Paper ref: TB (12/18) 012

Transcription

1 Paper ref: TB (12/18) 12 Report Title Integrated Quality & Performance Report (IQPR) October 218 Sponsoring Executive Toby Lewis, Chief Executive Report Author Dave Baker, Director of Partnerships and Innovation Yasmina Gainer, Head of Performance & Costing Meeting Trust Board 6 th December Suggested discussion points [two or three issues you consider the Committee should focus on] Emergency care performance remains the most significant issue in October reporting. November as at 21 st Nov is showing performance at 8.8% with large daily fluctuations at Sandwell site during the month. Detailed recovery plans expect November to show performance improvement and a sustained control against current plan and delivery. The Patient Treatment List (Waiting list) has steadily increased throughout the year from 3,71 to 37,871 in October with a projection of 42, to 44, by the end of the year without intervention. A plan to address this across the first six months of 219 is being finalised. Beyond this we might note: 9x serious incidents (of which 5x are due to falls) Falls Increasing to a high 11 cases (possible validation down to 95) in October against a year to date avg trend of ~8 per month; with 5x serious injuries (pushing up the serious incidents count of 9). RTT delivers at 92.2% but with 2x Incomplete 52 week breaches in October. Cancer standards met Q2 constitutional standards. Alignment to 22 Vision [indicate with an X which Plan this paper supports] Safety Plan X Public Health Plan People Plan & Education Plan x Quality Plan x Research and Development Estates Plan Financial Plan Digital Plan Other [specify in the paper] 1. Previous consideration [where has this paper been previously discussed?] OMC, PMC, Quality & Safety Committee, CLE 2. Recommendation(s) The Trust Board is asked to: a. Note the performance for October. b. Assure that recovery plans are in place to address underperformance 3. Trust Risk Register Risk Number(s): all Board Assurance Framework Risk Number(s): all Equality Impact Assessment Is this required? Y N X If Y date completed Quality Impact Assessment Is this required? Y N X If Y date completed Page 1

2 October 218 Summary Notes from IQPR and Persistent Reds 1. Overall Performance Emergency Care, Diagnostic Imaging (DMO1) and mortality performance remain unacceptable, but are progressing individual recovery plans. The strategic importance of the DMO1 target warranted a Q recovery plans to recover DM1 (scanning performance) and create a 192 sustainability plan, which is being presented to the Trust Board in December. Delivering Performance: Cancer standards deliver full Q2 performance despite September 62 day being below 85%. RTT at 92.2% in October 21+ Stranded patients performing well against NHSI targets overall, with Dec target of 11 bed reduction reasonably expected to be in reach, if management of long stay patients continuous. However, we have underachieved October target by 6 beds and are behind for the November target at this stage. Exceptional UnderPerformance in October: In October the trust reports a high number of falls (11) of which 5 have been declared as a serious injury (this may reduce to 95 falls post validation, but remains a high number compared to previous month and warrants a detailed review and report). 2x Never Events due to wrong site surgery (Ophthalmology) and a case of a retained guidewire during a procedure in Cardiology (216/17 incident). 9x Serious Incidents (of which 5 are due to the falls injuries); this is a high incident rate for the trust and is unusual to be experienced in any single month, but overall impacted by the falls injuries. 4x cases of stillbirth in October causing a stillbirth rate at 7.86 in October (per 1, babies), which is the highest since last year same period. This is against 59 births in the month. 1x Patient Wait above 12 hours under the trolley wait rules in ED. Other Underperformance: VTE assessments missed for the fourth consecutive occasion in October, but reporting a much improved rate at 94.4% which has been achieved with intensive focus (449 assessments missed). A full quality improvement project plan is in progress to engage underperforming areas. Diagnostics fails to recover to 99% standard for the last eight months, with the highest level of breaches in October reported at 31 (293 of which are in Imaging). The performance at October is at 96.79% vs the 99% target (98.27% in September). CT, MRI and ultrasound scanning were the main causes of underperformance driven by consultant vacancies. The Executive team are well sighted on the imaging pressures and recovery of this DM1 reported performance is planned to recover in January 219. Pressure Ulcers have increased in October and show large variation to long term averages. 2x Pressure Ulcers in total between acute and community settings were reportable in October including a Grade 4 PU. Page 2

3 Neutropenic sepsis performance in October reports at 89% with 4/37 patients breaching. This is a much better improved performance compared to September (which was lowest performance since Dec216), but overall does not achieve the 1% standard. Stroke ward admissions within 4 hours are below the 8% target at 61%. 2. IQPR Persistent Red indicators Generally progressing steadily, but it seems difficult to move on some of the others Total Indicators 23 Note: Some are grouped and are in fact two or more separate indicators Resolved so far 6 WHO Safer Surgery (to 1%); Early Booking Assessment; Patient Safety Thermometer (to 95%); Cancellations (2pm) Cancellations as %age of elective admissions (.8%) PDR (to 95%) and estimated at 96% at October Delivery Expected Achieved standard for 2 months Achieved standard for 1 month Significant improvement close to target 1 Medical Appraisal (to upper quarterile).. at 9% in Oct Oct218 Working towards target improvement plans & expected to deliver in the near future 6 Mandatory Training (to 95%) Sickness Absence Rate / Sickness Absence cases (to 3%) Nursing (Band 5) / Workforce Turnover Treatment Functions Under 92% RTT Patients Waiting >52 weeks InSession Theatre Utilisation (to 85%) May219 Mar219 Mar219 Oct219 Apr219 JanMar219 Newly added and relapsing indicators 3 Diagnostics (to 99% standard) Unplanned A&E reattendances; Neck of Femur (to 85%) Jan219 Audit in progress TBC Actions TBC Without target improvement plans at this stage 5 Open Referrals Patient Bed Moves Mortality Reviews within 42 day Falls FFT Score & Responses Progressing plan Not identified Progressing plan Not identified Trajectory in progress Missing the set recovery plan 2 Neutropenic Sepsis Return to work interviews Actions TBC Was Sept18 New plan TBC 3. Introduction of New Indicators In October a new range of Workforce indicators has been added to the IQPR and some previously reported indicators have been removed. See workforce section. Page 3

