1. Trust Quality and Performance Report October 2013 Agenda item 11

2. Contents Slide numbers Executive Summary 2 - 4 Clinical Quality Priorities inc Ward Dashboard5 - 19 Local Priorities20 - 26 CQUIN27 - 29 Monitor Compliance30 Contract Priorities31 - 33 1

3. Executive Summary This commentary provides an overview of key issues during the month and highlights where performance fell short of the target values as well as areas of improvement and noticeable good performance. 1.A&E Performance for September was 98.08%, exceeding the 95% target for the fourth consecutive month and placing the Trust in the top decile nationally. Quarterly performance at 96.36% was the top performance in the Region. 2.There were three cases of C.Diff in August against a threshold of two, the target for both the month and the quarter has not been achieved. This is covered on page 12 of this report. 3.Performance on outpatient and inpatient discharge summaries continued below target. Working with the CCG, a number of new steps are being introduced through October. Further detail is on page 3. 4.Performance on MRSA screening of emergency admissions was 93% against the 100% target. This is covered on page 12 of this report. 5.Stroke targets were achieved with the exception of admission of patients in atrial fibrillation presenting with stroke and where clinically indicated will receive anti-coagulation. Four of the six patients missed this target, one patient refused and three patients, although clinically indicated were not clinically appropriate to receive anti-coagulation. See page 3. 2

4. 3 Performance IndicatorThresholdSeptemberLead Exec Discharge Summaries - Outpatients95% sent to GP’s within 3 days85.74&Dermot O’Riordan Performance IndicatorThresholdSeptemberLead Exec Discharge Summaries - Inpatients95% sent to GP’s within 1 day78.97%Dermot O’Riordan Performance IndicatorThresholdSeptemberLead Exec Proportion of patients in Atrial Fibrillation, presenting with stroke and where clinically indicated will receive anti-coagulation 60.00%33.00%Jon Green Executive Summary Clinical staff and the project team have been exploring options. In agreement with the CCG a number of non-critical areas have been removed as part of the performance framework while data collection has been extended beyond just EPRO. TEG have agreed a number of initiatives to address the key issues, including performance discussion at consultant appraisal, targeting the underperforming specialities in directorates, where the Ops Groups have agreed a new process. Looking at automating the process further by sending letters sooner In order to support Discharge Summaries and Letters the project team have been working with clinicians to explore a range of options in order to resolve the current performance. In agreement with the CCG a number of non-critical areas have been removed as part of the performance framework while data collection has been extended beyond just EPRO. In addition TEG have agreed a number of initiatives to address the key issues, including performance discussion at consultant appraisal, targeting the underperforming specialities in directorates including a new process agreed by the Ops Group. In addition looking at automating the process further by sending letters sooner Target includes within dominator patients that refuse or are clinically inappropriate for anti-coagulation drugs. Four of the six patients during the month fell into this category (one patient refused and three patients were clinically inappropriate). The other two patients were appropriately treated. Year to date performance remains above 60.00%.

5. 4 Performance IndicatorThresholdSeptemberLead Exec MRSA – Emergency Screening All emergency patients admissions are to be screened for MRSA within 24 hours of admission 93.03%Nichole Day Executive Summary Performance IndicatorThresholdSeptemberLead Exec Performance IndicatorThresholdSeptemberLead Exec Sickness absence rate<3.5%3.91%Jan Bloomfield All staff to have an appraisal Both general and consultant staff each have a target of 90% to have had an appraisal within the previous 12 months. Appraisal is a rolling programme 85.85%Jan Bloomfield Performance IndicatorThresholdSeptemberLead Exec Clostridium (C.) difficile – meeting the C. difficile objective23Nichole Day There were three cases of C.Diff in September. The target for both the month and the quarter has not been achieved. An external view has been commissioned by the Trust and the formal report has been received. This is covered on page 12 of this report. Appraisals are monitored through the Trust’s Electronic Staff Record system (ESR), when a completed Personal Development Plan (PDP) is submitted to the HR Department (this can be done electronically or by using a paper based system). Reporting then takes place on a monthly basis, through the directorate performance management process. Managers can also request individual reports on their own staff from HR at any time. The Trust Board receive appraisal take up information monthly. The target is 90% and as at end September the Trust compliance figure is at 85.85%. Performance on MRSA screening of emergency admissions was 93% against the 100% target. This is covered on page 12 of this report.

