1 Information Governance Policy 1 SUMMARY This policy is intended to ensure that staff are fully aware of their Information Governance (IG) responsibilities, so that they can effectively manage and best utilise the information needed to do their jobs consistent with the law and expected standards. 2 RESPONSIBLE PERSON: Steve Beeho, Head of Integrated Governance 3 ACCOUNTABLE DIRECTOR: Jennie Williams, Executive Nurse and Director of Quality and Integrated Governance 4 APPLIES TO: All CCG-employed staff. Governing Body members. Third parties, those working on behalf of, but not directly employed by, the organisation, such as volunteers, students, work placements, contractors or temporary employees. 5 GROUPS/ INDIVIDUALS WHO HAVE OVERSEEN THE DEVELOPMENT OF THIS POLICY: Zeb Alam, Information Governance Lead, NEL CSU Jennie Williams, Executive Nurse and Director of Quality and Integrated Governance Steve Beeho, Head of Integrated Governance 6 GROUPS WHICH WERE CONSULTED AND HAVE GIVEN APPROVAL: Haringey CCG Senior Management Team. Haringey CCG Quality Committee.
2 7 EQUALITY IMPACT ANALYSIS COMPLETED: Policy Screened Yes Template completed Yes 8 RATIFYING COMMITTEE(S) & DATE OF FINAL APPROVAL: Quality Committee Quality Committee VERSION: 3.1 Intranet Website 10 AVAILABLE ON: Yes Yes 11 RELATED DOCUMENTS: Confidentiality and Disclosure of Information Policy (2015) Calendar, and Internet Policy (2015) Information Management Policy (2015) Information Security Policy Information (2015) Information Governance Strategy and Framework (2015) 12 DISSEMINATED TO: All staff in Haringey CCG. 13 DATE OF IMPLEMENTATION: DATE OF NEXT FORMAL REVIEW: December 2017
3 DOCUMENT CONTROL Date Version Action Amendments First draft Second draft Following feedback from SMT Revised Annual revisions made, including additional Appendix detailing training requirements for different roles Revised Privacy markings (Appendix D) and training requirements (Appendix E) amended for clarity Revised Updated to reflect that the revised policy has now been approved via Chair s Action Reviewed Changes to include reference to Caldicott Guardian plan and assurance with the Caldicott review. Referenced Public Interest Disclosure Act on protected disclosures and Public Information Revised Amended to reflect approval by Quality Committee.
4 Contents Section Page 1. Introduction 6 2. Policies statement 6 3. Purpose 7 4. Scope of this policy 7 5. Who this policy applies to: Roles and Responsibilities 7 7. Policy Standards Accountability and Governance Managing Information Risk Openness and Transparency Use of information Personal Confidential Data Use of Information to improve performance Information Security Records Management Information Quality Relationship with Service Providers Clinical Services Support services Equality and Diversity Training Dissemination and Implementation 16
5 12. n Conformance with this Policy Monitoring and Review 16 Appendices Appendix A. Evaluation protocol 18 Appendix B. Equality Analysis 19 Appendix C. Definitions used in this policy 20 Appendix D. Privacy Markings 21 Appendix E. Training 22
6 1. Introduction Information Governance is a framework to manage information appropriately. It ensures confidentiality and security, as well as that processes are in place to ensure appropriate standards of quality and ethical use of personal information. Corporate information and records must also be managed appropriately, and where possible and appropriate provided to the public to ensure transparency and accountability. The CCG uses information to support the commissioning and management of commissioning of patient healthcare. 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 of Personal Data and 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 IG 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 or organisational requirements. Good quality information forms a key component of the NHS Information Revolution, with the aim of giving people more control over their own care. This restates the NHS s intention to promote effective decision making and ensure patients are informed and empowered through provision of information that is accurate, accessible and coherent. 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. This policy provides an overview of how information will be governed and used in the CCG; it also outlines how the organisation will discharge it duties. This requires a systematic and consistent approach based on controls owned, understood and supported by all those working on its behalf. 2. Policies Statement Haringey Clinical Commissioning Group (CCG) has put this policy in place to ensure CCGemployed staff and Governing Body members are fully aware of their Information Governance (IG) responsibilities. This policy is important as it should help you understand how to look effectively manage and best utilise the information needed to do your jobs consistent with the law and expected standards. Information is a valuable asset to a commissioning organisation to enable it to effectively make informed decisions. Therefore it is important to ensure we maximise the value of information as an asset in compliance with legal requirements. To do this we will ensure information is:
7 Held securely and confidentially; Obtained fairly and lawfully; Recorded accurately and reliably; Used effectively and ethically; and Shared and disclosed appropriately and lawfully. The CCG is committed to ensuring that information, in whatever its context, is processed as determined by prevailing law, statute and best practice including the Caldicott 2 Report 2013 and its recommendations. Compliance with all organisation policies is a condition of employment and a breach of policy may result in disciplinary action. 3. Purpose The Policy is intended to achieve and maintain the following IG objectives: Confidentiality Assuring that sensitive information or data is accessible to only authorised individuals, and is not disclosed to unauthorised individuals or the public unless appropriate and lawful. 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. Accountability Users will be aware of their responsibilities in relation to their collection, use and processing of data and information. 4. Scope of this policy This policy covers all aspects of holding, obtaining, recording, using, sharing and disclosing of data/information or records, held in a manual/paper or electronic format, by or on behalf of the CCG. This includes, but is not limited to; staff employed by the organisation; those engaged in duties for the organisation under a letter of authority, honorary contract or work experience programme; volunteers and any other third party such as contractors, students or visitors.
