INFORMATION GOVERNANCE POLICY

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1 INFORMATION GOVERNANCE POLICY Issued by: Senior Information Risk Owner Policy Classification: Policy No: POLIG001 Information Governance Issue No: 1 Date Issued: 18/11/2013 Page No: 1 of 16 Review Date: 17/11/2014 Document Title: Information Governance Policy Issue date: Nov 2013 Document Status: Ratified by Governing Body 18/11/2013 Review date: Nov 2014 Page 1 of 16

2 Document control Document Information Document Name: Directorate: Consultation: Policy Information Governance NHS Bromley Clinical Commissioning Group (CCG) Governing Body Information Governance Steering Group Approved by: Information Governance Steering Group Date: Supersedes: Description: Not Applicable A policy on Information Governance covering the approach and objectives around the control of information held and used by NHS Bromley Clinical Commissioning Group Audience: Contact details: All staff South London Commissioning Support Unit, Information Governance Function Change History Version Date Author Approver Reason 0.1 May-13 SL CSU,IG Manager, SL CSU, Head of IG, 1 st Draft H Thomas D Stone 0.2 Sept-13 SL CSU,IG Manager, H Thomas SL CSU, Head of IG, D Stone 2 nd Draft Governance This policy is aligned to the Assurance Framework for Information Governance. It has been adopted by the NHS Bromley Clinical Commissioning Group (CCG) Governing Body of NHS Bromley Clinical Commissioning Group. This policy applies to all staff working on behalf of the NHS Bromley Clinical Commissioning Group. The policy applies to all hosted bodies and those working on behalf of NHS Bromley Clinical Commissioning Group (CCG) Governing Body or its constituent bodies. Equality Statement This document demonstrates the Organisation s commitment to create a positive culture of respect for all individuals, including staff, patients, their families and carers as well as community partners. The intention is, as required by the Equality Act 2010, to identify, remove or minimise discriminatory practice in the nine named protected characteristics of age, disability, sex, gender reassignment, pregnancy and maternity, race, sexual orientation, religion or belief, and marriage and civil partnership. It is also intended to use the Human Rights Act 1998 and to promote positive practice and value the diversity of all individuals and communities. Details of the Equality Analysis can be found in Annexe A Document Status: Ratified by Governing Body 18/11/2013 Review Date: Nov 2014 Page 2 of 16

3 Table of Contents 1 Introduction Policy statement and aim Objectives Promoting Equality Scope of this Policy Bromley Clinical Commissioning Group Members Governance Accountability and Responsibility The Use of Information Personal Confidential Data Use of Information to improve performance Information Quality Information Security Information Management Audit and monitoring criteria Monitoring and Reporting of compliance Table 1 Control Audit Non Compliance Review Next formal review Latest Version Statement of evidence/references Key Legislative and Regulatory Environment Other References Implementation and dissemination of document Annexes Annexe A - Equality Analysis Checklist Annexe B - Definitions Page 3 of 16

4 Document Consultation Record Version 0.1 Date Name Post Organisation Comments 20-Jun-13 Z Alam IG Manager (CCGs) CSU 10-Aug-13 L Struffolino IG Business Manager CSU Style and Grammar Page 4 of 16

