INFORMATION GOVERNANCE POLICY & FRAMEWORK

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1 INFORMATION GOVERNANCE POLICY & FRAMEWORK Version 1.2 Committee Approved by Audit Committee Date Approved 5 March 2015 Author: Responsible Lead: Associate IG Specialist, YHCS Corporate & Governance Manger Review Date February

2 Version Control Sheet Document Title: Information Governance Policy and Framework Version: 1.1 The table below logs the history of the steps in development of the document. Version Date Author Status Circulation 1.0 Oct 13 Associate IG Specialist, YHCS Draft Corporate & Governance Manager, Senior Management Team 1.0 Nov 2013 Approved Approve by Audit and Committee 1.1 Oct 2014 Associate IG Specialist, CSU March 2015 Associate IG Specialist, CSU Under review Approved by Audit Committee Corporate & Governance Manager, Senior Management Team CCG Staff 2

3 Section Contents 1 Introduction 4 2 Aims and Objectives 4 3 Scope of the Policy 4 4 Accountability 5 5 Definition of Terms 5 6 Procedure 6 7 Training & Guidance 7 8 Implementation and Dissemination 8 9 Monitoring Compliance with and the Effectiveness of the policy 9 11 References 9 12 Associated Documentation 9 Appendix List appendices below Appendix A IG Framework 11 Appendix B IG Training Strategy 22 3

4 1 INTRODUCTION 1.1 NHS Calderdale Clinical Commissioning Group, hereafter referred to as the CCG, recognises the importance of reliable information, both in terms of the clinical management of individual patients and the efficient management of services and resources. Information governance plays a key part in commissioning quality services, supporting clinical governance, service planning and performance management that will improve local patients experiences of care and their health outcomes. 1.2 Information Governance addresses the demands that law, ethics and policy place upon information processing holding, obtaining, recording, using and sharing of information. It is crucial to ensure that staff are aware of these demands and the implications for patient care. 2. AIMS AND OBJECTIVES 2.1 The aim of this policy is to ensure that all staff understand their obligations with regard to any information which they come into contact with in the course of their work and to provide assurance to the Governing Body that such information is dealt with legally, securely, efficiently and effectively. 2.2 The CCG will establish and maintain policies and procedures linked to this policy to ensure compliance with the requirements of Data Protection Act 1998, Records Management Guidance, Information Security Guidance and other related legislation and guidance, contractual responsibilities and to support the assurance standards of the Information Governance Toolkit. These standards are:- Information Governance Management Confidentiality and Data Protection Assurance Information Security Assurance Clinical Information Assurance 2.3 This policy supports the CCG in its role as a Commissioner of Health Services and will assist in the safe sharing of information with its partner and agencies. 4

5 3 SCOPE 3.1 This policy must be followed by all staff who work for or on behalf of CCG including those on temporary or honorary contracts, secondments, pool staff and students. The Information Governance policy is applicable to all areas of the organisation and adherence should be included in all contracts for outsourced or shared services. There are no exclusions. This policy covers: all aspects of information within the organisation, including (but not limited to): Patient/Client/Service User information Personnel/Staff information Organisational information All aspects of handling information, including (but not limited to): o Structured record systems - paper and electronic o Transmission of information fax, , post and telephone o All information systems purchased, developed and managed by/or on behalf of, the organisation o Photographic images, digital, text or video recordings o CCG information held on paper, floppy disc, CD, USB/Memory sticks, computers, laptops, tablets, mobile phones and cameras The processing of all types of information, including (but not limited to): o Transmission of information verbal, fax, , post, text and telephone o Sharing of information for clinical, operational or legal reasons o The storage and retention of information o The destruction of information. 3.2 The CCG recognises the changes introduced to information management as a result of the Health and Social Care Act 2012 and will work with national bodies, member practices and partners to ensure the continuing safe use of information to support services and clinical care. 3,4 Failure to adhere to this Policy may result in disciplinary action and/or referral to the appropriate regulatory bodies including the police and professional bodies. 5

