Thyroid cancer - clinical quality performance indicators: engagement document

Appendix 3: 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 PHS 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.

*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.