mins) Mean Time To Identify Category Incidents (where Category incidents are identified with Nature of Call or Pre-Triage Questions) (Seconds) 9th centile Time To Identify Category Incidents (where Category incidents are identified with Nature of Call or Pre-Triage Questions) (Seconds) Call Answering - Mean Answer Time (Seconds) Call Answering - 9th Percentile Answer Time (Seconds) Call Answering - 99th Percentile Answer Time (Seconds) % of Calls Closed with Telephone Advice or Referral to Other Service Mean Number of Ambulance Resources Allocated per Category Incident Mean Number of Ambulance Resources Arriving at Scene per Category Incident Mean Number of Ambulance Resources Allocated per Category Incident Mean Number of Ambulance Resources Arriving at Scene per Category Incident Mean Number of Ambulance Resources Allocated per Category Incident Mean Number of Ambulance Resources Arriving at Scene per Category Incident Mean Number of Ambulance Resources Allocated per Category (999) Incident Mean Number of Ambulance Resources Arriving at Scene per Category (999) Incident Period National Average East Midlands East of England London North East North West South Central South East Coast South Western West Midlands Yorkshire Nov- :: :: :: :: :: :: :: :: :: :: :: Nov- :: :: :: :: :: :: :: ::9 :: :: :: Nov- :: :: :: :9: :: ::9 :: :: :: :: :: Nov- :: :: :: :: :: :: :: :9: :: :: ::9 Nov- :: :: :: :: :: :9: :: :: :9: ::9 :: Nov- :: :: :: :: :: :: :: :: :: :9: :: Nov- :: ::9 :: :: :9: :: :: ::9 :: :: :: Nov- :: :: :: :: :: ::9 :: ::9 :: :: :: Nov- 9 9 Nov- 9 Nov- 9 Nov- 9 Nov- 9 Nov-.%.%.%.%.%.%.%.%.%.%.% Nov Nov Nov Nov Nov Nov Nov Nov Category - Mean Response (Mins) Category - 9th Percentile Response (Mins) Category - Mean Response (Mins) Category - 9th Percentile Response (Mins) Yorkshire :: Yorkshire :: Yorkshire ::9 Yorkshire :: West Midlands :: West Midlands :: West Midlands :: West Midlands ::9 South Western :: South Western :: South Western :: South Western :9: South East Coast :: South East Coast ::9 South East Coast :9: South East Coast :: South Central :: South Central :: South Central :: South Central :: North West :: North West :: North West :: North West :9: North East :: North East :: North East :: North East :: London :: London :: London :: London :: East of England :: East of England :: East of England :: East of England :: East Midlands :: East Midlands :: East Midlands :: East Midlands :: National Average :: National Average :: National Average :: National Average :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: :: Integrated Corporate Performance Report 9

23 Category - 9th Percentile Response (Mins) Category (999) - 9th Percentile Response (Mins) Mean Time to Identify Cat (NOC and PTQ) 9th Percentile Time to Identify Cat (NOC and PTQ) Yorkshire :: Yorkshire :: Yorkshire Yorkshire West Midlands :: West Midlands :: West Midlands 9 West Midlands South Western :: South Western :: South Western South Western South East Coast ::9 South East Coast ::9 South East Coast South East Coast South Central :: South Central :: South Central 9 South Central 9 North West :: North West ::9 North West North West North East :9: North East :: North East North East London :: London :: London London East of England :: East of England :: East of England East of England East Midlands ::9 East Midlands :: East Midlands East Midlands National Average :: National Average :: National Average National Average :: :: :: :: :: :: :: :: :: :: :: % Calls Closed with Tel Advice/Referral Mean Call Answer Time (Secs) 9th Percentile Call Answer Time (Secs) 99th Percentile Call Answer Time (Secs) Yorkshire.% Yorkshire Yorkshire Yorkshire West Midlands.% West Midlands West Midlands West Midlands South Western.% South Western South Western South Western South East Coast.% South East Coast South East Coast South East Coast South Central.% South Central South Central South Central North West.% North West North West North West North East.% North East North East North East London.% London London 9 London 9 East of England.% East of England 9 East of England East of England East Midlands.% East Midlands East Midlands East Midlands National Average.% National Average National Average National Average.%.%.%.%.%.% Mean Number of Ambulance Resources Arriving at Scene (Cat Incidents) Mean Number of Ambulance Resources Arriving at Scene (Cat Incidents) Mean Number of Ambulance Resources Arriving at Scene (Cat Incidents) Mean Number of Ambulance Resources Arriving at Scene (Cat (999) Incidents) Yorkshire. Yorkshire. Yorkshire. Yorkshire. West Midlands. West Midlands. West Midlands. West Midlands. South Western. South Western. South Western. South Western. South East Coast. South East Coast. South East Coast. South East Coast. South Central. South Central. South Central. South Central. North West. North West. North West. North West. North East. North East. North East.9 North East. London. London. London. London. East of England. East of England. East of England. East of England.9 East Midlands. East Midlands. East Midlands. East Midlands.9 National Average. National Average. National Average.9 National Average Integrated Corporate Performance Report

24 Ambulance Clinical Indicators Outcome from Cardiac Arrest - Number of Patients who had resucitation commenced/continued by ambulance service following cardiac arrest Outcome from Cardiac Arrest - Return of Spontaneous Circulation at time of arrival at hospital (overall) Outcome from Cardiac Arrest - Number of Patients who had resucitation commenced/continued by ambulance service following cardiac arrest (Utstein Comparator Group) Outcome from Cardiac Arrest - Return of Spontaneous Circulation at time of arrival at hospital (Utstein Comparator Group) Outcome from Cardiac Arrest - Survival to Discharge - Number of patients who had resuscitation by ambulance service following cardiac arrest Outcome from Cardiac Arrest - Survival to Discharge - overall survival rate Outcome from Cardiac Arrest - Survival to Discharge - Number of patients who had resuscitation by ambulance service following cardiac arrest (Utstein Comparator Group) Outcome from Cardiac Arrest - Survival to Discharge - Utstein Comparator Group survival rate Outcome from Cardiac Arrest - Number of patients with ROSC Outcome from Cardiac Arrest - percentage receivin post-rosc care bundle Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - Number of patients with a pre-hospital diagnosis of suspected STEMI confirmed on ECG - Quarterly Data from (Jan, Apr, Jul and Oct) Outcome from Acute STEMI - % of patients with a pre-hospital diagnosis of suspected STEMI confirmed on ECG receiving an appropriate care bundle - Quarterly Data from Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - Number of paitents directly admitted with an initial diagnosis of 'definite Myocardial Infarction' Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - Number of paitents directly admitted with an initial diagnosis of 'definite Myocardial Infarction' who had primary percutaneous coronary intervention (PPCI) Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - Mean time from call for help to catheter insertion for angiography for paitents directly admitted with an initial diagnosis of 'definite Myocardial Infarction' (hours:minutes) Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - 9th centile time from call for help to catheter insertion for angiography for paitents directly admitted with an initial diagnosis of 'definite Myocardial Infarction' (hours:minutes) Outcome from Stroke for Ambulance Patients - Number of suspected stroke or unresolved transient ischaemic attack pateints assessed face to face - to be published times a year (Feb, May, Aug and Nov) Outcome from Stroke for Ambulance Patients - % of suspected stroke or unresolved transient ischaemic attack pateints assessed face to face that received an appropriate diagnostic bundle - to be published times a year (Feb, May, Aug and Nov) Outcome from Stroke for Ambulance Patients - Number of patients either FAST positive, or with provisional daignosis of stroke transported by the Ambulance Service Outcome from Stroke for Ambulance Patients - Mean time from call to hospital arrival for patients either FAST positive, or with provisional daignosis of stroke transported by the Ambulance Service (hours:minutes) Outcome from Stroke for Ambulance Patients - th centile time from call to hospital arrival for patients either FAST positive, or with provisional daignosis of stroke transported by the Ambulance Service (hours:minutes) Outcome from Stroke for Ambulance Patients - 9th centile time from call to hospital arrival for patients either FAST positive, or with provisional daignosis of stroke transported by the Ambulance Service (hours:minutes) Target/ KPI Rolling Months Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- n/a, 9 9.%.%.% 9.%.%.%.%.%.%.%.% 9.%.9%.% n/a.%.%.%.%.%.%.%.%.%.%.%.%.9%.% n/a, %.%.% 9.%.%.% 9.%.%.% 9.% 9.%.%.9%.% n/a 9.%.%.%.%.% 9.%.%.%.%.%.%.%.9%.% n/a 9 tbc 9.%.%.% n/a, %.%.%.%.%.%.9% 9.9%.%.% n/a,9 9 n/a, 99 tbc :9 : :9 : : :9 : : : tbc : : : : : : : : : n/a, % 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.9% n/a, 9 9 tbc : : : :9 :9 : :9 : : tbc : : : : : : : : : tbc :9 : : : : : : : : Outcome from Stroke for Ambulance Patients - Number of stroke patients in SSNAP who had a CT scan Outcome from Stroke for Ambulance Patients - Mean time from arrival at hospital to CT scan for stroke patients in SSNAP who had a CT scan (hours:minutes) Outcome from Stroke for Ambulance Patients - Median time from arrival at hospital to CT scan for stroke patients in SSNAP who had a CT scan (hours:minutes) Outcome from Stroke for Ambulance Patients - 9th centile time from arrival at hospital to CT scan for stroke patients in SSNAP who had a CT scan (hours:minutes) Outcome from Stroke for Ambulance Patients - Number of stroke patients in SSNAP who had thrombolysis Outcome from Stroke for Ambulance Patients - Mean time from arrival at hospital to thrombolysis for stroke patients in SSNAP who had thrombolysis (hours:minutes) Outcome from Stroke for Ambulance Patients - Median time from arrival at hospital to thrombolysis for stroke patients in SSNAP who had thrombolysis (hours:minutes) Outcome from Stroke for Ambulance Patients - 9th centile time from arrival at hospital to thrombolysis for stroke patients in SSNAP who had thrombolysis (hours:minutes) Outcomes from Sepsis for Ambulance Patients - number of suspected Sepsis and patients with National Early Warning Score (NEWS) of or more Outcomes from Sepsis for Ambulance Patients - percentage of suspected Sepsis and patients with National n/a, 9 9 tbc : : : : : : : : : tbc : : : : : : : : : tbc : : : : : : :9 : : n/a 9 tbc : : : : : : : : : tbc : : : : : : :9 :9 : tbc :9 :9 : : : : : : : n/a 9 9 Early Warning Score (NEWS) of more who received the Sepsis care bundle tbc.9%.9% Integrated Corporate Performance Report

