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					           GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST


Title                                         Performance Management Report

Report date                                   October 2011

Please classify the paper as:
   1. For discussion/decision
   2. Performance reporting
   3. For Information                         2. Performance Reporting

Executive Summary                             To present to the Board the organisational
                                              performance across the key strategic
                                              objectives
                                                         Our Business
                                                         Our Services
                                                         Our Patients
                                                         Our Staff

Please describe as appropriate the link to:   The PMF reports progress on Trust
   1. The Trust Strategic Objectives          objectives.
   2. The Trust In-Year Objectives



Please identify the outcomes from this Patient experience reported
paper for public accountability and
engagement.


Please identify any other significant         Failure to achieve some performance targets
impact or outcomes (where applicable) in      can result in financial penalties for the Trust.
relation to Financial issues, Equality and
Diversity, the NHS Constitution, Legal        Patients may have a legal right enshrined in
issues or Sustainable Development             the NHS Constitution to receive services that
                                              meet certain key performance levels included
                                              in this report.

Recommendation                                The Board is asked to ENDORSE the
                                              performance report and the action identified to
                                              improve organisational performance.

Author                                        Helen Munro
                                              Head of Information

Presenting Director                           Evelyn Barker
                                              Deputy Chief Executive & Chief Operating
                                              Officer




Performance Management Report                                                         Page 1 of 1
Main Board – October 2011
                                   GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST




                  PERFORMANCE MANAGEMENT FRAMEWORK



                                              OCTOBER 2011




Performance Management Framework                                                    Page 1 of 18
Main Board – October 2011
                                (intentionally blank)




Performance Management Report                           Page 2 of 18
Main Board – October 2011
DOMAIN: OUR BUSINESS

                                                                                                               Current       Latest                                                                                                              Year end
Measure                                                                          Standard         Frequency     Data        Quarter/      April        May       June          July       Aug      Sept     Oct   Nov   Dec   Jan   Feb   Mar    expected
                                                                                                               Mth/Qtr        ytd                                                                                                                position


Monitor Financial Risk Rating                                                      level 3           M         Sep-11          n/a          3            3          3            3          3        3                                               3
                                                                                                                                                         on                                                                                     forecast
                                                                                Achieved or                                             on course               on course    on course
Achieve planned Income & Expenditure position at year end                                            M         Sep-11          n/a                     course                             -£1.4m   -£2.2m                                       outturn to
                                                                               better at yr end                                         for yr end              for yr end   for yr end                                                         reach even
                                                                                                                                                     for yr end

Emergency readmissions within 30 days of elective admission                         ≤ 2%             M         Sep-11       2.28% ytd    2.62%        2.41%      1.87%        2.45%       2.45%    1.94%                                            2%


Emergency readmissions within 30 days of emergency admission                        ≤ 7%             M         Sep-11       9.66% ytd    8.82%        8.35%      9.98%       10.51%       9.78%    10.27%                                           9%

                                                                                   range
GP referrals year to date - within 2.5% of plan                                                      M        to 30/09/11   -2.8% ytd     5.3%         3.8%       1.7%         0.9%       -0.7%    -2.8%                                            0%
                                                                               +2.5% to -2.5%
                                                                                   range
Elective spells year to date - within 2.5% of plan                                                   M        to 30/09/11   -3.6% ytd     3.7%        -1.0%      -1.5%        -1.7%       -2.5%    -3.6%                                           -1.5%
                                                                               +2.5% to -2.5%
                                                                                   range
Emergency Spells year to date - within 2.5% of plan                                                  M        to 30/09/11   -3.8% ytd    -5.5%        -6.1%      -5.7%        -4.5%       -4.6%    -3.8%                                           -2.5%
                                                                               +2.5% to -2.5%

LOS for general and acute emergency spells - reduce ALOS by 0.5 days              <5.8days           M         Sep-11         6.17        6.30         6.30       6.40         6.03        6.22     6.27                                            5.8

                                                                                   range
OP attendance & procedures year to date - within 2.5% of plan                                        M        to 30/09/11   -1.0% ytd     0.0%         1.6%       0.7%        -0.3%       -0.8%    -1.0%                                            0%
                                                                               +2.5% to -2.5%

% records submitted nationally with valid GP code                                  ≥ 99%             M          Jul-11       99.8%       99.8%        99.8%      99.8%        99.8%                                                                 99%


% records submitted nationally with valid NHS number                               ≥ 99%             M          Jul-11       99.5%       99.5%        99.4%      99.5%        99.1%                                                                 99%


% inpatients with valid ethnic origin codes on Patient Administration System       ≥ 85%             M         Sep-11        96.5%       94.0%        95.0%      97.0%        96.0%       97.0%    96.0%                                            95%


Carbon Utilisation : 1.5% below 2010/11 levels                                      -1.5%            M          Aug-11       -2.6%       -6.1%        -0.4%      -1.5%        -2.0%       -2.9%                                                    -2.0%




Performance Management Framework                                                                                                                                                                                                          Page 3 of 18
Main Board – October 2011
DOMAIN: OUR SERVICES

                                                                                                             Current    Latest                                                                                         Year end
Measure                                                                        Standard          Frequency    Data     Quarter/   April   May     June    July    Aug     Sept    Oct   Nov   Dec   Jan   Feb    Mar   expected
                                                                                                             Mth/Qtr     ytd                                                                                           position


Number of Clostridium Difficile (C-Diff) infections - post 48 hours          73 cases/year          M        Sep-11     54 ytd     7       9       9       10       9      10

Number of Methicillin-Resistant Staphylococcus Aureus (MRSA) infections -
                                                                              5 cases/year          M        Sep-11      1ytd      1       0        0       0       0       0
post 48 hours
                                                                                                                                                                                                                        No more
Number of Never Events                                                              0               M        Sep-11       0        2       1        0       0       0       0                                            Never
                                                                                                                                                                                                                         Events

Hospital Standardised Mortality Ratio (HMSR)                                      <110              M        Jul-11      n/a      79.1    89.5    81.0    69.5                                                            90.0


Crude Mortality rates                                                              <2               M        Sep-11     0.87      1.00    1.11    0.98    0.85    0.87    0.90                                            1.00

                                                                            <1.6 per thousand
Number of Patient Falls causing harm : 10% below 2010/11 levels :                                   Q        Sep-11      1.4       1.8     1.7     1.7     1.5     1.5     1.2                                             1.6
                                                                                bed days

