Operational Performance. SaTH Overall Performance

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1 Balanced Scorecard Summary 3 Operational Performance inance Previous This Year to Date Previous This Year to Date Number Number Number Number Number Green Green Amber Amber Red Red Applied Applied SaTH Overall Performance Previous This Year to Date Number Number Number Green Amber Red Applied Quality Safety Previous This Year to Date Previous This Year to Date Number Number Number Number Number Number Green Green Amber Amber Red Red Applied Applied

2 Domain Lead Exec OP WD A&E A&E A&E A&E A&E Indicator Sickness absence rate Cancelled ops Definition Performing Under performing 3.39% % 4.60% 4.15% 4.33% N/A our hour maximum wait in A&E from arrival to admission, 95% 94% % 90.91% 94.50% % transfer or discharge 1 Unplanned re attendance rate Unplanned re attendance at A&E within 7 days of original attendance (including if referred back by another health professional) Left department without being seen rate Time to initial assessment 95th centile Time to treatment in department median Breaches of 28 days readmission as % of Prev month cancelled ops RTT admitted 95th RTT non admitted 95th RTT incomplete 95th RTT admitted 90% in 18 weeks Operational Performance RTT non admitted 95% in 18 weeks 2 week GP referral to 1st outpatient 2 week GP referral to 1st outpatient breast symptoms >5% % >5% % 1.78% 1.89% 2.06% 1.91% 0.91% 1.28% 1.30% 1.17% >15 Mins Minutes >60 Mins Minutes Continue to manage implementation of agreed action plan ongoing. Director of Operations and Director of Patient Safety & Quality 1 Continue to manage implementation of agreed action plan ongoing. Director of Operations and Director of Patient Safety & Quality 2 Contracts & Performance to seek confirmation from the Centre that they are the Time to Initial Assessment numbers are accurate and are signed off on a monthly basis 5% 15% % 17.24% 5.76% June information not available at time of publishing the report. <=23 >27.7 Weeks <=18.3 Weeks <=28 >36 Weeks % 85% % 85.22% 82.84% 77.54% 81.63% 95% 90% % 95.04% 96.08% 96.59% 95.90% 93% 88% % 97.85% 94.46% % 93% 88% % 98.41% % % Centre Chiefs for Ophthalmology & T&O are to sign off detailed action plans from both specialties within a fortnight Centre Chiefs for Ophthalmology & T&O are to sign off detailed action plans from both specialties within a fortnight Urgent Care Pathway Improvement Action Plan Urgent Care Pathway Improvement Action Plan 31 day second or subsequent treatment surgery 31 day second or subsequent treatment drug 31 day diagnosis to treatment for all cancers Proportion of patients waiting no more than 31 days for second or subsequent cancer treatment (radiotherapy treatments) 62 day referral to treatment from screening 62 day referral to treatment from hospital specialist 62 days urgent GP referral to treatment of all cancers 94% 89% % 91.67% 94.34% % 98% 93% % 96.49% 98.77% % 96% 91% % 98.13% 97.35% % 94% 89% % 100% 98.65% % 90% 85% % 94.44% 92.86% % 85% 80% % 96.55% 94.67% % 85% 80% % 86.42% 82.43% % Stroke Cancelled ops Patients that have spent more than 90% of their stay in hospital on a stroke unit 80% 60% % 86.30% 83.60% 89.90% 85.80% Delayed transfers Delayed transfers of care 4% 5% % 3.23% 3.85% 3.38% 3.38% of care Ops Cancelled on day of or following Admission for non Medical reason Number

3 Quality Domain Lead Exec Indicator Definition Target / Q DQ&S Single Sex Accommodation Breaches Number Q DQ&S RED rated areas on your maternity dashboard? Number No No No No Q DQ&S alls resulting in severe injury or death Number Q DQ&S Grade 3 or 4 pressure ulcers Number Q DQ&S ormal complaints received Number Q DQ&S Certification against compliance with requirements regarding access to healthcare for people with a learning disability Certification against compliance with requirements regarding access to healthcare for people with a learning disability Associate Director of Quality & Patient Experience is implementing the agreed action plan which is anticipated to deliver compliance with all 6 measures by Dec 2012 Quality & Safety Report

4 Domain Lead Exec Indicator Definition Target / S MD SHMI latest data Ratio N/A S MD Venous Thromboembolism (VTE) Screening 90% % 90.05% 91.72% 90.12% 90.97% S MD Elective MRSA Screening % 90.16% % N/A S MD Non Elective MRSA Screening % % N/A S DQ&S Open Serious Incidents Requiring Investigation (SIRI) Number N/A S DQ&S "Never Events" in month 0 Number S DCRM CQC Conditions or Warning Notices Number S DCRM Open Central Alert System (CAS) Alerts Past Completion Date Number N/A S MD 100% compliance with WHO surgical checklist 100% Y/N 99.60% 99.50% 100% N/A S MD Clostridium Difficile 45 Number S MD MRSA 2 Number Are there any compliance conditions on registration No No N/A outstanding. Are there any restrictive compliance conditions on registration outstanding. Moderate CQC concerns regarding the safety of Yes No No N/A healthcare provision Major CQC concerns regarding the safety of healthcare provision Safety ormal CQC Regulatory Action resulting in Compliance Action 1 Root Cause Analysis(RCA) of all cases is being undertaken by the Infection Prevention & Control team. 2 indings to be presented at the routine Infection Prevention and Control Operational Meeting 3 escalted to the relevant Centres if apprpriate. HCAI Report S DCRM CNST ormal CQC Regulatory Action resulting in Enforcement Action NHS Litigation Authority ailure to maintain, or certify a minimum published CNST level of 1.0 or have in place appropriate alternative arrangements

5 inance Domain Lead Exec Indicator Definition Target / D Agency and bank spend as a % of turnover % 6.61% 5.30% 5.70% 5.80% RR Underlying performance EBITDA margin % N/A RR Achievement of plan EBITDA achieved % N/A RR inancial efficiency Return on assets % N/A RR inancial efficiency I&E surplus margin % N/A RR Liquidity Liquid ratio days N/A RR Average Weighted Average N/A D D Unplanned decrease in EBITDA margin in two consecutive quarters Quarterly self certification by trust that the financial risk rating (RR) may be less than 3 in the next 12 months RR 2 for any one quarter Yes Yes Yes N/A Working capital facility (WC) agreement includes default clause N/A N/A N/A N/A Debtors > 90 days past due account for more than 5% of total debtor balances Creditors > 90 days past due account for more than 5% of total creditor Yes No No N/A balances Two or more changes in inance Director in a twelve month period Interim inance Director in place over more than one quarter end Quarter end cash balance <10 days of operating expenses Yes Yes Yes N/A Capital expenditure < 75% of plan for the year to date No No Yes N/A Please refer to the 3 inance Report for actions and narrative related to the inance Measures. 3 inance Report