Integrated Performance Report February 15 (Month 11)

Transcription

1 Governing Body Agenda Item: 9 Date: 7 April 2015 Author: Sara Stiddard Clinical ead: CCG Director/Manager: Dr M Backhouse Mike Vaughton Chief Financial Officer Integrated Performance Report February 15 (Month 11) Recommendations The Governing Body is asked to: Discuss the Clinical Commissioning Group s latest performance delivery as at February 2015 for Finance and January 2015 for Performance standards. Review mitigating actions for those areas of exception. Review the current risks to the financial position. ote some commentaries are missing due to the reporting timetable for this month. Background Everyone Counts: Planning for Patients 2014/15 to 2018/19 sets out HS ambitions to achieve high quality care for all over the next five years and provides planning guidance to support delivery. The CCG will be judged on delivery of the commitment to patients set out in the HS Constitution the quality of outcomes set out in the HS Outcomes Framework 2014/5, and the management of expenditure within budget. Purpose This report provides an overview orth Somerset CCG performance on HS Constitutional rights, quality of outcomes, financial delivery including performance against key commissioning contracts and progress on QIPP. It covers the period ending 28 February 2015 for finance and 31 January 2015 for all other metrics. Mitigating actions to support delivery are described for the main areas of poor performance and/or substantial risk. If you require this document in an alternative format please telephone Governing Body Meeting 7 th April 2015 Page 1 of 3

2 Financial impact This paper presents the year to date financial position of orth Somerset CCG. orth Somerset CCG is required to meet its financial duties each year; mitigating actions have been identified within the report to address any financial risks. Safety and Quality Impact This paper reports on a series of safety and quality indicators relating to orth Somerset CCG and Providers of locally commissioned services. Consultation, Involvement and Engagement Key members of the Finance and Performance team have been in discussions with various Governing Body members and CCG staff on ambitions for performance reporting in an integrated manner. All suggestions have been considered in producing this report. Equality Impact Assessment one Risk Assessment The reported overall performance position of the CCG has been assessed for risks and includes the expected impact of relevant mitigating actions. Appendices Appendix 1 Quality, Safety and Performance Metrics by Provider Appendix 2 Quality Dashboard Appendix 3 Income and Expenditure Appendix 4 Cash Flow position Appendix 5 Acute Contract Performance Appendix 6 Risks & Mitigations If you require this document in an alternative format please telephone Governing Body Meeting 7 th April 2015 Page 2 of 3

3 Glossary HS CB ational Health Service Commissioning Board CCG Clinical Commissioning Group QIPP Quality, Innovation, Prevention and Productivity RAG Red, Amber and Green rating KPI s Key Performance Indicator s SWCSU South West Commissioning Support Unit UHB University Hospitals Bristol BT orth Bristol Trust WAHT Weston Area Health Trust ACC Ambulatory Care Centre at Weston IF Items ot ormally Funded HPA Health Protection Agency SWASFT South Western Ambulance Service HS Foundation Trust CPMG Contract Performance Management Group RTT Referral to Treatment OP Outpatient ISTC Independent Sector Treatment Centre MRI Magnetic Resonance Imaging HCAI Healthcare Acquired Infections BSSG Bristol, orth Somerset, South Gloucestershire. ICE ational Institute of Clinical Excellence FFT Friends and Family Test If you require this document in an alternative format please telephone Governing Body Meeting 7 th April 2015 Page 3 of 3

4 If you require this document in an alternative format please telephone Governing Body Meeting 7 th April 2015 Page 4 of 3

5 Item 9 Integrated Performance Report M /15 Prepared by: Sara Stiddard, Performance Manager 16 March 2015 Creating the Healthiest Community Together 1

6 Structure of the Document The report is written to enable the CCG to review the key domains of finance, QIPP, performance, quality and safety in an assimilated format. The purpose of reporting in this way is to support the CCG s committees in their consideration of the current status of the above domains as well as the interdependencies between them. The report focuses on the current status of all key domains of quality & safety; finance & QIPP; and performance. It is structured to focus on the performance of the CCG but additionally provides a comprehensive overview of the range of indicators used to assess our main provider organisations: orth Bristol Hospital Trust, United Hospitals Bristol and Weston Area Hospital Trust. Quality dashboards are included in section 3, and Performance dashboards are included in section 4, to provide a highlevel overview of all performance domains, highlighting where performance is reported to have some variance from plan (amber rated) or where there is significant variance from plan (red rated). Dashboards are included for the CCG and for the three providers noted above within Appendices 1 and 2. An overview of the CCG s QIPP and current financial position is included in section 5 and Appendices 3, 4, 5, and 7. In Section 6, the report focuses in detail on those areas that are shown on the dashboards as having deviated from target. The tables included in Section 6 set out a description of these performance issues and include details of the forums the CCG uses to monitor and address these issues. Section 7 provides an opportunity to address Exception Reporting for areas of provider performance which are not covered by HS Constitution or Quality standards. Creating the Healthiest Community Together 2

7 Structure of the Document Assurance on the full range of quality measures can also be sought from provider Integrated Quality and Performance Reports at: Weston - BT - UHB - SCP - AWP SWAST - Brisdoc - Care UK - The data and information included in the Integrated Performance Report is sourced from provider contract monitoring and finance reports, CCG QIPP and finance reports and provider quality, safety and performance reports. The reporting period included varies as some reports are quarterly and others monthly, although the data included in this report is as follows unless otherwise stated in the report: Table 1: Integrated Performance Report Data Sources and Period Covered Data Source Period Covered Finance CCG finance team M11 Performance Indicators & Targets SWASFT (Provider data) HS Constitution (S CCG data) M10 Quality Exceptions CSU Quality team M10/11 Serious Incidents CSU Quality team M11 Creating the Healthiest Community Together 3

8 1. Executive Summary Areas of good performance BT MRSA; MSSA; Cdiff; mortality rates; staff appraisal; FFT response rates inpatient and maternity; Care UK s new Frequent Caller Process (GP Practices contacted within 24 hours) Good use of BrisDoc professional line by healthcare partners SWAST s participation in the national pilot of dispatch on disposition is going well. Areas of challenging performance Weston - Delirium and Dementia FAIR CQUI has not been achieved in Q1,Q2,or Q3 YTD. Weston - Increasing staff turnover since August 2014 current figure for January 15.1%. Weston - There has been an increased number of formal complaints received in January 23 against athreshold of per month. AWP Sickness absence 7.76% against target of 4.5% BT- cancer pathway performance struggling to recover following Christmas period. BT falls, overdue complaints; serious incident rate; never event; malnutrition screening; VTE screening; WHO checklist; staff sickness; staff turnover UHB - waiting times for fractured femur and dental never events SCP Pressure Ulcers grade 3 and 4 continue to rise HS111 Care UK - drop in call answering performance Early Warnings AWP 2 system CQUIS remain amber. BT - FFT ED response rate; UHB - Dementia find, assess and refer SWAST - Red 1 and 2 Performance is down due to huge increase in demand and resourcing issues. Staff sickness has increased to 6.19% against a target of 4 4% and turnover remains high. SWASFT Complaints have increased which is mainly due to the new reporting process which was commenced in This process groups complaints, comments and concerns. The way in Recent Quality issues Weston There have been separate outbreaks of orovirus in December resulting in ward closures totalling 65 days. There was one confirmed outbreak in January Weston have reported 2 Serious Incidents in February for missed/delayed cancer diagnosis. AWP Four enforcement notices lifted, CQC Compliance Action plans remain in progress BT dementia FAIR; 62 day referral to treatment; harm free rate; falls BT- production of CQC action plan which the data is reported is currently being negotiated under the Creating the Healthiest Community Together 4 quality schedule.

9 2. orth Somerset CCG and Providers Performance Summary Dashboard HS orth Somerset CCG Red Rated DoT Amber Rated DoT Green rated DoT Performance United Hospital Bristol Trust Red Rated DoT Amber Rated DoT Green rated DoT Performance orth Bristol Hospital Trust Red Rated DoT Amber Rated DoT Green rated DoT Performance Weston Area Hospital Trust Red Rated DoT Amber Rated DoT Green rated DoT Performance SWASFT Red Rated DoT Amber Rated DoT Green rated DoT Performance ot all providers reporting the same amount of indicators. Review commenced 26 ovember Quality dashboard summary to be added following review. Creating the Healthiest Community Together 5

10 3. orth Somerset CCG Outcome & Quality Dashboards Indicator Target Apr- 14 May- 14 Domain 1. Preventing People from Dying Prematurely Cancer- 2 Week wait Jun-14 Monthly & Quarterly Performance Jul-14 Aug- 14 Sept- 14 Oct-14 ov-14 Dec-14 Jan-15 Detail on Page BT 93% 93.5% 93.8% 92.4% 91.7% 91.7% 94.7% 94.8% 93.20% 93.2% 90.8% 41 Percentage of patients treated within 62 days from referral WAHT 85% 85.9% 85.7% 85.1% 79.0% 88.1% 72.1% 89.3% 88.9% 88.1% 75.4% 41 UHB 85% 75.3% 81.1% 85.1% 79.4% 77.6% 74.3% 79.6% 81.0% 84.6% 80.0% 41 BT 85% 72.1% 76.7% 74.8% 72.5% 80.0% 77.0% 76.5% 85.8% 85.1% 83.0% 41 Red 1 Performance orth Somerset SWASFT 75% 57.1% 75.7% 60.9% 60.6% 70.3% 82.7% 75.4% 72.1% 64.6% 57.6% 42 Red 2 Performance orth Somerset SWASFT 75% 71.2% 68.5% 70.5% 69.9% 74.2% 74.1% 71.8% 68.7% 62.2% 66.3% 42 Category A- 19 minute Transportation time- orth Somerset SWASFT 95% 94.7% 94.8% 95.7% 93.0% 95.2% 94.4% 93.5% 93.4% 88.9% 93.7% 42 This report focuses on Red and rising amber performance and is reviewed in more detailed in Section 6. Full performance detail can be found in the Appendices that accompany this report. 6

11 o commentary available 3. orth Somerset CCG Outcome & Quality Dashboards Indicator Target Apr- 14 May- 14 Monthly & Quarterly Performance Jun-14 Jul-14 Aug- 14 Sept- 14 Oct-14 ov-14 Dec-14 Jan-15 Detail on Page Urgent consultation within 2 hours BRISDOC 95% 93% 93% 90% 92% 93% 90% 91% 92% 90% 23 Care UK (BSSG): % of calls answered within 60 seconds following introductory message Care UK (BSSG): % of calls requiring 111 Clinical Advisor passed as a live transfer and not a call back 95% % 97.6% 95.2% 88.5% 74.8% 94.9% 24 98% % 72.2% 69.4% 59.4% 42.2% 42.0% 24 % of patients advised to attend Accident and Emergency Department 5% 6.9% 6.5% ive Transfer time less than 5 minutes 100% 97.5% 97.2% Time taken for call back less than 10 minutes if live transfer not possible 95% 34.9% 31.4% This report focuses on Red and rising amber performance. Full performance detail can be found in the Appendices that accompany this report. 7

12 3. orth Somerset CCG Outcome & Quality Dashboards Indicator Target Apr- 14 May- 14 Jun- 14 Domain 2 Enhancing quality of life for people with long term conditions Monthly & Quarterly Performance Oct- Jul-14 Aug-14 Sept Percentage of patients aged 75 and over where dementia case finding question is asked ov-14 Dec-14 Jan-15 Detail on Page WAHT 90% 27% 12% 17% o data o data o data o data o data o data o data 25 UHB 90% 57.1% 52.3% 49.0% 62.1% 67.5% 66.6% 61.4% 63.7% 62.9% 78.3% 25 Percentage of patients with positive screening test who have formal screening assessment WAHT 90% 18% 12% 18% o data o data o data o data o data o data o data 25 UHB 90% 71.7% 78.3% 59.5% 84.7% 81.7% 87.3% 87.1% 92.2% 82.2% 90.7% 25 Percentage of patients with a new positive dementia screening question, referred for specialist diagnosis WAHT 90% 0% 8% 7% o data o data o data o data o data o data o data 26 UHB 90% 47.6% 56.5% 33.3% 55.2% 50.0% 35.9% 78.3% 73.3% 68% 82.4% 26 This report focuses on Red and rising amber performance and is reviewed in more detailed in Section 6. Full performance detail can be found in the Appendices that accompany this report. 8

13 3. orth Somerset CCG Outcome & Quality 3. orth Somerset CCG Dashboards cont.. Dashboards Monthly & Quarterly Performance Indicator Target Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sept-14 Oct -14 ov-14 Dec-14 Jan-14 Detail on Page Domain 3. Helping people recover from episodes of ill health or following injury Percentage of patients with fractured neck of femur operated on within 36 hours WAHT 100% 100% 100% o data UHB 90% 88.9% 70.0% 82.6% 82.1% 71.4% 61.3% 77.8% 73.3% 70% 78.3% 26 Emergency readmissions within 30 days of discharge from hospital o data o data o data o data o data o data 26 WAHT 24.42% 21.12% 19.12% 20.74% 21.1% 18.34% 20.07% 17.97% Due March Due April 27 UHB 18.8% 17.0% 19.7% 16.5% 18.6% 17.09% 17.52% 14.79% o data o data 27 Emergency admissions for acute conditions that should not usually required hospital admissions BT o data UHB o data o data o data o data o data o data o data This report focuses on Red and rising amber performance and is reviewed in more detailed in Section 6. Full performance detail can be found in the Appendices that accompany this report. 9

14 3. orth Somerset CCG Outcome & Quality Dashboards Monthly & Quarterly Performance Indicator Target Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sept-14 Oct -14 ov-14 Dec-14 Jan- 14 Detail on Page Domain 4: Patient Experience Friends & Family Test Response Rate AWP 10.9% 9.8% 11.7% 12.2% 12.6% 12.8% 13.6% o data 28 Friends & Family Test - Provider Response Rate (emergency department) BT 8.4% 4.9% 21.5% 22.8% 26.5% 28.0% 18.7% 21% 4% 10% 28 Friends & Family Test - Response Rate (birth) BT 13.9% 17.2% 15.0% 14.5% 25.7% 16.2% 15.4% 15% 18% 15% 29 This report focuses on Red and rising amber performance and is reviewed in more detailed in Section 6. Full performance detail can be found in the Appendices that accompany this report. 10

