Integrated Performance Report M04 – July2013

Management Board – 28th August 2013 Integrated Performance Report M04 – July2013 Presented by:Paul Bostock (Chief Operating Officer) Des Holden (Medical Director) Yvonne Parker (Director of HR) Paul Simpson (Chief Financial Officer) An Associated University Hospital of Brighton and Sussex Medical School 1

Performance July 2013 Summary: • DH Performance Framework - For July 2013 the Trust is expecting to be rated as “Performing” for the Quality of Services based on the DH performance framework. • Deliver Safe, High Quality, Co-ordinated Care - 18 weeks continue to exceed expected standards and ED performance was delivered in month. Stroke and #NOF performance remain challenging, partly driven by the high levels of bed occupancy at the Trust but plans are in place to improve performance. Cancer performance has been adverse in two of the measures. • Ensure patients are cared for and cared about - The Trust continues to demonstrate improvements in ensuring patients are cared for and cared about as reflected in the friends and family test and Your Care Matters results. The July friends and family score is improved against June. • Work in Partnership with our community – the trust continues to work with the local health system to significantly reduce the number of patients in the hospital who no longer require acute carewith final commissioning decisions expected in September. • Become a sustainable, effective organisation - At Month 4 the Trust is favourable to plan with a £0.2m surplus. The forecast remains breakeven. Within workforce, the focus is on continuous recruitment to our nursing vacancies and the most cost effective use of contingent workforce to ensure that the highest quality standards are maintained and deliver financial savings. Action: The Board are asked to note and accept this report Notes: 2 2

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1. National Quality of Services Measures Overview • This section of the report outlines the Trust’s performance for Quality of Services under the Department of Health Performance Framework. • For July 2013 the Trust is expected to be rated as “Performing” for Quality of Services based on the ratings shown below for each of the individual domains within the framework. • Charts

1. National Quality of Services Measures Integrated Measures • For July 2013, the Trust is forecasting an in-month score of 2.64 which would rate the Trust as “Performing” for the Integrated Measures. • The table below shows the performance against each of the individual Integrated Measures on an in-month basis.

1. National Quality of Services Measures Integrated Measures • Significant points of note regarding performance include: • ED Performance was sustained in July 2013. • There were no incidences of MRSA and four incidences of C-Diff during July with the Trust being on plan for both indicators. • RTT performance continued to perform with the 90% Admitted, 95% non-admitted and 92% incompletes measures all being achieved in aggregateand for the first time, all measures were achieved across all DH specialties. • Although there was an increase in patients waiting over 6 weeks for diagnostics resulting from the new radiology IT system implementation, this was still within the 1% tolerance. • Cancer performance deteriorated in month with the breast symptomatic and 62 day screening targets not being achieved. • The delayed transfers of care measure continued to underperform in monthalthough the percentage of delays has fallen since June 2013.

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2. Deliver Safe, High Quality Coordinated Care Achievement of national best practice in clinical care - Core Standards and Patient Safety • There were six serious incidents in July one of which was a Never Event. • The Trust has 17 serious incidents that are overdue for Trust closure and additional resources are being put in place to help resolve this. It should be noted that although these SI’s have not been closed, key learning and actions have been taken where required. Progress update from mid August suggests that due to significant work through July and August this figure should reduce significantly during September.