4 Key IQPR Indicators Summary for October (month 7): Infection Control: Performing very well overall. The Trust has had 2x CDiff case in October, performing very well against this standard with year to date position of 8 cases against the year to date target of 17. Tracking well against the annual ceiling of 29. At trust level MRSA screening, electively and nonelectively achieves targets routinely, but PCCT and Medicine & Emergency Care are not. MSSA Bacteraemia (rate per 1, bed days) in October has seen an increase in rate which is at 15.7 compared to target of 9.42; year to date however in line with target at 6.8 vs 9.42 target despite this spike which appears to be a random variation caused by three unlinked patients. Harm Free Care : 2x Never events in October were reported in Ophthalmology and Cardiology. Wrong site surgery (Ophthalmology) and a retained guidewire during a procedure in Cardiology (216/17 incident). Serious incidents reported are the highest for a long period of time, at 9xcases in October, of which are 5x falls related. Achievement of 1% target against the WHO Safer Surgery continued into October; manual intervention is still required as the system for capturing the briefings information is not fully working (being addressed with clinical effectiveness and IT). Safety Thermometer at 99.5% in October against the 95%, this reports new harm only caused by SWB. In October there were 2 Pressure Ulcers reported; 13x PUs in the acute hospital setting (hospital acquired, avoidable), an increase to previous month; 3xgrade 3, 1x grade 4 and 9x grade2; the PUs per 1, Occupied Bed Days rate is.6; additionally there were 7x PU case in the district community setting. In October we have reported a large increase in falls (25% increase to year to date averages), with 5x falls resulting in serious injury reportable as a serious incident. The high levels are on AMUs, D16, N4, and L4. We have been seeing falls rise steadily in the last months. The year to date number of falls incurred is 584 against an annual target of 84; using the year to date value and assuming future falls are at current year avg, this this would imply a year end position of 11 falls; using a projection of year to date plus last three month avg this would project year end at 1,29. VTE assessments have been below required levels for a further month but reporting an improved position of 94.4% missing 449 assessments in the month. A project plan has been put into action to address compliance rates, and intensive monitoring effort is being made to recover the positon to target. The major underperforming areas remain the assessment units. Key Access Targets : 1 RTT & Diagnostics RTT signed off at 92.2% for October with 2x 52 week breaches. The waiting list has risen from 3,71 at the end of March 218 to 37,871 in October with a potential trajectory without intervention to between 42, and 44,. Acute Diagnostics (DM1) reporting at 96.79% in October. 31 total breaches reported by the trust; CT/MRI/Ultrasound accounted for 289 of these. A Sustainability project has been put in place having Page 4

5 not achieved previous recovery plans; the plan is aiming to address Q4 DM1 delivery for January 219 and 192 forecast demand and capacity. 2 Cancer Cancer performance reports one month in arrears to allow cancer network validations to take place; in October we report therefore the September position. Recognised as a delivering Trust; meeting routinely most of the cancer standards and this continuous into August. There were 7.5 breaches of the 62 day standard in September, overall resulting in the 62 day performance of 84.5% below the target of 85%, this was as projected last month, and does not impact the Q2 delivery of the standard which is at 86.5% again meeting the second quarter this year. 1. patient waited above 14 days. The case studies are routinely now submitted to the CEO for review The longest waiting patient to receive treatment was at 86 days. Neutropenic sepsis in October sees improvement from September and reports at 89.2% with 33/37 patients have been treated within the hour and 4 patients breached due to a number of different reasons (detailed, separate OMC report). All breaches are RCAed at the time and subject to a full review at a Breach Meeting. The Door to Needle time is in October remains steady at an average of 45 minutes compared to the 6 minutes requirement. Note: Referral to Faster diagnosis; a new cancer diagnosis standard, designed to ensure that patients find out within 28 days whether or not they have cancer, will be introduced in 22. collection starts in Emergency Care & Patient Flow EC performance for October was reported at 81.2%, with 3354 breaches against 17,819 attendances in the month. There was 1x trolley wait > 12 hours reportable; the first since Dec17. The unplanned reattendance rate has unfortunately increased again to 5.2% having reached lower levels before as part of the persistent red focus; a full audit is being reviewed to identify improvement themes. DTOCs are holding up to previous levels and in October the trust reports 2.7% against the 3.5% target. WMAS handovers between 36 minutes were at 121 with only 6 breaching the 6 minutes target giving us a.13% performance against the very ambitious target of.2% and high levels of total ambulance conveyances (4622 in October, second highest this year). Fractured Neck of Femur Best Practice Tariff delivery for October at 84% slightly below the 85% target in the month. Patient bed moves for nonclinical reasons in October at 54 against aspiration of zero. 21+ long stay patients have been subject to robust monitoring against the NHSI agreed trajectory to achieve 25% nominal bed reductions by the end of December 218. Baseline position as at August18 was beds occupied by patients at =>21 days, with the objective to reduce nominal beds by 25% to 11. With the dataoutage we have had some bugs in reporting, which have been experienced in the October position previously reporting as delivering against the target, but on correction we have been 8 beds higher than expected. The November position is unlikely to improve much from where we are now leaving December to recover to agreed targets. The calculations mirror NHSI approach. Page 5

