Integrated Performance Report December 2015

Transcription

1 Portsmouth Hospitals NHS Trust QAH Hospital Page 1 Integrated Performance Report December 2015

2 Portsmouth Hospitals NHS Trust QAH Hospital Page 2 Contents Section Page 1 Performance Outcomes 3 2 Quality Performance 4 3 Operational Performance 31 4 Financial Performance 46 5 Contractual Performance 55 6 Workforce Performance 57 7 Key 64

3 Portsmouth Hospitals NHS Trust QAH Hospital Page 3 Enablers Performance Outcomes Performance Outcomes December 2015 Integrated Performance Outcomes Overall performance against the quality of care indicators remains positive for December; with the exception of patient moves which has seen a deterioration in performance. The Trust has reported zero grade 3 or 4 avoidable and unavoidable pressure ulcers in December; the first month in 2015/16 to do so. There remains a continued focus on patient moves and the Friends and Family Test. The Trust performed well, with three outcomes better compared to other trusts (partner involvement, reasonable response times after birth and information and explanations). A&E performance remains challenging, there were 9,0581 type 1 attendances in December equating to an average of 302 per day compared to an average of 287 type 1 attendances per day in December last year. Emergency admissions were also up by the equivalent of an extra ward, with a conversion rate of 38% The average bed occupancy for the Trust was 94.8% despite achieving the national directive of 80% at midnight on Christmas Eve, with a maximum occupancy of 97.6% in month. There were an average 26 escalation beds open and a maximum of 49, which required additional agency staff.. Delayed transfers of care deteriorated to 2.6%. Despite these pressures performance remained stable at 78.3%. The key area for further improvement is delivery of the ward standards and discharge targets set by CSCs in their Safer bundles. This will require an improvement in the number of simple discharges achieved by clinical teams at PHT and an increase in the number of complex discharges health and social care organisations are able to support, particularly at week-ends. In expectation of a challenging unscheduled care position the elective programme was significantly reduced during December focusing on urgent and day case treatment and as a result there were only 70 on the day cancellations and 2 breaches of the 28 day guarantee. However this meant that less long waiting routine patients were treated and the number of patients waiting over 35 wks increased to 94. The Trust is forecasting achievement of 7 of the 8 national cancer standards, the 62 day screening standard has not been achieved. The 62 day first definitive treatment standard is expected to be achieved once validation and capture of all treatments is completed. There were 7 patients waiting more 104 days for treatment, 6 of these were due to complexity or late referral, however one was due to capacity in urology for complex surgery. The Income and Expenditure annual plan delivers a 9.7m deficit stretch target. The year to date Income and Expenditure financial position was a 21.7m deficit against a planned deficit of 9.3m. The annual CIP target is 29.95m following the inclusion of the stretch target and additional recovery actions. Full-year delivery is currently forecast at 16.2m. The Capital Resource Limit (CRL) is 15.7m net charge of capital expenditure. The trust has spent 5.8m capital to date. The External Financing Limit (EFL) has been set at 2.5m year-end cash balance. The trust has a cash balance of 6.6m at the end of December. There has been a small decrease in substantive staffing for December. Temporary staffing use for July has marginally increased and remains consistent with recent months usage to manage additional activity and capacity requirements. A small increase has been observed in monthly sickness rates and appraisal compliance has reduced to just below the 85% target. Targeted work focusing on those staff who have not had an appraisal for the longest period has resumed. Essential skills compliance has increased in month and is now back above target.

4 Portsmouth Hospitals NHS Trust QAH Hospital Page 4 Quality of Care Executive Summary Quality of Care Key Exceptions December performance Exceptions to note in performance Domain Indicator Oct. Nov. Dec. Comment Safe Effective Caring Responsive Well-led Other Avoidable pressure ulcers Grades 3 & 4 Falls Red and amber incidents SIRIs AKI CQUIN - HSMR - Dementia CQUIN - Patient moves (non-clinical) after midnight Friends and Family Test (FFT) Zero grade 3 or 4 avoidable and unavoidable pressure ulcers reported in December. This is the first month of zero avoidable or unavoidable pressure ulcers in 2015/16. Year-to-date position remains at 12 avoidable grade 3 and 0 (zero) grade 4 pressure ulcers against a trajectory of 16 (year end target of 24). 1 case of a falls incident in December resulting in severe harm. Year-to-date position of 32 cases of falls resulting in harm (25 severe and 7 moderate harm incidents). The Trust has been highlighted following the National Audit of Inpatient falls as an exemplar site for falls prevention by the Royal College of Physicians and has been invited to present at a National Conference. Of the 9 SIRIs reported in December; 1 was a 12 hour Decision To Admit (DTA) breach and 2 ambulance diverts. Audit results will be submitted to the National submission deadline of the 12 th February It is anticipated that the Trust will report a quarter 3 compliance of 39% against a target of 30%. The Trust annual HSMR for the period April 2014 to March 2015 is This is within the confidence interval of and is therefore; within the expected range. Dr Foster have informed the Trust that annual HSMR rates will no longer be published. The weekday and weekend HSMR reported to date has been a fixed annual position. The Trust is currently working with Dr Foster to enable this to be updated and reported monthly. Delivery of step 3 of the CQUIN relating to plan of care on discharge is dependent on adapting the Electronic Discharge Summary system (EDS). EDS is currently in the early implementation phase across the Trust and there is a concern that adding extra fields at this time will affect the completion of the current EDS. Discussions are underway regarding delivery of the CQUIN requirements. In December non-clinical moves between 2100 and midnight was 132; compared to 222 in November; equating to an average of 4.2 per day. This exceeds the CQC improvement plan target of less than 3 nonclinical moves after The number of moves continue to be informed by the high level of medically fit for discharge patients that remain in acute beds and the requirement to create acute bed capacity. The number of non-clinical moves after midnight increased from 103 in November (average 3.4 per day) to 113 in December (average 3.6 per day). The daily average deficit between admissions and discharges during December reduced to 1.35 compared to 1.4 in November. In-patient response rate 22.7% 24.7% 24.2% The total number of responses for both ED and in-patients has decreased; this may be due to the Christmas period and delays in postage in getting the surveys to IWantGreatCare. ED response rate 15.7% 17.4% 14.3% ED has seen a decrease in the number of responses in December, however; this remains above the national average of 13.1% in November. % recommend positive 95.9% 96.5% 96.5% The In-patient response rate has also decreased in December; this is just below the national average of 25.1% in November. % recommend negative 0.8% 0.7% 0.6% The reported percentage positive recommendations remains above the national average of 96% at 96.5%. CQC National Maternity Survey The Trust performed well, with three outcomes better compared to other trusts (partner involvement, reasonable response times after birth and information and explanations). Patient and Family Centred Care (PFCC) living well to the The Trust has been successful in gaining a place on this programme (run in partnership between the Point of very end programme Care Foundation and NHS England South).

5 Portsmouth Hospitals NHS Trust QAH Hospital 1/28/2016 Page 5 Quality of Care Overview December 2015 Key: Safety - Overview Significant risk to achieving target Some concerns: action required to remain on track No concerns Performance the same Performance worsening Performance improving

6 Portsmouth Hospitals NHS Trust QAH Hospital Page 6 Safe Pressure Ulcers Pressure Ulcers (Quality Contract & Quality Account) December position Target: No more than 24 avoidable grade 3 or 4 hospital acquired pressure ulcers 2015/16 (lower than 2014/2015 outturn). Avoidable hospital acquired grade 3 and 4 The Trust reported 0 (zero) avoidable grade 3 pressure ulcer in December and 0 (zero) grade 4 pressure ulcers. This is the first month of zero avoidable or unavoidable pressure ulcers in 2015/16. The current year-to-date position is 12 avoidable grade 3 and 0 (zero) grade 4 pressure ulcers against a trajectory of 18 (year end target of 24). Unavoidable hospital acquired The Trust reported 0 (zero) unavoidable grade 3 pressure ulcers in December. Grade 1 and 2 The Trust reported 9 cases of grade 1 and 2 pressure ulcers in December compared to 2 in November. Actions and progress to date Medicine CSC continue to receive intensive support; a full action plan has been developed with good results being achieved. The Pharmacy and Tissue Viability Team have been recognised for their innovative work around the new dressings formulary. The wait for pressure relieving devices remains low as close monitoring continues. The Technical and Clinical teams are using an algorithm for allocation of pressure relieving mattresses; which is being put into practice alongside the daily review of patients waiting pressure relieving equipment. Work continues on the Purpose T Tool which will improve assessment and care of patients who are at risk of pressure damage. Implementation is planned for quarter /17. Present on admission A total of 44 present on admission pressure ulcers were reported in December compared to 112 in November. Feedback has been requested from Commissioners on actions being taken in the community. Data is being analysed to understand the decrease in numbers. Per 1,000 occupied bed days (OBD) Refreshed data for November shows a recorded total of 3.0 pressure ulcer incidents (all grades of harm) per 1,000 OBD. This is an increase on the reported 1.7 for November and is due to incidents being finally approved post report being produced. December is currently recording a total of 1.7 pressure ulcer incidents (all grades) per 1,000 OBD. n.b: There are no columns on the graph for December due to the small numbers reported.

7 Portsmouth Hospitals NHS Trust QAH Hospital Page 7 Pressure ulcers Skin bundle compliance (reporting only) December position Compliance is set against overall audit submission rates, which for December stands at 99% which is an improvement on the submission rate for November of 98%. Compliance with the SKIN bundle for December has increased to 92%, compared to 90% in November. Braden and SKIN Bundle compliance Month Braden SKIN Bundle Submission rate December 90% 92% 99% November 92% 90% 98% October % 92% 100% CSC Audit compliance November 2015 Safe Pressure Ulcers Compliance with Braden for December has decreased to 90%, compared to 92% in November. Actions and progress to date. Reminders are sent to all CSCs of the requirement to complete and submit compliance. Compliance is now monitored and discussed at the Executive Performance Reviews with each CSC. The Tissue Viability Nurse team are currently working on The Purpose T tool to replace the Braden. CSC Submission Braden Skin Bundle CHOC 100% 70% 68.% Emergency Medicine 100% 75% 79% HNU 100% 96% 100% Renal 100% 93.% 98% W & C 100% 100% 100% c Surgery 100% 77 % 91% MOPRS 100% 82% 94% MSK 92% 93% 98% Medicine 96% 89% 75% G5 100% 95% 100% CHAT 100% 100% 100% Trust 99% 90% 92%

8 Portsmouth Hospitals NHS Trust QAH Hospital Page 8 Safe - Falls Falls (Quality Contract & Quality Account) December position Target: Monthly monitoring of incidents resulting in moderate, severe or catastrophic harm. The Trust reported 1 fall incident in December resulting in severe harm within the Surgery and Cancer CSC. The current year-to-date position is 32 cases of falls resulting in harm (25 severe and 7 moderate harm incidents). The increase in numbers since the November position is due to incidents being finally approved post report being produced. Actions and progress to date Falls prevention and management nurse specialist commenced in January The Trust has been highlighted following the National Audit of Inpatient falls as an exemplar site for falls prevention; performing well in: - Carrying out an assessment for medications that increase fall risk, - ensuring the patient's mobility aid is in reach, - where continence problems are identified ensuring the patient has a continence or toileting care plan, - ensuring the call bell is in sight and in reach of the patient; and has been invited by the Royal College of Physicians to present at a National Conference. The Trust multimodal Fallsafe campaign which focused on the creation of Fallsafe Champions and the use of shorter nursing shifts, with an overlap period to enhance effective communication of key safety issues has been featured by the Health Foundation as an effective method of changing falls culture. Falls risk assessment Target: 95% of falls risk assessments completed within 48 hours per month. As noted last month, the audit now forms part of the Trust nursing documentation audit. In December, 97% of patients had a falls risk assessment completed. Falls per 1,000 occupied bed days Target: Quarterly rate of falls per 1,000 bed days to be 2.2 or less across the quarter average (2.5 target in Quality Account). Refreshed data for November shows a recorded total of 2.0 falls incidents (all grades of harm) per 1,000 occupied bed days, compared to a current recording of 1.0 for December.

