1. Trust Quality and Performance Report 28 March 2014 (February Performance Pack)

2. Contents 1 Slide numbers Executive Summary 2 - 4 Clinical Quality Priorities (inc Ward Dashboard)5 - 14 & 27 - 32 Local Priorities15 - 23 Monitor Compliance24 Contract Priorities25 - 26

3. Executive Summary This commentary provides an overview of key issues during the month and highlights where performance fell short of the target values as well as areas of improvement and noticeable good performance. 1.A&E Performance for January was 96.3%, the ninth month in a row that the Trust has achieved the target. Year to date performance remains above 95% and the Trust is on target to achieve this for the year. 2.There were zero cases of C.Diff in February against the threshold of two. This is covered within the quality report. The YTD position is 21 cases against a year end ceiling of 19. 3.The Trust achieved all Stroke targets for February. 4.Performance on outpatient and inpatient discharge summaries remains below target, although this has improved since January. See page 3. 5.Performance on MRSA screening of emergency admissions was 96.87% against the 100% target. This is covered on pages 3 & 6 of this report. 6.The Trust achieved all access targets including the six-week diagnostic test target for February. 2

4. 3 Executive Summary Performance IndicatorThreshholdFebruaryLead Executive Discharge Summaries - Outpatients95% sent to GP's within 3 days92.37%Dermot O'Riordan Significant improvement has been made since December, although further effort is needed to reach the 95% target. In addition to the interventions by the PMO the following steps have been taken to improve performance further:  The Medical Director has instructed the secretaries that they and their consultants have three working days to dictate, type, correct, authorise and send the Outpatient letters. If a letter is not approved by then they will be sent out clearly marked “dictated but not approved”.  Discharge summary and clinic letter performance is part of the new Appraisal system that is in the process of being implemented and consultants will be expected to present their figures. Performance IndicatorThreshholdFebruaryLead Executive Discharge Summaries - Inpatients95% sent to GP's within 1 day91.91%Dermot O'Riordan Since the PMO team have been chasing up ward clerks and ward managers on outstanding discharge summaries we have noticed a change in behlaviour leading to performacne against this indicator improving significantly. Having resolved some of the operational issues the following changes will be implemented to embed behaviour and improve our performance in order to meet the 95% target:  Information Team will assume sole responsibility for data management and reporting of discharge summaries.  Compliance against this indicator will monitored at monthly Divisional Performance Management meetings and responsibility for addressing poor performance will lie with each Directorate.  The Medical Director will be receiving performance figures at an individual consultant level and will be writing to those with below target performance for both letters and in-patient summaries to improve performance further. Performance IndicatorThreshholdFebruaryLead Executive MRSA - emergency screening All emergency patients admissions are to be screened for MRSA within 24 hours of admission 96.87%Nichole Day MRSA screening shows some improvement following data scrutiny with the assistance of the information team, in that the Elective MRSA screening for February was 97%, Emergency MRSA screening was 96.87% All areas with deficits are given patient level information specific to their area in order to assist in improving compliance. Feedback is given to the information team in order to ensure the correct patient categories are captured.

5. 4 Performance IndicatorThreshholdFebruaryLead Executive Sickness absence rate<3.5%3.79%Jan Bloomfield The highest percentage continues to be Estates and Facilities Directorate at 4.88% (up by 0.12 from January), the lowest Corporate Services at 2.28 (up by 0.08). The Trust will be consulting with the Trade Union representatives at the end of this month with regard to; reducing the number of stages (from 4 or 2) that we go through when dealing with short term frequent absence, reducing the timescales for these stages down to six months from one year, and counting the 8 weeks redeployment time as part of contractual notice, thereby reducing the notice period required. Performance IndicatorThreshholdFebruaryLead Executive All Staff to have an appraisal Both general and consultant staff each have a target of 90% to have had an apprasial within the previous 12 months. Appraisal is a rolling programme 88.31%Jan Bloomfield Appraisal compliance has improved, with the Medical Directorate continuing to be the highest area (89.99). The lowest is again the Surgical Directorate (86.20). the Trust will be reviewing this KPI as part of the Staff Survey action.

