SUPPORTING PAPER (FOR ACTION) BOARD OF DIRECTORS MEETING

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1 SUPPORTING PAPER (FOR ACTION) BOARD OF DIRECTORS MEETING Date of meeting: Tuesday, 29 May 2012 Title of paper: Performance: Integrated Performance Report Reporting period April 2012 Performance Improvement Plan Presented by: Executive Summary: Nichola Fairless The attached papers consist of the: Integrated Performance Report as per the 2011/12 format (Including a letter from the Department of Health outlining a technical amendment to the Category A 8 minute performance measurement) Recommendations: Performance Improvement Plan 2012/13 The Board is asked to note the successful April Category A8 and A19 performance. CQC Essential Standards of Quality & Safety: Involvement and Information Personalised care, treatment and support Safeguarding and safety Suitability of staffing Quality and management Suitability of management Legal Issues: Author: Date: None identified Nichola Fairless 21 May

2 NORTH EAST AMBULANCE SERVICE NHS FOUNDATION TRUST PERFORMANCE IMPROVEMENT PLANS AND PERFORMANCE REPORTING FOR 2012/13 PRESENTED BY: ASSOCIATE DIRECTOR OF STRATEGY, CONTRACTING AND PERFORMANCE EXECUTIVE SUMMARY We continue to improve our performance management processes including developing the Integrated Performance Report (IPR) towards full automation and the creation of the Performance Improvement Plan (PIP) for 2012/13. The IPR for April demonstrates successful performance in our key targets, including Category A8 and A19 response times. The PIP highlights our areas of priority for performance management for 2012/13 and proposes target trajectories and thresholds. It is requested that the Board approve the PIP in its present state and as a developing process for the year. The Trust received a letter from the Department of Health which confirms the technical changes to our Category A8 response time target, which takes effect from 1 st June This letter is included for reference. PERFORMANCE IMPROVEMENT PLANS AND PERFORMANCE REPORTING FOR 2012/13 1. Introduction 1.1 This paper details a summary of a series of complementary reports that will be used to support Trust performance management throughout 2012/ The reports include: Integrated Performance Report as per the 2011/12 format Performance Improvement Plan 2012/13 A new Integrated Performance Report is being developed for the May Trust Board meeting and will be sent separately to this document. 2. Integrated Performance Report (2011/12 format) 2.1 The on-going development of the IPR has led to us continue with the production of the usual report. This will continue until we are satisfied we can assure the new reporting process and format. The most notable points in the IPR this month include: April A&E performance in the May IPR is strong, entering the financial year with strong Category A8 and A19 performances against the national targets of 75% and 95% retrospectively. A&E activity is high for this time of year and we are currently above contract levels. There are no Serious Incidents to report and we have seen a reduction in staff assaults. The number of staff assaults has been consistently reported in last year as increasing, however this has been attributed to improved reporting process (as confirmed in the most recent staff survey). 2