5 1 Introduction 1.1 Policy statement and aim This policy of NHS Bromley Clinical Commissioning Group will govern all the information within its remit to the standards required by law and regulation. It will support high quality commissioning and healthcare, through accurate, accessible and appropriately governed information. This policy and commitment extends to the services NHS Bromley Clinical Commissioning Group commissions, ensuring their appropriate use and control of information to deliver high quality healthcare and to support to our patients and our Organisation. This policy outlines the legal, regulatory and best practice framework that this Organisation works to and the methods used to deliver and maintain this policy. Background Information Governance is a framework to manage information appropriately. For personal information it ensures confidentiality and security as well as processes are in place to ensure appropriate standards of quality and ethical use. Corporate information and records must also be managed appropriately, where possible to be provided to the public to ensure transparency and accountability. NHS Bromley Clinical Commissioning Group, the Organisation, uses information to support the commissioning and the management of commissioning of healthcare for patients. Information is also used to support the administration of the NHS and wider health economy. In addition to these functions are the duties of the Clinical Commissioning Group as detailed in statute. The NHS and the administration of the NHS depends on the appropriate use Personal Confidential Data and the management of secondary use of this data. As a commissioner of services we require good quality information to be created, managed and utilised by those we commission. The Organisation is responsible for driving improvements in Information Governance from these services. This ensures an efficient, effective and accountable service. In those instances where we appropriately share or publish information, we must ensure that this done in a lawful and appropriate manner. Information is transferred to other organisations and the suppliers of services to support these functions and disclosed in accordance with statutory, regulatory and organisational requirements. Information forms a key component of the current Governments Information Revolution for the NHS. This restates the NHS intention to ensure effective decision making, inform and empower patients through the provision of accurate, accessible and coherent information. This organisation must discharge its statutory and organisational responsibilities. All staff, and those working on our behalf, are responsible and contribute towards effective and responsible governance of information in line with the organisation s aims and objectives. Page 5 of 16

6 This policy provides an overview of how information will be governed and used in NHS Bromley Clinical Commissioning Group; it outlines how the organisation will discharge its duties. This requires a systematic and consistent approach based on controls owned, understood and supported by all those working on its behalf. The policy is part of a suite which relate to Information Governance and sets out the expected standards and controls around its use. They are: Information Governance, Information Quality, Information Management and Information Security. The concepts and standards are interrelated. It is important to consider all of our obligations and intentions across the suite of policies. 1.2 Objectives The Organisation is committed to ensuring that all information for which it is responsible and that of its partners, hosted bodies, which relates to patients, clients and staff, is processed, protected and disclosed appropriately to provide improved healthcare and decisions for patients. Information related to its functions, activities and decisions must be managed to the appropriate standards. The Organisation seeks the same standards and commitments from those services we commission. The right information, to the right people at the right time This policy sets out the Organisation s aims for the governance of information and associated risk. This includes: Effective and efficient management of information for the commissioning of care for service users and the management of care services; Effective and efficient management of information for the commissioning of services that support the work of this organisation; Actively advance the management of information to improve the provision of services, information and care of patients; Engage with partner organisations, where appropriate and support the lawful sharing of information to support care and the public interest; Discharge its obligations to disclose information in response to lawful requests with due regard to its duties of confidence by following clear and systematic processes; To actively provide information in line with the Freedom of Information Act 2000 and other statutory, regulatory or organisational requirements; Ensure that systems and processes are effective to ensure the confidentiality and security of personal and other sensitive information; Ensure that all information and data processed, held and managed is of the highest quality in terms of completeness, accuracy, relevance, accessibility and timeliness supported by process that validate and ensure its reliability; Ensure that all information and data is held in a consistent and systematic manner that ensures its confidentiality, availability and integrity throughout its lifecycle; Ensure those working on behalf of the organisation and the patients it commissions services on behalf of, are informed, trained and active in the appropriate management of information, and; Page 6 of 16