9 Portsmouth Hospitals NHS Trust QAH Hospital Page 9 Safe Safety Thermometer Patient Safety Thermometer (Contract) December position Target: Submit data to the National Patient Safety Thermometer The Trust achieved 100% data collection for December. To date the Trust has maintained high submission rates, with 100% being achieved each month. Actions and progress to date Sustain 100% audit submission on all patients and validation of all harm events. Percentage of harm free care (contract) Target: Report percentage of harm free care. In December the Trust recorded in-patient harm free care of 97.88%, compared to 98.36% in November. The total harm free care which includes pre-hospital admission harm events, was recorded as 95.19% which is a slight decrease compared to November s data of 95.94%. The Trust has seen a steady improvement in harm free care since July, and has exceeded the national percentage of 94.2% harm free care for December. (HSCIC December 2015 December Official statistics published: 8 th January 2016). Harm free care Actions and progress to date Continued monthly reporting to the Director and Deputy Director of Nursing and Head of Nursing for each CSC with feedback to ward teams. Specialist nurses working on education. Clinical Dashboard available as a hard copy and via the intranet. Service improvement work streams for all harm events. Month December 2015 November 2015 October 2015 Total Harm Free Care (data collection from number of patients) 95.19% (1,039) 95.94% (1,034) 95.40% (1,022) Trust Harm Free Care 97.88% 98.36% 98.43%

10 Portsmouth Hospitals NHS Trust QAH Hospital Page 10 Healthcare Acquired Infection (National) Safety Infection Control December position MRSA (Incidence more than 48 hours after admission) Target: 0 (zero) The Trust reported 0 (zero) patients with MRSA bacteraemia attributed to the Trust in December. The Trust s year-to-date position is 0 (zero) cases, against an objective of 0 (zero) avoidable cases. C.Difficile (Incidence more than 72 hours from admission) Target : 40 cases The Trust reported 1 patient with C.difficile attributed to the Trust in December against a monthly objective of 4. The case occurred within Medicine. The Trust s year-to-date position is 18 cases against an objective of 30 (annual target of 40 cases). MSSA bacteraemia (Incidence more than 48 hours after admission) MSSA bacteraemia are not subject to DH trajectories, but are closely monitored by the Trust due to the high incidence of morbidity and mortality associated with these infections. There were 3 patients reported with MSSA bacteraemia attributed to the Trust in December.

11 Portsmouth Hospitals NHS Trust QAH Hospital Page 11 Venous Thrombo-embolism Screening (National) December position VTE Screening Target: 95% per month The VTE risk assessment figure for December is 97.3%, compared to the November figures of 97.7%. The National average for VTE assessment (NHS England, Quarter ) is 96%. VTE Appropriate prophylaxis Target: Monitoring and reporting The VTE appropriate prophylaxis figure for December is 96.6% (subject to validation) which is comparable to the November figure. VTE Serious Incidents Requiring Investigation (SIRIs) and Incidents Target: Monitoring and reporting There have been 0 (zero) reported VTE SIRIs in December which is comparable to November. Safe - VTE 93 VTE events were reported in December compared to 82 in November. - Of these 25 were hospital associated events (HAT), compared to 20 in November and 68 were community associated events (CAT) compared with 62 in November. VTE Root Cause Analysis (RCA) Target: Monitoring and reporting 100% of VTE HAT events underwent a RCA investigation. Actions and progress to date Sustain performance and actions from investigations.

12 Portsmouth Hospitals NHS Trust QAH Hospital Page 12 Safe Serious Incidents Serious Incidents Requiring Investigation (SIRIs) (Contract and National) December position SIRIs (including HCAIs and as reported on STEIS) Target: Monitoring and reporting 9 SIRIs were reported in December compared to 10 in November December shows a recorded rate of 0.3 SIRIs (red incidents) per 1,000 occupied bed days which is comparable to November. SIRIs over 60 day deadline Target: Monitoring and reporting There was 1 open SIRI at the end of December which had exceeded the 60 day deadline for submission to the Commissioner. Never Events Target: 0 (zero) 0 (zero) Never Events reported in December. Duty of Candour The Trust is required to inform the patient and/or other relevant person within 10 operational days that the safety incident (SIRI) has occurred or is suspected to have occurred. All patients, or their relatives where applicable, involved in SIRIs in December, were informed of the incident within the deadline and are aware of the on-going investigation. SIRI CSC Formal Ambulance Divert (x 2) Corporate 12 hour Decision To Admit (DTA) Breach (x1) Emergency Medicine Delay in referral for treatment (x1) Head and Neck Unsafe transfer/potential failure to treat adequately (x1) Medicine Delay in referral for treatment (x1) Medicine Fall resulting in subarachnoid haemorrhage (x1) Surgery and Cancer Unexpected death (x1) Surgery and Cancer Potential re-infibulation (x1) Women and Children

13 Portsmouth Hospitals NHS Trust QAH Hospital Page 13 Patient safety incidents (excluding SIRIs) (Contract) December position Target: Monitoring and reporting At the time of reporting, the top three reported incidents for December were: Slips, trips and falls Pressure Sore/Decubitus Ulcer Staffing levels that could lead to incidents. This compares with Slips, trips and falls Implementation of care or on-going monitoring other Pressure Sore/Decubitus in November. The reported pressure sores include present on admission from the community. Safe - Incidents Actions and progress to date Continue safety work streams to reduce avoidable harm. Following Trust Board approval to carry out an upgrade to the Datix Web reporting system, the comprehensive action plan, as outlined in the final review report, is continuing to be implemented and is currently on track to meet the project completion target date. The formal launch of the upgrade project has been completed on time, the target date to roll out the new reporting system Trust-wide is April Month Reported incidents at time of report Incidents Adjusted to include receipt of late reports Previously reported December November October

14 Portsmouth Hospitals NHS Trust QAH Hospital Page 14 Patient safety incidents (Contract) The first chart provides a comparison of finally approved incidents by severity. Incident severity is coded by the reviewing manager at close of investigation, therefore, it must be noted that some data is not yet complete due to reporting timeframes. This is always updated for each subsequent Board report. This should be considered when interpreting data. It should be noted that all incidents including SIRIs are graded on the severity of actual harm suffered by the patient. Safe - Incidents The Total PHT reported Patient Safety Incidents Jan 14 Dec 15 graph represents the total number of all patient safety incidents reported by Trust staff (including community incidents and incidents which have not been Finally Approved ). There has been a reduction in the number of reported incidents for which there is no discernible cause. The Risk Management Department continue to escalate all incidents waiting approval to the CSC Management Team

15 Portsmouth Hospitals NHS Trust QAH Hospital Page 15 Coroner s recommendations and CAS alerts (Contract) December position Coroners recommendations Regulation 28 reports (previously referred to as Rule 43 letters to prevent future deaths) Target: Monitoring and reporting The Trust received no Regulation 28 reports in December. CAS Alerts over deadline Target: Monitoring and reporting 12 alerts were issued in December of which 3 were applicable to the Trust. One remains open at the time of producing this report; but within date. 2 alerts were closed within deadline. One alert issued in August remains open but within deadline, this being September An automated system is in place sending weekly reminders of outstanding alerts to the Governance leads and reminders sent to Carillion. Actions and progress to date Sustain positive action of CAS alerts. Safe

16 Portsmouth Hospitals NHS Trust QAH Hospital Page 16 Medication (Contract & Quality Account) December position Target: Monthly monitoring of incidents resulting in moderate, severe or catastrophic harm. Improve awareness and reporting of medication incidents based on 2014/2015 outturn. Safe Medication incidents There have been no confirmed moderate or severe harm medication incidents reported in December. The Trust year-to-date position is 16 cases of moderate or severe harm (15 x moderate and 1 x severe). Actions and progress to date Continue positive reporting and increase data report quality, feedback and learning. Increase reporting of no harm and near miss incidents. A working group is being established to increase insulin safety and guidance. In response to the reported number of opioid related incidents the Acute Pain Management Guideline is being updated by the Acute Pain Team and is expected to be approved in January Medication incidents per 1,000 occupied bed days Target: Quarterly rate of medication incidents per 1,000 bed days to be 1.0 or less across the quarter average. Refreshed data for November shows a recorded total of 0.4 medication incidents (all grades of harm) per 1,000 occupied bed days, compared to a current recording of 0.2 for December.

17 Portsmouth Hospitals NHS Trust QAH Hospital Page 17 National CQUIN CQUIN (Commissioning for Quality and Innovation) is a national quality incentive scheme which enables Commissioners to reward excellence, by linking a proportion of the providers' income to the achievement of quality improvement goals. Acute Kidney Injury (AKI) The percentage of patients with AKI treated in an acute hospital whose discharge summary includes each of four key items: Effective AKI (CQUIN) 1. Stage of AKI (a key aspect of AKI diagnosis). 2. Evidence of medicines review having been undertaken (a key aspect of AKI treatment). 3. Type of blood tests required on discharge; for monitoring (a key aspect of post discharge care). 4. Frequency of blood tests required on discharge for monitoring (a key aspect of post discharge care). December position The Electronic Discharge Summary (EDS) template has been revised and was rolled out on the 8 th December with good response. However, monitoring to date has indicated that minor stage1 AKI episodes are being overlooked. To overcome this the AKI specialist nurse has been given access to the EDS and will populate the Stage 1 episodes directly into the discharge summaries as they occur; this will improve compliance. Audit results will be submitted to the National submission deadline of the 12 th February It is anticipated that the Trust will report a quarter 3 compliance of 39% against a target of 30%. The Trust is required to achieved 90% in quarter 4; to assist in achieving this weekly monitoring of compliance will be carried out by the AKI Nurse Specialist. The graph above shows the significant number of patients triggering AKI Alerts for quarter 3.

18 Portsmouth Hospitals NHS Trust QAH Hospital Page 18 National CQUIN CQUIN (Commissioning for Quality and Innovation) is a national quality incentive scheme which enables Commissioners to reward excellence, by linking a proportion of the providers' income to the achievement of quality improvement goals. Sepsis December position Two part indicator: a) The total number of patients presenting to emergency departments and other units that directly admit emergencies who met the criteria of the local protocol and were screened for sepsis. Effective Sepsis (CQUIN) A monthly audit of 50 sets of patient notes (part a) is complete for October; November is almost complete. The notes for December s audit are more difficult to access, as many are still being coded or needed for outpatient appointments. b) The number of patients who present to emergency departments and other wards/units that directly admit emergencies with severe sepsis, Red Flag Sepsis or Septic Shock (as identified retrospectively via case note review of patients with clinical codes for sepsis) and who received intravenous antibiotics within 1 hour of presenting. To be reported from quarter 2. A monthly audit of 30 sets of patient notes (part b) is complete for October and November. The notes for December s audit have been requested. Audit results will be submitted to the National submission deadline of the 12 th February Discussions are on-going with Commissioners regarding the CQUIN targets for quarters 3 and 4.