8 5. Who this policy applies to: Roles and responsibilities The CCG has identified the following relevant roles and responsibilities within the organisation. Role Governing Body Responsibilities In line with the Guidance for NHS Boards: Information Governance, the governing body will ensure that its organisation has taken appropriate steps to meet IG standards. In particular it will seek assurance against following questions: 1. What have we done, as an organisation, to ensure we have implemented adequate policies and procedures, and are addressing the responsibilities and key actions required to support effective IG? 2. What were the outcomes of our most recent annual IG assessment, and what measures (if any) have been put in place to address any identified deficiencies? 3. What plans do we have in place to ensure our organisation remains compliant with national standards for IG? 4. Do we as an organisation have the capacity and capability to guarantee our plans for IG can be implemented? 5. Do our IG arrangements adequately encompass all teams and work areas that we are legally accountable for? 6. What plans do we have in place to ensure commitment to the Caldicott 2 recommendations in relation to strengthening our process for managing patients dissent to use of their information? 7. How would we manage FOI request on disclosure of Information as a result the Public Information Regulations? Accountable Officer Has overall accountability and responsibility for governance within the organisation. Is to provide assurance that all risks to the organisation, including those relating to information, are effectively managed and mitigated.
9 Role Senior Information Risk Owner (SIRO) Caldicott Guardian Responsibilities Has overall responsibility for ensuring that effective systems and processes are in place to address the IG agenda. Fosters a culture for protecting and using data. Ensures information risk requirements are included in the corporate Risk and Issue Management Policy. Ensures Information Asset Owners (IAOs) undertake risk assessments of their assets. Is responsible for the Incident Management process ensuring identified information security risks are followed up, incidents managed and lessons learnt. Provides a focal point for the management, resolution and/or discussion of information risk issues. Ensures that the CCG s approach to information risk is effective in terms of resource, commitment and execution and that this is communicated to all staff. Ensures the Governing Body is adequately briefed on information risk issues. Is accountable for information risk. The SIRO roles and responsibilities are defined in Appendix A of the NHS Information Risk Management Guidance. The role holder will be supported and advised by the IG Team. The role of the Caldicott Guardian is an advisory role acting as the conscience of the organisation for management of patient information and a focal point for patient confidentiality & information sharing issues. The Caldicott Guardian ensures that the CCG completes all requirements in the Caldicott work plan relevant to the CCG. These requirements are further linked into the annual IG work plan. The Caldicott Guardian is supported in this role by the IG Lead and the IG Team. There are delegated roles and responsibilities and other delegated roles within the CCG and CSU to support delivery of the Caldicott Work Plan and assist with the completion of the Caldicott plan for the organisation. The Caldicott Guardian is required to maintain an Issue log. IT Security Lead Information Security Officer See Information Security Officer This role will be fulfilled by the rth East London CSU IG Team, IT team and local facilities management depending on the requirement. Provides advice to information owners on potential information risks and controls. Support in any risk reviews with departments.