2. Deliver Safe, High Quality Coordinated Care Achievement of national best practice in clinical care - Core Standards and Patient Safety • The previous months score (June ) for the NHS Safety Thermometer has triggered as Amber having dropped below the 95% target. Following the drop, which was effected in part by changes in criteria of patients included in the data capture, the Trust score for July rose to 94%. The score is based on four outcomes; pressure ulcers, falls, urinary tract infection in patients with catheters and VTE. It is calculated based on the prevalence of both of these outcomes while patients are in hospital. Patients who come into the hospital from the community with one of these outcomes will also be included in the audit. In month 4 The Trust scored 95.68% in the delivery of no new harm. • The Safety Thermometer indicator remains a high priority for Nursing teams and is regularly discussed at all levels across the organisation. Data collection allows for specific ward based analysis and interventions. • The never event was an “inappropriate administration of daily oral methotrexate”. There was one incorrect administration of the drug, which was identified by the ward pharmacist. Although an incorrect dosage was given it was within the safe range for the medication. The dosage is not believed to have caused any harm and initial investigation indicates human error as the cause of the administration. There was no prescribing error. This has been declared as a Serious Incident. • There was no Grade 3 or 4 pressure damage in July 2013 but Grade 2 pressure damage was above expectations. • There were no medication errors resulting in severe harm or death. • VTE assessment and WHO checklist compliance achieved expected levels of performance

2. Deliver Safe, High Quality Coordinated Care Achievement of national best practice in clinical care - Mortality and Readmissions • Overall mortality as measured by HSMR continues to remain below 100 on a 12 month basis and this is rated as ‘significantly lower than the expected rate’ by Dr Foster. In all three monitored groups, mortality also fell and Stroke now falls within the expected range as defined by Dr Foster when compared nationally although he rate remains higher than 100. COPD now has the third lowest rate in the region and Fractured NoF is rated 5th lowest in the region. The latest SHMI data published in April showed a SHMI value of 0.94 reflecting deaths are in line with expected. • There has been a mortality review by lead clinicians for the Stroke and NOF pathways. In both cases no clinical concerns were identified the executive team has been reassured there is an on-going process in place for reviewand CCG’s are engaged. • Readmission rates within 2 days are within expected levels and 30 day readmissions following non-elective admission have also reduced in month. A joint clinical audit with commissioners took place in July to understand the underlying health system issues that, if resolved, could help reduce readmission rates. After extensive clinical review by hospital consultants and local GPs, only 2% of readmissions were viewed as avoidable (inappropriate or could have been treated in a community setting). Commissioners have subsequently provided an alternative view and a contractual process has been initiated to resolve the differences.

2. Deliver Safe, High Quality Coordinated Care Achievement of national best practice in clinical care - Infection Control • MRSA and C.Diff incidence remain on at expected levels. • There were no MRSA bloodstream infections (BSIs) and four incidences of C.diff during July 2013. • The Trust is 0.3 cases below trajectory for C. diff and on trajectory for delivery of the MRSA objective. • The Infection Prevention Control & Antimicrobial Stewardship Team, working through the Task Force continues its focus on: • Antimicrobial stewardship, driven primarily by the hospital’s medical staff and pharmacists which is reflected by on-going improvements over recent months in compliance with the monthly Good Antimicrobial Prescribing (GAP) audits. • Management of invasive devices such as urinary catheters and vascular cannula – with use of high intervention impact care bundles.

2. Deliver Safe, High Quality Coordinated Care Achievement of national best practice in clinical care - Emergency Department ED Performance is based on sum of weekly data to align monitoring with external reporting • Performance against the 4 hour target has been maintained in July • Median time to treatment continues to be maintained at consistent levels. • The consultant led clinics continue to work well to maintain the performance for unplanned re-attendance within 7 days . • Proposals for Ambulance Handover validation have been circulated and applied to July’s data, which has shown considerable reduction in over 30 minute delaysand there were no over 60 minute handover delays in July. • The changes in staffing at streaming area have been maintained, this is now demonstrating an improvement in performance. • Internal escalation and utilisation of CDU with a more structured admission process and guidelines is being implemented to support on-going maintenance of targets.

2. Deliver Safe, High Quality Coordinated Care Achievement of national best practice in clinical care - 18 Weeks • In July, all RTT and diagnostic targets were achieved. • The Trust achieved the Admitted, Non-admitted and Incomplete targets at aggregate level and for the first time all three measures were achieved at speciality level, one month ahead of plan. • Performance in relation to the 28 day guarantee for cancellations and urgent cancellations remains at expected levels. • The diagnostic target was again achieved in July 2013 although there was a slight increase in radiology waits over 6 weeks as a result of some of the operational issues following the implementation of the new Radiology IT system. This is expected to return to normal levels in August.