6. Clinical Quality Priorities: Summary An outbreak of Norovirus affecting 33 patients and 5 staff in February resulted in the closure of 2 wards for a total of 17 days. A further ward had 1 bay closed for 6 days. 50 patients fell during February; an increase of 12 compared to January. No patients sustained serious harm. There were no hospital associated C. difficile infections in February. 5

7. Quality Priority: Infection Control MRSA Bacteraemia There were no hospital associated MRSA bacteraemias during February MSSA Bacteraemia 1 hospital attributable MSSA bacteraemia was reported in February on G5. An investigation has been completed and the root cause of this bacteraemia was paratitis. C. difficile There were no hospital acquired C.difficile infections during February. The Trust was notified on the 7 th March by the CCG that the area team had turned down one of the CDT cases sent for appeal against trajectory. The main aspect on which the appeal was not upheld was that the cleaning score for the ward was 92% and the area team assessor’s criteria is set at 95%. Norovirus In February there were 2 wards affected by Norovirus G3 & G5 which resulted in ward closure. The index case is thought to be a patient admitted from a Nursing Home to G3 who developed symptoms following admission. Prior to the result being available a contact transferred to G5 and is this is the likely index case for G5. G8 had a single bay affected and closed to admissions. Due to the fact that Bay A could be segregated from the rest of the ward by closing doors it was possible to contain the outbreak. This outbreak has been declared a SIRI due to impact on service delivery. MRSA Screening The number of both elective and emergency patients screened for MRSA has increased this month. Elective 97% from in 95% January Emergency 96.8% from 95.9% in January 6

8. Quality Priority: Ward Performance Issues Ward F9 continues be monitored closely and monthly meetings held between the Head of Nursing, Matron, Ward Manager and Service Manager. There is an improving trend in quality generally, however, there was an increase in the number of inpatient falls (6) with 1 resulting in minor harm. A two week audit has commenced to monitor hydration documentation to address February’s low score. The on going work to reduce noise at night has shown signs of improvement this month resulting in a score of 46% compared with 26% last month. Sickness is being robustly managed and has reduced to 4.3% compared to 9.2% in January. Ward G4 reported low scores on MEWS and hydration documentation. Weekly audits will commence in March to monitor compliance with MEWS scoring & documentation of IV fluid completion time. Patient experience has improved with a score of 90% for satisfaction and a with recommender score of 81%. Ward G5 was reported last month as having a number of red and amber indicators. An action plan was developed to address the identified issues. Work to reduce falls has decreased the number to 2 this month compared to 8 in January. Patient experience indicators scored low in many areas and work is in progress to improve this. There are 6.5 WTE vacancies which are being advertised for recruitment. This may have had an affect on patient satisfaction. Ward F4 had a low score of 15% for noise at night although this is not reflected in verbal feedback from patients on Matron’s rounds. All patients admitted to F4 will be given ear plugs on admission and the Site Clinical Practitioners have been asked to visit the ward at night to assess noise levels. A pain re- audit this month showed a 90% compliance in documentation, an increase on January’s performance. 7

9. Quality Priority: Falls 8 Falls Performance There were 50 falls this month, 12 of which resulted in negligible or minor harm, one incurred moderate harm there were no falls with serious harm. The rate per 1,000 occupied bed days is 4.61 (January 3.1). The National average is 5.6% (NPSA 2010) Safety Thermometer WSNHSFT falls with harm Feb: 0%, National falls with harm Feb: 0.8% (Safety Thermometer 2014). Themes We continue to monitor the number of falls occurring in toilets: there were 5 this month, 10% of our total number, which was down by 1 fall in January. Detailed intelligence continues to be collected to reveal what the patient was actually doing at the time of the fall. Most patients were attempting to stand from the toilet seat, none had pressed the call bell. A three month trial is due to commence in April using patient alert systems in toilets and on commodes in ward G3. Work is almost completed to fit hand rails in all toilets.