                                                                             84 per annum
Number of Hospital associated pressure sores : 20% below 2010/11 levels                             Q        Jun-11      27         -       -       -
                                                                            (21 per quarter)
Number of incidents of serious harm from medication errors : 10% below
                                                                                                    Q          n/a
2010/11 levels
Number of patients compliant with sepsis care bundle : 50% ptts with 100%   50% of patients       Q (from                                                                                                              50% of patients
                                                                                                             Jun-11       -         -       -      0%                                                                  from A&E\ACU
compliance                                                                    with 100%          June 11)                                                                                                                 with 100%


                                                                               90% of all
Deliver National Safety CQUIN targets for VTE risk assessments                                      Q        Sep-11     93.3%     91.2%   91.1%   91.2%   92.3%   93.4%   94.3%                                           95%
                                                                                patients

Number of Dead legs removed from Trust water systems : on trajectory         100% removal           Q          Q2        N/A       N/A     N/A     N/A    4.7%    17.3%   30.4%                                          100%

Number of physically aggressive Incidents towards staff (actual and near     <1.6 per 1000
                                                                                                    Q        Sep-11      2.3       3.7     2.9     2.4     3.2     1.2     2.6
miss) : 10% below 2010/11 levels                                              head count

Number of Non Clinical staff sharp injuries : 20% below 2010/11 levels      <25.7 per 1000
                                                                                                    Q        Sep-11     20.6      20.0    23.4    23.3    16.7    31.7    13.3                                            25.7
                                                                            non-clinical staff

                                                                             <1.6 per 1000
Number of staff slips/falls : 10% below 2010/11 levels                                              Q        Sep-11      0.8       1.6     2.0     1.7     0.8     0.9     0.8                                             1.6
                                                                              head count




Performance Management Report                                                                                                                                                                                   Page 4 of 18
Main Board – October 2011
DOMAIN: OUR PATIENTS

PATIENT EXPERIENCE
                                                                                                                             Current      RAG                                                                                                             Year end
                                                                                                                                                   Latest
Measure                                                                          Standard       Measure        Frequency      Data       status               April    May     June      July     Aug       Sept    Oct   Nov   Dec   Jan   Feb     Mar   expected
                                                                                                                                                   Quarter
                                                                                                                             Mnth/Qtr    current                                                                                                          position
18 WEEKS

Admitted pathways - % treated in 18 weeks                                          ≥ 90%       Discharges          M          Sep-11       R       89.70%    88.00%   89.96%   90.01%   89.84%   89.31% 90.03%                                              90%+


Admitted pathways - 95th percentile treated in 18 weeks                         ≤ 23 weeks     Discharges          M          Sep-11       G        21.6      22.7     23.1     21.1     21.1     21.3      22.4                                          <23 weeks


Non-admitted pathways - % treated in 18 weeks                                      ≥ 95%       Discharges          M          Sep-11       G       98.02%    97.80%   98.30%   98.50%   98.12%   97.90% 98.05%                                              95%+


Non-admitted pathways - 95th percentile treated in 18 weeks                     ≤ 18.3 weeks   Discharges          M          Sep-11       G        15.3      14.2     15.3     15.0     15.9     14.9      15.1                                          <18 .3 wks


15 key Diagnostic tests : numbers waiting over 6 weeks at month end                  0         No. waiitng         M          Sep-11       R         n/a       96      189      165      103       65       112                                               0


ED

% patients spending 4 hours or less in ED: Countywide Q1, Trustwide Q2+            ≥ 95%       Attendances         M          Sep-11       R       95.10%    95.40%   95.90%   97.40%   96.15%   95.01%    94.10%                                           95%


Number of ambulance handovers delayed over 20 minutes                                0         Attendances         M          Sep-11       R        715       335      384      257      210      177       328

CANCER

Max 2 week wait for patients urgently referred by GP                               ≥ 93%       Attendances         M          Aug-11       G       90.3%     90.6%    88.0%    92.2%    88.6%    93.4%                                                      93%


Max 2 week wait for patients referred with non cancer breast symptoms              ≥ 93%       Attendances         M          Aug-11       R       81.6%     73.3%    73.3%    97.1%    71.3%    87.3%                                                      93%


Max wait 31 days decision to treat to treatment                                    ≥ 96%       treatments          M          Aug-11       G       99.5%     99.2%    99.4%    99.7%    99.3%    99.6%                                                      96%


Max wait 31 days decision to treat to subsequent treatment : surgery               ≥ 94%       treatments          M          Aug-11       G       100.0%    100.0%   100.0%   100.0%   100.0%   100.0%                                                     100%


Max wait 31 days decision to treat to subsequent treatment : drugs                 ≥ 98%       treatments          M          Aug-11       G       100.0%    100.0%   100.0%   100.0%   100.0%   100.0%                                                     100%


Max wait 31 days decision to treat to subsequent treatment : Radiotherapy          ≥ 94%       treatments          M          Aug-11       G       100.0%    100.0%   100.0%   100.0%   100.0%   100.0%                                                     100%


Max wait 62 days from urgent GP referral to 1st treatment                          ≥ 85%       treatments          M          Aug-11       G       83.3%     86.9%    81.0%    81.6%    81.1%    90.4%                                                      85%


Max wait 62 days from national screening programme to 1st treatment                ≥ 90%       treatments          M          Aug-11       G       94.7%     100.0%   93.5%    89.7%    100.0%   92.9%                                                      90%


Screening Programmes

Cervical Screening results to GP within 10 days of date sample taken               100%        results times       M          Aug-11       G       99.8%     99.9%    99.8%    99.8%    99.8%    99.6%                                                      99%


Delayed Discharges

Number of delayed discharges at month end                                           25           patients          M          Sep-11       G         n/a       48       48       44       19       17        14                                              <25



                                                                                 ≥90% Q1
Patient Discharge Summaries sent to GP by next working day                                     summaries           M          Sep-11       R       66.0%     60.1%    65.0%    57.5%    63.5%    67.0%     67.4%
                                                                                 ≥95% Q2

Number of Breaches of Mixed sex accommodation                                        0           patients          M          Sep-11       R         n/a       22       7        16       12       10        15