2. Deliver Safe, High Quality Coordinated Care Achievement of national best practice in clinical care - Cancer • Following the achievement of all measures in June, the Breast Symptomatic and 62 day referral from screening were not achieved in July. • Failure against the breast symptomatic standard in July was due to a higher level of patient referrals than in previous months. An audit of processes and timeliness of booking mammography outpatient appointments is being undertaken. • 62 Day Screening performance was not achieved in July 2013 due to one patient deferring diagnostics due to holiday. Sussex Breast screening patients are now being offered the choice of referral to SaSH, although uptake rates are not as high as expected, but volumes of treatments for this target will continuously remain low with single breaches impacting the performance • SaSH Cancer services are currently being reconfigured within the Trust with the new structure expected to be in place in September 2013.

2. Deliver Safe, High Quality Coordinated Care Achievement of national best practice in clinical care - Stroke Care • From month 05 the Trust will align it’s Stroke performance reporting with the outcomes and metrics that are collected through the Sentinel Stroke National Audit Programme (SSNAP) This will provide reliable data from which the Trust can benchmark it’s performance regionally and nationally. Although access to the unit remains a challenge, overall the Trust scored in the upper quartile for quality of service as compared to other providers in the region. • The July performance for admission to ASU within 4 hours has improved by 8%. While some of this is reflective of July it also pertains to performance over previous months as Stroke performance is recorded based on the month of discharge. Daily reports for Stroke admissions (via ED) during July are tracking at 80% for access to ASU within 4 hours. Ring fencing of the Stroke unit is having a positive impact when effectively implemented. • The percentage of patients spending 90% of their time on ASU shows a 15% improvement. Ring fencing will also assist this area of performance but again this is dependant on consistently effective implementation. • High risk TIA patients treated within 24 hours has maintained the expected level of performance.

2. Deliver Safe, High Quality Coordinated Care Achievement of national best practice in clinical care - Stroke Care • Stroke patients scanned within 1 hour of arrival has continued to improve in month, albeit marginally. Policy authorising Stroke Nurses to order scans is expected to help maintain and improve performance and has now been fully authorised. Effectiveness is being audited by Radiology. Stroke patients scanned within 24 hours: 100%. • The Stroke Mortality data for March showed an unexpected rise and has been investigated. The lead Clinician audited 10/17 notes and presented findings to the Medical Division Board. There were no immediate clinical concerns however there were some coding issues which significantly skewed performance. An action plan has been agreed and includes RCA of all stroke deaths. The coding issues identified will be corrected but will take some time to be reflected in the HSMR due to the process of SUS submission and Dr Foster processing.

2. Deliver Safe, High Quality Coordinated Care Achievement of national best practice in clinical care - #NOF Care • This month the Trust has changed it’s triggers to align with the National average as reported by the National Hip Fracture database (NHFD) . As with the NHFD audit data; this will allow the Trust to benchmark itself nationally. • The Trust continues to demonstrate overall steady performance in the access to ward in 4hours indicator, with our best performance year to date, due to the ring fencing of orthopaedic beds. • The percentage of patients achieving all criteria of best practice shows a marginal improvement of 3% on the previous month. Of the patients not meeting the criteria, the majority were due to theatre delays and a small number experienced delayed Orthogeriatrician assessments. • The number of patients admitted to the #NoF ward has improved in month. 3 fractured NoFs resulted from in-patient falls on medical wards and were not transferred to the #NoF ward until post surgery, as it is quicker to do this but it counts adversely in the data. • Fractured NoF performance is closely linked to overall trauma activity for the trust, particularly regarding access to theatres. Trauma complexity and activity remained high in July (140 cases) which impacted on theatre waiting times. It is also important to note that 16% of patients that failed the theatre targets were medically unfit for surgery during the first 48hrs of their admission. • The time to theatre escalation process has been reviewed and reinforced with the clinical team to ensure patient’s have their operation at the right time. • With regards to mortality, we expect the next Dr Foster report to show an improved position following the resubmission of coded data. A routine process to review of clinical coding for all fractured NoF deaths has been agreed and implemented.