25 Note - For July data the STEMI timeliness data received from MINAP is incomplete due to a migration to a new data platform. NHSE is discussing further with MINAP during December. As part of the Ambulance Response Programme review of Clinical Outcomes, new timelines measures have been introduced for STEMI and Stroke, superseding the previous measures. Full definitions can be found at ST-segment elevation myocardial infarction (STEMI) The Myocardial Ischaemia National Audit Project (MINAP) have supplied: the count of patients transported by Ambulance Services in England with an initial diagnosis of definite Myocardial Infarction ; of those, how patient many had primary percutaneous coronary intervention (PPCI): inflation of a balloon inside a blood vessel to restore blood flow to the heart; for those, the time (mean average, and 9th centile) from the call for an ambulance, until the insertion of a catheter into the blood vessels, to examine whether PPCI is clinically appropriate. Stroke The FAST procedure helps assess whether someone has suffered a stroke: Facial weakness: can the person smile? Has their mouth or eye drooped? Arm weakness: can the person raise both arms? Speech problems: can the person speak clearly and understand what you say? Time to call 999 for an ambulance if you spot any one of these signs. The Ambulance Services of England have supplied the numbers of patients they transported that were either FAST positive, or had a provisional diagnosis of stroke; and of those, the time from the call for an ambulance, until arrival at hospital. Complementing that, the Stroke Sentinel National Audit Programme (SSNAP) have supplied: the numbers of stroke patients who had a CT scan, and for those, the time from the hospital-recorded arrival to the CT scan; the numbers who had thrombolysis (injection of drugs to dissolve a blood clot), and for those, the time from the hospital-recorded arrival time to thrombolysis. All times supplied for stroke indicators are mean average, median, and 9th centile. % % % % % % % % Outcome from Cardiac Arrest - Return of Spontaneous Circulation at Time of Arrival at Hospital % % % % % % % % % % Outcome from Cardiac Arrest - Return of Spontaneous Circulation at Time of Arrival at Hospital (Utstein Comparator Group) % % % % % % % % Outcome from Cardiac Arrest - Surival to Discarge Rate (Overall) % % % % % % % % Outcome from Cardiac Arrest - Surival to Discarge Rate (Utstein Comparator Group) No. of Incidents Perf % Threshold No. of Incidents Perf % Threshold No. of Incidents Perf % Threshold No. of Incidents Perf % Threshold % % % % % % % % % Outcome from Cardiac Arrest - % Receiving post- ROSC Care Bundle 9 9 % 9% % % % % % % % % % Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - % of patients with a pre-hospital diagnosis of suspected STEMI confirmed on ECG receiving an appropriate care bundle : : : : : : Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - Mean time from call for help to catheter insertion for angiography for paitents directly admitted with an initial diagnosis of 'definite Myocardial Infarction' (hours:minutes) % 9% % % % % % % % % % Outcome from Stroke for Ambulance Patients - % of suspected stroke or unresolved transient ischaemic attack pateints assessed face to face that received an appropriate diagnostic bundle,, : No. of Incidents Perf % No. of Incidents Perf % Threshold No. of Incidents Perf % Threshold : : : : : : Outcome from Stroke for Ambulance Patients - Mean time from call to hospital arrival for patients either FAST positive, or with provisional daignosis of stroke transported by the Ambulance Service (hours:minutes) : : : : : : : Outcome from Stroke for Ambulance Patients - Mean time from arrival at hospital to CT scan for stroke patients in SSNAP who had a CT scan (hours:minutes) :. : : : : : : Outcome from Stroke for Ambulance Patients - Mean time from arrival at hospital to thrombolysis for stroke patients in SSNAP who had thrombolysis (hours:minutes) % % % % % % Outcomes from Sepsis for Ambulance Patients - percentage of suspected Sepsis and patients with National Early Warning Score (NEWS) of or more who received the Sepsis care bundle : : : No. of Incidents Perf % Integrated Corporate Performance Report

26 Period National Average East Midlands East of England London North East North West South Central South East Coast South Western West Midlands Yorkshire Ambulance Clinical Indicators - National Benchmarking Outcome from Cardiac Arrest - Return of Spontaneous Circulation at time of arrival at hospital (overall) Outcome from Cardiac Arrest - Return of Spontaneous Circulation at time of arrival at hospital (Utstein Comparator Group) Outcome from Cardiac Arrest - Survival to Discharge - overall survival rate Outcome from Cardiac Arrest - Survival to Discharge - Utstein Comparator Group survival rate Outcome from Cardiac Arrest - % of patients with ROSC receiving a post-rosc care bundle (figures reported in April, July, October and January) Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - % of patients with a prehospital diagnosis of suspected STEMI confirmed on ECG receiving an appropriate care bundle - (figures reported in April, July, October and January) Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - Mean time from call for help to catheter insertion for angiography for paitents directly admitted with an initial diagnosis of 'definite Myocardial Infarction' (hours:minutes) Outcome from Acute ST-Elevation Myocardial Infarction (STEMI) - 9th centile time from call for help to catheter insertion for angiography for paitents directly admitted with an initial diagnosis of 'definite Myocardial Infarction' (hours:minutes) Outcome from Stroke for Ambulance Patients - % of suspected stroke or unresolved transient ischaemic attack pateints assessed face to face that received an appropriate diagnostic bundle - (figures reported in May, August, November and February) Outcome from Stroke for Ambulance Patients - Mean time from call to hospital arrival for patients either FAST positive, or with provisional daignosis of stroke transported by the Ambulance Service (hours:minutes) Outcome from Stroke for Ambulance Patients - th centile time from call to hospital arrival for patients either FAST positive, or with provisional daignosis of stroke transported by the Ambulance Service (hours:minutes) Outcome from Stroke for Ambulance Patients - 9th centile time from call to hospital arrival for patients either FAST positive, or with provisional daignosis of stroke transported by the Ambulance Service (hours:minutes) Outcome from Stroke for Ambulance Patients - Mean time from arrival at hospital to CT scan for stroke patients in SSNAP who had a CT scan (hours:minutes) Outcome from Stroke for Ambulance Patients - Median time from arrival at hospital to CT scan for stroke patients in SSNAP who had a CT scan (hours:minutes) Outcome from Stroke for Ambulance Patients - 9th centile time from arrival at hospital to CT scan for stroke patients in SSNAP who had a CT scan (hours:minutes) Outcome from Stroke for Ambulance Patients - Mean time from arrival at hospital to thrombolysis for stroke patients in SSNAP who had thrombolysis (hours:minutes) Outcome from Stroke for Ambulance Patients - Median time from arrival at hospital to thrombolysis for stroke patients in SSNAP who had thrombolysis (hours:minutes) Apr to Jul.%.9%.%.% 9.%.%.%.%.9%.%.% Apr to Jul.9%.% 9.%.%.%.% 9.%.9%.%.%.% Apr to Jul.%.9%.9%.%.% 9.%.%.9%.%.%.% Apr to Jul.%.%.%.%.%.%.%.%.9%.% 9.% Apr to Jul.9%.%.%.%.9%.9%.%.% 9.%.9%.% Apr to Jul.% 9.% 9.%.%.% 9.9%.% 9.%.% 9.%.% Jul- : : : : : : : : : :9 : Jul- : : : : : : :9 :9 : :9 : Apr to Jul 9.% 9.% 99.% 9.% 99.% 9.% 9.% 9.% 9.9% 99.% 9.% Jul- : :9 : : : : : : : : : Jul- : : : : : : : : : : : Jul- : : : : : : : : : : : Jul- :9 : :9 : : : : : : : : Jul- : : : : : : : : : : : Jul- :9 : : : : : : : : :9 : Jul- : :9 : :9 : : : : : : : Jul- : : : : : :9 : : : : : Outcome from Stroke for Ambulance Patients - 9th centile time from arrival at hospital to thrombolysis for stroke patients in SSNAP who had thrombolysis (hours:minutes) Outcomes from Sepsis for Ambulance Patients - percentage of suspected Sepsis and patients with National Early Warning Score (NEWS) of or more who received the Sepsis care bundle Jul- : : : : : : : : : : : Apr to Jul.%.%.%.9%.%.%.%.%.9%.%.9% Integrated Corporate Performance Report

27 Outcome from Cardiac Arrest - Return of Spontaneous Circulation at Time of Arrival at Hospital Outcome from Cardiac Arrest - Return of Spontaneous Circulation at Time of Arrival at Hospital (Utstein Comparator Group) Outcome from Cardiac Arrest - Surival to Discarge Rate (Overall) Outcome from Cardiac Arrest - Surival to Discarge Rate (Utstein Comparator Group) Yorkshire West Midlands South Western South East Coast South Central North West.%.%.9%.%.%.% Yorkshire West Midlands South Western South East Coast South Central North West.%.%.%.9% 9.%.% Yorkshire West Midlands South Western South East Coast South Central North West.%.%.%.9% 9.%.% Yorkshire West Midlands South Western South East Coast South Central North West 9.%.%.9%.%.%.% North East 9.% North East.% North East.% North East.% London.% London.% London.% London.% East of England.% East of England 9.% East of England.9% East of England.% East Midlands.9% East Midlands.% East Midlands.9% East Midlands.% National Average.% National Average.9% National Average.% National Average.% % % % % % % % % % % % % % % % % % % % % % % % % % % % % Outcome from Cardiac Arrest - % of Patients with ROSC Receiving post-rosc Care Bundle Outcome from Acute STEMI - % of Patients Receiving an Appropriate Care Bundle Outcome from Acute STEMI - Mean time from call for help to catheter insertion for angiography Outcome from Stroke - % of Suspected Stroke or Unresolved Transient Ischaemic Attack Patients Assessed Face to Face Receiving an Appropriate Diagnostic Bundle Yorkshire West Midlands South Western South East Coast South Central.%.9% 9.%.%.% Yorkshire West Midlands South Western South East Coast South Central 9.%.%.%.% 9.% Yorkshire West Midlands South Western South East Coast South Central :9 : : : : Yorkshire West Midlands South Western South East Coast South Central 9.% 9.% 99.% 9.9% 9.% North West.9% North West 9.9% North West : North West 9.% North East.9% North East.% North East : North East 99.% London.% London.% London : London 9.% East of England.% East of England 9.% East of England : East of England 99.% East Midlands.% East Midlands 9.% East Midlands : East Midlands 9.% National Average.9% National Average.% National Average : National Average 9.% % % % % % % % % % % % % % % % % % % % 9% 9% 9% 9% 9% 9% 9% 99% % Outcome from Stoke - Meant time from call to hsopital arrival for patients either FAST positive or with provisional diagnosis of stroke transported by ambulance service Outcome from Stroke - Mean time from arrival at hospital to CT scan Outcome from Stroke Patients - Mean time from arrival at hospital to thrombolysis Outcomes from Sepsis for Ambulance Patients - percentage of suspected Sepsis and patients with National Early Warning Score (NEWS) of or more who received the Sepsis care bundle Yorkshire : Yorkshire : Yorkshire : Yorkshire.9% West Midlands : West Midlands : West Midlands : West Midlands.% South Western : South Western : South Western : South Western.9% South East Coast : South East Coast : South East Coast : South East Coast.% South Central : South Central : South Central : South Central.% North West : North West : North West : North West.% North East : North East : North East : North East.% London : London : London :9 London.9% East of England : East of England :9 East of England : East of England.% East Midlands :9 East Midlands : East Midlands :9 East Midlands.% National Average : National Average :9 National Average : National Average.% % % % % % % % % % % % % % % % % % % % % % % % % % % % Integrated Corporate Performance Report