15 3. orth Somerset CCG Outcome & Quality Dashboards Monthly & Quarterly Performance Indicator Target Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sept-14 Oct -14 ov-14 Dec-14 Jan- 14 Detail on Page Domain 4: Patient Experience Total number of complaints received WAHT UHB o data o data o data o data o data 29 BT o data Percentage of complaints responded to within agreed timescales WAHT 90% 37% 73% 88% 82% 90% 85.0% 80.0% 50.0% 73.0% 88% 30 UHB 90% 93.1% 82.5% 83.3% 91.5% 83.3% 88.1% 84.4% 82.9% 82.9% 84.8% 30 BT 90% o data o data o data o data o data o data o data o data o data o data 30 This report focuses on Red and rising amber performance and is reviewed in more detailed in Section 6. Full performance detail can be found in the Appendices that accompany this report. 11

16 3. orth Somerset CCG Outcome & Quality 3. orth Somerset CCG Dashboards cont.. Dashboards Indicator Target Apr-14 May- 14 Jun- 14 Monthly & Quarterly Performance Jul-14 Aug-14 Sept- 14 Oct- 14 ov 14 Dec-14 Jan-15 Detail on Page Domain 5: umber of Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemia (post 48 hours) UHB Incidence of Clostridium difficile (Post 72 hours) WAHT UHB umber of Meticillin Sensitive Staphylococcus aureus (MSSA) bacteraemia (post 48 hours) WAHT UHB <2 per month <3 per month This report focuses on Red and rising amber performance and is reviewed in more detailed in Section 6. Full performance detail can be found in the Appendices that accompany this report. 12

17 3. orth Somerset CCG Outcome & Quality Dashboards Indicator Target Apr-14 May- 14 Jun- 14 Monthly & Quarterly Performance Jul-14 Aug-14 Sept- 14 Oct- 14 ov 14 Dec-14 Jan-15 Detail on Page Domain 5: Proportion of adult inpatients who have had a VTE assessment on admission to hospital (CQUI) BT 95% 95% 95.0% 94.8% 94.0% 93.6% 94.1% 94.1% 96.0% 94.2% 92.9% 33 ever Events BT UHB umber of Serious Incidents reported(si) WAHT This report focuses on Red and rising amber performance and is reviewed in more detailed in Section 6. Full performance detail can be found in the Appendices that accompany this report. 13

18 3. orth Somerset CCG Outcome & Quality 3. orth Somerset CCG Dashboards cont.. Dashboards Indicator Target Apr-14 May-14 Domain 6. Staff wellbeing Jun- 14 Monthly & Quarterly Performance Sept- Jul-14 Aug-14 Oct ov 14 Dec-14 Jan-15 Detail on Page Percentage of staff sickness /absence WAHT 3% 3.9% 4.3% 3.9% 4.5% 4.4% 4.5% % 4.3% UHB 3.5% 3.8% 3.7% 4.1% 4.0% 3.6% 4.0% 4.5% 4.5% 4.6% o data BT 4.10% 3.80% 4.20% 4.20% 4.29% 4.40% 2.50% o data 4% 5% SWASFT 5.72% 5.71% 5.7% 5.97% 5.9% 6.05% - - o data o data 37 SCP 3.6% 3.5% 3.7% 3.1% 3.4% 4.0% 4.0% 4.6% 5.2% 5.0% 37 Percentage staff turnover (rolling 12 months) WAHT 12% 11.9% 12.0% 12.1% 11.8% 12.3% 13.2% 13.3% 13.5% 14.8% 15.1% 38 UHB 11% 11.0% 11.2% 11.5% 12.1% 12.9% 13.3% 13.2% 13.3% 13.5% 13.8% 38 SCP 0.68% 2.01% 2.76% 3.87% 5.05% 6.29% 7.72% 8.65% 9.9% 11.0% 38 SWASFT % % % 12.27% 12.42% o data o data 38 Percentage of staff completing dementia training General WAHT 90% 56.82% o data o data o data o data o data 65.85% o data 39 This report focuses on Red and rising amber performance and is reviewed in more detailed in Section 6. Full performance detail can be found in the Appendices that accompany this report. 14

19 3. orth Somerset CCG Outcome & Quality Dashboards Indicator Target Apr-14 May-14 Jun- 14 Monthly & Quarterly Performance Jul-14 Aug-14 Sept- 14 Oct-14 ov 14 Dec-14 Jan-14 Detail on Page Percentage of staff having had an annual appraisals (rolling 12 months) WAHT 90% 83.80% 80.60% 84.20% 85.50% 87.80% 87.00% 85.10% 85.60% 86.6% 88.1% 36 UHB 90% 87.1% 86.3% 87.2% 86.3% 86.9% 85.3% 84.4% 83.5% 85.1% 83.7% 36 Vacancy rate UHB 4% 2.2% 5.5% 5.6% 5.4% 5.6% 5.1% 5.7% 6.1% 6.1% 5.5% 38 Percentage of staff completing safeguarding children level 2 (rolling 12 months) SCP 90% 79% 81% 79% 79% 79% 80% 80% 80% 82% 38 WAHT 90% 87% 86.40% 87.40% o data o data o data o data o data Percentage of staff suffering work-related stress in last 12 months 80.50% / 63.47% o data 38 UHB 41% 39 Percentage of staff witnessing potentially harmful errors, near misses or incidents in the last month UHB 39% 39 This report focuses on Red and rising amber performance and is reviewed in more detailed in Section 6. Full performance detail can be found in the Appendices that accompany this report. 15

20 3. orth Somerset CCG Outcome & Quality Dashboards Serious Incidents: Reported by Trust Provider DEC (M9) Month JA (M10) FEB (M11) Creating the Healthiest Community Together YTD BT UHB WAHT SWASFT AWP A S SCP BRISDOC CARE UK earning and Actions BT continue steady reporting of Slip trips and falls which make up 40% of overall reported SI s The trust investigate each fall through the falls group implemented last year following high falls rates. ever Event. Due to surgical error. Guide wire found in iliac vein. YTD to 4. UHB is putting together the requested assurance from the CCG s against the 4 Dental ever Events to ensure no further occurrences of this type happen again. ever Event. Wrong site surgery at BCH Oral surgery. Child dental tooth extraction. YTD 6, 4 of which are dental related. WAHT have reported 2 SI s relating to missed diagnosis that are Cancer related. The SI s are under investigation with the trust. SWASFT, Brisdoc and Care UK are showing no SI s for the orth Somerset area. SCP A Pressure Ulcer action plan is under development and is to be shared with the CCG. A joint SI is under investigation with WAHT that is Cancer related and a potential missed diagnosis. AWP- orth Somerset area has had a further 2 SI s reported for Unexpected deaths of Community patients bringing the year to date figure to 7 and 39% overall of all reported SI s for this area. An external investigation has been agreed by the CCG to take place with the report shared once complete. 16

21 4. S CCG Constitution Dashboard Monthly & Quarterly Performance Indicator Target Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 ov-14 Dec-14 Jan-15 Year to Date 2014/ 15 Detail on Page RTT: Admitted 52 Week Waits RTT: on-admitted 52 Week Waits Diagnostic 6 Week Waits 99.0% 98.7% 97.5% 96.8% 95.9% 97.0% 98.5% 99.2% 98.3% 96.8% 95.8% 95.8% 40 Cancer 31 day subsequent treatments - surgery 94.0% 91.4% 90.5% 82.8% 94.7% 100.0% 97.1% 87.9% 92.3% 89.7% 100.0% 92.5% 41 Cancer 62 day referral to first treatment - GP referral 85.0% 82.7% 85.0% 78.6% 70.9% 78.56% 75.7% 88.3% 88.4% 91.0% 74.7% 81.3% 41 Cancer 62 day referral to first treatment - Consultant referral upgrade A&E 4hr Waiting Time Performance- 85.0% 100.0% 66.7% 83.3% 100.0% 66.7% 80.0% 100.0% 75.0% 85.7% 71.4% 81.7% 41 WAHT 95.0% 96.6% 96.3% 98.0% 93.7% 89.2% 90.7% 89.7% 92.8% 90.4% 91.8% 92.9% 41 UHB 95.0% 94.5% 94.3% 95.2% 92.4% 93.7% 92.4% 93.8% 88.6% 86.3% 90.9% 92.2% 41 BT 95.0% 91.3% 88.9% 84.1% 86.0% 82.1% 83.8% 80.7% 83.3% 84.1% 83.4% 84.9% 41 Ambulance - Category A - 19 minute transportation time 95.0% 94.7% 94.8% 95.7% 93.0% 95.2% 94.4% 93.5% 93.4% 88.9% 93.7% 93.6% 42 Ambulance - Category A (Red2) - 8 minute response 75.0% 71.2% 68.5% 70.5% 69.9% 74.2% 74.1% 71.8% 68.7% 62.2% 66.3% 69.5% 42 Ambulance - Category A (Red1) - 8 minute response 75.0% 57.1% 75.7% 60.9% 60.6% 70.3% 82.7% 75.4% 72.1% 64.6% 57.6% 68.3% 42 This report focuses on Red and rising amber performance and is reviewed in more detailed in Section 6.. Full performance detail can be found in the Appendices that accompany this report. 17

22 4. S CCG Constitution Support Measures Dashboard Indicator Monthly & Quarterly Performance Target Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 ov-14 Dec-14 Jan-15 Year to Date 2014/ 15 Detail on Page Eliminating Mixed Sex Accommodation UHB Cancelled Operations for non clinical reasons WAHT 0.8% 2.70% 2.80% 0.80% 0.60% 3.50% 2.70% 1.50% 0.50% 2.80% 0.50% 1.80% 43 UHB 0.8% 0.98% 0.96% 1.10% 1.35% 0.97% 1.14% 0.84% 1.96% 0.73% 1.00% 1.10% 43 BT 0.8% 1.07% 1.65% 2.65% 1.90% 2.28% 2.55% 2.17% 1.97% 1.44% 2.50% 2.03% 43 Cancelled Operations rebooked within 28 days- UHB 95.0% 94.2% 85.2% 94.4% 95.3% 90.5% 85.2% 85.3% 90.4% 87.0% 82.9% 89.1% 43 BT 95.0% 89.1% 86.2% 83.2% 89.7% 87.5% 90.3% 91.6% 94.4% 93.6% 79.8% 88.2% 43 Trolley Waits in A&E > 12 hours WAHT UHB This report focuses on Red and rising amber performance and is reviewed in more detailed in Section 6. Full performance detail can be found in the Appendices that accompany this report. 18

23 4. S CCG Constitution Support Measures Dashboard Indicator Target Apr-14 May- 14 Monthly & Quarterly Performance Jun-14 Jul-14 Aug- 14 Sep- 14 Oct-14 ov- 14 Dec- 14 Year to Date Detail on Page Jan / 15 Ambulance Handovers - number >1hour WAHT /A UHB BT Ambulance Handovers - number >30 minutes < 1hour WAHT /A UHB BT This report focuses on Red and rising amber performance and is reviewed in more detailed in Section 6. Full performance detail can be found in the Appendices that accompany this report. 19

24 Planned Care Unplanned Care Programme Intervention Pathway Redsign :Opthalmology Pathway Redsign : Dermatology Pathway Redsign : MSK GP Referrals - Management GP Referrals - Reduce Variation Enhanced Community Access Proactive case management Budget 000s Year to Date Actual 000s Variance 000s Budget 000s Forecast Actual 000s Variance 000s (172) (263) R 1,182 0 (1,182) 1,405 0 (1,405) R Perf Transactional - Recurrent Contract Enforcement Decommision AP 1, (1,050) 1, (855) R Transactional - on Recurrent Capital to Revenue Budget Review/ Financial Management Other transactional savings 4,233 5,283 1,050 5,232 7,755 2,523 G Sub Total 7,620 6,266 (1,354) 9,200 9,200 0 G Medicines management * Various A Total Planned Savings 8,353 6,999 (1,354) 10,000 10,000 0 G Memorandum QIPP- Unallocated savings 5,283 5, ,482 6,482 0 G QIPP -Allocated to budgets 3,070 1,716 (1,354) 3,518 1,850 (1,668) R RAG rating relates to year to date position and Amber/Red rated issues are reviewed in further detail in Section 6, page 24.

