Thyroid cancer - clinical quality performance indicators: engagement document

Appendix 2: 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 3).

1. National QPI Development Stage

• QPIs developed by QPI development groups, which include representation from Regional Cancer Networks, Healthcare Improvement Scotland, PHS, 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 appendix 4.
• Submit yearly reports to PHS for collation and publication every 3 years.
• National comparative report approved by NHS Boards and RCAGs.
• PHS produce comparative, publicly available, national report consisting of trend analysis of 3 years data and survival analysis.

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 Strategic Board.

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 Strategic Board 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 Strategic Board and escalation with a proposal to take forward to Scottish Government Health Department.

*The Regional Cancer Planning Group (South and East of Scotland) and the North Cancer Clinical Leadership Group (North Cancer Alliance) are equivalent to the Regional Cancer Advisory Group (RCAG) in the West of Scotland.