INTEGRATED PERFORMANCE REPORT

APPENDIX 1 INTEGRATED PERFORMANCE REPORT BOARD OF DIRECTORS 17 FEBRUARY 2016 1

Contents Section Page Executive Summary 3 Trust Performance Overview 7 Trust Performance Report by Exception 9 MSSA bacteraemia - Actual numbers 9 C Diff Actual numbers 9 Incidents - Incidents not approved after 35 days 10 Average Length of Stay (by discharges) - Average LoS Non Elective 10 Sickness Absence - All days LoS as a percentage of those available 11 Appraisals - Completed appraisals last year 11 Mandatory Training Overall percentage of completed mandatory training 12 Efficiency - Variance from plan 12 Ambulance Turnaround - Time taken for ambulance handover of patient 15 & 30 minutes 13 18 week waits referral to treatment time Percentage of admitted patients treated within 18 weeks 13 52 week waits Actual numbers 14 6 week diagnostic waiting Percentage of patients seen within 6 weeks 14 Cancelled Outpatient Appointments - Percentage of outpatient appointments cancelled by hospital 15 Cancelled Outpatient Appointments - Percentage of outpatient appointments cancelled by patient 15 DNA rate Percentage of new out-patient appointments where patients DNA 16 DNA rate Percentage of follow-up out-patient appointments where patients DNA 16 Cancer Waits - 62 days from referral to treatment (GP referral) 17 Choose & Book Utilisation - Percentage appointments booked through C&B 17 New out-patient attendances - Variance from contract schedules 18 Follow-up out-patient attendances - Variance from contract schedules 18 A & E attendances - Variance from contract schedules 19 FFT Response Rates Increased response rate for A&E 19 Directorate Dashboards 20 Deep Dive 23 2

EXECUTIVE SUMMARY REPORT TO THE BOARD OF DIRECTORS Subject: Integrated Performance Report Supporting Directors: Kirsten Major, Director of Strategy & Operations; Neil Priestley, Director of Finance; Hilary Chapman, Chief Nurse; Mark Gwilliam, Director of Human Resources & OD; David Throssell, Medical Director. Author(s): Paul Buckley, Deputy Director of Strategy & Planning; Balbir Bhogal, Director of Information and Performance; Annette Peck, Head of Information. Status (see footnote): A PURPOSE OF THE REPORT To provide the Board with a detailed assessment of the performance against the agreed indicators and measures. The report describes the specific actions that are under way to deliver the required standards. Following the discussion at the Board of Directors meeting in January, TEG is considering how to incorporate the patient voice into future deep dive reports within the IPR. RECOMMENDATIONS The Board is asked to: a) Receive the Integrated Performance Report for December 2015. b) Be assured that where performance standards are not currently met, a detailed analysis has been undertaken and actions are in place to ensure an improvement is made. IMPLICATIONS APPROVAL PROCESS STH Strategic Aims Tick as appropriate Meeting Trust Executive Group Finance, Performance & Workforce Committee Board of Directors 1 Deliver the best clinical outcomes Approved Y/N Y Y 2 Provide patient centred services Date 10 February 2016 8 February 2016 17 February 2016 3 Employ caring and cared for staff 4 Spend public money wisely 5 Deliver excellent research, education & innovation A = Approval; A* = Approval & Requiring Board Approval; D = Debate; N = Note. 3

Executive Summary Deliver The Best Clinical Outcomes There have been 0 cases of Trust assigned MRSA bacteraemia recorded for the month of December. The year to date total remains nil. There were 6 Trust attributable cases of MSSA bacteraemia recorded, which is worse than the monthly trajectory that the Trust has set itself. The year to date performance is 47 cases of MSSA against an internal threshold of 32 cases. The Trust recorded 11 cases of C.diff for December. This is worse than the monthly target of 7.25 cases. The year to date performance is 53 cases against an internal threshold of 59 cases and a Monitor threshold of 65. Safer staffing overall, the actual fill rate for day shifts for registered nurses was 93.1% and for other care staff against the planned levels was 99.3%. At night these fill rates were 92.0% for registered nurses and 104.7% for other care staff. On a number of individual wards the fill rate fell below 85%. In addition to vacant nursing posts in December, for this group of staff sick leave was 3.3% above the planned level of 4% at 7.3% and parenting leave was 1.1% above planned levels of 2% at 3.1%. Average length of stay for non-elective spells remains above the Dr Foster benchmark. The numbers of incidents not approved within the 35 day target remains above the required standard. Employ Caring & Cared For Staff Sickness absence in December was 4.91% against a target of 4%. The year to date figure as at end of December was 4.5% compared with 4.35% for the same period the preceding year. These figures can be split as follows: Long term 2.86% (YTD) and short term 1.64% (YTD). There were 2940 episodes of sickness absence during December of which 591 were for more than 28 days and 85 for 6 months and longer. All directorates which are above the Trust target of 4% have developed their own action plans and are continuously reviewed. The HR Business Partners are working with directorates to ensure that anyone who has been off sick for more than 3 months has an individual action plan thereby ensuring that all long term sickness cases are closely monitored. The Working Together Programme partners have agreed to enter into a procurement process for an absence management system. The Trust is involved in the national Healthy NHS Workforce programme launched by Simon Stevens and a bid has been submitted to introduce health assessments for staff over the age of 40. A review of the current Managing Attendance Policy will commence shortly. The Trust saw a slight rise in the number of appraisals which have been carried out in the preceding 12 month period with the rate at the end of December standing at 89.8%, just failing to meet the target of 90%. There continues to be steady progress in compliance levels for mandatory training with the figure of 88.1% as at the end of December. Monthly summits chaired by the Chief Executive continue to take place with regard to both appraisals and mandatory training. Notifications to line managers and individual members of staff flagging expiry dates have commenced. The Trust is now offering flu vaccinations to all staff. We continue to monitor the uptake for front line staff and submit these figures to Public Health England. We are currently reporting an uptake of 49%. 4