25 4. S CCG Finance Dashboards Year to Date Forecast End of Year Budget ( '000) Actual ( '000) Variance ( '000) Budget ( '000) Actual ( '000) Variance ( '000) Acute 138, ,743 (176) 151, , G Primary Care 35,333 35, ,546 38, A Mental Health 21,840 21,403 (436) 23,825 23,467 (358) G Community Health Services 22,130 22,009 (121) 24,142 24,052 (90) G Continuing Care 12,611 13, ,758 14, R Corporate 4,746 4,744 (2) 5,178 5,177 (1) G Other 2,464 2, ,688 2, G Reserves 8,658 8, ,376 9,847 (529) G Savings Programme (5,283) (5,283) 0 (6,482) (6,482) 0 A Expenditure v Budget 241, ,418 (0) 263, ,888 0 G ess Unfunded Budget (9,953) 0 9,953 (10,000) 0 10,000 G Expenditure v Allocation 231, ,418 9, , ,888 10,000 G Planned Run Rate 9,953 10,000 G Perf RAG rating relates to year to date position and Amber/Red rated issues are reviewed in further detail in Section 6, page 24. Creating the Healthiest Community Together 21

26 6. Performance Variance and Assurance Information Additional Finance assurance The CCG continues to forecast achievement of the planned position at year end Acute contract performance shows overspends in two of our main acute providers. Elective spend is under against plan overall although activity and costs are above plan at Weston. on-elective activity is slightly below plan overall and there has been a shift in non-elective work from UHB to BT following the opening of the new A&E service at Southmead Hospital Acute contracts are showing an overspend relating to diagnostic services, critical care and costs associated with implementation of ICE guidance The CCG is reporting a significant cost pressure for Continuing Health Care services and this is in line with previous reports Risks of 450k have been identified in particular around failure to deliver planned savings and further over-performance on Acute contracts. Mitigating actions of 450k are shown against these risks and this reflects current assumptions on contract challenges, fines and penalties The CCG expects to be compliant with the Better Payment Performance target for the year and live within the notified cash limit. This report focuses on Red and rising amber performance. Full performance detail can be found in the Appendices that accompany this report. Creating the Healthiest Community Together 22

27 Urgent Consultation withi n 2 hours (BRISDOC) Summary hospitallevel Mortality Indicator (SHMI) Issue BT UHB WAHT SWAFT AWP 6. Performance Variance and Assurance Information The table below includes all red and amber related performance, quality & safety and financial domains included in the above dashboards. The table states the domain concerned, provides a synopsis of the matters arising and includes details of the forum in which the issue is addressed and monitored. This table is provided as a comprehensive overview and it is anticipated that CCG commissioners and committees should direct detailed questions to commissioning leads and /or further reference the orth Somerset CCG Integrated Performance report or the reports listed in Section 1. Where applicable, a reference has been provided to link the Issue to the CCG Risk Register. Domain 1: Synopsis of Issue Current Actions Forum Issue is addressed Recovery dates Responsible CCG Officer and CCG Clinical ead Risk Register Reference o risk recorded Urgent consultation within 2 hours (HS 111 breaches excluded) 90% Options to change the operating model have been explored to identify alternative options for managing the workflow received from Care UK. BrisDoc is committed to running a pilot to test changes to the HS 111/OOH interface - a proposed Baseline weekend is being planned for the Easter period, in which the demand from HS 111 will be streamed Creating the Healthiest and Community appointments Together 23 managed by BrisDoc. Commissioners will be advised of the trial date. Monitored at IQPM Jacqui Chidgey- Clark Kevin Haggerty UC7

28 Care UK (BSSG): % of calls requiring clinical 111 Clinical Advisor Care UK (BSSG): % of calls answered within 60 seconds Issue BT UHB WAHT SWAFT AWP CARE UK 6. Performance Variance and Assurance Information Synopsis of Issue Current Actions Forum Issue is addressed Recovery dates Responsible CCG Officer and CCG Clinical ead Risk Register Reference Domain 1 During December 2014 there continued to be an unexpected uplift in call volume over and above what had been previously seen and forecasted. % of calls answered within 60 seconds, 74.82% Dec % of calls requiring 111 Clinical Advisor passed as a live transfer and not a call back 42.15% Dec A recovery plan to address call answering difficulties has been agreed with Care UK and Commissioners. A Care UK has developed a Clinical Prioritisation Model which is being amended following tabling at the new BBGWaS IQPMG (covering the CCG localities of Bristol, orth Somerset, South Gloucestershire, Bath and orth East Somerset, Gloucestershire, Wiltshire and Swindon). Care UK is keen for HS 111 Commissioners to agree this model and implement with a redefined KPI. IQPM IQPM Weekly trajectory for improvement is shared with commissioners. Jacqui Chidgey-Clark Kevin Haggerty Jacqui Chidgey- Clark Kevin Haggerty o risk recorded o risk recorded 24

29 Issue %of patients aged 75 and over where dementia question is asked % of patients with a new positive dementia screening BT UHB WAHT SWAFT AWP Performance Variance and Assurance Information Synopsis of Issue Current Actions Forum Issue is addressed Recovery dates Responsible CCG Officer and CCG Clinical ead Risk Register Reference Domain 2 WAHT. CQUI has not been achieved in Q1, Q2, or Q3. An audit assistant was employed to monitor performance and improve clinical engagement Dementia lead has been active in promoting the FAIR process There is a recovery plan in place IQPM. on payment for CQUI for Q!, Q2, Q3, for 2014/15 as Trust did not meet thresholds set. Dementia and Delirium confirmed as a national CQUI 2015/16. March 2015 Jacqui Chidgey-Clark Jeremy Maynard o risk recorded

30 % of patients with fractured OF operated on within 36hrs Percentage of patients with a new dementia screening referred for specialist diagnosis Issue BT UHB WAHT SWAFT AWP 6. Performance Variance and Assurance Information Domain 2 continued Synopsis of Issue Current Actions Forum Issue is addressed Recovery dates Responsible CCG Officer and CCG Clinical ead Risk Register Reference See previous page for WAHT commentary IQPM CQUI runs until March 2015 Jacqui Chidgey- Clark Jeremy Maynard o risk recorded Domain 3: WAHT. o data available since July 2014 WAHT- CCG has requested through Q2 contract query and monitoring letter for the trust to retrospectively validate year to date performance against the 36hr requirement. Jacqui Chidgey- Clark Jeremy Maynard UHB 78.3% of patients were operated on within time frames the highest figure since July From 1 ov 2014 weekend trauma capacity increased to all day Saturday/Sunday s. ew transformation programme includes work stream focussing on trauma and orthopaedic efficiencies and team culture. Objectives to be agreed during February. o risk recorded 26

31 Emergency Admissions for acute conditions Emergency readmissions within 30 days Issue BT UHB WAHT SWAFT AWP 6. Performance Variance and Assurance Information Domain 3: Synopsis of Issue Current Actions Forum Issue is addressed Recovery dates Responsible CCG Officer and CCG Clinical ead Risk Register Reference UHB not meeting best practice wait times for fractured neck femur treatment Produced as an exception report in February. Ongoing clinical coding review to be provided by the Trust on completion From 1st ovember weekend trauma capacity has increased to all day on Saturday and Sunday. Jacqui Chidgey- Clark Jeremy Maynard Jacqui Chidgey- Clark Jeremy Maynard o risk recorded o risk recorded 27

32 Friends and Family test- provider response rate (Emergency Dept) Friends & Family response rate Issue BT UHB WAHT SWAFT AWP 6. Performance Variance and Assurance Information Domain 4: Synopsis of Issue Current Actions Forum Issue is addressed Recovery dates Responsible CCG Officer and CCG Clinical ead Risk Register Reference AWP- Improving picture for December 13.6%. Several teams have been identified as having low scores. BT - the Emergency Department response rate rose slightly to 10% from 4% in December. All identified teams are reviewing practice and providing updates to monthly SMT meeting. Early Intervention team have introduced an Ipad and additional admin support to help improve rate. The ED have an improvement plan in place. CCG/BT Quality group Jacqui Chidgey- Clark Jeremy Maynard Jacqui Chidgey- Clark Jeremy Maynard o risk recorded o risk recorded This report focuses on Red and rising amber performance. Full performance detail can be found in the Appendices that accompany this report. Creating the Healthiest Community Together 28

33 Total number of complaints received Friends & Family test- provider response rate (birth) Issue BT UHB WAHT SWAFT AWP 6. Performance Variance and Assurance Information Synopsis of Issue Current Actions Forum Issue is addressed Recovery dates Responsible CCG Officer and CCG Clinical ead Risk Register Reference Domain 4: BT- achievement dropped to 15% from 18% in December. There is no national threshold for response rate to maternity FFT. The BSSG CCGs have agreed a local threshold of 15% response rate for the birth part of the maternity pathway. The Trust has been asked to look at ways to increase their response rate to consistently meet the 15% during 2015/16. Maternity staff have been reminded of the need to ensure patients complete the FFT survey post birth of their baby. UHB Data not submitted- to be reviewed as part of new 2015/16 dashboards. Awaiting trajectory. BT- see slide 30 (percentage of complaints responded to within agreed timescales) CCG/BT Quality group Jacqui Chidgey-Clark J. Maynard o risk recorded ICQPM 29

34 Percentage of complaints responded to within agreed timescales Issue BT UHB WAHT SWAFT AWP 6. Performance Variance and Assurance Information Domain 4: Synopsis of Issue Current Actions Forum Issue is addressed Recovery dates Responsible CCG Officer and CCG Clinical ead Risk Register Reference WAHT UHB Review of individual complaints by the patient support and complaints team and monitored within the patient experience group BT - The number of overdue A proposed plan has complaints remains high. been submitted by the Trust aimed at sustainable complaints management. A temporary resource is in place to assist dealing with the complaints backlog. The quality sub group have approved this approach in the This report focuses on Red and rising amber performance. Full performance detail can be medium term but have found in the Appendices that accompany this report. requested a trajectory for clearance of the Creating the Healthiest Community Together o trajectory submitted. Quality team to address at next sub group J. Chidgey- Clark J. Maynard o risk recorded 30

35 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 ov-14 Dec Performance Variance and Assurance Information Domain 5. Falls Rate Weston, BT and UHB Comments Weston - has seen an increase in the number of falls over the last 3 months. The rate of falls per 1,000 bed days, against a standard of 4.7: o.falls per 1,000 bed days BT UHB WAHT October 5 ovember 7 December 7.4 January 5.5 BT - in January there were 2 falls which resulted in severe harm, though this number is significantly improved against that reported between July and October. The rate of falls per 1,000 bed days resulting in any level of harm rose in January to 7.4. Mitigations Weston - the Trust has a falls strategy in place Ward sisters review incident forms and take appropriate actions that risks identified for vulnerable patients are minimised with regards to falls. The lead nurse for falls prevention has assessed aids and equipment which may be used across all areas of the trust to further protect patients who are at risk of falling. Creating the Healthiest Community Together BT - Management of this ongoing risk continues to receive the highest priority, with a range of actions agreed and monitored within the Trust s Falls Group and directorates. Falls reduction is one of the improvement work streams within the Trust s Sign up to Safety pledges. CCG to monitor Progress through the quality dashboard and discussion at IQPM. 31

36 6. Performance Variance and Assurance Information Pressure ulcers SCP umber of reported PU`s reported by SCP 2013/14 and 2014/15 YTD SCP SI reported 13/14 SI reported 14/15 Grade YTD Grade YTD SCP Acquired 13/14 Inherited 13/14 Acquired 14/15 Inherited Grade YTD 34 YTD Grade YTD 125 YTD Comments This data shows a reduction in both Grade 1 and Grade 2 pressure ulcers reported in 2013/14 and 2014/15. However, Grade 3 pressure ulcers YTD have only reduced slightly and Grade 4 pressure ulcers have shown an increase. Mitigation Pressure ulcers are a standing agenda item at the monthly IQPM. Each month SCP pressure ulcers PU`s. are monitored by SCCG through the quality dashboard, CQUI report, Serious Incident data and SCP PU action plan. CCG to monitor SCCG have recently requested an assurance report from SCP on the management of the prevention and reduction of pressure ulcers. This report will be presented at the March QAG meeting. Creating the Healthiest Community Together 32

37 6. Performance Variance and Assurance Information VTE Screening BT Comments BT - Compliance to venous thromboembolism risk assessment remains below the threshold for the second quarter running. Data is submitted one month in arrears. Factors impacting on the Trust s ability to meet the 95% threshold includes the increased use of temporary notes, which are not available to clinical coders in a timely way following hospital discharge. At the time of reporting compliance for ovember 2014 was 94.2% with the expectation that this would increase to >95% as a result of 169 uncoded cases. Mitigation The Trust has been asked to produce an action plan aimed at improving compliance by the end of February Creating the Healthiest Community Together CCG to monitor Monitor delivery of action plans through the Quality Sub Group. 33

38 6. Performance Variance and Assurance Information Malnutrition Screening and WHO Checks - BT Malnutrition Screening Trust-wide compliance for nutrition screening for December was 80.7% (target 90%) against a rolling YTD mean of 67%. This is the first blip on the previously improving trend since June Malnutrition screening and compliance to completion of the WHO Checklist are two main areas of concern for BT. The Trust achieved 61.5% compliance to malnutrition screening in quarter 2. This rose significantly in quarter 3 to 79.2% but still failed to reach the target of 90%. Compliance to WHO surgical safety checks stands at 93.8% ytd against a target of 100%. Mitigation Weekly lists (patients who were not screened from the previous week) continue to be sent to the ward sisters (Matrons/HOs copied in) to follow up non-compliance and tracked through the nursing senior team. WHO Checklist The Trust reported 95.3% compliance in December reflecting a similar position to that of ovember. Main directorate breakdowns are: Gynaecology 98.6% Surgery 97.4% Musculo-Skeletal 96.2% eurosciences 94.2% Mitigation The Theatre Programme Board continues to drive safety improvement and the Quality Committee review this metric at each meeting. Creating the Healthiest Community Together 34

39 te of SI s per 0 bed days umber of Serious Incidents (SI s) umber of MSSA bacteraemia Incidence of CDiff umber of MRSA bacteraemia Issue BT UHB WAHT SCP SWAFT AWP Care UK 6. Performance Variance and Assurance Information Domain 5 Synopsis of Issue UHB HCAI group and MRSA IVDU groups have been set up and performed there first meeting at South Plaza on the 13 th March. Relevant UHB infection control membership are present at this meeting. The group is specifically targeting C. Diff and MRSA. UHB Clostridium difficile cases are 43 including December data against a target of 40 for 2014/15. Current Actions Bristol CCG undertakes monthly reviews of CDI. IQPM Forum Issue is addressed HCAI review meetings Bristol CCG. IQPM Recovery dates Responsible CCG Officer and CCG Clinical ead Jacqui Chidgey- Clark Jeremy Maynard Jacqui Chidgey- Clark Jeremy Maynard Risk Register Reference o risk recorded o risk recorded UHB- WHAT 7 SI`s were reported in January. Year to date umbers are 67 cases against a standard of 50. SI`s are discussed at IQPM. Trends are pressure ulcers and falls. Jacqui Chidgey- Clark Jeremy Maynard Jacqui Chidgey- Clark Jeremy Maynard o risk recorded o risk recorded Creating the Healthiest Community Together Jacqui Chidgey- Clark Jeremy o risk 35 recorded