10. Quality Priority: Pressure Ulcers The performance target is to have no avoidable Hospital Acquired Pressure Ulcers (HAPU) Grade 2, 3 or 4 during 2013-14. Grade 2 Pressure Ulcers There were six grade 2 HAPU this month four of which we believe to have been unavoidable, the CCG have yet to confirm this. Grade 3 pressure Ulcers No grade 3 HAPU We have had no grade 4 HAPU during 2013/14 We currently have several initiatives in progress to help prevent pressure damage: Stop the Clock Stop the Pressure Project launched on F9 this month. Stop clocks are being used to monitor the time an immobile patient stays sitting in a chair, a change of position is required at least every two hours. All wards have a Tissue Viability link nurse, a study event was held this month to share in-depth information and teaching on wound care and pressure ulcer prevention.. 9

11. Safety Thermometer results 10 The National ‘harm free’ care composite measure is defined as the proportion of patients without a pressure ulcer (ANY origin, category II-IV), harm from a fall in the last 72 hours, a urinary tract infection (in patients with a urethral urinary catheter) or new VTE treatment. The data can be manipulated to just look at “new harm” (harm that occurred within our care) and with this parameter, our Trust score is 0.51% therefore, our new harm free care is 99. 49%. The National new harm for February is 2.8% and national harm free is 93.3%. The data for February shows we had 0% of falls with harm and the national performance for February 2014 was 0.8%. The data also shows we had 0% of new pressure ulcers recorded in February 2014 against the national performance of 1.1% It should be noted that the Safety Thermometer is a spot audit and data is collected on a specific day each month. Jan 13Feb 13Mar 13Apr 13May 13Jun 13Jul 13 Aug 13Sep 13Oct 13Nov 13Dec 13Jan 14Feb 14 Harm Free93.0293.3693.6891.4793.2092.6093.22 92.6891.0392.4690.2893.0093.8694.09 Pressure Ulcers – All5.173.553.514.504.285.363.52 2.985.164.064.723.253.074.63 Pressure Ulcers - New0.520.710.940.951.010.001.08 0.001.090.000.830.250.00 Falls with Harm0.780.710.231.660.000.260.81 0.270.00 1.110.500.510.00 Catheters & UTIs1.031.662.580.951.761.532.17 2.983.603.483.333.002.301.03 Catheters & New UTIs0.260.470.230.240.000.510.54 1.080.820.000.831.000.26 New VTEs0.260.710.471.420.760.260.54 1.360.540.580.830.500.510.26 All Harms6.986.646.328.536.807.406.78 7.328.977.549.727.006.145.91 New Harms1.812.611.874.271.761.022.98 2.712.450.583.612.251.280.51 Sample387422427422397392369 368345360400391389 Surveys1718 17 18

12. Safety Thermometer Rolling Programme CQUIN Target started April 2012. 11

13. Quality Priority: Patient Experience – Achievement of 85% satisfaction 12 ‘Achieve at least 85% satisfaction in internal patient satisfaction surveys’ is a Quality Priority for the Trust. The overall score for the inpatient survey was 90%, in line with previous months. Privacy during examinations is the highest scoring question. Noise at night from other patients and timeliness of call bell response are the lowest scoring questions and remain the areas of focus. Call bell response times recorded electronically (across 5 wards) indicates that 76% of patients call bells are answered in the target time of 2 minutes.. Analysis of patient satisfaction questionnaire responses reveals that 20% of patients stated that call bell answered immediately and 50% stated call bell was answered within 1-2 minutes. From this data source 70% of patients call bells were answered between 0-2 minutes. There is a small discrepancy between actual response time and perception. Actions to improve call bell response times such as increasing visibility of nurses in bays, installing wall clocks and reducing the need for use of call bells have been implemented as part of the Patient Association call bell project. 1 outstanding action is the reorganisation of care activities to enable prompt answering of call bells. This will be piloted on 1 ward in March to understand benefits. G3 F5 F6