Spend Public Money Wisely The month 9 position shows a 3,642.5k (0.5%) deficit against plan. Whilst the position against operating budgets has continued to decline, the release of unplanned savings on capital charges and T3 costs (project and recurrent) has resulted in an overall improvement from month 8. The major activity under-performance has continued to grow and now stands at 11.9m. This is a deterioration of 1.4m in December. The under-performance remains largely in respect of elective activity, out-patients, critical care and a larger than expected deduction for emergency readmissions within 30 days. There are still data issues following the implementation of the new Lorenzo PAS towards the end of September which are creating challenges in reporting complete and accurate income figures. However, it is clear that the bigger issue is the operational impact of the new system on booking and scheduling processes, particularly in out-patient services. There was an overall pay overspend of 1.7m (0.4%) in the first 9 months of the year. This continues to reduce but within this the medical staffing pressures continue to grow ( 5.3m overspend). The focus on reducing bank and agency staffing costs (usage and rates) continues. There was a 4.4m under delivery against efficiency plans at month 9. Overall, Clinical Directorates reported positions 17m worse than their plans. Given the very difficult national position, all providers are under great pressure to deliver their 2015/16 financial plans and deliver the best possible position in the last quarter of the year. The key risks for the year remain delivery of activity/efficiency/financial plans, particularly with the consequences of the Lorenzo implementation, Junior Doctor industrial action and winter; contractual issues relating to challenges, performance penalties and delivery of the Local Quality Incentive Schemes; and service/cost pressures. There are no issues of concern at this stage in respect of the working capital position, balance sheet or capital programme. There has been some progress with the level of overdue debts owed by local foundation trusts where there are financial difficulties. Discussions with the trusts continue. The position at the end of month 9 remains of concern. Action is being pursued to improve the delivery of activity, efficiency and financial plans and to mitigate risks and maximise contingencies. Resolving the issues following the Lorenzo implementation and getting activity back to normal levels is critical. Every effort must be made to deliver the Trust s 2015/16 financial plan and to create a more stable platform with which to enter 2016/17. Provide Patient Centred Services New outpatient activity was 12.4% below target in December and is 3.1% below target for the year to date. Follow up activity was 14.6% below target in December and is 5.7% below for the year to date. The level of elective inpatient activity was 3.7% below target in December and is 2.3% below for the year to date. Non elective activity was 1.0% below target in December and was 0.2% below for the year to date. Accident and Emergency activity was 10.8% below target in December and is 1.1% below for the year to date. The data on patients whose discharge from hospital was delayed for non-clinical reasons is currently unavailable. It is anticipated that this report will be generated from Lorenzo in the near future. The number of patients on incomplete pathways rose from 47,836 at the end of November to 50,483 at the end of December. 92.8% of these had a waiting time of less than 18 weeks. There was one patient who waited more than 52 weeks for treatment. The referral had been received from another hospital when the patient had already waited 50 weeks. The patient pathway was closed in January. The percentage of patients referred through the e-referrals service continues to increase and is now at 39.7%. The number of elective operations cancelled on the day for non clinical reasons has fallen below target in December. The 18 week referral to treatment time target for admitted patients was not met at 87.3% compared to the target of 90% but has increased for the first time since July 2015. The cancer target for 62 days from GP referral to treatment is not yet being met for Q3 but data is still being entered and validated. 5

Provide Patient Centred Services - continued The target for diagnostic waits was not met in December as it was 93.97% compared to the target of 99.0% The handover time for ambulance patients arriving at Accident & Emergency continues to be below target but is improving. The DNA rates for both new and follow-up outpatient attendances remain above the national benchmark. The cancellation rate for outpatient attendances by the hospital and the patient remains above the national benchmark. The data on the percentage of patients waiting more than 4 hours in Accident & Emergency is not available for December. Complaints 89% of complaints were responded to within 25 working days. FFT response rates inpatient the response rate in December was 30% which is the same as the internal target of 30%. FFT response rates A&E the response rate in December was 18.9% which is below the internal target of 20%. Deliver Excellent Research, Education & Innovation Performance for 2015/16 for recruitment to trials is on target, as demonstrated by both the total number of patient accruals to portfolio studies and the percentage of clinical trials meeting the NIHR 70 day benchmark, which is used nationally as an indicator of efficient study setup. The number of patient accruals to portfolio adopted grant and commercial studies for 2015/16 Q3 was 1,948. This was 91% of our Yorkshire and Humber Clinical Research Network Q3 target of 2,150, with the Trust remaining one of the networks top performers. Performance over the three quarters is 105% against our Yorkshire and Humber Clinical Research Network YTD target of 6,450. Performance for clinical trials meeting the NIHR 70 day benchmark (from receipt of a Valid Research Application to Recruitment of First Eligible Patient) for 2015/16 Q1 was 96%. This is significantly above the NIHR national target of 80%. STH continues to maintain research performance as a result of several factors including shortened R&D setup times and active recruitment by researchers. 6