19 Portsmouth Hospitals NHS Trust QAH Hospital Page 19 Effective Local CQUIN Local CQUIN Local and specialised CQUINs: used as an incentive to ensure providers of specialised services offer continuous improvement in line with best practice, benchmarked utilisation, appropriate care and quality indicators. December position CQUIN Details Target Specialised 1 CUR (Clinical Utilisation Review). Project team are due to commence in January. Specialised 2 Neonatal Unit Admissions. Reduce separation of mothers and babies and reduce demand on neonatal services by improving learning from avoidable term admissions ( 37wk gestation) into neonatal units. Specialised 3 Specialised 4 National 1 Urgent Care IT Interoperability Urgent Care 1.0 Urgent Care Care Closer To Home 2.0 Development of MSK Support and Education Care Closer To Home 4.1 Diagnostic Imaging & Pathology Care Closer To Home 4.2 Elective Pathways Care Closer To Home 5.0 Long Term Conditions (Discharge Summaries Support the local implementation of IVIG demand management plan. Support the Wessex Dental Network. Screening and Immunisation Governance: All NHS England Commissioned Screening Programmes. All patients on IVIG are approved by panel. Attendance at IVIG meetings. All patients to be recorded on the regional IVIG database. Involvement in the dental network service with clinician involvement. Develop and implement a robust internal governance and accountability framework for all screening programmes. To implement electronic communication system between GP's and doctors in the Emergency Department via Hampshire Health Record and Summary Care Record for applicable patients. Analysis of attendances in UCC with an aim to provide data and education around attendances as well as the aim to reduce attendances. Current status December 2015 (M9 Q3) Project team identified. Order for the software has been placed. Project details have been sent to the commissioners for approval. Q2 achieved. Q3 has been sent the commissioners for approval. Q2 achieved. Q3 has been sent the commissioners for approval. Ongoing achievement with the CSC. Data not due to be sent to Commissioners until year end. Q2 achieved. Q3 has been sent the commissioners for approval. PHT have achieved all actions however ongoing discussions with Commissioners to agree targets are met. Targets merged into the Urgent Care Board milestones and working to achieve these. Revised proposal being agreed in January. Working with community providers to offer advice and hold joint MDT's. Q1 and Q2 discussions continue with commissioners. Q3 achieved and evidence to be submitted. Revision of the referral pathways for diagnostic imaging requests from GP's. Education back to GP's as to validity of tests. Information and education towards the aim of reducing unnecessary GP requests for Direct Access diagnostic tests. Scrutiny and education regarding elective referrals, triaged and returned referrals are returned with education for Gastro, UGI, Colorectal, Urology, T&O, ENT and Rheum. To submit discharge summaries for patients with COPD (Chronic Obstructive Pulmonary Disease) and ILD (Interstitial Lung Disease), Heart Failure and Diabetic patients with additional information. Q1 and Q2 discussions continue with commissioners. Q3 achieved and evidence to be submitted. Q1 and Q2 discussions continue with commissioners. Q3 achieved and evidence to be submitted. Q1 and Q2 discussions continue with commissioners. Q3 achieved and evidence to be submitted.

20 Portsmouth Hospitals NHS Trust QAH Hospital Page 20 Mortality indicators: HSMR and SHMI (Contract and Quality Account) December position Current HSMR October 2014 September 2015 Effective - Mortality Hospital Standardised Mortality Ratio (HSMR) Target: To be within expected range. The Trust HSMR for the 12 months to September 2015 is This is within the confidence interval of and is therefore; within the expected range. The Trust annual HSMR for the period April 2014 to March 2015 is This is within the confidence interval of and is therefore; within the expected range. Dr Foster have informed the Trust that annual HSMR rates will no longer be published. The weekday and weekend HSMR reported to date has been a fixed annual position. The Trust is currently working with Dr Foster to enable this to be updated and reported monthly. The Clinical Effectiveness and Mortality Steering Group (CEMSG) continues to investigate any potential anomalies which appear. Feedback from recent coding audits has shown there to be no inconsistencies or causes for concern within coding. Summary Hospital-level Mortality Indicator (SHMI) Target: To be within expected range. The Trust SHMI for April 2014 to March 2015 is ; which is a slight decrease from the previous quarter s figures of Whilst this figure is above the National Average of 100, it is within the official control limits. CEMSG continues to investigate some of the issues surrounding this with the benchmarking provider, Dr Foster. Definitions: HSMR: The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower would be expected. The national average is 100 and a score of below this indicates less deaths than this average. HSMR covers 56 groups of diagnosis and only relates to patients that have died whilst in hospital. SHMI: The Summary Hospital-level Mortality Indicator (SHMI) is a high level mortality indicator that is published by the Department of Health on a quarterly basis. It follows a similar principal than HSMR, however SHMI covers all diagnosis groups and relates to all patients that have died (whether the patient died whilst in hospital or not). It does not take account of deprivation. HSMR: (within expected range) Annual HSMR April 2014 to March 2015 (n.b Dr Foster are no longer publishing the annual HSMR rate) HSMR: (within expected range) Weekday HSMR: (within expected range) Weekend HSMR: (within expected range) Current SHMI April 2014 March 2015 SHMI: (within expected range)

21 Portsmouth Hospitals NHS Trust QAH Hospital Page 21 Dementia (National CQUIN) December position Dementia CQUIN compliance Element 1: Find, Assess, Investigate and refer* Target: 90% or greater in steps 1 and 2 each quarter. 90% or more for step 3 for the whole of quarter 4. October 2015 November 2015 December 2015 Caring Dementia (CQUIN) There has been continued compliance with step 1 in December with a recorded total of 95.3%. Although a slight reduction on the reported November figure it remains above the required target. Delivery of step 3 of the CQUIN relating to plan of care on discharge is dependent on adapting the Electronic Discharge Summary system (EDS). EDS is currently in the early implementation phase across the Trust and there is a concern that adding extra fields at this time will affect the completion of the current EDS. Discussions are underway regarding delivery of the CQUIN requirements. Element 3: Carers of people with dementia and delirium feel adequately supported The Carers questionnaire continues. Unfortunately only 3 questionnaires have been returned in December. A review is underway to change the current process in order to gain more feedback. From the small sample, analysis shows that carers feel that their loved ones are cared for with dignity and compassion on the wards. Work is on-going with Portsmouth Carers to provide information to support carers during and after hospital admission. * Definition of steps: Step 1 Case finding: The number of patients >75 admitted as an emergency who are reported as having a known diagnosis of dementia or clinical diagnosis of delirium, or who have been asked the dementia case finding question, excluding those for whom the case finding question cannot be completed for clinical reasons (e.g. coma). Step 2 - Assessment: Number of above patients reported as having had a diagnostic assessment including investigations. Step 3 Onward referral under development: Numbers of above patients who have a plan of care on discharge that is shared with general practice. Step 1: Case finding 95.4% 97.5% 95.3% Step 2: Assessment 100% 100% 100% Step 3: Plan of care Under development

22 Portsmouth Hospitals NHS Trust QAH Hospital Page 22 Mixed Sex Accommodation (National) Caring Mixed Sex Accommodation December position Non-clinically justified single sex accommodation breaches Target: 0 (zero) There have been 0 (zero) non-clinically justified Single Sex Accommodation breaches in December. The Trust year-to-date total is 0 (zero) non-clinically justified Single Sex Accommodation beaches. Facilities single sex accommodation breaches Target: Monitoring and reporting There have been 0 (zero) single sex accommodation breaches relating to facilities in December.

23 Portsmouth Hospitals NHS Trust QAH Hospital Page 23 Complaints (Contract and National) December position Target: Monitoring and reporting Month No. of Complaints received 2013/ / /16 Variance year on year Variance month on month Dec Nov A total of 39 complaints were received in December, an expected seasonal reduction from 64 received in November. Oct Complaints Nov-15 Dec-15 CHAT 0 1 CORP 0 0 CSS 5 2 DMOP 2 1 ED 11 4 Caring - Complaints Reporting per 1,000 contacts is one month in arrears; data for November equates to 0.9 compared to 0.78 in October. To date 5 (13 %) complaints received in December have been responded to within 30 working days and 34 (87%) remain on target. H&N 6 8 MED MSK 6 5 Renal 0 1 S&C 13 2 W&C 9 5 TOTAL Breakdown of Subjects - December 2015 ADT Admission, discharge, transfer 8 21% COMM Communication 7 18% AACT All aspects of clinical treatment 7 18% APDEL Appointment delay/cancellation 6 15% O Outpatient AOS Attitude of staff 4 10% ANC Aspects of nursing care 4 10% Appointment delay/cancellation APDELI 2 5% Inpatient PPD Patient Privacy & Dignity 1 3% COMPLAINTS NOVEMBER UPDATE Sent late 0 0% Sent on time 30 49% On-going Late 20 31% On-going on target 13 20%

24 Portsmouth Hospitals NHS Trust QAH Hospital Page 24 Complaints (Contract and National) December position Complaint acknowledgment rate (national requirement) Target: Monitoring and reporting 100% of complaints were acknowledged within the 3 working day target in December. Caring - Complaints Parliamentary Health Service Ombudsman (PHSO) (National requirement) Target: Monitoring and reporting The Trust received no new notifications from the PHSO in December. To date all complaints reviewed have not been upheld. Plaudits Target: Monitoring and reporting The Trust received 794 messages of thanks during December. PHSO Total rec'd Under review Upheld Part upheld Not upheld

25 Portsmouth Hospitals NHS Trust QAH Hospital Page 25 Complaints, PALS and patient satisfaction (Contract) December position PALS contacts Target: Monitoring and reporting 117 contacts were received in December, a reduction from 171 in November. 107 (89%) have now been resolved to the satisfaction of the individual. 87 (81%) of the closed cases were resolved within 5 working days. Caring Complaints PALS conversion to complaints Target: Monitoring and reporting 9 cases were converted to a formal complaint. With closer working between PALS and Complaints complex PALS cases are being escalated quicker to formal complaint for investigation. Patient Satisfaction Target: Monitoring and reporting The overall satisfaction score for December was 89.62% with 240 responses, this compares with 92% and 385 responses for November. During December each active survey was reviewed. It was identified that some surveys did not have an overall satisfaction score; leaving a missed opportunity to gather important feedback. The overall satisfaction score question has now been included in all surveys. December Top 5 Trust-wide themes Complaints PALS Total OP appt delay/cancellation (most common Urology, ENT and Gastro) Communication Discharge Clinical treatment Attitude of staff

26 Portsmouth Hospitals NHS Trust QAH Hospital 1/28/2016 Page 26 Patient Moves December position Target: <3 non-clinical moves after 2100 Patient moves Responsive Patient Moves Work continues to be undertaken to limit the number of non-clinical moves experienced by patients. Data is collected for moves between 2100 and midnight and after midnight. In December the number of reported non-clinical moves between 2100 and midnight was 132; compared to 222 in November; equating to an average of 4.2 non-clinical moves between 2100 and midnight per day. This exceeds the CQC improvement plan target of less than 3 non-clinical moves after The number of moves continue to be informed by the high level of medically fit for discharge patients that remain in acute beds and the requirement to create acute bed capacity. The number of non-clinical moves after midnight increased from 103 in November (average 3.4 per day) to 113 in December (average 3.6 per day). It is noted that the daily average deficit between admissions and discharges during December reduced to 1.35 compared to 1.4 in November. Month Midnight After midnight No. Average per day No. Average per day December November October