2. Deliver Safe, High Quality Coordinated Care Achievement of national best practice in clinical care - Maternity Care • The Maternity services at the Trust continue to deliver high quality services following the significant investments over previous years in midwifery and medical staffing. • In July, 408 women were delivered, which was the highest number since October 2010. In part this is attributed to the successful marketing campaign following the opening of the refurbished birthing unit. • The improvement in the percentage of women receiving 1:1 care in labour is being sustained, although the Trust’s internal stretch target of 100% has not been achieved, the Trust is providing 1:1 care to a larger proportion of women than many peers. • The department is compliant with the Safer Childbirth recommendation in relation to the number of hours required for Consultant presence on the Labour Ward. Based on a birth rate in excess of 4000 there is now 98 hour Consultant presence on the Labour Ward. • The number of emergency caesareans is adverse and all decisions are being audited daily. There does not appear to be a discernible pattern, checking day or night time, weekday or weekends or individual clinicians. The review has identified very few emergency caesarean sections that the reviewing consultant felt were not clinically justified. Where this was the case the appropriate learning has been disseminated. The Division has been asked to present a clearer picture to better understand the position linked to performance in other areas.

2. Deliver Safe, High Quality Coordinated Care – Achieve best practice in the use of quality and patient safety indicators • The Trust remains on plan for developments in relation to the two main schemes for the use of quality and patient safety indicators • Synbiotix is an electronic system which has been procured to enable nursing staff to audit quality practice at ward/Divisional level by providing real-time data and identifying areas of best practice and areas that require support. • The system rolled out within the Trust from 1st June 2013 as a trial period and various issues were identified, and are being rectifiedbefore the full roll out is completed. • The Trust continues to work with external parties as required in relation to the National Quality dashboard and until this is published the Trust continues to review and incorporate into governance / oversight processes other similar national dashboard (eg the Workforce Assurance Framework and Greater East Midlands Commissioning Support Unit Acute Care Dashboard) as well as the outputs from the Dr Foster product suite that the Trust utilises.

2. Deliver Safe, High Quality Coordinated Care Ensure patients are cared for in the right place at the right time • The Trust continues to operate at high levels of bed occupancy although there has been a significant improvement in the percentage of patients in an appropriate bed. • While neither indicator is achieving the expected levels of performance, a downward tread in bed occupancy and upward trend in patients in the right bed can be seen. • The trust has a significant programme of work across the health system to reduce the bed occupancy and improve the number of patients that are cared for in the “right bed, first time”. The internal element of this programme falls within the Urgent Care and Patient Flow Board and is focussed on the following: • Embedding Professional Standards around patient care • Review of Medical staffing rotas • Developments of Frail Elderly services including the recruitment of Community geriatrics • Implementation of Electronic whiteboards on inpatient wards • Improvements to the discharge process • Procurement of an Acute “Hospital at Home” Service • The internal programme is expected to deliver improvements in bed occupancy which will be further bolstered by the Health system plans to put in place c.100 community beds to allow the patients at the Trust who no longer require care in an acute bed to move into a more appropriate community setting.

2. Deliver Safe, High Quality Coordinated Care Work well within clinical networks and develop clinical partnerships • Progression of Vascular network plans across the Sussex health system are experiencing some slippage. Arterial elective activity is now undertaken at BSUH as part of the network arrangements. Emergency activity is yet to move. This is on hold while the financial model is evaluated by all parties in the network • The Trust continues to maintain its Trauma Unit designation. • Chemotherapy – the first patients have been repatriated, with 2-3 patients per week receiving care at SaSH who previously had to travel to Guildford. The remaining breast patients are due for repatriation by September, although this is dependant upon the recruitment of an oncologist by Royal Surrey, which is proving challenging. • Radiotherapy is likely to be slightly delayed due to build issues, the is expected to be on line by April 2014