Trust Performance Overview Indicator Measure Standard Target Type Current Data Month CQC Compliance Number of high risk indicators Actual (increase or decrease) National December H CQC Compliance Priority banding for inspection Category 5 or 6 by CQC National December H Monitor Compliance Continuity of Services Risk Rating Category 3 or 4 National Q2 15/16 H Monitor Governance Rating Compliance with Monitor defined targets Green/Amber or better National Q2 15/16 H Deliver The Best Clinical Outcomes Hospital Mortality HSMR As expected or lower Local Aug 14-July 15 H Hospital Mortality SHMI As expected or lower Local Apr14 - Mar15 H MRSA bacteraemia Actual numbers Zero cases Local December 0.00 0 H MSSA bacteraemia Actual numbers Max 3.5 case a month Local December 6 47 H C Diff Actual numbers 7.25 cases or less per month National December 11 53 H Serious Untoward Incidents Number of serious untoward incidents (SUI) Number Local December 0 24 Serious Untoward Incidents Approved SUI Report submitted within timescales No overdue reports Local December 0 Incidents Increase in incident reporting levels Monthly increases in reporting Local December 8.29% H Incidents Incidents not approved after 35 days Zero Local December 1025 Average Length of Stay (by discharges) Average LOS Elective 4.14 days (Dr Foster) Local Nov 14 to Oct 15-0.42 Average LOS Non Elective 5.31 days (Dr Foster) Local Nov 14 to Oct 15 0.14 Staff Friends & Family Recommend as a place to be treated National Average Local Q1 15/16 89.00% Patient Falls Number of patient falls 331 (5% reduction from 14/15) Local December 275 2422 H Never Events Number of never events Zero National December 0 2 H Employ Caring & Cared for Staff Sickness Absence All days lost as a percentage of those available 4.00% Local December 4.91% 4.50% M Appraisals Completed appraisals in last year 90% Local December 89.82% M Mandatory Training Overall percentage of completed mandatory training 90% Local December 88.07% M Safer Staffing Percentage of planned shifts worked by Registered Nurses/midwives during the day 85% of planned hours or greater worked Local December 93.10% M Percentage of planned shifts worked by Registered Nurses/midwives during the night 85% of planned hours or greater worked Local December 92.00% M Percentage of planned shifts worked by Clinical Support Workers during the day 85% of planned hours or greater worked Local December 99.30% M Percentage of planned shifts worked by Clinical Support Workers during the night 85% of planned hours or greater worked Local December 104.70% M Staff Friends & Family Recommend as a place to work National Average Local Q1 15/16 69.23% Agency spend Agency and bank spend as a percentage of total pay budget 8% Local December 6.32% M Spend Public Money Wisely I & E Variance from plan On plan Local December 1.30% H Contract performance Variance from plan On plan Local December -1.69% H Efficiency Variance from plan On plan Local December -24.26% M Cash Actual Above profile Local December H Capital expenditure Variance from plan On plan Local Q2 15/16 106.30% H Month Actual YTD Trend Data Quality 7

Trust Performance Overview Provide Patient Centred Services A&E 4-hour wait Patients seen within 4 hours 95% National September 94.1% L >12 hr Trolley waits in A&E No. of patients waiting > 12 hours Zero National December 0 0 H Ambulance turnaround Time taken for ambulance handover of patient 100% within 15 minutes National December 63.96% 69.40% H Ambulance turnaround Time taken for ambulance handover of patient 0% in excess of 30 minutes National December 3.43% 0.45% H 18 week waits referral to treatment time Percentage of admitted patients treated within 18 weeks 90% National December 87.30% M Percentage of non-admitted patients treated within 18 weeks 95% National December 96.30% M Percentage of patients on incomplete pathways waiting less than 18 weeks 92% National December 92.80% M 52 week waits Actual numbers Zero National December 1 12 M 6 week diagnostic waiting Percentage of patients seen within 6 weeks 99% National December 93.97% M Cancelled Operations Cancelled Outpatient appointments DNA rate Cancer Waits Number of operations cancelled on the day for non clinical reasons 75 per month Local December 755 H Number of patients cancelled on the day and not readmitted within 28 days Zero Local December 9 H Percentage of out-patient appointments cancelled by hospital 6.1% (Nat aver 13/14) Local December 9.38% 9.82% H Percentage of out-patient appointments cancelled by patient 6.0%(Nat aver 13/14) Local December 8.91% 10.86% H Percentage of new out-patient appointments where patients DNA 7.0% (Nat aver 13/14) Local December 7.90% 7.15% H Percentage of follow-up out-patient appointments where patients DNA 7.0% (Nat aver 13/14) Local December 8.31% 7.03% H Patient seen within 2 weeks 93% National Q3 as at 11/01/201 94.10% H Breast symptomatic seen within 2 weeks 93% National Q3 as at 11/01/201 97.10% H 62 days from referral to treatment (GP referral) 85% National Q3 as at 11/01/201 79.20% H 31 day first treatment 96% National Q3 as at 11/01/201 97.40% H 31 day subsequent treatment (Surgery) 94% National Q3 as at 11/01/201 96.40% H 31 day subsequent treatment (Radiotherapy) 94% National Q3 as at 11/01/201 98.60% 31 day subsequent treatment (Drugs) 98% National Q3 as at 11/01/201 100.00% Choose & Book Utilisation Percentage appointments booked through C&B 50% Local December 39.66% 29.43% Ethnic Origin data collection % valid ethnic group 85% National December 92.36% 94.14% H Elective Inpatient activity Variance from contract schedules On plan Local December -3.70% -2.30% H Non elective inpatient activity Variance from contract schedules On plan Local December -1.00% -0.20% H New outpatient attendances Variance from contract schedules On plan Local December -12.40% -3.10% H Follow up op attendances Variance from contract schedules On plan Local December -14.60% -5.70% H A&E attendances Variance from contract schedules On plan Local December -10.81% -1.15% H Complaints Percentage of complaints answered within 25 working days 85% answered within 25 days Local December 89.31% 82.98% M FFT Response Rates Increased response rates for inpatient areas 30% National December 29.90% M FFT Recommended Patients recommending STH for treatment 95% Local December 95.83% FFT Response Rates Increased response rates for A&E 20% National December 18.90% M Community care information completeness RTT information completeness 50% National Q2 15/16 Referral information completeness 50% National Q2 15/16 Activity information completeness 50% National Q2 15/16 Day surgery rates BADS - day surgery rates 88% Local December 88.00% 89% M Mixed Sex Accommodation Number of breaches of Mixed Sex Accommodation standard Zero National December 0 0 Deliver Excellent Research, Education & Innovation Recruitment to trials Annually Reported Indicators Total number of patient accruals to portfolio studies 7977 Regional -Y&H Q2 15/16 70 Day Benchmark for recruitment of first patient to a clinical trial 80% National Q1 15/16 Safety Thermometer Harm free 95% harm free National 2014 75% Quality recommendation % staff who would recommend STH to a friend / relative for treatment 67% National 2014 0.78 M Work recommendation % staff who would recommend STH as a place to work 61% National 2014 0.70 M Staff Engagement Staff engagement score 3.69 weighted National 2014 3.81 8