14. Quality Priority: Patient Experience – Achievement of 85% satisfaction ‘Achieve at least 85% satisfaction in internal patient satisfaction surveys’ is a Quality Priority for the Trust. Overall satisfaction scores for the OPD, A&E, and short stay were maintained at a high level. Work is planned during March to review the questions which comprise the internal satisfaction surveys to ensure we gain maximum benefit from the questions we ask. Work is in progress in A&E to meet the proposed 2014/15 CQUIN increased response rate for FFT. This includes exploring other ways of conducting surveys. DepartmentScore A&E94 OPD95 Short stay97 13

15. Quality Priority: Patient Experience – recommend the service ‘Patients would recommend the service to their family and friends’ is a Quality Priority for the Trust. The Trust achieved a Friends and Family test score of 88 for inpatients during February, maintaining the high scores of previous months. G5 scored 50% for the Friend and Family test. This reflects the overall low scoring for patient experience indicators. The Ward Manager has been tasked to improve patient perception of care which centred on waits for care associated with staffing levels. The recommender score for A&E has improved with a score of 72 for February compared to 64 in January and is the highest score this financial year. Maternity recommender scores at all stages of the pathway are indicated below: The post natal ward scored 70 which is a slight decrease from the January score of 75. No trends could be identified from comment analysis. Antenatal careBirthing Unit Only Labour SuitePost natal wardPost natal community care 8494867090 14

16. Local Priorities: Exception Report Late by Directorate Red (RAG) 12 th Feb12 th Marchchange Clinical Support>1568 - Estates and Facilities>10106  Medical>70101103 - Surgical>404944  Women & Children’s Health>152212  OtherNo target86 - TOTAL >150196179  Incidents (Amber / Green) with investigation overdue (over 12 days) This has improved over the last month. A message has been included in the Medical bulletin highlighting staff’s responsibilities to ensure timely completion of incident investigations and an escalation process agreed whereby all green and amber outstanding incidents will be monitored against time frames and escalated; initially to the Clinical Director (when one month overdue) and subsequently to the Medical Director (when two months overdue). RCA actions overdue A number of RCA actions became due in February / March that have not been confirmed as closed. It has been agreed that from April 2014 Governance will provide the General Managers with a regular report on the first working day of the month listing all overdue and upcoming RCA actions. Progress with closing these actions will then be monitored through the Directorate performance meetings. Complaint second letters There were six second letter received in the month. All are requests for further clarification on the information provided. Two of these complaints have had RCA investigations and a local resolution meeting in addition to the detailed investigation undertaken by the Complaints Manager. Review of the initial complaint letters does not show any theme/trend in the nature of the complaint. These six second letters relate to responses from December, January and February (a total of 69 first response letters). 15

17. Local Priorities - Governance Dashboard IndicatorPerformance targetRAGFeb14Commentary Timely completion of incident investigations and actions Red non-SIRI investigation not complete more than 45 days after incident reported >31 - 300 RCA Actions beyond deadline for completion>=105 - 90 - 419See exception report for details. Incidents (Amber / Green) with investigation overdue (over 12 days) >15050 - 150<50179See exception report for details. Timely reporting of SIRIs SIRIs reported > 2 working days from identification as red >11007/7 incidents were submitted to STEIS within two working days of identification as red. One was identified through an inquest notification following a death in the community (21 working days after the incident). One was initially reported as an amber however was upgraded to red once it was identified that surgery would be required following a fall with moderate harm (5 working days after the incident) SIRI final reports due in month submitted beyond 45 working days >11001/1 were submitted within 45 working days. SIRI final reports due in month submitted beyond local target (40 working days, 30days for pressure ulcers) >11001/1 were sent on or before Day 40 Number of SIRI reports open on STEIS more than 45 days after initial notification >106 - 100-50Two incidents have an CCG agreed “stop the clock” and are therefore excluded from this indicator. 16