10 Role Information Asset Owners Responsibilities All senior staff at Director level are required to act as Information Asset Owners for the information assets within their remit. They will provide assurance to the SIRO that information risk is managed effectively for the information assists identified as within their remit. They will also: Ensure all Information Assets and flows of data within their remit are identified and logged ensuring each has a legal basis to be processed. Identify, manage and escalate all information security (for example, dependencies and access control) and information risks as appropriate. Information Asset Administrators IG Lead NEL CSU IG Team All Substantive /Permanent Staff Third parties CCG Member Practices The IAOs will be supported by IAAs who will ensure the above takes place. The detailed roles and responsibilities are defined in Appendix A of the NHS Information Risk Management Guidance Information Asset Administrators (IAAs) are the most senior individual user or direct users of systems and have an understanding as to how they work and how they are used. They will ensure there are procedures for using them, control access to them and understand their limitations. The detailed roles and responsibilities are defined in Appendix A of the NHS Information Risk Management Guidance Senior CCG Manager responsible for ensuring suitable advice, guidance support, tools and training are available to those with the CCG who handle data, to ensure they do so appropriately. This role will be the main point of contact for the NEL CSU IG Team. Provide specialist advice and support, under contract, to the organisation in relation to IG subject matters. They will also form part of the Caldicott function and associated plan All those working for the CCG have legal obligations, under the Data Protection Act and common law of confidentiality; and professional obligations, for example the Confidentiality NHS Code of Practice and professional codes of conduct to manage information appropriately. These are in addition to their contractual obligations which include adherence to policy, and confidentiality clauses in their contract. The same responsibilities as for permanent staff apply to those working on behalf of the organisation, whether they are volunteers, students, work placements, contractors or temporary employees. Those working on behalf of, but not directly employed by, the organisation are required to sign a third party agreement outlining their duties and obligations. This policy should be followed where any member is processing information on behalf of or in relation to the CCG delivery of its functions. However it is recommended that similar policy standards are in place within each member practice regarding the management of its own data and information.
11 6. Policy Standards This policy document, as part of a suite of supporting IG related policies, sets out the standards that those working for or on behalf of the CCG are expected to adhere to when handling data or information Accountability and Governance The CCG will put in place suitable controls to: Assign responsibilities to oversee the delivery of standards set out in this policy; Report on compliance against IG to a suitable committee within the organisation; Ensure that all staff have been made aware of their responsibilities, how to comply with them and have available advice and guidance and training programmes to do so Ensure the consistency of IG across the organisation; Develop IG policies and procedures; Ensure compliance with Data Protection, and other information security related legislation; Provide support to the team who handle Freedom of Information requests; Provide support to the Caldicott Guardian and Senior Information Risk Owner (SIRO) Managing Information Risk The CCG will put in place suitable mechanisms to ensure staff identify and manage information risks in line with existing risk management policy and processes. A failure to effectively implement information could lead to the following risks. Risk Reputational Damage Example Making decisions from inaccurate information could undermine any commissioning decision could affect organisational reputation. Financial Loss Loss of information could lead to financial penalties of up to 500,000 Inefficient use of information may lead to duplication and wasted time. Failure to comply with legal, regulatory or NHS requirements There are a number of lawful requirements to manage information such as the Data Protection Act, Freedom of Information Act, Public Records Act and Caldicott principles which could also lead to reputation or financial loss Failure to be compliant with NHS Constitution or NHS Care Records Guarantee or CCG Authorisation requirements.
12 6.3. Openness and Transparency The CCG will put in place systems and processes to ensure, where appropriate, unrestricted information is made available to the public. Individuals should be aware of how to access this and their own information: Suitable processes will be put in place to meet requirements of the Freedom of Information Act 2000 and NHS Code of Openness including Staff will be made aware of the need to use protective markings such as NHS Official as defined within the Information Security Policy and Appendix D. Individuals will be made aware of how their information will be processed using privacy notices, unless legally exempt from the requirement Requests for access to personal data will be managed in line with legal requirements and best practice Information, including personal and sensitive data, will be shared with other agencies only where there is a legal basis to do so and to comply with the Caldicott 2 recommendations 6.4. 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 , databases, the internet or 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, and are accountable for the appropriateness and accessibility of information they create Personal Confidential Data Personal Confidential Data (PCD) relates to information about patients, service users and members of staff and can include anything that makes them identifiable. It does not have to include particular 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, is carried out 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 and processed, for what purpose it is processed and who it is shared with and what governs that process.
