Title: Information Quality Assurance Policy Document type: Policy Document Control Page Version number as from December 2004: 2 Classification: Policy Scope: Trust wide Author: Rachel Dunscombe Chief Informatics Officer (CIO) Groups Consulted: Executive Board Nominees, Informatics Validated by: Rachel Dunscombe Equality Impact Assessed: Yes Date: October 2013 (Reviewed) Janet Heaton Teresa Jowett (If appropriate) Replaces: Version 1 Description of amendments: Updated to reflect organisational changes Authorising Body: Informatics Committee Date of Authorisation: November 2013 Master Document Controller: Tracey Moss Review Date October 2015 Key words:information Quality Assurance, IQA, Patient Data,
INDEX Purpose and Scope of Document 3 Accountability 4 Policy statement 5 Quality Standards 5 Patient Information Confidentiality 6 Validation & Quality Assurance 6 Communications 7 Data Quality Improvement Process and Management Reporting Structure Audit Development Programme and Performance Monitoring 8 References 9 Definitions 9 Appendices A - New template request form B - Equality Impact Assessment 8 10 11 2
INFORMATION QUALITY ASSURANCE POLICY Purpose and Scope of Document This policy relates to all systems but please note that the IQA department only validate the data within LE2.2 and Lorenzo. 1.1 High quality information is needed to make the link between data and direct patient care and also non-operational functions such as clinical governance, performance management and service planning. For this purpose 100% accuracy 100% of the time must be the goal. The future will be driven by a fully integrated EPR and EDMS 1.2 Good data quality depends on sound operational processes and accurate and complete data at the point of capture. Clinical and administrative processes need in-built quality control, with routine validation and verification. Divisional data quality will be reported to the nominated board owner to enable the board to manage divisional quality. 1.3 The achievement of the modernisation agenda set out within the NHS Plan and NHS wide developments requires the availability of consistent, accurate and secure information about individual patients and service users, their needs, their care plans, the care they receive and the outcomes of this care. This information must be made accessible as necessary to all those involved in providing care. This will be the key driver for clinical and care systems investment strategies both locally and nationally. This will assist in delivering both safe patient care and improved healthcare outcomes 1.4 Having a policy is the first step to ensure standardisation of patient access and data collection. The Trust must be sure that, through audit and documented processing, all patient activity is collected and recorded consistently. Divisions must ensure process are in place to check the quality of their data 1.5 Much of the data collected is directly related to patient care. This includes a whole range of data including, personal demographics, care episodes, tests, examinations, operations performed, diagnoses and in the future clinical outcomes. Poor quality information impacts directly upon each and every use made of that information For example: In clinical care, poor quality information may:result in patients being harmed or distressed or undermine the trust s confidence in recorded information In disease surveillance, poor quality information may:undermine the validity of conclusions drawn or obscure facts and put the public at risk 3
Robust health research is dependant on reliable, credible data and un-assured data will damage the reputation of the organization. Robust systems of research governance form part of this process. In medical research, poor quality information may undermine the credibility of evidence based care, cause the validity of findings to be questioned In health service management, poor quality information may prevent understanding of best clinical practice and or result in resources being poorly targeted 1.6 In order to understand the information collected there must be comprehension in the context in which it is used. The Department of Health demands uniformity in the data collected and the way in which it is collected. If these standards are ignored then the Trust will be unable to analyse or communicate information in a meaningful way. Missing, incorrect, or incomplete data directly affects the provision of quality patient care. 1.7 High quality clinical information underpins high quality clinical care; Wherever possible, information should be captured once only and should be Accountability accurate and complete valid reliable recorded in a timely manner relevant 2.1 The prime responsibility for the validity and accuracy of data lies with the individual who is the source of the data and with the organisation in which the individual works. Divisions/Departments are responsible for the quality of their own data. Increasingly the data within patient records will be maintained directly by clinicians and care professionals, capturing information at the point of care and supported by software applications. 2.2 Information assembled from these patient and service user records is essential for the planning, commissioning and performance management of services. It is essential that clinicians and care professionals be supported by the appropriate expertise, which both enable and ensure the quality of the information in patient records. 2.3 The Chief Executive of the Trust is responsible for signing off the Trust s data for the Department of Health. 2.4 The lead director responsible for data quality is the Director with Data Quality in their portfolio Senior Management responsibility lies with the CIO Operational responsibility lies with divisional/department managers 4