27 Portsmouth Hospitals NHS Trust QAH Hospital Page 27 Well-Led Friends and Family Friends and Family Test (FFT): Increasing response rate in Inpatient areas and ED (National) December position Target: Maximise the number of responses from service users. The total number of responses for both ED and in-patients has decreased slightly from 3,592 in November to 3,189 in December. This may be due to the Christmas period and delays in postage in getting the surveys to IWantGreatCare. ED has seen a decrease in the number of responses from 17.4% in November to 14.3% in December. This however; remains above the national average of 13.1% in November. The In-patient response rate has also decreased from 24.7% in November to 24.2% in December; this is just below the national average of 25.1% in November. The reported percentage positive recommendations remains above the national average of 96% at 96.5%. Outpatient Department (OPD) In December, there was a reduction in the number of responses, which was an anticipated response to reduced clinics over the Christmas period. Overall, the Trust continues to receive positive responses. Actions and progress to date Data cleansing and additional checks continue within Information Services for internal validation prior to national reporting. Comments: Friends and Family Response rates Month December 15 November 15 October 15 Trust 14.3% 1267/ % 1643/ % 1523/9727 ED Total response rate (responses / eligible patients) National average Trust Friends and Family percentage to recommend rates In-patient National average Recommendation percentage % recommend Month % not National Trust recommend average December % 96% 0.6% November % 96% 0.7% October % 95% 0.8% % 14.1% 24.2% 1922/ % 1949/ % 1936/ % 24.5%

28 Portsmouth Hospitals NHS Trust QAH Hospital Page 28 Well-Led Friends and Family Friends and Family Test Improving positive responses in ED, In-patient areas and maternity(national) December position Improving positive responses in ED A small increase in the reported satisfaction rate to 92.2% was seen in December. The Trust continues to compare favourably with the national benchmark of 87%. The expectation is for a summary of actions to be submitted in response. New methods of collection have been implemented and monitored for sustainability and further improvement. Improving positive responses in In-patient areas The reported satisfaction remains consistent at 96.5% in December, this compares to 95% reported nationally. Key themes are being reviewed at a local level. A review of the negative responses (not recommend) continues to show positive comments in contrary to the not recommend score. The expectation is for a summary of actions to be submitted in response. Improving positive responses in Maternity There has been a slight decrease in the number of responses with a slight decrease in positive responses from 98.9% to 97.5%. This is likely to be due to a increase in activity and acuity. Improving positive responses Month Total number likely and very likely EMERGENCY DEPARTMENT Total number responses (including don t know ) Overall compliance December % November % October % Improving positive responses Month Total number likely and very likely INPATIENT AREAS Total number responses (including don t know ) Overall compliance December % November % October % Improving positive responses Month Total number likely and very likely MATERNITY Total number responses (including don t know ) Overall compliance December % November % October %

29 Portsmouth Hospitals NHS Trust QAH Hospital Page 29 Friends and Family Test Maternity (National) Well-led Friends and Family December position Target: Maximise the number of responses from service users. Women are asked to complete a Friends and Family form at four points of contact and respond to four specific questions. There has been a decrease in the response rate seen in December to 21.4% compared to 24.4% in November. Actions and progress to date: The results continue to be circulated to all staff showing the response rates for all questions. Clinical Team leaders will be asked to encourage uptake within individual clinical areas. An advert is currently out to recruit Band 2 staff; band 2 and Band 3 staff will continue to have specific responsibility for ensuring question 1 and 4 forms are completed by women. Feedback from NHS England suggests to manage internally; feedback is awaited from other Trusts regarding management of collection of data for questions 1and 4. Response themes: The majority of responses are positive. Positive comments: Staff constantly check on you and give amazing advice. Everyone very knowledgeable and helpful. Amazing care-reassuring kind supportive midwife. Excellent facilities and accommodating to my wishes. Good advice given. Very good security. Great support with breastfeeding. All staff seemed genuinely interested in me. Regular appointments with the same midwife. Good care Negative comments: Occasionally difficult to get hold of staff at Blake over the phone - Staff have now been recruited at Blake maternity centre which will support triaging of telephone calls for women. Induction process should be quicker - All community midwives and doctors have been ed and reminded off the correct process for induction and the appropriate time frames involved which will ensure women are given the correct information about the process Maternity Friends and Family response rates Q. Oct 15 Nov 15 Dec % 6% 7.9% 2. 19% 32.6% 26.1% % 39.5% 34.2% % 21.2% 17.5% Rate 12.03% 24.4% 21.4% Maternity Friends and Family questions Q1. Antenatal care (community based care up to 36 weeks). Q2. Intrapartum labour care. Q3. Immediate postnatal care. Q4. Postnatal care up to discharge to Health Visitors.

30 Portsmouth Hospitals NHS Trust QAH Hospital Page 30 Experience of maternity care (CQC survey) Experience of Maternity Care CQC National Survey Care Quality Commission undertook a survey of all women who gave birth in February The survey sample was drawn from all women aged 16 and over who had a live birth between 1 st and 28 th February Trust response rate was 43%, compared to the overall national response rate of 41%, there were 20,000 responses nationally. The Trust performed well, with three outcomes better compared to other trusts (partner involvement, reasonable response times after birth and information and explanations). The questionnaire included a section where women could make comments about the care they received. The majority of comments were positive however; the service is working to address areas for improvement and an action plan is in place. Survey CQC Maternity Survey 2015 Patient response Compared with other trusts Care during labour and birth 9.0 / 10 About the same Advice at the start of labour 8.4 / 10 About the same Moving during labour 8.5 / 10 About the same Skin to skin contact 9.1 / 10 About the same Partner involvement 9.8 / 10 Better Staff during labour and birth 8.8 / 10 About the same Staff introduction 9.3 / 10 About the same Being left alone 7.9 / 10 About the same Raising concerns 8.4 / 10 About the same Reasonable response time during labour 8.7 / 10 About the same Clear communication 9.4 / 10 About the same Involvement in decisions 8.5 / 10 About the same Respect and dignity 9.4 / 10 About the same Confidence and trust 9.0 / 10 About the same Care in hospital after birth 8.0 / 10 About the same Length of hospital stay 7.2 / 10 About the same Reasonable response time after the birth 8.1 / 10 Better Information and explanations 8.4 / 10 Better Kind and understanding care 8.6 / 10 About the same Partner length of stay 5.5 / 10 About the same Cleanliness of room or ward 9.2 / 10 About the same Cleanliness of toilets and bathrooms 9.1 / 10 About the same The Trust compares favourably with other local trusts ranking as third overall.

31 Portsmouth Hospitals NHS Trust QAH Hospital Page 31 Performance Against TDA Accountability Framework December Responsive Operational Overview

32 Portsmouth Hospitals NHS Trust QAH Hospital Page 32 NHS Constitution performance key Standards - December Responsive Operational Overview Referral to Treatment (RTT) Incomplete standard This is all patients waiting for treatment (total waiting list) The Trust achieved the standard at aggregate level with speciality fails for urology, surgery, gastroenterology, ENT and other due to capacity issues which are being addressed. There were 2 patients waiting more than 52 wks for treatment, (both previously reported as patients chose to delay treatment until after Christmas) Both were treated in early January. Diagnostic waits The maximum 6 week waiting time for diagnostics was not achieved, performance was 98.6% compared to South of England performance of 98.3% (October) A&E service quality standards Performance was 78.3% against the 95% standard, compared to 78.4% in November. Attendances in December averaged 366 per day compared to 341 a day in December last year. There was 1 breach of the 12 hr trolley wait standard Cancer standards - Provisional 6 of the 8 national standards were achieved. 62 day first definitive treatment standard has not been achieved at present, but is expected to achieve standard once validation and inclusion of confirmed treatments is completed. 62 day screening standard not achieved and not expected to be recovered. There were 7 patients waiting more than the new maximum wait standard of 104 days, 3 clinically complex, 2 late referrals, 1 unfit and 1 due to capacity in urology. Cancelled operations There were 2 breaches of the 0 tolerance 28 day guarantee. No urgent operations were cancelled for a second time. Delayed Transfers of Care 2.6% of patients were officially delayed in their transfer of care.

33 Portsmouth Hospitals NHS Trust QAH Hospital Page 33 Contractual and Local Standards December Performance Responsive Contractual and local Contractual and Local Standards Ambulance delays 287 patients experienced an ambulance delay of more than 30 minutes, compared to 359 last month and 887 in December last year. 50 patients experienced a delay of more than 60 minutes compared to 90 last month and 574 in December last year. Stroke Care Provisional (see exception report) 90% stay target was achieved with performance at 87.9% Direct admission target not achieved at 89.7% Assessment of TIA was achieved. The Trust is working with commissioners to agree metrics and monitoring closely aligned to national stroke data and this is likely to result in reporting 1 month in arrears Admission Avoidance These standards will be measured a month in arrears as requires activity to be coded. Emergency Angioplasty Emergency angioplasty within 90 mins of arrival was achieved for 85.2% of patients. (standard 80%) Emergency angioplasty within 60 mins was achieved for 70.4% of patients. (standard 70%) RTT Backlog and long waiters The number of patients waiting more than 18 wks for treatment increased by 105, (non-admitted reduced by 25 and admitted increased by 130). The number of patients waiting more than 35 weeks increased to 94.. Cancer 62 day consultant upgrade (provisional) Performance was 33.3% against the 86% standard due to 1 breach of the standard.

34 Portsmouth Hospitals NHS Trust QAH Hospital 1/28/2016 Page 34 Responsive Unscheduled Care Exception Report : A&E waiting time standard performance December performance against the 4-hour A&E and 12 hr Trolley Wait standards. Performance against the 4 hr standard was 78.3%, compared to 78.4% in November. There was 1 breach of the 12 hr Trolley Wait Standard. Contributing factors Continued increase in QA type 1 attendances compared to last year with an average of 302 per day (see graph 2) compared to 287 last December. The conversion rate to admission during increased to 38%. (graph 3) High numbers of medically fit patients waiting for packages of care and placement Actions and progress to date Improve the model of care for short stay medical patients in relation to current AMU and creation of a short stay hour medical ward(s), with increased continuity of care and rapid access to diagnostics and discharge to assess capacity Re-establish frailty model at front door with health and social care partners increasing < 48 hour turnaround Bring forward discharges earlier in the day, in line with the national profile Monitoring plans at Clinical Service Centre level to support delivery of each HIC Work with partners to deliver system wide key performance indicators agreed at the Systems Resilience Group to deliver including a 5% reduction in conveyance, 4 % reduction in frail elderly attendances and reducing the number of patients MFFD who do not need an acute bed down from 118 to <64 Through Systems Resilience Board, increase discharge to assess capacity at home/ in the community for AEC/ AMU and medical wards to access quickly to prevent admission and speed up discharge SAFER Programme run up to Christmas and first week in January.

