1. Enc F2 Attachment Stewart Messer, Chief Operating Officer 1 Report to Board INTEGRATED PERFORMANCE REPORT September 2014

2. Enc F2 Attachment Trust Balance Scorecard 2

3. Enc F2 Attachment 3 Quality & Outcomes Effectiveness – HSMR / SHMI Quality & Outcomes Effectiveness – HSMR / SHMI HSMR- Whilst 2014/15 figures appear to show an improving trend at this stage this must be viewed with caution. Future data uploads will add more complex patients into the calculation which tends to increase the HSMR figure. Trends in the diagnostic groups contributing to the 2014/15 HSMR will continue to be tracked and where indicated ‘deep dive’ reviews of patient groups will be undertaken. Routine reviews of all deaths will commence in November 2014. SHMI- The SHMI profile continues to mirror the HSMR profile with the diagnostic groups contributing also mirroring the HSMR groups indicating no concerns with respect to post discharge mortality risk.

4. Enc F2 Attachment 4 Quality & Outcomes Safety - Falls Quality & Outcomes Safety - Falls Falls continue to reduce overall per 10,000 bed days.

5. Enc F2 Attachment 5 Quality & Outcomes Experience – Friends & Family Quality & Outcomes Experience – Friends & Family F&F responses will be available on Hospedia as of 20 October to improve response rates The Q2 quality report will cover trends in the scores and relevant actions taken to improve these

6. Enc F2 Attachment 6 Performance & Efficiency 4 Hour Emergency Access Standard (EAS) Performance & Efficiency 4 Hour Emergency Access Standard (EAS) The Emergency Access Standard (EAS) was achieved (95.21%) for September 2014 and for Quarter 2 (95.39%) despite continued levels of emergency demand and significant delays in discharging patients. At the end of September there were 80 patients within the Trust on the Fit to Go list. A broader selection of A&E quality standards have been produced (below) which give a better overall view of performance than simply measuring the 4 hour standard. It can be seen that the Trust achieved 3 out of 5 standards in September.

7. Enc F2 Attachment 7 Performance & Efficiency Factors Affecting 4 Hour EAS Performance & Efficiency Factors Affecting 4 Hour EAS Emergency admissions and delayed discharges are two of the main factors that influence the Trust’s ability to achieve the 95% standard. The chart shows the overall trends in total emergency admissions over the last 3 years. As can be seen from the chart, the Trust is still experiencing high levels of demand in emergency admissions compared to the same period previously. This unplanned increased has left the Trust in a position where it has had to cancel elective work in order to prioritise patient safety. The trust has still had no respite in the acuity of patients presenting with age related illness. (Please refer to slide 10) Patients presenting as emergency is still higher than expected for the period with the majority presenting in the early and late evening. Weeks have been normalised to allow comparison of full weeks across years. This Year is 31 st March 2014 to 29 th March 2015. Last year 1 st April 2013 to 30 March 2014 Growth in Emergency Admission 2014/15 compared with 2013/14

8. Enc F2 Attachment 8 Performance & Efficiency Factors Affecting 4 Hour EAS Performance & Efficiency Factors Affecting 4 Hour EAS The Trust regularly has between 60-80 patients that are medically fit for discharge, equating to between 3 and 4 wards. It should be noted that 80 patients are currently waiting (Sept). This is the highest number of medically fit patients waiting for discharge for a 12 month period in terms of bed days.

9. Enc F2 Attachment 9 Performance & Efficiency A&E Attendances Performance & Efficiency A&E Attendances There has been no change in A&E attendances and they continue to increase compared to the previous year. A&E attendances have historically been relatively static but since Nov 2013 attendances increased by 7% compared to the same period in the previous year. The Trust is at present auditing the over 75 patient admissions in line with the current spate of nursing home closures across the county to see if there is a correlation.