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3. Ensure patients are cared for and cared about - Be recommended on the basis of customer care • The Trust continues to demonstrate improvements in ensuring patients are cared for and cared about. • The National Friends and Family Test results are calculated using an underlying “Net Promoter Score” ‘which takes the proportion of patients who are ‘Extremely Likely” to recommend minus those who are unlikely or neutral, to give a score from -100 to +100. The Friends and Family Test score for July 2013 for Inpatients is +64 an improvement on last month. For the Emergency Department patients the score is +43 which demonstrates a decline in performance.

3. Ensure patients are cared for and cared about Be recommended on the basis of customer care • The national FFT results were published in July 2013 and the Trust’s June inpatient Net Promoter Score (NPS) of 54 put it as the seventh lowest Trust in England. The Trust also had one of 36 wards in England with a negative NPS – Newdigate – with a NPS of -17. (Of the six patients who completed the FFT survey for Newdigate in June only one recorded a negative view but the way the NPS score works only counts Highly Likely votes as being promoters) • The overall England mean NPS score was 70 putting the Trust someway behind the national average. Internal discussion suggests that to some extent the reason for the Trust’s lower score is the time at which we ask the FFT question. The majority of Trusts use simple, one question, paper returns completed at the time of discharge. The Trust previously found that this approach tends toward a more positive response as patients appear reluctant to be negative whilst they are still in the hospital. As a result, the Trust elected to use a more sophisticated tool – Your Care Matters (YCM) – which not only asks the FFT question but asks a much wider range allowing much better understanding of the real issues affecting patients and providing the opportunity to address those concerns and improve the patient experience. • Given the disparity between our results and other Trusts we are now looking at simplifying the way that we ask the FFT question whilst at the same time keeping all the benefits of the Your Care Matters programme. This work will be concluded so that the new process starts from the beginning of September 2013. • The July national data is not yet available however the Trust’s overall score has risen to 63. As a result of their negative score for June, and recognising the acuity and dependency of Newdigate patients, the ward commenced FFT data collection in hard copy form asking just the FFT question in July 2013. Newdigate now has a score of 89. This indicates some of the disadvantages in utilising YCM on wards of this nature and indicates an improved scoring with hard copy on ward data collection. • We had already recognised that some patients had difficulties with the full survey so had implemented a paper based return in some other areas previously. Because of this we are able to calculate that our NPS score for paper results alone would be 71 in July against the overall score of 63.

3. Ensure patients are cared for and cared about Be recommended on the basis of customer care • The Safety & Quality Committee (August 2013) received a paper following a review of complaints in the Trust. The purpose of the review was to provide information, assurance and highlight further work required on formal complaints received by the Trust. • In accordance with Trust policy, the definition of the complaint is, an expression of dissatisfaction from a patient, their representative or a potential user of Trust services requiring a formal response. • During 2012/13 the Trust received 450 formal complaints. Issues ranked highest on the table are Medical Care followed by Diagnosis and also Nursing/Midwifery, Communication and Attitude/Courtesy. All 450 complaints have been closed for the year. • Ombudsman current cases are also included in the report with the current status. There are currently three cases open with the Ombudsman. There is one case for the Medical division and two cases for the Surgical division. The three themes represented are rudeness, delay in treatment and poor outcome. The complaints department have supplied the Ombudsman with the information/files required and the Trust is awaiting feedback. • A draft Standard Operating Procedure for Complaints was also developed as part of the paper outlining the functions and responsibilities of the teams. • The quality of the old complaints codes were identified as not sufficient to obtain in-depth analysis, subsequently new coding has been developed, based on incident reporting, providing a systematic and structured approach to allow specialist sub categories to be interpreted. As a result of the new incident coding, an opportunity for complaints and PALS to be aligned in future reports creating in depth analysis of themes, trends and potential risks is now achievable. • To note for the year 12/13 to 13/14 first quarters there is a decrease of complaints relating to treatment, communication, attitude/courtesy and discharge.