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11. Clinical Quality Priorities: Summary The increase in C. difficile infections reported at the end of August continued in September and this continues to be a challenge for the Trust. An external review, commissioned by the Trust, was carried out on 7 th October 2013 and the formal report has been received and has been circulated to the Board. The updated C. difficile action plan will be presented to the Clinical Safety & Effectiveness Committee in November and to the Board at the end of November. The Friends and Family score for inpatients returned to 87 after a slight fall last month. The Friends and Family score was commenced at four points of maternity care in September and the results are reported. The score for the post natal ward is lower than at other points of care but this is in line with scores in previous months (the post natal ward has carried out the Friends and Family test within the inpatient maternity questionnaire previously). 10

12. Quality Priority: Ward Performance Issues No ward had more than 3 red scores in patient satisfaction. Ward F3 continues to have a number of vacancies due to turnover. Six beds have been closed on the ward to ensure that patient safety and quality are maintained. Uplifts in nurse establishments have been agreed for wards F9 and G3. The newly opened F7/8 scored poorly in some of the quality audits such as hydration and MEWS in September. The ward is not up to a full complement of permanent staff yet and a large number of temporary staff have been utilised to fill the gaps. This has meant that there was less awareness of the documentation requirements for these areas of care, but it is being addressed by the acting unit manager. 11.

13. Quality Priority: Infection Control 12 MRSA Bacteraemia There were no hospital associated MRSA bacteraemia during September C. difficile There were three hospital acquired C. difficile infections this month and a period of increased incidence has been declared on ward G4 following 2 infections within 28 days. The ward has been deep cleaned. An independent review has been carried out and the team visited the Trust on 7 th October 2013. Informal feedback at the end of the day identified some areas of action for the Trust which are being addressed. The formal report has now been received and the key areas of focus are included in the Chief Executives report. Hand Hygiene Hand hygiene compliance was 100%. MRSA screening Elective: 91.3%Non Elective: 93% Compliance in both elective and non-elective MRSA screening has increased this month but further improvements are needed if we are to achieve 100% compliance as required by the Commissioners. Discussions have taken place with the Oncology Day Unit to further investigate the issues to ensure improved compliance in this group of patients. In addition, plans to incorporate screening with the electronic risk assessment should also ensure that targeted action can be taken to address both elective and non-elective screening.

14. Quality Priority: Falls Falls performance This month we have changed the definition of falls which now includes patients who faint or collapse due to medical reasons. This brings us inline with other Trusts in the region; for this reason we anticipated a rise in the total number of falls per month. There were 49 falls across the Trust during September, 3 of which were faints and collapse; 15 of these falls resulted in harm but none resulted in serious harm. The rate per 1,000 occupied bed days is 5.31 (August 4.53). Themes Our preliminary work on falls in toilets has shown that in July, 15 falls or 17% of the total falls occurred in the WC, August had 5 or 10% of the total number and September 6 falls, which was 11.7% of the total number of falls. Detailed intelligence is being collected in October to reveal what the patient was actually doing at the time of the fall. The Estates Department are carrying out further assessment of the requirements for the provision of side rails in all toilets. No other themes have been identified to date.. 13

