NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST. Documentation Control PATIENT DATA QUALITY POLICY

Transcription

1 Reference NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST Documentation Control PATIENT DATA QUALITY POLICY GG/INF/019 Approving Body Senior Management Team Date Approved 3 Implementation Date 3 Summary of Changes from Previous Version Policy review and update to include Ward Audit requirements Supersedes GG/INF/019 Version 4(April 2015) Consultation Undertaken Information Governance Committee Deputy Director of Operations Date of Completion of Equality Impact Assessment 16/03/17 Date of Completion of We Are Here for You 16/03/17 Assessment Date of Environmental Impact Assessment (if N/A applicable) Legal and/or Accreditation Implications N/A Target Audience All Trust staff who collect or process patient data Review Date April 2019 Lead Director Director of Finance and Procurement Author/Lead Manager Further Guidance/Information Name : Steve Baxter Job title : Head of Information Extension : Name : Andrea Race Job title : Assistant Director of Information & Performance Extension 1

2 CONTENTS Paragraph Title Page 1. Introduction 3 2. Executive Summary 3 3. Policy Statement 4 4. Definitions (including Glossary as needed) 5 5. Roles and Responsibilities 5 6. Policy and/or Procedural Requirements 7 7. Training, Implementation and Resources 9 8. Impact Assessments Monitoring Matrix Relevant Legislation, National Guidance and Associated NUH Documents 14 Appendix 1 Flow charts relating to section 6 15 Appendix 2 Data Output Standards 20 Appendix 3 Equality Impact Assessment 22 Appendix 4 Environmental Impact Assessment 24 Appendix 5 Here For You Assessment 26 Appendix 6 Certification Of Employee Awareness 28 2

3 1.0 Introduction 1.1 Nottingham University Hospitals NHS Trust requires the collection, storage and management of patient data to be accurate, timely, relevant and secure in order to support the delivery of effective and efficient patient care and the achievement of the Trusts core business objectives and statutory obligations. Good quality data is not an optional extra; it is a fundamental requirement for the delivery of high standard services. 2.0 Executive Summary 2.1 This policy applies to the administrative and clinical patient related data contained within the Trusts electronic and paper based systems. Such data can be classified into 3 groups: Patient demographic data (name, date of birth, GP, NHS Number ) Patient care management data (admission date, ward, clinic, consultant ) Patient clinical data (diagnoses, procedures, tests, HRG ) This policy is a statement of intent which members of staff are expected to follow and should be regarded as mandatory by all staff. Failure to follow a trust policy could result in disciplinary action being taken, up to and including dismissal. Patient data is collected and processed by many staff across the Trust. Data quality may be affected by a wide range of activities; the need for good quality data must therefore be embedded in the culture, values and actions of Trust staff. This policy complements the following Trust policies: Health Records Management Policy Health Records Keeping Policy Data Protection, Confidentiality and Disclosures Policy 3

4 Information Security & Risk Policy Information Governance Policy Corporate Data Validation Policy 3.0 Policy Statement 3.1 The Trust will: Ensure that operational and clinical staff are fully aware of the importance and value of good quality patient data. Continue to identify and implement ways of achieving and sustaining improved data quality through training, technical and process developments and collaborative working between staff. Adhere to standards set out in the NHS Data Dictionary and will ensure that locally developed standards are consistent with the NHS Data Dictionary. Continue to set standards for patient data quality that are challenging, consistent with national targets and support high quality patient care. Maintain and regularly review its Information Governance Policies to ensure that it continues to underpin data quality principles. Staff must abide by the principles contained in the Data Protection, Confidentiality and Disclosures Policy, and in particular, be familiar with the principles set out in the Data Protection Act (1998). Have a nominated Information Governance Manager and Caldicott Guardian. Data Custodians will be identified throughout the Trust to ensure that Data Protection and Caldicott principles are fully observed and complied with. The roles and responsibilities of these officers will be set out in the Trust s Data Protection, Confidentiality and Disclosures Policy. Ensure staff abides by Trust policy for the communication of personal and sensitive data in the process of rectifying data quality issues. All personal and sensitive data must be transferred by either NHS Mail, or if using NUH mail systems, encrypted to NHS standards using software approved by the Trust in accordance with the Trust s Policy. Ensure users sign a confidentiality clause and an undertaking to take reasonable steps to ensure the accuracy of information they enter on the computer system. Users will only be given 4