3 There has been one public liability claim and three employer liability claims. Overall last year we had no public liability claims and 24 employer liability claims. All are under review. The public liability claim is in relation to PTS vehicle parts. Sickness absence has increased from March to 5.97%. Operational areas are high. A&E Operations was discussed in the inaugural A&E SLM meeting and lessons were to be learnt from the approach in the Durham Division and it was confirmed that many actions were being undertaken to improve the position. 2.2 There is no financial information available in this edition of the IPR due to the timing of publication of the IPR coinciding with annual reporting and annual planning activity. The final May IPR will be made available early June for completeness. 2.3 The Cost Improvement Plan shown in the IPR is an indicative position and shows the planned annual savings against each scheme/area. There is an allocation of 900k to unidentified schemes shown in the report. A CIP Recovery Planning session was held to review the CIP scheme for 2012/13 and future years and there are now anticipatory plans to mitigate the 900k risk that will be made available by the Service Lines Managers by the end of June. The PMO is compiling a register of potential schemes to provide further mitigations for those schemes not specifically allocated to a service line. 2.4 The financial tracking is being developed for each scheme now the indicative CIP is completed and will be in place for next month s report. 3. Performance Improvement Plan 2012/ The Performance Improvement Plan has been compiled drawing on a variety of reporting and performance sources. This is included with the IPR as it provides details of the proposed RAG rating for 2012/13 monitoring and exception reporting. The Trust Board is asked to review and approve the reporting thresholds that are proposed. 3.2 Key areas for improvement include: Improved rural A&E response performance NHSLA Compliance Data Quality management Reduce sickness absence Violence against staff Percentage of Staff experiencing discrimination Patient flagging (in the Control room) Reducing Hospital Turnarounds 4. New IPR for 2012/ The new IPR that has been shared this month is still work in progress. A number of outstanding developments will be progressed throughout the remainder of May and June: Incorporation of targets and monitoring thresholds Scope for exception reporting Further developing the data capture - staff reporting have asked to be able to provide more detail than what is required of the IPR and the now delegated reporting to support other reporting process and local monitoring Testing the aesthetics/presentation 3

4 4.2 A second iteration of the new IPR will be available in June for the Board to review. 4.3 In addition to the previously agreed content, it is also now proposed to incorporate additional A&E reporting in line with the recent announcement of the changes to Call Connect. From 1 June 2012 Category A s will be reported as Red 1 s and Red 2s. This is to account for the clock start change for Red 2 s. The clock start will either be: the time at which a disposition is reached (dx code in NHS Pathways), the time of first allocated vehicle, or when 60 seconds has elapsed, whichever is sooner. 4.4 Centrally, we are required to continue to report Category A8 and achieve the 75% target, responding to calls within 8 minutes, and to also report the response times for Red 1 s at the 95 percentile. There is an expectation that we will demonstrate continuous improvement in performance to reach 80% of Red 1 calls by April The Gateway letter detailing the changes is attached at Appendix 1. There are a number of issues that will be required to be managed throughout 2012/13: The number of Red 1 calls for NHS Pathways users remains low, making it challenging to achieve 75% (1 missed incident result in whole percentage reduction), and even more challenging to achieve 80%. The performance gain achieved from changing the clock start for Red 2 s, leads to an inequitable performance gain across the region, with the urban areas seeing greater performance improvements. Clarification is to be sought regarding reporting of the year end position and how to account for April and May performance reporting. Nichola Fairless Associate Director of Strategy, Contracting and Performance 21 May 2012 N:\Public\Performance Management & Business Planning\IPR\ \April Data - May Meeting\IPR - Cover Sheet and Paper - May 2012 Board.docx 4

5 Performance Improvement Plan 2012/2013 Date: 09 th May 2012 Version 1.1 Document Control Date Version Amendments Author 09/5/ R Lonsdale, Business Planning and Performance Manager 1.1 Additions NF 5