Patient Experience
                                                                                                                                          RAG
                                                                                                                              Current                                                                                                                     Year end
                                                                                                                                         status    Latest
Measure                                                                          Standard       Measure        Frequency       Data                           April    May     June      July     Aug       Sept    Oct   Nov   Dec   Jan   Feb     Mar   expected
                                                                                                                                         current   Quarter
                                                                                                                             Month/Qtr                                                                                                                    position
                                                                                                                                         Month
% Patients who say they definitely received sufficient information about ward                                   Bi-monthly               W&C R                                                            W&C 57%
                                                                                  ≥ 80%                         from May
                                                                                                                              Sep-11                 n/a       _       69%       _       53%       _                _           _           _               ≥ 75%
routines                                                                                                                                 D&S R                                                            D&S 62%
% Patients who say they were definitely involved as much as they wanted to                                      Bi-monthly               W&C G                                                            W&C 91%
                                                                                  ≥ 80%                         from May
                                                                                                                              Sep-11                 n/a       _       84%       _       71%       _                _           _           _               ≥ 75%
be in decisions about their care (CQUIN 2011-2012)                                                                                       D&S G                                                            D&S 85%
% Patients who said they definitely found someone on the hospital staff to                                      Bi-monthly               W&C G                                                            W&C 90%
                                                                                  ≥ 80%                         from May
                                                                                                                              Sep-11                 n/a       _       88%       _       72%       _                _           _           _               ≥ 75%
take to about worries and fears (CQUIN 2011-2012)                                                                                        D&S R                                                            D&S 68%
% Patients who say they had been made aware of how personal information                                         Bi-monthly               W&C G                                                            W&C 80%
                                                                                  ≥ 80%                         from May
                                                                                                                              Sep-11                 n/a       _       41%       _       35%       _                _           _           _               ≥ 75%
is used                                                                                                                                  D&S R                                                            D&S 42%
% Patients who say they were always given enough privacy when discussing                                        Bi-monthly                 G
                                                                                  ≥ 80%                         from May
                                                                                                                              Sep-11                 n/a       _       n/a       _       88%       _      D&S 90%   _           _           _               ≥ 75%
their condition or treatment (CQUIN 2011-2012)


Performance Management Report                                                                                                                                                                                                                     Page 5 of 18
Main Board – October 2011
DOMAIN: OUR STAFF



                                                                                                        Current                                                                                                          Year end
                                                                                                                  Latest
Measure                                                                         Standard    Frequency    Data                April     May     June      July     Aug      Sept     Oct   Nov   Dec   Jan   Feb    Mar   expected
                                                                                                                  Quarter
                                                                                                        Mth/Qtr                                                                                                          position


Total PayBill spend £'000                                                       on target      M        Sep-11      n/a     £21,374   £21,514 £21,756   £21,665 £21,777   £21,399                                        £21,063

Total worked FTE                                                                on target      M        Sep-11      n/a     6416.6    6466.5   6443.2   6446.3   6464.0   6390.1                                          6051.4

Annual sickness absence rate                                                    <3.75%         M        Aug-11    3.63%     3.54%     3.55%    3.80%    3.96%    3.93%                                                    3.75%

Staff who have annual appraisal                                                   90%          M        Sep-11    80.0%     79.0%     79.0%    79.0%    80.0%    81.0%    79.0%                                           90.0%

Staff who completed mandatory training                                            90%          M        Sep-11    78.6%     74.0%     76.0%    77.0%    78.0%    78.0%    80.0%                                           90.0%

Staff involvement and engagement with Trust                                       65%          A        Jul-11      n/a       _         _        _       60%       _        _                                             65.0%

Staff who report Trust Communicates clearly with them about what it is trying
                                                                                  35%          A        Jul-11      n/a       _         _        _       32%       _        _                                             35.0%
to achieve

Annual turnover                                                                  7-8.9%        M        Aug-11    7.41%     7.52%     7.36%    7.36%    7.49%    7.14%                                                    6.96%




Performance Management Report                                                                                                                                                                                     Page 6 of 18
Main Board – October 2011
OUR BUSINESS

                                                                                                                                                                                            Trust Standard

This relates to patients admitted as an emergency within 30 days of emergency discharge.

      Standard                 Month                   Actual           RAG for current month                                                                   Activity

         ≤ 7%                  Sep-11                 10.27%                        R
What is driving the reported underperformance

NHSG, in line with national guidance, requires emergency admissions following an emergency
admission to reduce by 25%. This gives GHNHSFT a target rate of 7% in 2011/12.
The position YTD for emergency admission following an emergency admission is 9.66%.




Actions taken to improve performance

The teams are reviewing frequent attenders where a patient has been admitted three or more times
in the previous 12 weeks to establish trends and determine with the commissioners how these
patients could be case managed in future.

Expected date to meet standard                                        Nov-11

Lead Director                                                         Evelyn Barker




                                                                                                                                                                                            Trust Standard

GP referrals to consultant led clinics year to date to plan

      Standard                 Month                   Actual           RAG for current month                                                                   Activity

 within 2.5% of plan     YTD - end Sept 11             -2.80%                       A
What is driving the reported underperformance                                                                                           Average GP Referrals per Working Day

                                                                                                                                  500
GP referrals have been below plan for the last 3 months and are 4.4% lower than the same time last




                                                                                                      Avg. Refs per working day
                                                                                                                                  450
year. The position by Division is;
Surgical -3.6%; Medical -4.8%; W&C +1.8%; D&S +12.2% (small numbers)                                                              400
                                                                                                                                  350

Last month GP referrals to T&O were above plan by 6% YTD, but below plan in September. However                                    300
the increase from Physiotherapy PCT commissioned Spinal Assessment Service has been sustained                                     250
                                                                                                                                  200
Actions taken to improve performance                                                                                              150
                                                                                                                                  100
The increase in T&O referrals from the NHSG commissioned service has been raised with NHSG as
                                                                                                                                   50
this impacts on our ability to deliver 18 weeks in T&O. Further information is being ascertained on
                                                                                                                                    0
the exact pathway.                                                                                                                        A pr   M ay   Jun   Jul   A ug   Sep   Oct   No v    Dec    Jan    Feb   M ar
                                                                                                      201 /1 A vg. Refs
                                                                                                         1 2                              441    441    413   415   383    378    0     0        0     0      0      0
Expected date to meet standard                                                                        201 1A vg. Refs
                                                                                                         0/1                              436    465    427   426   400    408   427   424      314   424    436    429

Lead Director                                                         Evelyn Barker




Performance Management Report                                                                                                                                                                                      Page 7 of 18
Main Board – October 2011
OUR BUSINESS