Trust Performance Report by Exception Deliver The Best Clinical Outcomes Deliver The Best Clinical Outcomes MSSA Bacteraemia Actual Numbers During December the Trust did not meet its monthly target for MSSA, recording 6 cases against a target of 3.5. In line with the rest of the country, the Trust has had more cases than this time last year. Analysis of the data has not identified any clusters or patterns of infections in either individual clinical areas or by source of infection (i.e. intravenous lines, post-surgical infections etc.). The action report last month of contacting the two best Trusts to look at their practice is underway. Also, we are looking at the care of intravenous cannulas on some of the Firth wards to see whether there are improvements that can be made and implemented across the Trust. April Hilary Chapman, Chief Nurse C Diff Actual Numbers During December, the Trust did not meet its monthly target for C.diff, recording 11 cases against a target of 6.5. This is only the second month this year that we have had more cases than the Trust monthly target. For the YTD the Trust is 6 cases below its internal target and 12 cases below its Monitor target. Compared to this time last year the Trust has had 20 fewer cases which equates to a 27% reduction. Whilst both campuses have had 10 fewer cases this equates to a nearly 50% reduction at the central campus. The significant reduction in cases at the central campus may be due to the consistent delivery of the Deep Clean Programme. Therefore, there will be a focus on trying to achieve a greater number of deep cleans at the Northern General Hospital during Quarter 4. April Hilary Chapman, Chief Nurse 9

Trust Performance Report by Exception Deliver The Best Clinical Outcomes Deliver The Best Clinical Outcomes Incidents - Incidents not approved after 35 days There has been a slight worsening of the position across all directorates in December and it is anticipated that this was due to the CQC visit. Monthly updates on the numbers of incidents and those requiring approval beyond the target have been provided to all Risk s for the last 6 months. Developments are also being implemented to ensure that incidents are reviewed as speedily as possible to front load the process. Weekly updates are to be provided from January onwards to enable improvements (or any deterioration in the position) to be recognised as early as possible. Average LOS (by discharges) Average LOS Non Elective The average length of stay for non-elective remains above the Dr. Foster benchmark and is based on the period November 14 to October 15. Further embedding of changes around the AMU and emergency pathway; Ongoing focus on increasing ambulatory work in a range of specialties, supported by Service Improvement. 12 wards have participated in the MCA Ward Collaborative and have made a number of improvements to their processes to be shared at an event in March. The Chief Operating Officer is planning a programme of work to embed the emergency care pathway changes and other improvements within the Trust. March April David Throssell, Medical Director Kirsten Major, Director of Strategy & Operations 10

Trust Performance Report by Exception Employ Caring & Cared for Staff Employ Caring & Cared for Staff Sickness Absence All days LoS as a percentage of those available The monthly sickness absence figure for December is 4.91% with a year to date figure of 4.5%. This is compared to 4.35% for the same period last year. 20 directorates continue to be above the target of 4%. An update to the action plan has been recently shared with TEG. All directorates which are above the Trust target of 4% have developed their own action plans which are continuously reviewed. HR Business Partners are working with directorates to develop individual action plans for all those staff who have been off sick for more than 3 months. March Appraisals - Completed appraisals in last year The cumulative position for completed appraisals during the past twelve months at the end of December is 89.8%, which was just short of the target of 90%. Monthly summits continue to be held with members of the Operational Board and their representatives led by the Chief Executive. As a number of directorates are struggling to achieve the target a focussed approach continues to be undertaken with those directorates to explore how they might improve compliance rates. March Mark Gwilliam, Director of Human Resources & OD Mark Gwilliam, Director of Human Resources & OD 11

Trust Performance Report by Exception Employ Caring & Cared for Staff Spend Public Money Wisely Mandatory Training Overall percentage of completed mandatory training There continues to be a steady increase in compliance with the rate at the end of December being 88.1%. Whilst the Trust met the quarter 1 target of 70% we continue to make progress towards the next target of 90%. Monthly Chief Executive-led summits continue to be held with members of the Operational Board and their representatives resulting in steady progress being made towards the target. Central mandatory training sessions have been arranged in order to make the training more readily available. In addition, topic rolling programmes are being trialled. Clinical areas continue to make use of their clinical educators in delivering this training locally. March Mark Gwilliam, Director of Human Resources & OD Efficiency - Variance from plan Directorates have underperformed significantly at M9, with a deficit position of 4.4m or 22% behind plan. A number of strategic discussions have been held to consider how we can increase our transformation efforts and delivery of efficiency for 2016/17. A refreshed transformation programme framework has been developed capturing 8 priority work streams for the Trust. The programme will require significant leadership efforts to inspire and engage the organisation in this approach. Regular month on month performance management of directorates with financial challenges continues, with a particular focus on improving activity delivery. March Neil Priestley, Director of Finance 12

Trust Performance Report by Exception Provide Patient Centred Services Provide Patient Centred Services Ambulance Turnaround - Time taken for ambulance handover of patient - 15 & 30 minutes The percentage of 999 arrivals clinically handed over within 15 minutes rose considerably in December from 56.97% to 63.69%. Clinical handovers taking more than 30 minutes also significantly reduced to 132. The latter delays can be linked to crowding in the Emergency Department and inability to create trolley space for new arrivals. Continued audit and challenge of C3 data for all clinical handovers in excess of 30 minutes to ensure data is robust. Wider work on flow both within the Emergency Department and on the admitting units will link into creating capacity for prompt handover. Re-focus on clinical handover times by utilising the Trust pin. Move towards a nurse-led ambulance triage service from April 2016. May 18 week waits RTT - Percentage of admitted patients treated within 18 weeks The Trust did not meet the target for admitted pathways in December. The position improved for the first time since July from 86.4% to 87.3%. Recovery plans are in place to deliver the target from March onwards. Where capacity constraints exist, services have been securing the additional capacity from the Independent Sector. Opportunities to manage demand are being explored with the CCG through the CASES model. March Kirsten Major, Director of Strategy & Operations Kirsten Major, Director of Strategy & Operations 13