6 Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct Estimated Bed Days : 21+ Days Estimated Beds 21+ Days NHSI Target Beds 21+ Days NHSI Obstetrics: CSections in October reported at 25.5% against target of 25%; year to date at 26.6% normalising more to previous trends Stillbirth rate in October reported at 7.68 per 1, babies with 4x stillbirths in October out 59 births. Adjusted Perinatal Mortality Rate (per 1 babies) year to date coming down to 7.86 compared to target rate of 8. Breastfeeding initiation continues to routinely deliver, with a small blip in September, but picking up to 77.4% in October. Stroke & Cardiology: At this stage in the month the IQPR reports the WD5 positon (not postvalidated WD2 position) reporting a drop in performance against a couple of indicators. The performance in October is generally good for both services with only the access to stroke wards in 4 hours behind targets. Thrombolysis within the hour is often affected by clinical reasons and some operational processes, which are RCAed routinely and managed. October is at 85.7% vs 85% target and year to date is also in line with target at 86.5%. Admissions to Stroke Ward within 4 hours remained under pressure due to medical outliers occupying stroke beds. October performance at 61%; year to date below the target at 67% versus target of 8%; Patient Staying on Stroke Ward meets target of 9% reporting in October at 9.4%. Year to date at 89.9% almost hitting the target standard. TIA (High Risk) Treatment <24 Hours from receipt of referral is 95.7% in October vs target of 7% TIA (Low Risk) Treatment <7 days from receipt of referral is at 98% in October vs target of 75%. Both TIA indicators delivery routinely to standard. For October Primary Angioplasty Door to balloon time (<9 minutes) is meeting the target of 8% at 93.8%delivery. Primary Angioplasty Call to balloon time (<15 minutes) at 1% vs 8% target. Both are consistently delivering. Page 6

7 Rapid Access Chest Pain seen within 14 days consistently delivering at 1% in October and consistently for a number of years. Workforce : A number of new indicators has been introduced from October reporting to provider further insight into workforce. Some previously reported indicators have been removed. Due to the recent introduction not all have been populated for this month s reporting. Mandatory Training in October reporting slipping to 89.9% against target of 95%; Health & Safety related training is below the 95% target at 91.9% in October and we observe a dip in performance in the last three month after a very stable delivery over a long period of time. PDR completion approach has changed to an annual cycle reporting quarterly delivery this year; in October the performance was at 91.2% against the 95% target. November is estimated to deliver 97% and so would exceed target, making this a successful initiative following the introduction of Aspiring to Excellence PDR process. October inmonth sickness rate is at 4.97%, a worsening to last month against Trust aspirations of 3%. The Sickness improvement trajectory (persistent red trajectory) was at 4.15% for October, lower than our actual rate of 4.97% We observe a growth in short term sickness in October, which is likely to have driven up the sickness rate b, but the rate is also impacted by the number of days each sickness incurs. The Workforce Director will be reporting to the Trust Board in a separate paper with more granular analysis of the drivers. October return to work interviews inmonth at 85.8% (year to date at 84.7% (below the trust target of 95%, continuing to be a difficult target to improve to. On boarding of new starters in October was at 97.65% (with 83/85 staff attending) against a target of 1%. Flu vaccination for October reporting at a good 8% of all frontline staff being vaccinated Mortality: Mortality indicators are in line with confidence limits against most of the mortality indicators, other than our HSMR which is currently reported (June 218 latest data) at 128 for SWBH and still outside statistical confidence limits. There is ongoing Trust scrutiny and oversight of mortality statistics at the Executive Quality Committee. A report was commissioned with HED, analytics provider, which concluded: Sandwell General Hospital is a statistically significant HSMR outlier. City Hospital remains within expected limits. Following MDO review of emergent divergence between weekday and weekend rates, this will result in a focus on the Sandwell site weekend mortality; the weekend rate reports at 119 for the latest period which is June218 and hence not moving significantly in the right direction. Mortality reviews in the Trust are at 42% for the latest period. There is renewed effort to support reviews including introduction of medical examiner screening and this is going to improve performance. Mortality reviews are discussed at the Learning from Deaths Committee, where a holistic review process needs to be embedded and measureable. Cancellations and Theatre Utilisation: Performance has been kept up in October resulting in low level of cancellations. In October we report cancellations on the day at 25 against the internal trust target of 2, but a tolerance of up to 27 in order to meet national targets. Whilst slightly higher than the internal target of Page 7

8 2, this is still below the national level of.8% against actuals of.6% counting late cancellations on the day against elective admissions in the month. 9/25 were avoidable (~36%) which is a high number, but avoidable is not only hospital related e.g. it will include patients who may have eaten on the day of surgery for example. There were no 28 Day breaches in month and no urgent cancelations in the month. Theatre insession utilisation is still below target of 85%, at 76% in October and whilst some specialities have increased utilisations others are still much lower than the target. Each speciality has a target for improvement. Overall session utilisation (outside routine session timings) for October is at 82.1% and getting closer to that 85% target; the aim should be to get insession utilisation to same levels as running outside sessional time may impact on other, subsequent theatre sessions. Completeness: Open Referrals without Future Activity/ Waiting List Requiring Validation have increased to ~178, in October. A recovery process was agreed at PMC. All our mandatory national data capture metrics are performing well to targets except of Completion of Valid NHS Number Field in acute (inpatient) data set submissions to SUS which is at 97.7% compared to the target of 99%. The Head of Information is reviewing shortfalls. Performance Notices & IBNs : The CCG has issued a Performance Notice for the maternity indicator 9 CO Level >4ppm Referred For Smoking Cessation); working with the deputy director of midwifery we have made proposals on how to recount this indicator and an action plan is progressed A&E Diagnosis codes indicator is also below the required threshold and the CCG are seeking for assurance on this the service manager has been asked to work to improve performance Early morning discharges indicator (35% target for discharges between 6am1am) has been failing persistently, the CCG has now requested to review internal processes on managing this. CQUINs for Q1 have not been submitted in required timelines, the CCG is considering issuing an IBN for this, but now have withdrawn this intention; however expect the trust to identify a way forward in delivering the Risky Behaviours CQUIN which has not been progressed as yet. The CCG has emphasised that it expects the Trust to manage its waiting list down to March 218 position and have raised concerns regarding patient clearance rates and backlog. Page 8

