SABP/INFORMATIONSECURITY- SUMMARY CARE RECORD ACCESS/0003

Transcription

1 SABP/INFORMATIONSECURITY- SUMMARY CARE RECORD ACCESS/0003 PROCEDURE NAME REASON FOR PROCEDURE WHAT THE PROCEDURE WILL ACHIEVE? WHO NEEDS TO KNOW ABOUT IT? Summary Care Record Access Procedure Permission to view Medication, Allergy and Alerts. This procedure is intended to ensure that all doctors, nurses and qualified pharmacy staff adhere to the agreed principles on view access to the summary care record. Enables clinical staff to access the people who use our services Medication, Allergy and Alert information through their summary care record. This will assist in the continuity of care for the people who use our services. Clinical staff need to be aware of the ability to check, with the permission from the person who uses our services Medication, Allergy and Alert records on the Summary Care Record. The process also allows consent over-ride in an emergency. DATE APPROVED 24 th September 2013 VERSION NUMBER APPROVING COMMITTEE DATE OF IMPLEMENTATION DATE OF FORMAL REVIEW AUTHOR(s): DIRECTORATE RESPONSIBLE: DISTRIBUTION V1.0 Executive Board 24 th September years after implementation. NHS Surrey Information Governance & Security Manager Quality Doctors, Nurses and Qualified Pharmacy Staff. Page 1 of 16

2 VERSION CONTROL SHEET Version Date Author Status Comment /7/12 Colin Lee Draft For initial comment /10/2012 Lesley Thomson, IG/IS Manager Draft Adjusted for use within Surrey & Borders Partnership Foundation NHS Trust 0.3 5/2/2013 SCR Group Draft Completion of Equality Assessment prior to IGSG 01/3/2013 IGSG Draft For approval 01/3/2013 IGSG Approved 15/3/2013 CPG Draft For approval 15/3/2013 CPG Approved 0.4 9/5/2013 Lesley Thomson, IG/IS Manager 0.5 6/6/2013 Lesley Thomson, IG/IS Manager Draft Draft Addition of reference to Medicines Policy Changes after PAG 1.0 4/7/2013 PAG Approved to go to Exec Board /9/2013 Executive Board Approved Summary of Changes since Version (Include version control number here) Page /Paragraph/ Appendix Number (select the appropriate action) Section 1 Original / New / Amendment / Deleted Statement (select the appropriate action) Strengthen wording on how access will happen Section 9 Add SABP policies that tie in with this procedure Make reference to section 4 Section 1 Principle 6 Section 7 Move to section 4 History of consent Move to be an appendix Page 2 of 16

3 Section 8 Training not formal but staff required to undertake both sessions through ESR as detailed. Page 3 of 16

4 CONTENTS Summary Care Record - Permission to view Medication, Allergy and Alerts Procedure. The procedure will link to the Information Security Policy INTRODUCTION PURPOSE AND SCOPE DUTIES AND RESPONSIBILITIES APPROVAL, RATIFICATION AND REVIEW PROCESS DISSEMINATION AND IMPLEMENTATION MONITORING COMPLIANCE AND EFFECTIVENESS PERMISSION TO VIEW.6 8. REFERENCES... 7 Page 4 of 16

5 1. INTRODUCTION The NHS has introduced Summary Care Records to enable Clinicians (including out of hours and emergency access) access to important information about the people who use our services this being, Medication, Allergy and Alerts. This will assist in treatment and to improve the quality of care. All existing Doctors, Nurses and Qualified Pharmacy Staff will be granted access via their Smartcard. Access to this system will be applied automatically to your smartcard through the Registration Authority Process. This Procedure is to be read in conjunction with the Principles for implementing Permission to View Summary Care Records detailed in section 7. The nationally approved consent model is based upon the following six fundamental principles 1 :- Principle 1 The explanation to a person who uses our services, as part of seeking permission to view, should be simple, straightforward, honest and appropriately communicated. Principle 2 - A person who uses our services permission to view should be sought by the care setting wishing to view the Summary Care Record Principle 3 Care settings should be explicit about the scope of permission being sought. i.e. who is giving permission, for how long and in what context Principle 4 The scope of permission obtained must be recorded Principle 5 - Before setting the Not to be asked in future consent status for a person who uses our services, the user must be sure of the person who uses our services wishes in terms of scope of this permission Principle 6 - Permission to view does not apply where the person who uses our services is unable to give permission to view and the clinician acts in the best interests of the person who uses our services. Please see section 4 for further information. 2. PURPOSE AND SCOPE This Procedure is intended to ensure that all doctors, nurses and qualified pharmacy staff adhere to the agreed principles outlined above when accessing Summary Care Records. This Procedure applies to all NHS staff, Independent Sector Healthcare Providers and Private Healthcare organisations providing Healthcare and require access to Summary Care Records 1 NPFIT-SCR-SCRDOCS Principles for implementing Permission to View for Summary Care Records Page 5 of 16