28 YTD A&E Incident Numbers Actual A&E Incident Numbers / Actual A&E Incident Numbers / Actual A&E Incident Numbers /9 Variance / vs / Contract A&E Incident Numbers /9 Variance Actual vs Contract / 9, A&E Incident Numbers 9,,,99,,,,,,9,,,9,9,,9,9,9,,,,,, 9,,,,9,,,9,,,,9,.%.%.%.%.%.9% -.% -.%.9%,9,,,,,9,9,,9, 9,,,.9% -.%.%.9%.%.% -.% -.9%.% Ambulance Incidents by CCG Year to Date,,,, South Devon & Torbay CCG, % Swindon CCG,9 % Wiltshire CCG,9 % Unknown CCG, % Bath & North East Somerset CCG, % Bristol, North Somerset & South Gloucestershire CCG, %,,, Actual A&E Incident Numbers / Actual A&E Incident Numbers / Actual A&E Incident Numbers /9 Contract A&E Incident Numbers /9 Somerset CCG, % Dorset CCG 9, % All Ambulance Incidents per Week, 9, 9, NEW Devon CCG, % Gloucestershire CCG, %,, Kernow CCG, %,,,, Integrated Corporate Performance Report

29 YTD A&E Incident Numbers Bath & North East Somerset CCG Bristol, North Somerset & South Gloucestershire CCG Dorset CCG Gloucestershire CCG Kernow CCG NEW Devon CCG Somerset CCG South Devon & Torbay CCG Swindon CCG Wiltshire CCG Unknown CCG Trust Total A&E Incident Numbers % Variance /9 vs / Bath & North East Somerset CCG Bristol, North Somerset & South Gloucestershire CCG Dorset CCG Gloucestershire CCG Kernow CCG NEW Devon CCG Somerset CCG South Devon & Torbay CCG Swindon CCG Wiltshire CCG Trust Total A&E Incident Numbers % Variance Actual vs Contract /9 Bath & North East Somerset CCG Bristol, North Somerset & South Gloucestershire CCG Dorset CCG Gloucestershire CCG Kernow CCG NEW Devon CCG Somerset CCG South Devon & Torbay CCG Swindon CCG Wiltshire CCG Trust Total,,,,,,,,,,,,,,,,,9, 9,,9,99,,9,,,,9,,,,,,,9,,,,999,,,,,,,9,,,,9,,,,9,9,,,,,,,,,,,,9,9,,,,,,9,,9,,9,,,,,9,9,9,9,,,,,, 9 9 9,9,,,9,,,,9,.%.%.%.9%.%.%.%.%.9%.% -.%.9%.%.9%.%.% -.%.%.99%.%.%.%.%.% -.9% -.%.%.%.%.%.%.%.%.% -.%.% -.% -.% -.%.% -.% -.% -.% -.% -.%.% -.%.%.%.99%.%.% -.%.9%.% 9.%.99%.9%.%.9% -.% -.%.9%.%.99%.%.%.9%.% -.% -.%.%.%.%.%.%.%.9% -.% -.% -.%.9% -.%.9%.%.%.% -.%.%.99%.%.%.%.%.%.9% -.% -.%.9%.9%.%.9%.9%.%.%.%.%.%.% -.% -.9%.%.%.9%.9% -.%.9% -.9% -.%.%.%.% -.9% -.% -.% -.%.% -.%.9%.%.%.%.% -.%.% -.% -.% -.% -.% -.% -.% -.% -.% -.% -.% -.%.%.%.% -.% -.% -.% -.9%.%.%.%.%.9%.% -.% -.%.% -.99%.%.%.%.% -.% -.9% -.9% -.%.% -.%.9%.%.9%.% -.% -.% -.%.% -.%.9%.%.%.% -.%.%.%.9% -.%.%.9%.%.% -.% -.9%.% Integrated Corporate Performance Report

30 A&E Incident Outcomes Hear & Treat % See & Treat % See & Convey Non ED % See & Convey ED % % of Incidents Resolved Without Any Conveyance (Non Conveyance) % of Incidents Resolved Without Conveyance to ED (Non Conveyance to ED) Source of A&E Incidents Public Incidents HCP Incidents NHS Incidents Total Category of Incidents Category Category Category Category (999) Category (HCP) Category Total Target/ KPI YTD.% 9.%.9%.%.%.9%.9%.%.%.%.%.%.9%.%.%.%.9%.%.%.%.%.%.%.%.%.9%.%.% 9.%.%.%.%.% 9.% 9.% 9.9%.%.9%.9%.%.%.%.%.%.9%.%.%.%.%.%.%.%.%.% YTD,,9,,9,9, 9,9,9,, 9, 9,9 9, 9, 9,9 9, 9,9,,,,,,9,,,,,,,,,,,,9, YTD 9,,,,9,,,9,,,,9,9,9, 9,, 9,9,,,,9,,99,9,9,,,9,, ,9,,9,,,,9,,,9,,,9,9,,,9,,,,,,,,,9, A&E Incident Outcomes (YTD) Hear & Treat % % Source of A&E Incidents (YTD) NHS Incidents % Category of A&E Incidents (YTD) Category % Category (HCP) Category (999) % % Category % See & Convey ED % 9% HCP Incidents % See & Treat % % Public Incidents % Category % Category % See & Convey Non ED % % Integrated Corporate Performance Report

31 Handover Delays Total Number of Handovers Reported at Acute Hospitals / Total Number of Handovers in Excess of Minutes / % of Handovers in Excess of Minutes / Total Operational Resources Hours Lost to Handover Delays in Excess of Minutes / Average Operational Resources Hours Lost to Handover Delays in Excess of Minutes per Day / Total Number of Handovers Reported at Acute Hospitals /9 Total Number of Handovers in Excess of Minutes /9 % of Handovers in Excess of Minutes /9 Total Operational Resources Hours Lost to Handover Delays in Excess of Minutes /9 Average Operational Resources Hours Lost to Handover Delays in Excess of Minutes per Day /9 Handover to Clear Delays Total Number of Handover to Clear Times Recorded at Acute Hospitals Total Number of Handover to Clears in Excess of Minutes % of Handover to Clear Times in Excess of Minutes Total Operational Resources Hours Lost to Handover to Clear Delays in Excess of Minutes Average Operational Resources Hours Lost to Handover to Clear Delays in Excess of Minutes per Day YTD,,,,,9,,,,,9,9,,9,,,,,9,,9,, 9,,,9,.%.%.% 9.%.9%.%.99%.% 9.%.%.%.%.% : : : : : : : : : : : : : : : 9: : : : :9 : : : 9:9 : :, 9,,,9,,,,,9,9,9 9,, 9,9 9,, 9, 9,.9%.%.%.%.%.%.%.%.% : : : : : : : : 9: : : : : : 9: : : 9:,,,9,,,,,,9,,,,,9,,99,,.%.%.%.%.9%.%.%.%.9% : : : : :9 99: 9: : : 9: : : 9: : 99: 9: : :9 Average Daily Operational Time Lost to Handover Delays at Hospitals in Excess of Minutes Average Daily Operational Time Lost to Handover to Clear Delays at Hospitals in Excess of Minutes : : : : 9: 9: : : : : : : : : : : Average Operational Resources Hours Lost to Handover Delays in Excess of Minutes per Day / Average Operational Resources Hours Lost to Handover Delays in Excess of Minutes per Day /9 : : : : : : Average Operational Resources Hours Lost to Handover to Clear Delays in Excess of Minutes per Day Integrated Corporate Performance Report

32 Number of Handovers by Acute Hospital Bristol Royal Infirmary Cheltenham General Hospital Derriford Hospital Dorset County Hospital Gloucester Royal Hospital Great Western Hospital Musgrove Park Hospital North Devon District Hospital Poole Hospital Royal Bournemouth Hospital Royal Cornwall Hospital Royal Devon & Exeter Hospital Royal United Hospital Bath Salisbury District Hospital Southmead Hospital Torbay Hospital Weston General Hospital Yeovil District Hospital Total All Hospitals YTD,9,,,,9,,,,9, 9 9,,,,,,,,9,,,9,,,99,,,9,,,,9,,9,9,,,,,,,,,,,, 9,9,,,,,,,9,,99,9,,,,,,,,,,,,,,,,,9,9,,9,9,9,99,,99,9,,,,9,,,,,9,9,9,,9,,,9,,9,9,9,,9,99,,,9 9,,,9,,,,,,,9,9,,9,,,,,9 9,9,,,,,,,9,, 9,,9,,9,, 9,,9,,,,,,,, 9,, 9,,9 9,9 9,9,9, Average Handover Time per Incident (Mins:Sec) Bristol Royal Infirmary Cheltenham General Hospital Derriford Hospital Dorset County Hospital Gloucester Royal Hospital Great Western Hospital Musgrove Park Hospital North Devon District Hospital Poole Hospital Royal Bournemouth Hospital Royal Cornwall Hospital Royal Devon & Exeter Hospital Royal United Hospital Bath Salisbury District Hospital Southmead Hospital Torbay Hospital Weston General Hospital Yeovil District Hospital Total All Hospitals YTD : : : : : : : : : 9: 9:9 9: : : : : 9: 9: : : : : : : : : : : : : : : : 9:9 : : 9: : : : 9: 9: 9: 9: 9: :9 9: : : :9 : : : : : : :9 9:9 : : : : : : : 9: :9 9: : : 9: 9: : : : : : : :9 :9 : : : : : : : : : :9 : : :9 : : : : : : : : :9 : : : : : 9: 9: : : : : : : 9: 9: 9:9 : 9: : :9 9: : : 9: :9 : : : : :9 : : : : : : : : : : : : : : : :9 : : : :9 : 9: 9: :9 : 9: : 9: 9: 9: : : : : : : : : : Integrated Corporate Performance Report 9