6 NORTH EAST AMBULANCE SERVICE NHS FOUNDATION TRUST Performance Improvement Plan 2012/13 1. Introduction 1.1 The Trust is committed to continuous quality improvement and is focussed on delivery of the performance improvement strategy and the Trust s vision and long-term strategic direction. The strategy outlines the vision for performance management for 2011/ /14 and the steps required to put in place to achieve that vision. 1.2 As part of the strategy it is a requirement to establish an effective process that will ensure that there is improvement focus and where necessary, investment focus, on the areas that have either been identified as non-compliant, of poor performance or are high risk, as part of the annual review process and in year monitoring. 1.3 The refresh of the annual performance improvement plan is intended to provide that focus. 2. Identifying performance improvement priorities for 2012/ The Trust Board and the Executive Team annually drive the development of the Trust s strategic direction and use a variety of performance reports and business intelligence to inform the setting of the strategic objectives for the year. This is followed by an inclusive event for all managers to participate in, to risk assess each strategic objective which then leads to the production of the Trust s Board Assurance Framework for the year. 2.2 The performance improvement priorities are then compiled by the Business Planning and Performance Team in discussion with Trust managers and are then put forward to the Trust Board for approval. The priorities will be determined using a variety of sources including the monthly QRPs, compliance frameworks, NHSLA standards, emerging themes from root cause analyses, complaints, emerging evidenced-based practice, surveys, focus groups. This list is not exhaustive. 2.3 Performance improvement trajectories will also be agreed and put in place for key metrics, currently a selection of those contained within the monthly Integrated Performance Report. 2.4 It is expected that each of the improvement areas identified will be monitored via existing reporting; the monthly Integrated Performance Report, Quarterly Performance Report, Quality and Risk Profile Summaries, working groups and committees. Each priority area will have an identified lead and improvement action plan to monitor delivery and will be expected to report into their relevant working group or committee. Progress reports on action plan delivery or ongoing risk to delivery will be reported through structures such as Programme Boards and Service Line Groups where they exist and will be reported/escalated up to the Board of Directors via monthly and quarterly performance reporting. 3. Priorities for 2012/13 and setting of local performance trajectories 3.1 There are 24 performance improvement areas identified as priorities for 2012/13. The rationale for their identification and summary of actions are shown in the attached Table in Appendix 1. The monitoring procedure in place is also described. 3.2 As part of the development of quarterly and monthly performance reporting the Business Planning and Performance Team has been working with leads to review historical performance trends, available benchmarking and their business plans in order to set performance trajectories for key indicators that are being actively monitored. Red, Amber, Green (RAG) reporting has also been agreed to enable 6

7 appropriate escalation. All Red rated indicators will require an exception report for Board reporting. The key indicator performance trajectories and associated RAG ratings used are shown in Appendix Performance trajectories are not in place for all indicators and where an agreed trajectory is not in place or the performance area is new; it is the intention to use 2011/12 reporting to establish a baseline. There are also a number of zero tolerance indicators where we have set a target of zero, for example, in the case of Serious Incidents. 3.4 The performance trajectories are to be utilised to drive and evidence progressive improvement, however 100% achievement will be the ultimate goal to ensure that service provision is fair. Whilst 95% performance is considered good in most situations, the poorer performance is not acceptable for the remaining 5%. Rachel Lonsdale Business Planning and Performance Manager 09/05/2012 7

8 Performance Improvement Priorities 2012/13 The QRP referenced was April 2012 (March 2012 report period) Improvement Priority Information Source Rationale for inclusion in Plan Lead Summary of actions and monitoring A&E Category A8 performance 2012/13 achievement of 75% in each Quarter and at year-end A&E Category A8 performance 2012/13: Redcar & Cleveland: 75% in each Quarter and at year-end County Durham: 71% at year end, and one day at 75% Northumberland: 71% at year end, and one day at 75% NHS National Ambulance Service Contract and CQUIN Scheme for 2012/13 QRP Outcome 4 Care and Welfare of people who use the services Category A8 is a key national target and as an FT it is one of two indicators used in the compliance framework by Monitor. Targets for rural areas (Redcar & Cleveland / County Durham / Northumberland) have been set by commissioners this year and additional funding has been received through the CQUIN schedule for 2012/13 to support attainment of these targets. The Trust supports equitable service delivery and acknowledges without additional funding achievement will be challenging. 71% (or 75%) attainment is not sustainable into 2013/14 without recurring funding and increased funding Paul Liversidge, Chief Operating Officer A&E Review will deliver efficiencies and an element of the new targets. An action plan to achieve rural performance is in development and includes: Increasing resources Urgent Desk to manage urgent and community first responder deployment Enhanced escalation procedure Interim arrangement for PTS support and expansion of use of agency paramedics Monitoring: The action plan and improvements will be monitored and reported through the CQUIN route and internal reporting lines. Monthly performance review meeting (likely to be superseded by Service Line Management meeting) A&E Review; highlight and exception reporting via PMO to ISG NHSLA attainment of CNST Level 1 Mock assessment July 2012 The mock assessment results indicated the inability to progress to Level 2 and raised concerns regarding sustaining attainment of Level 1. Non-attainment of Level 1 poses threat to our Governance Risk Rating as assessed by Monitor. Ann Fox, Director of Clinical Care and Patient Safety A revised action plan has been developed to ensure the necessary improvements are made to maintain level 1. An informal (mock) assessment is planned for July 2012 with the formal assessment to follow in September Monitoring: The plan is monitored fortnightly by the Risk and Claims team in conjunction with the Monitoring and Compliance Officer. Limited progress to Level 2 increased risk to CIP contribution in 2014/15 QRP regularly updated, and every quarter reported to the Governance & Risk Committee and to the Quality Committee. Cost Improvement Programme Assessor case (Monitor) Trust financial requirement Increased challenge for 2012/13 as assessor case increased from 4% to 4.5%. Target set at 4,370 Achievement of the CIP is paramount to our business plan for 2012/13. Efficiency savings will continue to be challenging and focus on each scheme will be key to our financial sustainability. Simon Featherstone, Chief Executive Schemes are identified to the value of 3.5m. Mitigation schemes are being identified following a risk assessment of the current CIP. Monitoring: Programme Management Office and Improvement Steering Group. Summary reporting in IPR. Reporting to BIF Committee 8