7 To ensure that change is undertaken in a structured and systematic manner that ensures information governance issues are dealt with in a timely, proportionate and appropriate manner. In Summary Our objective is the effective and appropriate governance of information by NHS Bromley Clinical Commissioning Group, and those working on its behalf in accordance with best practice, statute and regulatory requirements. This policy supports these aims and objectives. 1.3 Promoting Equality Information Governance promotes the fair, equitable and opens access to high quality healthcare. By promoting better quality Data and Information this Organisation can meet its statutory duty to address health inequality and commission high quality healthcare. 2 Scope of this Policy This policy is applicable to: All records, information and data held and processed by NHS Bromley Clinical Commissioning Group. All information must be managed and held within a controlled environment. This includes personal data of patients and staff, patient level data (non-identifiable) as well as corporate information. This applies to records, information and data regardless of format, in addition to legacy data held by the organisation; The standards expected from services commissioned by our Organisation for healthcare and non-healthcare purposes; All permanent, contract or temporary personnel and all third parties who have access to NHS Bromley Clinical Commissioning Group premises, systems or information. Any reference to staff within this document also refers to those working on behalf of the Organisation on a temporary, contractual or voluntary basis. This includes Members of the Clinical Commissioning Group discharging obligations, roles or work on behalf of the Organisation; Information systems, data sets, computer systems, networks, software and information created, held or processed on these systems, together with printed output from these systems, and All means of communicating information, both within and outside the Cluster and both paper and electronic, including data and voice transmissions, s, post, fax, voice and video conferencing. This document will refer to information to encompass the terms information, data and records. The Cabinet Office defines Data as qualitative or quantitative statements or numbers that are assumed to be factual, and not the product of analysis or interpretation and Information as output of some process that summarises interprets or otherwise represents data to convey meaning. This definition will be used throughout this document. Page 7 of 16

8 See Annex B for definitions 2.1 Bromley Clinical Commissioning Group Members Those members undertaking roles or work for the Clinical Commissioning Group are required to work to this policy alongside the related protocols and procedures. In doing so they are fulfilling a different role and obligations to those within their normal duties. They will be supported in doing so in line with this policy. 3 Governance 3.1 Accountability and Responsibility Responsibility and accountability ultimately resides in the Accountable Officer for the Clinical Commissioning Group, Chief Officer. They are supported in this role by the work of the NHS Bromley Clinical Commissioning Group (CCG) Governing Body and delegated sub-committees as outlined in the Information Governance Framework. The Senior Information Risk Owner (SIRO) is a NHS Bromley Clinical Commissioning Group (CCG) Governing Body - appointee accountable to the NHS Bromley Clinical Commissioning Group (CCG) Governing Body for the appropriate management of risk associated with the Organisation s use and holding of information. The Caldicott Guardian (CG) is responsible for leading the assurance agenda for the use of personal information within the Clinical Commissioning Group. They are responsible for advising the NHS Bromley Clinical Commissioning Group (CCG) Governing Body on the standards expected for maintaining the expected standards of confidentiality and data protection. Both the SIRO and Caldicott Guardian are responsible for ensuring that the Organisation s strategic objectives account for their respective agendas, and that controls are in place to ensure appropriate standards are set and met, and that relevant risks are identified. Supporting the Board and office holders, the Information Governance Working Group, a NHS Bromley Clinical Commissioning Group (CCG) Governing Body sub-committee and the delegated authority, is responsible and accountabilities are outlined in its terms of reference. The NHS Bromley Clinical Commissioning Group (CCG) Governing Body is responsible for approving the policy and strategy framework. The Information Governance Steering Committee reports to NHS Bromley Clinical Commissioning Group (CCG) Governing Body, monitors the implementation of the policy and approves necessary supporting controls such as protocols and procedures. Senior managers are responsible for identifying and managing information risks in their remit. Staff nominated as Information Risk Owners (Information Asset Owners) and those responsible for operating Information Assets as Information Risk Administrators (Information Asset Administrators) are accountable to the SIRO for the appropriate identification and management of risks. All staff are responsible for maintaining the controls for the use of information. This includes operating policy, protocol and procedures, completing mandated training and ensuring they are Page 8 of 16

