Breast Cancer Clinical Quality Performance Indicators Engagement Document.

8. Governance and Scrutiny

A national and regional governance framework to assure the quality of cancer services in NHSScotland has been developed; key roles and responsibilities within this are set out below. Appendices 4 and 5 provide an overview of these governance arrangements diagrammatically. The importance of ensuring robust local governance processes are in place are recognised and it is essential that NHS Boards ensure that cancer clinical audit is fully embedded within established processes.

8.1 National

• Scottish Cancer Taskforce
  • Accountable for overall national cancer quality programme and overseeing the quality of cancer care across NHS Scotland.
• Healthcare Improvement Scotland
  • Proportionate scrutiny of performance.
  • Support performance improvement.
  • Quality assurance: ensure robust action plans are in place and being progressed via regions/Boards to address any issues identified.
• Information Services Division ( ISD)
  • Publish national comparative report on tumour-specific QPIs and survival for approximately 3 tumour types per annum as part of the rolling programme of reporting.

8.2 Regional - Regional Cancer Networks

• Annual regional comparative analysis and reporting against tumour-specific QPIs.
• Support national comparative reporting of specified generic QPIs.
• Identification of regional and local actions required and development of an action plan to address regional issues identified.
• Performance review and monitoring of progress against agreed actions.
• Provide assurance to Board Chief Executive Officers that any issues identified have been adequately and timeously progressed.

8.3 Local - NHS Boards

• Collect and submit data for regional comparative analysis and reporting in line with agreed measurability and reporting schedule (generic and tumour-specific QPIs).
• Utilise local governance structures to review performance, develop local action plans and monitor delivery.
• Demonstrate continual improvements in quality of care through on-going review, analysis and feedback of clinical audit data at an individual MDT or unit level.