6 3. DUTIES AND RESPONSIBILITIES All staff must adhere to the principles outlined above when wishing to access Summary Care Record, ensuring that person who uses our services consent is correctly recorded in their progress notes on RIO. If the records are accessed in an emergency this access too must be detailed in the progress notes on RIO. Line Managers will ensure that all staff under their direct management (including any temporary and contracting staff) are made aware of this Procedure. Managers must regularly monitor that the person who uses our services wishes are respected, and in cases of misuse, report the matter immediately to the Trust Caldicott Guardian for investigation. Privacy Officers are expected to undertake regular spot audits, using the reporting tool to identify if there are any suspicious patterns of behaviour. This procedure is to be read in conjunction with the compliance of the SABP Medicines Policy, reference 0017 available on the Trust website. This procedure is to be read in conjunction with the compliance of the SABP Information Security Policy, reference 0003 available on the Trust website. 4. PERMISSION TO VIEW In addition to the legitimate relationship, in order to actually view a patient's Summary Care Record the patient must give his or her consent. This can be done for an individual clinician or for a workgroup e.g. hospital department. The only times that a record can be accessed without this consent are: In an emergency and the best interest of the patient, e.g. patient who does not have capacity and unable to consent. This action should be undertaken in the best judgment of the clinician and will generate an alert to allow monitoring by the organisation. By court order e.g. as part of a police investigation When it is in the public interest e.g. to help with investigation of communicable diseases When access is required by statute e.g. the Data Protection Act requirement to maintain accuracy of personal data. The key thing to note about Permission to View is that as long as the patient has been asked for their permission (whether for an individual or a group of staff) and have recorded this permission, then the SCR can be viewed to be used in the course of the patient's treatment. 5. APPROVAL, RATIFICATION AND REVIEW PROCESS This procedure is ratified by the Executive Board and will be regularly reviewed by the Information Governance Steering Group. Page 6 of 16

7 6. DISSEMINATION AND IMPLEMENTATION The IGSG are required to disseminate this procedure along with the guidance referred to above. This procedure forms part of the overall Information Governance requirements laid down by the NHS. 7. MONITORING COMPLIANCE AND EFFECTIVENESS The Caldicott Guardian for Surrey and Borders Foundation NHS Trust shall have responsibility for monitoring compliance and effectiveness within their organisation, and take the appropriate action where breaches occur. 8. Review What will be monitored Access to the records is legitimate How/ Method Audit from system Frequency Lead Reporting to Deficiencies / gaps recommendation and action Regular Spot Checks IG/IS Manager Director of Quality and Knowledge Management Failure to adhere to this procedure could lead to disciplinary action. 8. TRAINING Whilst no formal training is required, staff who have access need to ensure they familiarise themselves prior to accessing the system and undertaking the two sessions through ESR as detailed below: SCR Access with Consent elearning SCR Access in an Emergency elearning Instructions on how to access elearning on ESR is available on the Trust Web at 9. REFERENCES Permission to View Guidance Consent Model Privacy Officer and Caldicott Guardian guidance SCR Viewing systems (including links to training materials SCR Posters for staff and patients ndservices/scr/staff/impguidpm/ig/ptoview ndservices/scr/staff/impguidpm/ig/ptoview ndservices/scr/staff/impguidpm/ig/iguidepocg ndservices/scr/staff/impguidpm/scra/viewsystem ndservices/scr/staff/aboutscr/comms/publication s/posters Page 7 of 16