5 4.0 Definitions access to the menus and access levels that are appropriate to their job. If a user changes their job within the hospital, access to hospital systems will be reviewed, to ensure that they do not retain any inappropriate access. Systematically monitor, review and report on compliance with this policy 4.1 CSA Clinical Spine Application CCG Care Commissioning Group SUS Secondary Uses Service HED Hospital Evaluation Data CNST Clinical Negligence Scheme for Trusts HSCIC Health & Social Care Information Centre 5.0 Roles and Responsibilities 5.1 Committees The Trust Board is responsible for ensuring that arrangements are in place so that it can be assured about patient data quality and compliance with this policy The Information Governance Committee is responsible for: Overseeing implementation of data quality improvement plans as part of the NHS Information Governance programme The Data Quality Committee is responsible for: Setting standards for the completeness, accuracy and timely capture of patient data Ensuring robust sign off and validation processes for internal and external reporting Ensuring application of correct indicator definitions and data scoping 5

6 5.2 Individual Officers The Chief Operating Officer is responsible for the promotion and implementation of this policy The Director of ICT is responsible for the technical integrity of Trust-wide electronic systems used for recording patient data and for delivery of training in the use of these systems The Deputy Director of Information & Insight is responsible for: Providing support and advice about NHS Data Standards, their interpretation and implementation Corporate monitoring, validation and reporting of patient data quality and operational procedures for the collection and use of patient data Taking remedial action where patient data quality is found to be below acceptable standards Monitoring, reviewing and reporting on compliance with this policy Maintenance of consistent, shared and up to date reference data Operational post-hoc validation, verification and correction of data Departmental Managers are responsible for ensuring that their staff: Are fully aware of the importance of good quality patient data Have access to and apply local Standard Operating Procedures that set out the procedures for patient data recording in accordance with Trust standards Have sufficient training and understanding in the use of systems (paper and electronic) used for recording patient data All staff have a responsibility to ensure that they record patient data promptly and accurately with reference to the latest procedures and definitions. 6

7 6.0 Policy and/or Procedural Requirements Departments System users must have up to date written departmental procedures available which include procedures for the collection, validation and entry of data. The procedures will be available to staff in all appropriate locations and will be updated in accordance with changes to guidelines, data definitions and software. As a minimum the following procedures will be documented: Registering a patient GP Referral to Outpatient Clinic or Test Attendance, Cancellation, DNA at outpatient clinic and outcome Add patient to Inpatient Waiting List Emergency or Elective admission, transfer and discharge Attendance in the Emergency Department Individual Users All service user and associated data must be entered in accordance with defined standards. It is expected that the Bed State on Medway PAS will show the current location and management of all Inpatients and Day Case patients at NUH. Inpatients should be admitted, transferred and discharged on Medway contemporaneously with their actual admission, transfer or discharge. It is expected that all Out Patient appointments will be fully outcomed within 24 hours of the end of the clinic. Staff who collect and enter service user data have a responsibility to ensure that it is verified with service users or national databases and that any necessary corrections are made promptly. Inaccurate demographics may result in important letters being misdirected or the incorrect identification of a service user. 7

8 The NHS Number is the national unique patient identifier. Users should collect and record it as part of patient registration. It should be included on all patient level communications that transfer or cross NHS system or organisational boundaries Core Systems Managers All reference tables, such as GP, Specialty and Postcodes, will be updated within a month of publication unless there are doubts about the quality of the data supplied. All coded data items held on Trust computer systems must comply with national standards or map to national values. Wherever possible, computer systems will be programmed to only accept valid entries Data Quality Staff Where key data items are missing from (or uncoded in) patients records it is the responsibility of DQ staff (following written procedures) to use their best endeavours to complete the data. Reports on missing NHS Numbers are produced daily. Other reports are addressed periodically. DQ staff have the responsibility of responding to queries from CCGs Compliance and Audit Internal Data Quality reports will be produced under the aegis of the Data Quality Committee and communicated to the IG Committee, Divisions and CCGs. These will be used to inform management, improve service user processes, ensure targeted training and support, enhance documentation and enable more complete and accurate data capture. Accredited external organisations will be used to assist in the communication of data quality assurance issues and may include the following: 8