40 Percentage of staff having had an annual appraisal Percentage of SI dsclosed within agreed timeframe Issue BT UHB WAHT SCP SWAFT AWP Care UK 6. Performance Variance and Assurance Information Domain 5 Synopsis of Issue Domain 6. Staff wellbeing UHB December data shows that only 33.5% of SI were closed within agreed time frame. Current Actions Review dated January 2015 of all 15 falls which resulted in severe harm and had a completed RCAs from 2014/15. The contributory factors from the avoidable falls included: ack of staff training Key member of staff was off the ward at the time of the fall ack of 1:1 support for patients who are very high risk i.e. dementia, learning difficulties, alcohol detox and confusion UHB A recent audit IQPM 85.1% of staff have had an undertaken has appraisal (rolling 12 identified actions aimed months) at improving the quality of appraisals completed WAHT which will be taken 86.6% of staff have had an forward and shared This report appraisal focuses (rolling on Red 12 and rising with amber managers performance. Full performance detail can be found in the months) Appendices that accompany this report. Creating the Healthiest Community Together Forum Issue is addressed Recovery dates The trust will incur a financial penalty for each avoidable fall in 2014/15. Responsible CCG Officer and CCG Clinical ead Jacqui Chidgey- Clark Jeremy Maynard Jacqui Chidgey- Clark Jeremy Maynard Risk Register Reference o risk recorded o risk recorded 36

41 Percentage of staff sickness Issue BT UHB WAHT SWAFT AWP 6. Performance Variance and Assurance Information Domain 6: Synopsis of Issue Current Status Forum Issue is addressed Recovery dates Responsible CCG Officer and CCG Clinical ead Risk Register Reference UHB - Sickness has increased month on month 4.6% - December Percentage of staff suffering work related stress in the last 12 months, 41% - December BT Sickness in December is 4% There is a trust wide sickness absence management action plan in place which includes: Identification of stress, flow chart, robust approach to risk assessments where stress is an issue, management of results of audits. Drop in sessions for managers to empower and improve confidence in sickness management BT are continuing to review and provide support to hotspot areas within trust. A trust wide sickness absence action plan is being developed. IQPM IQPM Jacqui Chidgey- Clark Jeremy Maynard o risk recorded WAHT - Sickness has remained higher than this time last year, however there has been a downward trend over the past 3 months. 4.3% - December Sickness absence continues to be managed in line with HR policies Creating the Healthiest Community Together 37 IQPM

42 Percentage of staff completing safeguarding training Vacancy Rate Percentage of staff turnover Issue BT UHB WAHT SWAFT AWP SCP 6. Performance Variance and Assurance Information Synopsis of Issue Current Actions Forum Issue is addressed Recovery dates Responsible CCG Officer and CCG Clinical ead Risk Register Reference WAHT-Staff turnover has continued to increase since April December 14.8% UHB-Staff turnover has continued to increase since April December 13.5% UHB- There is a recovery plan in place: Tackling bullying and harassment, staff survey on shift patterns, evaluation of staff survey FFT, recognising success awards for staff and volunteers, speaking out policy, and improved staff exit information Jacqui Chidgey- Clark Jeremy Maynard Jacqui Chidgey- Clark Jeremy Maynard o risk recorded o risk recorded SCP ICQPMG Feb 2015 Jacqui Chidgey-Clark Jeremy Maynard o risk recorded 38

43 Percentage of staff witnessing potentially harmful errors Percentage of staff suffering work related stress in the last 12 months Percentage of staff completing dementia training Issue BT UHB WAHT SWAFT AWP SCP 6. Performance Variance and Assurance Information Synopsis of Issue Current Actions Forum Issue is addressed Recovery dates Responsible CCG Officer and CCG Clinical ead Risk Register Reference Jacqui Chidgey- Clark Jeremy Maynard Jacqui Chidgey- Clark Jeremy Maynard o risk recorded o risk recorded This report focuses on Red and rising amber performance. Full performance detail can be found in the Appendices that accompany this report. 39

44 Diagnostic 6 week waits RTT: on-admitted 52 Week Waits RTT: Admitted 52 Week Waits Issue BT UHB WAHT 6. Performance Variance and Assurance Information Synopsis of Issue Performance- Constitution Measures UHB: Increased to 33 in January. More long wait patients are being treated as planned to reduce backlogs. BT: Increased to 31 in January. Work continues to treat longest waiting patients. UHB: Increased to 18 in January. More long wait patients are being treated as planned to reduce backlogs. BT: Remained at 3 in January. Work continues to treat longest waiting patients. UHB: Main fails were audiology, echocardiography, MRI, gastroscopy. High demand including to reduce RTT long waiters. Impacted by staff absences. BT: Failed for Echocardiography, Cystoscopy, CT and Barium Enema (1 breach). Significant resourcing issue in echocardiography. Current Actions UHB: CCGs testing assumptions to inform recovery trajectory. BT: Specialty level improvement plans in place. UHB: CCGs testing assumptions to inform recovery trajectory. BT: Specialty level improvement plans in place. UHB: IMAS-based recovery trajectory and capacity plans developed. BT: Test level improvement plans. Medicine seeking independent sector capacity. Forum Issue is addressed UHB monthly ICQPM BT monthly Access Performance Group UHB monthly ICQPM BT monthly Access Performance Group UHB monthly ICQPM BT monthly Access Performance Group Recovery dates UHB: Increase predicted. Recovery trajectory to be developed. UHB: Increase predicted. Recovery trajectory to be developed. UHB: From June BT: Revised trajectories show failure to the end of March. Responsible CCG Officer and CCG Clinical ead Debbie Campbell John Heather Debbie Campbell John Heather Debbie Campbell John Heather Risk Register Reference o UHB risk recorded BT spinal risk P6 o UHB risk recorded BT spinal risk P6 o risk recorded 40

45 Cancer 62 days wait GP referral Cancer 31 days wait for subsequent treatmentanti-cancer drugs Cancer 31 days wait for first treatment Cancer- 2 week waitnon suspected breast symptoms Cancer- 2 week waits - All Issue BT UHB WAHT 6. Performance Variance and Assurance Information Synopsis of Issue Performance- Constitution Measures BT: 128 breaches out of 1399 cases due mainly to bank holidays, patient choice and Christmas period capacity. BT: 11 breaches out of 93 cases due mainly to bank holidays, patient choice and Christmas period capacity. Current Status BT: Implementing improvement actions, consisting of implementation of Direct Booking (choose & book) for breast and dermatology referrals. BT: Implementing improvement actions Forum Issue is addressed BT monthly Access Performance Group BT monthly Access Performance Group Recovery dates BT: recovery not expected for February, and Q4 predicted to failure at this point. BT: February 2015 Responsible CCG Officer and CCG Clinical ead Debbie Campbell John Heather Debbie Campbell John Heather Risk Register Reference o risk recorded P4 BT: 12 breaches out of 244 cases. BT: Implementing improvement actions BT monthly Access Performance Group BT: February 2015 Debbie Campbell John Heather P4 WAHT: 1 breach out of 19. Small numbers impact on performance. WAHT: 8 breaches out of Cases cover complex pathways to neighbouring tertiary centres. UHB: 15.5 breaches out of Below trajectory. Challenging following transfer of breast and urology services. BT: 23 breaches out of 135. WAHT: Daily and weekly monitoring. Close liaison with tertiary centres to streamline pathways. WAHT: Daily and weekly monitoring. Close liaison with tertiary centres to streamline pathways. UHB: Implementing cancer action plan. BT: Implementing improvement actions WAHT monthly ICQPM WAHT monthly ICQPM UHB monthly ICQPM BT monthly Access Performance Group UHB: February 2015 BT: February 2015 Debbie Campbell John Heather Debbie Campbell John Heather 41

46 A&E Waits Cancer 62 days wait HS Screening Cancer 62 days wait from Consultant referral upgrade Issue BT UHB WAHT 6. Performance Variance and Assurance Information Synopsis of Issue Performance- Constitution Measures Small numbers impact on performance. WAHT: 1 breach out of 5. Cases cover complex pathways to neighbouring tertiary centres. UHB: 2.5 breaches out of 16. As above. BT: 1.5 breaches out of 6. UHB: 1 breach out of 3. Small numbers impact on performance. As Above. Current Status WAHT: Daily and weekly monitoring. Close liaison with tertiary centres to streamline pathways. UHB: Implementing cancer action plan. BT: Implementing improvement actions. UHB: Implementing cancer action plan. Forum Issue is addressed WAHT monthly ICQPM UHB monthly ICQPM BT monthly Access Performance Group UHB monthly ICQPM Recovery dates UHB: Achievement at risk in future quarters. Responsible CCG Officer and CCG Clinical ead Debbie Campbell John Heather Debbie Campbell John Heather Risk Register Reference WAHT: Failed to achieve Q3 trajectory (91%). Bed demand outstripped capacity. Outbreaks of orovirus and D&V. UHB: Mismatch of bed demand and availability, increase in over 75s admissions more complex and longer lengths of stay. WAHT Implementation of recovery plan. Focus at March ICQPM. UHB: Implementation of emergency access plan. Recovery trajectory plan is being failed. WAHT Urgent Care etwork and monthly ICQPM UHB Monthly CQPM BT: Main cause is bed BT: Joint plan being BT System Flow availability for admissions, implemented. Delivery Partnership with Mondays continuing to against plan is Red. This report focuses be challenging. on Red Increased and rising amber performance. Full performance detail can be found in the attendances Appendices and that >14 accompany day this report. OS peaked at 300 (target = Creating the Healthiest Community Together 200). WAHT: 95% by Q4. UHB: Recovery by Q1 with failure from September BT: 92% by March, 95% by July. Jacqui Chidgey- Clark Kevin Haggerty UC8 42

47 Ambulance - Category A - 19 minute transportation time Ambulance - Category A (Red2) - 8 minute response Ambulance - Category A (Red1) - 8 minute response Issue BT UHB WAHT SWAFT AWP 6. Performance Variance and Assurance Information Synopsis of Issue Performance- Constitution Measures Current Status Forum Issue is addressed Recovery dates Responsible CCG Officer and CCG Clinical ead Risk Register Reference Trustwide Category Red 1 Performance has declined through the winter with high activity to a position where the Trust is below the national standard 75%. Vacancy issues and handover to clear delays impacting on service delivery. High levels of activity throughout winter has contributed significantly to this. Vacancy issues and handover to clear delays impacting on service delivery. Particular focus being spent on the orth Division where performance is lower. Performance sustainability plan being applied. A new dispatch trial is in place which hopes to improve response times. Performance sustainability plan being applied. A new dispatch trial is in place which hopes to improve response times. Performance sustainability plan being applied. A new dispatch trial is in place which hopes to improve response times. Monitored closely through Q4 between trust and commissioners Monitored closely through Q4 between trust and commissioners Monitored closely through Q4 between trust and commissioners Q4. Recovery dependant on trial outcome. Q4. Recovery dependant on trial outcome. Q4. Recovery dependant on trial outcome. Jacqui Chidgey- Clark Kevin Haggerty Jacqui Chidgey- Clark Kevin Haggerty Jacqui Chidgey- Clark Kevin Haggerty UC9 UC9 UC9 43

48 Trolley waits in A&E Mental Health Measure - Improved Access to Psychological Services (IAPT) Cancelled Operations (Provider position) Issue BT UHB WAHT SWAFT AWP 6. Performance Variance and Assurance Information Synopsis of Issue Performance- Constitution Support Measures Current Status Forum Issue is addressed Recovery dates Responsible CCG Officer and CCG Clinical ead Risk Register Reference UHB: High cancellations in ovember, bed pressures, more urgent patients needing priority and clinician availability. BT: Impact of emergency bed pressures, kit problems and inefficiencies in theatre. People receiving psychological therapies increased from 540 people in Q2 to 625 in Q3. UHB: Ongoing patient flow work in progress and implementation of recovery plan. BT: More real time information being worked up. improvement actions being implemented and monitored. UHB monthly ICQPM BT monthly Access Performance Group UHB: Action plan received. Recovery to 95% standard expected June BT: monthly improvement predicted. Julie Kell Mike Jenkins o risk recorded o risk recorded BT- UHB- Total of 10 incidents but reported as 2 SI s. 2 SI s reported and RCA s still waiting for be submitted for review o risk recorded 44

49 Ambulance Patient Handovers > 1hour (provider position) Ambulance Patient Handovers > 30 minutes (provider position) Eliminating Mixed Sex accommodation Issue BT UHB WAHT SWAFT AWP 6. Performance Variance and Assurance Information Synopsis of Issue Performance- Constitution Support Measures Current Status Forum Issue is addressed Recovery dates Responsible CCG Officer and CCG Clinical ead Risk Register Reference UHB- relating to ED breaches inked to patient flow and 4hr performance. CCG currently questioning if this is a breach as taken place within ED and therefore not sleeping accommodation. ICQPM Jacqui Chidgey- Clark Kevin Haggerty Jacqui Chidgey- Clark WAHT: Awaiting agreed Q3 position based on WAHT validated data. 24% failed against 10% target as at 25 Jan 15. YTD is 23%. WAHT: Implementation of recovery plan. WAHT monthly ICQPM Kevin Haggerty UHB: 21% failed against 10% target. YTD is 26%. BT: 37% failed against 10% target. YTD is 46%. As above UHB: Implementation of emergency access plan. BT: Implementation of system wide 4hr recovery plan. UHB monthly ICQPM BT monthly ICQPM `Jacqui Chidgey- Clark UC5 Kevin Haggerty Creating the Healthiest Community Together 45 UC5