13 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 Use of Information to improve performance The CCG will actively seek opportunities to improve its performance and the performance 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 support appropriate information sharing initiatives and ensure that the patient and public can exercise choice about the use of their data as well as ensuring they are kept informed about proposed uses including the sharing of their information. Any change processes within the organisation are required to account for the requirements to ensure appropriate and effective information management. All staff managing change must ensure that they scope potential IG issues before commencing the change process Information Security The CCG will put in place systems and processes to maintain the security of information where it is required. This will include: Establishing and maintaining policies for the effective and secure management of information assets and resources. Undertaking or commissioning annual assessments and audits of its information and IT security arrangements. Promoting effective confidentiality and security practice to its staff through policies, procedures and training. The training required by role is set out at Appendix E. Having in place secure mechanisms for the exchange of information in a variety of forms, including but not limited to secure post, , encrypted storage media etc. Encouraging safe and secure utilisation of IT services and products to meet efficiency demands whilst still maintaining the suitable availability, confidentiality and integrity of the data at all times Establishing and maintaining incident reporting procedures and monitoring and investigating all reported instances of actual or potential breaches of confidentiality and security. Such incidents will be managed in accordance with the Checklist Guidance for Reporting, Managing and Investigating Information Governance Serious Incidents Requiring Investigation. Undertaking information risk assessment, in conjunction with overall priority planning of organisational activity to determine appropriate, effective and affordable IG controls are in place in relation to the acquisition, transfer and storage of data Where information risks are assessed these will be considered in line with the latest international information security standards.
14 Further information can be found in the Information Security Policy Information / Records 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 management of information from creation and use, all the way through to 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. The CCG 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. 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 Information Management Policy (Records and Quality) provides more details Information Quality: The CCG recognises the importance of quality information to make informed decisions. As such the CCG will ensure processes are in place to maintain: 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 and working practice ensures it is routinely captured Relevance information is kept relevant to the issues the CCG faces 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. Further details can be found in the Policy on Information Management. 7. Relationship with Service Providers As a commissioner of clinical and support services the CCG will ensure that any organisations from which it buys services meets expected IG standards.
15 7.1. Clinical Services All clinical services commissioned by or on behalf of the CCG will be required to: Have a suitable contract in place to form a joint data controller relationship regarding the information required to effectively monitor commissioned services The services commissioned meet the requirements of the Data Protection Act when providing services including, but not limited to, fair processing and maintaining a registration with the Information Commissioners Office Complete the annual Information Governance Toolkit and undertake an IG Toolkit service review, to be disclosed to the CCG on request in order to provide assurance they have met expected requirements. Ensure privacy notices make individuals aware of a CCGs role in commissioning and the personal and sensitive data it may receive to undertake such a role. Ensure that where any IG incidents occur that they are reported to the CCG via routes determined within the contract Support services All support services that process information on behalf of the CCG will be required to ensure: A suitable contract is in place to form a Data Controller to Data Processor relationship where Personal or Personal Sensitive data is managed on behalf of the CCG The services commissioned meet the requirements of the Data Protection Act when providing services including, but not limited to, fair processing and maintaining a registration with the Information Commissioners Office Completion of the annual Information Governance Toolkit and undertake an independent IG Toolkit service review to be disclosed to the CCG on request in order to provide assurance they have met expected requirements. That any new processing is within the remit of the contract or seek written confirmation if there is any ambiguity Report any known incidents or risks in relation to the use or management of information owned by the CCG. 8. Equality and Diversity As part of its development, this policy and its impact on staff, patients and the public have been reviewed in line with expected Legal Equality Duties. The purpose of the assessment is to improve service delivery by minimising and if possible removing any disproportionate adverse impact on employees, patients and the public on the grounds of protected characteristics such as race, social exclusion, gender, disability, age, sexual orientation or religion/belief. The equality impact assessment has been completed and has identified impact or potential impact as minimal impact. 9. Training All staff are, as a minimum, mandated to undertake the Introduction to Information Governance e-learning module once, followed by the Information Governance Refresher on an annual basis. Additional training needs analysis will be undertaken periodically and staff