15. Quality Priority: Pressure Ulcers 14 The performance target is to have no avoidable Grade 2, 3 or 4 pressure ulcers 2013-14 Grade 2 pressure ulcers There were three grade 2 pressure ulcers this month. The Trust has recently purchased 30 new pressure relieving mattresses to replace some of our aging equipment and to increase the overall number of specialist mattresses available to patients Grade 3 and 4 pressure ulcers There were two hospital associated grade 3 pressure ulcers this month. One was a patient who was admitted with a grade 2 sacral ulcer which unfortunately deteriorated on F3 ward. This patient was receiving end of life care and despite taking all preventative measures, including specialist mattress and regular turning, the ulcer unfortunately deteriorated. The second grade three occurred on ward G9. This patient was 28 years of age and independent and suffered from type one diabetes with peripheral neuropathy and mental heath issues. They had previously sustained lower limb injuries and required to wear an orthopaedic boot, under the boot was a recently heeled ulcer and the new skin was very delicate. The patient refused to allow staff to check their pressure areas and the ulcer broke down again during their hospital stay.

16. Safety thermometer results Current performance for harm-free care is 91.03%. National September performance is 93.1%. The National ‘harm free’ care composite measure is defined as the proportion of patients without a pressure ulcer (ANY origin, category II-IV), harm from a fall in the last 72 hours, a urinary tract infection (in patients with a urethral urinary catheter) or new VTE treatment. The data can be manipulated to just look at “new harm” (harm that occurred within our care) and with this parameter, our Trust score is 97.55%. National September performance is 97.2%. Aug 12Sep 12Oct 12Nov 12Dec 12Jan 13Feb 13Mar 13Apr 13May 13Jun 13Jul 13 Aug 13Sep 13 Harm Free92.4492.1592.7193.7795.6693.0293.3693.6891.4793.2092.6093.22 92.6891.03 Pressure Ulcers – All3.783.804.023.381.795.173.553.514.504.285.363.52 2.985.16 Pressure Ulcers - New0.580.251.510.261.020.520.710.940.951.010.001.08 0.001.09 Falls with Harm0.000.760.750.260.510.780.710.231.660.000.260.81 0.270.00 Catheters & UTIs2.032.782.012.081.791.031.662.580.951.761.532.17 2.983.60 Catheters & New UTIs0.290.25 0.000.26 0.470.230.240.000.510.54 1.080.82 New VTEs2.031.010.500.780.26 0.710.471.420.760.260.54 1.360.54 All Harms7.567.857.296.234.346.986.646.328.536.807.406.78 7.328.97 New Harms2.912.283.021.042.041.812.611.874.271.761.022.98 2.712.45 Sample344395398385392387422427422397392369 368 Surveys17 18 17 15

17. Patient Safety High Impact Medication Errors During Quarter 2 July 2013 to 30 September 2013 there were 149 medication related incidents reported on the Datix system. Of these, 11 (7.4%) were classified as HIME’s. The Drugs and Therapeutics Committee continues to monitor all medication errors and ensure that organisation learning is disseminated. A Safety Bulletin from the Drugs and Therapeutics Committee has been developed to raise awareness of the issues and provide a monthly notification of current themes. Deteriorating patient The on going focus on early identification and escalation of patients who trigger on the MEWS score is ensuring that compliance is over 90%. There was a low score of 50% on F7/8; this is referred to in the ward performance summary of this report and is being addressed by the acting unit manager. 16

18. Quality Priority: Patient Experience – Achievement of 85% satisfaction 17 ‘ Achieve at least 85% satisfaction in internal patient satisfaction surveys’ is a Quality Priority for the Trust. The overall score for the inpatient survey was 91%, in line with previous months. A workshop was held for the wards to discuss the findings of the Call Bell project and agree an action plan. This is reported separately. Overall satisfaction scores for the OPD, A&E, short stay and Maternity services were maintained at a high level. The graphs below give some of the detail for the maternity survey. This shows a variation in the recommender score but this is not reflected in the scores for other questions.