50 QIPP Unplanned Care QIPP- Planned Care Primary care Continuing Healthcre Issue BT UHB WAHT SWAFT AWP 6. Performance Variance and Assurance Information Finance/QIPP Synopsis of Issue Current Status Forum Issue is addressed Recovery dates Responsible CCG Officer and CCG Clinical ead Risk Register Reference Continuing healthcare budget overspending related to increasing number of high cost individual care packages. Options for bringing spend back in to line with budget under development. Clinical Commissioning Group 2015/16 Julie Kell./ Miriam Ainsworth FI10 Prescribing Budget overspending due to Class M drugs. Outpatients currently underspending against budget but unable to separately assess impact of GP referral management. Reported saving includes all underspending against budget. Cost impact being reevaluated and options for bringing spend back into line with budget Work ongoing to separately evaluate impact of referral management Clinical Commissioning Group Performance and delivery Group 2015/16 Debbie Campbell/ John Heather MM7 FI2 Under delivery of savings related to in year slippage in implementation of schemes QIPP savings shortfall offset by in year underspending in other contract areas Performance and delivery Group 2015/16 Julie Kell/Miriam Ainsworth FI2 Creating the Healthiest Community Together 46

51 7. Exception Reporting This section of the report is designed to provide the Governing Body with assurance that red and/or rising amber indicators, that are not covered by the HS Constitution, are being monitored and managed through CCG forums. Quarter 3- Quality Premium Domain Domain % Domain Amount Risk Score Comment 1. Preventing People from dying prematurely 15.00% 161, Enhancing quality of life for people with long term conditions 15.00% 161,250 YTD 8.93% 2. Enhancing quality of life for people with long term conditions 3. Helping people to recover from episodes of ill health or following injury 25.00% 268, Ensuring that people have a positive experience of care 15.00% 161, Treating and caring for people in a safe environment and protecting them from avoidable harm 6. Enhanced access to health checks programme 15.00% 161,250 Patient right or pledge (a) Patients on incomplete non-emergency pathways (yet to start treatment) should have been waiting no more than 18 weeks from referral. (b) Patients should be admitted, transferred or discharged within four hours of their arrival at an A&E department. (c) Maximum two week (14-day) wait from urgent GP referral to first outpatient appointment for suspected cancer. (d) Red 1 ambulance calls resulting in an emergency response arriving within 8 minutes % 161,250 Data still not available from acute trusts Penalty % Penalty Amount Risk Score 25% 268,750 Incomplete pathway YTD 89.1% 25% 268,750 25% 268, % 25% 268,750 YTD performance reporting as 69.2% for orth Somerset. Creating the Healthiest Community Together 47

52 7. Exception Reporting The external auditors have issued a report under section 19 of the Audit Commission Act 1998 to Secretary of State for Health because they had a reason to believe that orth Somerset Clinical Commissioning Group expected to breach its revenue resource limit for the year ending 31 March At the end of the financial year the CCG expects to report that it has not met its statutory financial target to achieve a balanced financial position. The CCG's financial plan for was for a revenue deficit of 10m. During the year the CCG has consistently forecast a deficit of 10m and the expected position reported is an overspend of 10m. Creating the Healthiest Community Together 48

53 Further indicators to be added to this dashboard, currently under review HS Constitution Acute Quality and Performance Metrics For the period ending 31st January 2015 Item 9 Referral to Treatment Times PI RAG Count (based on latest period) Red Apr-14 May-14 Jun-14 Q1 2014/15 Jul-14 Aug-14 Sep-14 Q2 2014/15 Oct-14 ov-14 Dec-14 Q3 2014/15 Jan /15 Green Amber Red Total Organisation Indicator Target Threshold Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT WAHT RTT: Admitted 52 Week Waits UHB RTT: Admitted 52 Week Waits BT RTT: Admitted 52 Week Waits S CCG RTT: Admitted 52 Week Waits WAHT RTT: on-admitted 52 Week Waits UHB RTT: on-admitted 52 Week Waits BT RTT: on-admitted 52 Week Waits S CCG RTT: on-admitted 52 Week Waits Diagnostic Test Waiting Times Organisation Indicator Target Red Threshold Q1 Q2 Q3 Apr-14 May-14 Jun /15 Jul-14 Aug-14 Sep /15 Oct-14 ov-14 Dec /15 Jan /15 Green Amber Red Total Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT WAHT Diagnostic 6 Week Waits 99.00% 94.99% 99.94% 99.68% 99.93% 99.85% % 99.82% 99.48% 99.76% 99.80% 99.88% 99.81% 99.83% 99.87% 99.82% UHB Diagnostic 6 Week Waits 99.00% 94.99% 98.30% 96.55% 97.28% 97.37% 97.71% 96.96% 98.13% 97.60% 99.14% 98.32% 95.85% 97.32% 95.48% 97.25% BT Diagnostic 6 Week Waits 99.00% 94.99% 97.78% 94.67% 91.59% 94.46% 91.06% 92.94% 96.73% 93.45% 97.99% 96.99% 93.12% 95.28% 90.40% 94.13% S CCG Diagnostic 6 Week Waits 99.00% 94.99% 98.69% 97.48% 96.78% 96.78% 95.89% 97.00% 98.52% 98.52% 99.22% 98.26% 96.78% 96.78% 95.78% 95.78% Cancer Waits - 2 Week Waits Organisation Indicator Target Red Threshold Q1 Q2 Q3 Apr-14 May-14 Jun /15 Jul-14 Aug-14 Sep /15 Oct-14 ov-14 Dec /15 Jan /15 Green Amber Red Total Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT WAHT Cancer 2 Week Wait - All 93.00% 87.99% 95.71% 95.00% 97.91% 96.14% 99.17% 97.36% 97.85% 98.21% 98.90% 97.92% 98.01% 98.28% 97.33% 97.44% UHB Cancer 2 Week Wait - All 93.00% 87.99% 97.12% 96.98% 95.98% 96.68% 96.98% 93.17% 94.79% 95.02% 94.56% 96.32% 97.49% 96.09% 94.33% 95.76% BT Cancer 2 Week Wait - All 93.00% 87.99% 93.20% 93.78% 92.83% 93.23% 92.93% 93.61% 94.68% 93.66% 94.49% 93.25% 93.06% 93.50% 90.85% 93.29% S CCG Cancer 2 Week Wait - All 93.00% 87.99% 95.46% 94.67% 95.99% 95.35% 97.38% 95.37% 95.19% 96.06% 95.24% 96.84% 96.30% 96.11% 95.62% 95.83% WAHT Cancer 2 Week Wait - non-suspected cancer Breast symptoms 93.00% 87.99% 78.46% 90.57% 93.33% 86.50% 96.30% 97.37% 90.63% 94.85% 94.00% 98.28% 93.62% 95.48% 95.00% 92.09% BT Cancer 2 Week Wait - non-suspected cancer Breast symptoms 93.00% 87.99% 93.69% 96.67% 90.91% 94.30% 85.97% 87.50% 90.57% 88.61% 98.21% 94.44% 95.56% 95.85% 88.17% 92.45% S CCG Cancer 2 Week Wait - non-suspected cancer Breast symptoms 93.00% 87.99% 83.33% 91.84% 95.46% 89.54% 90.63% 92.31% 90.32% 91.18% 94.23% 96.67% 92.59% 94.58% 95.00% 92.19% Cancer Waits - 31 Days Organisation Indicator Target Red Threshold Q1 Q2 Q3 Apr-14 May-14 Jun /15 Jul-14 Aug-14 Sep /15 Oct-14 ov-14 Dec /15 Jan /15 Green Amber Red Total Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT WAHT Cancer 31 Day first treatment 96.00% 90.99% % 98.15% % 99.35% 92.16% % % 97.14% % % % % % 98.98% UHB Cancer 31 Day first treatment 96.00% 90.99% 97.93% 97.92% 96.20% 97.36% 96.77% 96.20% 96.15% 96.38% 95.09% 94.27% 98.52% 96.06% 97.84% 96.72% BT Cancer 31 Day first treatment 96.00% 90.99% 93.42% 90.95% 87.02% 90.64% 90.11% 95.50% 95.26% 93.38% 96.77% 94.65% 95.73% 95.84% 95.08% 93.54% S CCG Cancer 31 Day first treatment 96.00% 90.99% 96.24% 95.90% 97.00% 96.34% 91.41% 97.14% 97.27% 95.04% 98.37% 94.12% 97.69% 96.90% 97.09% 96.19% UHB Cancer 31 day subsequent treatments - radiotherapy 94.00% 84.99% 97.87% 98.89% 95.07% 97.20% 97.65% 98.45% 97.40% 97.81% 98.19% 99.48% 97.24% 98.31% 96.39% 97.65% S CCG Cancer 31 day subsequent treatments - radiotherapy 94.00% 84.99% 97.92% 97.06% 95.56% 96.85% 98.25% 98.04% 98.18% 98.16% 95.92% % 97.67% 97.83% 95.35% 97.45% WAHT Cancer 31 day subsequent treatments - anti-cancer drugs 98.00% 92.99% % % % % 91.67% % % 98.15% % % % % 94.74% 98.86% UHB Cancer 31 day subsequent treatments - anti-cancer drugs 98.00% 92.99% % % 98.97% 99.68% % % % % % 98.86% % 99.63% 98.98% 99.70% BT Cancer 31 day subsequent treatments - anti-cancer drugs 98.00% 92.99% % % % % % 90.00% % 96.67% % % % % % 99.03% S CCG Cancer 31 day subsequent treatments - anti-cancer drugs 98.00% 92.99% % % 97.06% 99.06% % 96.77% % 98.98% % 95.24% % 98.61% 96.43% 98.68% WAHT Cancer 31 day subsequent treatments - surgery 94.00% 88.99% % % % % 92.86% % % 96.88% % % % % % 98.78% UHB Cancer 31 day subsequent treatments - surgery 94.00% 88.99% 97.87% 93.18% 93.48% 94.89% 94.00% 97.83% 91.67% 94.44% 96.15% 91.89% 95.00% 94.57% 95.46% 94.71% BT Cancer 31 day subsequent treatments - surgery 94.00% 88.99% 92.59% 89.47% 84.62% 89.09% 92.16% 96.70% 91.84% 93.15% 91.09% 93.02% 90.91% 91.73% 97.65% 92.04% S CCG Cancer 31 day subsequent treatments - surgery 94.00% 88.99% 91.43% 90.48% 82.76% 88.24% 94.74% % 97.14% 97.22% 87.88% 92.31% 89.66% 89.77% % 92.52% Cancer Waits - 62 Days Organisation Indicator Target Red Threshold Q1 Q2 Q3 Apr-14 May-14 Jun /15 Jul-14 Aug-14 Sep /15 Oct-14 ov-14 Dec /15 Jan /15 Green Amber Red Total Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT WAHT Cancer 62 day referral to first treatment - GP referral 85.00% 79.99% 85.86% 85.71% 85.08% 85.59% 79.01% 88.06% 72.09% 79.06% 89.33% 88.89% 88.14% 88.83% 75.39% 83.40% UHB Cancer 62 day referral to first treatment - GP referral 85.00% 79.99% 75.32% 81.12% 85.08% 80.23% 79.36% 77.62% 74.34% 77.11% 79.63% 80.95% 84.62% 81.80% 80.00% 79.78% BT Cancer 62 day referral to first treatment - GP referral 85.00% 79.99% 72.10% 76.70% 74.76% 74.56% 72.45% 80.00% 76.98% 76.02% 76.45% 85.77% 85.05% 82.58% 82.96% 78.50% S CCG Cancer 62 day referral to first treatment - GP referral 85.00% 79.99% 82.67% 85.00% 78.57% 82.49% 70.89% 78.57% 75.68% 74.89% 88.33% 88.41% 91.03% 89.37% 74.65% 81.27% WAHT Cancer 62 day referral to first treatment - Consultant referral upgrade 85.00% 79.99% 50.00% 55.56% % 68.75% % 80.00% 66.67% 83.33% 85.71% 60.00% % 86.96% 80.00% 80.88% UHB Cancer 62 day referral to first treatment - Consultant referral upgrade 85.00% 79.99% 97.50% 86.11% % 95.31% 86.67% 70.00% 89.29% 83.33% 85.71% % 90.48% 90.41% 84.38% 90.03% BT Cancer 62 day referral to first treatment - Consultant referral upgrade 85.00% 79.99% 88.89% % 62.50% 86.84% 90.91% % 85.71% 88.89% 96.88% % 83.33% 94.37% 75.00% 90.97% S CCG Cancer 62 day referral to first treatment - Consultant referral upgrade 85.00% 79.99% % 66.67% 83.33% 75.00% % 66.67% 80.00% 85.71% % 75.00% 85.71% 89.47% 71.43% 81.67% WAHT Cancer 62 day referral to first treatment - HS Screening referral 90.00% 84.99% % % % % 0.00% /A /A 0.00% % % % % % 96.77% UHB Cancer 62 day referral to first treatment - HS Screening referral 90.00% 84.99% 89.55% 90.48% 90.91% 90.14% 90.20% 94.29% 83.33% 90.00% 73.33% % 90.91% 84.38% 66.67% 88.97% BT Cancer 62 day referral to first treatment - HS Screening referral 90.00% 84.99% 84.21% 86.67% 90.91% 87.10% 92.86% 91.67% 94.12% 93.02% 88.68% % 94.74% 93.75% 96.36% 92.23% S CCG Cancer 62 day referral to first treatment - HS Screening referral 90.00% 84.99% 89.29% 81.25% 94.44% 88.71% 72.73% % % 81.25% % % % % % 90.20% A&E Waits 4hr Performance Organisation Indicator Target Red Threshold Q1 Q2 Q3 Apr-14 May-14 Jun /15 Jul-14 Aug-14 Sep /15 Oct-14 ov-14 Dec /15 Jan /15 Green Amber Red Total Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT WAHT A&E 4hr Waiting Time Performance 95.00% 93.99% 96.60% 96.30% 97.90% 96.90% 93.66% 89.21% 90.73% 91.26% 89.72% 92.80% 90.41% /A 91.80% 92.90% UHB A&E 4hr Waiting Time Performance 95.00% 93.99% 94.51% 94.28% 95.21% 94.67% 92.40% 93.65% 92.37% 92.78% 93.81% 88.62% 86.27% 89.59% 90.87% 92.18% BT A&E 4hr Waiting Time Performance 95.00% 93.99% 91.28% 88.87% 84.14% 88.13% 85.99% 82.14% 83.80% 84.02% 80.74% 83.27% 84.06% /A 83.44% 84.88% Category A Ambulance Calls Organisation Indicator Target Red Threshold Q1 Q2 Q3 Apr-14 May-14 Jun /15 Jul-14 Aug-14 Sep /15 Oct-14 ov-14 Dec /15 Jan /15 Green Amber Red Total Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT SWASFT Ambulance - Category A - 19 minute transportation time 95.00% 89.99% 95.40% 95.25% 95.00% 95.21% 94.57% 95.31% 95.25% 95.04% 93.87% 93.34% 89.71% 92.20% 92.50% 93.97% S CCG Ambulance - Category A - 19 minute transportation time 95.00% 89.99% 94.73% 94.75% 95.66% 95.06% 92.96% 95.19% 94.38% 94.16% 93.53% 93.36% 88.92% 91.78% 93.70% 93.60% SWASFT Ambulance - Category A (Red2) - 8 minute response 75.00% 69.99% 76.78% 75.48% 75.65% 75.95% 74.05% 76.53% 76.86% 75.78% 73.56% 70.83% 63.33% 69.01% 67.95% 72.99% S CCG Ambulance - Category A (Red2) - 8 minute response 75.00% 69.99% 71.23% 68.48% 70.51% 70.05% 69.88% 74.23% 74.14% 72.68% 71.83% 68.66% 62.20% 67.28% 66.30% 69.51% SWASFT Ambulance - Category A (Red1) - 8 minute response 75.00% 69.99% 76.18% 75.31% 75.02% 75.50% 73.74% 75.20% 77.56% 75.44% 75.13% 74.67% 69.63% 72.91% 73.39% 74.42% S CCG Ambulance - Category A (Red1) - 8 minute response 75.00% 69.99% 57.14% 75.68% 60.94% 65.17% 60.61% 70.27% 82.72% 71.95% 75.39% 72.06% 64.63% 70.23% 57.63% 68.25% HS Constitution Support Measures Mixed Sex Accommodation Breaches Organisation Indicator Target Red Threshold Q1 Q2 Q3 Apr-14 May-14 Jun /15 Jul-14 Aug-14 Sep /15 Oct-14 ov-14 Dec /15 Jan /15 Green Amber Red Total Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT WAHT Eliminating Mixed Sex Accommodation UHB Eliminating Mixed Sex Accommodation BT Eliminating Mixed Sex Accommodation Cancelled Operations Organisation Indicator Target Red Threshold Q1 Q2 Q3 Apr-14 May-14 Jun /15 Jul-14 Aug-14 Sep /15 Oct-14 ov-14 Dec /15 Jan /15 Green Amber Red Total Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT WAHT Cancelled Operations for non clinical reasons 0.80% 1.51% 2.70% 2.80% 0.80% 2.10% 0.60% 3.50% 2.70% /A 1.50% 0.50% 2.80% /A 0.50% 1.80% UHB Cancelled Operations for non clinical reasons 0.80% 1.51% 0.98% 0.96% 1.10% 1.02% 1.35% 0.97% 1.14% 1.16% 0.84% 1.96% 0.73% 1.16% 1.00% 1.10% BT Cancelled Operations for non clinical reasons 0.80% 1.51% 1.07% 1.65% 2.65% 1.78% 1.90% 2.28% 2.55% 2.24% 2.17% 1.97% 1.44% 1.88% 2.50% 2.03% WAHT Cancelled Operations rebooked within 28 days 95.00% 84.99% % % % % % 99.00% % 99.00% % % % % /A % UHB Cancelled Operations rebooked within 28 days 95.00% 84.99% 94.20% 85.20% 94.40% 91.30% 95.30% 90.50% 85.20% 90.60% 85.30% 90.40% 87.00% 87.30% 82.90% 89.10% BT Cancelled Operations rebooked within 28 days 95.00% 84.99% 89.13% 86.21% 83.18% 85.31% 89.66% 87.50% 90.27% 89.19% 91.59% 94.38% 93.55% 93.02% 79.83% 88.17%

