Cancer Audit Reporting Governance Framework May 2017 Purpose Complete and accurate data is essential to be able to measure standards of care and outcome of treatment. The objective of Audit is to evaluate the standards of cancer care and equity of cancer treatments throughout. Audit coordinates preparation of Comparative Audit Reports, these contain; analysis of information about the numbers of patients diagnosed annually, their diagnosis, staging, treatment, and outcome of treatment. Results are measured against nationally agreed Quality Performance Indicators, or other quality standards for cancers. Objective Reports identify action points arising from the results to drive change and improvements in standards of patient care. The comparative report will include: Quality Process Measures Other Standards/ measures using the National Dataset as agreed by the group and chair. Timescales The audit team will aim to achieve target dates throughout the reporting process, according to the Reporting schedule within the context of National Reporting. Distribution of Report The draft audit report will be issued for discussion and agreement of management actions with: Lead Clinicians and Regional Audit Staff Sub- The final audit report will be issued to: Tumour, Clinical Governance leads and Regional Cancer planning. A website report will be published after 3 6 months following circulation to clinical governance. Action Plans NHS Board Action Plans will be agreed where appropriate using the clinical recommendations provided in the report. Formal responses to the action plans are required from Lead Clinicians with approval by Board in each Board. Lorna Bruce Audit Manager Page1
Key deadlines and staff involved Time Point Action Responsible Members Data is signed off at Board level by Local data Local and Audit local clinical lead either by email or clinical sign Off facilitator. meeting. Clinical sign off Final draft issued for final comments Final Report Action Plans Meeting to go through draft report to identify actions and provide clinical commentary Report including clinical comment. Identification of actions and recommendations Report including clinical comment. Identification of actions and recommendations Action plans will be completed at board level by Lead Clinicians and approved by Chair, Regional Clinical Leads and Audit facilitators Tumour Tumour, Clinical Governance leads Health Board Dumfries & Fife Clinical Governance Leads: Judith Smith Lead Cancer Clinician Cliff Sharp Medical Director Justin Wilson Clinical Governance and Quality Facilitator Maria Bews-Hair, Lead Cancer Clinician Ken Donaldson, Associate Medical Director Carole Morton, Nurse Manager Cancer and Palliative Care Scott McLean, Executive Lead for Cancer Rob Cargill, Associate Medical Director Andrea Wilson, General Manager, Clinical Support & Access Kathy Nicoll, Cancer Services Improvement Manager Anne Milburn Service Manager for Women and Children s Services Tracey Gillies, Executive Medical Director McLoughlin, Peter, Strategic Programme Manager Bennett, Jo, Clinical Governance Manager Henderson, Annette A, Patient Safety Programme Manager, Clinical Governance MacDonald, Kate Network Manager, Chris Stirling, Site Director WGH David Hood, General Manager, WGH David Cameron Director of Cancer Services & consultant medical oncology Gemma, Service Manager for cancer and Palliative Services Page 2