9 Integrated Quality & Performance Report Reported: October 218 Reported as at: 27/11/218 TRUST BOARD

10 Contents Item Page Item Page At A Glance Referral To Treatment 12 Completeness 13 Patient Safety Infection Control 3 Workforce 14 Patient Safety Harm Free Care 4 CQUINS (Reported Quarterly) 15 & 16 Patient Safety Obstetrics 5 Service Quality Performance Report Local Quality Requirements Clinical Effectiveness Mortality & Readmissions 6 Clinical Effectiveness Stroke Care & Cardiology 7 Clinical Effectiveness Cancer Care 8 Patient Experience Friends & Family Test, Mixed Sex Accommodation and Complaints 9 Patient Experience Cancelled Operations 1 Legend 2 Emergency Care & Patient Flow 11 Group Performance

11 Patient Safety Infection Control Source Quality PAF Indicator Measure Trajectory Previous s Trend (From May 217) Group Year M J J A S O N D J F M A M J J A S O Period M SS W P I PCCT CO Trend 4 d C. Difficile <= No Oct d MRSA Bacteraemia <= No Oct MSSA Bacteraemia (rate per 1, bed days) <= Rate Oct E Coli Bacteraemia (rate per 1, bed days) <= Rate Oct MRSA Screening Elective => % 8 8 Oct MRSA Screening Non Elective => % 8 8 Oct MRSA Screening Elective 1 MRSA Screening Non Elective 35 C Diff Infection Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 SWBH NHS Trust Medicine & Emergency Care Surgical Services Women's & Child Health Primary Care Community & Therapies Nov Jan Mar May Jul Sep Nov Jan Mar May Jul Sep SWBH NHS Trust Medicine & Emergency Care Surgical Services Women's & Child Health Primary Care Community & Therapies Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 SWBH NHS Trust C Difficile Cumulative (Post 48 hours) Trajectory PAGE 3

12 Patient Safety Harm Free Care Source Quality PAF Indicator Measure Trajectory Previous s Trend (since May 217 ) Group Year M J J A S O N D J F M A M J J A S O Period M SS W P I PCCT CO Trend 8 d Patient Safety Thermometer Overall Harm Free Care => % Oct d Patient Safety Thermometer Catheters & UTIs % Oct Number of DOLS raised No Oct Number of DOLS which are 7 day urgent No Oct Number of delays with LA in assessing for standard DOLS application No Oct Number DOLs rolled over from previous month No Oct Number patients discharged prior to LA assessment targets No Oct Number of DOLs applications the LA disagreed with No Oct Number patients cognitively improved regained capacity did not require LA assessment No Oct Falls <= No Oct Falls with a serious injury <= No Oct Grade 2,3 or 4 Pressure Ulcers 8 <= No Oct (Hospital Aquired Avoidable) Avoidable Grade 2,3 or 4 Pressure Ulcers (DN Caseload Acquired) <= No Oct NEW Pressure Ulcers per 1 Occupied Bed Days Rate Oct d Venous Thromboembolism (VTE) Assessments => % Oct WHO Safer Surgery Audit 3 sections (% pts where all 3 => % 1 1 Oct sections complete) 3 WHO Safer Surgery brief (% lists where complete) => % 1 1 Oct WHO Safer Surgery Audit brief and debrief (% lists 3 => % 1 1 Oct where complete) 9 d Never Events <= No Oct d Medication Errors causing serious harm <= No 1 Oct d Serious Incidents <= No Oct Open Central Alert System (CAS) Alerts <= No Oct Open Central Alert System (CAS) Alerts beyond deadline 9 d No Oct date Safety Plan Input NonCompliant Days <= No <=3 Per Ward Aug Safety Plan Checks Compliant % Under Review Aug Safety Plan Missed Checks => No <=3 Per Ward Aug VTE Assessments Missed Falls Acute & Community Hospital Acquired Avoidable Pressure Sores by Grade Number of Assessments Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Community Acute Grade 4 Grade 3 Grade 2 PAGE 4

13 Patient Safety Obstetrics Source Quality PAF Indicator Measure Trajectory Previous s Trend (since May 217) Year M J J A S O N D J F M A M J J A S O Period Trend 3 Caesarean Section Rate Total <= % Oct Caesarean Section Rate Elective <= % Oct Caesarean Section Rate Non Elective <= % Oct d Maternal Deaths <= No Oct Post Partum Haemorrhage (>2ml) <= No 48 4 Oct Admissions to Neonatal Intensive Care (Level 3) <= % Oct Adjusted Perinatal Mortality Rate (per 1 babies) <= Rate Oct Stillbirth Rate (Corrected) (per 1 babies) Rate Oct Neonatal Death Rate (Corrected) (per 1 babies) Rate Oct Early Booking Assessment (< weeks) SWBH Specific => % Oct Early Booking Assessment (< weeks) National Definition => % Oct Breast Feeding Initiation (Quarterly) => % > > > Oct Puerperal Sepsis and other puerperal infections <= % (variation 1 ICD1 O85 or O86) (%) Oct Puerperal Sepsis and other puerperal infections <= % (variation 2 ICD1 O85 or O86 Not O864) (%) Oct Puerperal Sepsis and other puerperal infections <= % (variation 3 ICD1 O85) (%) Oct Caesarean Section Rate (%) 12 Registrations & Deliveries Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Caesarean Section Rate Total Caesarean Section Rate Elective Caesarean Section Rate Non Elective Caesarean Section Total Rate Target Registrations SWBH Bookings Deliveries Linear (Registrations) Linear (SWBH Bookings) Linear (Deliveries) PAGE 5

