Breast Cancer Clinical Quality Performance Indicators Engagement Document.

Appendix 4: 3-Yearly National Governance Process and Improvement Framework for Cancer Care

This process is underpinned by the annual regional reporting and governance framework (see appendix 5).

1. National QPI Development Stage

• QPIs developed by QPI development groups, which include representation from Regional Cancer Networks, Healthcare Improvement Scotland, ISD, patient representatives and the Cancer Coalition.

2. Data Analysis Stage:

• NHS Boards and Regional Cancer Advisory Groups ( RCAGs)* collect data and analyse on yearly basis using nationally agreed measurability criteria and produce action plans to address areas of variance, see section 2.
• Submit yearly reports to ISD for collation and publication every 3 years.
• ISD produce comparative, publicly available, national report consisting of trend analysis of 3 years data and survival analysis.
• National comparative report approved by NHS Boards and RCAGs.

3. Expert Review Group Stage (for 3 tumour types per year):

• Expert group, hosted by Healthcare Improvement Scotland, review comparative national results.
• Write to RCAGs highlighting areas of good practice and variances.
• Where required NHS Boards requested to submit improvement plans for any outstanding unresolved issues with timescales for improvement to expert group.
• Improvement plans ratified by expert group and Scottish Cancer Taskforce.

4. Improvement Support Stage:

• Where required Healthcare Improvement Scotland provide expertise on improvement methodologies and support.

5. Monitoring Stage:

• RCAGs work with Boards to progress outstanding actions, monitor improvement plans and submit progress report to Healthcare Improvement Scotland.
• Healthcare Improvement Scotland report to Scottish Cancer Taskforce as to whether progress is acceptable.

6. Escalation Stage:

• If progress not acceptable, Healthcare Improvement Scotland will visit the service concerned and work with the RCAG and Board to address issues.
• Report submitted to Scottish Cancer Taskforce and escalation with a proposal to take forward to Scottish Government Health Department.

*In the South and East of Scotland Cancer Network ( SCAN) the Regional Cancer Planning Group is the equivalent group to Regional Cancer Advisory Group ( RCAG).