8 Bribery Act 2010 SABP Information Security Policy Disciplinary Policy Medicines Policy tents F/SABP%200036%20Disciplinary%20Policy%2 0_2_.pdf/view O/0017%20Medicines%20Policy%20v3.pdf/view Page 8 of 16

9 Appendix 1 History of the Consent Model and Permission to View Following extensive consultation with key stakeholders, the Summary Care Record Advisory Group (SCRAG) which represents the BMA and Royal Colleges, proposed the move to a Permission to View model in July The Chair of the National Information Governance Board for Health and Social Care confirmed that the proposal is entirely in keeping with the NHS Care Record Guarantee for England and that, as well as being completely acceptable from a governance point of view, brings simplicity and clarity. We have listened to doctors and nurses who raised concerns about the complexity of the earlier model and are certain we now have a model which will work across a full range of care situations. The focus of the revised consent model is on two questions asked of the patient: 1. Do you want a Summary Care Record? 2. Can I look at your Summary Care Record? Page 9 of 16

10 Equality Analysis (EA s) (Formally known as Equality Impact Assessments) Introduction The equality duty now makes it clear that public authorities are expected to consider the need to remove or minimise disadvantage or to meet particular needs, such as through providing services for particular groups. Public authorities are also required to think about how to encourage participation in public life. The good relations duty now applies across all of the protected characteristics. In particular, public authorities must have due regard to the need to tackle prejudice and promote understanding between people who share a protected characteristic and those who do not. Equality Analysis starts prior to procedure/function development or at the early stages of a review. It is not a one-off exercise, it is ongoing and cyclical and it enables equality considerations to be taken into account before a decision is made. Equality Analysis of proposed policies will involve considering their likely or possible effects in advance of implementation. It will also involve monitoring what actually happens in practice. Waiting for information on the actual effects will risk leaving it too late for your Equality Analysis to be able to inform decision-making. Be wary of general conclusions it is not acceptable to simply conclude that a procedure will universally benefit all and therefore the protected groups will automatically benefit, without having evidence to support that conclusion. When you decide that a Procedure is not relevant to equality, you will need to document this, along with the reasons and the information that you used to make this decision. A simple statement of no relevance to equality without any supporting information is not likely to be sufficient, nor is a statement that no information is available. This is particularly important where you are not familiar with methods of equality analysis or with equality concerns, as you could inadvertently overlook issues that could indicate relevance to equality. This could leave you vulnerable to legal challenge. This is a summary of the general duty and how they apply to each protected characteristic: General equality duty Protected Characteristic To eliminate unlawful discrimination, harassment and victimisation To advance equality of opportunity between different groups Page 10 of 16 To foster good relations between different groups Age Disability Sex

11 Race Religion Sexual orientation Gender reassignment Marriage / civil partnership X X Pregnancy / maternity Please refer to Equality analysis and the Equality Duty: A guide for public authorities for more information. Who should be present at the Screening of an Equality Analysis? A diverse group of people must be in attendance of the Screening; this must involve the Procedure author, Staff, people who use services, Carers and other users of the Trust services if they are affected by the Procedure. For example, if the Procedure has a potential affect on just the staff, some staff must be invited to provide their views on the possible impact. A Screening should be carried out BEFORE the Procedure is placed out for consultation. At this stage a Full Equality Analysis could be identified. If a Full Equality Analysis is required, the outcomes should be carried over into the Action Plan. After the consultation deadline, all the data must be summarised and attached to the Screening and/or with Full Equality Analysis as a form of evidence. Equality Analysis (EA s) Screening Tool To be completed for all new proposals or reviews of existing policies, procedures, plans, services or functions. This screening should be undertaken at as an early a stage as possible, in order to address any equality issues which are identified before consultation/approval. Name of Initiative: Summary Care Records view access Unit/Department: Quality Directorate Date: 5/2/2013 Time: From: 11:30 am To: 13:00 Briefly describe the purpose of the Procedure/Function: To allow dedicated staff view access to the medication, allergy and alert information from the summary care record. Page 11 of 16