9 Secondary Uses Service (SUS) Data Quality/Completeness Reports Healthcare Evaluation Data (HED) Data Quality Audits Performance Indicators (Annual Health Check) NHS Digital - Data Quality Maturity Index (DQMI) NHS Choices Indicators Service User Queries Commissioner Complaints 7.0 Training and Implementation 7.1 Training All users should be trained in: How to use relevant IT systems How to capture all necessary data items (not just those which are technologically mandatory) and the importance of such data items Departmental processes for recording and updating data Relevant data standards and requirements Staff must attend appropriate training to ensure an adequate level of competency in the patient administration functions used in their role. Refresher training will be offered as required. All training should include evaluation of its effectiveness in terms of staff feedback forms. 7.2 Implementation Appropriate staff will receive training on record keeping and management. (Refer to Training and User Guides for detailed training documentation) 9

10 7.2.2 All data entry systems should have an audit trail that is activated and used. Data Quality Standards The Trust s service users will expect that all data held on them will be 100% accurate Service user data held by the Trust must be fit for purpose. There are many aspects to good quality data: Completeness All mandatory data items within a data set should be completed. Use of default codes should only be used where appropriate, and not as a substitute for real data. Consistency Data items should be internally consistent. Patients with multiple episodes should have consistent dates. Operations and diagnoses will be consistent for ages and/or sex. Coverage Data must reflect all the work done by the Trust. A&E attendances, Admissions, Outpatient attendances, Diagnoses and Procedures must be recorded. Correct procedures are essential to ensure complete data capture. Spot checks and comparisons between systems will be used to identify missing data. Accuracy Data recorded in notes and on computer systems should accurately reflect what actually happened to a patient. Timeliness Recording of timely data is beneficial to the treatment of the patient. Entering test results into the computer or recording diagnoses and procedures makes that information available to all treating the patient even if they do not have access to the paper notes. All data must be recorded promptly. The accurate recording of data items must not be allowed to delay the urgent treatment of a patient. (Standards for service user data quality are contained in Appendix 2) 10

11 Accountability It is the responsibility of all staff for assuring the quality of data and information held on service users with whom they are in contact. Managers are accountable for the data quality within the services that they provide The lead director reporting to the Trust Board on data quality is the Chief Operating Officer. Audit & Monitoring (See Corporate Data Validation policy) The Trust will undertake audits and data quality checks. These will include: External clinical coding audits Internal audits (topics to be agreed) Accuracy checks Ward Audits Completeness and Validity checks Compliance checks The Trust has undertaken a review of integrated performance reporting with 360 Assurance (Internal Audit & Assurance), the results of which gave significant assurance regarding data quality processes. The reports are available from the NUH Information & Insight website: ReportsLibrary/Forms/current.aspx The Data Quality Committee will regularly review Performance against policy Additionally the Trust will use available external reports to monitor data quality and rectify issues identified wherever possible. Information Services will produce and monitor progress against an annual data quality work programme, reporting progress and issues to the Data Quality Committee. Communication on data quality issues to all staff will be 11

12 maintained through a Data Quality Newsletter, messages on system noticeboards, targeted messages to specific groups of users and through the Trust s team brief mechanisms. 7.3 Resources No additional resources needed 8.0 Trust Impact Assessments 8.1 Equality Impact Assessment An equality impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. 8.2 Environmental Impact Assessment An environmental impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. 8.3 Here For You Assessment A Here For You assessment has been undertaken on this document and has indicated the need for additional considerations which have been duly incorporated. 12

13 9.0 Policy / Procedure Monitoring Matrix Minimum requirement to be monitored Daily, Weekly and Monthly Validation reports Responsible individual/ group/ committee Directorate Managers Process for monitoring e.g. audit Error Reports, Audit of System/ Casenotes Frequency of monitoring Daily, Weekly and Monthly Responsible individual/ group/ committee for review of results Relevant staff members and Directorate Managers Responsible individual/ group/ committee for development of action plan Directorate Governance Forums Responsible individual/ group/ committee for monitoring of action plan Directorate Governance Forums 13