33 YTD Operational Resource Hours Lost to Handover Delays in Excess of Minutes (Hours:Mins) Bristol Royal Infirmary 9: : 9:9 9: : : :9 : : Cheltenham General Hospital : : : : 9:9 : : : : Derriford Hospital 9: 9: 9: : : : 9: : : Dorset County Hospital : :9 : : : : : 9: : Gloucester Royal Hospital : 9: : : : : : : : Great Western Hospital : : : : : : 9: : : Musgrove Park Hospital : :9 : : : : : 9: : North Devon District Hospital : : : :9 : 9: : :9 : Poole Hospital : : : : : : 9: :9 : Royal Bournemouth Hospital 9: : : 9:9 : : : : : Royal Cornwall Hospital :9 : : 9: 9:9 99: 9: 9: :9 Royal Devon & Exeter Hospital : : 9: 9: 9: : 9: 9: : Royal United Hospital Bath : : :9 : : 9: 9:9 :9 : Salisbury District Hospital : : : 9: : : : : : Southmead Hospital : : 9: : : : :9 : 99: Torbay Hospital 9: : : : : : : : : Weston General Hospital 9:9 : : 9: : : : : : Yeovil District Hospital : :9 :9 : : :9 : :9 : Total All Hospitals : 99: : : : : : : : Other Performance Metrics Target/ KPI YTD Vehicle deep cleaning compliance with schedule (A&E) 9.% 9.% 9.% 9.%.% 9.%.%.9% 9.% 9.%.% 9.% 9.%.% Vehicle Deep Clean Compliance (A&E Vehicles) 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9%.%.%.% 9.% 9.%.% 9.%.%.9% 9.% 9.%.%.% Other Metrics to be developed and included in future reports (when available): Infection Prevention and Control Metrics (Quarterly) Training Compliance (Annual Development Day and Training Workbook completion compared to plan) Integrated Corporate Performance Report

34 Out of Hours Patient Contacts Dorset Out of Hours Patient Contacts - Actual / Target/ KPI YTD,9,,,,9,,,9,, 9,,, Dorset Out of Hours Patient Contacts - Actual /9,9 9, 9,,,,9,,9, Dorset Out of Hours Patient Contacts - Actual /9 vs / -.% -.%.%.% -.%.%.% -.% -.%, Dorset Out of Hours Patient Contacts,,,,,, / /9 Integrated Corporate Performance Report

35 Out of Hours - Home Visits - Urgent Completed within Hours Dorset - % of Urgent Home Visits Completed within Hours - / Dorset - Number of Urgent Home Visits /9 Dorset - % of Urgent Home Visits Completed within Hours - /9 Out of Hours - Home Visits - Less Urgent Completed within Hours Dorset - % of Less Urgent Home Visits Completed within Hours - / Dorset - Number of Less Urgent Home Visits /9 Target/ KPI YTD 9.% 9.% 9.%.% 9.% 9.%.% 9.%.% 9.% 9.9% 9.% 9.% 9.%, % 9.% 9.%.9% 9.% 9.% 9.% 9.9% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.9% 9.% 9.% 9.% 9.% 9.9% 9.9%,,, 9 9 Dorset - % of Less Urgent Home Visits Completed within Hours - /9 9.% 9.% 9.% 9.9% 9.% 9.9% 9.9% 9.% 9.% 9.99% Target Call 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% Dorset Out of Hours - Urgent Home Visits Completed in Hours Dorset Out of Hours - Less Urgent Home Visits Completed in Hours.% 9.%.%.%.%.%.% Dorset - Number of Urgent Home Visits /9 % Completed in Hours / % Completed in Hours /9 Target Target Call 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% Target/ YTD KPI Out of Hours - Treatment Centres - Urgent Completed within Hours Dorset - % of Urgent Treatment Centre Completed within Hours - / Dorset - Number of Urgent Treatment Cente Appointments / Dorset - % of Urgent Treatment Centre Completed within Hours - / Out of Hours - Treatment Centres - Less Urgent Completed within Hours Dorset - % of Less Urgent Treatment Centre Completed within Hours - / Dorset - Number of Less Urgent Treatment Centre Appointments / 9.% 9.% 9.% 9.% 9.%.%.9% 9.%.% 9.%.% 9.% 9.% 9.%, 9 9.% 9.%.% 9.99% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.9% 9.% 9.% 9.% 9.% 9.%,,9,9,,,,,,9 Dorset - % of Less Urgent Treatment Centre Completed within Hours - / 9.% 9.% 9.% 9.% 9.9% 9.% 9.% 99.% 9.9% 9.% Target Call 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9%.%.% 9.%.%.%.%.%.% Dorset Out of Hours - Urgent Treatment Centre Appointments Completed in Hours Dorset - Number of Urgent Treatment Cente Appointments / % Completed in Hours / Target Call Dorset - Number of Less Urgent Treatment Centre Appointments / % Completed in Hours / % Completed in Hours / Target % Completed in Hours / Target 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% Answering Integrated Corporate Performance Report.% 9.%.%.%.%.%.%.% 9.%.%.%.%.%.% Dorset - Number of Less Urgent Home Visits /9 % Completed in Hours / % Completed in Hours /9 Target Dorset Out of Hours - Less Urgent Treatment Centre Appointments Completed in Hours,,,,,,,,

36 Out of Hours Contract Quality Requirements - Dorset Target/ KPI YTD Providers must report regularly to NHS Commissioners on their compliance QR Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant with the Quality Requirements Percentage of Out of Hours consultation details sent to the practice where QR 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.9% 9.% 9.% the patient is registered by : the next working day Providers must have systems in place to support and encourage the regular QR exchange of information between all those who may be providing care to Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant patients with predefined needs Providers must regularly audit a random sample of patient contacts (audit QR should provide sufficient data to review the clinical performance of each Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant individual working within the service) Providers must regularly audit a random sample of patients' experiences of QR Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant the service Providers must operate a complaints procedure that is consistent with the QR Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant principles of the NHS complaints procedure Providers must demonstrate their ability to match their capacity to meet QR Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant predictable fluctuations in demand for their contracted service All immediately life threatening conditions (walk in patients) to be passed to QR 9.% n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a the ambulance service within minutes of face to face presentation Definitive Clinical Assessment for Urgent adult cases presenting at QRa 9.% n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a treatment location to start within minutes of arrival in the treatment centre Definitive Clinical Assessmnet for children who are ill and have an urgent QRa 9.% n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a Out of Hours to start within minutes of arrival in the treatment centre Definitive Clinical Assessment for Less Urgent cases presenting at QRb 9.% n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a treatment location to start within minutes of arrival in the treatment centre QRd At the end of an assessment, the patient must be clear of the outcome Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant QR Providers must ensure that patients are treated by the clinician best equipped to meet their needs in the most appropriate location Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant QR Emergency Consultations (presenting at base) started within hour 9.% n/a n/a ( cases) n/a ( cases) n/a ( cases) n/a ( cases) n/a ( cases) n/a ( cases) n/a ( cases) n/a ( cases) QR Urgent Consultations (presenting at base) started within hours 9.% 9.%.% 9.99% 9.% 9.% 9.% 9.% 9.% 9.% QR Less Urgent Consultations (presenting at base) started within hours 9.% 9.% 9.% 9.% 9.9% 9.% 9.% 99.% 9.9% 9.% QR Emergency Consultations (home visits) started within hour 9.% n/a n/a ( cases) n/a ( cases) n/a ( cases) n/a ( cases) n/a ( cases) n/a ( cases) n/a ( cases) n/a ( cases) QR Urgent Consultations (home visits) started within hours 9.% 9.% 9.%.9% 9.% 9.% 9.% 9.9% 9.% 9.% QR Less Urgent Consultations (home visits) started within hours 9.% 9.% 9.% 9.9% 9.% 9.9% 9.9% 9.% 9.% 9.99% Patients unable to communicate effectively in English will be provided with QR an interpretation service within minutes of initial contact. Providers must also make appropriate provision for patients with impaired hearing or Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant impaired sight Integrated Corporate Performance Report

37 NHS Calls Offered NHS - Dorset Calls Offered - Actual / NHS - Dorset Calls Offered - Actual /9 NHS - Dorset Calls Offered - Contract /9 Percentage of Calls Offered - NHS Dorset Actual vs Contract Target/ KPI YTD,9,9,, 9,9 9,, 9,,,,99,,,,,9,,, 9,9,,,,,9,,,,,, 9,, 9,99, -9.9% -9.% -.% -.% -.% -.% -.9% -.% -.9%, NHS Dorset Calls Offered,,,,,, Actual / Actual /9 Contract /9 NHS Call Answering in Seconds NHS - Dorset - Percentage of Calls Answered in Seconds / Target/ KPI YTD 9.%.%.9%.%.%.% 9.%.%.%.%.9% 9.% 9.%.9% NHS - Dorset - Percentage of Calls Answered in Seconds /9 9.%.% 9.%.9%.%.9%.9%.%.%.% Target Call 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9%.% 9.% 9.%.%.%.%.%.%.%.% NHS Dorset - % of Calls Answered in Seconds.% % Answered in Seconds / % Answered in Seconds /9 Target Call Answering Performance % Integrated Corporate Performance Report