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4. Work in partnership with our community Work with patients, the public and partners to develop services that meet the needs of our community DTOC values have been re-stated for April 2013 onwards following a review of the methodology to convert weekly data into monthly performance. • Delayed Transfers of Care decreased in July 2013 but remained above expectations . • The Trust is currently working with CCGs and health and social care providers to reduce the level of DTOCs through: • Re-design the discharge pathway, both within the Trust and externally to reduce duplication, paperwork and complex assessments and funding decisions in the acute environment. Moving to a ‘discharge to assess’ model • Increase actual or virtual bed capacity out of hospital by 100, supporting a model of “discharge to assess” for continuing health and social care needs. • Implement an Integrated Discharge Team, with all partners working together to support discharges earlier in the patients journey and resolve complex issues more rapidly • While some impact is expected in August and September, the step change is not expected until October 2013. • Other developments continue to be on plan with the new TB service now live and staff being recruited and the Endoscopy JAG accreditation programme is on plan in preparation for the Trust’s assessment in October.

4. Work in partnership with our community Improve the way people see and talk about SaSH • NHS Choices and Patient Opinion continue to be key channels for engaging with patients and the public • In July, 21 stories were posted on Patient Opinion that were viewed 2,884 times. 20 were about East Surrey Hospital and 1 comment was about the services provided by SASH at Dorking Hospital. • Patient Opinion rates the feedback received by the Trusts based on the stories content. Of the stories posted in July 48% were rated not critical, 20% were scored minimally/mildly critical; 10% were scored as moderately critical; 5% were rated strongly critical – this equate to 1 comment. 19% not rated (not rated stories are those which are fed from NHS Choices). • One of the themes in the feedback this month was around outpatient clinics. As a result the Trust has made changes to how those clinics are run to better address the needs of our patients. We will continue to engage with patients and staff to monitor the success of the changes. • As many Patient Opinion responses are from Surrey patients compared to Crawley and Horsham patients. This is different to last month where three times as many responses were from Surrey patients. • Patient Opinion allows us to have a direct conversation with patients and solve problems that may never have been heard through traditional routes. All Patient Opinion stories are fed directly to the inboxes of senior staff. As a Trust we are able to respond in a more ‘real time’ manner to feedback received. In July over 50% of comments were responded to within 24 hours. To date, 26 changes have been made through comments left on Patient Opinion. It is not always about solving issues, sometimes it is about listening and reassuring patients or their relatives.

4. Work in partnership with our community Improve the way people see and talk about SaSH • Press Coverage for the Trust has been mixed in July 2013 with no particular press story dominating the headlines. Stories included news about the heat wave and the implications on our Emergency Department, a story resulting from an Freedom of Information about unusual objects removed from patients, a story about health tourism sparked by MP Henry Smith stating that it is not Xenophobic to recover costs. • We responded to seven media enquiries, and all, or part of, of our statements were included in the articles. Of those responses, three stories are ranked as positive, and four stories are ranked as negative. • Of the negative coverage; following the trust raising a safeguarding concern regarding a child, a family member was unhappy about the police visiting the home. In this instance the correct procedure was followed by staff who placed the safety of the child first. There was also a misleading article about high mortality rates following admission to hospital on a Monday. The data around the mortality rates has been investigated. The investigation found that mortality rates on a Monday are not higher than any other day of the week. Aresponse was published on the homepage of our website and in the CEO’s weekly message. A radio interview with a Consultant also took pace to explain the data. • The Chief Executive Michael Wilson has a weekly column in the Surrey Mirror that continues to be an excellent channel for communication with the public about the day-to-day challenges and achievements of the Trust. • This month we issued three proactive press releases and achieved 100% pick-up rate.