19. Quality Priority: Patient Experience – recommend the service 18 ‘Patients would recommend the service to their family and friends’ is a Quality Priority for the Trust. The Trust achieved a net promoter score of 87 for inpatients during September, a return to a high score following a slight reduction in August. The score for A&E was 59. It would appear that the score of 72 for A&E in April was a higher than normal score as subsequent scores have been between 54 and 64. This month there were six comments from patients in response to reasons for not scoring “extremely likely”. Four of these related to waiting times and two gave reasons unrelated to the perception of care: “don’t live in the area” and “if A&E needed then would come regardless of recommendations”. Maternity services have been using the Friends and Family question within their survey for patients on the post-natal ward (F11) for over a year. However, the question has become a requirement nationally through CQUIN from this month. There is a requirement to ask the question four times; at the 36 week antenatal appointment, following birth in the delivery suite or birthing unit, post-natally on discharge from the post natal ward and lastly at the time of discharge in the community. The question is asked on its own except on the post natal ward. The scores for this month are shown below: It is too early to say whether these variations are significant. The score on the post-natal ward has shown some variability from month to month previously. AntenatalBirthPost natal wardCommunity 77916690

20. CQC Action Plan Following the recent CQC inspection, an action plan was presented to the Board last month to address the issues in relation to variability of staff knowledge and application of the mental capacity act and documentation of verbal consent. The intention is to provide an update in this report each month as to progress against the plan. Update The education and training activities identified in the action plan are progressing well. There have been a number of in-house sessions and several staff have attended a UEA study day on MCA and DOLS. The university have planned several repeat sessions and a total of 25 nursing staff have, or have booked to attend the study days. This includes a range of staff from matron to newly qualified nurses. Monthly staff education sessions are being held in conjunction with the County MCA and DOLS Coordinator. A session to discuss mental capacity assessment, DNACPR documentation and verbal consent was held at the Medical Directorate Governance/Audit afternoon in September and was well received. This will be repeated at the next Surgical Directorate Audit session. Briefing documents and a flowchart have been distributed to wards and departments in September and October as per the timescale in the action plan. The question has been added to the CQC assurance self assessment audits and the September results will be available next month. 19

21. Local Priorities - Governance Dashboard IndicatorPerformance targetRAGSep13Commentary Timely completion of incident investigations and actions Outstanding RCAs (non SIRI) more than 45 days after incident reported >1100 RCA Actions beyond deadline for completion>=51-403Discussed at Operational Steering Group Incidents (Amber / Green) with investigation overdue (over 12 days) >15050-150<50306See exception report for details Timely reporting of SIRIs SIRIs reported > 2 working days identified as red >11007 / 7 within deadline. Three were identified as red after the incident date: one through a review of amber investigations, one through audit and one through inquest SIRI final reports due in month submitted beyond timeframe >110011 / 11 within deadline Number of SIRI reports open on STEIS more than 45 days after initial notification >106-100-518See exception report for details Duty of CandourCompliance with Duty of Candour requirements <75%75 – 94%>=95%100%Duty of Candour achieved for all 18 applicable cases in September. This is the first time this indicator has been reported. Board approval of the KPI RAG rating is requested. Risk assessment Active risk assessments in date<75%75 – 94%>=95%100% Outstanding actions in date for Red / Amber entries on Datix risk register <75%75 – 94%>=95%96% 20

22. Local Priorities - Governance Dashboard (cont.) IndicatorPerformance targetRAGSep13Commentary Clinical AuditTrust participation in relevant ongoing National audits (reported by Quarter) <75%75 – 89% >=90% 100% Safer surgeryCompletion of WHO checks during surgery. This is a composite indicator of the checks at ward, sign-in, time-out and sign-out. <90%90% - 98% >98%94%Non compliance reported to individuals (daily) and Clinical Directors (weekly) NICETA (Technology appraisal) business case beyond agreed deadline timeframe >94 - 90 - 3 1These outstanding Five interventional procedures and Six Clinical Guidelines are outstanding baselines assessment and require targeted follow up. IPG (Interventional procedure guideline) baseline assessments beyond agreed deadline timeframe >94 - 90 - 3 5 CG (Clinical guideline) baseline assessments beyond agreed deadline timeframe >94 - 90 - 3 6 ComplaintsResponse within 25 days or negotiated timescale with the complainant <75%75 – 89%>=90% 86%5/35 responses due in September were sent out late Number of second letters received >=51-40 0 Health Service Referrals accepted by Ombudsman >=210 0 Red complaints actions beyond deadline for completion >=51-40 0 Number of PALS contacts becoming formal complaints >=106 - 9<=5 1 ComplimentsCompliments received centrally No RAG rating 52 21