38 NHS Contract Quality Requirements - Dorset Target/ KPI YTD Providers must report regularly to NHS Commissioners on their compliance QR Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant with the Quality Requirements Providers must send details of all consultations (including appropriate clinical QR information) to the practice where the patient is registered by. a.m. the 9.% 9.% 9.% 9.9% 9.% 9.% 9.% 9.% 9.% 9.9% next working day. Providers must have systems in place to support and encourage the regular QR exchange of information between all those who may be providing care to Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant patients with predefined needs QR Providers must regularly audit a random sample of patient contacts (audit should provide sufficient data to review the clinical performance of each individual working within the service) Compliance Partially Compliant Partially Compliant Partially Compliant Partially Compliant Partially Compliant Partially Compliant Partially Compliant Partially Compliant Partially Compliant Providers must regularly audit a random sample of patients' experiences of QR.%.%.%.%.%.9%.%.%.%.% the service Providers must operate a complaints procedure that is consistent with the QR Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant principles of the NHS complaints procedure QR Providers must demonstrate their ability to match their capacity to meet predictable fluctuations in demand for their contracted service Compliance Partially Compliant Partially Compliant Partially Compliant Partially Compliant Partially Compliant Partially Compliant Partially Compliant Partially Compliant Partially Compliant QRa No more than % of calls abandoned before being answered.%.9%.%.%.%.%.9%.9%.9%.% Calls to be answered within seconds of the end of the introductory QRb 9.%.% 9.%.9%.%.9%.9%.%.%.% message All immediately life threatening conditions to be passed to the ambulance QR9a 9.% 9.%.%.%.% 9.%.% 9.%.%.% service within minutes QR9b Patient callbacks must be achieved within minutes 9.%.%.%.%.%.9%.%.%.%.% Patients unable to communicate effectively in English will be provided with an QR interpretation service within minutes of initial contact. Providers must also make appropriate provision for patients with impaired hearing or impaired 9.%.%.%.%.%.%.%.%.%.% sight Providers must demonstrate the online completion of the annual assessment QR of the Information Governance Toolkit at level or above and that this is Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant audited on an annual basis by Internal Auditors using the national framework Providers must demonstrate that they are complying with the Department of QR Health Information Governance SUI Guidance on reporting of Information Compliance Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Compliant Governance incidents appropriately. Integrated Corporate Performance Report

39 NHS Sitrep Benchmarking NHS KPI Benchmarking - Weekly Sitrep Data - Call Answering Percentage of Calls Answered in Seconds - National Average Percentage of Calls Answered in Seconds - Dorset Percentage of Calls Answered in Seconds - National Highest Percentage of Calls Answered in Seconds - National Lowest NHS KPI Benchmarking - Weekly Sitrep Data - Call Abandonment Percentage of Calls Abandoned - National Average Percentage of Calls Abandoned - Dorset Percentage of Calls Abandoned - National Highest Percentage of Calls Abandoned - National Lowest Week Commencing Target -Sep- -Sep- -Sep- -Oct- -Oct- -Oct- -Oct- 9-Oct- -Nov- -Nov- 9-Nov- -Nov- -Dec- 9.%.%.%.%.9%.%.%.%.%.%.%.9%.9%.% 9.%.%.%.%.%.%.9%.9% 9.%.% 9.%.%.%.% 9.% 9.% 9.% 9.% 99.% 9.% 9.9% 9.% 9.% 9.% 9.% 9.% 9.% 9.% 9.%.% 9.%.%.9%.%.%.9% 9.%.9%.%.%.9%.%.%.%.%.%.%.9%.%.%.%.%.%.%.%.%.%.9%.%.9%.%.%.%.%.%.%.%.9%.%.%.% 9.% 9.% 9.% 9.9%.9%.%.%.%.%.% 9.%.%.%.%.9%.9%.9%.%.%.9%.%.%.%.%.%.%.9% Weekly National NHS Sitrep - % Calls Answered in Seconds Weekly National NHS Sitrep - % Calls Abandoned % % 9% % % % % % % % % % % -Sep- -Sep- -Sep- -Oct- -Oct- -Oct- -Oct- 9-Oct- -Nov- -Nov- 9-Nov- -Nov- -Dec- % -Sep- -Sep- -Sep- -Oct- -Oct- -Oct- -Oct- 9-Oct- -Nov- -Nov- 9-Nov- -Nov- -Dec- National Average Dorset Highest Lowest National Average Dorset Highest Lowest NHS KPI Benchmarking - Weekly Sitrep Data - % of Calls Answered or Dealt with by a Clinician Percentage of Call Backs Offered - National Average Percentage of Call Backs Offered - Dorset Percentage of Call Backs Offered - National Highest Percentage of Call Backs Offered - National Lowest NHS KPI Benchmarking - Weekly Sitrep Data - Call Backs in Minutes Percentage of Call Backs in Minutes - National Average Percentage of Call Backs in Minutes - Dorset Percentage of Call Backs in Minutes - National Highest Percentage of Call Backs in Minutes - National Lowest.%.%.%.%.%.%.%.9%.%.9%.%.%.%.9%.% 9.%.%.% 9.%.%.%.9% 9.%.% 9.9%.% 9.9%.% 9.%.% 9.%.%.%.9%.9%.%.% 9.%.%.%.% 9.% 9.% 9.%.%.%.%.9%.%.%.%.9% 9.%.%.%.% 9.%.%.9% 9.%.%.% 9.% 9.%.9%.% 9.%.%.%.% 9.%.9%.%.%.%.9%.9%.%.%.% 9.% 9.%.% 9.%.% 9.%.9%.%.9%.%.%.9%.%.% 9.% 9.%.%.% 9.99%.%.%.%.%.%.%.99% 9.%.% Weekly National NHS Sitrep - % of Calls Answered or Dealt with by a Clinician Weekly National NHS Sitrep - % of Call Backs in Minutes 9% % % % % % % % % % % % % % % % -Sep- -Sep- -Sep- -Oct- -Oct- -Oct- -Oct- 9-Oct- -Nov- -Nov- 9-Nov- -Nov- -Dec- % -Sep- -Sep- -Sep- -Oct- -Oct- -Oct- -Oct- 9-Oct- -Nov- -Nov- 9-Nov- -Nov- -Dec- National Average Dorset Highest Lowest National Average Dorset Highest Lowest Integrated Corporate Performance Report

40 Tiverton Urgent Care Centre Tiverton Urgent Care Centre Activity - Actual / Tiverton Urgent Care Centre Activity - Actual /9 * Tiverton Urgent Care Centre Activity - Contract Baseline /9 Percentage Actual vs Contract - Tiverton Urgent Care Centre Activity,,,, Target/ KPI YTD,,,,,,,,,,,9,,,,9,,,,,,,,,,,,9,9,,,,,,,.9% -.%.%.%.%.%.%.9%.% Tiverton Urgent Care Centre Activity,,9,,,,,,, Actual /9 Actual / Contract /9 Tiverton Urgent Care Centre Tiverton UCC - Number of Cases /9 Tiverton UCC - Number of Patients Seen within Hours /9 Tiverton UCC - % of Patients Seen within Hours /9 Tiverton UCC - Number of Cases /9 Tiverton UCC - Number of Patients Triaged within Minutes /9 Target/ KPI YTD,,,,,,,9,9,,,,,,,,,9, 9.% 99.% 99.% 99.% 99.% 99.% 99.% 99.% 99.% 99.%,,,,,,,9,9,,,,,,,9,,, Tiverton UCC - % of Patients Triaged within Minutes /9 9.% 9.9% 9.% 9.% 9.% 9.9% 9.% 9.% 99.% 99.% Target Call 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9% 9%.% 9.% 9.%.%.%.%.%.%.% Tiverton Urgent Care Centre - % of Patients Seen Within Hours /9,,,,,,.% 9.% 9.%.%.%.%.%.%.% Tiverton Urgent Care Centre - % of Patients Seen Within Hours /9,,,,,, Tiverton UCC - Number of Cases /9 Tiverton UCC - % of Patients Seen within Hours /9 Target Tiverton UCC - Number of Cases /9 Tiverton UCC - % of Patients Triaged within Minutes /9 Target Integrated Corporate Performance Report

41 Staff Metrics - Establishment and Staff Turnover Trust Summary- Staff Metrics Trust Total Establishment Support Services Establishment,,,,, Integrated Corporate Performance Report,, Trust Total Establishment - Funded WTE Trust Total Establishment - Actual WTE Support Services - Funded WTE Support Services - Actual WTE Trust Total Establishment - Actual WTE,9.,9.,9.,9.,9.,9.9,99.,99. Trust Total Establishment - Funded WTE,.,.,9.,.9,.,9.,.,. Variance Vacancy % -.% -.% -.% -.% -.% -.% -.% -.% Support Services - Actual WTE Support Services - Funded WTE Variance Vacancy % -.% -.% -.% -.9% -.% -.% -.% -.%.%.% Trust - Staff Turnover (exc Redundancies).%.%.%.%.%.%.%.9%.%.%.%.%.%.%.%.%.% Turnover % (excl redundancies) Trust Total Staff Turnover Turnover % (excl redundancies).%.%.%.%.%.9%.%.% Integrated Corporate Performance Report

42 A&E Operations Establishment A&E Operations - Lead Clinician Establishment A&E Operations - Emergency Care Assistants Establishment,9.,.,.,.,.,. 9.,.,..,..,.,..,.. Lead Clinician - Funded WTE Lead Clinician - Actual WTE Emergency Care Assistants- Funded WTE Emergency Care Assistants - Actual WTE Lead Clinician - Actual WTE,.,9.,.,.,.,.,.,.9 Lead Clinician - Funded WTE,9.,9.,9.,.9,.9,.9,.,. Variance Vacancy % -.% -.% -.% -.% -.% -.% -.% -.% Emergency Care Assistants - Actual WTE,.,.,9.,.,9.,.,.,. Emergency Care Assistants- Funded WTE Variance Vacancy %.%.%.% 9.%.%.%.%.% Total A&E Operations Establishment - Actual WTE,.9,.9,99.,99.,.,9.,.,9. Total A&E Operations Establishment - Funded WTE,.,.,.,.,.,.,9.,9. Variance Vacancy % -.% -.% -.% -.% -.% -.%.%.% A&E Operations - Lead Clinician Turnover A&E Operations - Emergency Care Assistants Turnover.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.9%.9%.%.9%.%.9%.%.%.%.%.%.%.%.%.%.%.% Turnover % (Lead Clinician) Turnover % (Emergency Care Assistants) A&E Operations - Turnover Turnover % (excl redundancies) 9.% 9.% 9.% 9.9% 9.% 9.% 9.%.9% Turnover % (Lead Clinician).%.%.%.%.%.%.%.% Turnover % (Emergency Care Assistants).%.9%.9%.%.9%.%.9%.% Integrated Corporate Performance Report 9

