Appendix 4: 3 Yearly National Governance Process &
Improvement Framework for Cancer Care
This process is underpinned by the annual regional reporting
and governance framework (see
development groups, which include representation from
Regional Cancer Networks, Healthcare Improvement
patient representatives and the Cancer Coalition.
2. Data Analysis Stage:
Boards and Regional Cancer Advisory Groups (
collect data and analyse on yearly basis using nationally
agreed measurability criteria and produce action plans to
address areas of variance, see section 2.
- Submit yearly reports to
collation and publication every 3 years.
produce comparative, publicly available, national report
consisting of trend analysis of 3 years data and survival
- National comparative report approved by
3. Expert Review Group Stage (for 3 tumour types
- Expert group, hosted by Healthcare Improvement
Scotland, review comparative national results.
- Write to
highlighting areas of good practice and variances.
- Where required
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 Taskforce.
4. Improvement Support Stage:
- Where required Healthcare Improvement Scotland
provide expertise on improvement methodologies and
5. Monitoring Stage:
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 Taskforce as to whether progress is acceptable
6. Escalation Stage:
- If progress not acceptable, Healthcare Improvement
Scotland will visit the service concerned and work with
Board to address issues.
- Report submitted to Scottish Cancer Taskforce and
escalation with a proposal to take forward to Scottish
Government Health Department.
*In the South and East of Scotland Cancer Network (
the Regional Cancer Planning Group is the equivalent group to
Regional Cancer Advisory Group (