Policy Statement 3.1 As the Trust develops services additional activity will need to be recorded. Therefore any ward/department wishing to record new activity or change the definition of existing activity, will be required to present their proposals to the IQA group. It is vital that any activity recorded meets the national definitions. A process is in place and must be adhered to, to ensure that relevant personnel are informed of any changes. These changes need to be communicated to the CCG prior to taking place (proforma attached) 3.2 Minimal changes will be made to the policy, however, it is important the document remains current, and therefore will be updated when required and changes/additions notified to staff. 3.3 As the Trust develops its use of systems and technology, it is important that data definitions and collection processes are consistent, ensuring that all national standards are met. 3.4 It is essential that all staff working with patient related information systems must be appropriately trained. It is the responsibility of all department managers to ensure that all staff have attended training, and re-training as required. Managers need to ensure that all staff are trained for the role they are undertaking. Managers are responsible for ensuring that when Bank/Agency staff are booked they have had the necessary training to carry out their role. Access levels will be set by role not individual. Staff should not be given access to any systems without having attended the relevant training 3.5 A formal record of attendance at each training session and exercises to demonstrate competence should be carried out by all staff responsible for data entry. 3.6 All relevant new members of staff must receive training in the application of standard work data collections procedures before they are allowed to undertake the duties of their role. A training needs assessment can be undertaken every to determine refresher training requirements, or earlier in the event of system upgrade and or process changes. 3.7 Consistent failure to comply with Trust data collection processes following training provision and support will result in IQA Manager liaison with the relevant line manager to formally progress the issue. Staff will be held accountable for their actions. Quality Standards Aim 4.1 To meet the current NHS Data Standards on: Security & Confidentiality Coverage Procedures to cover all areas of data collection Validation & Quality Assurance Training 5
Communications Accountability Health Records Management Equality and Diversity 4.2 To meet any future data standards without losing sight of our ultimate responsibility to patients. 4.3 Patient data held in Trust computer systems must be fit for purpose. Systems training processes have been designed to provide a quality training service. This service will provide role based training throughout the health community on a wide variety of software packages. All training provided includes a large aspect relating to data quality to ensure that staff are aware of the importance of their actions relating to data entry etc. 4.4 To ensure that supervisors and managers are aware of data quality issues and performance in order to monitor constant improvement in all appropriate areas. Patient Information Confidentiality 5.1 The Trust will follow a policy, where possible, of restricting access to personally identifiable information on its systems and using either aggregated or anonymised information. In addition research and analysis which is dependant upon identifying individuals will, where possible make use of identifiers such as NHS number rather than name and address. This is in accordance with the recommendations of the Caldicott review 2013 and the requirements of Research Governance 5.2 Patient information will only be handled by staff who are authorised to handle it as part of their duties. 5.3 Patient information will never, under any circumstances, be communicated to persons who are not authorised to receive it. 5.4 Patient information will only be discussed with persons who need to know it in order to carry out their work. 5.5 Access to all patient information, including health records, is on a needto-know basis. Access levels will be allocated to the staffs role and not to the individual. Validation & Quality Assurance 6.1 Regular accuracy and validity processes by competent and relevant staff will be undertaken on patient data to assess the accuracy and completeness of the information. 6.2 Accredited external sources of information will be used to assist with the validation of patient records. 6