6 4. ACCOUNTABILITY 4.1 Governing Body The Governing Body is responsible for ensuring that the necessary support and resources are available for the effective implementation of this Policy. 4.2 The Audit Committee The Audit Committee is responsible for the review and approval of this policy and IG related work plans, procedures and will receive regular updates on compliance and any related issues and risks Accountable Officer The Chief Officer is the Accountable Officer of the CCG and has overall accountability and responsibility for Information Governance within the CCG and is required to provide assurance, through the Statement of Internal Control that all risks to the CCG, including those relating to information, are effectively managed and mitigated. 4.4 Senior Information Risk Owner The Chief Finance Officer is the Senior Information Risk Owner (SIRO) and has organisational responsibility for all aspects of Information Governance, including the responsibility for ensuring CCG has appropriate systems and policies in place to ensure that the organisation has robust Information Governance procedures in place. 4.5 Caldicott Guardian The Caldicott Guardian for the CCG is Dr Matt Walsh, Governing Body Member. The Caldicott Guardian plays a key role in ensuring that the CCG satisfies the highest practical standards for handling patient identifiable information. 4.6 Senior Management Team The Senior Management Team will received IG progress reports, contribute to polices reviews and help manage the resolution of IG operational issues. 4.7 Information Governance Lead The Senior Level Information Governance Lead for the CCG is the Corporate and Governance Manager. The IG Lead is accountable for ensuring effective management, accountability, compliance and assurance for all aspects of IG. Some key tasks may be delegated to the Information Governance Team from commissioning support services. They are also responsible for reviewing the policy and ensuring it is updated in line with any changes to national guidance or local policy. 6

7 4.8 Information Asset Owners Information Asset Owners (IAO) are directly accountable to the SIRO and must provide assurance that information risk is being managed effectively in respect of the information assets that they are responsible for, and that any new or changes introduced to their business processes and systems undergo a privacy impact assessment. 4.9 Heads of Service. Heads of Service are responsible for ensuring that they and their staff are adequately trained, and are familiar with this policy and its associated guidance. They must ensure that any breaches of the policy are reported, investigated and acted upon Employees Information Governance compliance is an obligation for all staff. Staff should note that there is a Non-Disclosure of Confidential Information clause in their contract and that they are expected to participate in induction training, annual refresher training and awareness sessions carried out to inform/update staff on information governance issues. Any breach of confidentiality, inappropriate use of health, business or staff records or abuse of computer system is a disciplinary offence, which could result in dismissal or termination of your employment contract, and must be reported to the SIRO and (in the case of health or social care records) the Caldicott Guardian. All employees are personally responsible for compliance with the law in relation to Data Protection and Confidentiality 5. Definition of terms The words used in this policy are used in their ordinary sense and technical terms have been avoided. 7

8 6. PROCEDURE 6.1 Openness The CCG recognises the need for an appropriate balance between openness and confidentiality in the management and use of information. Information will be defined and where appropriate kept confidential, underpinning the principles of Caldicott and legislation as laid out in the Data Protection Act and Freedom of Information Act. Information about the organisation will be available to the public through the Freedom of Information Act, Environmental Information Regulations and Protection of Freedoms Act unless an exemption applies. The CCG will establish and maintain a Publication Scheme in line with legislation and Guidance from the Information Commissioner. Patients will have access to information relating to their own health care, options for treatment and their rights as patients. There will be clear procedures and arrangements for handling queries from patients and the public. Integrity of information will be developed, monitored and maintained to ensure that it is appropriate for the purposes intended. Availability of information for operational purposes will be maintained within set parameters relating to its importance via appropriate procedures and computer system resilience. Legislation, national and local guidelines will be followed. The CCG will undertake annual assessments and audits (through the Information Governance Toolkit) of its policies, procedures and arrangements for openness. 6.2 Legal Compliance The CCG regards all identifiable personal information relating to patients as confidential and compliance with legal and regulatory framework will be achieved, monitored and maintained. The CCG regards all identifiable personal information relating to staff as confidential except where national policy on accountability and openness requires otherwise. The CCG will establish and maintain policies and procedures to ensure compliance with the Data Protection Act, Human Rights Act, the common law duty of confidentiality and the Freedom of Information Act and Environmental Information Regulations. 8

