Gloucestershire Hospitals

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1 Gloucestershire Hospitals NHS Foundation Trust TRUST POLICY In the case of hard copies of this policy the content can only be assured to be accurate on the date of issue marked on the document. The Policy framework requires that the policy is fully reviewed on the date shown, but it is also possible that significant changes may have occurred in the meantime. The most up to date policy will always be available on the Intranet Policy web site and staff are reminded that assurance that the most up to date policy is being used can only achieved by reference to the Policy web site. INFORMATION GOVERNANCE POLICY Final version v1 () This document may be made available to the public and persons outside of the Trust as part of the Trust's compliance with the Freedom of Information Act 2000 Date of Issue Review Date January 2008

2 Gloucestershire Hospitals NHS Foundation Trust TRUST POLICIES Authorisation Form DOCUMENT: INFORMATION GOVERNANCE POLICY (Final version v1) We the author/sponsor confirm that we have taken into consideration that this policy either does not involve or impact on; (Please place an X in a,b and c, or in 2, if this applies) 1a Eliminating racial discrimination 1b Promoting equality of opportunity 1c promoting good race relations or where it does impact 2. An Equality & Diversity assessment form has been completed. Authorisation Name and Position Date Approved Responsible Author Policy Sponsor Assured by Sue Dennis Caldicott Guardian and Head of Information Governance Steve Peak Director of Service Delivery Consideration at authorised groups (e.g. Board, Board sub committees, Policy Group, Clinical policies Sub Group, Departmental meetings etc) Name of Group Minute details Date considered Information Governance Committee Trust Policy Group Circulated by for comments/amendments Trust Operational Board tbc February 2007 Trust Board Item 5

3 INFORMATION GOVERNANCE POLICY (Final version v1) 1.0 Introduction Information is a vital asset, both in terms of the clinical management of individual patients and the efficient management of services and resources. It plays a key part in clinical governance, service planning and performance management. It is therefore of paramount importance to ensure that information is efficiently managed, and that appropriate policies, procedures and management accountability and structures provide a robust governance framework for Information management. 2.0 Principles 2.1 The Trust recognises the need for an appropriate balance between openness and confidentiality in the management and use of information. The Trust fully supports the principles of corporate governance and recognises its public accountability, but equally places importance on the confidentiality of, and the security arrangements to safeguard, both personal information about patients and staff and commercially sensitive information. 2.2 The Trust also recognises the need to share patient information with other health organisations and other agencies in a controlled manner consistent with the interests of the patient and, in some circumstances, the public interest. 2.3 The Trust believes that accurate, timely and relevant information is essential to deliver the highest quality health care. As such it is the responsibility of all clinicians and managers to ensure and promote the quality of information and to actively use information in decision making processes. 2.4 There are 4 key interlinked strands to the Information Governance Policy: 3.0 Interlinks 3.1 Openness Openness Legal compliance Information security Quality assurance Non-confidential information on the Trust and its services should be available to the public through a variety of media. The Trust will establish and maintain policies to ensure compliance with the Freedom of Information Act 2000 Patients should have ready access to information relating to their own health care, their options for treatment and their rights as patients The Trust will have clear procedures and arrangements for liaison with the press and broadcasting media The Trust will have clear procedures and arrangements for handling queries from patients and the public

4 3.2 Legal Compliance The Trust regards all identifiable personal information relating to patients and staff as confidential and as such takes steps to ensure that the handling of such information complies with the Data Protection Act 1998 except where there is a legal requirement to override the Act. The Trust will undertake or commission annual assessments and audits of its compliance with legal requirements The Trust will establish and maintain policies to ensure compliance with the Data Protection Act 1998, the common law of confidentiality and the Freedom of Information Act The Trust will establish and maintain policies for the controlled and appropriate sharing of patient information with other agencies, taking account of relevant legislation (e.g. Health and Social Care Act 2001, Crime and Disorder Act 1998, The Children s Act 2004) 3.3 Information Security The Trust will establish and maintain policies for the effective and secure management of its information assets and resources The Trust will undertake or commission annual assessments and audits of its information and IT security arrangements The Trust will promote effective confidentiality and security practice to its staff through policies, procedures and training The Trust will maintain and review incident reporting procedures and will monitor and investigate all reported instances of actual or potential breaches of confidentiality and security. 3.4 Information Quality Assurance The Trust will establish and maintain policies and procedures for information quality assurance and the effective management of records. The Trust will undertake or commission annual assessments and audits of its information quality and records management arrangements Managers are expected to take ownership of, and seek to improve, the quality of information within their services Wherever possible, information quality will be assured at the point of Collection Data standards will be set through clear and consistent definition of data items, in accordance with national standards. The Trust will promote information quality and effective records management through policies, procedures/user manuals and training

5 4.0 Policies to be read in conjunction with this Policy Where Policies are not in place the Trust will develop the same and will ensure that they, and existing Policies, are subject to regular review in line with the Trust Policy Framework. Related Policies will include those addressing the following: Access to Health Records under the Data Protection Act 1998 and the Access to h Records Act 1990 Business and Systems Continuity Communication Data Protection and Confidentiality and Internet Health Records Information Quality Assurance Information Technology (IT) Information Security Intellectual Property Freedom of Information Records Management Reporting and Investigating Research Governance 5.0 Responsibilities 5.1 It is the role of the Trust Board to approve the Trust s Policy in respect of Information Governance, taking into account legal and NHS requirements. 5.2 The Director of Service Delivery is the named Executive Director on the Board with responsibility for Information Governance. The Medical Director is the named Executive Director with responsibility for Caldicott and both are members of the Information Governance Committee. 5.3 The Caldicott Guardian and Head of Information Governance will co-ordinate the work of the Information Governance Committee but members will have a responsibility to lead and implement as required on issues appropriate to their delegated areas. 5.4 The Information Governance Committee is accountable to the Trust s Clinical Governance and Risk Committee via the Chair. 5.5 The Caldicott Guardian and Head of Information Governance, in conjunction with members of the Information Governance Committee, will be responsible for overseeing day to day Information Governance issues; developing and maintaining policies, standards, procedures and guidance, coordinating Information Governance in the Trust and raising awareness of Information Governance.

6 5.6 Information Governance performance will be monitored by the Information Governance Committee and the audit results, once approved by the Trust Board, will be submitted on an annual basis to the Department of Health using the Department of Health Information Governance Toolkit : Fundamental to the success of delivering Information Governance is the continuing development of a culture of understanding within the Trust that information is a valuable asset. Awareness and training needs to be provided to all Trust staff who utilise information in their day to day work to promote this culture 5.8 Managers within the Trust are responsible for ensuring that this Policy and any supporting Policies, Standards and Guidelines are built into local processes and that there is on-going compliance. 5.9 All staff, whether permanent, temporary or contracted, and contractors are responsible for ensuring that they are aware of the requirements incumbent upon them and for ensuring that they comply with these on a day to day basis. 6.0 Policy Approval 6.1 The Trust acknowledges that information is a valuable asset, therefore it is wholly in the interest of the Trust to ensure that the information it holds, in whatever form, is appropriately governed, protecting the interests of all of its stakeholders. 6.2 This Policy and any supporting Policies, Standards and Guidelines are deemed fully endorsed b Board through the production of these documents and their minuted approval. Sue Dennis Caldicott Guardian and Head of Information Governance

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