Ayrshire and Arran NHS Board

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1 Paper 17 Ayrshire and Arran NHS Board Monday 19 May 2014 Information Governance Annual Report Author: Mrs Jillian Neilson Head of Information Governance Sponsoring Director: Dr Alison Graham Medical Director Date: 5 May 2014 Recommendation The Board is asked to receive the Annual Report for the Information Governance Committee which was approved at its meeting on Friday, 2 May Summary The Information Governance Committee is a recently established committee and is currently developing its approach and work-plan. Key Messages: The Committee are well cited on the requirements necessary to comply with the Public Records (Scotland) Act 2011; this agenda will be taken forward in the forthcoming year. The FairWarning tool has been implemented to strengthen privacy surveillance and privacy breach detection. 1 of 9

2 Monitoring Form Policy/Strategy Implications Workforce Implications Financial Implications Consultation (including Professional Committees) Risk Assessment Best Value The activities of the Information Governance Committee support the implementation of the Information Governance and Assurance agenda and will specifically support the requirement to comply with the Public Records (Scotland) Act Staffing and resource issues were identified as a constraint, it is planned to address this in the forthcoming year. Funding allocated to support information governance will need to be reviewed to support a requirement for the expanding remit. The Information Governance Committee members have been consulted in the preparation of this report. Information governance risks are reviewed by the Committee on an ongoing basis, with the Committee selecting areas for more in depth analysis. - Vision and leadership - Effective partnerships - Governance and accountability - Use of resources - Performance management Compliance with Corporate Objectives The Information Governance Committee has laid the foundations for taking forward the expanding remit of Information Governance to ensure mechanisms for the effective use of information are in place for the benefit of the patient and their family /carers. Supporting the person centred care through more effective use of information. Single Outcome Agreement Not required (SOA) Impact Assessment This document is an internal document and no impact assessment has been conducted. 2 of 9

3 NHS Ayrshire and Arran Information Governance Committee Annual Report 1. Introduction 1.1 The Information Governance Committee was established in March The Committee has a remit to consider a range of areas including; Caldicott Principles, Freedom of Information, NHS Code of Practice on Confidentiality, Data Protection, Information Assurance, ehealth and Data Sharing. 2. Remit 2.1 The Committee s Terms of Reference are detailed at Appendix 1 to this report. 3. Membership 3.1 The membership of the Information Governance Committee comprises:- Mr Stephen McKenzie (Chair) Councillor Hugh Hunter Councillor Douglas Reid Ms Lisa Tennant Mrs Lesley Bowie (from 24 th February 2014) Mr Bob Martin (from 24 th February 2014) 4. Meeting 4.1 The Committee met on three occasions between 1 April 2013 and 31 March of 9

4 4.2 The NHS Board agreed in 2010 that attendance at Committee meetings should be recorded in the relevant Annual Report. The attendance record of each member is shown below (x indicates attended). Dates Member Mr Stephen McKenzie Dr Martin Cheyne (in attendance) Councillor Hugh Hunter Councillor Douglas Reid 19/08/13 04/11/13 24/02/14 x x * x x x x x x Ms Lisa Tennant x x Mrs Lesley Bowie n/a n/a x Mr Bob Martin n/a n/a x *Absence due to family bereavement 5. Committee Activities 5.1 An Information Governance Committee Development Day was held on the 1 st May Included in the programme for the development day was a Data Protection Awareness session delivered by the Senior Policy Officer from the Information Commissioner s Office and a presentation from the Central Legal Office as well as discussing the vision for Information Governance and insight from the Caldicott Guardian. 5.2 A presentation from the Corporate Records Manager from NHS Fife was delivered to the Information Governance Committee in November 2013 to discuss their experience of developing and submitting a Records Management Plan in line with the Public Records (Scotland) Act The Information Governance Committee routinely receives an Information Governance breach report, decommissioning of premises reports as well progress reports on the implementation of the Public Records (Scotland) Act 2011 and Freedom of Information requirements. 4 of 9

5 5.4 Staffing and resource issues have meant that the development agenda of the Committee has been limited. Full procedures are in place, however, to assure full compliance with all information issue requirements. 5.5 Introduction of the Fairwarning System in October 2013 has been an aspect of the work of the Committee. 6. Priorities for 2014/ The main priority for the Information Governance Committee over the forthcoming year is to maintain oversight of the preparation and submission of a records management plan to the Keeper of the Records for Scotland and the subsequent implementation of the plan to satisfy the legal requirement to comply with the Public Records (Scotland) Act Supporting the integration of Health and Social care agenda also represents a key priority of the Information Governance Committee over the forthcoming year to ensure that the information governance arrangements support and enable the progression towards integrated working whilst ensuring compliance. 6.3 The Information Governance Committee will seek assurance in relation to the implementation of the ehealth programme. 7. Chair s Comments 7.1 The work of the Committee succeeds due in part to the engagement of non-executive and executive members. I would like to thank those who attend the meetings, in either capacity, for their commitment and contribution to the work of the group. 7.2 I would also wish to record my thanks, as Chair, to all officers and support staff who facilitate the work-stream of the Committee and who ensure meetings are serviced and informed, allowing proper and timeous consideration of all the key issues. 7.3 Key to the work of information management within the service, is the Operational Delivery group who monitor and assure the levels of compliance and development at operational level. This group is central to assuring the proper management of Information within the service and their work is recognised and appreciated. 7.4 Since the outset of this governance committee, which has only recently been formed and had a relatively short working life, there have been issues of resourcing, both in terms of staffing and systems. There is an awareness of these issues and work is being done to address these, with the expectation that there will be an appropriate complement of both in place very shortly. 7.5 The work of the Information Governance Committee reflects the increasing need to comply with legislative requirements, as well as the expectation that we will use information much more effectively and to the greater good of the patient and their family/carers. The key driver is that good Information management will ensure that the patient is at the centre of all our processes. Central to the work of the Committee is the 5 of 9