9 aware and comply with legal obligations. Line managers are responsible for ensuring the required standards are met. 4 The Use of Information Information is used, processed, or created by the Organisation for the pursuit of its legitimate business interests and discharge of its statutory functions. All use of information within the Organisation and by those working on its behalf must be in accordance with these objectives and obligations. All information must be used, created and managed in a professional and business-like manner. It must be accessible to the Organisation on a long term basis and must be stored in a systematic and consistent manner. Access to information systems, such as the , databases, the internet, network, and records of the Organisation are provided to staff for business purposes. All access and use must be appropriate and in line with the discharge of their duties. As staff create information, they are doing so on behalf of the Organisation, for example when sending s. They are accountable for the information they create for its appropriateness and accessibility. Any material produced by staff is potentially subject to disclosure to the individual concerned, through the Data Protection Act, into the public domain, under Freedom of Information, or to a court under the requirements of legal disclosure. 4.1 Personal Confidential Data Personal Confidential Data (PCD) relates to information about patients, service users and members of staff and can include any material that makes them identifiable. The term material refers to Information and Data, but is not limited to those terms. For instance it could include audio recordings and visual images. It does not have to include specific demographic information, such as name and address, and can consist of a combination of factors that would make it possible to identify the individual. Information provided to the NHS, is done so on the expectation of confidence and often in a healthcare setting. It is important for staff and working practice to account for this and to ensure that any secondary use of personal data, for non-care purposes, in done in accordance with legal, regulatory and organisational requirements. The Organisation will provide and maintain a privacy notice, or fair processing notice, which details what personal data is held, for what purpose it is processed and who it is shared with and what governs that process. Each directorate within the Organisation should provide a clear statement for their area of its responsibility where they process Personal Confidential Data. A definition of Personal Confidential Data is provided in Annexe B. Page 9 of 16

10 4.2 Use of Information to improve performance NHS Bromley Clinical Commissioning Group will actively seek opportunities to improve its performance and of those organisations it commissions by the better use of information and data. This includes: Use of pseudonymised, anonymised or de-identified patient data to inform better health care decisions for individuals and the community; To review processes and functions within the organisation to ensure efficient and effective data processing; To engage with partner organisations to support appropriate information sharing which ensures that the patient and public can exercise choice as well as ensuring they are kept informed about proposed uses and sharing of their information. Any change processes within the Organisation are required to be managed and to account for the requirements to ensure the appropriate and effective information management. All staff managing change must ensure that they scope potential information governance issues before commencing the change process. 5 Information Quality In order to support effective commissioning and to support efficiency, all systems and standard working practice involved in the processing of information must ensure the accuracy and quality of information. The Policy on Information Quality provides more details. Information Quality encompasses: Accessibility information can be accessed quickly and efficiently through the use of systematic and constituent filing; Accuracy information is accurate, with systems that support this work through guidance; Completeness - The relevant information required is identified. Systems, process and working practice ensures it is routinely captured. The specification what data is required for the defined need will be incorporated into processes, collection and validation; Relevance information is kept relevant to the issues rather than for convenience with appropriate management and structure; Reliability - Information must reflect a stable, systematic and consistent approach to collection, management and use; Timeliness information is recorded as close to possible to being gathered and can be accessed quickly and efficiently; Validity - Information must be collected, recorded and used to the standard set by relevant requirements or controls; 6 Information Security The purpose of information security is to ensure business continuity, to minimise the impact of security related incidents and to ensure the confidentiality and integrity of the information and data held by NHS Bromley Clinical Commissioning Group. Information Security enables information to be processed and shared with appropriate safeguards in place. It ensures the protection of information and assets as well as identifying and acting on threats to that security. Page 10 of 16