35 Portsmouth Hospitals NHS Trust QAH Hospital 1/28/2016 Page 35 Exception Report : ED waiting time standard performance Responsive Unscheduled Care

36 Portsmouth Hospitals NHS Trust QAH Hospital 12/02/14 Page 36 Responsive - RTT Exception Report: Referral to Treatment (RTT) December Performance against Incomplete RTT standard Standard achieved at Trust aggregate level, with speciality level fails. Trust achieved 92.01% for the incomplete standard compared to 91.5% for S England for October. Validation completed. There were 94 patients waiting >35 wks at the end of December. Admitted backlog 818 ( up 130) and non-admitted 1,347 (down 25)at the end of December with an overall backlog increase of 105. There were 2 breaches of the 52 wk maximum wait standard, both patients have been previously reported and chose to delay treatment until January, both have now been treated. Contributing factors Continued emergency pressures during December with a planned reduction of elective activity over the Christmas period to provide capacity for unscheduled care admissions with 300 less patients treated compared to November. ENT has not achieved the standard, work is on-going to validate the pathways of patients being managed at Chichester to ensure clock closes have been recorded and this may lead to the repatriation of the admin of these patients. Continued capacity shortfalls in urology, colorectal and gastro, with the ISTC unable to provide any capacity to support due to staffing issues. Actions, progress to date and risks Detailed recovery plans have been agreed and implementation commenced for key areas at risk, General Surgery, Urology, Gastro and Hepatology. Schedule assurance meeting reviewed to provide extended focus and support to specialties failing to achieve standard in a special measures approach. Impact of first potential Dr strike will be minimal for electives but will impact on outpatient delivery, and this is being closely monitored. Normal elective programme is currently suspended and the Trust remains in a difficult position with 97%+ occupancy and 39 escalation beds open, therefore January performance is currently at risk, capacity is being switched to day case where possible and the position is being closely monitored.

37 Portsmouth Hospitals NHS Trust QAH Hospital 12/02/14 Page 37 Exception Report: Referral to Treatment (RTT) Recovery Plan Progress to date against revised December trajectories (provisional) Booking in turn and maximising capacity for longest waiting patients Validation capacity increased. Clinical validation in hepatology continued. Responsive - RTT Urology deteriorating and behind trajectory Trajectory 89.1%, actual performance 86%. Overall elective capacity reduced over festive period with available capacity targeted at cancer patients. Agreement reached to outsource 40 patients in February and March. Review of all available theatre capacity being undertaken to ensure maximum utilisation and potential to pick up any lists from other specialities at short-notice. Speciality in special measures with additional focused reporting, monitoring and support from Director of Operations Scheduled Care T&O achieving trajectory Trajectory 93.5%, actual performance 93.7% and achieving standard. Undertaking weekend working to maintain improvement. Spinal capacity remains key risk but volume should not preclude delivery of the standard at speciality level. General Surgery improving and achieving trajectory Trajectory 88.5%, actual performance 89.5% with planned reduction in electives over festive period. Review of colorectal work programmes has been led by the Medical Director and recruitment process for additional substantive posts progressing. Additional ad hoc clinical sessions in place to support the service. Gastroenterology improved but behind trajectory Trajectory 76.5%, actual performance 75.6% and improved.. Outpatient capacity is a key driver. ISTC unable to accommodate any patients during December but have a agreed to a small number per week in January onwards. Additional ad hoc capacity has been provided to supplement the plan. All other capacity options including national scheme being explored. Validation of patients continues with the next cohort of patients waiting > 17wk is continuing.

38 Portsmouth Hospitals NHS Trust QAH Hospital 12/02/14 Page 38 Responsive - RTT Exception Report: > 35 weeks Recovery Trajectory Contributing factors The Trust has set itself an internal target of 0 patients waiting more than 35 weeks for first definitive treatment, and a stretch target to reduce this to 26 weeks. Underlying capacity issues in surgery, urology, gastroenterology and spinal surgery have led to long waiting times for outpatient assessment and then for surgery if required. Validation of pathways has found a small number of errors where clocks had been inappropriately closed and correction to the wait has made this >35 weeks. Reduction in routine elective capacity over Christmas limited ability to treat long waiting patients. Actions and progress to date The Trust is booking patients according to clinical priority and waiting time, and there were 94 patients waiting more than 35 wks against a target of 60. Speciality level improvement trajectories are in place and are reviewed weekly at the Access Assurance meeting, with remedial action plans put in place if required. This is being further strengthen with additional special measure with detailed review of performance, monitoring and support from Director of Operations scheduled care. Long waiting patients >40 weeks re-categorised as urgent to reduce risk of cancellation due to emergency pressures. Validation exercise underway, this has reduced the incomplete backlog and is continuing. Due to the admin errors in urology a full validation of the patients waiting will be carried out by the validation hit squad in January. Clinical outcome forms reviewed and revised to ensure admin staff are able to easily identify the clinical intention for the next stage of treatment. On-going Risks Non-admitted capacity constraints and difficultly in predicting whether attendance will stop the clock or pathway continue and as a result further long waiters. Capacity constraints: clinical, theatre, day surgery and beds to deliver additional capacity required. Continued cancellation of non-urgent long waiting patients and suspension of elective programme due to continued unscheduled care pressures.

39 Portsmouth Hospitals NHS Trust QAH Hospital 12/02/14 Page 39 Exception Report: Diagnostic 6 wk referral to test standard December performance against the 6 wk diagnostic standard Performance against the 6 wk standard was 98.6% against 99% standard South of England performance for October was 98.32% Contributing factors Key contributing factors where the cancelling of endoscopy lists due to the planned doctors strike Late notification from the ISTC that they would be unable to treat any patients in December. This and the limited ability to provide enough last minute additional in-house capacity to compensate, combined with the reduction in capacity due to the bank holidays meant that the standard was breached by 19 patients who could not be accommodated within standard. Responsive - RTT Actions and progress to date The ISTC has confirmed very limited endoscopy capacity for January, this will be used for planned patients, maximising in-house capacity for diagnostic patients to reduce risk to standard if ISTC unable to deliver. The Trust will continue to work with commissioners to improve the quality and relevance of diagnostic referrals. Contingency plans are being reviewed for those modalities most at risk of significant demand / capacity variation and to ensure additional capacity is provided to meet demand. Work is ongoing with the Gastro specialty to improve patient diagnostic pathways and capacity to support sustainability of the 6 week standard this continues to significantly reduce the number of breaches. Work on-going to minimise risk from planned Doctor strikes in January and re-provide capacity lost as a result.

40 Portsmouth Hospitals NHS Trust QAH Hospital 1/28/2016 Page 40 Responsive Cancelled operations Exception Report: Cancelled Operations 28 day Guarantee December Performance Cancelled Operations 28 day Guarantee No urgent operations were cancelled for a second time, all urgent patients cancelled were rebooked and treated. 28 day standard applies to patients cancelled on the day of or after admission for non-clinical reasons who have not been offered a binding date for surgery within the subsequent 28 days. This is a zero tolerance standard. There were 70 patients cancelled on the day for non-clinical reasons in December, 2 of these breached the 28 day rule, both have agreed treatment dates in January. Contributing factors Continued pressure from unscheduled care demand and high numbers of medically fit discharge ready patients. Complexity and continued bed pressures meant that the patients could not be treated within 28 days, though the proportion of cancellations resulting in a 28 day rule breach has continued to improve. Actions, progress to date and risks Planned reduction of the elective programme meant less patients were cancelled The standard operating procedure for non-clinical cancellations has been reviewed and strengthened to provide clear escalation points and actions and this will be re-launched in January, this includes the recommendation that the new date is before day 14 to reduce the risk of breach due to second cancellation. Patients previously cancelled are now re-designated as urgent and can only be cancelled in extreme circumstance following escalation and exploration of alternative options. The Trust is continuing to run a reduced elective programme due to unscheduled care pressures to maintain the overall safety of the hospital. This is reducing the number of last minute cancellations but has increased the risk of patients already subject to the standard ( those cancelled in December) not being treated within 28 days.

41 Portsmouth Hospitals NHS Trust QAH Hospital 1/28/2016 Page 41 Exception report: Cancer Standards (provisional position) Responsive - Cancer December provisional performance against national cancer standards and contributing factors ( national reporting deadline 6 th February 2016 performance subject to change including additional shared breaches until submission deadline) December performance is a very early and provisional unvalidated position, performance is expected to improve once validation undertaken. Currently 6 of the 8 key standards have been achieved for December, 62 day standard is expected to improve to achieve standard, 62 day screening is 89.5% and not expected to achieve standard. There were 7 patients waiting more than 104 days (3 last month). 5 of these are urology patients: 2 late referrals, 1 very unwell, requiring review of treatment options, 1 complex and 1 due to capacity,; 1 lower GI complex and unwell patient with change of treatment plan required, 1 breast - multiple diagnostics, histology sent to another provider for second opinion - cancer not yet confirmed. This is monitored on a named patient basis at the weekly assurance meeting which also includes patients breaching the internal stretch targets of 61 days for 31 day patients and 92 days for all 62 day patients..

42 Portsmouth Hospitals NHS Trust QAH Hospital 1/28/2016 Page 42 Responsive - Cancer Exception report: Cancer Standards continued December Performance 62 day first definitive treatment against recovery trajectory Provisional performance 84.2% against a trajectory of 85% (standard 85%) Performance is expected to achieve recovery standard once validation is undertaken. Actions and progress to date Urology, additional capacity provided in November not able to be sustained in December, and backlog of breached patients has increased. (see table) Speciality now in special measures with very close monitoring of performance and delivery by Director of Operations (Scheduled Care) due to current cancer and RTT position. Immediate additional capacity provided to support early diagnostic phase of pathway. Delivery of improvement plan on track and monitored at Cancer Steering Group, with weekly monitoring by Lead Cancer Manager and Director of Operations (Scheduled Care) Demand and capacity modelling at tumour site to underpin delivery of revised trajectory, supported by increased utilisation of lists and additional capacity planned awaiting support from cancer network Using existing root cause analyses of breaches to improve processes and reduce delay led through Cancer Steering Group. Weekly review of patients 14 days to breach on an individual basis to ensure treatment plan in place and delays mitigated where possible. Cancer operational and access policy has been updated and strengthen, this has been approved by commissioners and will go to operational board for ratification in January. On-going Risks Forecast under achievement of 62 day standard in January, achievement of standards from February based on ability to treat backlog patients during January. Unscheduled care pressures have limited ability to run additional weekend operating sessions and pressure on ITU beds has lead to the postponement of 1 cancer patient. This is being careful managed and risk to patients of delay clinically reviewed. Clinical workforce remains a risk due to the resignation of 1 cancer clinician and challenges to recruit nationally.

43 Portsmouth Hospitals NHS Trust QAH Hospital 1/28/2016 Page 43 Exception report: Cancer Standards continued 104 day maximum wait Contributing factors and actions taken Responsive - Cancer There were 7 patients breaching the standard at the end of December. Urology had 5 breaches of the standard, 2 of these were late referrals (1 of which at after breach date) 1 clinically complex patient, 1 patient unfit requiring review of treatment plan following further diagnostics, 1 due to surgical capacity. Breast had 1 breach, very complex requiring review of histology by another provider, cancer not currently confirmed. Lower GI 1 breach due to clinically complex pathway, patient unwell requiring review of treatment plan. All patients are reviewed weekly on a named patient basis and actions taken to expedite treatment where possible. Additional capacity being provided in January for urology for complex surgery. Special measures support in place and this includes review of all patients breaching pathway milestones to manage variation and delay at an earlier stage.

