A trust which manages three West Midlands hospitals has been given a final warning for keeping people waiting too long in its accident and emergency department.
The Heart of England NHS Foundation Trust, which runs Heartlands Hospital in Birmingham, Good Hope Hospital in Sutton Coldfield and Solihull Hospital could have board members removed if it does not improve.
Monitor, the organisation which polices foundation hospitals, has coded the trust's governance risk as red because it has failed to reach the target for patients being seen in accident and emergency for the past three years.
It is said to be in significant breach of its terms of authorisation.
In a letter seen by the BBC, Monitor remains concerned about the trust's governance arrangements and its ability to make the cultural and behavioural changes necessary. It highlighted the following as evidence:
• The repeated failure to deliver the target during winter periods
• Persistently poor performance at Heartlands and Good Hope despite the time of year
• Delay in identifying long stays in hospital as a key issue
• A lack of evidence that non-executive directors challenge and hold the management team to account.
The trust will now have to submit performance data and action plan updates on a monthly basis.
Medical director Ian Cunliffe has called an urgent meeting at Solihull Hospital on Wednesday evening which a raft of senior staff must attend.
It will be headed by chief executive Mark Goldman.
Mr Cunliffe said in the letter: "We will need to look together at our proposals for satisfying Monitor on our four-hour performance targets and agree a way forward.
"I appreciate that this is short notice, but there is an expectation on the trust to improve its performance in quarter four and there is no time to lose."
The trust has produced an action plan and has identified a need for patients to remain in hospital for shorter periods of time, as a way of moving people who need a hospital bed out of accident and emergency.
Figures show emergency patients stay in hospital 8.9 days on average across the trust when the national average for 2008-9 is 5.7 days.
The plan for 2010-12 will be to reduce this to 6.2 days and bring bed occupancy levels down.
Senior manager resources are also to be increased.
In its response to Monitor, the trust said it was "absolutely committed" to improving its performance so it consistently met the four-hour target in the future.
It said there had been a 13.6% increase in the number of patients over the past three years and the area it served had been at the centre of a swine flu epidemic during July and August.
It said other factors included covering one of the most deprived populations in the West Midlands conurbation and a high number of unnecessary A&E visits because of patients lacking faith in GP out of hours services.
A Heart of England NHS Foundation Trust spokesman said: "The trust has recognised this difficult position and has agreed plans with Monitor.
"The Trust is one of the busiest trusts in the NHS. Over the three sites it sees by far the most ambulance attendees of any trust in the region."