10. Enc F2 Attachment 10 Performance & Efficiency Referral to Treatment Performance & Efficiency Referral to Treatment Significant challenges remain on the admitted pathway and the Trust achieved 82.85% for September. It should be noted that the Trust continues to achieve the national targets for patients on the non- admitted and incomplete pathways. The total backlog remains a challenge however the inpatient backlog is now showing signs of reducing. Conversely the outpatient referrals and backlog continue to increase. Achieving the recovery trajectory is dependent on a reduction in both referrals and emergency demand which have not as yet materialised through delivery of the CCG QIPP schemes. Through the 18WRTT steering group (chaired by CEO) a number of work streams have been identified. This includes a weekly PTL meeting chaired by COO and DCOO. This approach ensures a comprehensive, multi-faceted approach to sustainability and recover the Trust’s overall 18 week RTT performance. This will be achieved with Operational and Corporate Directorates through a structured programme of work. Improvements in systems, processes, staff knowledge and consistency of approach will improve efficiency and effectiveness of pathways and in turn facilitate sustainable delivery of key performance metrics. Use of the independent sector for targeted cohorts of activity will provide short term headroom whilst the transformation programme delivers the expected benefits. This programme of work has already commenced to deliver 13 projects to provide the improvements required and meet key stakeholders expectations to improve performance against these targets, in particular the admitted target by November 2014. The programme will encapsulate both the administrative response needed and the clinical outcomes required. The proposed programme will deliver the following projects:  Leadership and management engagement & compliance ( 18WRTT Steering Group),  Improving data quality and validation of admitted, incomplete and non-admitted pathways ( Central validation of waiting lists)  PTL Management process review and redesign (Informatics and /Information)  Migrating to Oasis RTT clocks from current reporting ( Information/ Informatics/ Validation)  Comprehensive 18 RTT week reporting ( Information/ Informatics/ Validation)  Retraining of all staff on 18 week RTT rules and standards ( Training commenced)  Revision and implementation of the Trust’s Access Policy (TMC september2014)  Clinical pathway review and redesign (Divisionally led)  Analysis of capacity and demand ( working with 18 WRTT IST(IMAS))  Development of recovery plans for all Directorates ( Supported by IMAS/ Validation/ IS Outsourcing/ theatre utilisation)  Prediction of future performance ( Capacity and demand planning IMAS Modelling tool (T&0) Completed and ENT next speciality )  Increased utilisation and further implementation of e-referrals (CAB linked to and overall LHE response to include primary care and re-launch of DOS)  Access & Booking Services review and redesign. This is in line with the expectations of the Operational resilience and capacity planning document 2014/15 and the newly formed SRG

11. Enc F2 Attachment 11 Performance & Efficiency Referral to Treatment - Backlog Performance & Efficiency Referral to Treatment - Backlog The charts above show the number of patients waiting >18 weeks on the Inpatient and Outpatient waiting lists. The Trust has a target to bring backlog levels back down to January 13 levels by the end of November 2014.

12. Enc F2 Attachment 12 In line with the August performance it is the 62 day that remains a challenge and again in line with August all areas apart from the 62 days are achieving. The updated September figures show the Trust in green for the 2ww symptomatic breast patients (96.64% for the month and 90.48% year to date), green for the 31 day target for first treatments (96.12% for the month and 95.54% year to date), amber for the 62 day target with 124 treatments recorded and 21 breaches (83.06% for the month and 82.16% year to date), and amber for the 62 day screening target (88.89% for the month and 86.35% year to date). The Trust has completed the diagnostic proforma in regard of breaches and this information has been fed back to the directorates. The IST team has agreed with the Trust on a 2 day visit to support the on going work now being undertaken to support the on- going improvement of patient pathway processes. A meeting was convened with MDT clinical leads and CNS, to discuss current performance and improvements that could be initiated. It was agreed that the group would meet every 3 weeks to continue the following areas of improvement: Action plan to be developed and supported by IMAS, this will include review of MDT meetings, role of the MDT co-ordinator, discussion of current performance and forward plans to include delays in tertiary referrals and delays from tertiary centres, in house processes and where relevant reconfiguration of pathway. Performance & Efficiency Cancer Standards Performance & Efficiency Cancer Standards