44 Portsmouth Hospitals NHS Trust QAH Hospital Page 44 Responsive Coronary Heart Disease Exception Report Primary Angioplasty & Heart Disease October performance against primary angioplasty and heart disease contract standards The Trust achieved all 3 key measures: Door to balloon 60 mins 70.4% achieved (standard 70%) Door to balloon 90 mins 85.2% achieved (standard 80%) Call to balloon 150 mins (all patients including transfers from other providers) achieved 86.4% (standard top 75% of trust providing the service) Contributing factors There were 22 eligible call patients and 19 of these received treatment within the 150 mins standard 3 breaches of the standard; 1 patient was a secondary transfer from another hospital, 2 were initially taken to ED, 1 of these also delayed due to a procedure already taking place in the lab, 1 patient multiple comorbidities and complex. Actions and Progress to date All breaches reviewed on a case by case basis by cardiology team and process reviews recommended. Meeting has taken place with CSU to discuss ambulance conveyance times with the recommendation that compliance to the 60 minutes conveyance time is performance managed through the Service Level Agreement. Paramedic training days planned supplemented by local training delivered by SCAS ED teaching and education continuing.

45 Portsmouth Hospitals NHS Trust QAH Hospital Page 45 Exception Report: Stroke Contract Service Standards December Provisional Performance against Stroke Service Standards Work is on-going with partners to review and agree which standards are to be monitored under the terms of the contract and the specific criteria for each measure. The aim is that the Sentinel Stroke National Audit Programme (SSNAP) performance standards will be used as this is the data used nationally to review stroke care. SSNAP is also the chosen method for collection for stroke measures in the NHS Outcomes Framework and the CCG Outcomes Indicator Set. Responsive Stroke Care The SSNAP analysis tool is currently being tested to ensure performance data can be extracted and used to analyse performance against key measures and to aid local reporting. In order to provide an indicative performance forecast prior to publication of each final national quarterly report and to drive improvements in care, it will be necessary to continue to report in arrears (actual reporting timetable to be set and agreed). Based on current counting methodology (local Stroke Metric Summary primary strokes only): 89.7% of patients were admitted directly to a stroke unit against the 90% standard 87.9% of patients achieved the 90% stay on a stroke unit standard of 80% The priorities currently being focused on are: Thrombolysis pathway Door-to-Needle within 1 hour performance Direct Admit pathway (Transfer from ED to HASU) within one hour and 4 hours performance HASU bed capacity and staff competency CT Head scans within an hour MDT / Speech and language therapy assessment within 72 hours Community Stroke Rehabilitation / Early Supported Discharge increased capacity Six week follow up Use of F3 Gym for escalation

46 Portsmouth Hospitals NHS Trust QAH Hospital Page 46 Finance: Overview Summary The trust's I&E position at the end of Month 9 is an actual deficit of 21.7m, this is an adverse variance of 12.4m against overall plan. As a part of this position, Income is ahead of plan by 4.4m. Operating expenses are overspent by 16.2m of which pay costs are 9.2m. Savings of 9.7m have been recorded for the year to date against a plan of 17.3m. The annual CIP target is 29.95m following the inclusion of the stretch target and additional recovery actions. Full-year delivery is currently forecast at 16.2m. The trust has spent 5.8m capital to date. The revised programme for the year totals 15.7m with 50% released initially and Board approval required to release additional funds for medical equipping. The trust has a cash balance of 6.6m at the end of December. The minimum level of cash holding is expected to be 2.5m. Currently the trust has drawn down 28.6m of its working capital facility. In mid-december the Trust applied for a medium term cash loan of 39m. The application is subject to ongoing TDA review and is likely to be reduced to 32.6m. Financial Sustainability Risk Rating R Surplus/(Deficit) R Cash R Actual / Actual / Actual / Plan Forecast Plan Forecast Variance Plan Forecast Variance Current Month Metrics 1 1 Year to date - k (9,307) (21,667) (12,360) Current Cash & Cash Equivalents - k 2,500 6,561 4,061 Forecast End of Year Metrics 1 1 Year End Adjusted Trajectory - k (9,724) (25,700) (15,976) Year End Forecast - k 2,500 2,500 0 Enablers - Finance The Financial Sustainability Risk Rating adds 2 further metrics to Monitor's Continuity of Services Risk Rating (CoSRR). The trust s risk rating at the end of December is a 1, which is in line with plan. The end of year forecast indicates a risk rating is also a 1. NB - a NHS trust is rated as Red for its Financial Sustainability Risk Rating unless it achieves a score above 2.5. Income G Expenditure R Liquidity Days A Actual / Actual / Actual / Plan Forecast Variance Plan Forecast Variance Plan Forecast Variance Year to date - k 371, ,635 4,422 Year to date - k (380,520) (397,303) (16,783) Current Month Position - Days (26) (12) 14 Year End Forecast - k 495, ,510 7,385 Year End Forecast - k (504,849) (527,754) (22,905) Year End Forecast - Days (28) (29) (1) The trust is reporting an over-performance against all income of 4.4m for the year to date. The over-performance is driven by clinical income within which is 2.5m offsetting the overspend against Pass Through Drugs. Also included within the over-performance is income for Cedar & Artk Royal (wards) offsetting associated costs prior to their transfer in October Cost Improvement Plans (CIPS) R Capital G Actual / Actual / Plan Forecast Variance Plan Forecast Variance Year to date - k 17,336 9,738 (7,598) Year to date - k 15,192 5,759 9,433 Year End Forecast - k 29,925 16,174 (13,751) Year End Forecast - k 20,396 10,830 9,566 The total value of the savings programme has been increased from 16.95m to 29.95m following the inclusion of the revised target deficit and additional recovery actions. At month 9 delivery is 7.6m under plan and forecast to be 13.8m under by the financial year end. All workstreams are underperforming against the revised target the most notable of which are linked to workforce savings (forecast 1.3m adverse to plan) and the additional recovery actions (forecast 6.4m adverse to plan). Forecast CIP performance against the original At month 9 the trust is showing a deficit which is 12.4m adverse to plan. Income is showing an over-performance of 4.4m. This includes 2.5m against Pass Through Drugs, which offsets in related the overspend seen in Operating Costs. Pay costs are overspent by 9.2m, with total spend to date including 25.2m against all forms of temporary workforce costs. Clinical supply costs are overspent by 2.0m and other non pay costs are by 3.5m. The year end forecast includes an assessment of risks and opportunities and is currently recognised by the Board as a 23.6m deficit. The forecast reported to the TDA will be 25.7m deficit as it will exclude the capital to revenue transfer valued at 2.1m which is as yet unconfirmed by them. At the end of month 9 the trust is reporting an 16.8m overspend against expenditure. Pay is overspent by 9.2m with total costs including temporary workforce costs. The non pay overspend includes 2.5m against Pass Through Drugs, which is offset in full by related income. Clinical supplies are overspent by 1.8m. 'Other' non pay costs are overspent by 3.5m. Included within this are costs associated with Cedar & Ark Royal, which are offset in income, and CIP underperformance. The trust has spent 5.5m capital to the end of month 9. This is c. 10m less than originally planned reflecting the reduction to the total programme for the year, and Board agreement to release 50% of the funds so far. A further contingency sum has been released related to medical devices. The current forecast is to have slippage against the programme by a total of 2.1m but this will be dependant upon Board approval to release any remaining funds. Actual cash held at the end of December was 6.6m. The trust is required to hold a minimum cash level of 2.5m, and therefore has a positive variance against this requirement of 4.1m. It should be noted that by the end of December the trust had drawn down 28.6m of cash against its working capital facility. Cash is red rated due to the scale of risk associated with the changes to the mechanisms for securing cash support. The forecast position assumes the trust is successful in securing sufficient support in line with eventual I&E performance and other cash flow requirments. To this end an ITFF application of 32.6m will be submitted to replace the temporary borrowing facility. Liquidity days are calculated using the Continuity of Services Risk Rating Methodology, taking working capital compared to operating expenditure. The current position reflects the trust's I&E position, it improves in the forecast position after receiving cash support.

47 Portsmouth Hospitals NHS Trust QAH Hospital Page 47 Exception Report: Financial Performance - Income & Expenditure Enablers - Finance Performance The Trust has a deficit budget of 9.7m in reflecting the stretch target issued by the TDA. For December the Trust required income in month to be 0.2m in excess of expenditure. The actual position was 3.2m excess expenditure over income resulting in a 3.4m (adverse) variance to plan. PbR Income performance reflects the final figures for November combined with a forecast for December. The final PbR income figures for the year to date to November was 0.03m lower than that reported in month 8. The December income is lower than last months forecast and adverse to budget by 0.7m. Due to significant bed pressures and the number of delayed discharges at the end of December there may have been an increase in partially completed spells. This position is being investigated. Annual Budget December Budget December Actual December Variance Budget to Date Actual to Date Variance to Date '000 '000 '000 '000 '000 '000 '000 Income NHS PbR Income 402,900 34,148 32,852 (1,295) 301, ,827 1,930 Pass Through Drugs 38,271 3,164 3, ,929 31,375 2,445 Other Patient Related Income 3, (18) 2,882 2, Other Operating Income 50,044 4,333 4, ,470 37,474 4 Total Income 495,077 41,971 41,403 (568) 371, ,596 4,419 Operating Expenses Employee Benefit Expenses (279,170) (23,299) (24,149) (850) (210,095) (219,339) (9,243) Drugs Expenses (21,981) (1,664) (2,763) (1,099) (16,343) (16,313) 30 Pass Through Drugs (38,271) (3,164) (3,721) (557) (28,929) (31,375) (2,445) Clinical Supplies (50,439) (4,155) (4,595) (440) (38,160) (39,981) (1,821) Other Non-Pay (80,615) (6,634) (6,646) (11) (61,290) (64,048) (2,757) Total Expenditure (470,477) (38,916) (41,873) (2,957) (354,819) (371,056) (16,237) Earnings Before Interest, Taxation, Depreciation and Amortisation (EBITDA) 24,600 3,055 (470) (3,525) 16,359 4,541 (11,818) Depreciation (16,102) (1,339) (1,359) (20) (12,008) (12,093) (84) Net Profit/(loss) on disposal of assets (50) - (29) (29) (50) (179) (129) Impairments Interest receivable/(payable) (16,889) (1,439) (1,486) (47) (12,645) (12,870) (225) Dividends payable (1,980) (165) (1,485) (1,399) 86 Retained Surplus/(Deficit) (10,422) 113 (3,300) (3,413) (9,830) (21,999) (12,169) IFRS Adj. - Donated Asset Adj (191) Revised Retained Surplus/(Deficit) (9,724) 171 (3,223) (3,394) (9,307) (21,667) (12,360) +ve= favourable position (-ve) = adverse position