                                                                                                                                                                                                                                        Trust Standard

Number of IP and DC elective spells year to date compared to plan

      Standard                 Month                  Actual           RAG for current month                                                                                                        Activity

 within 2.5% of plan     YTD - end Sept 11           -3.60%                       A
                                                                                                                                                        Cumulative Elective Activity Variance against Plan
What is driving the reported underperformance
                                                                                                                                                         400




                                                                                                           YTD Variance against Plan
Elective IP are -8.4% and daycases -2.1% compared to plan. Activity has been below plan in each
                                                                                                                                                         200
month this year except April.
                                                                                                                                                           0
The position by Division is:-
Surgical Division -6.5% to plan, Medical Division +1.6%, Women & Children +17.8% and Diagnostics                                                        -200

& Specialties -8%.                                                                                                                                      -400
Most surgical sub-specialities are behind plan, with the exception of orthopaedics and pain.                                                            -600
                                                                                                                                                        -800
Actions taken to improve performance
                                                                                                                                                        -1000
The ophthalmology plan is to be reduced by 700 patients FYE (cataracts). The Surgical Division                                                          -1200
                                                                                                                                                                    A pr      M ay      Jun       Jul      A ug     Sep      Oct      No v     Dec      Jan    Feb    M ar
have been asked to submit an activity recovery plan in November.
                                                                                                    % IP Variance YTD                                               1.9%      -4.3%     -5.4%     -5.6%    -7.1%    -8.4%    0.0%     0.0%     0.0%     0.0%   0.0%   0.0%
                                                                                                    % Daycase Variance YTD                                          4.3%      0.0%      -0.2%     -0.5%      .1
                                                                                                                                                                                                           -1 %     -2.1%    0.0%     0.0%     0.0%     0.0%   0.0%   0.0%
Expected date to meet standard                                       tbc                            Elective IP Variance YTD                                         19       -95       -188      -265     -420     -608      0        0        0        0      0      0
                                                                                                    Daycase Variance YTD                                            138        3        -27       -69      -202     -485      0        0        0        0      0      0

Lead Director                                                        Evelyn Barker




                                                                                                                                                                                                                                           Trust Standard

Number of emergency spells year to date to plan. Non elective spells not included

      Standard                 Month                  Actual           RAG for current month                                                                                                        Activity

 within 2.5% of plan     YTD - end Sept 11           -3.80%                       A
                                                                                                                                                                Cumulative Emergency Activity Variance against Plan
What is driving the reported underperformance
                                                                                                                                                                0




                                                                                                                            YTD Variance against Plan
September is the first month this year where emergency spells have been higher than plan. At 122                                                            -100
/day this compares to the average YTD of 118/day.
                                                                                                                                                           -200
In the period April-September 2011 emergency spells are 6.2% lower than the same time last year.
                                                                                                                                                           -300
In September 2011 alone emergency spells were -1% lower than September 2010. Medical
                                                                                                                                                           -400
emergency admissions are +1.8% to plan and surgical -9.1% ytd.
                                                                                                                                                           -500
The reduction in surgical emergency spells is predominantly general surgery.
                                                                                                                                                           -600
Actions taken to improve performance                                                                                                                       -700
                                                                                                                                                           -800
The Surgical Divison are analysing what has changed in the general surgical pathway on presention                                                          -900
to A&E.
                                                                                                                                                           -1000
                                                                                                                                                                       A pr     M ay      Jun        Jul     A ug     Sep     Oct      No v     Dec      Jan   Feb    M ar

                                                                                                    % Emergency Variance YTD                                          -5.5%     -6.1%     -5.7%    -4.5%    -4.6%    -3.8%    0.0%     0.0%     0.0%    0.0%   0.0%   0.0%
Expected date to meet standard                                       tbc                            Emergency Variance YTD                                            -208      -468      -648      -684     -862    -848         0        0        0     0      0      0

Lead Director                                                        Evelyn Barker




Performance Management Report                                                                                                                                                                                                                                         Page 8 of 18
Main Board – October 2011
OUR BUSINESS




                                                                                                                                                                                 Trust Standard

LOS for General and Acute Emergency spells; excludes Paediatrics, Maternity and private patients

       Standard                  Month                   Actual             RAG for current month                                                       Activity

         ≤ 5.8                  Sep-11                    6.27                         R
                                                                                                                                    Gloucestershire Hospitals NHS Foundation Trust
What is driving the reported underperformance                                                                                          Average Length of Stay - April 2010 to date
LOS has remained at the same level as winter, yet we would expect this to reduce by 0.5 days in                                            General & Acute Specialties only
summer. Although some of this can be attributed to increased casemix and older patients, the
impact on bed occupancy is significant and reducing LOS is a key part of the Trust efficiency
                                                                                                                             7.00
programme
                                                                                                                             6.50




                                                                                                        Average LOS (Days)
Actions taken to improve performance                                                                                         6.00
There is a major initiative to improve the discharge process starting on 17th October. This includes;                        5.50
- new discharge planning tool
                                                                                                                             5.00
- new 'ticket home' given to patient on admission
- estimated date of discharge (EDD) added to PAS+ and whiteboards within 24 hours of admission                               4.50
- All admissions, discharges, transfers to be completed on PAS within 24 hours                                               4.00

                                                                                                                             3.50

Expected date to meet standard                                           Dec-11

                                                                                                                                          Average LOS   Mean (5.4)   UCL (5.8)     LCL (4.8)
Lead Director                                                            Evelyn Barker




Performance Management Report                                                                                                                                                                     Page 9 of 18
Main Board – October 2011
OUR SERVICES

                                                                                                                                                                                                                                                     Monitor Standard : quarterly
                                                                                                                                                                                                                                                      NHSG Financial Penalty

Number of Clostridium difficile cases - post 48 hours admissions

       Standard                  Month                   Actual             RAG for current month                                                                                                                             Activity

       73 / year              September                  54 / ytd                         R
                                                                                                                                                                        Cumulative Number of Inpatient cases of toxin producing clostridium difficile against Trajectory 2011/12
What is driving the reported underperformance
                                                                                                                                                                        GHNHSFT - post 48hr samples only
Change in the testing method of diarrhoea stools to PCR testing which commenced in March this is                                                                        (Data source: HCAI website submitted data)
a nationally recognised problem when changing to this method. A review of the effect of PCR
testing phased in from January to March 2011 and its effect on numbers of C. difficult detections in                                                      80
stool samples has been undertaken by Dr Philippa Moore, Consultant Microbiologist. The change in                                                          70
testing methodology has approximately doubled the rate of detection. An extra 16 extra cases per