13. Enc F2 Attachment 13 Workforce & Training - Overview Sickness The Trust’s sickness rate as reported in September 2014 was 4.09%. The cumulative sickness rate for the current year to date is marginally above target at 3.78%. This is very slightly above the cumulative figure reported in September 13 of 3.73% Benchmarking the levels of absence within the West Midlands Region, the Trust is in the top 50% for Acute Trusts. There are local challenges within Divisions that are being managed with appropriate HR support. The detail is set out below. Mandatory Training Monthly Mandatory Training Performance reports continue to be sent to Divisional Director of Operations, Nurse Directors and Medical Directors to cascade to managers within their Division so that managers know who needs to attend training. All but 3 of the topics are now on trajectory to meet the 95% target set for April 2015. The three topic areas that are not achieving 70% compliance are Medicines Management,Venous Thrombosis and Safeguarding Children and detailed action plans have been agreed with each of the topic leads and commenced implementation immediately, these include additional resources to deliver extra training sessions. Corporate Induction Attendance declined to 83% in September 2014 as there were 22 DNA’s at corporate induction programme 9 of which were junior doctors whose attendance has been followed up with the relevant clinical director to ensure that they complete the relevant e-learning modules. Staff Turnover Overall staff turnover reduced in September to 10.09% from 10.51% which is in line with normal range for Acute Trusts. The current overall turnover (excluding medics) for the Arden, Hereford and Worcester LETC is 10.1%. Qualified Nursing Staff turnover has reduced by 0.92% from 11.10% to 10.18%. Turnover of unqualified Nursing Staff has reduced this month by 0.35% from 13.06% to 12.71% which is reversing the upward trend, but is still an area for review.

14. Enc F2 Attachment 14 Workforce & Training - Overview Non Medical Staff Appraisals The Trusts non medical appraisal rate only improved by 0.42% since August 2014 to 70.12%. Each Division has been asked to review their performance and ensure appraisals are completed. All staff who are due an increment in the following month are sent a letter informing them unless they have had an up to date appraisal recorded they will not receive their incremental progression, this action has prompted some activity. Closer monitoring of PDR performance is being undertaken and the Learning and Development Department are contacting all Department achieving less than 70% completion to agree what support is required and an action plan to improve performance. Medical Staff Appraisals The rate of appraisal for all medical staff (including consultants, SAS and other career grade medical staff) continues to improve increasing by 1.8% in September to 72.9% with the rate of consultant appraisal increasing by 2.6 % to 77.6%. Progress of appraisal is monitored and reviewed on a monthly basis with Divisional Medical Directors (DMDs) provided with a RAG rated report on the appraisal status of doctors within their division for review and action. Divisions are asked to produce action plans to address doctors with expired appraisals. The RAG report to be issued to the DMDs in October will provide additional analysis on expired appraisals highlighting doctors with no progress over specific timeframes for urgent attention. A revised Medical Appraisal Policy has been drafted and includes a process for non-engagement in appraisal. The draft policy mirrors the national NHS England policy highlighting the importance of the Framework for Quality Assurance for Responsible Officers and process for postponement and non-engagement in appraisal process and the potential consequences of referral to the GMC in cases classified and non-engagement. Once ratified (anticipated to be following MMC Meeting 12 November 2014), implementation of the policy will ensure clear standards, expectations and processes are established and maintained resulting in an expected increase in the rate of appraisal.

15. Enc F2 Attachment 15 The Trust’s sickness rate has been increasing steadily from May 14 when the Trust met the target of 3.50%. The increase in rates is usually seen from October through to February so the seasonal effect has commenced early this year and is likely to add to the absence levels in the coming months. All the clinical Divisions are above target in September with the exception of Clinical Support Services and all Divisions saw an increase. The main reason for absence is September was gastrointestinal problems ( 158 episodes ( 20% of all absences)), followed by Muscular Skeletal problems ( 116 episodes ( 18% of all absences )) and then coughs, cold,flu ( 100 episodes ( 13% if all absences)). This is reflective of the impact of norovirus on staff. There has been progress in the Asset Management and WHITS Division over the last quarter where the rates have decreased by over 1% in 3 months. An impact has been made on the absence amongst the additional clinical services staff group with the trend showing a reduction in the last quarter. This staff group remains challenging as it is predominantly Health Care Assistants and is the subject of more targeted actions within Divisions. Workforce & Training Sickness and Absence Workforce & Training Sickness and Absence

16. Enc F2 Attachment 16 76.6% of eligible staff have completed training this month. Please note that the thresholds for Mandatory Training now reflect the required CCG reporting trajectory of 95% by year end. Workforce & Training Statutory and Mandatory Training Workforce & Training Statutory and Mandatory Training All topics reported here are now on target to meet the target set by the CCG’s contract query of 95% by April 2015. IG training has improved from 88% to 90%. Please note that the thresholds for Mandatory Training now reflect the required CCG reporting trajectory of 95% by year end.