9 Improvement Priority Hospital turnaround times Information Source Rationale for inclusion in Plan Lead Summary of actions and monitoring Reporting to acute trusts on weekly and monthly basis Turnaround problems continue to escalate and days lost due to delays over 25 minutes are now in excess of 70 days per month, compared to 30 days last year during the severe winter weather. Delays continue at City Hospitals Sunderland and an Emergency Care Intensive Support Team has been called in to review the situation. We have been working closely with commissioners and the hospital to resolve the issues locally. Paul Liversidge, Chief Operating Officer On-going development of user screens to ensure sufficient information is provided to help A&E departments prepare for patient arrivals. Kaizen development activity. Review of the Divert/Escalation Policy. Monitoring: A&E performance meetings (likely to be superseded by SLM meetings). Trust Board is interested and receives update reports through the Quarterly Performance Report. Continued reduction of sickness related absence Board IPR exception reporting above target each month 2011/12 CIP for 2012/13 The Trust has set a 5% sickness target. The target is to be achieved during 2012/13. During 2011/12 sickness absence in some service lines at times has reduced below 5% but has also reached in excess of 7% in some months. Sickness absence increases the use of overtime and cost to the Trust. This is an identified Cost Improvement Scheme for 2012/13 expected to deliver 486k savings. Elma Alexander, Interim Director of HR Pilot schemes initiated in 2011/12 have been extended into 2012/13 based on their evaluation and evidenced success. An HR Sickness Advisor has been appointed and changes have been made to the staff attendance policy to further reduce sickness absence. Monitoring: Absence is monitored by service line and each support function and will be reviewed monthly in the IPR and service line management meetings. Sickness absence CIP; highlight and exception reporting via PMO to ISG. Development of new national clinical quality indicators NHS National Ambulance Service Contract NHS Outcomes Framework As this is the second year of the new indicators, the first year being the development phase, monitoring thresholds have been set to establish performance improvement. Improvement methodologies will be developed throughout 2012/13. The thresholds are shown in Appendix 2. Ann Fox, Director of Clinical Care and Patient Safety Formally devolve reporting and performance management ownership to relevant service lines throughout 2012/13 from the current working group. Monitoring: AQI Development Group reporting progress to the Quality Committee. Trust Board via the IPR. Improve staff appraisal rates/support from immediate managers/ staff appraised with personal development plans Staff survey 2011 (KF12, 13, 14, 15) QRP-Outcome 14- Supporting staff The Trust improved the percentage of staff receiving an appraisal, from 39% in 2010/11 up to 73% in 2011/12. Continuous improvement in the process is important to ensure our workforce personal development needs are met and training is tailored to patient need. A target has been set at 80% for 2012/13 and improvements are being made to the appraisal. Elma Alexander, Interim Director of HR and Organisational Development To improve the cascading of expectations of managers with regards to staff development, objective setting and appraisal. To establish a more effective appraisal process than that adopted in 2011/12. It is expected staff will receive their appraisal from their known manager and the appraisal process will be supported with access to individual performance management information. Monitoring: Departmental achievement monitored and reported by Directorate as available via the IPR and quarterly 9