23. Patient Safety Incidents reported The rate of PSIs is a nationally mandated item for inclusion in the Quality Accounts. The NRLS target lines shows how many patient safety incidents WSH would have to report to fall into the median / upper and lower quartiles for small acute trusts reporting per 100 admissions. This was rebased in March to take into account the new dataset from the Apr12 - Sept 12 NRLS report showed a fall in the peer group median but upper and lower quartiles remained similar to previous reports. There were 432 incidents reported in September including 361 patient safety incidents (PSIs). The reporting rate rose in September to just above the upper quartile for the peer group.. The number of harm incidents in September was below the peer group average level. 22

24. Patient Safety Incidents (Severe harm or death) The percentage of PSIs resulting in severe harm or death is a nationally mandated item for inclusion in the Quality Accounts. The peer group average (serious PSIs as a percentage of total PSIs) has been rebased to 0.9% from the NPSA Apr ’12 – Sept ‘12 report and sits above the Trust’s average. The WSH data is plotted as a line which shows the rolling average over a 12 month period. The number of confirmed serious PSIs are plotted as a column on the secondary axis. The unconfirmed incident in June 2012 was identified through TARN audit and the October 2012 incident via a complaint - both reported retrospectively in September 2013. In July there were six ‘Red’ patient safety incidents: Incorrect implant (1) pressure ulcer (1), deteriorating patient(1) and three awaiting confirmation through RCA: Fall (2) and Inquest (1) 23

25. Local Priorities: Complaints There was a slight reduction in the number of complaints received in September 2013 although numbers remain high compared with 2012. Complaint response within agreed timescale with the complainant: 86% of responses due in September This represents 5 of the 32 complaint responses going out late. Of the 29 complaints received in September, the breakdown by Primary Directorate is as follows: Medical (15), Surgical (5), Clinical Support (0), Facilities (1), and Women & Child Health (8). The high number of complaints received in Woman & Child Health has been brought to the attention of the General Manager of this directorate. Trust-wide the top 5 most common problem areas are as follows: All Aspects of Clinical Treatment20 Communication / Information to Patients (written and oral)12 Attitude of Staff8 Admissions, Discharge and Transfer Arrangements4 Aids and Appliances, Equipment, Premises (including access)3 24

26. Local Priorities: PALS (Patient Advice & Liaison Service) In August 2013 there were 89 recorded PALS contacts. This number denotes initial contacts and not the number of actual communications between the patient/visitor which can, in some particular cases, be multiple. A breakdown of contacts by Directorate from Sep’12 to Sep‘13 is given in the chart and a synopsis of enquiries received for the same period is given below. Total for each month is shown as a line on a second axis. Trust-wide the most common five reasons for contacts are shown below. Information/Advice request36All aspects of clinical treatment24Appointments, delay, cancellation (outpatients)8 Communication/information to patients (written/oral)6Patients property and expenses5 The numbers across the different areas of concern remain constant and there are no particular themes that the PALS Manager has identified this month. Two areas featuring again are Patients Property/Expenses which continues to be a misunderstanding about the role of PALS in this respect and a number of queries related to orthopaedic surgery. Orthopaedic surgery has been identified as increasing for the month however there is no identified trend or theme. This area will be kept under review. It is evident that the PALS Manager, in addition to assisting with genuine concerns from patients and relatives, frequently signposts enquirers to other services. She is also actively involved in dealing with specific in-patients and their families concerns during the total admission period. 25

