SUPPORTING PAPER (FOR ACTION) BOARD OF DIRECTORS MEETING

(1)

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:

Nichola Fairless

Executive Summary:

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)

 Performance Improvement Plan 2012/13

Recommendations:

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:

None identified

Author:

Nichola Fairless

Date:

21 May 2012

(2)

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 2012. 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 2012/13.

1.2 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).

(3)

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 2012/13

3.1 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 2012/13

4.1 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

(4)

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 2013. 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\2012-13\April Data - May Meeting\IPR - Cover Sheet and Paper - May 2012 Board.docx

(5)

5

Performance Improvement

Plan

2012/2013

Date: 09

th

May 2012

Version 1.1

Document Control

Date

Version

Amendments

Author

09/5/2012

1.0 R Lonsdale, Business Planning

and Performance Manager

(6)

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

2011/12 – 2013/14 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 2012/13

2.1 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

(7)

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 2 .

3.3 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

(8)

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.

Limited progress to Level 2 increased risk to CIP contribution in 2014/15

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 2012.

Monitoring: The plan is monitored fortnightly by the Risk and

Claims team in conjunction with the Monitoring and Compliance Officer.

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

(9)

9

Improvement

Priority

Information Source Rationale for inclusion in Plan Lead Summary of actions and monitoring Hospital turnaround

times

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.

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.

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

(10)

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).

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

Improved Long Term Conditions

Management

Poor management of flagging has led to incorrect information being shared with crews

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%).

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%.

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

(11)

11

Improvement

Priority

Information Source Rationale for inclusion in Plan Lead Summary of actions and monitoring closed with telephone

advice (where clinically appropriate)

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.

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.

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.

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 2.92.

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.

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.

(12)

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%.

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.

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).

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.

Staff reporting errors, near misses or incidents

QRP Outcome 16-Assessing and monitoring the quality of service provision Staff survey 2011 (KF21)

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.

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.

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.

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.

The refining of the plan will be an iterative

Commercial Services has developed a three year business plan and we will track delivery of financial surpluses

Monitoring: Service line management meetings and IPR.

(13)

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.

(14)

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 <=20 21+ 95%

Appraisal 73% <=10 <=20 21+

The number of patients receiving PPCI treatment within 150 minutes (NOTE: figures shown are 3 months behind)

96% >=75 <75 75%

STEMI Care Bundle (Aspirin+GTN+Two

Pain Scores+Analgesia given) 78.8% <=81 <=86 >=87

Q1 Q2 Q3 Q4

87% 88% 89% 90%

Return of Spontaneous Circulation (ROSC) – palpable pulse on arrival at hospital following resuscitation attempt

21.53% <=16 <=21 >=22

Q1 Q2 Q3 Q4

22% 23% 24% 25%

Return of Spontaneous Circulation (ROSC) – palpable pulse on arrival at hospital following resuscitation attempt [UTSTEIN**] 46.61% <=44 <=49 >=50 Q1 Q2 Q3 Q4 50% 51% 52% 53% Survival to discharge 8.26% NA Q1 Q2 Q3 Q4 7% 7% 8% 8%

Survival to discharge [Utstein**] 27.12% NA Q1 Q2 Q3 Q4

32% 32% 33% 33%

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

86.47% <=85 <=90 >=91

Q1 Q2 Q3 Q4

91% 92% 93% 94%

Care Bundle (FAST + BM + BP

recorded) 92.76% <=90 <=95 >=96

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 <=20 >=21 >=25 Q1 Q2 Q3 Q4

35/Month 20 20 25 20

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 <=10 >=11 >=15 Q1 Q2 Q3 Q4

10.75 / Month 10 10 13 10

Category A8 R1 N/a >=80 <80 80%

Category A8 R2 N/a >=75 <75 75%

Category A19 98.45% >=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

(15)

15

IPR

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 procedure is in place

TBC TBC TBC

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 Median 95th %ile 99th %ile TBC TBC 6 mins 14 mins 22 mins Written response provided without

extending their response timeframe on more than two occasions

TBC Baseline to be established Baseline to be established

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 64 25 15 10 25

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 2125.54 TBC TBC

Staff in post 2017.42 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

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

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

(16)

16

IPR

Employers Liability Claims (actual

value) 12

Green:=

0 Red:>0 0

(17)

17

(18)