17. Enc F2 Attachment 17 Overall staff turnover reduced in September to 10.09% from 10.51% which is in line with normal range for Acute Trusts. The current overall turnover (excluding medics for the Arden, Hereford and Worcester LETC is 10.1%. Qualified Nursing Staff turnover has reduced by 0.92% from 11.10% to 10.18%. Turnover of unqualified Nursing Staff has reduced this month by 0.35% from 13.06% to 12.71% which is reversing the upward trend, but is still an area for review within the Divisions. Workforce & Training Turnover Workforce & Training Turnover

18. 18 Income for September has continued above Trust plan, at the highest rate for the year. Elective, Day Case and Outpatient points of delivery were all significantly over plan, although some of this has come at considerable premium cost. Additional activity for the A&E MIU and the ‘ramp up’ of the Oncology Centre has been included within the Trust income for the first time, although this increased income is offset with equal additional costs. Pay overspends are being driven by two main factors – firstly, the need to employ premium rate locum and agency staff – in part to fill gaps in clinical rotas as a result of dual site working. This has been exacerbated by the continued uncertainty around reconfiguration plans. Secondly, the current demand for both elective and emergency care has led to the Trust having to put in place additional premium cost medical capacity through agency staff and additional waiting list sessions, which are not allowed for within the standard tariff. QIPP performance has started to fall behind plan (£0.3m) due primarily to an inability to reduce premium costs at present due to the lack of substantive applicants The QIPP plan steps up in October which will require further savings to be made. In line with the performance management escalation framework, a number of monthly confirm and challenge sessions have been held. Whilst assurance was received that 4 out of the 5 clinical divisions were on track to deliver their revised forecast, it was clear that the Medicine division has an unrealistic forecast and the Executive team have agreed a range of enhanced support measures to enable the division delivers better value for money. On the back of concerns around the Medicine division’s current run rate and recovery trajectory, coupled with other risks and pressures, it is now predicted that the £12.5m forecast deficit should be considered a best case position, with a most likely position being a £15m forecast deficit after mitigations. In the meantime, discussions are on-going with the TDA and CCGs about the support that can be provided to assist the Trust to maintain the required quality of care and to deliver the expected access standards. Finance & Contractual Trust wide Position as at Month 6 Finance & Contractual Trust wide Position as at Month 6

19. 19 Based on a set of assumptions regarding activity levels and QIPP delivery, the Trust planned on a £9.8m deficit in 2014/15. Once adjusted for the impact of non recurrent funding rebates, the Trust’s underlying deficit was £3.8m (circa 1% of turnover). The Board will be aware that stepped improvements in the financial run rate were predicted from month 6, both in terms of additional income and reductions in temporary staffing costs. However, the £1.1m variance from plan at Month 5 prompted a series of mid year confirm and challenge meetings with divisions to assess the actions and controls to be put in place to recover the position. As a result, plans for a revised forecast trajectory were produced for the September Trust Board, demonstrating how the Trust could mitigate the revised ‘bottom up’ £15m forecast deficit back to a £12.5m deficit, pending any further support. Therefore, when reviewing performance, it should be noted we are comparing to both the original TDA plan and also against the revised trajectory. The Trust had a £1.7m adverse variance in September, compared to a £0.85m original planned variance and a revised trajectory variance of £1.5m. Therefore, as expected the Month 6 position was significantly worse than original plan and slightly worse than the revised trajectory. This leaves the Trust with a year to date adverse variance of £2m, which can be explained as follows; Premium costs of maintaining elective work & temporary medical staff related to vacancies and additional demand (£1.4m) Under achievement of QIPP schemes (£0.3m) Unfunded Governance Reviews (£0.3m)

20. Enc F2 Attachment 20 Finance & Contractual Income & Expenditure Position Finance & Contractual Income & Expenditure Position

21. Enc F2 Attachment 21 Finance & Contractual CIP Delivery Finance & Contractual CIP Delivery

22. Enc F2 Attachment 22 Finance & Contractual Activity Finance & Contractual Activity