Cover - Integrated Performance Report


Public Board



Report Title:

Integrated Performance Report 

Agenda Item:



Executive Directors

Lead Director:

Emma de Carteret, Director of Corporate Affairs and Performance


SR1a: If we do not ensure our people are safe and their wellbeing prioritised, there is a risk that we will be unable to attract, retain and keep all our people safe and well


SR1b: If we do not ensure our leaders are developed and equipped, there is a risk that we will not be able to change our culture, and value, support, develop and grow our people

SR2: If we do not deliver operational and clinical standards then there is a risk of poor patient outcomes and experience

SR3: If we do not ensure we have the ability to plan, influence and deliver across our systems to secure change, we will not be able to meet the needs of our public and communities

SR4: If we do not resolve long standing organisational inefficiencies we will be unable to deliver an effective, sustainable, value for money service to our public

SR5: If we do not clearly define our strategic plans we will not have the agility to deliver the suite of improvements needed

SR6: If we do not deliver sustainable regulatory compliance and develop positive relationships, we will have limited ability to deliver our strategy


Equality Impact Assessment

No negative impact identified




Note the areas of improvement and decline and seek assurance on plans to improve

Previously considered by:

 Executive Leadership Team - 28.02.2023


The purpose of this paper is to provide the Integrated Performance Report consisting of January 2023 data and up to date position on the strategic risks. The paper enables the Board to:

  • Discuss the performance areas identified and the actions offered to gain assurance or sufficient oversight.

Compare the current performance, critical issues and actions in place against the current risk profile to seek assurance on mitigations moving forward.

Executive Summary

The Integrated Performance Report (IPR) this month comprises of January 2023 data across the key areas of people, education, operations, systems, clinical and finance.

Key positives in month are as follows:

  • Employee relations casework continues to reduce as culture issues are addressed
  • Mandatory training and appraisal compliance continues to improve, with focus on reaching information governance and appraisal targets by the end of the financial year
  • In-month improvement in operational performance delivery, which whilst off track in terms of target has a positive impact on patient care. The operational improvement plan seeks to embed the improvement and continue to improve the position.

Key areas of concern:

  • Retention rate and the volume of leavers continues to be high which will impact delivery of the clinical workforce plan
  • Level of harm translating to serious incidents continuing its concerning trend
  • Handover delays, whilst significantly improved in month remains significantly off track against target
  • QCIP delivery remains low compared to original level, and is of concern moving in to the new financial year.

In the executive summary slide, the executive team has identified seven critical underlying issues, that impact across multiple measures and therefore our ability to deliver on the organisational objectives. These are as follows:

1)       Recruitment and training capacity to support an expedited workforce plan in line with the recovery fund

2)       Leadership capacity and capability both in terms of delivery against role and the associated impact upon culture

3)       The challenge associated with efficiency and improvement delivery and the need to review leadership, focus and prioritisation on efficiencies, moving to a culture of continuous improvement

4)       Risk to delivery of compliance with clinical training whilst balancing the need to maximise patient facing staff hours

5)       The impact of multiple external factors, in particular handover delays, has upon our ability to deliver a safe service

6)       Lack of oversight of critical compliance and priority improvement areas – risk of de-railment

7)       Culture across the organisation – inappropriate behaviour and lack of values-based behaviour

Also included within the IPR Executive summary is the position of the strategic risks, aligned within the pack by goal, and aligned to the key metrics summary slides for that goal. This should enable the Board to have an integrated discussion, in relation to delivery against targets and assurance on future delivery, as well as triangulation with the risks and the strategic actions planned. Committees are in the process of reviewing and seeking assurance on the strategic risks with good engagement on refinement.

Introduction/ Background
The Integrated Performance report consists of core metrics to monitor the performance across all main functions of the organisation in the pursuit of achievement of our strategic goals. Each of the relevant Executive Directors will provide a short overview of the key critical areas outlined in the section below and in the first executive summary page of the IPR document and draw a link to the relevant strategic risks.
Key Issues/ Risks

As highlighted above.

Limit Recalculation

Board should note that over the next two months, there is a need to evaluate and where necessary, recalculate the statistical limits on the charts and data within the IPR. There is no recommended frequency or standard, and the Trust has determined an annual review approach. The informatics team will be undertaking this in March, which means the Board will receive an IPR that has amended limits. This could change the representation (or colours) within the IPR. It is important to note this against the narrative in the next two reports, and the informatics team and DDCA&P will be supporting narrators to minimise disruption. Importantly, this means that for the June meeting (April data) all necessary limits will have been reprofiled ready for the full 2023/24 financial year.


Note the areas of progress.

Consider critical issue areas highlighted to gain assurance on the plans for mitigation



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