43 A&E Clinical Hub Establishment A&E Clinical Hub - Clinician Establishment A&E Clinical Hub - Total Establishment Clinician - Funded WTE Clinician- Actual WTE Total A&E Clinical Hub Establishment - Funded WTE Total A&E Clinical Hub Establishment - Actual WTE Clinician- Actual WTE Clinician - Funded WTE Variance Vacancy % -.% -.% -.% -.% -.% -.% -.% -.% Total A&E Clinical Hub Establishment - Actual WTE Total A&E Clinical Hub Establishment - Funded WTE Total Variance Vacancy %.%.%.%.% -.% -.% -.% -.% A&E Clinical Hub - Staff Turnover (exc Redundancies).%.%.9%.%.%.%.%.%.9%.9%.%.%.%.%.% Turnover % (excl redundancies) A&E Clinical Hub - Turnover Turnover % (excl redundancies).9%.%.%.%.%.%.9%.9% Integrated Corporate Performance Report

44 UCS - Out of Hours Establishment UCS Out of Hours - Clinician Establishment UCS Out of Hours - Total Establishment UCS Out of Hours Clinician - Funded WTE UCS Out of Hours Clinician - Actual WTE Total UCS Out of Hours Establishment - Funded WTE Total UCS Out of Hours Establishment - Actual WTE UCS Out of Hours Clinician - Actual WTE UCS Out of Hours Clinician - Funded WTE Variance Vacancy % -.% -.% -9.9% -.% -9.% -.% -9.% -.% Total UCS Out of Hours Establishment - Actual WTE Total UCS Out of Hours Establishment - Funded WTE Variance Vacancy % -.% -.% -.% -.% -.% -.% -9.% -.% Out of Hours Service - Turnover (excl redundancies).% Out of Hours Service Staff Turnover (excl redundancies).%.%.9%.9%.%.%.%.%.9%.%.%.%.%.% Turnover % (excl redundancies) UCS Out of Hours - Turnover Turnover % (excl redundancies).%.9%.%.9%.9%.%.%.% Integrated Corporate Performance Report

45 UCS - NHS Establishment NHS - Clinician Establishment NHS - Total Establishment NHS Clinician - Funded WTE NHS Clinician - Actual WTE Total NHS Establishment - Funded WTE Total NHS Establishment - Actual WTE NHS Clinician - Actual WTE NHS Clinician - Funded WTE Variance Vacancy %.% -.%.% -.% -.% -.% -.9% -9.% Total NHS Establishment - Actual WTE Total NHS Establishment - Funded WTE Variance Vacancy %.%.%.%.%.% -.% -.9% -9.% NHS Service - Turnover (excl redundancies).% NHS Service Staff Turnover (excl redundancies).% 9.% 9.% 9.9%.%.%.%.%.%.%.% 9.%.%.%.% Turnover % (excl redundancies) NHS Service - Turnover Turnover % (excl redundancies).%.%.% 9.%.% 9.% 9.% 9.9% Integrated Corporate Performance Report

46 Staff Metrics - Operational 'On the Road' Establishment Forecast The Operational establishment position is also analysed based on the date when the staff become operationally available (ie when new staff become operationally active after initial training and induction periods) In order to produce this adjusted position a set of simple rules have been agreed between Operations and HR which are applied to the date that a new member of staff commences employment with the Trust: Lead Clinicians - weeks after their commencement date Emergency Care Assistants - weeks after their commencement date Clinical Hub Call Takers - weeks after their commencment date Clinical Hub Clinicians - weeks after their commencement date The position detailed in the tables below are based on the forecast establishment positon at the time of the report. All of the figures below are based on the date the staff become operationally available. Trust Total Lead Clinician Establishment Emergency Care Assistant Establishment,,,,,,,, 9, 9,,,,,,, Apr-9 May-9 Jun-9 Jul-9 Aug-9 Sep-9 Oct-9 Nov-9 Dec-9 Jan- Feb- Mar- Apr-9 May-9 Jun-9 Jul-9 Aug-9 Sep-9 Oct-9 Nov-9 Dec-9 Jan- Feb- Mar- Lead Clinician - Actual 'On the Road' WTE Lead Clinician - Funded WTE Emergency Care Assistant - Actual 'On the Road' WTE Emergency Care Assistant - Funded WTE Actual WTE /9 Forecast WTE Based on Operational Assumptions Apr-9 May-9 Jun-9 Jul-9 Aug-9 Sep-9 Oct-9 Nov-9 Dec-9 Jan- Feb- Mar- Lead Clinician - Actual 'On the Road' WTE,9.,9.,.,.,.,.,.,.,99.,9.,.9,.9 Lead Clinician - Funded WTE,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,.,. Variance Vacancy % -.% -.% -.% -.% -.% -.% -.% -.% -.% -.% -.% -.% Emergency Care Assistant - Actual 'On the Road' WTE ,.,., Emergency Care Assistant - Funded WTE Variance Vacancy %.%.%.%.%.%.%.%.%.%.% -.%.% Total A&E Operations Establishment - Actual 'On the Road' WTE,.,.,.,.,.9,.,.,9.,9.9,.,9.,. Total A&E Operations Establishment - Funded WTE,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9,99.9 Variance Vacancy % -.9% -.% -.% -.% -.% -.% -.% -.% -.% -.% -.% -.% Clinical Hub Clinical Hub - Call Takers Establishment Clinical Hub - Dispatchers Establishment Clinical Hub - Clinician Establishment 9 Call Takers - Actual 'in The Room' WTE Call takers - Funded WTE Dispatchers - Actual 'In The Room' WTE Dispatchers - Funded WTE Clinician - Actual 'In The Room' WTE Clinician - Funded WTE Actual WTE /9 Forecast WTE Based on Operational Assumptions Apr-9 May-9 Jun-9 Jul-9 Aug-9 Sep-9 Oct-9 Nov-9 Dec-9 Jan- Feb- Mar- Call Takers - Actual 'in The Room' WTE Call takers - Funded WTE Variance Vacancy % -.% -.%.%.%.% -.% -.% -.%.% -.% -.% -.% -.%.%.%.%.%.9%.%.%.%.%.%.9% Dispatchers - Actual 'In The Room' WTE Dispatchers - Funded WTE Variance Vacancy % -.% -.9% -9.% -.% -9.% -.% -.% -.% -.% -.% -.% -.% -.% -.% -.% -.% -9.% -.9% -.% Clinician - Actual 'In The Room' WTE Clinician - Funded WTE Integrated Corporate Performance Report

47 Variance Vacancy % -.% -.% -.9% -.% -.% -.% -.% -.% -.% -.% -.% -.9% -.% -.% -.% -.% -.% -.% -.%.%.%.%.%.% Integrated Corporate Performance Report

48 Staff Metrics - Sickness Trust Total Sickness Abstraction % Support Services Sickness Abstraction % Trust Total Sickness % Support ServicesSickness %.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.9%.%.%.%.%.%.%.%.%.%.% Integrated Corporate Performance Report.%.%.%.%.%.%.%.%.%.%.9%.%.%.%.9%.%.%.%.9%.%.%.% Trust Total Long Term Sickness % Trust Total Short Term Sickness % Trust Total Sickness KPI Support Services Long Term Sickness % Support Services Short Term Sickness % Support Services Sickness KPI Trust Total Long Term Sickness %.%.%.%.%.%.%.%.% Trust Total Short Term Sickness %.9%.%.%.%.%.%.%.% Trust Total Sickness %.%.%.%.9%.%.%.%.9% Trust Total Sickness KPI.%.%.%.%.%.%.%.%.%.%.%.% Support Services Long Term Sickness %.%.%.%.%.%.%.9%.9% Support Services Short Term Sickness %.%.%.%.%.9%.%.%.% Support Services Total Sickness %.9%.%.%.%.%.%.%.% Support Services Sickness KPI.%.%.%.%.%.%.%.%.%.%.%.% A&E Operational Sickness Abstraction % A&E Clinical Hub Sickness Abstraction % A&E Operations Sickness % A&E Clinical Hub Sickness %.%.%.%.%.%.%.%.%.%.%.%.%.9%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.9%.%.%.9%.%.9%.%.%.%.%.%.%.%.9%.%.%.%.%.9%.%.% A&E Operations Long Term Sickness % A&E Operations Short Term Sickness % A&E Sickness KPI A&E Clinical Hub Long Term Sickness % A&E Clinical Hub Short Term Sickness % A&E Sickness KPI A&E Operations A&E Operations Long Term Sickness %.9%.%.%.9%.%.9%.%.% A&E Operations Short Term Sickness %.%.%.%.%.%.9%.%.% A&E Operations Total Sickness %.%.%.%.%.%.%.%.% A&E Sickness KPI.%.%.%.%.%.%.%.%.%.%.%.% A&E Clinical Hub A&E Clinical Hub Long Term Sickness %.%.%.9%.%.%.%.%.9% A&E Clinical Hub Short Term Sickness %.%.%.%.%.%.%.%.% A&E Clinical Hub Total Sickness %.%.%.%.%.%.%.%.9% A&E Sickness KPI.%.%.%.%.%.%.%.%.%.%.%.% Integrated Corporate Performance Report