Trust Performance Report by Exception Provide Patient Centred Services Provide Patient Centred Services 52 week waits Actual numbers There was one patient in Neurology who had waited more than 52 weeks for treatment at the end of December. The patient was referred from another hospital in December after they had waited for 50 weeks. The Trust was unable to contact the patient either by letter or telephone or through their GP. Two outpatient appointments were sent to them but they failed to attend. Their GP was contacted after both DNAs. The patient has now been discharged back to the care of their GP and so the clock was stopped in January. January 6 week diagnostic waiting - Percentage of patients seen within 6 weeks The Trust did not meet the target for diagnostic waits in December. The position deteriorated from 96.05% to 93.97%. The deterioration was most significant in Neurophysiology and Sleep Studies. The position improved in Gastroscopy and Flexi sigmoidoscopy. As reported last month work is underway to ensure that the data reported is robust and establish an in-month monitoring process. Plans are in place to recover the position but in some cases are dependent on staff recruitment. March Kirsten Major, Director of Strategy & Operations Kirsten Major, Director of Strategy & Operations 14

Trust Performance Report by Exception Provide Patient Centred Services Provide Patient Centred Services Cancelled Outpatient Appointments % of out-patient appointments cancelled by hospital The percentage of outpatient appointments cancelled by the hospital remains above the target and at a similar level to the previous month. A more detailed piece of work is underway to look at the reasons for the cancellations and the time between the cancellation and the scheduled appointment date. April Kirsten Major, Director of Strategy & Operations Cancelled Outpatient Appointments - % of out-patient appointments cancelled by patient The percentage of outpatient appointments cancelled by the patient remains above the target and is slightly higher than in the previous month. A more detailed piece of work is underway to look at the reasons for the cancellations, the demographics of the patients that cancel, the variation and the time between the cancellation and the scheduled appointment date. April Kirsten Major, Director of Strategy & Operations 15

Trust Performance Report by Exception Provide Patient Centred Services Provide Patient Centred Services DNA rate - Percentage of new out-patient appointments where patients DNA Since the implementation of Lorenzo the Trust has seen a rise in DNA rates for outpatient appointments. An analysis of the issues has shown that for some patients the DNA status was recorded incorrectly. In some cases, patients had not received an appointment letter. A number of patients had contacted the hospital via the text reminder service but this had not been actioned with the patient subsequently being recorded as a DNA. There were a proportion of patients that were inpatients at the time of their outpatient appointment. The Operational Change Managers continue to work with directorates to understand the reasons for DNA and actions required to improve. Work is underway with CSC to consider the improvements that can be made to help speed up the booking process. March DNA rate - Percentage of follow-up out-patient appointments where patients DNA Since the implementation of Lorenzo the Trust has seen a rise in DNA rates for outpatient appointments. An analysis of the issues has shown that for some patients the DNA status was recorded incorrectly. In some cases, patients had not received an appointment letter. A number of patients had contacted the hospital via the text reminder service but this had not been actioned with the patient subsequently being recorded as a DNA. There were a proportion of patients that were inpatients at the time of their outpatient appointment. The Operational Change Managers continue to work with directorates to understand the reasons for DNA and actions required to improve. Work is underway with CSC to consider the improvements that can be made to help speed up the booking process. March Kirsten Major, Director of Strategy & Operations Kirsten Major, Director of Strategy & Operations 16

Trust Performance Report by Exception Provide Patient Centred Services Provide Patient Centred Services Cancer Waits - 62 day referral to treatment (GP referral) The performance for Q3 (as at 25/01/16) is 80% (threshold 85%). The cancer sites that are below the threshold are Head & Neck, Lower GI, Lung, Sarcoma, Upper GI and Urology. Breaches are attributed to Inter Provider Transfers (IPT) received late (day 39 onwards), inadequate capacity and delay to diagnostic test. STHFT performance for non-shared pathways in Q3 to date is 85%. The utilisation of Lorenzo has meant delays to administrative processes affecting pathway management. Cancer waiting times performance is circulated throughout the organisation on a weekly basis for information and action. Lorenzo Cancer Pathway Master Classes commenced in January for administrative staff with the aim of applying the most efficient processes. Plans for the forthcoming 'Blood in Pee' Cancer Awareness Campaign are being finalised. March Choose & Book Utilisation - Percentage appointments booked through C&B The number of appointments booked through the e-referrals service continues to increase and is now at 39.7% compared to 16.3% in December 2014. The education and retraining programmes are continuing both with Trust staff and staff in primary care. The progress on developing a process and timetable for starting to return paper referrals to practices will be discussed with the Service Improvement Director. September Kirsten Major, Director of Strategy & Operations Kirsten Major, Director of Strategy & Operations 17

Trust Performance Report by Exception Provide Patient Centred Services Provide Patient Centred Services New outpatient attendances - Variance from contract schedules New outpatient attendances were 12.4% below target in December and are 3.1% below for the year to date. All the care groups were below target in December apart from MSK. For the year to date the care groups are below target except for Emergency Care, LEGION and MSK. Operations Directors are being held to account on a weekly basis for the number of clinic slots that are booked. The implementation of Lorenzo has meant that some administrative tasks around outpatient booking have been more time consuming. Lorenzo experts are visiting outpatient areas to assess the issues and recommend changes to processes where appropriate. March Kirsten Major, Director of Strategy & Operations Follow up out-patient attendances - Variance from contract schedules Follow up attendances were 14.6% below target in December and are 5.7% below target for the year to date. All the care groups except LEGION were below target in December and for the year to date. Operations Directors are being held to account on a weekly basis for the number of clinic slots that are booked. The implementation of Lorenzo has meant that some administrative tasks around outpatient booking have been more time consuming. Lorenzo experts are visiting outpatient areas to assess the issues and recommend changes to processes where appropriate. March Kirsten Major, Director of Strategy & Operations 18