48 Portsmouth Hospitals NHS Trust QAH Hospital Page 48 Enablers - Finance Progress Report: Variance in month by CSC Key variances The variance to budget in month 9 was 3.4m (adverse). PbR Income was 0.7m adverse variance to plan. Other income 0.2m favourable to plan linking primarily to a reduction in the provision for outstanding provider to provider issues ( 0.1m) and an increase in R&D income ( 0.05m). Pay was 0.9m adverse to plan. The key issues remain the excess cost of temporary workforce costs above budgeted levels and the cost of additional capacity provided to support urgent care needs. Non-pay was 1.9m adverse to plan linking significantly to adverse positions on drugs, clinical supplies and CIP targets. CSC/Division Base Budget Variance Pay Variances Over established / Pricing issues Pay CIP Pay legacy costs from previous year Pass Through Drugs Non-Pay Variances Base Budget Variance Non-pay CIP Non-pay legacy costs from previous year Income CSC Total PbR Income Net I&E variance '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 '000 CHAT (23) (243) - (59) 9 (231) 15 (216) Clinical Support Division 101 (44) (112) (107) - 38 (102) Corporate costs (41) (151) (92) Emergency Care 62 (267) (31) (9) (2) (67) (8) - (7) (328) (927) (1,255) Executive Division (28) (69) (44) - (44) Head & Neck 61 (54) - - (26) (123) (23) - 4 (160) 100 (59) Internal Medicine 69 (236) (14) - (406) (348) - - (8) (942) 634 (307) MOPRS 60 (282) (43) (100) 7 (59) (1) - 4 (415) 138 (277) MSK 24 (113) (41) (111) - (1) (198) (243) (441) PFI Unitary Payment Private Patients (2) (48) (26) - (26) Renal 2 (8) - (4) (18) 99 (155) (55) Research and Development (24) - - (4) Surgery & Cancer 32 (133) - - (237) 7 (43) - (10) (385) (248) (633) Pharmacy Trading (14) Women and Children's (3) (18) 12 (21) (29) (6) - (54) 3 (115) (91) (206) YTD CSC Expenditure Variance 569 (1,155) (76) (134) (557) (970) (293) (106) 172 (2,549) Corporate Reserves (55) (51) (106) (106) YTD Expenditure Variance 514 (1,155) (76) (134) (557) (1,021) (293) (106) 172 (2,656) SLA Income (1,296) (739) - YTD CSC Variance Against Plan 514 (1,155) (76) (134) 0 (1,021) (293) (106) (1,124) (3,394) (739) (3,394)

49 Portsmouth Hospitals NHS Trust QAH Hospital Page 49 Enablers - Finance Progress Report: SLA Income: Value year to date Scheme Forecast YTD Month 9 (Finance Reporting) YTD Month 8 (Contract Reporting) Plan Actual Variance Plan Actual Variance Plan Actual Variance '000 '000 '000 '000 '000 '000 '000 '000 '000 PbR Activity Income Non-Elective Spells 120, ,148 2,523 90,197 91,278 1,081 79,378 81,614 2,236 Elective Spells 80,521 83,302 2,781 60,309 62,267 1,958 54,097 55,641 1,544 Outpatient Attendances 82,438 83,475 1,037 62,355 62, ,469 55, ED Attendances 15,665 15,662 (3) 11,954 11, ,706 10,667 (39) Chemotherapy 6,335 5,959 (376) 4,789 4,467 (321) 4,264 4,004 (260) Maternity Pathway (Ante & Post) 11,387 11, ,537 8, ,611 7, NICU 6,177 6, ,712 4, ,168 4, ITU 11,028 11, ,286 8, ,352 7, Other 97, ,564 5,346 73,260 76,104 2,844 65,153 67,392 2,239 Contractual Adjustments Readmissions (2,574) (2,574) (0) (1,930) (1,930) (0) (1,716) (1,716) (0) CQUIN 9,608 9, ,206 7, ,405 6, Non-Elective Threshold (1,374) (1,712) (338) (1,029) (1,330) (302) (906) (1,343) (437) Penalties (2,000) (3,499) (1,499) (1,500) (2,581) (1,081) (1,333) (2,161) (828) Other 5,117 (272) (5,389) 2,930 (6) (2,936) 2,201 (156) (2,358) Outside Contract Payments 1,000 3,053 2, ,661 1, ,530 1,863 Grand Total 441, ,792 7, , ,202 4, , ,665 5,150 Income Performance: Final financial monitoring of contract income in month 8 resulted an income movement of m compared to that previously forecast. The forecast for month 9 is 0.7m below planned levels of income.

50 Portsmouth Hospitals NHS Trust QAH Hospital Page 50 Progress Report: Pay expenditure Pay expenditure: Total pay expenditure in December 2015 was 24.2m. This is against a budget provision of 23.3m an adverse variance of 0.9m. Enablers - Finance The use of temporary workforce costs in December was 2.4m. This represents 9.4% of the total pay costs. Total temporary workforce costs for the year to date are 25.2m. Temporary costs increased by 3% compared to last month, with agency commitments being the largest component at 1.15m The contracted number of substantive staff expressed as Full Time Equivalents (FTE) reduced by 22 since last months high point. The December 2015 payroll figure was 6,330 FTE.

51 Portsmouth Hospitals NHS Trust QAH Hospital Page 51 Progress Report: Forecast position Forecast: Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 m m m m m m m m m m m m Revised deficit budget 9.7m Original deficit budget 16m Run rate trajectory Current forecast Enablers - Finance The current Trust forecast deficit approved by the Board is 23.6m. This includes a view of relative risks and opportunities. The key assumption linked to this is a CSC view of activity and clinical income. The Trust forecast does not include full recovery of planned CIP and recovery initiatives. It does include an opportunity of 2.1m linked to a capital to revenue transfer. Work continues to assure delivery of the existing forecast and to identify further initiatives consistent with improving financial performance. Progress to be reported monthly to the Finance Committee and the Trust Board.

52 Portsmouth Hospitals NHS Trust QAH Hospital Page 52 Progress Report: Cost Improvement Programme Enablers - Finance CIP Performance The financial improvement target has been set at 23.25m, linked to the planned budget deficit of 9.7m. An additional sum of 6.7m has been integrated into the tracking of financial improvement linked to Recovery initiatives aimed at controlling the financial position. A review of the values attributed to CIP and recovery schemes has shown restricted delivery from high risk items based on plans in place. This is now reflected in the forecast out-turn for CIP and aligns with the Income and expenditure forecast. A process of assurance and validation to support risk reduction and delivery in these areas is continuing and updates will be reported to the Finance Committee in subsequent meetings. CSC Target Forecast Actual Forecast Variance YTD Target YTD Actual YTD Variance Dec-15 Target Dec-15 Actual Dec-15 Variance CHAT 1, (123) (58) Clinical Support 1,719 1,062 (657) 1, (586) (83) Corporate 1, (1,059) 1, (634) (166) Corporate Reserves 1, (1,093) (398) (44) Emergency Care 1, (546) (488) (37) Executive 1,241 1,025 (216) (187) (51) Head & Neck (57) (130) (13) Internal Medicine 1,592 1,438 (153) (342) MOPRS (280) (189) 48 7 (41) MSK 1, (721) (639) (96) PbR income 8,682 6,059 (2,623) 5,229 4,426 (803) (440) PFI Unitary Charge (0) Private Patient Unit (10) Renal Surgery & Cancer (152) (55) (11) W&C Recovery schemes* 6, (6,428) 3, (3,330) 1, (1,048) Total 29,925 16,174 (13,751) 17,336 9,738 (7,598) 3,559 1,566 (1,993) Scheme Target Forecast Actual Forecast Variance YTD Target YTD Actual YTD Variance Dec-15 Target Dec-15 Actual Dec-15 Variance '000 '000 '000 '000 '000 '000 '000 '000 '000 Back Office 1, (232) (147) (29) Clinical service efficiencies 1,600 1, ,200 1, Clinical support services 1, (635) (639) (105) CSC schemes 3,063 2,272 (791) 1,725 1,250 (475) (82) Data quality & Income 7,382 4,759 (2,623) 4,239 3,426 (813) (437) Estate Optimisation 2,801 1,727 (1,074) 2,027 1,393 (634) (166) Supply Chain 3,792 3,176 (616) 1,622 1,276 (347) (82) Workforce 2, (1,351) 1, (1,213) (44) Recovery schemes* 6, (6,428) 3, (3,330) 1, (1,048) Grand Total 29,925 16,174 (13,751) 17,336 9,738 (7,598) 3,559 1,566 (1,993)

53 Portsmouth Hospitals NHS Trust QAH Hospital Page 53 Progress Report: Capital Enablers - Finance Capital Performance Capital expenditure incurred in month 9 was 0.2m. The Trust s Capital Resource Limit (CRL) for is 20.5m. At present the Trust current programme of 15.7m is below the CRL enabling the Trust to avoid any additional borrowing requirements. (An undershoot against the CRL is acceptable). The Trust Board has approved 50% of the capital programme to be released together with some additional contingency sums linked to medical equipping.

54 Portsmouth Hospitals NHS Trust QAH Hospital Page 54 Progress Report: Cash Cash Balance The year-end cash balance associated with the External Financing Limit (EFL) is currently valued at 2.5m. Interim Financing Facility - The Trust has an interim revolving working capital facility (IRWCF) of 37.2m - To date 28.6m has been drawnd own, with an anticipated draw in February of 5.0m - Following the outcome of the long term financing application, it is anticipated that the full amount drawn down in 2015/16 IRWCF will be repaid by 31 st March Enablers - Finance The cash balance at 31 st December was 6.5m which was higher than anticipated due to early receipt of VAT reclaim and reduced creditor payments. The year to date performance against the Better Payment Practice Code is 94% by volume and 94% by value. Both measured against a 95% target. Long Term Financing Application - The ITFF financing application has been reduced from 39.0m to 32.6m following TDA initial review - Year end cash balance will be reduced to 2.5m (this is within the allowable range) - This reduced balance will require either support from Commissioners for continued early payment of SLA invoices in April or a draw against the IRWCF - The revised application was presented to the Finance Committee on 28 th January - The financing application will be presented to the ITFF meeting on 19 th February

55 Portsmouth Hospitals NHS Trust QAH Hospital Page 55 Enablers Contract Performance Theme Contracts Executive Summary key exceptions to note 15/16 contracts Summary - Contract information is dependent on validation processes so this report is regarding Month 8 Month 8 performance against all contracts is over-performing by 12.9 m (NB Trust expected income target is higher than Contract indicative value). Statements also include a 2.7m payment for services outside of the contract. CCG CCG contract is signed by all major CCGs. All unsigned CGGs have agreed the contract values and are paying 12ths payments on time and to a reasonable level. Other signature delays by Commissioners are currently not creating any cash concerns at the Trust. Local CQUIN scheme details are agreed for Elective Schemes and Emergency Schemes although the CCG have recently contested that agreement. This is subject to formal dispute discussions starting 4 January. Month 8 performance against all CCG contracts is over-performing by 9.7 m. NB Trust-expected income target is higher than Contract indicative value. Process regarding payments and reinvestments of fines as agreed is a material issue for our local LHE This is subject to formal dispute discussions starting 4 January. The CCG have provided the Trust with an extended list of data validation and payment challenges in month 7, which the Trust is responding to appropriately and quickly in order to achieve early resolution and minimise system risk. NHS England contracts NHSE contracts are over-performing by 1.9 m at Month 7, the majority of the over-performance is in Specialised, arising from nonrealisation of commissioner QIPP schemes which are included in the contract target. Discussions of alternatives are under way. Contract Notices and Remedial Action Plans There are no open Remedial Action Plans, although the Trust has been asked via Contract performance notices to convert existing Cancer and RTT recovery plans into full formal RAPs, which the Trust is achieving with CCGs. Following receipt of another CPN for Emergency Department 4-hour wait standard, the Trust is also agreeing a suitable RAP of all the actions required to help remedy the performance issue. 16/17 Contract Commissioning intentions and statutory notices have been exchanged on 30 th Sept, being 6 months to the start of the new contract year. The Trust is seeking agreement on a detailed timetable for the 16/17 Contract with clear delivery and escalation points. Next steps will be full-year activity planning. The Trust is also seeking agreement over terms of a review of local prices as part of this process. Commissioner CQUIN schemes are likely to include enhanced reporting of outcome measures. CSCs actions requested 1) minimise the financial risk of booking LCVs without authorisation 2) develop robust activity / capacity projections for 16/17, 3) to bring any other foreseen contractual issues to the attention of the Contracts team to assist the 16/17 process.