9 Awareness and understanding of all staff, with regard to responsibilities, will be routinely assessed and appropriate training and awareness provided. Risk assessment, in conjunction with overall priority planning of organisational activity will be undertaken to determine appropriate, effective and affordable information governance controls are in place. 6.3 Information Security The CCG will establish and maintain policies for the effective and secure management of its information assets and resources. Audits will be undertaken or commissioned to assess information and IT security arrangements. The CCG will ensure IG incidents are managed in accordance with the Checklist for Reporting, Managing and Investigating Information Governance Serious Incidents. The CCG will ensure that the security of the information it holds complies with national guidelines. Gain assurance from IT service providers as to the integrity of CCG s IT systems and that controls are in place to reduce exposure to potential cyber-crime through maintenance of robust information and network security practices 6.4 Information Quality Assurance The CCG will establish and maintain policies for information quality assurance and the effective management of records. Audits will be undertaken or commissioned of CCG s quality of data and records management arrangements. Managers will be expected to take ownership of, and seek to improve, the quality of data within their services. Wherever possible, information quality will be assured at the point of collection. The CCG will promote data quality through policies, procedures/user manual and training. 9

10 6.4 Clinical Information Assurance The CCG will establish and maintain policies for quality assurance of clinical information and the effective management of records. 7 TRAINING & GUIDANCE 7.1 Mandatory Training Information Governance training will be mandatory for all staff. This will include awareness and understanding of Caldicott principles and confidentiality, information security and data protection. Information Governance will be included in induction processes for all new staff. The necessity and frequency of any further training will be Personal Development Review (PDR) based. All staff will receive Information Governance Training via the CCG s Mandatory Training Programme and new starters will undertake IG training within 2 months of their starting date. All new starters will be issued with an IG User Handbook and they must sign an IG declaration as part of their induction process. 7.2 IG Training Principles: Undertaking of information governance training will be mandatory and will run on an annual basis Information governance training will be undertaken using the online Connecting for Health IG Training Tool (IGTT) or through attendance of a formal IG classroom based session. Based on their responsibilities and roles and required training needs outcomes, other staff groups may be resourced to undertake additional training as required Quarterly monitoring and reporting of uptake and completion of information governance training will be provided to the Audit Committee. 8 Implementation and dissemination Following ratification by the Audit Committee this policy will be disseminated to staff via the CCG s intranet and communication through inhouse staff briefings. 10

11 This Policy will be reviewed every year or in line with changes to relevant legislation or national guidance. 9 Monitoring compliance with and the effectiveness of the policy An assessment of compliance with requirements, within the Information Governance Toolkit (IGT), will be undertaken each year. Annual reports and proposed work programme will be presented to the Audit Committee for approval prior to submission to Health & Social Care Information Centre. 11 References Freedom of Information Act 2000 Data Protection Act 1998 Human Rights Act 1998 Common Law Duty of Confidence 12 ASSOCIATED DOCUMENTS (Policies, protocols and procedures) 12.1 The CCG will produce appropriate procedures and guidance relating to information governance as required by related policies. This will include an Information Governance handbook which will be updated annually and which will be given to all staff This policy should be read in conjunction with: Confidentiality & Data Protection Policy Information Sharing Protocol Information Security Policy Incident Reporting Policy and procedure Record Management Policy Access to Records Procedure Risk Management Framework Freedom of Information Policy System Level Security Policies Network Security Policy Privacy Impact processes Disciplinary Policy and Procedure Business Continuity Plan 11