54 WAHT Urgent Operations Cancelled for a Second Time UHB Urgent Operations Cancelled for a Second Time BT Urgent Operations Cancelled for a Second Time Mental Health Red Apr-14 May-14 Jun-14 Q1 2014/15 Jul-14 Aug-14 Sep-14 Q2 2014/15 Oct-14 ov-14 Dec-14 Q3 2014/15 Jan /15 Green Amber Red Total Organisation Indicator Target Threshold Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT Mental Health Measure - Care Programme Approach - 7 Day Follow Up S CCG post discharge 95.00% 84.99% ot Applicable 97.96% ot Applicable 98.46% ot Applicable % /A 98.86% S CCG Mental Health Measure - Improved Access to Psychological Services (IAPT) 12.70% 7.69% ot Applicable 8.93% ot Applicable 8.62% ot Applicable 9.97% /A 9.17% A&E Trolley Waits Organisation Indicator Target Red Threshold Q1 Q2 Q3 Apr-14 May-14 Jun /15 Jul-14 Aug-14 Sep /15 Oct-14 ov-14 Dec /15 Jan /15 Green Amber Red Total Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT WAHT Trolley Waits in A&E >12 hours UHB Trolley Waits in A&E >12 hours BT Trolley Waits in A&E >12 hours Ambulance Patient Handovers Organisation Indicator Target Red Threshold Q1 Q2 Q3 Apr-14 May-14 Jun /15 Jul-14 Aug-14 Sep /15 Oct-14 ov-14 Dec /15 Jan /15 Green Amber Red Total Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT WAHT Ambulance Handovers - number >1hour /A 106 UHB Ambulance Handovers - number >1hour BT Ambulance Handovers - number >1hour WAHT Ambulance Handovers - number >30 minutes < 1hour /A 189 UHB Ambulance Handovers - number >30 minutes <1 hour BT Ambulance Handovers - number >30 minutes <1 hour Planned Care Organisation Indicator Target Red Threshold Q1 Q2 Q3 Apr-14 May-14 Jun /15 Jul-14 Aug-14 Sep /15 Oct-14 ov-14 Dec /15 Jan /15 Green Amber Red Total Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT WAHT RTT: Admitted (Adjusted) 18 Weeks 90.00% 84.99% 89.43% 89.70% 85.43% 88.24% 83.73% 81.40% 91.42% 85.73% 95.24% 96.15% 96.06% 95.76% 95.47% 90.23% UHB RTT: Admitted (Adjusted) 18 Weeks 90.00% 84.99% 91.70% 91.61% 90.01% 91.07% 87.16% 84.38% 82.45% 84.66% 85.19% 83.14% 84.33% 84.27% 80.46% 85.85% BT RTT: Admitted (Adjusted) 18 Weeks 90.00% 84.99% 90.87% 90.34% 81.69% 88.05% 81.20% 81.51% 79.74% 80.80% 81.35% 78.68% 81.55% 80.55% 80.85% 82.38% S CCG RTT: Admitted (Adjusted) 18 Weeks 90.00% 84.99% 92.45% 91.39% 88.90% 91.00% 86.92% 85.49% 86.35% 86.27% 87.07% 85.15% 85.70% 86.02% 84.13% 87.30% WAHT RTT: on-admitted 18 Weeks 95.00% 89.99% 95.05% 95.25% 95.39% 95.23% 95.47% 96.30% 97.42% 96.45% 98.76% 97.51% 98.01% 98.11% 98.09% 96.78% UHB RTT: on-admitted 18 Weeks 95.00% 89.99% 93.59% 94.00% 92.79% 93.43% 89.74% 89.99% 88.97% 89.55% 89.23% 88.77% 89.91% 89.30% 88.91% 90.49% BT RTT: on-admitted 18 Weeks 95.00% 89.99% 95.78% 95.86% 95.79% 95.81% 95.15% 94.43% 93.23% 94.28% 92.44% 91.20% 91.00% 91.58% 90.21% 93.61% S CCG RTT: on-admitted 18 Weeks 95.00% 89.99% 94.32% 94.32% 95.58% 94.73% 94.38% 93.59% 93.29% 93.76% 93.17% 92.75% 93.02% 92.98% 92.84% 93.71% WAHT RTT: Incomplete Pathways 18 Weeks 92.00% 86.99% 92.56% 92.14% 92.84% 92.51% 86.38% 84.99% 98.44% 89.56% 98.41% 98.53% 98.25% 98.40% 97.55% 93.89% UHB RTT: Incomplete Pathways 18 Weeks 92.00% 86.99% 92.65% 92.45% 92.09% 92.40% 92.00% 91.09% 90.04% 91.04% 89.37% 88.72% 87.46% 88.53% 88.84% 90.51% BT RTT: Incomplete Pathways 18 Weeks 92.00% 86.99% 89.03% 88.06% 85.89% 87.68% 85.01% 84.54% 83.95% 84.50% 83.90% 83.53% 83.27% 83.57% 83.80% 85.14% S CCG RTT: Incomplete Pathways 18 Weeks 92.00% 86.99% 91.84% 91.26% 91.12% 91.12% 88.78% 87.92% 90.64% 90.64% 90.57% 89.65% 89.15% 89.15% 89.37% 89.37% ong Term Conditions High Risk TIA Organisation Indicator Target Red Threshold Q1 Q2 Q3 Apr-14 May-14 Jun /15 Jul-14 Aug-14 Sep /15 Oct-14 ov-14 Dec /15 Jan /15 Green Amber Red Total Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT UHB High risk TIA patients assessed and treated within 24 hours 60.00% 53.99% 60.00% 30.00% 57.10% 48.30% 25.00% 72.20% 66.70% 61.40% 58.80% 73.30% 64.70% 65.30% 50.00% 59.40% BT High risk TIA patients assessed and treated within 24 hours 60.00% 53.99% /A /A 76.50% /A 90.90% 72.70% 78.10% 80.80% 90.00% 76.50% 80.80% 82.26% 87.00% /A Unplanned Care Organisation Indicator Target Red Threshold Q1 Q2 Q3 Apr-14 May-14 Jun /15 Jul-14 Aug-14 Sep /15 Oct-14 ov-14 Dec /15 Jan /15 Green Amber Red Total Value Value Value Value Value Value Value Value Value Value Value Value Value Value DoT SWASFT Ambulance - Green 1-20 minute response 90.00% 89.99% 85.27% 82.58% 81.70% 83.18% 81.99% 83.90% 82.24% 82.72% 79.71% 81.62% 75.13% 78.73% 78.86% 81.23% S CCG Ambulance - Green 1-20 minute response 90.00% 89.99% 84.89% 85.60% 84.52% 84.96% 81.43% 77.18% 74.21% 77.46% 79.51% 81.67% 78.74% 79.95% 74.58% 80.21% SWASFT Ambulance - Green 2-30 minute response 90.00% 89.99% 90.12% 88.25% 87.87% 88.72% 86.21% 87.46% 87.54% 87.05% 85.78% 82.66% 73.43% 80.37% 80.30% 84.75% S CCG Ambulance - Green 2-30 minute response 90.00% 89.99% 86.28% 81.75% 83.90% 83.85% 81.85% 83.61% 81.25% 82.27% 82.81% 79.19% 73.59% 78.41% 79.16% 81.11% SWASFT Ambulance - Green 3-30/60 minute response 90.00% 89.99% 97.71% 97.18% 97.87% 97.57% 97.37% 97.20% 96.78% 97.12% 96.14% 95.56% 92.42% 94.64% 94.82% 96.24% S CCG Ambulance - Green 3-30/60 minute response 90.00% 89.99% 94.67% 96.55% 98.65% 96.60% 98.02% 97.96% 96.08% 97.34% 97.47% 96.97% 95.92% 96.74% 96.94% 96.92% SWASFT Ambulance - Green 4 - (2 hour urgent) responses within 120 minutes 70.00% 69.99% 69.76% 67.83% 70.22% 69.27% 65.12% 71.62% 67.11% 67.91% 64.40% 65.09% 65.58% 64.98% 70.66% 67.80% S CCG Ambulance - Green 4 - (2 hour urgent) responses within 120 minutes 70.00% 69.99% 70.21% 64.71% 71.43% 68.71% 68.63% 79.17% 52.00% 66.44% 59.57% 62.50% 73.08% 63.57% 71.43% 66.94% Green Amber Red Total Key to DoT Symbols Performance for the latest period has improved compared to the previous period Performance for the latest period has worsened compared to the previous period Performance for the latest period has remained the same compared to the previous period