18. Local Priorities - Governance Dashboard (cont.) IndicatorPerformance targetRAGFeb14Commentary Duty of Candour Compliance with Duty of Candour requirements >31 - 3022 (from a total of 14 cases) cases have not yet been undertaken. Duty of candour not conducted yet in line with CCG policy. These cases are being led by the Medical Director and Chief Nurse. Risk assessment Active risk assessments in date <75%75 – 94%>=95% 99% Outstanding actions in date for Red / Amber entries on Datix risk register <75%75 – 94%>=95% 96% Clinical AuditTrust participation in relevant ongoing National audits <75%75 – 89%>=90% 100% Safer surgery Completion of WHO checks during surgery. This is a composite indicator of the checks at ward, sign-in, time-out and sign-out. <90%90% - 98%>98% 97.6Non compliance is reported to individuals (daily) and Clinical Directors (weekly). This analysis is based on 4039 checks during the month. Ward Check 199.7 Ward Check 2 99.1 Sign In – Complete 100 Sign Out – Surgeon 96.7 Time Out - Scrub 94.8 17

19. Local Priorities - Governance Dashboard (cont.) IndicatorPerformance targetRAGFeb14Commentary NICE TA (Technology appraisal) business case beyond agreed deadline timeframe >94 - 90 - 31 The May Board (April data) will reflect the 2014/15 CCG contract relating to this data item. The Trust will be using the alerts module of the Datix system to allocate and monitor compliance with NICE guidance including Quality standards from April 2014 Complaints Response within 25 working days or negotiated timescale with the complainant <75%75 – 89%>=90%91% Number of second letters received>=51-40 6See exception report for details. Health Service Referrals accepted by Ombudsman >=210 0 Red complaints actions beyond deadline for completion >=51-40 0 Number of PALS contacts becoming formal complaints>=106 - 9<=5 4 18

20. Patient Safety Incidents Reported The rate of PSIs is a nationally mandated item for inclusion in the Quality Accounts. The NRLS target lines shows how many patient safety incidents WSH would have to report to fall into the median / upper and lower quartiles for small acute trusts reporting per 100 admissions. The Oct12 – Mar13 NRLS report was issued in December and the benchmark in the graph above was updated. This shows a increase in reporting across the peer group. The Trust reporting rate in February is just below the median for the peer group. There were 395 incidents reported in February including 319 patient safety incidents (PSIs). The reporting rate in February has fallen to a similar level as November and December although it is acknowledged that it is a shorter month which will have an impact on reporting numbers. The number of harm incidents in February remained below the peer group average. 19

21. Patient Safety Incidents (Severe harm or death) The percentage of PSIs resulting in severe harm or death is a nationally mandated item for inclusion in the Quality Accounts. The peer group average (serious PSIs as a percentage of total PSIs) from the NPSA Oct ’12 – Mar ‘13 report and sits below the Trust’s average. The WSH percentage data is plotted as a line which shows the rolling average over a twelve month period. The number of serious PSIs (confirmed and unconfirmed) are plotted as a column on the secondary axis with avoidable hospital acquired pressure ulcers indentified separately. The benchmark line applies the peer group percentage serious harm to the peer group median total PSIs to give a comparison with the Trust’s monthly figures. In December there were two patient safety incidents: one fall with fractured neck of femur and one delay in communication of an abnormal test result. 20

22. Local Priorities: Complaints There was an increase in the number of complaints received compared with the previous month but this number is still considerably less than other months throughout the financial year. Of these 24 complaints the majority were received with a very short timeframe of the episode of care. Complaint response within agreed timescale with the complainant: 91% in February. Of the 24 complaints received in February, the breakdown by Primary Directorate is as follows: Medical (9), Surgical (10), Clinical Support (1), Facilities (1), and Women & Child Health (3). Trust-wide the top 5 most common problem areas are as follows: All Aspects of Clinical Treatment15 Communication / Information to Patients (written and oral)11 Attitude of Staff6 Admissions, Discharge and Transfer Arrangements4 Appointments, Delay / Cancellation (outpatient)3 21