12 Appendix A INFORMATION GOVERNANCE MANAGEMENT FRAMEWORK 1. ORGANISATION CHART CCG GOVERNING BODY AUDIT COMMITTEE Assurance and approval of policies SIRO J. Lawreniuk CALDICOTT GUARDIAN Dr M Walsh Senior Management Team Progress updates and resolution of operational issues INFORMATION ASSET ADMINISTRATORS (IAAs) INFORMATION ASSET OWNERS (IAOs) 2. Outline of Roles and Responsibilities 2.1 The CCG Caldicott Guardian will: ensure that the CCG satisfies the highest practical standards for handling identifiable/confidential information act as the conscience of the CCG facilitate and enable information sharing and supported by expert advice from the commissioning support services IG Team, advise on options for lawful and ethical processing of information represent and champion Information Governance requirements and issues at executive level ensure that confidentiality issues are appropriately reflected in organisational strategies, policies and working procedures for staff 12

13 oversee all arrangements, protocols and procedures where confidential patient information may be shared with external bodies both within, and outside, the NHS The Caldicott Guardian also has a strategic role, which involves representing and championing confidentiality and information sharing requirements and issues at senior management level and, where appropriate, at a range of levels within the organisation s overall governance framework. 2.2 Caldicott Function In CCG the Caldicott Function will be undertaken by CCG s IG Lead with additional support from the commissioning support services IG Team. The key responsibilities of the Caldicott Function are to: support the Caldicott Guardian Function and Implementation Plan (Appendix B). ensure the confidentiality and data protection work programme is successfully co-ordinated and implemented ensure compliance with the principles contained within the Confidentiality: NHS Code of Practice and that staff are made aware of individual responsibilities through policy, procedure and training complete the Confidentiality and Data Protection Assurance component of the Information Governance Toolkit, contributing to the annual assessment provide routine reports to senior management on Confidentiality and Data protection issues as required review information sharing agreements for approval. 2.3 CCG Senior Information Risk owner (SIRO) will: be an Executive Director take overall ownership of the Organisation s Information Risk Policy act as champion for information risk within the CCG executive function and provide written advice to the Accountable Officer on the content of the Organisation s Statement of Internal Control in regard to information risk. understand how the strategic business goals of the Organisation and how other client organisations business goals may be impacted by information risks, and how those risks may be managed. implement and lead the CCG Information Governance (IG) risk assessment and management processes within the organisation advise the CCG Executive on the effectiveness of information risk management across the organisation receive training as necessary to ensure they remain effective in their role as SIRO. 13

14 2.4 CCG Information Asset Owners (IAO) will: know what information comprises or is associated with the asset, and understands the nature and justification of information flows to and from the asset know who has access to the asset, whether system or information, and why, and ensures access is monitored and compliant with policy understand and address risks to the asset, and providing assurance to the SIRO ensure any systems (or new business processes) which hold and use person identifiable information (patient or staff information) are tested for data protection and confidentiality compliance before they are procured or implemented assist in the development of Business Continuity Management arrangements for key information assets 2.5 CCG Information Governance Lead will: ensure that there is top level awareness and support for IG resourcing and implementation of improvements act as the organisational lead for Data Protection including subject access request, Freedom of Information, Information Security and Records Management. maintain comprehensive and appropriate documentation that demonstrates commitment to and ownership of IG responsibilities. Provide direction in formulating, establishing and promoting IG policies work the with the commissioning support services IG team to maintain an awareness of information governance issues within the CCG ensure appropriate IG training is made available to staff and completed as necessary to support their duties in conjunction with the commissioning support services IG Team review and audit all procedures relating to this policy where appropriate on an ad-hoc basis ensure that CCG team leaders are aware of the requirements of the policy ensure IG training requirements are included in overall mandatory and statutory training plans and monitor and report on IG Training compliance work with the commissioning support services IG Team to ensure that the IG Toolkit requirement evidence is collated and uploaded to the IG Toolkit website ensure that the IG Toolkit assessment is submitted by the 31 st March annually. 14