10 Improvement Priority Information Source Rationale for inclusion in Plan Lead Summary of actions and monitoring performance report. Improve use of alternative services CMS/DoS referral rates (Hear & Treat) See & Treat Conveyance to alternative providers (subject to contract agreement) IBP vision CQUIN Indicator for 2012/13 The on-gong development of the Director of Services (DoS) and pressures faced by Commissioner to reduce demand (and expenditure) on acute A&E departments, investment is being made in the Trust through the CQUIN scheme for us to increase the use of alternative services (as listed in the DoS). Paul Liversidge, Chief Operating Officer CMS Analyst in post to provide gap analysis information. Gap and service utilisation reports to be developed for Commissioners and Providers. Set successful referrals rates as high priority Contact Centre KPI to drive and monitor improvement. Monitoring: Success referral rates and CMS DoS offer rate to be reported in Quarterly Performance Report. Monthly review of indicator as part of the performance agenda item in the CC Service Line Management meeting. Improve patient flagging in the Control Room Incidents reported End of Life Care Charter Poor management of flagging has led to incorrect information being shared with crews Improved Long Term Conditions Management Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in the last 12 months Staff survey 2011 (KF25) Reported to be worse than average when compared to other Trusts for this key finding in the staff survey in 2011 (35% against a national ambulance trust average of 29%). Ann Fox, Director of Clinical Care and Patient Safety The Trust has significantly improved the reporting process making it much easier for staff to report. Trends and emerging issues are able to be flagged through Ulysses. The Risk and Claims team are liaising with NHS Protect to explore potential loneworker device solutions. 50% of frontline Trust vehicles are now fitted with CCTV to increase staff safety. Investigations take place for every reported incident of violence.monitoring: Governance and Risk Committee and near misses are reported in the IPR. QRP action plan which is included as part of a standing item at the Governance and Risk Committee. Percentage of staff suffering work-related injury in last 12 months Staff survey 2011 (KF17) 38% of respondents to the staff survey reported suffering work-related injuries in the last 12 months, against a national ambulance sector average of 33%. Ann Fox, Director of Clinical Care and Patient Safety A staff survey action plan has been compiled and areas being addressed include a review of how staff Monitoring: Governance and Risk Committee Percentage of staff experiencing discrimination at work in last 12 months Staff survey 2011 (KF38) 27% of respondents reported experiencing discrimination at work in the last 12 months, against a national ambulance sector average of 22%. Elma Alexander, Interim Director of HR and Organisational Development Ambulance calls QRP- Outcome 4- Acceptance rates from the DoS are lower than Tom Howard, Audit activity is ongoing to identify learning requirements for 10