16 should comply with any recommendations identified. There are specific e-learning training requirements specified in Appendix E by roles for the Senior Information Risk Owner (SIRO), Caldicott Guardian and Information Asset Owners (IAOs) and Information Asset Administrators (IAAs). 10. Dissemination and Implementation This policy will be made available to all relevant stakeholders via the CCG internet site. Additionally they will be made aware via and this policy will be included for reference where necessary. The need for staff to familiarise themselves with all information governance policies (including this one) is highlighted as part of the CCG induction pack. The policy will be supported by additional related policies and resources to support implementation. This will include the availability of, and access to, written and verbal advice, guidance and procedures where necessary. 11. n-conformance with this Policy Should it not possible to meet the requirements within this policy and associated guidelines this must be brought to the attention of the department s Information Asset Owner. Any issues will need to be documented as a risk and either: a. Accepted and reviewed in line with this policy b. Accepted with a view to implementing an action plan to reduce the risk c. t accepted and the practice will stop until such time as the risk can be reduced 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 Monitoring and Review Performance against the policy will be monitored against Availability and dissemination of policy, including in alternative formats where requested or need identified Acceptance and understanding of audience (training, spot checks, surveys) Reports of non-conformance i.e. incidents or risks Compliance against the Information Governance Toolkit
17 This policy will be reviewed every 2 years and in accordance with the CCG s governance processes following an as and when required basis: legislative or case law changes; changes or release of good practice or statutory guidance; identified deficiencies, risks or following significant incidents reported; changes to organisational infrastructure.
18 Appendices Appendix A. Evaluation protocol 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 IG Toolkit Incidents related to the breach of this policy Information Risks will be monitored through the Risk Register and management system. Compliance with law will be monitored through audit, work directed by the IG Toolkit and as directed by the SIRO The IG 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 The CSU IG Team and the CCG IG Lead for the relevant groups Incident reports will be produced by the nominated investigation officer Relevant CCG committees or groups with oversight of IG Senior Information Risk Owner Caldicott Guardian Yearly updates will be provided to the relevant groups, the SIRO and the CG Relevant Information Risks will be added to the Corporate Risk Register and reported in line with Risk Management system Annual (as a minimum) updates to the Board will be provided. 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
19 Appendix B. Equality Analysis This is a checklist to ensure relevant equality and equity aspects of proposals have been addressed either in the main body of the document or in a separate equality & equity impact assessment (EEIA)/ equality analysis. It is not a substitute for an EEIA which is required unless it can be shown that a proposal has no capacity to influence equality. The checklist is to enable the policy lead and the relevant committee to see whether an EEIA is required and to give assurance that the proposals will be legal, fair and equitable. The word proposal is a generic term for any policy, procedure or strategy that requires assessment. Challenge questions 1. Does the proposal affect one group more or less favourably than another on the basis of: Race Ethnic origin (including gypsies and travellers, refugees & asylum seekers) Nationality Gender Culture Religion or belief Sexual orientation (including lesbian, gay bisexual and transgender people) Age Disability (including learning disabilities, physical disability, sensory impairment and mental health problems) 2. Will the proposal have an impact on lifestyle? (e.g. diet and nutrition, exercise, physical activity, substance use, risk taking behaviour, education and learning) 3. Will the proposal have an impact on social environment? (e.g. social status, employment (whether paid or not), social/family support, stress, income) 4. Will the proposal have an impact on physical environment? (e.g. living conditions, working conditions, pollution or climate change, accidental injury, public safety, transmission of infectious disease) 5. Will the proposal affect access to or experience of services? (e.g. Health Care, Transport, Social Services, Housing Services, Education) Yes/ What positive or negative impact do you assess there may be?
20 Appendix C. Definitions used in this policy Term Definition Source Data Information Personal Confidential Data or PCD 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 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. The Information Governance Review, Mar 2013 (Gateway Ref: ) page 125
21 Appendix D: Privacy Markings Marking Protective Marking NHS Official NHS Official- Sensitive NHS Official- Sensitive: Personal NHS Official- Sensitive: Commercial Description Records should be marked to signify the nature of the contents and the level of security that should be applied to them. All routine CCG business, operations and services should be treated as OFFICIAL. Ordinarily NHS Official information does not need to be marked. This marking is necessary for person-identifiable information and commercially sensitive information and is applicable to paper and electronic documents/records. Personal information relating to an identifiable individual where inappropriate access could have damaging consequences. Commercial information, including that subject to statutory or regulatory obligations, which may be damaging to the CCG, other NHS body or a commercial partner if improperly accessed.