                                                                                                                  Cum ula tive Ca s e s / T ra je ctory
month were detected from April to July across the whole health community. GHNHSFT has seen an                                                             60
uplift of approximately 4 cases per month which has resulted in a missed trajectory. The increased
                                                                                                                                                          50
sensitivity of the test is resulting in earlier detection of CDI but it is suspected that it may also be
detecting more carriage                                                                                                                                   40

Actions taken to improve performance                                                                                                                      30

Extraordinary meeting held to review Trust strategy and included a review of C diff deaths, antibiotic                                                    20
prescribing including GP's. Review of proton pump inhibitor prescribing by GP's and Trust. Review
                                                                                                                                                          10
and implementation of Plymouth management model. The Medical Director will be presenting to
Clinical Priority Forum (GPs)week commencing 17.10.11. Antibiotic awareness sessions aimed at                                                              0
                                                                                                                                                               Apr-11   M ay-11        Jun-11        Jul-11          Aug-11        Sep-11   Oct-11    Nov-11      Dec-11   Jan-12   Feb-12   M ar-12
medical staff
                                                                                                           Cumulative Cases                                      7        16            25             35             44            54
Expected date to meet standard                                            Yearly target                    Trajectory                                            9        17            22             27             32            37       42         48         54       60        66       73


Lead Director                                                             Maggie Arnold




                                                                                                                                                                                                                                                               Trust Standard

Number of physically aggressive incidents towards staff - 10% below 2010-11 levels

       Standard                  Month                   Actual             RAG for current month                                                                                                                             Activity

 <1.6 per 1000 staff            Sep-11                     2.6                            R
What is driving the reported underperformance

The action plan to discharge the Improvement notice will raise the awareness of staff and there will
be an increase in reporting, this might mean that this year there is an increase of reported incidents
overall and the target of 10% reduction may not be achieved.




Actions taken to improve performance

The actions taken to discharge the Violence and Aggression Improvement Notice should begin to
have an affect on the current figures


Expected date to meet standard                                            Mar-13

Lead Director                                                             Ian Tait



Performance Management Report                                                                                                                                                                                                                                                                  Page 10 of 18
Main Board – October 2011
OUR PATIENTS

                                                                                                                                                                                                                                                                           NHSG Standard
                                                                                                                                                                                                                                                                        NHSG Financial Penalty

This relates to number waiting over 6 weeks for 15 key Diagnostic tests

      Standard                Month                  Actual           RAG for current month                                                                                                                                  Activity

          0                   Sep-11                   112                       R                                                                                            Gloucestershire Hospitals NHS Foundation Trust
What is driving the reported underperformance                                                                                                                                        Diagnostic Waits 2010/11 and 12

The breaches at the end of September were Neurophysiology - 1 patient, 1 cystoscopy and 110                                        6000
endoscopy patients.




                                                                                                   Patients Waiting at Month End
                                                                                                                                   5000

                                                                                                                                   4000

                                                                                                                                   3000

                                                                                                                                   2000
Actions taken to improve performance                                                                                               1000

Additional endoscopy sessions continue to be scheduled to increase capacity to meet the level of                                      0

demand. Patients are also being offered appointments at Emerson Green (ISTC), commencing                                                   Apr- May-          Jun-     Jul-   Aug-    Sep-         Oct- Nov- Dec-     Jan-       Feb-    Mar- Apr- May-         Jun-         Jul -   Aug-     Sep-
October. A locum Consultant Gastroenterologist commences January 2012                                                                       10   10            10       10     10      10           10   10   10       11         11      11   11   11           11           11      11       11
                                                                                                                                   06 +    151        43          30   20      7       0            4     20   27     60         35           21   96    189     165         103        65    112    0         0         0    0    0     0
                                                                                                                                   04<06   261        236     257      265    346     264          339   396   766    293        386      333      614   260     317         260      468     372    0         0         0    0    0     0
Expected date to meet standard                                      Feb-12
                                                                                                                                   02<04 1211 1538 1384 1375 1553 1356 1743 1631 2025 1747 1703 1825 2049 1725 1610 1536 1722 1759                                                                   0         0         0    0    0     0

Lead Director                                                       Evelyn Barker                                                  00<02 3096 2947 3054 3139 2732 3055 3260 3263 2252 3314 3310 3356 2497 3160 3136 3146 2967 3667                                                                   0         0         0    0    0     0




                                                                                                                                                                                                                                                                  Monitor Standard : quarterly
                                                                                                                                                                                                                                                                   NHSG Financial Penalty

This relates to the percentage of patients spending 4 hours or less in Emergency Department

      Standard                Month                  Actual           RAG for current month                                                                                                                                  Activity

      > 4hours                Sep-11                 94.10%                      R
                                                                                                                                                                               GLOUCESTERSHIRE HOSPITALS NHS FOUNDATION TRUST
What is driving the reported underperformance                                                                                                                                                GHFT: 4 Hour ED Waits April 10 - YTD
GRH achieved 96.2% in September but CGH was at 91.5%. ED attendances at CGH were 4.6%
                                                                                                                                   100%
higher in September 2011 than September 2010, with ambulance arrivals up 7.6% or +95. The
                                                                                                   % dealt with within 4 hours



                                                                                                                                   98%
increased peaks in activity of both urgent and non-urgent patients and gaps in the middle grade
                                                                                                                                   96%
doctor rota are the main drivers for deteriorating ED performance
                                                                                                                                   94%
                                                                                                                                   92%
                                                                                                                                   90%
Actions taken to improve performance
                                                                                                                                   88%

NHS Glos will launch their 'Choose Well' campaign earlier than planned, to direct the public to                                    86%
alternative sources of urgent care. A revised Emergency Nurse Practitioner (ENP) rota will be in                                   84%
place from November, when additional physical space will be created out-of-hours for 'minor'                                       82%




                                                                                                                                                                                                                                                                       Mar
                                                                                                                                                            May




                                                                                                                                                                                                                                                                                               May
                                                                                                                                                                                Jul




                                                                                                                                                                                                                                                                                                                   Jul
                                                                                                                                                                       Jun




                                                                                                                                                                                                                                                   Jan




                                                                                                                                                                                                                                                                                                         Jun
                                                                                                                                                                                             Aug