11 Information security covers controls across the spectrum of the technical and physical, as well as organisational and people. It ranges from the security of networks, to the use of appropriate passwords by staff and storage of confidential information in secure environments and storage. All staff contribute to information security and have are responsible for its maintenance. All staff are accountable for the security of information and all Information Risk Owners are required to manage and provide assurance on the information security and risks in place for the assets within their remit. Information security has three basic components: Confidentiality: assuring that sensitive information or data is accessible to only authorised individuals, and is not disclosed to unauthorised individuals or the public; Integrity: safeguarding the accuracy and completeness of information and software, and protecting it from improper modification; Availability: ensuring that information, systems, networks and applications as well as paper records are available when required to departments, groups or users that have a valid reason and authority to access them. Further details can be found in the Policy on Information Security. 7 Information Management Information is the key resource of the National Health Service (NHS) and the wider health economy; it enables the effective treatment of patients and the management of the NHS system and the services we commission. Information Management requires the control of information from creation, throughout use to conclude with destruction or archival retention. Appropriate management of information enables an Organisation, to reduce costs, improve efficiency and enhance the ability to monitor the performance of contracts and commissioned services. Understanding the information we hold and the way our Organisation uses it helps us to manage our responsibilities under legislation, such as the Data Protection Act. NHS Bromley Clinical Commissioning Group will ensure that Information Management principles, controls and standards are in place for each stage of the information s lifecycle. Staff are responsible for maintaining these controls and standards. Further details can be found in the Policy on Information Management. 8 Audit and monitoring criteria 8.1 Monitoring and Reporting of compliance This policy and the associated controls will be monitored through the Information Risk Management system for the Organisation. The Information Risk Register will be reviewed on a monthly basis, in response to any information incident or enforcement action by the Information Page 11 of 16

12 Commissioner s Office. Information Risk Management will be a key component of wider assurance and control in setting the priorities for the information governance work plan. Further assurance will be provided through the Information Governance Toolkit (IGT) and the associated audit. Reviews of the current controls and their operation will be undertaken in line with the quarterly timescales of the Information Governance Toolkit. It is noted that the Toolkit may supplementary work to ensure broader assurance. Information Risk Owners, assisted by Information Risk Administrators, will be required to routinely review the Risks and Information Flows associated with the Information Assets utilised to fulfil the business functions and activities within their remit. Further monitoring will be undertaken through the change control process. Table 1 provides more details Table 1 Control Audit Control Audit and Monitoring Table Monitoring requirements What in this document do we have to monitor Monitoring Method Monitoring prepared by Monitoring presented to Frequency of Review The management of information risks (Information Risk Management) Compliance with the law Compliance with the Information Governance Toolkit Incidents related to the breach of this policy Information Risks will be monitored through the Information Risk Register and management system. Compliance with law will be monitored through audit, work directed by the Information Governance Toolkit and as directed by Information Risk Management The Information Governance Toolkit will be monitored by assessment of evidence against the objective of the relevant requirement. In addition, the IGT will be audited by the Organisation s internal audit function before the annual submission. Incident reporting and management requirements Information Governance Function SL CSU supporting the IG Lead for the Clinical Commissioning Group and Information Governance Steering Group Incident reports will be produced by the nominated investigation officer Information Governance Steering Group Senior Information Risk Owner Caldicott Guardian Board and Accountable Officer Monthly updates will be provided to the IG Steering Group, the SIRO and the CG Page 12 of 16

13 Relevant Information Risks will be added to the Corporate Risk Register and reported in line with Risk Management system Annual (as a minimum) updates will be provided to the NHS Bromley Clinical Commissioning Group (CCG) Governing Body. The internal audit report on IGT performance will be provided to the Board or delegated sub-committee. Incident Reports will be reviewed on an annual basis and as directed by the seriousness of the incident 8.2 Non Compliance Failure to comply with the standards and appropriate governance of information as detailed in this policy, supporting protocols and procedures can result in disciplinary action. All staff are reminded that this policy covers several aspects of legal compliance, that as individuals they are responsible for. Failure to maintain these standards can result in criminal proceedings against the individual. These include, but are not limited to: Common law duty of confidentiality Computer Misuse Act 1990 Data Protection Act 1998 Freedom of Information Act 2000 Human Rights Act 1998 Public Records Act 1958 For a full list of relevant legislation and guidance see the Information Governance Framework. 9 Review 9.1 Next formal review Review will take place of the 1 st anniversary of adoption and subsequently every three years until rescinded or superseded. 9.2 Latest Version The audience of this document should be aware that a physical copy may not be the latest version. The latest version, which supersedes all previous versions, is available in the policy register for the Organisation. Those to whom this policy applies are responsible for familiarising themselves periodically with the latest version and for complying with policy requirements at all times. 10 Statement of evidence/references A full list of guidelines, evidence and references will be provided and maintained in the Information Governance Framework Key Legislative and Regulatory Environment The following is a list of the Key legislative and Regulatory Framework Legislation Data Protection Act 1998 Freedom of Information Act 2000 Page 13 of 16