22 Appendix E: Training Role(s) Senior Information Risk Owner (SIRO) Caldicott Guardian (CG) Information Asset Owners (IAOs) Information Asset Administrators (IAAs) IGTT Mandatory modules and HSCIC link NHS Information Risk Management for SIROs and IAOs Information Governance: The Refresher Module (if the Introduction to IG module has been completed previously) Business Continuity Management The Caldicott Guardian in the NHS and Social Care Information Governance: The Refresher Module (if the Introduction to IG module has been completed previously) Patient Confidentiality NHS Information Risk Management for SIROs and IAOs Information Governance: The Refresher Module (if the Introduction to IG module has been completed previously) Secure Transfers of Personal Data Business Continuity Management Secure Transfers of Personal Data Password Management Information Governance: The Refresher Module (if the Introduction to IG module has been completed previously) Information Security Guidelines IGTT Recommended module and HSCIC link Information Security Management Information Security Guidelines Information Security Guidelines Password Management Business Continuity Management All staff who completed IG training in the previous financial year Information Governance: The Refresher Module New entrants Introduction to Information Governance and others who have not completed any IG Training IG Lead Information Governance: The Refresher Module (if the Introduction to IG module has been completed previously) Information Security Management NHS Information Risk Management for SIROs and IAOs Records Management and the NHS Code of Practice Business Continuity Management Password Management
23 Role(s) IGTT Mandatory modules and HSCIC link Secure Transfers of Personal Data IGTT Recommended module and HSCIC link
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Information Governance Strategy ONCE PRINTED OFF, THIS IS AN UNCONTROLLED DOCUMENT. PLEASE CHECK THE INTRANET FOR THE MOST UP TO DATE COPY Target Audience: All staff employed or working on behalf of the
Information Governance Policy REFERENCE NUMBER IG 101 / 0v3 May 2012 VERSION V1.0 APPROVING COMMITTEE & DATE Clinical Executive 4.9.12 REVIEW DUE DATE May 2015 West Lancashire CCG is committed to ensuring
Policy: D9 Data Quality Policy Version: D9/02 Ratified by: Trust Management Team Date ratified: 16 th October 2013 Title of Author: Head of Knowledge Management Title of responsible Director Director of
Information Governance Strategy To whom this document applies: All Trust staff, including agency and contractors Procedural Documents Approval Committee Issue Date: January 2010 Version 1 Document reference:
Information Governance Policy Version - Final Date for Review: 1 October 2017 Lead Director: Performance, Quality and Cooperate Affairs NOTE: This is a CONTROLLED Document. Any documents appearing in paper
This document is uncontrolled once printed. Please check on the CCG s Intranet site for the most up to date version CONTRACTS REVIEW FOR INFORMATION GOVERNANCE COMPLIANCE PROCEDURE Document Title: Contracts
NHS Hartlepool and Stockton-on-Tees Clinical Commissioning Group Information Governance Strategy 2015/16 Document Status Equality Impact Assessment Final No impact Document Ratified/Approved By Hartlepool
Information Governance Plan 2013 2015 1. Overview 1.1 Information is a vital asset, both in terms of the clinical management of individual patients and the efficient organisation of services and resources.
Plymouth Community Healthcare CIC Information Governance Strategy Version No 2.0 Notice to staff using a paper copy of this guidance. The policies and procedures page of PCH Intranet holds the most recent
Information Governance Policy and Management Framework Policy Number: IG01 Version: 3.0 Ratified by: Governing Body Date ratified: February 2016 Name of originator/author: Louise Chatwyn Information Governance
Author: Susan Hall, Information Governance Manager Owner: Fiona Jamieson, Assistant Director of Healthcare Governance Publisher: Compliance Unit Date of first issue: February 2005 Version: 5 Date of version
Information Governance and Data Protection Policy Page 1 of 21 Document Control Sheet Name of document: Version: Owner: File location / Filename: Information Governance and Data Protection Policy Final
JOB DESCRIPTION POST TITLE: Information Governance Manager DIRECTORATE: ACCOUNTABLE TO: BAND: LOCATION: CSS Head of Information Governance 8a CSS Job Purpose The Information Governance Manager will ensure
Information Security Policy JUNE 2014 Author Responsibility Lynda Harris, Head of Information Governance, Central Eastern CSU, Bedfordshire and Luton All staff Effective Date June 2014 Review Date June
INFORMATION GOVERNANCE POLICY Name of Policy Author: Name of Review/Development Body: Ratification Body: Ruth Drewett Information Governance Steering Group Committee Trust Board : April 2015 Review date:
Information Governance Policy Version 1.1 Responsible Person Information Governance Manager Lead Director Head of Corporate Services Consultation Route Information Governance Steering Group Approval Route
Title: Reference No: NHSNYYIG - 007 Owner: Author: INFORMATION GOVERNANCE POLICY Director of Standards First Issued On: September 2010 Latest Issue Date: February 2012 Operational Date: February 2012 Review
Information Governance Strategy THCCGCG9 Version: 01 The information governance strategy outlines the CCG governance aims and the key objectives of its governance policies. The Chief officer has the overarching
INFORMATION GOVERNANCE STRATEGY NO.CG02 Applies to: All NHS LA employees, Non-Executive Directors, secondees and consultants, and/or any other parties who will carry out duties on behalf of the NHS LA.