11 Improvement Priority closed with telephone advice (where clinically appropriate) Information Source Rationale for inclusion in Plan Lead Summary of actions and monitoring Care and welfare of people who use services expected, based upon appropriateness of referrals. Head of Contact Centres call handlers to help improve the rate of accepts from the DoS. Individual performance reports are being developed for a sample of staff, which will be rolled out to all staff going forward. The new Team Leader tier will lead on driving improvements. Monitoring: The QRP action plan is included as part of a standing item at the Governance and Risk Committee and monitored monthly. Proportion of patients with clinical diagnosis of STEMI where two pain scores were recorded or a valid exception is recorded. QRP Outcome 4- Care and welfare of people who use services This is scored as worse than expected in the QRP, due to the Trust performing under the ambulance sector average for the period of QRP data (June 2011). As this forms part of the Ambulance Quality Indicators it is necessary to include in this performance improvement plan to ensure sufficient focus is retained on making consistent improvements. Ann Fox, Director of Clinical Care and Patient Safety The Trust has improved in this quality indicator, and is now performing above the national average. This is monitored by the Clinical Department and reported to the Board and the Quality Committee. Staff believing trust provides equal opportunities for career progression or promotion QRP-Outcome 12- Requirements relating to workers Staff Survey 2011 (KF 38) 68% of respondents felt the trust provides equal opportunities for career progression or promotion, which is slightly under the 70% national ambulance sector average. Elma Alexander, Interim Director of HR and Organisational Development The Trust is developing a Talent Management Programme which aims to identify and develop staff with potential for progression. Comprehensive training plan is in place for 2012/13 developed in line with Trust needs and following information supplied through the appraisal process. Monitoring: The QRP action plan is included as part of a standing item at the Governance and Risk Committee and monitored monthly. Trust commitment to work-life balance QRP Outcome 14- Supporting staff Staff survey 2011 (KF7) The trust scored 2.86 for this finding, against a national ambulance sector average of Elma Alexander, Interim Director of HR and Organisational Development The Trust will be procuring a Workforce Management System during 2012/13 which should improve work-life balance for Contact Centre staff. Recruitment of a Team Leader tier should also improve this. Monitoring: The QRP action plan is included as part of a standing item at the Governance and Risk Committee and monitored monthly. Staff experiencing physical violence from patients/relatives in last 12 months. QRP Outcome 14- Supporting staff Staff survey 2011 (KF23) 21% of respondents reported experiencing violence from patients/relatives in the last 12 months, against a national ambulance sector average of 19%. Alan Gallagher, Head of Risk and Claims Risk and Claims team are liaising with NHS Protect to explore potential loneworker device solutions. 50% of frontline Trust vehicles are now fitted with CCTV to increase staff safety. Investigations take place for every reported incident of violence. Monitoring: The QRP action plan is included as part of a 11

12 Improvement Priority Information Source Rationale for inclusion in Plan Lead Summary of actions and monitoring standing item at the Governance and Risk Committee and monitored monthly. Staff experiencing harassment, bullying or abuse from patients/relatives in last 12 months. QRP Outcome 14- Supporting staff Staff survey 2011 (KF25) 34% of staff reported experiencing harassment, bullying or abuse from patients/relatives in the last 12 months, against a national ambulance sector average of 29%. Alan Gallagher, Head of Risk and Claims Risk and Claims team are liaising with NHS Protect to explore potential loneworker device solutions. 50% of frontline Trust vehicles are now fitted with CCTV to increase staff safety. Investigations take place for every reported incident of violence. Monitoring: The QRP action plan is included as part of a standing item at the Governance and Risk Committee and monitored monthly. Consistency of reporting to the National Reporting Learning System (NRLS) QRP Outcome 16- Assessing and monitoring the quality of service provision An audit of all incidents from 31 March 2011 to September 2011 was conducted. The Trust found there were a significant number of Patient Safety Incidents not reported to the NPSA (these have all now retrospectively been sent). Alan Gallagher, Head of Risk and Claims The Risk and Claims team now carry out an audit of all reported incidents on a weekly basis to ensure accurate categorisation of all incidents including Patient safety Incidents and near misses. Monitoring: The QRP action plan is included as part of a standing item at the Governance and Risk Committee and monitored monthly. Staff reporting errors, near misses or incidents QRP Outcome 16- Assessing and monitoring the quality of service provision 89% of respondents reported witnessing an error, near miss or incident in the last month (within the staff survey) an increase of 1% against the 2010 survey result. Alan Gallagher, Head of Risk and Claims Ability to report online has encouraged staff to actively report, thus increasing reporting figures. A shortened reporting format has made near-miss reporting easier. Feedback and investigation processes have also improved. Staff survey 2011 (KF21) Monitoring: The QRP action plan is included as part of a standing item at the Governance and Risk Committee and monitored monthly. Audit of Trust corporate records and information as part of the records lifecycle management strategy. QRP Outcome 21- Records This is rated as Tending towards worse than expected in the QRP. Tia Cheang, Head of Informatics A revised ESR staff list will facilitate the update of the active directory from IT systems. Folders will be moved to the N drive structure going forward, following meetings with department heads. A new N Drive filing system will also be established. Monitoring: The QRP action plan is included as part of a standing item at the Governance and Risk Committee and monitored monthly. Commercial Services financial surplus Board IPR monthly exception reporting This has been regularly exception reported in the IPR due to level of contribution failing to achieve against plan. This has been primarily due to inappropriate profiling of the plan and inclusion of training centre costs that are not attributable to this service line. Paul Liversidge, Chief Operating Officer Commercial Services has developed a three year business plan and we will track delivery of financial surpluses Monitoring: Service line management meetings and IPR. Reporting to BIF Committee The refining of the plan will be an iterative 12