27. Local Priorities – Workforce Performance 26 Performance IndicatorThreshold Direct Financial Penalty 12 Month YTD CommentsLead Exec Workforce Sickness absence rate<3.5%NO3.91% Jan Bloomfield Turnover<10%NO7.76% Jan Bloomfield ReviewsGrievance/Banding reviewsNO10 No New Cases - 1 on-going Tribunal and 1 Outstanding Agenda for Change Banding Appeal Jan Bloomfield Recruitment TimescalesAverage number of weeks to recruit = 7NO5.7 Jan Bloomfield CRB Disclosures existing staffTo complete 95% of required CRB checksNO98.51% Jan Bloomfield All Staff to have an appraisal Both general and consultant staff each have a target of 90% to have had an apprasial within the previous 12 months. Appraisal is a rolling programme NO85.85% Jan Bloomfield Mandatory Training compliance (reported Quarterly) Jan Bloomfield

28. CQUIN – October 2013 27

29. CQUIN – October 2013 28

30. CQUIN – October 2013 29

31. Monitor Compliance Framework 30 Monitor Compliance Framework Performance IndicatorThresholdMonthQTDWeightingLead Exec Access: Maximum time of 18 weeks from point of referral to treatment in aggregate – admitted90% 98.08%98.53% 1.0Jon Green Maximum time of 18 weeks from point of referral to treatment in aggregate – non-admitted95% 99.87%99.96% 1.0Jon Green Maximum time of 18 weeks from point of referral to treatment in aggregate – patients on an incomplete pathway92% 100.00%99.97% 1.0Jon Green A&E: maximum waiting time of four hours from arrival to admission/transfer/discharge95% 98.11%96.36% 1.0Jon Green All cancers: 62-day wait for first treatment (5) from:Urgent GP referral for suspected cancer 85% 87.00%89.03% 1.0 Jon Green All cancers: 62-day wait for first treatment (5) from: NHS Cancer Screening Service referral90% 100.00% Jon Green All cancers: 31-day wait for second or subsequent treatment, comprising: Surgery94% 100.00% 1.0 Jon Green All cancers: 31-day wait for second or subsequent treatment, comprising: anti-cancer drug treatments98% 100.00% Jon Green All cancers: 31-day wait for second or subsequent treatment, comprising: radiotherapy - Not applicable to WSFT All cancers: 31-day wait from diagnosis to first treatment96% 100.00% 0.5Jon Green Cancer: two week wait from referral to date first seen (8), comprising: all urgent referrals (cancer suspected) 93% 97.02%97.64% 0.5 Jon Green Cancer: two week wait from referral to date first seen (8), comprising: for symptomatic breast patients (cancer not initially suspected) 93% 98.67%98.59% Jon Green Outcomes: Clostridium (C.) difficile - meeting the C.difficile objective - MONTH2 3 1.0 Nichole Day Clostridium (C.) difficile - meeting the C.difficile objective - QUARTER Q1 = 3, Q2 = 4, Q3 = 6, Q4 = 6 8 Nichole Day Clostridium (C.) difficile - meeting the C.difficile objective - ANNUALLY19 16 Nichole Day Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - MONTH0 0 1.0 Nichole Day Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - QUARTER0 0 Nichole Day Methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia – meeting the MRSA objective - ANNUALLY0 1 Nichole Day Certification against compliance with requirements regarding access to healthcare for people with a learning disabilityN/A--0.5Nichole Day