Table Updated May 2017 Tumour Breast Glyn Neades Fife) Mr Matthew Barber (St Johns), and Mr Oliver Young (EBU), NHS Miss Maria Bews-Hair, NHS Dumfries Mr Ahmed Mustafa, NHS Christine Dodds, Senior Martin Keith, Cancer Improvement Manager, NHS Dumfries Angela Gillie, Cancer Audit Alistair Johnston, Cancer Audit Facilitator, NHS Fife: Isla Barton : A Mustafa D&G: M Bews-Hair Fife: G Neades : O Young (EBU) & M Barber (SJH) Colorectal Satheesh Yalamarthi Fife) Mr K Pal, NHS Dr H Phillips Clinical Mr S Whitelaw, NHS Dumfries Mr R G Wilson, NHS Mr Natarajan Manimaran, NHS Fife Sarah Buchan Cancer Maureen Lamb, Cancer Audit Facilitator, NHS : Catherine Crombie : K Pal D&G: S Whitelaw Fife: N Manimaran : Gynae Cameron Martin Dr, Phillip Dutton, NHS Dumfries and Dr Scott Fegan, NHS Fife Dr Melanie Mackean, Dr Queenie Menezes, NHS Alison Stillie, NHS Lorraine Henderson, Martin Keith, Cancer Audit Facilitator, NHS Dumfries and Alistair Johnston, Cancer Audit NHS Facilitator, Jackie Stevenson, Cancer Audit : Anne Milburn : Q Menezes D&G: P Dutton Fife: S Fegan : A. Stillie Haematology Fiona Scott Dr Carolyn Bedi,, Dr Jenny Buxton NHS Dr Kerri Davidson, NHS Fife Dr Frances Yuille, Valerie Findlay Cancer Alison Robertson Cancer Audit Fife: Shirley Ann : J Buxton Fife: K Davidson : F Scott (Lymphoma) & H Roddie (Acute Leuk) Head & neck Iain Nixon Mr Esmond Carr, NHS Dr xxx xxx Xxxx xxxx Cancer Audit Facilitator : E Carr Page 3
Tumour Mr J Morrison, Fife Ms Marissa Botma, NHS Dumfries Mimi Bjelogrlic Cancer Audit Information Officer, Dumfries & Fife: Fiona Cameron : Isabel Penman D&G: M Botma Fife: J Morrison I. Nixon Lung Colin Selby Fife) Dr Simon Watkin, NHS Dr Jane Gysin, NHS Dumfries Dr Kris Skwarski, NHS Prof Allan Price, Ailsa Patrizio, Cancer Audit facilitator Mimi Bjelogrlic, Cancer Audit Facilitator, Fife Laura Allan, Cancer Audit facilitator, Dumfries Facilitator, Fife: Shirley Anne : Fiona Wilson : S Watkin D&G: J Gysin Fife: C Selby : K Skwarski Melanoma Megan Mowbray Fife) Dr Mark Butterworth, NHS Dr Ewan Brown, Dr Simone Laube, NHS Dr Alistair Law, Dr Marie Mathers, NHS Dr Lyndsey Yeo, NHS Dumfries and Jon Pullman, Cancer Audit facilitator Martin Keith Senior Cancer Information Officer, Dumfries & Jackie Stevenson, Cancer Audit Fife: Shirley Anne : Marie Gardiner : S Laube D&G: L Yeo Fife: M Mowbray : M Butterworth Neuro - Oncology Sara Erridge (ECNO Lead) Sharon Peoples, David Simpson, NHS Gail Thompson, CNS, D&G Martin Zeidler, NHS Fife Lorraine Henderson, : Chris Myers Sara Erridge Sarcoma Larry Hayward Joanna Nixon, Sam Patton, NHS Donald Salter, NHS Lorraine Henderson, Larry Hayward Upper GI Peter Lamb Anya Adair, NHS Jeyakumar Apollos, NHS Kirsty Martin Cancer Audit Facilitator : J Fletcher D&G: J Apollos Page 4
Tumour Dumfries Mr Jonathan Fletcher, NHS Miss Annabel Howell, NHS Mr Peter Driscoll, NHS Fife Dr Lucy Wall, Maureen Lamb, Cancer Audit Facilitator, Fife Facilitator, NHS : Iain Gorman Fife: P Driscoll : P Lamb (OG) A Adair (HPB) Urology Prasad Bollina Mr Ian Mitchell, NHS Fife Ms Robyn Webber, NHS Fife Dr Duncan McLaren, Mr Ben Thomas, NHS Mr M Khan NHS Dumfries and Adam Steenkamp Cancer Alison Robertson, Cancer Audit Angela Gillie, Cancer Audit Facilitator, NHS : Catherine Crombie : B Thomas D&G: M Khan Fife: I Mitchell (Bladder) R Webber (Testis, Renal, Prostate) : P Bollina (prostate), P Mariappan (Bladder), R Donat (Testis) Steve Leung (Renal) Page 5