14 Clinical Effectiveness Mortality & Readmissions Source Quality PAF Indicator Measure Trajectory Previous s Trend (since May 217) Group Year M J J A S O N D J F M A M J J A S O Period M SS W P I PCCT CO Trend 5 c Risk Adjusted Mortality Index (RAMI) Overall RAMI (12month cumulative) 5 c Risk Adjusted Mortality Index (RAMI) Weekday RAMI Admission (12month cumulative) 5 c Risk Adjusted Mortality Index (RAMI) Weekend RAMI Admission (12month cumulative) 6 c Summary Hospitallevel Mortality Index (SHMI) SHMI (12month cumulative) Below Upper CI Below Upper CI Below Upper CI Below Upper CI Below Upper CI Below Upper CI Below Upper CI Below Upper CI Jul Jul Jul Mar Hospital Standardised Mortality Rate (HSMR) Overall 5 c HSMR Jun (12month cumulative) 5 c Deaths in Low Risk Diagnosis Groups (RAMI) month RAMI Below Upper CI Below Upper CI Jul Mortality Reviews within 42 working days => % 9 9 Aug Crude InHospital Mortality Rate (Deaths / Spells) (by 3 % Sep month) Crude InHospital Mortality Rate (Deaths / Spells) (12 3 % Sep month cumulative) Deaths in the Trust No Sep Emergency Readmissions (within 3 days) Overall (exc. 2 % Sep Deaths and Stillbirths) month Emergency Readmissions (within 3 days) Overall (exc. 2 % Sep Deaths and Stillbirths) 12month cumulative Emergency Readmissions (within 3 days) CQC CCS 5 c % Sep Diagnosis Groups (12month cumulative) Emergency Readmissions (within 3 days) Same Specialty (exc. Deaths and Stillbirths) month % Sep Emergency Readmissions (within 3 days) Different Specialty (exc. Deaths and Stillbirths) month % Sep Emergency Readmissions (within 3 days) Same Specialty (exc. Deaths and Stillbirths) 12month cumulative % Sep Emergency Readmissions (within 3 days) Different Specialty (exc. Deaths and Stillbirths) 12month cumulative % Sep Nov 216 Nov 216 Dec 216 Jan 217 Feb 217 RAMI, SHMI & HSMR (12month cumulative) Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Mortality (RAMI) Weekend and Weekday (12month cumulative) Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Oct 217 Nov 217 Nov 217 Dec 217 Dec 217 Jan 218 Jan 218 Feb 218 Feb 218 Mar 218 Mar 218 Apr 218 Apr 218 May 218 May 218 Jun 218 Jun 218 Jul 218 Jul 218 Aug 218 Aug 218 Sep 218 Sep 218 Oct 218 Oct 218 RAMI SHMI HSMR Weekend WeekDay Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Mortality Reviews (%) Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 Jul 217 Crude Mortality Rate Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 Mortality Reviews Trajectory Cumulative Emergency 3day Readmissions (%) 12month cumulative CQC CCS Diagnosis Groups and monthly overall Trust CQC 12 mth Cumulative Trust By Peer CQC 12 mth Cumulative Linear (Trust CQC 12 mth Cumulative) PAGE 6

15 Clinical Effectiveness Stroke Care & Cardiology Source Quality PAF Indicator Measure Trajectory Previous s Trend (Since May 217) Year M J J A S O N D J F M A M J J A S O Period Trend 3 5WD: Pts spending >9% stay on Acute Stroke Unit => % Oct WD: Pts admitted to Acute Stroke Unit within 4 hrs => % Oct WD: Pts receiving CT Scan within 1 hr of presentation => % Oct WD: Pts receiving CT Scan within 24 hrs of presentation => % Oct WD: Stroke Admission to Thrombolysis Time (% within 6 mins) => Oct WD: TIA (High Risk) Treatment <24 Hours from receipt of referral => Oct WD: TIA (Low Risk) Treatment <7 days from receipt of referral => Oct Stroke Admissions Swallowing assessments (<24h) => % Oct Primary Angioplasty (Door To Balloon Time 9 mins) => % Oct Primary Angioplasty (Call To Balloon Time 15 mins) => % Oct Rapid Access Chest Pain seen within 14 days => % Oct Admissions (%) to Acute Stroke Unit within 4 hours Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 Actual Target CT Scan following presentation Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 CT Scan Within 1 Hour CT Scan Within 24 Hours CT Scan Within 1 Hour Target CT Scan Within 24 Hours Target TIA Treatment (%) Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 High Risk within 24 Hours Low Risk Within 7 Days High Risk Trajectory Low Risk Trajectory The stroke indicators in the IPR are based on patient arrivals not patient discharged as this monitors pathway performance rather than actual outcomes which may / may not change on discharge. National SSNAP is based on patient discharge which is more appropriate for outcomes based reporting. Both are valid but designed for slightly different purposes, however they will align overall, especially over a longer period of time (eg annually) PAGE 7