12 Who is it intended to benefit from this Procedure/Function? People who use our services, doctors, nursing and pharmacy staff What results are intended? To enable a better understanding of the health of the people who use our services. Why is it needed? To assist with clinical risk. Considered all Consultation feedback if this Equality Analysis is carried out after the consultation. What was the length of the Consultation Period: (From: To: ) Not required as agreed at June 2013 PAG What was the consultation feedback and actions taken: N/A EA s group: Identify a lead. Involve and consult stakeholders and people with expertise in the different equality areas get a balance of skills and experience including people who use services and community members. Lesley Thomson Nicki Rayment Liz Case-Green Jacqui Renfree Simon Whitfield Name IG/IS Manager Head of IT RA Manager Nursing Rep Pharmacy Rep Title Please ensure all parties present are aware that this document will be published on the Trust website and is accessible to members of public. Consider the potential Analysis of the effects on equality is intended to focus more attention on the quality of the effects on protected analysis and how it is used in decision-making, and less on the production of a document. You characteristics need to analyse the effect on equality for all of the protected characteristics, and all aims of the (PC s). general equality duty as set out below. Equality Act 2010 General Duty. Page 12 of 16

13 Age Disability Eliminate unlawful discrimination, Harassment and Victimisation There was positive evidence that this will enhance care for all people who use our services There was positive evidence that this will enhance care for all people who use our services and will work with those to ensure the impact is positive. Staff will work with those individuals with this PC to ensure they have a clear understanding around consent to view this information Advance equality of opportunity between people who share a PC and those who do not. Foster good relations between people who share a PC and those who do not. This procedure will have a positive impact and will deliver better quality healthcare as it does not negatively affect anyone of this PC. This procedure will have a positive impact and will deliver better quality healthcare as it does not negatively affect anyone of this PC. The Trust will work with those with a disability to ensure it does have a positive impact. Sex There is no evidence this the people who use our services. This procedure will help foster good relationships between different groups as it does not negatively affect anyone of this PC. Race There is no evidence this the people who use our services. This procedure will help foster good relationships between different groups as it does not negatively affect anyone of this PC. Religion and Belief There is no evidence this the people who use our services. This procedure will help foster good relationships between different groups as it does not negatively affect anyone of this PC. Sexual Orientation There is no evidence this This procedure will help foster good Page 13 of 16

14 Pregnancy and maternity Gender Reassignment Marriage/ Civil Partnership Carers Human Rights implications if relevant Other equality issues please state the people who use our services. There is no evidence this the people who use our services. Staff will be given assistance with access should this be required. There is no evidence this the people who use our services. There is no evidence this the people who use our services. There is no evidence this the carers of the people who use our services. There is no evidence this the people who use our services human rights. N/A relationships between different groups as it does not negatively affect anyone of this PC. This procedure will help foster good relationships between different groups as it does not negatively affect anyone of this PC and will work with those with a disability to ensure it does not.. This procedure will help foster good relationships between different groups as it does not negatively affect anyone of this PC N/A This procedure will help foster good relationships between different groups as it does not negatively affect carers for the people who use our services. This procedure will help foster good relationships between different groups as it does not negatively affect anyone of this PC HR and workforce issues/implications if relevant Access has been restricted to this system due to the likelihood of when information may be viewed as this is to be used by out of hours doctors, nurses and qualified pharmacy staff. Page 14 of 16

15 Evidence used in the decision-making.. If the responses affect any of the protected characteristics then please complete the Action Plan to avoid or mitigate the potential adverse effects on equality. Decision to proceed (please circle yes or no): No : We have decided that it is not necessary to carry out a full EA Action plan If no, briefly summarise reasons and the evidence for this decision: Signed by responsible Director or Associate Director: Ann Stevenson Name: Quality Directorate: Please send a copy of all completed screening and full EA s/action Plan to: Diversity & Inclusion Dept, Ramsay House, West Park, Epsom, Surrey KT19 8PB. If you require any assistance, please call Page 15 of 16

16 Equality Analysis (EA s) Action plan The action plan should provide a focused set of priorities for improvement. It should only include the key activities that are likely to have the greatest impact. Issue/change sought Evidence found in the screening of any issues that may have an effect on Equality for different PC S Action (SMART targets) E.g. Risk register/ Procedure Change/ training opportunities/ service plans Expected Outcome Milestones and key deliverables. How these will be addressed? By who /Lead/Directorate Who is responsible for taking forward the outcomes Target dates Page 16 of 16