14 10.0 Relevant Legislation, National Guidance and Associated NUH Documents 10.1 Equal Pay Act (1970 and amended 1983) Sex Discrimination Act (1975 amended 1986) Race Relations (Amendment) Act 2000 Disability Discrimination Act (1995) Employment Relations Act (1999) Rehabilitation of Offenders Act (1974) Human Rights Act (1998) Trade Union and Labour Relations (Consolidation) Act 1999 Code of Practice on Age Diversity in Employment (1999) Part Time Workers - Prevention of Less Favourable Treatment Regulations (2000) Civil Partnership Act 2004 Fixed Term Employees - Prevention of Less Favourable Treatment Regulations (2001) Employment Equality (Sexual Orientation) Regulations 2003 Employment Equality (Religion or Belief) Regulations 2003 Employment Equality (Age) Regulations 2006 Equality Act (Sexual Orientation) Regulations 2007 False or Misleading Information Act (2014) Data Protection Act (1998) NHS Data Model & Dictionary 14

15 APPENDIX 1 15

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20 Data Output Standards APPENDIX 2 Admitted Patient Care Percentage Complete & Valid NHS Number 98 Patient Pathway (PPI) 100 Postcode of Usual Address 100 Ethnic Category 95 GP Practice (registered) 99 Date of Birth 99 Sex 100 Source of Admission 99 Method of Admission 99 Admission date 99 Discharge Destination 99 Discharge Method 99 Discharge Date 99 Episode Start Date 99 Episode End Date 99 Intended management 98 Consultant Code 100 Treatment Specialty 100 Primary Diagnosis 99 Healthcare Resource Group Code (HRG) 99 Outpatients NHS Number 98 Patient Pathway (PPI) 100 Postcode of Usual Address 100 GP Practice (registered) 99 Date of Birth 99 Sex 99 Source of Referral 99 Referral Request Received date 99 Attended or Did Not Attend 99 First Attendance 99 Outcome of Attendance 99 Attendance Date 99 Consultant Code 100 Treatment Specialty

21 Emergency Department Percentage Complete & Valid NHS Number 98 Postcode of Usual Address 100 GP Practice (registered) 99 Date of Birth 99 Sex 99 Ethnic Group 99 Source of Referral 99 Discharge Destination 99 Primary Diagnosis 99 First Investigation 99 First Treatment 99 Attendance Date 100 Departure Time

22 Insert templates of relevant impact assessments (page break after each) APPENDIX 3 Equality Impact Assessment (EQIA) Form (Please complete all sections) Q1. Date of Assessment: 16/03/17 Q2. For the policy and its implementation answer the questions a c below against each characteristic (if relevant consider breaking the policy or implementation down into areas) Protected Characteristic a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups experience? i.e. are there any known health inequality or access issues to consider? The area of policy or its implementation being assessed: Race and Ethnicity No impact identified Gender No impact identified Age No impact identified Religion No impact identified Disability No impact identified Sexuality No impact identified Pregnancy and Maternity No impact identified Gender Reassignment No impact identified b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality 22

23 Marriage and No impact identified Civil Partnership Socio-Economic Factors (i.e. living in a poorer No impact identified neighbour hood / social deprivation) Area of service/strategy/function Q3. What consultation with protected characteristic groups inc. patient groups have you carried out? Following the above initial assessment, this policy does not have an impact either positively or negatively on any of the above strands of equality as the policy sets out the importance of the quality of data collection, for example the appropriateness on the electronic systems used to collect and record patient data not what data is actually being collected. Q4. What data or information did you use in support of this EQIA? Not Applicable Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? None Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups identified or to create confidence that the policy and its implementation is not discriminating against any groups What By Whom By When Resources required Q7. Review date March

24 APPENDIX 4 Environmental Impact Assessment The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b) implement mitigating actions. Area of impact Environmental Risk/Impacts to consider Action Taken (where necessary) Waste and materials Soil/Land Water Air Is the policy encouraging using more materials/supplies? Is the policy likely to increase the waste produced? Does the policy fail to utilise opportunities for introduction/replacement of materials that can be recycled? Is the policy likely to promote the use of substances dangerous to the land if released (e.g. lubricants, liquid chemicals) Does the policy fail to consider the need to provide adequate containment for these substances? (e.g. bunded containers, etc.) Is the policy likely to result in an increase of water usage? (estimate quantities) Is the policy likely to result in water being polluted? (e.g. dangerous chemicals being introduced in the water) Does the policy fail to include a mitigating procedure? (e.g. modify procedure to prevent water from being polluted; polluted water containment for adequate disposal) Is the policy likely to result in the introduction of procedures and equipment with resulting emissions to air? (e.g. use of a Not Applicable Not Applicable Not Applicable Not Applicable 24