16 Clinical Effectiveness Cancer Care Source Quality PAF Indicator Measure Trajectory Previous s Trend (since May 217) Group Year M J J A S O N D J F M A M J J A S O Period M SS W P I PCCT CO Trend 1 e 2 weeks => % Sep e 2 weeks (Breast Symptomatic) => % Sep e 31 Day (diagnosis to treatment) => % Sep e 31 Day (second/subsequent treatment surgery) => % Sep e 31 Day (second/subsequent treatment drug) => % Sep e 31 Day (second/subsequent treat radiotherapy) => % Sep Day (urgent GP referral to treatment) 1 e => % Sep Excluding Rare Cancer 62 Day (urgent GP referral to treatment) 1 => % Sep Including Rare Cancer 1 e 62 Day (referral to treat from screening) => % Sep Day (referral to treat from hosp specialist) => % Sep Cancer Patients Waiting over 62 days No Sep Cancer Patients Waiting over 14 days No Sep Cancer Longest Waiter in days No Sep Neutropenia Sepsis 1 <= No Oct Door to Needle Time Greater Than 1 Hour IPT Referrals Within 38 Days Of GP Referral for 62 day cancer pathway % Sep week wait from Referral to First Seen 2week wait from Breast Symptomatic Patients Trust National Forecast Trajectory Trust National Forecast Trajectory 9 Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct National Target 9 Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct National Target 31day Diagnosis to First Treatment 62day Urgent GP Referral to First Treatment Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Trust National National Target Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Trust Excl Rare Cancer Trust Incl Rare Cancer National Forecast Trajectory National Target NHSI Improvement Trajectory day Urgent GP Referral to First Treatment BreachBy Tumour Site Upper GI Testicular Skin Lung Lower GI Head & Neck Heamatology Gynaecology Childrens Breast Neutropenia Sepsis Door to Needle Time Greater Than 1 Hour Dummy Directorate General Surgery Scheduled Care/Long Term Conditions Theatres Ambulatory Therapies Gynaecology, GynaeOncology and GUM Acute & Community Paediatrics Community Medicine Performance (%) day Urgent GP Referral to First Treatment Number over 62 days Trust Incl Rare Cancer National Performance National Standard Patients PAGE 8

17 Patient Experience FFT, Mixed Sex Accommodation & Complaints Source Quality PAF Indicator Measure Trajectory Previous s Trend (since May 217) Group Period Year M J J A S O N D J F M A M J J A S O M SS W P I PCCT CO Trend FFT Response Rate Adult and Children Inpatients 8 b => % Oct (including day cases and community) FFT Score Adult and Children Inpatients (including day 8 a => No ### 179 Oct cases and community) FFT Response Rate: Type 1 and 2 Emergency 8 b => % Oct Department FFT Score Adult and Children Emergency Department 8 a => No Oct (type 1 and type 2) 8 FFT Response Rate: Type 3 WiU Emergency Department => % #### #### ##### #### #### #### ### #### Oct 218 FFT Score Adult and Children Emergency Department 8 => No Oct 218 (type 3 WiU) FFT Score Outpatients 8 => No Oct NEW FFT Score Maternity Antenatal => No Oct NEW FFT Score Maternity Postnatal Ward => No Oct NEW FFT Score Maternity Community => No Oct 218 FFT Score Maternity Birth 8 => No Oct FFT Response Rate Maternity Birth 8 => % Oct a Mixed Sex Accommodation Breaches <= No Oct No. of Complaints Received (formal and link) No Oct No. of Active Complaints in the System 9 No Oct (formal and link) 9 a No. of First Formal Complaints received / 1 bed days Rate Oct No. of First Formal Complaints received / 1 episodes of 9 Rate Oct care No. of Days to acknowledge a formal or link complaint (% 9 => % Oct within 3 working days after receipt) No. of responses which have exceeded their original agreed 9 <= % Oct response date (% of total active complaints) 9 No. of responses sent out No Oct Access to healthcare for people with Learning Disability 14 e Yes / No Yes Yes Aug 218 N N N N N N N No (full compliance) Patient Harm New Claims No Aug Patient Harm Ongoing Claims No Under Development Aug Patient Harm Closed Claims No Aug Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Mixed Sex Accommodation Breaches Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct No De Jan Feb Ma Apr Ma Jun Jul Complaints Number and Rate Au Sep Oct No De Jan Feb Ma Apr Ma Jun Jul Au Sep Oct Number of Complaints First Complaints / 1 episodes of care First Complaints / 1 bed days Responses (%) Exceeding Original Agreed Response ` PAGE 9

18 Patient Experience Cancelled Operations Source Quality PAF Indicator Measure Trajectory Previous s Trend (since May 217) Group Year M J J A S O N D J F M A M J J A S O Period M SS W P I PCCT CO Trend No. of Sitrep Declared Late Cancellations 2 <= No Oct Total 2 No. of Sitrep Declared Late Cancellations Avoidable No Oct No. of Sitrep Declared Late Cancellations 2 No Oct Unavoidable Elective Cancellations at last minute for nonclinical 2 <= % Oct reasons (as a percentage of elective admissions) 2 e Number of 28 day breaches <= No Oct No. of second or subsequent urgent operations 2 e <= No Oct 218 cancelled 2 Urgent Cancellations <= No.. Oct No. of Sitrep Declared Late Cancellations (Pts. >1 3 <= No Oct occasion) Multiple Hospital Cancellations experienced by same patient (all cancellations) <= No Oct All Hospital Cancellations, with 7 or less days notice <= No Oct Weekday Theatre Utilisation (as % of scheduled) => % Oct NEW Overall Theatre Utilisation (as % of scheduled) => % Oct SitRep Late Cancellations 9. Weekday Theatre Utilisation (%) Scheduled Sessions (within routine session time) 1 Overall Theatre Utilisation (%) Scheduled Sessions (outside routine session times) Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Elective Admissions Cancelled at Last Minute for Non Clinical Reasons (%) Trust Trajectory Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Weekday Theatre Utilisation (as % of scheduled) Target Overall Theatre Utilisation (as % of scheduled) Target PAGE 1