15 3.0 Resources 3.1 Commissioning Support Service Information Governance Support The commissioning support service has an Information Governance team that provides expert advice and guidance to CCG staff on all elements of Information Governance. The team is will provide the following support to NHS Calderdale CCG: advice and guidance on Information Governance advice and template resources relating to the CCG s Information Governance Toolkit requirement ensuring the consistency of information governance across the organisation. developing information governance policies and procedures. establishing protocols on how information is to be shared. developing information governance awareness and training programmes supporting organisational compliance with Data Protection, Freedom of Information and other information security related legislation. implementing NHS Commissioning Board, NHS Information Centre for Health and Social Care and Department information governance guidance and policy. provide support to the Caldicott Guardian and SIRO. The commissioning support services IM&T and Information Governance Teams have Specialists that hold professional certification in Data Protection, Freedom of Information and information security. They will support the CCG IG Lead in fulfilling the following specific roles: Data Protection Officer The Data Protection Officer is tasked with providing advice on all aspects of the Data Protection Act and NHS Code of Confidentiality, utilising their own expertise and, where necessary, external advice. They are also responsible for co-ordinating the work of other staff with data protection responsibilities Information Security Lead - The Information Security Lead is tasked with providing advice on all aspects of information security management, utilising their own expertise and, where necessary, external advice. Records Management Lead - The Records Management Lead is tasked with providing advice on all aspects of records management and lifecycle of information, utilising their own expertise and, where necessary, external advice. 15

16 4.0 Governance Framework 4.1 Staff Contracts All CCG staff contracts currently contain Information Governance related clauses within them (see Appendix A). 4.2 Non-NHS Third Party Contract Confidentiality Clause Any non-nhs third party with whom the organisation contracts should include as a minimum a confidentiality clause. The CCGs also requests all third party contractors to sign a declaration that they are registered with the Information Commissioner for Data Protection Purposes and that they encrypt all mobile devices to minimum standard required by the NHS. (See Organisation of Information Security) 4.3 Information Assets and Asset Owners Each asset has been allocated an Information Asset Owner (IAO) and an Information Asset Administrator (IAA). The Information Asset Owner will review their asset entries on the Information Asset Register annually and undertake regular risk assessments of these assets and report their findings to the SIRO. 5.0 IG Training 5.1 Mandatory IG Training The NHS Operating Framework requires that all staff must undergo Information Governance training. The CCG will strive to meet this requirement. The CCG includes Information Governance as part of its mandatory training for all staff annually. All new staff is required to complete the Introduction to Information Governance training module via the online IG Training Tool, when they first join the organisation unless they have completed appropriate IG Training within the last year and can evidence this. The CCG also requires all existing staff to complete online IG Training annually, if they have previously completed the Introduction to Information Governance then they can complete the Refresher Module thereafter. 5.2 Role Specific Training The CCG has identified other recommended training for staff members whose role has information governance responsibilities and requires further role specific training, also referred to as a training needs analysis. This can be delivered through the online training tool or suitable alternatives such as workshops, face to face training and keeping up to date through briefing materials and newsletters. Details of the specific training requirements are included in the CCG s IG Training Strategy (Appendix B). 16