55 A.1 A.2 B.1 B.2 C.1 C.2 D.1 E.1 E.2 F.1 G.1 G.2 HS Outcomes Framework 2014/15 orth Somerset CCG Outcome Measures G.1 ocal () or ational () Measure? Measure Threshold 2014/15 out-turn Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 ov-14 Dec-14 Jan-15 Comment or Trend graph Unplanned hospitalisation (number of admissions) for chronic ambulatory care sensitive conditions (adults) Standardised rate of unplanned hospitalisation (number of admissions) for chronic ambulatory care sensitive conditions (adults) umber of unplanned admissions for children with lower respiratory tract infections Standardised rate of unplanned admissions for children with lower respiratory tract infections umber of unplanned admissions for asthma, diabetes and epilepsy in children Standardised rate of unplanned admissions for asthma, diabetes and epilepsy in children Emergency admissions for acute conditions that should not usually required hospital admissions Emergency Admissions for alcohol related liver disease (adults =>19) Standardised rate of Emergency Admissions for alcohol related liver disease (adults =>19) Summary Hospital-level Mortality Indicator (SHMI) < 100 per month Percentage of patients with diabetic foot ulceration referred to multidisciplinary team with 24 hours (ICE standard - Clinical Guidelines 119) Percentage of diabetic amputations against total number of admissions for diabetic patients MRSA (CCG) includes pre 48 hour MRSA <65% = Red, 66-89% = Amber, 90% =Green > 0.25% = Red % = Amber 0.12% = Green orth Somerset CCG (Quality Dashboard) - January 2015 TBC 0.34% Data to be poputated Data to be populated 0 Public Health England G.2 C Diff (CCG) 73 for 2014/15 Public Health England Weston Area Healthcare Trust (Quality Dashboard) -IFR - Feb Preventing people from dying prematurely 2. Enhancing quality of life for people with long term conditions 3. Helping people recover from episides of ill Summary Hospital-level Mortality Indicator (SHMI) Percentage of patients with suspected assesed within two weeks from GP referral to first appointment Percentage of patients treated within 62 days from referral Smoking cessation rates Enhanced access to health checks programme Percentage of patients aged 75 and over where dementia screening question is asked. Percentage of patients with positive screening test who have formal screening assessment Percentage of patients with a new positive dementia screening question, referred for specialist diagnosis < 100 per month % 96.03% 95.70% 95.00% 93.50% 99.20% 97.40% % 98.00% Due APR >85% = Green 98.75% 85.90% 85.70% 85.10% 79.00% 88.10% % 100% TBC <65% = Red, 66-89% = Amber, 90% =Green <65% = Red, 66-89% = Amber, 90% =Green <65% = Red, 66-89% = Amber, 90% =Green 51.11% A 27% 12% 17% A 18% 12% 18% A 0% 8% 7% Emergency readmissions within 30 days of discharge from hospital <15% 15.02% 24.42% 21.12% 19.12% 20.74% 21.06% 18.34% 20.07% 17.97% due March Due APR Patient reported outcome measures - hip replacement Patient reported outcome measures - knee replacement A 0.42 A % Due APR Improvement in heath gain compared to 2012/13. Information available quarterly Improvement in heath gain compared to 2012/13. Information available quarterly

56 HS Outcomes Framework 2014/15 episides of ill health or following injury 4. Ensuring that people have a positive experience of care ocal () or ational () Measure? Measure Patient reported outcome measures - groin hernia umber of "zero hours" emergency admissions Percentage of patients with fractured neck of femur operated on within 48 hours Threshold 2014/15 out-turn Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 ov-14 Dec-14 Jan-15 Comment or Trend graph Improvement in heath gain compared A 0.08 to 2012/13. Information available quarterly TBC 32,661 per month Data not yet available Proxy measures against HS Outcomes Framework <100% = Red 80-99% = Amber Friends & Family Test - Provider Response Rate (CQUI) < 10% = Red 11-14% = Amber 15%= Green Friends & Family Test - Provider Response Rate (inpatient) <15% Green 10-15% Amber 10> Red Friends & Family Test - Provider Response Rate (emergency department) Friends & Family Test - et Promoter Score of patients who would recommend the provider to a friend or family (CQUI) Friends & Family Test - score of patients who would recommend the provider to a friend or family (inpatient) Friends & Family Test - score of patients who would recommend the provider to a friend or family (emergency department) Friends & Family Test - Response Rate (Antenatal care) Friends & Family Test - et Promoter Score (Antenatal care) Friends & Family Test - Response Rate (birth) Friends & Family Test - et Promoter Score (birth) Friends & Family Test - Response Rate (post natal ward) Friends & Family Test - et Promoter Score (post natal ward) Friends & Family Test - Response Rate (post natal community) Friends & Family Test - et Promoter Score (post natal community) Total number of complaints received <15% Green 10-15% Amber 10> Red < 50% = Red < 60% = Amber >70%= Green Score ranges from -100 to Score ranges from -100 to <15% Green 10-15% Amber 10> Red Score ranges from -100 to <15% Green 10-15% Amber 10> Red Score ranges from -100 to <15% Green 10-15% Amber 10> Red Score ranges from -100 to <15% Green 10-15% Amber 10> Red Score ranges from -100 to /13 = 260. Aim for 5% reduction which equates to per month 100% 100% 100% 100% Requsted Requsted Requsted Requsted Requsted Requsted Requsted TBC TBC 37.5% 34.65% 41.25% 37.90% 28.61% 40.97% 48.9% 51.9% 39.5% 47.9% 17.0% 14.30% 22.70% 21.90% 13.10% 25.70% 27.7% 21.9% 18.6% 28.9% ew measure 15.60% 10.20% 18.60% ew measure % ew measure 46.20% 50.00% 27.30% 31.80% 42.90% 100% 42.1% 56.5% due March ew measure ew measure 15.30% 36.2% 25% ew measure ew measure 0% 14.20% 10.80% ow reported seperately ow reported seperately ew measure /A Data Currently Unavailable Data Currently Unavailable Data Currently Unavailable Due APR Due APR Due APR Due APR Complaints received as a rate per 1,000 bed days TBC Percentage of complaints responded to within agreed timescales Percentage of carers of people with dementia who feel supported (CQUI) Percentage of patients rating overall care as satisfactory umber of local satisfaction surveys conducted < 75% = Red 76% -89% = Amber, >90% = Green Red =< 60% Amber = 61-75% Green = >76% 95% TBC 1.30% 1.30% 1.20% 1.2% TBA Apr TBC 37% 73% 88% 82% 90% 85.0% 80.0% 50.0% 73.0% 88% TBC 100% 100% 100% TBC TBC ocal satisfaction survey and FFT umber of Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemia (post 48 hours) Incidence of Clostridium difficile (Post 72 hours) 2013/14 = /15 = 17 umber of Meticillin Sensitive Staphylococcus aureus (MSSA) <2 3 bacteraemia (post 48 hours)

57 HS Outcomes Framework 2014/15 5. Treating and caring for people in a safe environment and protecting then from avoidable harm ocal () or ational () Measure? Measure umber of ever Events umber of Serious Incidents reported(si) Proportion of adult inpatients who have had a VTE assessment on admission to hospital (CQUI) umber of confirmed cases of avoidable hospital acquired pulmonary embolism or deep vein thrombosis umber of RCAs completed for avoidable hospital acquired pulmonary embolism or deep vein thrombosis Threshold 2014/15 out-turn Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 ov-14 Dec-14 Jan-15 Comment or Trend graph >95% = Green 95% 94.90% 95.80% 98.40% 98.90% 96.80% 97.20% TBA TBC TBC TBC TBC umber of hospital acquired pressure ulcers grade 2 and above TBC, but aiming for 50% reduction on 13/14 TBC Rate of hospital acquired pressure ulcers grade 2 and above per 1,000 bed days TBC TBC umber of slips, trips and falls (patient) incidents reported TBC TBC Rate of slips, trips and falls per 1,000 bed days TBC umber of slips, trips and falls resulting in moderate or severe Report by exception TBC harm 5.17 Percentage of Medication errors resulting in harm TBC Percentage of harm free care reported (CQUI) Data to be populated due March due March Due APR Due APR CQUI figures not reported by month CQUI figures not reported by month CQUI 13/14: Data to be reviewed at Contract Performance Management Group (CPMG) meetings <75% = Red, 76-89% = Amber, 90% =Green TBC 90.09% 86.92% 85.32% 85.32% 86.30% 90.95% % IFR Staff wellbeing Percentage of staff sickness / absence Percentage staff turnover (rolling 12 months) umber of shifts filled by temporary staff (bank or agency) umber of unsafe staffing incidents reported Percentage of staff completing safeguarding children (rolling 12 months) level 2/ evel 3 Percentage of staff completing safeguarding vulnerable adult training (rolling 12 months) evel 1 Percentage of staff completing dementia training - General Percentage of staff having had an annual appraisals (rolling 12 months) 3.00% 4.09% % 3.9% 4.5% 4.4% 4.5% 4.4% 4.1% 4.3% 4.3% 12% TBC % 12.1% 11.8% 12.3% 13.2% 13.3% 13.50% 14.80% 15.10% TBC TBC Data Under review Information to be sought from Trust TBC TBC <75% = Red, 76-89% = Amber, 90% =Green <75% = Red, 76-89% = Amber, 90% =Green <75% = Red, 76-89% = Amber, 90% =Green <75% = Red, 76-89% = Amber, 90% =Green Staff recommendation of the trust as a place to work or receive treatment Baseline from 2013 annual staff survey Percentage of staff suffering work-related stress in last 12 months Baseline from 2013 annual staff survey Percentage of staff witnessing potentially harmful errors, near misses or incidents in the last month Baseline from 2013 annual staff survey TBC 87% 86.40% 87.40% Requsted Requsted Requsted Requsted Requsted 80.50% / 63.47% TBC Requsted Requsted Requsted Requsted Requsted Requsted Requsted Requsted 92.93% TBC 56.82% Requsted Requsted Requsted Requsted Requsted 65.85% 83.11% 83.80% 80.60% 84.20% 85.50% 87.80% 87.00% 85.10% 85.60% 86.60% 88.10% % 37% orth Bristol HS Trust Quality Dashboard - January 2015 Information to be sought from Trust Significant mprovement from 2012 staff survey but below the average of 3.68 for all acutetrusts Slight improvement from 2012 staff survey and below the 37% average of all acutetrusts Significant improvement from 2012 staff survey and above the 33% average for all acute Trusts or Quarter 1 Quarter 2 Q3 HS Outcomes ational Data Reported Framework () Measure Threshold by 2012/13 Measure? Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 ov-14 Dec-14 Jan-15 Comment or Trend graph 1. Preventing Summary Hospital-level Mortality Indicator (SHMI) < 100 per Trust month Currently awaiting data

58 HS Outcomes Framework 2014/15 people from dying prematurely 2. Enhancing quality of life for people with long term conditions 3. Helping people recover from episides of ill health or following injury ocal () or ational () Measure? Measure Threshold Percentage of patients with suspected assesed within two weeks from GP referral to first appointment 93% Percentage of patients treated within 62 days from referral >85% = Green Percentage of patients aged 75 and over where dementia case finding question is asked. Percentage of patients with positive screening test who have formal screening assessment Percentage of patients with a new positive dementia screening question, referred for specialist diagnosis Emergency readmissions within 30 days of discharge from hospital Patient reported outcome measures - hip replacement Patient reported outcome measures - knee replacement Patient reported outcome measures - groin hernia Emergency admissions for acute conditions that should not usually required hospital admissions Percentage of patients with fractured neck of femur operated on within 36 hours umber of patients admitted with a fractured neck of femur Friends & Family Test - Provider Response Rate (inpatient & ED) <65% = Red, 66-89% = Amber, 90% =Green <65% = Red, 66-89% = Amber, 90% =Green <65% = Red, 66-89% = Amber, 90% =Green 19.50% <100% = Red 80-99% = Amber A 2014/15 out-turn Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 ov-14 Dec-14 Jan-15 Comment or Trend graph Trust Trust Performance Team Performance Team Performance Team Information Team Information Team Trust Trust HS England Website 93.5% 93.8% 92.4% 91.7% 91.7% 94.7% 94.8% 93.20% 93.2% 90.8% 74.4% 70.8% 82.6% 71.0% 78.4% 75.4% 75.9% 85.70% 85.30% 81.60% 92.53% 88.60% 93.02% 92.8% 91.6% 93.4% 95.8% 97% 99% 92.50% 77.80% 79.19% 84.8% 80.6% 83.3% 90.7% 93.00% 95.0% 79.31% 51.90% 65% 66.7% 75.0% 72.0% 87.2% % 97.00% 18.24% 17.90% 19.98% 20.85% 21.27% 20.67% 17.71% 18.75% 18.95% % 88% 87% 87% 78% 83% 97% 91% 81% 100% ow reported seperately Improvement in heath gain compared to 2012/13. Information available quarterly Improvement in heath gain compared to 2012/13. Information available quarterly Improvement in heath gain compared to 2012/13. Information available quarterly Friends & Family Test - Provider Response Rate (inpatient) Friends & Family Test - Provider Response Rate (emergency department) Friends & Family Test - score of patients who would recommend the provider to a friend or family (inpatient and ED) Friends & Family Test - score of patients who would recommend the provider to a friend or family (inpatient) Friends & Family Test - score of patients who would recommend the provider to a friend or family (emergency department) Friends & Family Test - Response Rate (Antenatal care) <15% Green 10-15% Amber 10> Red <15% Green 10-15% Amber 10> Red Score ranges from -100 to Score ranges from -100 to <15% Green 10-15% Amber 10> Red HS England Website 32.6% /A 14.1% 27.1% 19.7% 19.1% 26.0% 30% 30% 33% HS England Website 8.4% 4.9% 21.5% 22.8% 26.5% 28.0% 18.7% 21% 4% 10% HS England Website HS England Website 68 /A % HS England Website % HS England Website 18% 21% 14% ow reported seperately no longer reported

