Minutes of the Public Health Wales Information Governance Committee

39.24 Minutes of the Public Health Wales Information Governance Committee Date of meeting: 27 March 2015 Time of meeting: 09:00 10.30 Venue for meeting: Boardroom, 14 Cathedral Road, Cardiff Version: v1 Present Mr John Spence (Chair) Dr Carl Clowes Mr Terry Rose Board Member, Public Health Wales Board Member, Public Health Wales Board Member, Public Health Wales In attendance Mrs Rhiannon Beaumont-Wood Mr Keith Cox Miss Cerian Dovey Ms Jane Evans Ms Eleanor Higgins Mr John Morley Director of Nursing Board Secretary Business Support Manager Information Governance Manager Corporate Governance Manager Information Governance Manager Apologies Dr Tracey Cooper Dr Quentin Sandifer Chief Executive Executive Director of Public Health Services Date: 5 June 2015 Version: 1 Page: 1

Public Health Wales Minutes Information Governance 27 March 2015 1. Welcome and apologies The Chair welcomed all those in attendance to the meeting of the Public Health Wales Information Governance Committee. Ms Rhiannon Beaumont-Wood was welcomed to the Committee as the new Executive lead for Information Governance. Apologies were received from Dr Tracey Cooper and Dr Quentin Sandifer. 2. Declarations of interest There were no declarations of interest to register. 3. Minutes and matters arising The minutes from the previous meeting were received by the Committee and approved as an accurate account. Actions arising Ms Jane Evans provided an update on EU Data Protection legislation (action 18.04). A recent news article announced that the European Union has provisionally agreed to proposals meaning data can be shared without explicit consent for clinical purposes; for the provision of health or social care; for the treatment or management of health or social care systems and services; and for public health purposes. The Committee heard that NWIS have also been drafting a Memorandum of Understanding to address Section 251 (action 19.02). This draft is currently with the Department of Health for comment. Legal advice was being sought on whether a Memorandum of Understanding was required. The Committee agreed that regardless of the legal advice received, a Memorandum of Understanding would provide added assurance. 4. Information Governance incidents report The Committee members received and noted the above report for information. Mr John Morley presented the report (item 19.02) to the Committee. The Committee discussed the presentation of the report. Action: RBW/JM/JE to discuss how the results in the incidents report could be updated to represent trends better. Date: 5 June 2015 Version: 1 Page: 2

Public Health Wales Minutes Information Governance 27 March 2015 The Committee also discussed the table outlining the details of incidents categorised as moderate and above. Action: JE/JM to update the table to show whether it is the Health Board s or Public Health Wales responsibility to resolve the incident. The Committee discussed how some clinical incidents were being incorrectly classified in DATIX under IG records management. However, the greatest risk to the patient was inappropriate case management / treatment because records were missing or mislaid. Therefore they should be reported under patient safety rather than Information Governance. The committee discussed the relationship between Public Health Wales and Health Boards, where incidents are picked up through Public Health Wales systems but originate in a Health Board. There is a concern that it is not always known who should be contacted in the Health Board to take any actions forward. Action: RBW and JE/JM to clarify the process of reporting clinical incidents. The Committee were concerned over an incident regarding babies records. The Committee were advised that the allocation of NHS numbers is now completed by NWIS for babies born in Wales. The Committee requested further information regarding the Information Governance implications for Public Health Wales in relation to the new system for allocating NHS numbers. Action: JE to produce a report on the process of allocating NHS numbers to babies, highlighting the number of Information Governance incidents before and after the function moved from England to NWIS. 5. Freedom of Information Act report The Committee members received and noted the above report (item 19.03) for information. The Committee noted the improvements made in content of the report. 6. Information Governance training report The Committee members received and noted the above report for information. Ms Jane Evans presented the report (item 19.04) to the Committee. Date: 5 June 2015 Version: 1 Page: 3

Public Health Wales Minutes Information Governance 27 March 2015 The Committee heard of a new induction package for new starters at Public Health Wales, which would provide information regarding statutory and mandatory training. Action: The draft induction pack to be circulated to the Committee for information. 7. Caldicott principles into practice (CPIP) The Committee members received and noted the above report for information. Mr John Morley presented the report (item 19.05) to the Committee. It was noted that the compliance table should also demonstrate what is happening to address those areas of partial or non compliance. The Committee noted that they need assurances that mechanisms will be put in place to ensure future compliance. Action: JM/JE to amend the table to show how the areas of partial compliance and non compliance are being addressed. The Committee discussed their concerns that although there is a home working policy, compliance cannot be monitored. It was also noted that the Our Space project is expected to encourage more home working. The Committee discussed the possibility of using a self-assessment tool where home workers will declare that they are following policy. The Non-Executive Directors discussed their own home working arrangements and the need for encrypted laptops and lockable drawers. The Committee requested a paper on the potential risks associated with home working and how they can be mitigated. This report should include the option of a self-assessment tool and the approach of the Our Space project to home working. The Committee will then be able to discuss their risk appetite on this topic. Action: JE/JM to produce a report on the current situation and potential risks associated with home working for the Committee. Action: RBW to add the risk associated with home working to the Information Governance risk register when produced. The Committee discussed the need for a review of the implementation dates in the improvement plan. Date: 5 June 2015 Version: 1 Page: 4