49 UCS Out of Hours Sickness Abstraction % NHS Sickness Abstraction % UCS Out of Hours Sickness % NHS Sickness %.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.9%.%.%.%.%.%.9%.%.%.%.%.%.%.%.%.%.%.%.%.%.% 9.9% 9.9%.%.%.%.9%.%.% UCS Out of Hours Long Term Sickness % UCS Out of Hours Short Term Sickness % UCS Out of Hours Sickness KPI NHS Service Long Term Sickness % NHS Service Short Term Sickness % NHS Service Sickness KPI UCS Out of Hours Service UCS Out of Hours Long Term Sickness %.%.%.%.9%.9%.%.%.% UCS Out of Hours Short Term Sickness %.%.%.%.%.%.%.%.% UCS Out of Hours Total Sickness %.9%.9%.%.9%.%.%.%.% UCS Out of Hours Sickness KPI.%.%.%.%.%.%.%.%.%.%.%.% NHS Service NHS Service Long Term Sickness %.% 9.9%.%.% 9.9%.9%.%.% NHS Service Short Term Sickness %.%.%.%.%.%.%.%.% NHS Service Total Sickness % 9.%.9% 9.%.%.9% 9.9%.%.% NHS Service Sickness KPI.%.%.%.%.%.%.%.%.%.%.%.% Integrated Corporate Performance Report

50 Staff Metrics - Staff Appraisal Completion % Trust Total Appraisals Completed % Support Services Appraisals Completed %.%.% 9.% 9.%.%.%.%.%.%.%.%.%.% 9.% 9.% 9.% 9.%.%.%.%.% Integrated Corporate Performance Report.%.%.% 9.% 9.% 9.% 9.% 9.%.%.%.%.%.%.%.%.%.% Trust Total % Appraisals Completed Appraisals Completion KPI Support Services % Appraisals Completed Appraisals Completion KPI Trust Total % Appraisals Completed 9.% 9.% 9.% 9.%.%.%.%.% Support Services % Appraisals Completed 9.% 9.% 9.% 9.% 9.%.%.%.% Appraisals Completion KPI.%.%.%.%.%.%.%.%.%.%.%.% A&E Operations - Appraisals Completed % A&E Clinical Hub - Appraisals Completed %.%.% 9.% 9.%.%.%.%.%.%.%.% 9.% 9.% 9.% 9.%.9%.%.%.%.9%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.%.% A&E Operations % Appraisals Completed Appraisals Completion KPI A&E Clinical Hub % Appraisals Completed Appraisals Completion KPI A&E Operations % Appraisals Completed 9.% 9.% 9.% 9.%.9%.%.9%.% A&E Clinical Hub % Appraisals Completed.%.%.%.%.%.%.%.% Appraisals Completion KPI.%.%.%.%.%.%.%.%.%.%.%.% Integrated Corporate Performance Report

51 UCS Out of Hours - Appraisals Completed % NHS - Appraisals Completed %.%.% 9.% 9.%.%.%.%.%.%.%.%.%.%.% 9.% 9.% 9.% 9.% 9.%.% 9.%.%.%.%.%.%.%.%.%.%.%.99%.9%.%.%.%.%.% UCS Out of Hours % Appraisals Completed Appraisals Completion KPI NHS Service % Appraisals Completed Appraisals Completion KPI UCS Out of Hours % Appraisals Completed 9.% 9.% 9.% 9.% 9.%.% 9.%.% NHS Service % Appraisals Completed.%.%.%.%.%.99%.9%.% Appraisals Completion KPI.%.%.%.%.%.%.%.%.%.%.%.% Integrated Corporate Performance Report

52 A&E Service Adverse Incidents reported relating to medication administration, prescription and supply errors 9 Number of Adverse Incidents Reported 9 Of the Adverse Incidents Reported: Number of Adverse Incidents Reported Relating to the Trust 99 Number of Adverse Incidents Reported Relating to external services 9 Number of Adverse Incidents Closed Number of Adverse Incidents Currently Under Investigation (as of last day of month) Central Alert System (CAS) received Central Alert System Warnings (outside deadline) Number of Adverse Incidents Reported 9 Integrated Corporate Performance Report 9 Number of Adverse Incidents Outstanding Central Alert System (CAS) Number of Adverse Incidents Reported Adverse Incidents reported relating to medication administration, prescription and supply errors Number of Adverse Incidents Currently Under Investigation (as of last day of month) Central Alert System (CAS) received Central Alert System Warnings (outside deadline) Percentage of Serious Incident investigations completed within working days Serious Incidents Identified in Month Serious Incidents Investigated and Presented to Panel Serious Incidents Currently Under Investigation Never Events' Identified in Month (included in Serious Incidents figure above) Number of Moderate Incidents confirmed in Month Number of Moderate Incidents Under Investigation Percentage of Moderate Incidents closed in the month which were investigated within working days Percentage of Moderate Incidents where contact has been made with the patient or relative (where this is possible) in accordance with the Duty of Candour Percentage of Serious and Moderate Incidents where feedback has been completed within deadline, in accordance with Duty of Candour % % % % % % % % n/a % % n/a % n/a n/a % % % % % % % % % % % % % % n/a % % % 9% % % % % % % % % % % of Serious Incidents Completed Within % Working Days % % % % % % Number of Serious Incidents Identified in Month Number of Serious Incidents Currently Under Investigation Percentage of Serious Incident investigations completed within working days Serious Incidents Identified in Month Serious Incidents Currently Under Investigation Number of Moderate Incidents Confirmed in Month Number of Moderate Incidents Under Investigation % 9% % % % % % % % % % % of Moderate Incidents Where Contact is Made in % % % % Accordance with Duty of Candour % % % % % 9% % % % % % % % % % % of Closed Moderate Incidents Investigated Within Working Days % % % % Number of Moderate Incidents confirmed in Month Number of Moderate Incidents Under Investigation Percentage of Moderate Incidents where contact has been made with the patient or relative (where this is possible) in accordance with the Duty of Candour Percentage of Moderate Incidents closed in the month which were investigated within working days Integrated Corporate Performance Report 9

53 A&E Service Number of Ombudsman referrals upheld Number of Complaints Reported 9 9 Number of Complaints Closed (resolved with the Complainant and all investigations completed) Number of Complaints Resolved (with the Complainant but internal investigation ongoing) Number of Complaints Open (not resolved with the complainant and currently under investigation) 9 9 Number of Complaints where an investigation has been returned but the complainant is still awaiting feedback. 9 Total PALS Reported Total PALS Closed Total PALS Currently ongoing 9 Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Compliments Received Available Available Available Available Available Available Available Available 9 Number of Complaints Reported 9 Number of Complaints Outstanding 9 9 Number of Complaints Where The Complainant is Awaiting Feedback 9 Number of Complaints Reported Number of Complaints Open (not resolved with the complainant and currently under investigation) Number of Complaints where an investigation has been returned but the complainant is still awaiting feedback. 9 Number of PALS Reported Number of PALS Outstanding 9 Number of Compliments Received Total PALS Reported Total PALS Currently ongoing Compliments Received Number of Security Incidents Reported (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Number of Security Incidents Closed (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Number of Security Incidents Currently Under Investigation (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Safeguarding Referrals - it is a statutory duty for all organisations that work with children or vulnerable adults to share information, in a timely manner when abuse or neglect is identified or suspected. Any staff member who has a concern about a vulnerable child or adult will complete a safeguarding referral that is submitted to the SWASFT safeguarding hub. This referral is then triaged and sent out to the relevant agency according to need i.e adult or child social services, GP, Fire, Police, CQC, Named Nurse etc. Number of Safeguarding Referrals,,9,,,,,9,9 9 9 Number of Security Incidents Reported Number of Security Incidents Under Investigation 9,,,,,,,9, Number of Safeguarding Referrals,9,,9,, Number of Security Incidents Reported (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Number of Security Incidents Currently Under Investigation (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) The above figures can change on a daily basis as Complaints, Adverse Incidents and Serious Incidents are often recoded depending on the level of harm caused. Adverse Incidents, Moderate Incidents and Complaints can be deemed a Serious Incident and then downgraded to their original status, some complaints and plaudits get logged after the report is generated depending on where they are receive in the Trust. Integrated Corporate Performance Report Number of Safeguarding Referrals

54 Out of Hours Service Adverse Incidents reported relating to medication administration, prescription and supply errors Number of Adverse Incidents Reported 9 9 Number of Adverse Incidents Reported Relating to the Trust 9 9 Number of Adverse Incidents Reported Relating to external services Number of Adverse Incidents Closed Number of Adverse Incidents Currently Under Investigation (as of last day of month) Number of Adverse Incidents Reported 9 Number of Adverse Incidents Outstanding 9 9 Number of Adverse Incidents Reported Adverse Incidents reported relating to medication administration, prescription and supply errors Number of Adverse Incidents Currently Under Investigation (as of last day of month) Percentage of Serious Incident investigations completed within working days Serious Incidents Identified in Month Serious Incidents Investigated and Presented to Panel Serious Incidents Currently Under Investigation Never Events' Identified in Month (included in Serious Incidents figure above) Number of Moderate Incidents confirmed in Month Number of Moderate Incidents Under Investigation Percentage of Moderate Incidents closed in the month which were investigated within working days Percentage of Moderate Incidents where contact has been made with the patient or relative (where this is possible) in accordance with the Duty of Candour Percentage of Serious and Moderate Incidents where feedback has been completed within deadline, in accordance with Duty of Candour n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a % n/a n/a n/a n/a n/a % n/a n/a n/a n/a n/a n/a n/a % % of Serious Incidents Completed Within Working Days Number of Serious Incidents Identified in Month Number of Serious Incidents Currently Under Investigation % 9% % % % % % % % % % % % % % % % % Percentage of Serious Incident investigations completed within working days Serious Incidents Identified in Month Serious Incidents Currently Under Investigation Number of Moderate Incidents Confirmed in Month Number of Moderate Incidents Under Investigation % % of Moderate Incidents Where Contact is Made in Accordance with Duty of Candour % % % of Closed Moderate Incidents Investigated Within Working Days 9% 9% % % % % % % % % % % % % % % % % % % % % % % % % % % % % % Number of Moderate Incidents confirmed in Month Number of Moderate Incidents Under Investigation Percentage of Moderate Incidents where contact has been made with the patient or relative (where this is possible) in accordance with the Duty of Candour Percentage of Moderate Incidents closed in the month which were investigated within working days Integrated Corporate Performance Report

