Breast Cancer Clinical Quality Performance Indicators Engagement Document.

4. Format of the Quality Performance Indicators

QPIs are designed to be clear and measurable, based on sound clinical evidence whilst also taking into account other recognised standards and guidelines.

• Each QPI has a short title which will be utilised in reports as well as a fuller description which explains exactly what the indicator is measuring.
• This is followed by a brief overview of the evidence base and rationale which explains why the development of this indicator was important.
• The measurability specifications are then detailed; these highlight how the indicator will actually be measured in practice to allow for comparison across NHSScotland.
• Finally a target is indicated, this dictates the level which each unit should be aiming to achieve against each indicator.

In order to ensure that the chosen target levels are the most appropriate and drive continuous quality improvement as intended they will be kept under review and revised as necessary, if further evidence or data becomes available.

Rather than utilising multiple exclusions, a tolerance level has been built into the QPIs. It is very difficult to accurately measure patient choice, co-morbidities and patient fitness therefore target levels have been set to account for these factors. Further detail is noted within QPIs where there are other factors which influenced the target level.

Where 'less than' (<) target levels have been set the rationale has been detailed within the relevant QPI. All other target levels should be interpreted as 'greater than' (>) levels.