                                                                                                                                                                                                         Sep




                                                                                                                                                                                                                                        Dec




                                                                                                                                                                                                                                                          Feb




                                                                                                                                                                                                                                                                                                                             Aug


                                                                                                                                                                                                                                                                                                                                   Sep
                                                                                                                                             Apr-10




                                                                                                                                                                                                                                                                                     Apr-11
                                                                                                                                                                                                                Oct


                                                                                                                                                                                                                           Nov
patients to be seen
Expected date to meet standard                                      Dec 2011
                                                                                                                                                                                                                  GHFT %                                        Target 95%
Lead Director                                                       Evelyn Barker




Performance Management Report                                                                                                                                                                                                                                                                                                Page 11 of 18
Main Board – October 2011
OUR PATIENTS


                                                                                                                           12:00
                                                                                                                           11:00
                                                                                                                           10:00
                                                                                                                           09:00
                                                                                                                           08:00
                                                                                                                           07:00                100%
                                                                                                                                                                                                                                                   NHSG Standard
                                                                                                                                                                                                                                                NHSG Financial Penalty

This relates to ambulances delayed over 20 minutes at month end

      Standard                 Month                  Actual          RAG for current month                                                                                                                           Activity

          0                   Sep-11                   328                       R
                                                                                                                                                                   Ambulances Queuing over 20 minutes 2010/11 & 2011/12 YTD
What is driving the reported underperformance
                                                                                                                               800
The new touch screen system started on 1st September in both Emergency Departments. The
                                                                                                                               700
number of breaches of the standard have been validated and agreed with GWAS and NHSG - this




                                                                                                                    No. of Ambulances
                                                                                                                               600
has reduced the number by almost 50% over the previous reported position.
                                                                                                                               500
                                                                                                                               400
                                                                                                                               300
                                                                                                                               200
Actions taken to improve performance
                                                                                                                               100
Meetings have been held with GWAS to agree the validation process.                                                                       0




                                                                                                                                                40422




                                                                                                                                                           40452




                                                                                                                                                                       40483




                                                                                                                                                                                   40513




                                                                                                                                                                                               40544




                                                                                                                                                                                                              40575




                                                                                                                                                                                                                            40603




                                                                                                                                                                                                                                    Apr-11




                                                                                                                                                                                                                                               May-11




                                                                                                                                                                                                                                                         Jun-11




                                                                                                                                                                                                                                                                       Jul-11




                                                                                                                                                                                                                                                                                        Aug-11




                                                                                                                                                                                                                                                                                                        Sept-11
Expected date to meet standard                                                                                                                                                                                        Week Ending
                                                                                                                                                                   Over 20 mins (< 1hr)                Over 1hr (<= 2hrs)           Over 2hrs (<=3hrs)            Over 3hrs
Lead Director                                                        Evelyn Barker
                                                                                                                                                100%



                                                                                                                                                                                                                                             Monitor Standard : quarterly
                                                                                                                                                                                                                                              NHSG Financial Penalty

This relates to patients referred urgently by their GP with non cancer breast symptoms seen in 14 days

      Standard                 Month                  Actual          RAG for current month                                                                                                                           Activity

         93%                  Aug-11                  87.3%                      R                                                                                       The Percentage of Patients Meeting The 14 Day Targets for Cancer Waiting Time
                                                                                                                                                                                      Patients exhibiting (non-cancer) breast symptoms
What is driving the reported underperformance                                                                                                                                                               GHNHSFT
                                                                                                                                                                                                  (Data Source: Open Exeter)

The 2ww standard was not achieved in month. The reasons for failing to achieve 93% continues
                                                                                                                              100.0
due to both Patient Choice and long term unplanned sickness absence within the Breast Surgery
team. There was an improvement in August.
                                                                                                                                        95.0
                                                                                                % Meeting Targets




                                                                                                                                        90.0
                                                                                                                                                                                                                                                                                2ww B reast Sympto ms Target



Actions taken to improve performance                                                                                                    85.0
                                                                                                                                                                                                                                                                                2ww B reast Sympto ms % achieved


A locum breast consultant has started in September.                                                                                     80.0


                                                                                                                                        75.0


Expected date to meet standard                                       Sep-11                                                             70.0
                                                                                                                                               Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul- Aug-
                                                                                                                                                10   10   10   10   10   10   10   10   10  10    10   10   11   11   11   11   11   11  11    11
                                                                                                                                                                                               M onth
Lead Director                                                        Evelyn Barker



Performance Management Report                                                                                                                                                                                                                                                                    Page 12 of 18
Main Board – October 2011
OUR PATIENTS


                                                                                                                                                                                                                                           NHSG Standard
                                                                                                                                                                                                                                        NHSG Financial Penalty

This relates to discharge summaries sent to GP within one working day using Infoflex System

      Standard                  Month                  Actual            RAG for current month                                                                                                     Activity

         95%                    Sep-11                 67.4%                        R
                                                                                                                                        Trust Percentage of Discharge Summaries issued
What is driving the reported underperformance
                                                                                                                                          within 1 working day - NHS Gloucestershire
The Discharge Summary working group has reviewed the criteria to measure this standard. The




                                                                                                       % within 1 working day
group has agreed to change the criteria to include all patients discharged from PAS rather than just
those for whom an infoflex record was created. This change was made as it was recognised there                                  100%
was a significant chohort of patients for whom no infoflex record was created. This has reduced the                              90%
percentage recorded as sent in a day but is felt to be correct and auditable.                                                    80%
                                                                                                                                 70%
                                                                                                                                 60%                                                                                                                      Target
Actions taken to improve performance                                                                                             50%
                                                                                                                                 40%                                                                                                                      Performance
There is a working group to focus on this.                                                                                       30%




                                                                                                                                         Apr-11




                                                                                                                                                                             Aug-11




                                                                                                                                                                                                         ov-11

                                                                                                                                                                                                                 Dec-11
                                                                                                                                                           Jun-11




                                                                                                                                                                                      Sep-11

                                                                                                                                                                                               Oct-11




                                                                                                                                                                                                                                   Feb-12
                                                                                                                                                   ay-11




                                                                                                                                                                                                                          Jan-12



                                                                                                                                                                                                                                             ar-12
                                                                                                                                                                    Jul-11




                                                                                                                                                                                                                                            M
                                                                                                                                                  M




                                                                                                                                                                                                        N
Expected date to meet standard                                         Mar-12
                                                                                                                                                                                      Month
Lead Director                                                          Sean Elyan




                                                                                                                                                                                                                                           NHSG Standard
                                                                                                                                                                                                                                        NHSG Financial Penalty

Numbers of patients breaching same sex accommodation

      Standard                  Month                  Actual            RAG for current month                                                                                                     Activity

           0                    Sep-11                   15                         R
What is driving the reported underperformance

There were a total of 15 breaches in providing same sex accommodation in September that were
not clinical exemptions.All breaches occurred in ACUC at CGH.

