Renal Cancer Clinical Quality Performance Indicators: Engagement Document

This document is being circulated for comment and feedback in order to ensure wide

engagement with professional groups, health service staff, voluntary organisations, patients affected by renal cancer and the wider public.


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

Flow Chart

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).

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