32. Contract Priorities Dashboard 31 Performance IndicatorThreshold In Month Performan ce YTDCommentsLead Exec A&E A&E - Threshold for admission via A&E i) if the monthly ratio is above the corresponding 2011/12 monthly ratio for two month in a six month period ii) if year end is greater than 27% 23.90%24.92% Jon Green A&E - Timeliness Indicators To satisfy at least one of the following Timeliness Indicators: 1. Time to initial assessment (95th percentile) below 15 minutes 2. Time to treatment in department (median) below 60 minutes ONE MET- Jon Green Stroke Stroke -Proportion of Patients admitted to an acute stroke unit within 4 hours of hospital arrival 90%92.00%84.83% Jon Green Proportion of patients in Atrial Fibrillation, presenting with stroke and where clinically indicated will receive anti-co-agulation. 60%33.00%65.83% Jon Green Stroke - % of Stroke patients with access to brain scan within 24 hours 100%100.00%98.33% Jon Green Stroke - Proportion of Stroke Patients and carers with a joint health and social care plan on discharge 85%100.00%90.67% Jon Green Stroke - Patients (as per NICE guidance) with suspected stroke to have access to an urgent brain scan in the next slot within usual working hours or less than 60 minutes out of hours as defined from time to time by the ASHN 100% of stroke patients eligible for a brain scan scanned within one hour 100.00%92.33% Jon Green >80% treated on a stroke unit >90% of their stay80%88.00%87.83% Jon Green >60% of people who have a TIA and are high risk (ABCD 2 score 4 or more) are scanned and treated within 24 hours of 1st contact but not admitted 60%75.00%76.33% Jon Green Stroke - 65% of patients with low risk TIA have access to MRI or carotid scan within 7 days (seen, investigated and treated) 65%76.00%74.83% Jon Green % of Patients eligible for Thrombolysis, Thrombolysed within 4.5 hours 100% of all eligible patients100.00% Jon Green

33. Contract Priorities Dashboard 32 Discharge Summaries Discharge Summaries - Outpatients95% sent to GP's within 3 days85.74%84.62% Dermot O'Riordan Discharge Summaries - A&E 95% of A&E Discharge Summaries to be sent to GPs within one working day 97.67%97.50% Dermot O'Riordan Discharge Summaries - Inpatients95% sent to GP's within 1 day78.97%82.92% Dermot O'Riordan Choose & Book Provider failure to ensure that “sufficient appointment slots” are made available on the Choose and Book system A maximum of 3% slots unavailable (£50 per appointment over 5%. Threshold applied over monthly figures) 3.00%- The Threshold applied to fines is 5% Jon Green All 2 Week Wait services delivered by the Provider shall be available via Choose & Book (subject to any exclusions approved by NHS East of England) 100%100.00%- Jon Green Cancelled Operations Provider cancellation of Elective Care operation for non-clinical reasons either before or after Patient admission i) 1% of all elective procedures1.66%1.15% Jon Green Patients offered date within 28 days of cancelled operation 100% 100.00% Jon Green Maternity Access to Maternity services (VSB06):- 90% of women who have seen a midwife or a maternity healthcare professional, for health and social care assessment of needs, risks and choices by 12 completed weeks of pregnancy. 97.45%95.94% Nichole Day Maintain maternity 1:30 ratio1:30 1:29 Nichole Day Pledge 1.4: 1:1 care in established labour1:1 100.00% Nichole Day Breastfeeding initiation rates.80% 76.68%78.93% Nichole Day Reduction in the proportion of births that are undertaken as caesarean sections. Suffolk PCT Only 1% reduction in proportion compared to 2011/12 baseline - 22.70% 21.31%18.84% Nichole Day

34. Contract Priorities Dashboard 33 Other contract / National targets Mixed Sex Accomodation breaches0 Breaches02 Jon Green Consultant to consultant referral Commisioner to audit if concern about levels of consultant referrals 6.57%5.92% Jon Green Current ratios of OP procedure to day case for agreed list of procedures to be maintained or improved, i.e. the Commissioner will not fund a higher level of admitted patients for such procedures, unless clinical reasons can be demonstrated for increase in admissions. Maintain or improve the mix as specified = 90.17% 87.29%87.58% Jon Green MRSA - emergency screening All emergency patients admissions are to be screened for MRSA within 24 hours of admission 93.03%92.02% Nichole Day Rapid access - chest pain clinic 100% of patients should have a maximum wait of two weeks 100.00%74.72% Jon Green New to Follow up Thresholds set at each speciality - overall Trust Threshold is 1.9 1.781.86 Jon Green