Breast Cancer Clinical Quality Performance Indicators Engagement Document.

Appendix 5: Regional Annual Governance Process and Improvement Framework for Cancer Care

1. Regional QPI Implementation Stage:

• National cancer QPIs and associated national minimum core dataset and measurability specifications, developed by QPI development groups.
• Regional implementation of nationally agreed dataset to enable reporting of QPIs.

2. Data Analysis Stage:

• NHS Boards collect data and data is analysed on a yearly basis using nationally agreed measurability criteria at local/ regional level.
• Data/results validated by Boards and annual regional comparative report produced by Regional Networks.
• Areas of best practice and variance across the region highlighted.
• Yearly regional reports submitted to ISD for collation and presentation in national report every 3 years.

3. Regional Performance Review Stage:

• RCAGs* review regional comparative report.
• Regional or local NHS Board action plans to address areas of variance developed.
• Appropriate leads identified to progress each action.
• Action plans ratified by RCAGs.

4. Monitoring Stage:

• Where required, NHS Boards monitor progress with action plans and submit progress reports to RCAGs.
• RCAGs review and monitor regional improvement.

5. Improvement Support Stage:

• Where required Healthcare Improvement Scotland maybe requested to provide expertise to NHS Boards/ RCAGs on improvement methodologies and support.

6. Escalation Stage:

• If progress not acceptable, RCAGs will escalate any issues to relevant Board Chief Executives. If progress remains unacceptable RCAGs will escalate any relevant issues to Healthcare Improvement Scotland.

*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).