17 5.3 Adhoc Training In addition to the above any member of staff involved in an Information Governance related incident may be required to undertake one or more modules of the IG Training Tool, the modules to be taken will depend on the type of incident and the outcomes of any investigations into the incident. 6.0 Information Security Incidents Information security incidents are any event that has resulted or could have resulted in the disclosure of confidential information to an unauthorised individual, the integrity of the system or data put at risk or the availability of the system or information being put at risk. Incidents may include theft, misuse or loss of equipment containing confidential information or other incidents that could lead to unauthorised access to data all of which will have an adverse impact to patients and to the organisation e.g. embarrassment to the patient/patients/organisation threat to personal safety or privacy legal obligation or penalty loss of confidence in the organisation financial loss disruption of activities Whenever an incident, near miss or hazard occurs it must be reported using the incident reporting system. Information security incidents will be highlighted to the CCG IG Lead and the commissioning support services IG Team for investigation and advice. All IT security incidents should be reported to the Health Informatics Service Desk upon detection to obtain support with preserving data, preventing an incident being prolonged, and enabling an audit trail and technical investigations to commence without delay. These will be highlighted to the CCG IG Lead and the commissioning support services IG Team. The service desk will advise of any additional steps that are required to make the information secure, including initiating policy and procedure. Incidents classified at an IG SIRI severity level 2 are those that are classed as a personal data breach (as defined in the Data protection Act) or high risk of reputational damage that are reportable to the Department of Health and the Information Commissioner s Office. These incidents will be detailed individually in the annual report. 7.0 Communication 7.1 Communication with Staff The Information Governance operational policies and procedures will be made available in electronic format and will be located on CCG Intranet. Any updates/ new policies / procedures are approved by the Audit Committee and are communicated to staff via the intranet. Information Governance alerts will be issued by the commissioning 17

18 support services IG team as appropriate, authorised by the IG Lead at NHS Calderdale CCG. Every new member of staff will be issued with the Information Governance user handbook about handling patient information as part of the recruitment process. All staff are reminded to re-read the Information Governance booklet on an annual basis. The commissioning support services IG Team will support the CCG to continue to raise the profile and understanding of Information Governance through mandatory and ad hoc training, IG Alerts, staff newsletters, s, intranet sites and staff briefings. 18

19 APPENDIX A STAFF CONTRACT CLAUSES CONFIDENTIALITY OF INFORMATION 1. You are subject directly or indirectly to the Data Protection Act. This Act covers the confidentiality of personal information held on computer and manual systems. Every employee is now personally liable to respect and protect the confidentiality of the information they enter, process and encounter and should not discuss this information or disclose it to any unauthorised person or company. 2. Anyone who discloses personal information, intentionally or otherwise, can be sued for damages by the individual affected and the person concerned may be subject to disciplinary procedures. 3. NHS Calderdale CCG reserves the right to monitor telephone calls and e- mails in circumstances that may warrant such action. 4. By signing this contract you consent to both NHS Calderdale CCG and the commissioning support service, both manual and by electronic means your personal and sensitive data for the purposes of the administration and management of your employment and/or NHS Calderdale CCG business. You also agree to comply with the relevant Confidentiality/Data Protection Policy. 19

20 Appendix B CALDICOTT FUNCTION SPECIFICATION AND IMPLEMENTATION PLAN In accordance with the Information Governance Toolkit requirements the Caldicott function has been established to support the Caldicott Guardian. The Caldicott Guardian is required to be at Director Level and have a clinical background. The CCG s should also appoint a deputy Caldicott Guardian, also with clinical expertise, who will act on behalf of the main post holder in their absence. The Caldicott Guardians will perform the functions as laid down in the Caldicott Guardian Manual, available on the Health & Social Care Information Centre website, and will be responsible for protecting patient and service user confidentiality and enabling information sharing. The Caldicott Guardian will also have a strategic role in representing and championing Information Governance requirements and issues at Board level. The role of the Caldicott Guardians will be specified and promoted throughout the IG Management Framework documentation and will be made readily accessible to staff via the CCG s staff intranet. This role will be primarily supported by the NHS Code of Confidentiality. The Caldicott Guardians will be supported by the CCG s Information Governance Lead with additional support available from the commissioning support services IG team on issues concerning data protection and will provide advice on the release of information to the Police and other agencies as appropriate. Where CCG and Commissioning Support Unit staff processing personal confidential data on behalf of the CCG feel that meeting IG standards may cause operational difficulties or they feel that meeting IG standards would compromise patient care or safety, they can apply to the Caldicott Guardian for a decision on whether an acceptable risk status can be agreed. Caldicott Issues Log -Any incidents relating to patient confidentiality will be recorded and monitored through the existing CCG incident management system. Other patient confidentiality or information sharing issues will be managed by the Caldicott function and where necessary, escalated to Caldicott Guardian and recorded on the Caldicott Issues Log, the IG Lead will support the Caldicott Guardian to ensure that the CCGs benefit from lessons learned by sharing with senior managers and, where relevant, within appropriate CCG Quality and Governance (or equivalent) Committees. 20