Public Health Wales Minutes Information Governance 27 March 2015 Action: JM to review the expected closure dates for actions in the Caldicott Improvement Plan for 2015/16. 8. Information Commissioners IG audit of Public Health Wales JE updated the Committee on the Information Commissioner s audit of Information Governance arrangements in Public Health Wales. The audit went well, with the only notable recommendation being the need for changing electronic door codes regularly. An action plan is in place following the audit and the door codes have since been changed. RBW advised the Committee that the working group will be reviewing the audit in more detail. 9. Risk It was confirmed that the Information Governance group will be producing a register for the Committee. 10. Information Governance audits The above report (item 19.06) was received and noted by the Committee members for information. 11. Minutes from Information Governance Working Group The above minutes (item 19.07) were received and noted by the Committee members for information. The Committee discussed the need for a one page update on the most recent working group meeting, along-side the approved minutes. Action: A one page update on the most recent Information Governance working group meeting to be produced for the Committee. 12. Publication of papers It was agreed that all items can be published with the exception of the Caldicott principles into practice (CPIP) report. 13. Dates of future meetings 4 June 2015 10 September 2015 10 December 2015 14. Any Other Business With the changes to the Executive Team structure, the Committee noted the absence of a representative for informatics for this Committee. Date: 5 June 2015 Version: 1 Page: 5

Public Health Wales Minutes Information Governance Committee Actions in progress No. Action Who Start End Status 16.02 Include an item on agenda for a CO 12.03.14 04.06.14 In progress will be discussed by future meeting where risk refreshed Information Governance appetite can be reviewed Working Group and further update provided at Committee meeting in June. 19.02 Seek legal advice regarding content of Memorandum of Understanding for Section 251 19.03 JM/JE to make amendments to leaflet and paper and work towards gaining full compliance by end of the financial year. JE 17.12.14 04.06.15 In progress - Legal advice has been received and is included in papers for the Committee held 4 June 2015. JM/JE 17.12.14 02.09.15 In progress - Generic Public Health Wales and specific CDSC information leaflets have been sent to the public user engagement panel for redrafting into a user friendly language used in the Screening divisions. This panel meets in July. 19.04 HG to provide Committee with progress updates on the NWIS outage incident. 20.01 RBW/JM/JE to discuss how the results in the incidents report could be updated to represent trends better. 20.02 In the incidents report, JE/JM to update the table of incidents HG 17.12.14 04.06.15 HG to pick up this action with NWIS. RBW/JM/JE 27.03.15 02.09.15 In progress - A draft report will be reviewed by the working group. JE/JM 27.03.15 02.09.15 In progress - The report has been updated, however further work is Date: 5 June 2015 Version: 1 Page: 6

Public Health Wales Minutes Information Governance Committee categorised as moderate and above to show whether it is the Health Board s or Public Health Wales responsibility to resolve the incident. 20.03 RBW and JE/JM to clarify the process of reporting clinical incidents. required to improve the data. A request has been made to have a mandatory field in Datix for Health Board involvement. RBW/JE 27.03.15 02.09.15 In progress - This action relates to 20.02. The requested change to Datix is needed to clarify the process. COMPLETED ACTIONS No. Action Who Start End Status 18.04 (agenda item 6) Continue to provide regular updates to the Committee on the progress of the EU Data Protection legislation. HG / RBW 27.10.14 17.12.14 Complete There is no update from the European Commission. However, it is expected to be adopted by the EU in December 2015, with the UK be given two years to use the legislation, before roll out in December 2017. 20.04 JE to produce a report on the process of allocating NHS numbers to babies, highlighting the number of Information Governance incidents before and after the function moved from England to NWIS. JE 27.03.15 Complete - This is included on the agenda for 4 June 2015. Date: 5 June 2015 Version: 1 Page: 7

Public Health Wales Minutes Information Governance Committee 20.05 The draft induction pack to be circulated to the Committee. 20.06 JM/JE to amend the compliance table in the Caldicott Principles into Practice report to show how the areas of partial compliance and non compliance are being addressed. 20.07 JM/JE to produce a report on the current situation and potential risks associated with home working for the Committee. This report to include the option of a self-assessment tool and the approach of the Our Space project to home working. 20.08 A risk to be added to the Information Governance risk register, when produced, in relation to home working and the expected increase in homeworking with the introduction of Our Space. JM 27.03.15 Complete - A draft induction pack was circulated 11 May 2015. The draft will be discussed at the Leadership and Delivery meeting in June. JM/JE 27.03.15 Complete - This is included on the agenda for 4 June 2015. JE/JM 27.03.15 Complete - This is included on the agenda for 4 June 2015. Jane and John will continuing working with the Our Space project team to ensure risks are considered and a privacy impact assessment is carried out. RBW 27.03.15 Complete - This has been added to the risk register (risk 451). Date: 5 June 2015 Version: 1 Page: 8

Public Health Wales Minutes Information Governance Committee 20.10 JM to review the expected closure dates for actions in the Caldicott Improvement Plan for 2015/16. 20.11 A one page update on the most recent Information Governance working group meeting to be produced for each Committee meeting. JM 27.03.15 Complete - This is included on the agenda for 4 June 2015. RBW 27.03.15 Complete - This is included on the agenda. Date: 5 June 2015 Version: 1 Page: 9