14 Computer Misuse Act 1990 Common law duty of confidentiality Human Rights Act 1998 Health and Social Care Act 2012 Regulation and Guidance NHS Constitution Information Commissioner Offices guidance, passim. Care Quality Commission Requirements (for commissioned healthcare services) A full list of current guidance will be maintained in the Information Governance Framework Other References Other relevant policies are: Information Quality Information Management Information Security A list of related protocols and procedures will be maintained in the Information Governance Framework 11 Implementation and dissemination of document The Policy, once approved will be shared with all staff through the all staff , updated on the intranet, included in staff briefings and placed in the policy register. A team and management briefing will be provided to support this dissemination. In addition to the monitoring detailed above, awareness of the policy will be checked through a staff survey and spot checks on at least an annual basis. 12 Annexes Annexe A - Equality & Equity Impact Assessment Checklist Annexe B - Definitions Page 14 of 16

15 Annexe A - Equality Analysis Checklist This is a checklist to ensure a relevant equality analysis is undertaken of proposals, that issues are addressed either in the main body of the document or in a separate equality analysis checklist. It is not a substitute for a full equality assessment which is required, unless a proposal has no capacity to influence equality. The checklist is to enable the policy lead and the relevant committee to assess whether a full analysis is required and to give assurance that the proposals will be legal, fair, and equitable to promote access. Policy leads are required to consider the following questions against each of these five questions. What evidence has been used for this analysis? What engagement and consultation has been used Identify positive and negative impacts How are you going to address issues identified? Lead and Timeframe The word proposal is a generic term for any policy, procedure or strategy that requires assessment. Equality Analysis Response for this Policy The principles of Information Governance supports fair, equitable access to services our Organisation commissions. Good quality information, understanding the information and data landscape helps to map and understand the needs of our communities. Impacts from meeting the standards and principles expected in the policy will have a positive impact on the communities our customers serve. Yes/No What positive or negative impact do you assess there may be? 1. Does the proposal affect one group more or less favourably than another on the basis of: Age Disability Gender Reassignment Marriage and Civil Partnership Pregnancy and maternity Race Religion or Belief Sex Sexual Orientation No An answer of Yes to any of the above question will require the Policy lead to undertake a full Equality Analysis Checklist and to submit the assessment for review when the policy is being approved. Page 15 of 16

16 Annexe B - Definitions Term Definition Source Data Data is used to describe qualitative or quantitative statements or numbers that are assumed to be factual, and not the product of analysis or interpretation. Information Personal Confidential Data or PCD Information is the output of some process that summarises interprets or otherwise represents data to convey meaning. This term describes personal information about identified or identifiable individuals, which should be kept private or secret. For the purposes of this review personal includes the Data Protection Act definition of personal data, but it is adapted to include dead as well as living people and confidential includes both information given in confidence and that which is owed a duty of confidence and is adapted to include sensitive as defined in the Data Protection Act. Definition taken from The Information Governance Review, Mar 2013 (Gateway Ref: ) 1 based on the Cabinet Office definition Definition taken from The Information Governance Review, Mar 2013 (Gateway Ref: ) Definition taken from The Information Governance Review, Mar 2013 (Gateway Ref: ) 1 See https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192572/ _infogovernance_accv2.pdf, p. 24 Page 16 of 16

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