6 aspiration that the service will continue to develop all aspects of information management and use this to support better integrated and informed support for those for whom we care and will engage and support all our users in a true spirit of respect and partnership. It is clear that patients will respond and improve more positively, if they are given the responsibility and respect of an equal partner in assuring their own health. 7.6 Engaging and assuring that the sharing of patient information with patients, their carers and the professionals who support them is properly managed and delivered, is a central task of the Committee. This will grow in importance as the information landscape becomes more challenging, through the Integration agenda and the natural path of technological development. As Chair I would wish to give the Board the assurance that the Committee is aware of the areas of responsibility and development that they need to address and the group does so with commitment and enthusiastic engagement. 6 of 9

7 Appendix 1 1 Introduction NHS AYRSHIRE & ARRAN INFORMATION GOVERNANCE COMMITTEE TERMS OF REFERENCE 1.1 The Information Governance Committee is identified as a Committee of the NHS Board. The approved Terms of Reference and information on the composition and frequency of the Committee will be considered as an integral part of the Standing Orders. 1.2 The Committee will be known as the Information Governance Committee of the NHS Board and will be a Standing Committee of the Board. 2 Remit 2.1 To provide assurance to the NHS Board that information governance is being discharged in relation to the Boards statutory duty for quality of care. 3 Committee Membership 3.1 The Committee shall be established by the full NHS Board and be composed of four Non-Executive members and the Chairman. The Chair will be appointed by the Chairman of the NHS Board. 3.2 Committee membership will be reviewed at least annually. 4 Quorum 4.1 Three Non-Executive members will constitute a quorum. 5 Attendance 5.1 The Executive Medical Director, the Director of Information and Clinical Support Services and the Assistant Medical Director (as Chair of the Information Governance Operational Delivery Group) will attend in an exofficio capacity to provide the Committee with advice and guidance. The Chief Executive will also be in attendance. 5.2 The Committee may co-opt additional advisors as required. 7 of 9

8 5.3 With the prior approval of the Chair, the Executive Medical Director and the Director of Information and Clinical Support Services will be able to provide deputies on an exceptional basis. 6 Frequency of Meetings 6.1 The Committee will normally meet bi-monthly but will meet at least four times per annum. 6.2 The Chair may, at any time, convene additional meetings of the Committee. 7 Authority 7.1 The Committee is authorised to investigate any matters which fall within its Terms of Reference, and obtain external professional advice. 7.2 The Committee may form one or more Sub-committees to support its functions. 7.3 The Committee is authorised to seek and obtain any information it requires from any employee whilst taking account of policy and legal rights and responsibilities. 7.4 The Committee will have the authority to require the attendance of any employee of NHS Ayrshire and Arran, as may be required. 8 Duties The Committee shall be responsible for the oversight of information governance arrangements within NHS Ayrshire and Arran. Specifically it will: 8.1 Consider and scrutinise the health system s compliance with relevant legislation and performance against national standards with regards to information governance. 8.2 Hold the relevant officers of NHS Ayrshire and Arran to account in respect of their compliance with relevant information governance legislation, organisational and national standards. 8.3 Review action taken by the organisation on recommendations made by the Committee or the NHS Ayrshire and Arran Board on information governance 8 of 9

9 matters. 8.4 Monitor and review risks falling within its remit. 8.5 Receive annual reports and quarterly updates on Information Governance performance in order to provide assurance and accountability. 8.6 Provide assurance to the NHS Board on compliance with information governance legislation, organisational and national standards, highlighting issues, breaches and action being taken where appropriate. 9 Conduct of business 9.1 Meetings of Committee will be called by the Committee Chair. 9.2 The agenda and supporting papers will be sent to members at least ten working days before the date of the meeting. Any additional papers can be circulated via Reporting Arrangements 10.1 Minutes will be kept of the proceedings of the Committee. These will be circulated, in draft normally within five working days to the Chair of the Committee and within five working days thereafter to members, prior to consideration at a subsequent meeting of the Committee The Chair of Committee shall provide assurance on the work of the Committee and the approved minutes will be submitted to the NHS Board meeting for information The Committee will conduct an annual review of its role and function and report to the NHS Board in June each year Items requiring urgent attention by the NHS Board can be raised at any time at NHS Board Meetings, subject to the approval of the Chair. 9 of 9

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