56 Portsmouth Hospitals NHS Trust QAH Hospital Page 56 Contracts Executive Summary Enablers Contract Performance Theme Trust Contract Activity / Cost Summary by Commissioner (Contracting Month 8) Performance v contracted plan at Month 6 POD Group Description 3 CCG's Other CCG's Wessex Area Team Specialist Other Local Area Team Activity Act Var '000 Var Activity Act Var '000 Var Activity Act Var '000 Var 04 Total Non-Elective Activity 35,191 1,598 3,918 2, , Total Elective Spells 35,088 1,285 2,534 3, , ,891 (36) Total Accident & Emergency 89,654 3, , ,161 (22) (12) 07 Outpatients 384,720 20,418 1,702 46,492 4, , (46) 21,206 1, Chemotherapy ,112 (996) (253) Direct Access 3,086,627 66,090 (6) 1, (1) ,502 (3,212) (54) 10 Maternity Pathway 8, NICU , ITU 3,354 (129) (118) (179) 1, (41) (60) 13 Rehab/DSC 36, ,934 (150) (27) 1,317 (211) (169) 30 1 (4) 14 Drugs (852) Renal Dialysis ,256 (412) Other 33,628 7, ,444 1, ,124 3, ,594 1, Contractual Adjustment (5) 0 0 (508) 0 0 (195) 18 Information Validation 0 0 1, (32) 0 0 1, Performance Adjustment 0 0 (2,091) 0 0 (67) 0 0 (3) Outside Contract Adjustment 0 0 2, Grand Total 3,713, ,984 11,533 67,146 7, ,664 3,533 1, ,034 (1,078) 137 POD Group Description Audiology any qualified Provider Cancer Drugs Fund / IFR Public Health England All Contracts Activity Act Var '000 Var Activity Act Var '000 Var Activity Act Var '000 Var Activity Act Var '000 Var 04 Total Non-Elective Activity ,956 1,754 4, Total Elective Spells (87) (35) 43,587 1,397 2, Total Accident & Emergency ,467 3, Outpatients 860 (229) (62) ,980 26,788 2, Chemotherapy ,112 (996) (253) 09 Direct Access ,121,949 63,050 (61) 10 Maternity Pathway , NICU , ITU , Rehab/DSC ,082 (136) (134) 14 Drugs , , Renal Dialysis ,256 (412) 6 16 Other ,791 14,518 1, Contractual Adjustment 0 0 (2) (1) 0 0 (615) 18 Information Validation , Performance Adjustment (2,161) 20 Outside Contract Adjustment ,705 Grand Total 860 (229) (64) 0 0 1, (86) (35) 4,091, ,310 15,593 Bridge from Trust Contract Report to Trust Income Report Non Contract Activity: 13,203 (210) 432 Trust Plan Assumption: (8) (18,069) (10,875) Total Trust Income Reporting: 4,104,253 92,031 5,150

57 Portsmouth Hospitals NHS Trust QAH Hospital Page 57 Workforce Executive Summary key exceptions to note Well Led Workforce Performance Theme Performance Theme The total workforce capacity decreased by 8.8 FTE to 6,746.1 FTE in December and is 172 FTE over the funded establishment. The temporary workforce capacity increased by 15.6 FTE to FTE in December and comprises 5.9% of the total workforce capacity. There are FTE vacancies against budgeted establishment in December. This is an increase since the previous reporting period and is 3.4 % of establishment in December. Staffing levels (as per NQB Safe Staffing Levels) are reported as 100.2% in December, this is a decrease compared to November (101.6%). Appraisal compliance decreased to 83.3% in December and is below the 85% target. Total essential skills increased in December from 84.6% to 85.9 and currently records above the 85% target. All CSCs essential skills compliance increased in-month and recorded above the 85% target in December. Information Governance Training has increased by 0.6% to 93.4% for December and remains below the 95% target. Fire Safety (face to face training) increased by 1.3% to 70.8% in December, however this remains below the 85% target. Sickness Absence Rate (12 month rolling average) remained at 3.5% in November and remains above the target. In-month sickness absence increased by 0.2% to 3.6% in November and is above the target. 60.8% of the workforce have had this years flu vaccination.

58 Portsmouth Hospitals NHS Trust QAH Hospital Page 58 Exception Report: Workforce Capacity Safe Workforce capacity Where we want to be: targets and benchmarks Target: Establishment of 6,596 FTE, with target of substantive staff in post at 100% of establishment Trends and Patterns Following further adjustment to the budget for the new financial year, funded establishment (excluding CIP) has increased by 3.1 FTE in month to 6,573.4 FTE, which is a net increase of 232 FTE since March The total workforce capacity decreased by 8.8 FTE to 6,746.1 FTE in December and is 172 FTE over the funded establishment. Substantive workforce capacity decreased by approximately 24.5 FTE in December to 6,349.3 FTE, but is an increase of 260 FTE since March The temporary workforce capacity increased by 15.6 FTE to FTE in December and comprises 5.9% of the total workforce capacity. There are FTE vacancies against budgeted establishment in December. This is an increase since the previous reporting period and is 3.4 % of establishment in December. Root Cause analysis and insights A significant temporary staffing resource is still required to fill existing vacancies across all areas. There are FTE vacancies remaining in substantive staffing, split across all staff groups, though 45.4 FTE vacancies are within qualified nursing and midwifery staff, both ward and non ward based and is approximately 10.8 FTE decrease since November. Temporary staffing is being used to fill these vacancies as required. Actions and progress to date Continued recruitment is taking place, with further international nursing recruitment schemes taking place in 2015, and associated work with NHS Professionals having a positive impact on registered nursing vacancies. International recruitment is in progress for medical and nursing vacancies. Substantive Staffing FTE Establishment Substantive Vacancies CHAT CSC Clinical Support CSC Emergency CSC Head & Neck CSC Medicine CSC MOPRS CSC Musculo-skeletal CSC Renal CSC Surgery & Cancer CSC Women & Children CSC Corporate Functions Total Trust Workforce Capacity FTE Temporary Total Workforce CHAT CSC Clinical Support CSC Emergency CSC Head & Neck CSC Medicine CSC MOPRS CSC Musculo-skeletal CSC Renal CSC Surgery & Cancer CSC Women & Children CSC Corporate Functions Total Trust

59 Portsmouth Hospitals NHS Trust QAH Hospital 28 January 2016 Page 59 SAFE Safe Staffing Reports / NQB Where we want to be :targets and benchmarks Target: Planned staffing levels are 100%, planned skill mix 70.1% RN:29.9% HCSW ratio Trends and Patterns The evidence collected for December indicates that overall staffing levels have decreased, from 101.6% to 100.2% compared to planned levels. The planned skill mix decreased in December for Registered Nurses (RNs), and the actual skill mix for the Trust was 65.5%. Health Care Support Workers (HCSWs) has decreased from 35.6% to 34.5% Root Cause analysis and insights There are a number of vacancies remain due to difficulty in recruiting qualified nurses, however the vacancies are decreasing monthly. Actions and progress to date Recruitment continues locally, nationally and internationally, additional health care support workers are being used to supplement staffing numbers, and close working with NHSP continues to resolve this issue. Planned vs Actual Staff Numbers These figures include ED, Day Units, and Flexible/Unfunded Capacity Registered Nurse Healthcare Support Worker Combined P A % P A % P A % % % % NHS Choices These figures do not include ED, Day Units, or Flexible/Unfunded Capacity Queen Alexandra Hospital NHS Choices These figures do not include ED, Day Units, or Flexible/Unfunded Capacity Planned vs Actual Staff Hours (Day and Night) P A % Planned vs Actual Staff Hours (Day) Registered Nurse 101% Healthcare Support Worker P A % P A % Actual Staff Numbers and Skill Mix Average Fill Rate Skill Mix Registered Nurses HCSW Planned Actual % % RN:HCSW RN:HCSW Mar % 118.7% 71.1% : 28.9% 65.2% : 34.8% Apr % 120.1% 70.2% : 29.8% 64.4% : 35.6% May % 120.8% 70.3% : 29.7% 64.7% : 35.3% Jun % 119.5% 70.4% : 29.6% 64.7% : 35.3% Jul % 123.7% 70.3% : 29.7% 64.0% : 36.0% Aug % 121.5% 70.1% : 29.9% 63.8% : 36.2% Sep % 121.9% 70.2% : 29.8% 64.1% : 35.9% Oct % 117.4% 70.4% : 29.6% 65.2% : 34.8% Nov % 122.9% 70.6% : 29.4% 64.4% : 35.6% Dec % 117.3% 70.5% : 29.5% 65.5% : 34.5% Queen Alexandra Hospital NHS Choices These figures do not include ED, Day Units, or Flexible/Unfunded Capacity Queen Alexandra Hospital % % Planned vs Actual Staff Hours (Night) Registered Nurse Healthcare Support Worker P A % P A % % %

60 Portsmouth Hospitals NHS Trust QAH Hospital Page 60 Appraisal and Essential Skills Compliance Well Led Appraisal and EST Where we want to be: targets and benchmarks Target: The compliance target for Appraisals is 85% Trends and Patterns Appraisal compliance decreased to 83.3% in December and is below the 85% target. Root Cause analysis and insights As of December, the 85% appraisal target has not been met by; Clinical Support, CHAT, Emergency, Head and Neck, Medicine, Renal and Surgery and Cancer CSCs. This is the same CSCs as reported last month. Actions and progress to date A targeted approach to address appraisal compliance has been adopted, which involves contacting the staff and managers of those who s appraisal was most out of date. This approach has continued throughout December. Where we want to be: targets and benchmarks Target: the compliance target for Essential skills is 85% (Target for Information Governance is 95%) Trends and Patterns Total essential skills increased in December from 84.6% to 85.9 and currently records above the 85% target. There has been a increase in month in essential skills across all CSCs in December. Root Cause analysis and insights All CSCs are above target of 85% in December. Overall Safeguarding Children compliance has increased to 84.8% and is slightly below the 85% target. Level 2 has increased to 88.5% and is above the 85% target. Level 3 continues to be below target and increased to 65.8% in December. Fire Safety (face to face training) increased by 1.3% to 70.8% in December. Information Governance Training has increased by 0.6% to 93.4% for December and remains below the 95% target. Actions and progress to date The L&D team are highlighting staff who are out of date with 3 or more essential skills. Chiefs of Service are being provided with regular information on Medical and Dental compliance to help meet the requirements of the CQC Action Plan. Appraisals and Essential Skills Compliance and in month change TARGET Appraisals 85% Essential Skills 85% CHAT CSC 76.4% 86.4% Clinical Support CSC 85.2% 90.8% Emergency CSC 74.5% 81.5% Head & Neck CSC 79.9% 80.4% Medicine CSC 74.6% 80.8% MOPRS CSC 88.2% 87.1% Musculo-skeletal CSC 90.1% 85.7% Renal CSC 83.5% 88.6% Surgery & Cancer CSC 83.9% 83.4% Women & Children CSC 87.2% 87.7% Corporate Functions 93.0% 87.4% Total Trust 83.3% 85.9%