Trust Performance Report by Exception Provide Patient Centred Services Provide Patient Centred Services A&E Attendances The attendances in A&E in December were 10.81% below target but are only 1.2% below for the year to date. The under performance is across all three departments but is more significant in the main A&E department at Northern General Hospital. The introduction of revised pathways for emergency admissions from GPs and patients returning to the Trust post discharge has reduced the number of attendances at the A&E department as these are now going straight to a more appropriate location The emergency care programme continues to review the pathways within the A&E department to ensure that the patients are seen in the appropriate setting. FFT Response Rates Increased response rates for A&E The Trust failed to achieve the internal response rate target for Friends and Family Test for Accident and Emergency by 1.1%. The response rate from the A&E department at NGH continues to bring the overall response rate total down for A&E. We have discovered that there is an error in the data extract which is sent to Healthcare Communications. The eligible figures don t match those we are reporting through Unify, so not all those patients who should have received a survey have received a survey. Patient Partnership is working with Information Services to address this issue. Despite this, it is important to note that the overall response rate for A&E continues to be above the national average by 5.9%. March March Kirsten Major, Director of Strategy & Operations Hilary Chapman, Chief Nurse 19

Directorate Dashboard Indicator Measure Diab & Endo 8.54% 2.84% 9.64% 5.61% 13.25% 0.00% Integ Prim Emerg Resp Gastro Pharm Comm GSM Care & Med Med Care Int/Serv Therap & Pall Care Oral & Dental ENT Neuro Ophthal MRSA bacteraemia Actual numbers 0 0 0 0 0 0 0 0 0 0 0 0 0 MSSA bacteraemia Actual numbers 1 1 0 0 0 0 1 0 0 0 1 1 0 C Diff Actual numbers 0 0 1 0 0 0 4 0 0 0 0 0 0 Serious Untoward Incidents Approved SUI Report submitted within timescales 0 0 0 0 0 0 0 0 0 0 0 0 Serious Untoward Incidents Number of Serious Untoward Incidents 0 0 0 0 0 0 0 0 0 0 0 0 Incidents Increase in incident reporting levels (increase or decrease from previous month) 1 46 19 4 10 17-1 -2 8 5-15 -1 Incidents Incidents not approved after 35 days 33 157 17 25 36 49 129 17 33 17 38 16 Average Length of Stay (by discharges) Average LOS Elective 1.67-0.80-1.50-0.69-4.00-0.75-0.20-2.24-0.52 Average LOS Non Elective 0.79-2.91 0.96-0.12 3.20-0.87-0.70-0.58-0.40 Patient Falls Number of patient falls 14 12 16 0 17 2 96 7 0 2 21 1 Never Events Number of never events 0 0 0 0 0 0 0 0 0 0 0 0 Sickness Absence All days lost as a percentage of those available 4.21% 4.60% 3.71% 4.80% 5.77% 4.47% 6.90% 5.18% 3.98% 3.19% 4.02% 4.26% Appraisals Completed appraisal in last year 87.20% 85.04% 88.21% 90.79% 76.60% 90.03% 75.88% 96.71% 93.16% 94.19% 92.11% 96.10% Mandatory Training Overall percentage of completed mandatory training 86.18% 73.30% 83.61% 95.26% 85.41% 84.38% 67.50% 89.95% 87.81% 88.44% 87.59% 90.34% Agency spend Agency and bank spend as a percentage of total pay budget 4.85% 15.24% 8.42% 2.69% 7.95% 4.68% 8.53% 2.91% 2.19% 10.80% 2.51% 13.63% I & E Variance from plan 8.54% 2.84% 9.64% 5.61% 4.13% 0.80% 13.25% 3.27% 0.02% 1.25% 5.90% 5.20% Contract performance Variance from plan -0.82% 0.66% -2.01% -55.82% -0.30% -1.98E-05 3.05% -1.70% -0.55% -7.26% -2.42% 1.18% Productivity & Efficiency Variance from plan -13.45% 7.18% -15.43% -6.30% -54.35% -8.91% -41.53% -62.09% -37.04% -27.75% -52.70% -32.30% Percentage of admitted patients treated within 18 weeks (90%) 100.00% 100.00% 87.88% 95.12% 100.00% 91.26% 79.45% 94.55% 86.13% 18 week waits referral to treatment Percentage of non-admitted patients treated within 18 weeks (95%) time 99.28% 89.16% 97.20% 95.00% 97.14% 97.38% 95.34% 94.41% 99.14% Percentage of patients on incomplete pathways waiting less than 18 weeks (92%) 99.51% 87.90% 91.04% 99.00% 97.43% 91.46% 93.23% 89.21% 91.31% 94.67% 52 week waits Actual numbers 0 0 0 0 0 0 0 0 1 0 6 week diagnostic waiting Percentage of patients seen within 6 weeks 91.62% 63.72% 94.55% 55.52% Cancelled Operations Number of operations cancelled on the day for non clinical reasons 43 6 50 7 22 89 Number of patients cancelled on the day and not readmitted within 28 days 0 0 0 0 0 0 0 0 0 0 0 0 Percentage of out-patient appointments cancelled by hospital 8.43% 4.23E-03 21.07% 16.27% 3.97% 16.94% 8.12% 8.62% 7.10% 12.19% 5.32% Cancelled Outpatient appointments Percentage of out-patient appointments cancelled by patient 11.90% 3.45% 11.88% 11.86% 10.91% 13.02% 4.86% 14.45% 12.45% 14.99% 13.28% DNA rate Cancer Waits Percentage of new out-patient appointments where patients DNA 11.65% 1.80% 10.90% 8.47% 9.84% 11.40% 2.52% 10.02% 5.41% 8.71% 5.60% Percentage of follow-up out-patient appointments where patients DNA 11.11% 12.12% 9.64% 9.75% 7.36% 9.97% 2.65% 10.97% 5.05% 8.92% 5.08% Patient seen within 2 weeks (93% compliance) Breast symptomatic seen within 2 weeks (93% compliance) 62 days from referral to treatment (85% compliance) 31 day first treatment (96% compliance) Choose & Book Utilisation Percentage appointments booked through C&B 25.00% 42.11% 33.87% 35.38% 25.00% 0.00% 1.75% 71.43% 39.30% 28.20% Ethnic Origin data collection % valid ethnic group (85%) 96.45% 92.77% 92.21% 96.40% 95.46% 100.00% 92.82% 91.90% 90.88% 90.10% Elective Inpatient activity Variance from contract schedules -13.48% 3.83% 3.60% -23.08% 1.02% -16.55% -6.67% -1.86% Non elective inpatient activity Variance from contract schedules -3.44% -12.23% -4.30% -6.51% 5.70% -4.97% 23.34% -0.81% -30.77% New outpatient attendances Variance from contract schedules 8.50% 7.02% -13.12% -3.12% -3.29% -14.11% -36.32% -9.50% -11.46% -9.37% -9.45% Follow up op attendances Variance from contract schedules -8.21% 351.85% -21.06% -1.12% -0.25% -8.35% -12.00% 6.02% -20.94% -0.87% 0.99% Complaints Percentage of complaints answered within 25 working days 100% 76% 80% 100% 100% 88% 100% 100% 100% FFT Response Rates Increased response rates for inpatient areas 15.49% 38.25% 33.78% 40.05% 41.79% 38.45% FFT Recommended Patients recommending STH for treatment 97.83% 94.53% 95.32% 98.33% 96.53% 95.75% 98.47% FFT Response Rates Increased response rates for A&E 18.90% Day surgery rates BADS - day surgery rates 100.00% 123.08% 87.50% 95.30% 114.44% 77.50% 95.49% Mixed Sex Accommodation Number of breaches of Mixed Sex Accommodation standard 0 0 0 0 0 0 0 0 0 0 0 0 Performance is YTD unless specified: Last complete month Rolling 12 months Current quarter to date Directorates in Special Measures 20