21 INFORMATION GOVERNANCE TRAINING STRATEGY This Training Strategy is in support of the Information Governance Toolkit. The strategy links directly to the following legislation, NHS commitments and best practice: Principle 7 of the Data Protection Act 1998 Schedule I Part II paragraph 10 of the Data Protection Act 1998 Caldicott: Report on the Review of Patient Identifiable Information 1997: Recommendation 2 Protecting and Using Patient Information, Caldicott Management Audit points 3, 4 and 5: Confidentiality and Security Training Needs NHS Care Record Guarantee, Commitment 9 Confidentiality: NHS Code of Practice Page 3, paragraph 7 Links to Other Associated Documents: This strategy is supported by a range of policies relating to various aspects of Information Governance. These are:- Information Governance Policy and Framework Confidentiality and Data Protection Policy Information Security Policy Records Management Policy Incident and Serious Incident Reporting Procedure Overall Aim of Training: To ensure that all staff, including new starters, temporary, student and contract staff members complete basic level information governance training. Additionally a secondary aim is to ensure that specialist information governance training is targeted at specific staff groups across the organisation to comply with a number of the Information Governance Toolkit requirements. Training Objectives: Overall the training objectives for Information Governance are: To ensure compliance with the Data Protection Act 1998 To ensure the confidentiality and legitimate use of personal or medical Information 21

22 To ensure consent is obtained where appropriate and/or individuals are fully aware of the uses of their personal data To ensure the accuracy, availability and integrity of records held by the organisation To ensure appropriate technical and organisational measures are in place to protect information against security threats Endorsed By: This strategy is endorsed by the Organisation s Audit Committee and has sponsorship from the Caldicott Guardian and Senior Information Risk Owner (SIRO). The Corporate and Governance Manager is responsible for monitoring the IG Training compliance. Requirements The basic mandatory information governance training requirement which links to job role is one of the following e-learning modules:- Introduction to Information Governance for all staff Refresher Module a shorter refresher training module for subsequent years Written training materials and class room training can be provided to staff locally (and will meet the mandated training requirement) by commissioning support services. Specialist/Advanced Training The Information Governance Toolkit sets out minimum additional training requirements for specific staff groups/roles, these are:- Requirement The Information Governance agenda is supported by adequate confidentiality and data protection skills, knowledge and experience which meet the organisation s assessed needs. Element 2b All staff assigned responsibility for co-ordinating and implementing the confidentiality and data protection work programme have been appropriately trained to carry out their role Requirement There are appropriate procedures for recognising and responding to individuals requests for access to their personal data Element 2a All staff assigned responsibility for processing subject access requests have been appropriately resourced and trained to do so Requirement The Information Governance agenda is supported by adequate information security skills, knowledge and experience which meet the organisation s assessed needs Element 1a The role of Information Security Manager/Officer has been appropriately assigned. The appropriateness of the assignment will be in formal qualifications, or post holders membership of a relevant professional body, or certificates of training attendance records. 22

23 Requirement An effectively supported Senior Information Risk Owner takes ownership of the organisation s information risk policy and information risk management strategy. Element 2a The SIRO and all other staff assigned responsibility for co-ordinating and implementing information risk management (Information Asset Owners - IAOs) have been appropriately trained to carry out their role. Requirement The Information Governance agenda is supported by adequate information quality and records management skills, knowledge and experience. Element 2b All staff assigned responsibility for Information Quality and Records Management Assurance have been appropriately trained to carry out their role. Structure: Who needs to do this training? Caldicott Guardian Information Governance Officer Senior Information Risk Owner (SIRO) and Information Asset Owners Records staff and those handling subject access requests All Staff Expert * Level Essential Level * Awareness / Basis Level * How will we deliver it? (See Table 1, Method of Delivery column) IG Training Tool Information Security Examination Board (ISEB) IG Training IG Training IG Training IG Training Tool/written materials/class room * See Table 1 over the page Additional Information 23