19 Access To Emergency Care & Patient Flow Source Quality PAF Indicator Measure Trajectory Previous s Trend (From ) Unit Year M J J A S O N D J F M A M J J A S O Period S C B Trend NEW Emergency Care Attendances (Including Malling) No Oct e Emergency Care 4hour waits => % Oct Emergency Care 4hour breach (numbers) No Oct e Emergency Care Trolley Waits >12 hours <= No.. Oct Emergency Care Timeliness Time to Initial Assessment (95th centile) <= No Oct Emergency Care Timeliness Time to Treatment in Department (median) <= No 6 6 Oct Emergency Care Patient Impact Unplanned Reattendance Rate (%) <= % Oct Emergency Care Patient Impact Left Department Without Being Seen Rate (%) <= % Oct WMAS Finable Handovers (emergency conveyances) 11 <= No 3 6 mins (number) Oct WMAS Finable Handovers (emergency conveyances) 11 <= No >6 mins (number) Oct WMAS Handover Delays > 6 mins (% all emergency 11 <= %.2.2 Oct conveyances) 11 WMAS Emergency Conveyances (total) No Oct Delayed Transfers of Care (Acute) (%) <= % Oct Delayed Transfers of Care (Acute) (Av./Week) 2 <= No attributable to NHS <1 per site <1 per site Oct Delayed Transfers of Care (Acute) Total Bed Days 2 <= No (All Local Authorities) 3.5% of available 3.5% of available Oct Delayed Transfers of Care (Acute) Finable Bed Days 2 <= No (Birmingham LA only) Oct Patient Bed Moves (1pm 6am) (No.) ALL No Oct Patient Bed Moves (1pm 6am) (No.) exc. 2 No Assessment Units Oct NEW Patient Bed Moves (1pm 6am) (No.) exc. Assessment Units and Transfers for Clinical Reasons No Oct Hip Fractures Best Practice Tarriff Operation < 36 hours of admission (%) => % Oct

20 Inpatients Staying 21+ Days At End Census NEW NHSI No Inpatients Staying 21+ Days At End Census NEW SWBH No Oct Oct NEW 21+ Days Long Stay Rate NHSI % NEW Estimated Beds 21+ Days NHSI No Oct Oct PAGE Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct Available Beds End (Weekly SITREP) Hip Fractures BPT Operation Within 36 hours of admission (%) Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct EC Attenders EC Attendances (City) EC Attendances (Sandwell) EC Attendances (BMEC) EC Attendances (City Malling) EC Attendances (Sandwell Malling) Trust Trajectory Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 Nov 218 Dec 218 Jan 219 Feb 219 Mar 219 Apr 219 Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct EC 4Hour Recovery Plan Recovery to Standard of 95% planned for March 219 Performance 95% Standard SWB Internal Plan Days Long Stay Rate NHSI Estimated Bed Days 21+ Days Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 Estimated Beds 21+ Days NHSI Target Beds 21+ Days NHSI

21 Referral To Treatment Source Quality PAF Indicator Measure Trajectory Previous s Trend (since May 217) Group Year M J J A S O N D J F M A M J J A S O Period M SS W P I PCCT CO Trend 2 e RTT Admittted Care (18weeks) => % Oct e RTT Non Admittted Care (18weeks) => % Oct e RTT Incomplete Pathway (18weeks) => % Oct NEW RTT Waiting List Incomplete No Oct RTT Backlog No Oct e Patients Waiting >52 weeks <= No Oct e Patients Waiting >52 weeks (Incomplete) <= No Oct Treatment Functions Underperforming 2 <= No Oct (Admitted, NonAdmitted, Incomplete) Treatment Functions Underperforming (Incomplete) <= No Oct Acute Diagnostic Waits in Excess of 6weeks 2 e <= % Oct (End of Census) Acute Diagnostic Waits in Excess of 6weeks (In Waiters) No Sep Routine Outpatient Appointments with Short NEW % Oct Notice(<3Wks) Routine Outpatient Appointments with Short NEW No Oct Notice(<3Wks) NEW Short Notice Inpatient Admission Offers (<3wks) % Oct NEW Short Notice Inpatient Admission Offers (<3wks) No Oct RTT Admitted Care RTT Incomplete pathway RTT Waiting List and Backlog Percentage (%) Nov Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Number of Treatment Functions Trust (%) National Target (%) SWB Forecast Treatment Function Underperforming Percentage (%) Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct Number of Breachs Trust 18 Weeks (%) National Target 18 Weeks (%) SWB Forecast Over 52 Week Incomplete (Number) Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 RTT Waiting List Incomplete RTT Backlog Percentage (%) RTT NonAdmitted Care Nov Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Axis Title Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Number of Treatment Functions RTT Backlog By Group Trust (%) National Target (%) SWB Forecast Treatment Function Underperforming 2 Medicine & Emergency Care 3 Surgical Services 5 Women's & Child Health 8 Primary Care Community & Therapies 46 X1 Other Percenatge (%) Treatment Function Underperforming (Incomplete) Diagnostic Waits (% and No.) Greater Than 6 Weeks Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 Number of Patients TRAUMA & ORTHOPAEDICS UROLOGY RHEUMATOLOGY RESPIRATORY MEDICINE PLASTIC SURGERY Other Specialties ORAL SURGERY OPHTHALMOLOGY NEUROLOGY GYNAECOLOGY GERIATRIC MEDICINE GENERAL SURGERY GASTROENTEROLOGY ENT DERMATOLOGY CARDIOTHORACIC SURGERY CARDIOLOGY Trust (%) National Target (%) SWB Forecast Number of Patients >6 weeks RTT Functions Underperforming Treatment Functions Underperforming 1 Improvement Trajectory 5 Number of Patients Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct Diagnostic Waits (In ) Greater Than 6 Weeks PAGE 12