Directorate Dashboard Indicator Measure Lab Med MIMP OGN MSK OSSCA Cardiac Renal Vasc Comm Dis & Spec Spec Rehab Spec Cancer Gen Surg Plastic Surg MRSA bacteraemia Actual numbers 0 0 0 0 0 0 0 0 0 0 0 0 0 0 MSSA bacteraemia Actual numbers 0 0 0 0 0 1 0 0 0 0 0 0 0 0 C Diff Actual numbers 0 0 0 1 0 0 2 0 0 0 1 1 0 1 Serious Untoward Incidents Approved SUI Report submitted within timescales 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Serious Untoward Incidents Number of Serious Untoward Incidents 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Incidents Increase in incident reporting levels (increase or decrease from previous month) 56-2 5-6 -17 32 6 2-9 13-5 11 0 4 Incidents Incidents not approved after 35 days 21 10 28 76 52 46 9 12 46 12 30 45 7 22 Average Length of Stay (by discharges) Average LOS Elective -0.61-0.18 0.50-2.70-1.00 3.54 4.20-1.42 0.85-0.58-0.40 Average LOS Non Elective -0.04-0.04 0.64 1.60-1.40 1.55 66.40-2.33-0.12-0.55-1.60 Patient Falls Number of patient falls 0 1 1 20 0 11 9 12 7.00 3.00 9.00 9 3 2 Never Events Number of never events 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Sickness Absence All days lost as a percentage of those available 3.69% 2.77% 5.24% 4.69% 6.04% 5.81% 3.89% 2.20% 5.41% 8.00% 3.72% 4.95% 3.57% 4.73% Appraisals Completed appraisal in last year 91.50% 94.19% 84.63% 88.79% 90.92% 93.23% 92.47% 92.21% 83.33% 88.57% 91.58% 90.83% 89.81% 86.96% Mandatory Training Overall percentage of completed mandatory training 96.36% 93.49% 76.92% 91.15% 83.97% 87.47% 93.16% 88.81% 90.85% 86.00% 92.79% 91.26% 91.34% 91.68% Agency spend Agency and bank spend as a percentage of total pay budget 0.74% 3.99% 1.28% 7.20% 7.26% 6.40% 1.16% 6.55% 4.01% 10.78% 5.54% 4.27% 3.31% 3.20% I & E Variance from plan 0.73% 3.98% 6.63% 3.77% 7.47% 9.59% 1.50% 4.09% -7.71% 2.39% 4.01% 1.68% -0.18% 6.47% Contract performance Variance from plan -2.95% -3.25% -1.13% -5.39% -65.93% -0.09% -0.68% -2.37% 0.07% 0.21% 0.45% -0.68% -1.38% -0.95% Productivity & Efficiency Variance from plan -18.54% -50.32% -76.24% 5.62% -28.89% 35.29% -34.69% -32.55% -0.85% -29.87% -22.44% -23.61% -36.87% -44.60% Percentage of admitted patients treated within 18 weeks (90%) 93.47% 84.15% 81.85% 100.00% 91.43% 98.25% 100.00% 100.00% 80.89% 86.57% 84.34% 18 week waits referral to treatment Percentage of non-admitted patients treated within 18 weeks (95%) time 95.00% 98.13% 95.41% 88.13% 100.00% 96.18% 96.59% 94.44% 100.00% 91.45% 97.93% 95.23% Percentage of patients on incomplete pathways waiting less than 18 weeks (92%) 75.79% 95.29% 90.48% 100.00% 84.78% 96.98% 90.43% 94.89% 89.61% 99.09% 89.89% 89.13% 94.59% 52 week waits Actual numbers 0 0 0 0 0 0 0 0 0 0 0 6 week diagnostic waiting Percentage of patients seen within 6 weeks 100.00% 99.98% 99.62% 100.00% 81% 95.95% Cancelled Operations Number of operations cancelled on the day for non clinical reasons 26 92 183 8 12 3 4 82 42 86 Number of patients cancelled on the day and not readmitted within 28 days 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Percentage of out-patient appointments cancelled by hospital 6.88% 16.34% 9.04% 9.31% 11.04% 10.06% 11.05% 10.39% 10.12% 11.97% 6.52% 11.12% Cancelled Outpatient appointments Percentage of out-patient appointments cancelled by patient 7.44% 12.85% 16.70% 11.28% 9.92% 9.47% 9.50% 13.17% 4.87% 12.88% 11.28% 12.15% DNA rate Cancer Waits Percentage of new out-patient appointments where patients DNA 6.94% 7.54% 11.91% 7.67% 11.11% 4.73% 9.76% 14.02% 6.16% 8.84% 4.88% 9.95% Percentage of follow-up out-patient appointments where patients DNA 3.37% 8.51% 9.51% 7.23% 10.61% 4.89% 6.79% 6.09% 5.56% 6.87% 7.13% 6.79% Patient seen within 2 weeks (93% compliance) Breast symptomatic seen within 2 weeks (93% compliance) 62 days from referral to treatment (85% compliance) 31 day first treatment (96% compliance) Choose & Book Utilisation Percentage appointments booked through C&B 23.52% 42.50% 31.72% 26.76% 53.10% 62.04% 0.00% 0.00% 38.30% 49.74% 53.90% Ethnic Origin data collection % valid ethnic group (85%) 95.31% 92.32% 85.36% 97.67% 95.62% 93.29% 79.76% 85.60% 94.51% 93.54% 93.52% Elective Inpatient activity Variance from contract schedules -1.34% -14.07% -2.12% -10.87% -3.12% 4.13% 5.91% -16.69% -11.57% -9.07% Non elective inpatient activity Variance from contract schedules -100.00% 6.81% -5.28% 3.07% -11.17% -2.16% -10.32% 0.01% -2.75% 8.31% 2.05% New outpatient attendances Variance from contract schedules 19.37% 4.26% 0.72% -88.92% -5.17% -11.58% 1.92% -2.51% 11.47% 9.08% -7.81% 0.88% -2.16% Follow up op attendances Variance from contract schedules -41.11% 2.08% -11.26% 2.98% -4.55% -12.58% -13.44% -18.74% 0.68% -16.83% -4.70% -10.05% Complaints Percentage of complaints answered within 25 working days 83% 93% 100% 86% 100% 67% 100% 100% 83% 100% 100% FFT Response Rates Increased response rates for inpatient areas 27.14% 0.4465753 0.297593 30.06% 34.44% 14.19% 18.86% 18.53% FFT Recommended Patients recommending STH for treatment 98.38% 0.9450172 0.9846051 97.11% 97.48% 97.42% 91.14% 98.47% 90.49% FFT Response Rates Increased response rates for A&E Day surgery rates BADS - day surgery rates 104.29% 90.11% 100.00% 86.86% 88.53% 89.50% 99.18% 28.36% 100.00% 82.57% 95.13% 97.77% Mixed Sex Accommodation Number of breaches of Mixed Sex Accommodation standard 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Urology Performance is YTD unless specified: Last complete month Rolling 12 months Current quarter to date Directorates in Special Measures Deep Dive Average Length of Stay for Non Elective Spells 21