Corporate IG02: Data Quality Version Number Date Issued Review Date V4 07/12/2015 01/01/18 Prepared By: Consultation Process: Senior Governance Manager, North of England Commissioning CCG Quality & Safety
INFORMATION GOVERNANCE POLICY Including the Information Governance Strategy Framework and associated Information Governance Procedures Last Review Date Approving Body N/A Governing Body Date of Approval
Corporate CCG: IG06: Records Management Policy and Strategy Version Number Date Issued Review Date V3 08/01/2016 01/01/2018 Prepared By: Consultation Process: Senior Governance Manager, NECS CCG Head of
Information Governance Policy Document Number 01 Version Number 2.0 Approved by / Date approved Effective Authority Customer Services & ICT Authorised by Assistant Director Customer Services & ICT Contact
Information Governance Policy UNIQUE REF NUMBER: AC/IG/013/V1.2 DOCUMENT STATUS: Approved by Audit Committee 19 June 2013 DATE ISSUED: June 2013 DATE TO BE REVIEWED: June 2014 1 P age AMENDMENT HISTORY
Information Governance Policy Version: Revised: Consultation: Ratified by: 1.0 Information Governance Committee Governance Committee Date ratified: 19 March 2008 Name of originator/author: David McGrath
Information Security Policy Reference No: Version: 5 Ratified by: CG007 Date ratified: 26 July 2010 Name of originator/author: Name of responsible committee/individual: Date approved by relevant Committee:
NETWORK SECURITY POLICY Policy approved by: Governance and Corporate Affairs Committee Date: December 2014 Next Review Date: August 2016 Version: 0.2 Page 1 of 14 Review and Amendment Log / Control Sheet
NHS DORSET CLINICAL COMMISSIONING GROUP GOVERNING BODY INFORMATION GOVERNANCE TOOLKIT REPORT 9.7 Date of the meeting 15/07/2015 Author Sponsoring Clinician Purpose of Report Recommendation J Green - Head
INFORMATION GOVERNANCE POLICY POLICY NO IM&T 011 DATE RATIFIED January 2012 NEXT REVIEW DATE January 2015 POLICY STATEMENT/KEY OBJECTIVE: To provide an overarching framework through which Information Governance
INFORMATION GOVERNANCE AND SECURITY 1 POLICY DRAFTED BY: INFORMATION GOVERNANCE LEAD 2 ACCOUNTABLE DIRECTOR: SENIOR INFORMATION RISK OWNER 3 APPLIES TO: ALL STAFF 4 COMMITTEE & DATE APPROVED: AUDIT COMMITTEE
Information Sharing Policy REFERENCE NUMBER IG 010 / 0v3 February 2013 VERSION V1.0 APPROVING COMMITTEE & DATE Clinical Executive Committee 5.2.13 REVIEW DUE DATE February 2016 West Lancashire CCG is committed
Directorate of Performance Assurance INFORMATION GOVERNANCE POLICY Reference: DCP074 Version: 2.5 This version issued: 27/03/15 Result of last review: Minor changes Date approved by owner (if applicable):
Policy Checklist Name of Policy: Information Governance Policy Purpose of Policy: To provide guidance to all staff on their responsibilities regarding information governance and to ensure that the Trust
` Information Incident Management and Reporting Procedures Compliance with all CCG policies, procedures, protocols, guidelines, guidance and standards is a condition of employment. Breach of policy may
SOMERSET PARTNERSHIP NHS FOUNDATION TRUST RECORDS MANAGEMENT STRATEGY Report to the Trust Board 22 September 2015 Sponsoring Director: Author: Purpose of the report: Key Issues and Recommendations: Director
Proforma: Information Policy Security & Corporate Policy Procedures Status: Approved Next Review Date: April 2017 Page 1 of 17 Issue Date: June 2014 Prepared by: Information Governance Senior Manager Status:
NHS South West Lincolnshire Clinical Commissioning Group (CCG) INFORMATION ASSURANCE DOCUMENTED PLAN Document History: Document Reference: Document Purpose: IG18 To provide guidance to all CCG staff about
INFORMATION RISK MANAGEMENT POLICY DOCUMENT CONTROL: Version: 1 Ratified by: Steering Group / Risk Management Sub Group Date ratified: 21 November 2012 Name of originator/author: Manager Name of responsible
Information Governance Policy Implementation date: 30 September 2014 Control schedule Approved by Corporate Policy and Strategy Committee Approval date 30 September 2014 Senior Responsible Officer Kirsty-Louise
RECORDS MANAGEMENT POLICY Version 8.0 Purpose: For use by: This document is compliant with /supports compliance with: To outline the lifecycle of a record and to provide guidance on retention and disposal
Department / Service: IM&T Originator: Ian McGregor Deputy Director of ICT Accountable Director: Jonathan Rex Interim Director of ICT Approved by: County and Organisation IG Steering Groups and their relevant
INFORMATION GOVERNANCE POLICY Version Version 1 Ratified By Date Ratified PROPOSED FOR APPROVAL 15/11/12 Author(s) Responsible Committee / Officers Date Issue November 2012 Review Date November 2013 Intended
MOORLAND SURGICAL SUPPLIES LTD INFORMATION GOVERNANCE POLICY Moorland is committed to ensuring that, as far as it is reasonably practicable, the way we provide services to the public and the way we treat
INFORMATION ASSURANCE DOCUMENTED PLAN Document Reference: Document Purpose: IG20 Date Approved: Approving Committee: To provide guidance to all CCG staff about the CCG s documented plan for Information
Surrey & Sussex Healthcare NHS Trust An Organisation-wide Policy for Information Governance (IG) Version 1.3 Status Ratified Date Ratified March 2008 Name of Owner Name of Sponsor Group Name of Ratifying
GUIDANCE 1 TITLE: INFORMATION GOVERNANCE FRAMEWORK 2 POLICY AREA: INFORMATION GOVERNANCE 3 ACCOUNTABLE DIRECTOR FOR POLICY AREA: DIRECTOR OF QUALITY AND GOVERNANCE 4 GUIDANCE DRAFTED BY: INTEGRATED GOVERNANCE
Courier Policy UNIQUE REF NUMBER: AC/IG/009/V1.2 DOCUMENT STATUS: Approved by Audit Committee 19 June 2013 DATE ISSUED: June 2013 DATE TO BE REVIEWED: June 2014 1 P age AMENDMENT HISTORY VERSION DATE AMENDMENT
Ref No: IN-101 INFORMATION GOVERNANCE POLICY (INCORPORATING INFORMATION GOVERNANCE MANAGEMENT FRAMEWORK) AREA: POLICY SPONSOR: Trust Wide Director of Finance IMPLEMENTED: October 2009 REVISED: June 2011
Information Governance Training Plan To meet requirements of IGT v13 Lincolnshire East Clinical Commissioning Group Page 1 of 17 Contents Introduction Page 3 Training Provision Page 4 Staff Induction Awareness
Version 2.0 LOGOLOGO Information Governance Strategy Includes Information risk & incident management methodology Approved by: Quality & Governance Committee Ratification date: May 2014 Review date: May
CORE SKILLS FRAMEWORK INFORMATION GOVERNANCE LESSON NOTES AND TIPS FOR A SUGGESTED APPROACH These notes are designed to be used in conjunction with the core training PowerPoint slides. The purpose of the
INFORMATION GOVERNANCE HANDBOOK SECTION ONE Author Tracey Burrows Role Information Governance Manager (CSCSU) Date / Version February 2015 Version FINAL V1.0 Approved by IM&T Board Date 27 February 2015