Most breaches lasted for 0-6 hours



Actions taken to improve performance
The Strategic Health Authority and the Commissioners visited ACUC in August following repeated
breaches in delivering same sex accommodation. The action plan to address the breaches was
shared. A date for the relocation of ACUC is to be confirmed for November 2011.


Expected date to meet standard                                         Dependent on move of CGH
                                                                       ACU
Lead Director                                                          Maggie Arnold
                                                                                                                                 100%



Performance Management Report                                                                                                                                                                                                                                    Page 13 of 18
Main Board – October 2011
OUR PATIENTS



                                                                                                                                                                                                                                                  Trust Standard




      Standard                  Month                    Actual                RAG for current month                                                                                                       Activity
                                               Women's and children 57%
         ≥ 80%                 Aug/Sept        Diagnostic & Specialist 62%
                                                                                               R                                                                          % of patients who definitely received enough information about ward routines

What is driving the reported underperformance                                                                                                                            maternity               D&S           childrens            Gynae            target

NB This real time survey data is for the Women's and Children Division and the Diagnostic and                                    90
Specialist division. 357 patients were surveyed from these divisions. Range of scores 50-67%. Red                                80
status achieved by Maternity ward, Children's Inpatient Ward, 2a, Rendcomb, Lillybrook. Wards




                                                                                                                    Percentage
                                                                                                                                 70
had taken some actions to improve information available on ward routines but this has clearly not
                                                                                                                                 60
influenced the scores.
                                                                                                                                 50
                                                                                                                                 40
Actions taken to improve performance
                                                                                                                                 30
                                                                                                                                                     Jun 10                       Sept 10                          Jan 11                          Apr 11          Sept 11
At point of writing this report, the data had not yet been received by wards. Further discussion with
                                                                                                                    maternity                         68                             70                                                              58              54
ward managers will take place to identify actions to improve this aspect of patient care.
                                                                                                                    D&S                               49                             52                              56                              75              62
                                                                                                                    childrens                                                                                        47                              61              50
                                                                                                                    Gynae                             50                             70                              61                              83              67
Expected date to meet standard                                               March 2012 (at point of next survey)
                                                                                                                    target                            80                             80                              80                              80              80
                                                                             Gill Brook, Julie Garnham D&S                                                                                                       Month
Lead Director                                                                division, V Mortimer Women's and
                                                                             children.




                                                                                                                                                                                                                                                  Trust Standard



      Standard                  Month                    Actual                RAG for current month                                                                                                       Activity
                                               Women's and children 90%      Women's and children GREEN
         ≥ 80%                 Aug/Sept        Diagnostic & Specialist 68%   Diagnostic & Specialist RED                                                            % of patients who definitely had someone to talk to about any worries or fears
What is driving the reported underperformance                                                                                                                                   maternity         D&S           childrens        Gynae          target


Range of scores 62-91%. Red status achieved by Lillybrook and Rendcomb. Drivers for                                                            100
underperformance are - staff needing to use time available to provide these opportunities for                                                  90
patients                                                                                                                                       80
                                                                                                                                  percentage



                                                                                                                                               70
                                                                                                                                               60
                                                                                                                                               50
Actions taken to improve performance                                                                                                           40
                                                                                                                                               30
At point of writing this report, the data had not yet been received by wards. Further discussion with                                                      Jun 10                     Sept 10                         Jan 11                        Apr 11         Sept 11
ward managers will take place to identify actions to improve this aspect of patient care. This will                              maternity                    97                            94                                                       100             91
include understanding actions taken in areas with better scores and consider application.                                                                     53                            68                            83                             91          68
                                                                                                                                 D&S
                                                                                                                                 childrens                                                                                83                             96          89
Expected date to meet standard                                               March 2012 (at point of next survey)
                                                                                                                                 Gynae                        62                            77                            71                             83          91
                                                                             Gill Brook, Julie Garnham D&S Div. V                target                       80                            80                        80                                 80          80
Lead Director                                                                                                                                                                                                        Month
                                                                             Mortimer Women's and children.




Performance Management Report                                                                                                                                                                                                                                         Page 14 of 18
Main Board – October 2011
OUR PATIENTS




                                                                                                                                                                                                                                             Trust Standard



       Standard                    Month                      Actual                RAG for current month                                                                                             Activity
                                                    Women's and children 80%      Women's and children GREEN
          ≥ 80%                   Aug/Sept          Diagnostic & Specialist 42%   Diagnostic & Specialist RED                                                  % of patients who said that they had been made aware of how personal information is used
What is driving the reported underperformance                                                                                                                                             D&S              Gynae           target
                                                                                                                                        90
Not a patients priority concern whilst in hospital. Staff do not routinely explain this ; this is                                       80
appropriate as clinical issues are a priority. Range of scores 42-80%. Red status achieved in                                           70
Knightsbridge, Lillybrook and Rendcomb. The results for Women's and Children division are based
                                                                                                                                        60
on ward 2a as this question is only asked in this ward. Considerable effort had been made in
                                                                                                                                        50




                                                                                                                         Percentage
producing posters and improving availability of leaflets on this matter and this had probably
increased the score.                                                                                                                    40
                                                                                                                                        30
Actions taken to improve performance
                                                                                                                                        20
Include - leaflets available on ward (core leaflets set) / volunteers giving leaflets on this matter after                              10
they gather real time survey response to question /encouraging staff to routinely explain to patients                                    0
simply how information is used at appropriate time during admission. Explore the application of 2A's                                                  Jun 10            Sept 10                     Jan 11                      Apr 11                    Sept 11

approach to improve patient knowledge on this matter.                                                                                 D&S              33                 33                          40                            48                      42
Expected date to meet standard                                             March 2012 (at point of next survey)                       Gynae            41                 52                          63                            56                      80
                                                                                                                                      target           80                 80                          80                            80                      80
                                                                                  Gill Brook, Julie Garnham D&S Div. V
Lead Director                                                                     Mortimer Women's and children.                                                                                        Month

