1. 1 Integrated Quality and Performance Report M3– June 2011 Presented by: Bernie Bluhm (Chief Operating Officer) and Jo Thomas ( Chief Nurse) Author: Char Fletcher (Senior Performance Manager) Trust Board – 21 July 2011 Agenda item: 4.1

2. 22 Performance Report M3 - June Summary: The report updates the Board on the key national, contractual KPIs across the Trust for the Month 3 of 2011-12 (June). The Q1 forecast for the trust remains ‘underperforming’ There remain some Issues with validating the 18 week position. The data was not available at the time of this report. No exception report has been provided for Appraisal and Statutory and Mandatory compliance as data the data is currently being mapped to each division New workforce exception reports are under development. They will utilize SPC charts to identify when a KPI is outside of control limits. Data quality indicators are under development Action: The Trust Board is asked to Note and accept this report Notes: Legal: What are the legal considerations & implications linked to this item? Please name relevant Act Not applicable. Regulation: What aspect of regulation applies and what are the outcome implications? This applies to any regulatory body – key regulators include: Care Quality Commission, MHRA, NPSA & Audit Commission) Department of Health. Trust objective : Please list number and statement. this paper relates to. Deliver safe, high quality co-ordinated care; Develop an effective organisation Trust Board Agenda Item:4.1

3. 3 Contents 1. Integrated Quality and Performance Dashboard  Page 4 Operating framework metrics  Page 5 Outcomes framework metrics  Page 6 internal metrics 2. Exception Reports 3. Glossary of Terms

4. Indicators used for external assessment

6. Indicators used for Internal assessment

7. 7 Contents 1. Integrated Quality and Performance Dashboard 2. Exception Reports 3. Glossary of Terms

8. 8 2. Charts for Performance Exception Areas

14. 14 FnoF – Exception graphs

21. 21 Contents 1. Integrated Quality and Performance Dashboard 2. Exception Reports 3. Glossary of Terms

22. 22 3. Glossary Of terms MRSA - Methicillin-resistant Staphylococcus aureus Cdiff - Clostridium difficile HSMR – Hospital Standardised Mortality Rates TIA - Transient Ischaemic Attack RIDDOR – Reporting of Injuries Dieses And Dangerous Occurrences ITU – Intensive Treatment Unit WTE – Whole Time Equivalent FFCE – First Finished Consultant episode AMI – Acute Myocardial Infraction RACP – Rapid Access Chest Pain CDS – Commissioning Data Set LOLER - Lifting Operations and Lifting Equipment Regulations 1998 SUI – Serious Untoward Incident ITU – Intensive Treatment Unit H&S – Health and Safety