59 HS Outcomes Framework 2014/15 4. Ensuring that people have a positive experience of care ocal () or ational () Measure? Measure Friends & Family Test - et Promoter Score (Antenatal care) Friends & Family Test - Response Rate (birth) Friends & Family Test - et Promoter Score (birth) Friends & Family Test - Response Rate (post natal ward) Friends & Family Test - et Promoter Score (post natal ward) Friends & Family Test - Response Rate (post natal community) Threshold Score ranges from -100 to <15% Green 10-15% Amber 10> Red Score ranges from -100 to <15% Green 10-15% Amber 10> Red Score ranges from -100 to <15% Green 10-15% Amber 10> Red 2014/15 out-turn Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 ov-14 Dec-14 Jan-15 Comment or Trend graph HS England Website % HS England Website 13.9% 17.2% 15.0% 14.5% 25.7% 16.2% 15.4% 15% 18% 15% HS England Website % 97% 95% 95% HS England Website 15.2% 18.9% 8.8% HS England Website % 86% 94% 89% HS England Website 18.5% 20.3% 22.0% no longer reported 4.13 Friends & Family Test - et Promoter Score (post natal HS England Score ranges from community) Website -100 to % Total number of complaints received 12/13 = 260 Trust Percentage of carers of people with dementia who feel Red =< 60% Perfomance supported (CQUI) Amber = 61- Team 75% Data Under Review 4.16 Green = >76% 4.17 umber of local satisfaction surveys conducted TBC Trust umber of Meticillin Resistant Staphylococcus aureus Perfomance 5.1 (MRSA) bacteraemia (post 48 hours) 0 Team Incidence of Clostridium difficile (Post 72 hours) Perfomance Team umber of Meticillin Sensitive Staphylococcus aureus Perfomance 5.3 (MSSA) bacteraemia (post 48 hours) Team umber of ever Events 0 Quality Team umber of Serious Incidents reported(si) Report by Quality Team 5.5 exception Rate of SIs per 1,000 bed days 0.21 Trust Proportion of adult inpatients who have had a VTE Trust 5.7 assessment on admission to hospital (CQUI) >95% = Green 95% 95.0% 94.8% 94.0% 93.6% 94.1% 94.1% 96.0% 94.2% 92.9% umber of hospital acquired pressure ulcers grade 2 and Trust above 5. Treating and caring for people in a safe environment and protecting then from avoidable harm TBC, but aiming for 50% reduction on 12/13 no longer reported Rate of hospital acquired pressure ulcers grade 2 and above Trust 5.9 per 10,000 bed days TBC Rate of slips, trips and falls per 1,000 bed days TBC Trust umber of Medication errors causing serious harm Trust 0 0 umber of slips, trips and falls resulting in moderate or Report by Trust 5.11 severe harm exception Percentage of harm free care reported (CQUI) <75% = Red, HSCIC Website 76-89% = Amber, 90% 94.4% 93.3% 92.2% 95.8% 93.5% 91.1% 90.8% 92.09% 94.60% 92.70% 5.12 =Green 6.1 Percentage of staff sickness / absence 3.00% Trust 4.10% 3.80% 4.20% 4.20% 4.29% 4.40% 2.50% 4% 5% 6.2 Percentage staff turnover (rolling 12 months) 12% Trust 13.9% 14.2% 14.1% 14.3% 14.60% 8.81% 10.0% % 10.50% umber of shifts filled by temporary staff (FTE bank or Trust 6.3 agency) A ~690 ~

60 CCG Outco me HS Outcomes Framework 2014/15 6. Staff wellbeing ocal () or ational () Measure? Measure Percentage of staff completing safeguarding children (rolling 12 months) ocal () or ational () Measure? Percentage of staff completing safeguarding vulnerable adult training (rolling 12 months) Percentage of staff completing dementia training Percentage of staff having had an annual appraisals (rolling 12 months) Staff recommendation of the trust as a place to work or receive treatment Percentage of staff suffering work-related stress in last 12 months Percentage of staff witnessing potentially harmful errors, near misses or incidents in the last month Threshold <75% = Red, 76-89% = Amber, 90% =Green <75% = Red, 76-89% = Amber, 90% =Green <75% = Red, 76-89% = Amber, 90% =Green <75% = Red, 76-89% = Amber, 90% =Green Baseline from 2012 annual staff survey Baseline from 2012 annual staff survey Baseline from 2012 annual staff survey 2014/15 out-turn Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 ov-14 Dec-14 Jan-15 Comment or Trend graph Trust Trust Trust Trust Trust Trust Trust HS Outcomes Framework 2012/13 Measure Threshold 88.6% 87.90% % >85% 11.0% Quality Dashboard UHB - March % 93% 62.0% 91% 93% Quarter 1 Quarter 2 Quarter 3 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 ov-14 Dec-14 Jan-15 Information to be sought from Trust Information note included in CQUI return from Trust. To follow up. ational average of all Trusts 3.68 in 2013 HS staff survey ational average for all Trusts 37% in 2013 HS staff survey ational average for all Trusts 90% in 2013 HS staff survey Trend ine 1.1 Summary Hospital-level Mortality Indicator (SHMI) > = 80 Trust Preventing people from dying prematurely 2. Enhancing quality of life for people with long term conditions umber of patients identified with high alcohol consumption offered brief intervention A Trust Percentage of patients suspected of cancer waiting less than two weeks for first appointment >93% = Green, 88-93% - Amber, <88% - Red Percentage of patients treated within 62 days from referral >85% = Green, 80-85% - Amber, <80% - Red Percentage of patients aged 75 and over where dementia case finding question is asked. Percentage of patients with positive screening test who have formal screening assessment Percentage of patients with a new positive dementia screening question, referred for specialist diagnosis <65% = Red, 66-89% = Amber, 90% =Green <65% = Red, 66-89% = Amber, 90% =Green <65% = Red, 66-89% = Amber, 90% =Green Information Team 97.10% 97.00% 96.00% 97.00% 93.20% 94.40% 95.50% Information Team 75.30% 81.10% 85.10% 79.40% 77.60% 74.00% 79.40% Performance Team 57.1% 52.3% 49.0% 62.1% 67.5% 66.6% 61.4% 63.7% 62.9% 78.3% Performance Team 71.7% 78.3% 59.5% 84.7% 81.7% 87.3% 87.1% 92.2% 82.2% 90.7% Performance Team 47.6% 56.5% 33.33% 55.2% 50.0% 35.9% 78.3% 73.3% 68.0% 82.4% 2.4 Percentage of diabetic amputations against total number of admissions for diabetic patients Information Team Business intelligence requested to re-run this audit 3.1 Emergency readmissions within 30 days of discharge from hospital (percentage) 17.0% Information Team 18.81% 17.01% 19.69% 16.45% 18.64% 17.09% 17.52% 14.79% Data unavailable CWCSU Data unavailable CWCSU Helping people recover from episodes of ill health or following injury Emergency admissions for acute conditions that should not usually required hospital admissions Percentage of patients with fractured neck of femur operated on within 36 hours 370 = Red = Amber >314 Information Team = Green <80% = Red 80-90% = Amber >90% = Green Trust 88.9% 70.0% 82.6% 82.1% 71.4% 61.3% 77.8% 73.3% 70.0% 78.3%

61 3.4 HS Outcomes Framework 2014/15 ocal () or ational () Measure? Measure umber of patients admitted with fractured neck of femur Threshold 2014/15 out-turn Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 ov-14 Dec-14 Jan-15 Comment or Trend graph A Information Team Data Unavailable UHB 4.1 Friends & Family Test - Provider Response Rate (inpatient & ED) < 10% = Red HS England 11-19% = Amber website 20%= Green 4.2 Friends & Family Test - Provider Response Rate (inpatient) <15% Green HS England 10-15% Amber website 10> Red 45.8% 39.5% 39.5% 31.8% 32.8% 33.1% 36.1% 42.0% 29.5% 37.9% 4.3 Friends & Family Test - Provider Response Rate (emergency <15% Green HS England department) 10-15% Amber 15.7% 21.1% 19.2% 16.1% 22.7% 26.2% 20.2% 14.9% 16.0% 17.3% website 10> Red 4.3 Friends & Family Test - score of patients who would recommend the Score ranges HS England provider to a friend or family (inpatient and ED) from ow reported seperately website -100 to Friends & Family Test - score of patients who would recommend the Score ranges HS England provider to a friend or family (inpatient) from % 92% 92% website -100 to Friends & Family Test - score of patients who would recommend the Score ranges HS England provider to a friend or family (emergency department) from % 94% 96% website -100 to Friends & Family Test - Response Rate (Antenatal care) <15% Green HS England 28.7% 23.2% 36.1% Data no longer reported 10-15% Amber website 4.4 Friends & Family Test - et Promoter Score (Antenatal care) Score ranges HS England from website -100 to % 96% 93% 4.8 Friends & Family Test - Response Rate (birth) <15% Green HS England 4. Ensuring that 10-15% Amber website people have a 10> Red 10.4% 7.5% 22.6% 8.1% 52.2% 29.6% 7.1% 56.9% 17.9% 4.9 positive experience Friends & Family Test - et Promoter Score (birth) Score ranges HS England of care % 100% 100% from website 4.10 Friends & Family Test - Response Rate (post natal ward) <15% Green HS England 10-15% Amber 8.04% 7.5% 27.5% Data no longer reported website 10> Red 4.11 Friends & Family Test - et Promoter Score (post natal ward) Score ranges HS England from % 91% 79% website -100 to <15% Green 4.12 Friends & Family Test - Response Rate (post natal community) HS England 10-15% Amber 25.9% 21.8% 31.7% Data Currently Unavailable website 10> Red 4.13 Friends & Family Test - et Promoter Score (post natal community) Score ranges HS England % 99% 97% from website 4.14 Total number of complaints received Aim for 5% reduction ( 127 Trust Complaints received per total patients treated Trust 0.240% 0.226% 0.277% 0.282% 0.321% 0.226% 0.224% 0.25% 0.22% 0.27% 4.16 Percentage of complaints responded to within agreed timescales 4.17 Percentage of carers of people with dementia who feel supported (CQUI) 4.18 umber of new surveys approved by UHB governance committee < 75% = Red 76% -89% = Amber, >90% = Red =< 60% Amber = 61-75% 10 Trust Data Unavailable HS England Data Unavailable HS England Data Unavailable HS England Data Unavailable HS England Data Unavailable HS England Data Unavailable HS England Data Unavailable HS England Trust 93.1% 82.5% 83.3% 91.5% 83.3% 88.1% 84.4% 82.9% 82.9% 84.8% Performance Team 60% 62.50% 90% ow reported seperately Data Currently Unavailable Data no longer reported Percentage of patients rating staff attitude as excellent or very good This should be changed to patient experience score that UHB use 85 Trust Data Currently Unavailable umber of Meticillin Resistant Staphylococcus aureus (MRSA) bacteraemia (post 48 hours) 0 = Green Performance Team Incidence of Clostridium difficile (Post 72 hours) > 41 = Red = Amber Performance Team < 35 =Green umber of Meticillin Sensitive Staphylococcus aureus (MSSA) bacteraemia (post 48 hours) >3 per month Performance Team umber of E-Coli bacteraemia (post 48 hours) Data unavailable Data unavailable >19 per month Performance Team UHB UHB 5.5 umber of ever Events 0 CSU Quality Team umber of Serious Incidents reported(si) >8 per month CSU Quality Team Treating and Rate of SIs per 1,000 bed days Percentage of SIs closed within agreed timeframe 0 CSU Quality Team <75% = Red, 76-89% = Amber, 90% =Green CSU Quality Team 100% 50% 83.3% 70.0% 85.7% 100.0% 50.0% 66.7% 37.5% 80.0%

62 HS Outcomes Framework 2014/15 caring for people in a safe environment and protecting then from avoidable harm ocal () or ational () Measure? Measure Threshold 2014/15 out-turn Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 ov-14 Dec-14 Jan-15 Comment or Trend graph Proportion of adult inpatients who have had a VTE assessment on admission to hospital (CQUI) >95% = Green Performance Team 98.9% 98.7% 98.1% 98.4% 98.6% 98.9% 98.7% 99.0% 99.0% 99.1% umber of confirmed cases of avoidable hospital acquired pulmonary embolism or deep vein thrombosis 0 Performance Team umber of RCAs completed for avoidable hospital acquired pulmonary embolism or deep vein thrombosis 100% Performance Team umber of hospital acquired pressure ulcers grade 2 and above 15% reduction on Performance Team 12/ Rate of hospital acquired pressure ulcers grade 2 and above per 1,000 bed days < green Trust umber of slips, trips and falls (patient) incidents reported >150 per month Trust Rate of slips, trips and falls per 1,000 bed days <5.6 - green Trust umber of slips, trips and falls resulting in severe harm 0 Trust Percentage of Medication errors resulting in harm Data Unavailable TBC Trust 1.30% 0% 0.78% 1.09% 0.52% 0.56% 0% 0.57% 0% UHB 5.18 umber of safeguarding alerts generated by provider TBC Trust 5.19 Percentage of harm free care reported (CQUI) <75% = Red, 76-89% = Amber, Performance Team 95.70% 96.7% 96.0% 96.7% 96.9% 96.5% 95.6% 96.7% 97.0% 96.7% 90% =Green 6.1 Percentage of staff sickness / absence Data Unavailable 3.50% Trust 3.8% 3.7% 4.1% 4.0% 3.6% 4.0% 4.5% 4.5% 4.6% UHB 6.2 Percentage staff turnover (rolling 12 months) 11% Trust 11.0% 11.2% 11.5% 12.1% 12.9% 13.3% 13.2% 13.3% 13.5% 13.8% 6.3 Vacancy rate 4% Trust 2.2% 5.5% 5.6% 5.4% 5.6% 5.1% 5.7% 6.1% 6.1% 5.5% 6.4 umber of shifts filled by temporary staff (FTE bank or agency) A Trust Staff wellbeing Percentage of staff completing safeguarding children (rolling 12 months) Percentage of staff completing safeguarding vulnerable adult training (rolling 12 months) Percentage of staff completing dementia training Percentage of staff having had an annual appraisals (rolling 12 months) Staff recommendation of the trust as a place to work or receive treatment <75% = Red, 76-89% = Amber, 90% =Green <75% = Red, 76-89% = Amber, 90% =Green <75% = Red, 76-89% = Amber, 90% =Green <75% = Red, 76-89% = Amber, 90% =Green Trust Trust Performance Team Trust 87.1% 86.3% 87.2% 86.3% 86.9% 85.3% 84.4% 83.5% 85.1% 83.7% Baseline from Performance Team 2012 staff survey 3.76 Improvement upon 2012 staff survey. Above the average of all Trusts in England which is Percentage of staff suffering work-related stress in last 12 months Baseline from 2013 Annual staff Trust survey 41% Deterioration upon 2012 staff survey. Above the average of all Trusts in England which is 37%. Best score for Trusts 29% Percentage of staff witnessing potentially harmful errors, near misses or incidents in the last month Baseline from 2013 Annual staff Trust survey 39% Slight drop upon 2012 staff survey. Above the average of all Trusts in England which is 33%. Best score for Trusts 18%