55 Out of Hours Service Number of Ombudsman referrals upheld Number of Complaints Reported Number of Complaints Closed (resolved with the Complainant and all investigations completed) Number of Complaints Resolved (with the Complainant but internal investigation ongoing) Number of Complaints Open (not resolved with the complainant and currently under investigation) Number of Complaints where an investigation has been returned but the complainant is still awaiting feedback. Total PALS Reported Total PALS Closed Total PALS Currently ongoing Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Compliments Received Available Available Available Available Available Available Available Available Number of Complaints Reported Number of Complaints Outstanding Number of Complaints Where The Complainant is Awaiting Feedback Number of Complaints Reported Number of Complaints Open (not resolved with the complainant and currently under investigation) Number of Complaints where an investigation has been returned but the complainant is still awaiting feedback. Number of PALS Reported Number of PALS Outstanding Number of Compliments Received 9 Total PALS Reported Total PALS Currently ongoing Compliments Received Number of Security Incidents Reported (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Number of Security Incidents Closed (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Number of Security Incidents Currently Under Investigation (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Safeguarding Referrals - it is a statutory duty for all organisations that work with children or vulnerable adults to share information, in a timely manner when abuse or neglect is identified or suspected. Any staff member who has a concern about a vulnerable child or adult will complete a safeguarding referral that is submitted to the SWASFT safeguarding hub. This referral is then triaged and sent out to the relevant agency according to need i.e adult or child social services, GP, Fire, Police, CQC, Named Nurse etc. Number of Safeguarding Referrals Number of Security Incidents Reported Number of Security Incidents Under Investigation Number of Safeguarding Referrals Number of Security Incidents Reported (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Number of Security Incidents Currently Under Investigation (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) The above figures can change on a daily basis as Complaints, Adverse Incidents and Serious Incidents are often recoded depending on the level of harm caused. Adverse Incidents, Moderate Incidents and Complaints can be deemed a Serious Incident and then downgraded to their original status, some complaints and plaudits get logged after the report is generated depending on where they are receive in the Trust. Integrated Corporate Performance Report Number of Safeguarding Referrals

56 NHS Service Adverse Incidents reported relating to medication administration, prescription and supply errors Number of Adverse Incidents Reported 9 Of the Adverse Incidents Reported: Number of Adverse Incidents Reported Relating to the Trust 9 Number of Adverse Incidents Reported Relating to external services Number of Adverse Incidents Closed 9 Number of Adverse Incidents Currently Under Investigation (as of last day of month) 9 Number of Adverse Incidents Reported 9 Number of Adverse Incidents Outstanding 9 Number of Adverse Incidents Reported Adverse Incidents reported relating to medication administration, prescription and supply errors Number of Adverse Incidents Currently Under Investigation (as of last day of month) Percentage of Serious Incident investigations completed within working days Serious Incidents Identified in Month Serious Incidents Investigated and Presented to Panel Serious Incidents Currently Under Investigation Never Events' Identified in Month (included in Serious Incidents figure above) Number of Moderate Incidents confirmed in Month Number of Moderate Incidents Under Investigation Percentage of Moderate Incidents closed in the month which were investigated within working days Percentage of Moderate Incidents where contact has been made with the patient or relative (where this is possible) in accordance with the Duty of Candour Percentage of Serious and Moderate Incidents where feedback has been completed within deadline, in accordance with Duty of Candour n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a % n/a % % n/a n/a n/a n/a n/a n/a n/a % % of Serious Incidents Completed Within Working Days Number of Serious Incidents Identified in Month Number of Serious Incidents Currently Under Investigation % 9% % % % % % % % % % % Percentage of Serious Incident investigations completed within working days Serious Incidents Identified in Month Serious Incidents Currently Under Investigation Number of Moderate Incidents Confirmed in Month Number of Moderate Incidents Under Investigation % % of Moderate Incidents Where Contact is Made in Accordance with Duty of Candour % % of Closed Moderate Incidents Investigated Within Working Days 9% 9% % % % % % % % % % % % % % % % % % % % % % Number of Moderate Incidents confirmed in Month Number of Moderate Incidents Under Investigation Percentage of Moderate Incidents where contact has been made with the patient or relative (where this is possible) in accordance with the Duty of Candour Percentage of Moderate Incidents closed in the month which were investigated within working days Integrated Corporate Performance Report

57 NHS Service Number of Ombudsman referrals upheld Number of Complaints Reported 9 Number of Complaints Closed (resolved with the Complainant and all investigations completed) Number of Complaints Resolved (with the Complainant but internal investigation ongoing) Number of Complaints Open (not resolved with the complainant and currently under investigation) Number of Complaints where an investigation has been returned but the complainant is still awaiting feedback. Total PALS Reported Total PALS Closed Total PALS Currently ongoing Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Compliments Received Available Available Available Available Available Available Available Available Number of Complaints Reported Number of Complaints Outstanding Number of Complaints Where The Complainant is Awaiting Feedback Number of Complaints Reported Number of Complaints Open (not resolved with the complainant and currently under investigation) Number of Complaints where an investigation has been returned but the complainant is still awaiting feedback. Number of PALS Reported Number of PALS Outstanding Number of Compliments Received 9 Total PALS Reported Total PALS Currently ongoing Compliments Received Number of Security Incidents Reported (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Number of Security Incidents Closed (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Number of Security Incidents Currently Under Investigation (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Safeguarding Referrals - it is a statutory duty for all organisations that work with children or vulnerable adults to share information, in a timely manner when abuse or neglect is identified or suspected. Any staff member who has a concern about a vulnerable child or adult will complete a safeguarding referral that is submitted to the SWASFT safeguarding hub. This referral is then triaged and sent out to the relevant agency according to need i.e adult or child social services, GP, Fire, Police, CQC, Named Nurse etc. Number of Safeguarding Referrals 99 9 Number of Security Incidents Reported Number of Security Incidents Under Investigation Number of Safeguarding Referrals Number of Security Incidents Reported (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Number of Security Incidents Currently Under Investigation (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) The above figures can change on a daily basis as Complaints, Adverse Incidents and Serious Incidents are often recoded depending on the level of harm caused. Adverse Incidents, Moderate Incidents and Complaints can be deemed a Serious Incident and then downgraded to their original status, some complaints and plaudits get logged after the report is generated depending on where they are receive in the Trust. Integrated Corporate Performance Report Number of Safeguarding Referrals

58 Tiverton Urgent Care Centre Adverse Incidents reported relating to medication administration, prescription and supply errors Number of Adverse Incidents Reported Number of Adverse Incidents Reported Relating to the Trust Number of Adverse Incidents Reported Relating to external services Number of Adverse Incidents Closed Number of Adverse Incidents Currently Under Investigation (as of last day of month) Number of Adverse Incidents Reported Number of Adverse Incidents Outstanding 9 Apr- May- Jun- Jul- Aug- Sep- Nov- Oct- Dec- Jan-9 Feb-9 Mar-9 Number of Adverse Incidents Reported Adverse Incidents reported relating to medication administration, prescription and supply errors Number of Adverse Incidents Currently Under Investigation (as of last day of month) Percentage of Serious Incident investigations completed within working days Serious Incidents Identified in Month Serious Incidents Investigated and Presented to Panel Serious Incidents Currently Under Investigation Never Events' Identified in Month (included in Serious Incidents figure above) Number of Moderate Incidents confirmed in Month Number of Moderate Incidents Under Investigation Percentage of Moderate Incidents closed in the month which were investigated within working days Percentage of Moderate Incidents where contact has been made with the patient or relative (where this is possible) in accordance with the Duty of Candour Percentage of Serious and Moderate Incidents where feedback has been completed within deadline, in accordance with Duty of Candour n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a n/a % of Serious Incidents Completed Within Working Days Number of Serious Incidents Identified in Month Number of Serious Incidents Currently Under Investigation % 9% % % % % % % % % % Percentage of Serious Incident investigations completed within working days Serious Incidents Identified in Month Serious Incidents Currently Under Investigation Number of Moderate Incidents Confirmed in Month Number of Moderate Incidents Under Investigation % % of Moderate Incidents Where Contact is Made in Accordance with Duty of Candour % % of Closed Moderate Incidents Investigated Within Working Days 9% 9% % % % % % % % % % % % % % % % % % % Number of Moderate Incidents confirmed in Month Number of Moderate Incidents Under Investigation Percentage of Moderate Incidents where contact has been made with the patient or relative (where this is possible) in accordance with the Duty of Candour Percentage of Moderate Incidents closed in the month which were investigated within working days Integrated Corporate Performance Report

59 Tiverton Urgent Care Centre Number of Ombudsman referrals upheld Number of Complaints Reported Number of Complaints Closed (resolved with the Complainant and all investigations completed) Number of Complaints Resolved (with the Complainant but internal investigation ongoing) Number of Complaints Open (not resolved with the complainant and currently under investigation) Number of Complaints where an investigation has been returned but the complainant is still awaiting feedback. Total PALS Reported Total PALS Closed Total PALS Currently ongoing Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Data Not Yet Compliments Received Available Available Available Available Available Available Available Available Number of Complaints Reported Number of Complaints Outstanding Number of Complaints Where The Complainant is Awaiting Feedback Number of Complaints Reported Number of Complaints Open (not resolved with the complainant and currently under investigation) Number of Complaints where an investigation has been returned but the complainant is still awaiting feedback. Number of PALS Reported Number of PALS Outstanding Number of Compliments Received 9 Total PALS Reported Total PALS Currently ongoing Compliments Received Number of Security Incidents Reported (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Number of Security Incidents Closed (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Number of Security Incidents Currently Under Investigation (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Safeguarding Referrals - it is a statutory duty for all organisations that work with children or vulnerable adults to share information, in a timely manner when abuse or neglect is identified or suspected. Any staff member who has a concern about a vulnerable child or adult will complete a safeguarding referral that is submitted to the SWASFT safeguarding hub. This referral is then triaged and sent out to the relevant agency according to need i.e adult or child social services, GP, Fire, Police, CQC, Named Nurse etc. Number of Safeguarding Referrals Number of Security Incidents Reported Number of Security Incidents Under Investigation Number of Safeguarding Referrals Number of Security Incidents Reported (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Number of Security Incidents Currently Under Investigation (SIRS) (A&E Activity, Control, Operations, Fleet, Admin, Education & Training and Patient Safety Incidents) Number of Safeguarding Referrals The above figures can change on a daily basis as Complaints, Adverse Incidents and Serious Incidents are often recoded depending on the level of harm caused. Adverse Incidents, Moderate Incidents and Complaints can be deemed a Serious Incident and then downgraded to their original status, some complaints and plaudits get logged after the report is generated depending on where they are receive in the Trust. Integrated Corporate Performance Report