13 Improvement Priority Information Source Rationale for inclusion in Plan Lead Summary of actions and monitoring process and whilst this is a relatively small service line, the level of contribution may become significant longer term as the service line develops. Data quality Gap in reporting As the Trust strengthens and increases the provision of information and performance information and greater reliance is placed on information to help make decisions it is important to have high quality data, and information that is timely and reliable. The Trust is required to report on the quality of data used to inform the Quality Accounts Priorities. Roger French, Director of Finance A new Information Governance Officer is has been appointed who leads on Data Quality within the Trust.. A Data Quality Assurance working group is now in place. EIS development project is underway and this will be monitored throughout the year. Monitoring: Introduction of data quality indicators derived from the Data Quality Plan are reported to Service Line Groups where established and progress monitored through the Information Governance Working Group. 13

14 Key indicator performance trajectories and RAG ratings for 2012/13 as reported in the IPR IPR Indicator 11/12 Outturn G% A% R% Target Essential Annual Training 79% <=10 <= % Appraisal 73% <=10 <= The number of patients receiving PPCI treatment within 150 minutes (NOTE: figures shown are 3 months behind) STEMI Care Bundle (Aspirin+GTN+Two Pain Scores+Analgesia given) Return of Spontaneous Circulation (ROSC) palpable pulse on arrival at hospital following resuscitation attempt Return of Spontaneous Circulation (ROSC) palpable pulse on arrival at hospital following resuscitation attempt [UTSTEIN**] 96% >=75 <75 75% 78.8% <=81 <=86 >= % <=16 <=21 >= % <=44 <=49 >=50 Survival to discharge 8.26% NA Survival to discharge [Utstein**] 27.12% NA FAST positive patients (assessed face to face) potentially eligible for stroke thrombolysis within agreed local guidelines arriving at hospital with a hyperacute stroke centre within 60 minutes of call connect Care Bundle (FAST + BM + BP recorded) 86.47% <=85 <=90 >= % <=90 <=95 >=96 Q1 Q2 Q3 Q4 87% 88% 89% 90% Q1 Q2 Q3 Q4 22% 23% 24% 25% Q1 Q2 Q3 Q4 50% 51% 52% 53% Q1 Q2 Q3 Q4 7% 7% 8% 8% Q1 Q2 Q3 Q4 32% 32% 33% 33% Q1 Q2 Q3 Q4 91% 92% 93% 94% Q1 Q2 Q3 Q4 96% 96% 97% 97% Response performance distribution <=1 >=1.1 1% per month Serious Incidents (actual value) 7 =0 >=1 0 Patient Safety Incidents (actual value) 417 Q1 Q2 Q3 Q4 <=20 >=21 >=25 35/Month Near misses clinical (actual value) 36 <=2 >=3 >=6 2 per month Neas misses non clinical (actual value) 26 <=2 >=3 >=6 2 per month Assaults on staff (actual value) 126 <=11 >=12 >=15 11 per month Aggression (actual value) 129 Q1 Q2 Q3 Q4 <=10 >=11 >= / Month Category A8 R1 N/a >=80 <80 80% Category A8 R2 N/a >=75 <75 75% Category A % >=95 <95 95% A&E call answer performance 97.2% >=95 >=92 <91 95% in 5secs PTS call answer performance 84.34% >=90 >=87 <87 90% in 30secs 111 call answer performance 98.07% >=95 >= 92 < 92 95% in 80secs 111 call abandonment 0.49% <=1 <=3 >3 >80secs 999 call abandonment 0.84% <=0.5 <=1 >1 1% PPCI 96% >=75 <=74 75% RE-CONTACT RATE following discharge of care by Telephone Advice 14.99% TBC 17% 14