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5. Become a sustainable, effective organisation Live within our means both in year and sustainably into the future • At Month 4 the Trust is favourable to plan with a £0.2m surplus. The forecast remains breakeven. • The Trust is intending to write to the TDA regarding resolution of non recurrent income/cash support (as discussed at the Board previously), as no further information has been received. • Month 4 has been another stable month, building on the improvements seen since the first couple of months of the year. This is reflected in the overall position and the improved savings position (£1.8m achieved year to date). But, contract income is below the Trust plan. Although we are reducing outsourcing early (hence the jump in savings) and 18 weeks performance is strong, in all specialties volumes of elective activity have not caught up the loss of activity in April. It should be noted that several corporate budgets are overspending slightly at M04.

5. Become a sustainable, effective organisation Live within our means both in year and sustainably into the future • The Trust has shared forecast annual contract performance with the CCG’s, and vice versa, and the different positions have been aired at two major meetings. The Trust view is that there will be significant over performance (adverse) to CCG plans, while the CCG view is that QIPP plans based on admission avoidance action for non elective activity will impact in the last half of the year. The latter would require a 10-20% reduction in activity against a context of July having the greatest number of A&E attendances all year and non elective activity volumes being the highest all year • The cash balance has dropped from last month but is still healthy at £3.7m, and is on plan. The cash flow forecast assumes receipt of the £5.5m non recurring support income. • The PACS/RIS implementation problems reported elsewhere will have a financial impact (the cost of additional radiology reporting/services) and potentially an income impact. It is difficult to quantify that at this stage.

5. Become a sustainable, effective organisation Development of our workforce • The focus of work within the Trust is on continuous recruitment to our nursing vacancies and the most cost effective use of contingent workforce to ensure that the highest quality standards are maintained and deliver financial savings. • The vacancy rate and turnover have fallen in July 2013. This is the first time both have fallen in month and is an encouraging sign that recruitment and retention initiatives are taking effect. • There is a small increase in agency use with a more significant reduction in bank use this month. Despite the reduction in agency the % of pay on agency has increased due to the increase in use of locums.

5. Become a sustainable, effective organisation Development of our workforce • Sickness absence has fallen slightly this month to 3.4% which is also lower than the same period last year (3.8%) with the reduction being in short term absences. The summer months traditionally show lower absence rates and so the reductions over the past 5 months need to be sustained into the winter in order to achieve the 3.5% target. • The top 3 reasons for absence are unchanged from last month (Surgery, Anxiety/stress/depression/other psychiatric illnesses followed by Gastrointestinal problems ). • Both appraisal and mandatory training compliance are now at target and actions will continue to ensure this is sustained throughout the year. • IG governance training compliance is below target for YTD with actions in place to ensure training activity is spread throughout the year to minimise service disruption.

5. Become a sustainable, effective organisation UPDATE Implement our plans to become an FT by 2014 and Ensure that the estate and infrastructure supports our sustainability • The FT project board continues to meet on a six weekly basis. FT progress is also reviewed at the monthly TDA oversight meeting. The Trust submitted its Long Term Financial Model in August to the TDA. • The 2013/14 capital plan is progressing as expected with significant work underway on the Theatre rebuild. • In relation to the IT Strategy, we are experiencing some problems with the PACS/RADNET implementation however there has been considerable movement in addressing some of the issues in recent weeksWe will continue to work closely with both BT and Cerner to implement a solution as quickly as possible.

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6. AppendicesGlossary of Terms AMI Acute Myocardial Infarction C diff Clostridium difficile CDSCommissioning Data Set FFCE First Finished Consultant Episode H&SHealth and Safety HSMRHospital Standardised Mortality Rates LOLERLifting Operations and Lifting Equipment Regulations 1998 MRSAMethicillin-Resistant Staphylococcus aureus RACPRapid Access Chest Pain RIDDORReporting of Injuries, Diseases and Dangerous Occurrences Regulations SUI Serious Untoward Incident TIATransient Ischaemic Attack WTE Whole Time Equivalent 37

6. Appendices18 Week Waits – Breach Reasons 38

6. Appendices18 Week Waits – Breach Reasons 39

Integrated Performance Report M04 – July2013