                                                                                                                                               100%




Performance Management Report                                                                                                                                                                                                                                       Page 15 of 18
Main Board – October 2011
OUR STAFF


                                                                                                                                                                                                         Trust Standard

Total Paybill spend £'000

      Standard                  Month                    Actual             RAG for current month                                                                         Activity

      On Target                 Sep-11                  £21,399                         A                                                                   Total Paybill against Workforce plan

What is driving the reported underperformance                                                                                                                             Actual        Plan
For the first month since April, actual spend aligned itself much more closely with planned spend.          22000
Whilst Bank and Agency remain an issue, the month saw improvements on both fronts
                                                                                                            21750

                                                                                                            21500

                                                                                                            21250

Actions taken to improve performance                                                                        21000

                                                                                                            20750
 Tighter controls are being implemented on the use of Bank, Agency and Overtime to reduce these
variable spends                                                                                             20500

                                                                                                            20250

Expected date to meet standard                                           Dec-11                             20000
                                                                                                                     Apr-11    May-11    Jun-11    Jul-11     Aug-11    Sep-11     Oct-11      Nov-11   Dec-11   Jan-12   Feb-12    Mar-12
Lead Director                                                            Dave Smith



                                                                                                                                                                                                         Trust Standard

Total worked fte

      Standard                  Month                    Actual             RAG for current month                                                                         Activity

      On Target                 Sep-11                    6390                          A                                                                   Worked Fte against Workforce plan
What is driving the reported underperformance
                                                                                                                                                                         Actual        Plan
In conjunction with spend, wte worked numbers aligned more closely with planned numbers with clear
                                                                                                            6750
improvements in Bank and Agency. Every Division contributed to the reductions over the month with
marked progress in D+S as well as Medicine. Given the shape of the plan in October and for the
remainder of the year, those reductions will need to continue apace.
                                                                                                            6500


Actions taken to improve performance
                                                                                                            6250
A number of workforce projects are in train to address this including an Admin and Clerical Review in
the Clinical Divisions. Numbers will also reduce in October post the implementation of the default
retirement age. In addition, Divisions are identifying by staff group, the posts that will need to reduce
                                                                                                            6000
by year end and to actively plan for those reductions, capitalising on natural turnover
Expected date to meet standard                                           Dec-11
                                                                                                            5750
                                                                         Dave Smith
                                                                                                                    Apr-11    May-11    Jun-11    Jul-11     Aug-11    Sep-11      Oct-11     Nov-11    Dec-11   Jan-12   Feb-12   Mar-12
Lead Director




Performance Management Report                                                                                                                                                                                                      Page 16 of 18
Main Board – October 2011
OUR STAFF



                                                                                                                                                                                                                 Trust Standard

Annual Sickness Absence Rate

      Standard                  Month                   Actual             RAG for current month                                                                                 Activity

       < 3.75%                  Aug-11                  3.93%                          A
                                                                                                                                                                Annual Sickness Absence Rate
What is driving the reported underperformance
                                                                                                                                                                              Actual         Target
.A slight improvement in the month (0.3%) and reversing the previous upward trend, however still
above the standard set. Focus will need to be applied to ensure that Winter sickness levels do not         4.00%
impact on operational effectiveness.
                                                                                                           3.90%


                                                                                                           3.80%
Actions taken to improve performance
                                                                                                           3.70%
 A full analysis of sickness trends as well as a set of recommendations is being prepared for Board
consideration. Significant publicity is being produced for the flu vaccination programme to ensure staff
                                                                                                           3.60%
understand their responsibilities in staying well this Winter

Expected date to meet standard                                          Dec-11                             3.50%
                                                                                                                     Apr-11      May-11     Jun-11     Jul-11      Aug-11     Sep-11      Oct-11     Nov-11    Dec-11    Jan-12      Feb-12    Mar-12
Lead Director                                                           Dave Smith




                                                                                                                                                                                                                 Trust Standard

Annual Appraisal Rate

      Standard                  Month                   Actual             RAG for current month                                                                                 Activity

         90%                    Sep-11                  79.00%                         R                                                                   GHNHSFT Staff who have had annual appraisal
What is driving the reported underperformance
                                                                                                                           Corporate                            Diagnostics & Specialty         Estates & Facilities              Medicine
Divisional leads have been asked to comment on the underperformance where for the first time in                            Surgery                              Womens & Children               Summary Completion %              Target
2011, the percentage slipped backwards (2%)                                                                   100%

                                                                                                               95%

                                                                                                               90%
Actions taken to improve performance
                                                                                                               85%
As part of the mid year appraisal review for senior managers, they will understand that the collective
score will influence their own appraisal score and that they urgently need to address this.                    80%

                                                                                                               75%
Expected date to meet standard                                          Mar-12                                 70%

                                                                                                               65%
Lead Director                                                           Dave Smith                                      Apr-11     May-11     Jun-11     Jul-11      Aug-11     Sep-11      Oct-11    Nov-11    Dec-11    Jan-12      Feb-12    Mar-12
                                                                                                                      100%
                                                                                                                      100%



Performance Management Report                                                                                                                                                                                                                  Page 17 of 18
Main Board – October 2011
OUR STAFF



                                                                                                                                                                                                       Trust Standard

Staff who completed mandatory training

      Standard                  Month                    Actual             RAG for current month                                                                    Activity

         90%                    Sep-11                    80%                           A                                                   GHNHSFT Staff who completed mandatory training
What is driving the reported underperformance
                                                                                                                      Corporate                      Diagnostics & Specialty            Estates & Facilities            Medicine
A moderate increase on the month, taking the indicator into the 'amber' for the first time.
                                                                                                                      Surgery                        Womens & Children                  Summary Completion %            Target
                                                                                                          100%
                                                                                                          95%
                                                                                                          90%
                                                                                                          85%
Actions taken to improve performance                                                                      80%
E-learning is the prime method of delivery and the team are making classroom/library sessions             75%
available for staff who cannot do this within the workplace. A project is also underway to consider the   70%
frequency of modules and how these may be extended without creating risk to quality of care.              65%
                                                                                                          60%
Expected date to meet standard                                           Mar-12                           55%
Lead Director                                                            Dave Smith                              Apr-11   May-11   Jun-11   Jul-11     Aug-11    Sep-11        Oct-11     Nov-11    Dec-11     Jan-12   Feb-12     Mar-12




Performance Management Report                                                                                                                                                                                                      Page 18 of 18
Main Board – October 2011

				
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