6.3 External audits of data quality are regularly undertaken by external auditors (PWC). The Trust has been involved in the following: Inpatients Outpatients Advancing Quality Payment by Results 6.4 Managers must work with the IQA Manager to review regular data quality reports to trace trends of poor data quality capture and if necessary identify staff who may require refresher training. The IQA Manager will liaise with the system training team to ensure refresher training is provided as required. Communications 7.1 Commitment to data quality is the responsibility of all staff and must be defined in job descriptions for all relevant roles within the Trusts such that staff recognise their responsibilities as an integral part of their role/profession. The need to communicate the issues surrounding data quality is essential. This will be achieved by: Intranet Newsletters Notice boards Team Brief Standardised query proforma Data Quality Review meetings Elective Care Steering Group 7.2 All queries relating to data and information standards will be processed through the IQA team. All data quality queries must be emailed to the dedicated email address, (Data quality LE2.2/PDS) which can be found in the Trust email address book. This will allow the team to respond in a timely manner. The IQA Manager will reference the Data Dictionary/Data Standards definitions which are available via the internet. The IQA Manager will seek advice from the Data Standards request service when the reference to guidance documents does not provide clarity. 7
Data Quality Improvement Process and Management Reporting Structure 8.1 NHS Data Standards impact on the design of systems and then the use of those systems along with the data collection processes are reflected in local procedures. Staff, therefore, need to be trained in local procedures, use of systems and an understanding of data standards (dependent on their role). 8.2 Some data collected are subject to validation routines and audit programmes to measure the quality of the data against the national standards. Errors relating to specific members of staff are reported to the appropriate line manager, who takes action including re-training of the staff member (and so the improvement cycle continues). 8.3 The remaining errors are analysed and investigated, then the results are reported to the IQA Team, which decides on the necessary action. This could include changes to local procedures, training programmes and systems. 8.4 Once changes have been made to systems, local procedures and/or training programmes, staff are re-trained and further audit and validation are carried out to check if the problems previously identified have now been resolved. The quality improvement cycle, however, continues with further validations, audits, etc. 8.5 If issues are identified that may be of a more serious nature e.g. require considerable resource to rectify the problem. These examples will be referred to the Informatics committee for consideration. Audit Development Programme and Performance Monitoring 9.1 The accuracy of data is a key element of information quality. 9.2` The Department of Health has placed a requirement on trusts to ensure they hold good quality patient care data that is used to for central returns, submissions to the Secondary Uses Service (SUS), Hospital Episode Statistics (HES) and Payment by Results (PBR). 9.3 In order to provide assurance to themselves as well as external users the Trust should have a documented audit procedure in place to support the audit process. The procedure will need to ensure that a regular audit cycle is in place to check that the quality of patient care data it holds is accurate, complete and reliable. 9.4 The audit process will require the Trust to cover all the patient care datasets included in the Information Governance toolkit guidance (Secondary Use Assurance Acute Trusts Guidance - requirement 506) and all the key data items as listed in each dataset along with any locally agreed subset of data. 8
9,.5 It is planned that the Trust will initially audit 3 types of patient care datasets: Admitted Patient Care Outpatient CDS(Commissioning Data Set) Accident & Emergency CDS Maternity CDS Paediatrics CDS CAMHS CDS References 1. Caldicott Review 2013 https://www.gov.uk/government/publications/the-information-governancereview 2. Bolton NHS Foundation Trust Data Protection Policy Definitions Definition of Data Data is information that is: Being processed by means of equipment operating automatically in response to instructions given for that purpose; or Recorded with the intention that it should be processed by means of such equipment; or Recorded as part of a relevant filing system or with the intentionthat it should form part of a relevant filing system; or Forms part of an accessible record. Personal Data Any data relating to an identified, or identifiable, living individual Media All media - microfilm, film CCTV as well as paper and electronic formats. The individual is entitled to be informed about what data is being stored, for what purpose and in what format. Sensitive Personal Data Includes the following items: Racial or ethnic origin Political opinions Religious or similar beliefs Membership of trade unions Physical or mental health IQA Manager Information Quality Assurance Manager 9