1. Introduction As part of the Trust s Service Improvement Programme there is a dedicated workstream looking at the length of stay (LOS) for non elective spells with the aim of reducing the length of stay for these patients. Whilst all specialties are working to reduce their LOS the main focus is on Geriatric and Stroke Medicine, Respiratory Medicine, Gastroenterology & Hepatology, Endocrinology, Diabetes, Nephrology, Colorectal Surgery and Trauma & Orthopaedics. The LOS in these specialities is high when compared to the expected LOS that is produced as part of the benchmarking information provided by Dr Foster on a monthly basis. This data looks at the expected LOS based on the performance of other trusts across the country and is adjusted to reflect the case mix at STH. The improvement work is being driven by: Spreading good practice process improvement learning from the Respiratory Change Room microsystem and the Elderly Care Big Room. Tacking the issue of unnecessary hospital admissions by developing a comprehensive diagnostic tool to support directorates to identify opportunities for ambulatory care pathways. An Emergency Care Pathway Review has led to the implementation of 16 recommendations including development of a medical ambulatory assessment area and development of the STH SAFER care bundle. Repeated annual analysis for each specialty to track performance against Dr Foster data for case-mix adjusted length of stay and ward level metrics including weekly admission, discharge and ward based length of stay information is now sent routinely to Nurse Directors and Operations Directors. 2. Current Performance Overall the non elective LOS for the Trust has been above the Dr Foster benchmark for some time. The graph below illustrates this for the period April 2014 to December 2105 (Graph 1). Graph 1- Average LOS for non elective spells compared to the Dr Foster expected level The expected LOS (target) has risen over the period indicating an increase in the complexity of the case mix. The actual LOS has fallen over the period from 5.8 days to 5.4 days whereas the expected level has risen from 5.2 days to 5.3 days 22

Compared to a peer group of 29 University Hospitals with more than 50,000 non elective spells per annum, STH are one of 10 Trusts that are above the Dr Foster expected LOS (Graph 2). This is for the period October 2014 to September 2015. The actual LOS for the group varies from 3.3 days for Bradford Teaching Hospitals to 5.7 days for Leeds Teaching Hospitals. For the Trust the actual LOS is 5.4 days compared to the expected of 5.2 days. Graph 2 Comparison with a peer group for observed v Dr Foster expected LOS Detailed analysis of LOS at individual specialty level and at the more granular level of care pathways has been undertaken as part of the planning for the quality and efficiency programme for 2016/17. This has revealed that the top three non-elective pathways with the highest bed day opportunities are in acute cerebrovascular disease, congestive heart failure (non hypertensive) and pneumonia. This more detailed analysis is helpful as for example in Cardiology at a specialty level the average LOS for non elective spells has been below the Dr Foster benchmark since October 2014 (Graph 3). However, the analysis at pathway level shows that the LOS for some pathways in significantly above the benchmark (Table 1). 23