15 IPR Indicator 11/12 Outturn G% A% R% Target RE-CONTACT RATE following discharge of care from Treatment at scene 5.22% TBC 7% Proportion of Calls from patients for whom a locally agreed frequent caller TBC TBC TBC procedure is in place Call Closed with telephone advice 3.35% TBC 3.5% Incidents managed without the need to transport to A&E 33.07% TBC 33% Time to Answer Call 95th %ile 1 TBC 1 second Time to Treatment 6 mins Median TBC TBC 14 mins 95th %ile 22 mins 99th %ile Written response provided without extending their response timeframe on TBC Baseline to be established Baseline to be established more than two occasions Complaints received 291 TBC 0.79 per 1000 incidents Appreciations 271 TBC 0.74 per 1000 incidents EBITDA Margin 12.02% >=9 <=8.9 <=1 9.2% Cash budget 9,576,000 TBC TBC Liquidity ratio I&E Surplus Margin 3.3% NA >=-1.9 <=-2 1.1% CIP 4,704,718 >=0 >-5 but <0 of total CIP <-5 of total CIP 4.807M (of which 4.370M CIP and 0.436M Revenue Generating) Commercial Services Income 954,562 TBC TBC Commercial services Surplus 253,684 TBC TBC Establishment TBC TBC Staff in post NA NA Occupied rate 94.72% NA NA Staff leaving trust 0.78% NA NA Absence % 6.32% >=5 >=5.1 >=5.6 5% Absence YTD 5.82% >=5 >=5.1 >=5.6 5% Quality Account Patient Experience TBC Baseline to be established Baseline to be established Call Closed with telephone advice 3.35% As above As above Incidents managed without the need to transport to A&E 33.07% As above As above Rural Performance: 77.53% >=75 <75 Redcar and Cleveland 75% 66.95% >=71 <71 County Durham 71% 67.79% >=71 <71 Northumberland 71% Accuracy of triage of major trauma pathways TBC Baseline to be established Baseline to be established CQUIN Patient Experience TBC As above As above Call Closed with telephone advice 3.35% As above As above Incidents managed without the need to transport to A&E 33.07% As above As above Rural Performance As above As above As above Non IPR Core Business Risk - IT TBC Clinical Negligence Claim (actual value) 4 =0 >0 0 Public Liability Claim (actual value) 0 Green:= 0 Red:>0 0 Proven cases of fraud (actual value) 0 Green:= 0 Red:>0 0 Vehicle Cleanliness swabs 91% >=95 >=90 <=89 95% 15

16 IPR Indicator 11/12 Outturn G% A% R% Target Employers Liability Claims (actual Green:= 12 value) 0 Red:>0 0 Root Cause Analysis Panels TBC 16

17 Appendix 1 17

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