22 Completeness Source Quality PAF Indicator Measure Trajectory Previous s Trend (since May 217) Group Year M J J A S O N D J F M A M J J A S O Period M SS W P I PCCT CO Trend 14 Completeness Community Services => % Oct Percentage SUS Records for AE with valid entries in => % mandatory fields provided by HSCIC Sep Percentage SUS Records for IP care with valid entries => % in mandatory fields provided by HSCIC Sep Percentage SUS Records for OP care with valid entries => % in mandatory fields provided by HSCIC Sep Completion of Valid NHS Number Field in acute 2 (inpatient) data set submissions to SUS => % Oct Completion of Valid NHS Number Field in acute 2 (outpatient) data set submissions to SUS => % Oct Completion of Valid NHS Number Field in A&E data set 2 submissions to SUS => % Oct Ethnicity Coding percentage of inpatients with recorded 2 response => % Oct Ethnicity Coding percentage of outpatients with recorded response => % Oct Protected Characteristic Religion INPATIENTS with recorded response Protected Characteristic Religion OUTPATIENTS with recorded response Protected Characteristic Religion ED patients with recorded response Protected Characteristic Marital Status INPATIENTS with recorded response Protected Characteristic Marital Status OUTPATIENTS with recorded response Protected Characteristic Marital Status ED patients with recorded response % Sep % Sep % Sep % Sep % Sep % Sep Maternity Percentage of invalid fields completed in 2 SUS submission <= % Oct Open Referrals No 245,16 25,72 254, ,8 262,63 27, , , , , , , ,679 35,223 31,94 314, , ,632 Oct , ,51 44,28 9, , ,632 Open Referrals without Future Activity/ Waiting List: Requiring Validation No ###### ###### ###### ###### ###### ###### ###### ###### ###### ###### ###### ###### ###### ###### ###### ###### ###### ###### Oct ,852 85,12 27,469 4, , Religion Inpatients With Invalid / Incompete Response Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct Religion Outpatients With Invalid / Incompete Response Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct Religion ED Attenders With Invalid / Incompete Response Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 Current Open Referrals Amber Green Other Red Marital Status Inpatients With Invalid / Incompete Response Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct Marital Status Outpatients With Invalid / Incompete Response Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct Marital Status ED Attenders With Invalid / Incompete Response Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 RED : To be validated and closed by clinical groups. AMBER : To be validated and closed by clinical groups. GREEN : Automatic Closures. PAGE 13

23 Workforce Source Quality PAF Indicator Measure Trajectory Previous s Trend (since May 217) Group Year M J J A S O N D J F M A M J J A S O Period M SS W P I PCCT CO Trend 3 b PDRs 12 month rolling => % > > > > > Sep b Medical Appraisal => % Sep b Sickness Absence (Rolling 12 s) <= % Oct Sickness Absence (ly) <= % Oct Sickness Absence Long Term (ly) No Oct Sickness Absence Short Term (ly) No Oct Return to Work Interviews following Sickness Absence 3 => % Oct (Cumulative) Return to Work Interviews following Sickness Absence NEW => % Oct (In ) 3 Mandatory Training => % Oct Mandatory Training Health & Safety (% staff) => % Oct NEW WeConnect Staff Satisfaction Score => No Jan NEW WeConnect Staff Satisfaction Response Rate => % Jan NEW WeConnect Staff Satisfaction Disengagement Rate => % Jan NEW Band 5 Nurse Staff Turnover <= % Jan NEW Band 5 Nurse Vacancy Rate <= % Jan NEW New Starters Complete Onboarding Process => % Jan NEW Flu Vaccination Rate => % Oct18 6 Sickness Absence (Trust %) 12 Long / Short Term Sickness Absence Trust 88 Return to Work Interviews (Trust %) % Number of Cases Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov 216 Dec 216 Jan 217 Feb 217 Mar 217 Apr 217 May 217 Jun 217 Jul 217 Aug 217 Sep 217 Oct 217 Nov 217 Dec 217 Jan 218 Feb 218 Mar 218 Apr 218 May 218 Jun 218 Jul 218 Aug 218 Sep 218 Oct 218 Sickness Absence 12 month rolling % Sickness Absence monthly Sickness Absence Long Term monthly Sickness Absence Short Term monthly Cumulative ly PAGE 14

24 Local Quality Indicators 218/219 Source Quality PAF Indicator Measure WHO Safer Surgery Audit brief and debrief (% lists where complete) SQPR Trajectory Previous s Trend (From May 217) Group Year M J J A S O N D J F M A M J J A S O Period M SS W P I PCCT CO => % Oct Trend Morning Discharges (: to 12:) SQPR => % Oct ED Diagnosis Coding (Mental Health CQUIN) SQPR => % Oct CO Monitoring by 12+6 weeks of pregnancy SQPR => % Oct Community Nursing Falls Assessment For Appropriate Patients on home visiting caseload => % Oct Community Nursing Pressure Ulcer Risk Assessment For New community patients at intial assessment => % Oct PAGE 17

25 Legend Sources Indicators which comprise the External Performance Assessment Frameworks Groups 1 Cancer Services NHS TDA Accountability Framework M Medicine & Emergency Care 2 Information Department a Caring A Surgery A 3 Clinical Archive b Wellled B Surgery B 4 Microbiology Informatics c Effective W Women & Child Health 5 CHKS d Safe P Pathology 6 Healthcare Evaluation (HED) Tool e Responsive I Imaging 7 Workforce Directorate f Finance PCCT Primary Care, Community & Therapies 8 Nursing and Facilities Directorate Monitor Risk Assessment Framework CO Corporate 9 Governance Directorate CQC Intelligent Monitoring 1 Nurse Bank 11 West Midlands Ambulance Service Quality Kitemark Each outer segment of indicator is colour coded on kitemark to signify strength of indicator relative to the dimension, with following key: 12 Obstetric Department Granularity Assessment of Exec. Director Timeliness Red Insufficient 13 Operations Directorate Green Sufficient 14 Community and Therapies Group White Not Yet Assessed 15 Strategy Directorate Completeness Audit The centre of the indicator is colour coded as follows: 16 Surgery B Red / Green As assessed by Executive Director 17 Women & Child Health White Awaiting assessment by Executive Director 18 Finance Directorate Validation Source If segment 2 of the Kitemark is Blank this indicates that a formal audit of this indicator has not yet taken place 19 Medicine & Emergency Care Group 2 Change Team (Information) PAGE 2