24 Additional Information: Training Needs Analysis Table 1 Staff Group Level Training Objective/Aim Module/Course Name Method of Delivery Frequency of Training All Staff Basic Level An introductory level module aimed at all staff to inform them about good Information Governance. Introduction to Information Governance NB. In subsequent years The Refresher Module NLMS (e-learning) or written materials or class room based learning Yearly Records Management staff Basic Level A foundation level module designed to provide practical information to enable understanding of the importance of good records management. Records Management and the NHS Code of Practice IG Training Tool (e-learning) or classroom based sessions 3 yearly Staff handling subject access requests Information Asset Owners (IAOs) Basic Level Essential Level A practitioner level module providing advice on dealing with requests for access to patient records, both from the patient themselves and their friends and family. An introductory level that describes key responsibilities for the SIRO and IAO roles, and outlines the structures required within organisations to support those staff with SIRO or IAO duties. Access to Health Records Information Security Guidelines NHS Information Risk Management for SIROs and IAOs Secure Transfers of Personal Data IG Training (delivered by the commissioning support services IG Service) IG Training Tool (e-learning) or Classroom based sessions/one to one and issue of IAO Handbook (delivered by the commissioning support services IG Service) 3 yearly 3 yearly SIRO Expert Level A foundation level module intended to assist staff whose roles involve responsibility for the confidentiality, security and availability of information assets, in understanding and NHS Information Risk Management Secure Transfers of Personal Data IG Training Tool (e-learning) or Classroom session (study day provided by external Yearly 24

25 fulfilling their duties. NHS Information Risk Management for SIROs and IAOs training provider) Staff Group Level Training Objective/Aim Module/Course Name Method of Delivery Frequency of Training Caldicott Guardian Expert level The Caldicott Guardian in the NHS and Social Care 3 yearly A practitioner level module aimed at newly appointed Caldicott Guardians and those needing to know more about the role of the Caldicott Guardian. Patient Confidentiality IG Training Tool (e-learning) or classroom learning (study day provided by external provider) Information Governance Support Expert Level In depth understanding of the Data Protection Act 1998 (and associated legislation) and information security Information Security Examination Board (ISEB) Data Protection, and Information Security courses. Specialist Courses and examinations Once only Formal qualification in records management 25

26 Training will Improve Patient Experience: Training staff in Information Governance gives the public and patients greater confidence and assurance of organisational compliance with the law (i.e. Common Law Duty of Confidence, Data Protection Act 1998 and Freedom of Information Act 2000) and central guidelines relating to Information Governance and the confidence that their information will be handled responsibly and confidentially. Diversity Issues Have Been Addressed Within This Strategy: In relation to the provision of basic mandatory information governance training requirement to staff, one to one training can be commissioned from the Information Governance Service to meet the special requirements of specific members of staff. Evaluation: The effectiveness of the training will be demonstrated in a number of ways. Reactive Evaluation - Training feedback forms assessing the trainers performance as well as whether training objectives were met, are provided at all class room based learning events. Evaluating Learning - Increase in knowledge after the training is measured by post training assessment test (either online assessment test or paper based assessment test). 80% is the pass mark for the assessments. Successful achievement of the assessment test is recorded against the learners training record. Behaviour - The extent to which Information Governance training has been put into practice will be subjectively measured by: The results of regular staff IG spot checks (typically administered via questionnaire) Results of service user satisfaction surveys where questions on confidentiality and information security are included Numbers of Information Governance related incidents reported Training Strategy Review Date: October

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