Appendix A NEW TEMPLATE REQUEST FORM A MINIMUM OF 6 WEEKS NOTICE MUST BE GIVEN Please answer ALL the following questions about the new clinic you require: Date proforma submitted Division Speciality Treatment function code Requested start date of new clinic Name of person completing this request Approval of Clinician (if not completing form) Approval of OBM / Clinical Manager Is the clinic Consultant, Nurse or technician led Full name of clinician If new to Bolton FT, GMC code of clinician Does the clinic need to be published on C & B / Does DoS need updating Describe the purpose of the clinic Which day/s will the clinic take place Location of the clinic Is the clinic AM or PM How many new patients How many follow patients Start time of first appointment Time of last appointment Slot times for new patients (i.e. 20 mins) Slot times for follow up patients (i.e. 10mins) Any instructions about order of clinic, i.e. new patients first Total number of patients Frequency of clinics Weekly, Alternate weeks or Monthly Attendance type i.e. face to face, tel Is this new activity If this is NOT new activity list the clinic code this replaces If this is NOT new activity does this lead to a decrease in capacity Any alterations to requirements for support areas, i.e. bloods, ECG, radiology Any additional elective access, case notes, booking or reception service requirements 10
Appendix B Equality Impact Assessment Initial Screening Tool This Initial Screening Tool is the first step in completing an Equality Impact Assessment (EIA) of your activity (strategies, functions, policies, procedures, projects, services etc). Once this is completed, it will be apparent whether or not a full EIA is required. This proforma should be used in conjunction with the EIA Guidance available on the Trust s intranet website under A-Z Services, using the Equality & Diversity link, where you will also find links to the Trust s Single Equality Human Rights Scheme (SEHRS). 1. Directorate Finance, Information and Procurement 2. Department Information 3. Name of activity being assessed Data Quality 4. Person completing this form Graham Fullarton 5. Date 24 th January 2011 6. Monitoring data/statistics compare activity data with population data (see Guidance) Patients Staff Equality Target Groups (ETGs) (See guidance for detail) 7. Which of the following Equality Target Groups will this activity impact on? 8. Could this activity have a positive and/or negative impact? yes no Positive* Negative* A. Age x x B. Disability x x C. Gender x x D. Race x x E. Religion/Belief x x F. Language x x G. Sexual Orientation x x H. Gypsy/Roma/Traveller x x I. Carers x x J. Employees x x 9. Consultation/Involvement during the development of this activity? (see Guidance) Information Quality Assurance Group, IM & T Committee 10. Details of positive and negative impacts Positive Impacts Accurate recording of information better measures of compliance with statutes Negative Impacts 11. Give details of actions required to remedy any negative impact(s) identified above. Action to address negative impact Who Target Date 11
Positive impact Age Disability Gender Race Religion/ Belief Language Sexual Orientation Gypsy/roma Traveller Carers Employees Negative Impact Age Disability Gender Race Religion/Belief Language Sexual Orientation Gypsy/roma Traveller Carers Employees 12. If the actions in 11 above are completed (answer Yes or No) revisit section 12 when action in 11 complete 1. Will the activity present any problems or barriers to any community or group? 2. Will any group of people be excluded as a result of your activity? 3. Does the activity have the potential to worsen existing discrimination and inequality? 4. Will the activity have a negative effect on community relations? Could the activity reduce inequalities? Will it (answer Yes or No) No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No 5. Promote equality of opportunity? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 6. Eliminate discrimination? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 7. Eliminate harassment? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 8. Promote good community relations? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 9. Promote positive attitudes towards disabled people? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 10. Encourage the participation of disabled people? 11. Consider more favourable treatment of disabled people? 12. Promote and protect human rights? Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Decision Work through the flowchart on page 24 of the Guidance, to determine whether you need to complete a Full EIA or not. Details of any objective justifications or amendments agreed with Divisional E&D Lead: Full EIA required? Yes No x Date approved by Divisional Boards: Completed by: Graham Fullarton Job Title: Information Governance Manager 24/1/2011 Thank you for completing this EIA initial screening tool. Please forward an electronic copy of the completed tool to your Divisional E&D Lead for ratification by your Divisional Board and a copy to: Suzanne Hudson Email: suzanne.hudson@rbh.nhs.uk Telephone extension: 4017 12