23. Local Priorities: PALS (Patient Advice & Liaison Service) In February 2014 there were 78 recorded PALS contacts. This number denotes initial contacts and not the number of actual communications between the patient/visitor which can, in some particular cases, be multiple. A breakdown of contacts by Directorate from April 13 to March 2014 is given in the chart and a synopsis of enquiries received for the same period is given below. Total for each month is shown as a line on a second axis. Trust-wide the most common five reasons for contacts are shown below. All aspects of clinical treatment24Information/Advice request11Communication4 Appointments, delay, cancellation8Admission/discharge and transfer arrangements 8Attitude of staff4 The numbers of contacts have reduced slightly in February which reflects the shorter reporting period. The numbers per Ward/Department remain small and consistent when spread across all areas of care provided, although the PALS Manager continues to receive complaints about cancellations. A number of enquiries relate to out-patients but they are not necessarily complaints – more clarification about appointment times. It is evident that the PALS Manager, in addition to assisting with genuine concerns from patients and relatives, frequently signposts enquirers to other services including the formal complaints process. She is also actively involved in dealing with specific in-patients and their families’ concerns during the total admission period. This last month has been particularly busy with patient families raising queries with the PALS Manager. 22

24. Local Priorities – Workforce Performance 23 Performance IndicatorThreshold Direct Financial Penalty YTDCommentsLead Exec Workforce Sickness absence rate<3.5%NO3.79% Jan Bloomfield Turnover<10%NO7.95% Jan Bloomfield ReviewsGrievance/Banding reviewsNO8 All cases now complete/resolved Jan Bloomfield Recruitment TimescalesAverage number of weeks to recruit = 7NO6 Jan Bloomfield DBS ChecksTo complete 95% of required DBS checksNO98.74% Jan Bloomfield All Staff to have an appraisal Both general and consultant staff each have a target of 90% to have had an appraisal within the previous 12 months. Appraisal is a rolling programme NO88.31%  Jan Bloomfield

25. Monitor Compliance Framework 24 Monitor Compliance Framework Performance IndicatorThresholdMonthQTDWeightingLead Exec Access: Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted90%0.00%95.18%1.0Jon Green Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted95%0.00%98.96%1.0Jon Green Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway92%0.00%98.89%1.0Jon Green A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge95%96.30%95.70%1.0Jon Green All cancers: 62-day wait for first treatment (5) from:Urgent GP referral for suspected cancer 85%87.00%89.00% 1.0 Jon Green All cancers: 62-day wait for first treatment (5) from: NHS Cancer Screening Service referral90%100.00% Jon Green All cancers: 31-day wait for second or subsequent treatment, comprising: Surgery94%100.00% 1.0 Jon Green All cancers: 31-day wait for second or subsequent treatment, comprising: anti-cancer drug treatments98%98.00%99.00%Jon Green All cancers: 31-day wait for second or subsequent treatment, comprising: radiotherapy - Not applicable to WSFT All cancers: 31-day wait from diagnosis to first treatment96%100.00% 0.5Jon Green Cancer: two week wait from referral to date first seen (8), comprising: all urgent referrals (cancer suspected) 93%99.20%98.65% 0.5 Jon Green Cancer: two week wait from referral to date first seen (8), comprising: for symptomatic breast patients (cancer not initially suspected) 93%99.20%99.60%Jon Green Outcomes: Clostridium (C.) difficile - meeting the C.difficile objective - MONTH20 1.0 Nichole Day Clostridium (C.) difficile - meeting the C.difficile objective - QUARTER Q1 = 4, Q2 = 5, Q3 = 5, Q4 = 5 0Nichole Day Clostridium (C.) difficile - meeting the C.difficile objective - ANNUALLY19 21Nichole Day Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - MONTH00 1.0 Nichole Day Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - QUARTER0 0Nichole Day Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - ANNUALLY0 1Nichole Day Certification against compliance with requirements regarding access to healthcare for people with a learning disability N/A--0.5Nichole Day