25 Energy Nuisances furnaces; combustion of fuels, emission or particles to the atmosphere, etc.) Does the policy fail to include a procedure to mitigate the effects? Does the policy fail to require compliance with the limits of emission imposed by the relevant regulations? Does the policy result in an increase in energy consumption levels in the Trust? (estimate quantities) Would the policy result in the creation of nuisances such as noise or odour (for staff, patients, visitors, neighbours and other relevant stakeholders)? Not Applicable Not Applicable 25

26 APPENDIX 5 We Are Here For You Policy and Trust-wide Procedure Compliance Toolkit The We Are Here for You service standards have been developed together with more than 1,000 staff and patients. They can help us to be more consistent in what we do and say to help people to feel cared for, safe and confident in their treatment. The standards apply to how we behave not only with patients and visitors, but with all of our colleagues too. They apply to all of us, every day, in everything that we do. Therefore, their inclusion in Policies and Trust-wide Procedures is essential to embed them in our organization. Please rate each value from 1 3 (1 being not at all, 2 being affected and 3 being very affected) Value Score (1-3) 1. Polite and Respectful Whatever our role we are polite, welcoming and positive in the face of adversity, and are always 3 respectful of people s individuality, privacy and dignity. 2. Communicate and Listen We take the time to listen, asking open questions, to hear what people say; and keep people 3 informed of what s happening; providing smooth handovers. 3. Helpful and Kind All of us keep our eyes open for (and don t avoid ) people who need help; we take ownership of 2 delivering the help and can be relied on. 4. Vigilant (patients are safe) Every one of us is vigilant across all aspects of safety, practices hand hygiene & demonstrates 2 attention to detail for a clean and tidy environment everywhere. 5. On Stage (patients feel safe) 2 26

27 We imagine anywhere that patients could see or hear us as a stage. Whenever we are on stage we look and behave professionally, acting as an ambassador for the Trust, so patients, families and carers feel safe, and are never unduly worried. 6. Speak Up (patients stay safe) We are confident to speak up if colleagues don t meet these standards, we are appreciative when they do, and are open to positive challenge by colleagues 7. Informative We involve people as partners in their own care, helping them to be clear about their condition, choices, care plan and how they might feel. We answer their questions without jargon. We do the same when delivering services to colleagues. 8. Timely We appreciate that other people s time is valuable, and offer a responsive service, to keep waiting to a minimum, with convenient appointments, helping patients get better quicker and spend only appropriate time in hospital. 9. Compassionate We understand the important role that patients and family s feelings play in helping them feel better. We are considerate of patients pain, and compassionate, gentle and reassuring with patients and colleagues. 10. Accountable Take responsibility for our own actions and results 11. Best Use of Time and Resources Simplify processes and eliminate waste, while improving quality 12. Improve Our best gets better. Working in teams to innovate and to solve patient frustrations TOTAL

28 APPENDIX 6 CERTIFICATION OF EMPLOYEE AWARENESS Document Title Patient Data Quality Policy Version (number) 5 Version (date) 3 I hereby certify that I have: Identified (by reference to the document control sheet of the above policy/ procedure) the staff groups within my area of responsibility to whom this policy / procedure applies. Made arrangements to ensure that such members of staff have the opportunity to be aware of the existence of this document and have the means to access, read and understand it. Signature Print name Date Division/ Directorate The manager completing this certification should retain it for audit and/or other purposes for a period of six years (even if subsequent versions of the document are implemented). The suggested level of certification is; Clinical Divisions - Divisional General Manager or nominated deputies Corporate Directorates - deputy director or equivalent. The manager may, at their discretion, also require that subordinate levels of their directorate / department utilize this form in a similar way, but this would always be an additional (not replacement) action. 28