26. Contract Priorities Dashboard 25 Contract Priorities with financial penalty Performance IndicatorThreshold In Month Performance YTDCommentsLead Exec A&E A&E - Threshold for admission via A&E i) if the monthly ratio is above the corresponding 2011/12 monthly ratio for two month in a six month period ii) if year end is greater than 27% 27.50%25.76% Jon Green A&E - Timeliness Indicators To satisfy at least one of the following Timeliness Indicators: 1. Time to initial assessment (95th percentile) below 15 minutes 2. Time to treatment in department (median) below 60 minutes ONE MET- Jon Green Stroke Stroke -Proportion of Patients admitted to an acute stroke unit within 4 hours of hospital arrival 90%100.00%88.64% Jon Green Proportion of patients in Atrial Fibrillation, presenting with stroke and where clinically indicated will receive anti-co-agulation. 60%75.00%68.36% Jon Green Stroke - % of Stroke patients with access to brain scan within 24 hours100%100.00%98.82% Jon Green Stroke - Proportion of Stroke Patients and carers with a joint health and social care plan on discharge 85%100.00%91.82% Jon Green Stroke - Patients (as per NICE guidance) with suspected stroke to have access to an urgent brain scan in the next slot within usual working hours or less than 60 minutes out of hours as defined from time to time by the ASHN 100% of stroke patients eligible for a brain scan scanned within one hour 100.00%95.82% Jon Green >80% treated on a stroke unit >90% of their stay80%89.00%89.64% Jon Green >60% of people who have a TIA and are high risk (ABCD 2 score 4 or more) are scanned and treated within 24 hours of 1st contact but not admitted 60%100.00%78.27% Jon Green Stroke - 65% of patients with low risk TIA have access to MRI or carotid scan within 7 days (seen, investigated and treated) 65%65.00%72.18% Jon Green % of Patients eligible for Thrombolysis, Thrombolysed within 4.5 hours100% of all eligible patients100.00% Jon Green Discharge Summaries Discharge Summaries - Outpatients95% sent to GP's within 3 days92.37%85.62% Dermot O'Riordan Discharge Summaries - A&E 95% of A&E Discharge Summaries to be sent to GPs within one working day 97.45%97.11% Dermot O'Riordan Discharge Summaries - Inpatients95% sent to GP's within 1 day91.91%84.20% Dermot O'Riordan

27. Contract Priorities Dashboard 26 Choose & Book Provider failure to ensure that “sufficient appointment slots” are made available on the Choose and Book system A maximum of 3% slots unavailable (£50 per appointment over 5%. Threshold applied over monthly figures) 3.00%- The Threshold applied to fines is 5% Jon Green All 2 Week Wait services delivered by the Provider shall be available via Choose & Book (subject to any exclusions approved by NHS East of England) 100%100.00%- Jon Green Cancelled Operations Provider cancellation of Elective Care operation for non-clinical reasons either before or after Patient admission i) 1% of all elective procedures0.99%1.10% Jon Green Patients offered date within 28 days of cancelled operation100% 100.00%97.64% Jon Green Maternity Access to Maternity services (VSB06) 90% of women who have seen a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks and choices by 12 completed weeks of pregnancy. 93.82%96.36% Nichole Day Maintain maternity 1:30 ratio1:30 1:29 Nichole Day Pledge 1.4: 1:1 care in established labour1:1 100.00% Nichole Day Breastfeeding initiation rates.80% 84.92%80.35% Nichole Day Reduction in the proportion of births that are undertaken as caesarean sections. Suffolk PCT Only 1% reduction in proportion compared to 2011/12 baseline - 22.70% 19.50%19.00% Nichole Day Other contract / National targets Mixed Sex Accomodation breaches0 Breaches04 Jon Green Consultant to consultant referral Commisioner to audit if concern about levels of consultant referrals 7.40%- Jon Green Current ratios of OP procedure to day case for agreed list of procedures to be maintained or improved, i.e. the Commissioner will not fund a higher level of admitted patients for such procedures, unless clinical reasons can be demonstrated for increase in admissions. Maintain or improve the mix as specified = 90.17%88.02%87.64% Jon Green MRSA - emergency screening All emergency patients admissions are to be screened for MRSA within 24 hours of admission 96.87%92.42% Nichole Day Rapid access - chest pain clinic 100% of patients should have a maximum wait of two weeks 100.00%85.59% Jon Green New to Follow up Thresholds set at each speciality - overall Trust Threshold is 1.9 1.86- Jon Green Patients receiving primary diagnostic test within 6 weeks of referral for diagnostic test 99%100.00%98.07% Jon Green

28. A3 Printout of Ward Analysis Quality Report From Trust Dashboard Clinical Quality Priorities: Ward Dashboard 27-32