TRUST POLICY FOR DATA QUALITY

Transcription

1 TRUST POLICY FOR DATA QUALITY Reference Number: IG Version: 2.3 Status: Final Author: Vanessa Forman Job Title: Head of Information Version / Amendment History Version Date Author Reason 1 September Vanessa Forman Original version May 2009 Vanessa Forman Updated for new roles and responsibilities 2.1 June 2011 Monitoring section updated 2.2 March 2012 Jane McFarlane Minor amendments 2.3 March 2016 Avril Ariss Minor amendments Intended Recipients: All staff responsible for the input of patient data both electronically and hard copy. Training and Dissemination: Via the intranet and internally by Data Quality Support Officers To be read in conjunction with: Records Management Policy; Information Security Policy, Data Protection Act In consultation with and Date: Information Governance Steering Group EIRA stage one Completed Stage two Completed Yes No Procedural Documentation Review Group Assurance and Date Approving Body and Date Approved Yes March 2016 Minor amendments approved by PDRG on behalf of TMT Date of Issue March 2016 Review Date and Frequency Contact for Review Executive Lead Signature March 2017 then annual review Head of Information Director of Finance & Information Approving Executive Signature Director of Finance & Information Trust Policy for Data Quality v2.3 March 2016 Page 1

2 Contents Section Page 1 Introduction 3 2 Purpose and Outcomes 3 3 Definitions Used 3 4 Key Responsibilities/Duties Senior Managers in Informatics/Records Management/Clinical Coding/Data Protection and Caldicott All Relevant Trust Staff and Non-Executive Directors Director of Finance and Information/Head of Information Operational Managers 4 5 Implementing the Policy for Data Quality Data Quality Principles Controls Assurance 5 6 Monitoring Compliance and Effectiveness 6 7 References 7 Trust Policy for Data Quality v2.3 March 2016 Page 2

3 TRUST POLICY FOR DATA QUALITY 1 Introduction This policy is intended to cover all types of patient information recorded within the Trust. Reliable information is a fundamental requirement for the Derby Teaching Hospitals NHS Foundation Trust to conduct its business efficiently and effectively. Data quality is crucial pre-requisite to information that is complete, relevant, accurate and timely. Ever-increasing use of computerised systems increases the risk of misinformation if the data from which it is derived is not of good quality. NHS Trusts are assessed and judged on the quality of the data they produce. National performance indicators and audit assessments (including those by Care Quality Commission (CQC) and Health and Social Care Information Centre (HSCIC) depends on good quality data for their accuracy. Compliance with high Data Quality Assurance standards is an implicit requirement for Foundation Trust status. It is for these reasons that the Trust requires a data quality policy. This policy applies to all staff that use, or supply data that is input to, those systems. It outlines good practice and identifies the roles and responsibilities of both the Trust and its staff in terms of data quality. 2 Purpose and Outcomes In common with other NHS Trusts, the Trust will be required by the CQC and HSCIC to achieve at least level 2 for Data Quality as set out in the Information Governance Toolkit (with particular reference to requirement 507). The principles and standards outlined are also expected to be achieved for all Trust data. The importance of achieving good data quality will be addressed with all relevant staff as part of the induction process at commencement of their employment. All users will be made aware of their individual and the Trust s corporate responsibility for confidentiality and security of data through the Trust s relevant policies. 3 Definitions Used The system refers to any of the patient-based systems as defined in the scope. National Data Standards are those listed in the NHS Data Dictionary & Manual. Trust Policy for Data Quality v2.3 March 2016 Page 3

4 4 Key Responsibilities/Duties 4.1 Director of Finance and Information/Associate Director of IM&T Responsibility for the strategic management of data quality in the Trust. Data Quality Manager Responsibility for ensuring that Information Standard Notices and any other statutory data requirements are actioned by the appropriate Department Information Governance Steering Group Responsibility for monitoring the effectiveness of the policy. 4.3 Managers Managers at all levels have a responsibility to ensure that the staff for whom they are responsible adhere to this Policy. They are also responsible for ensuring staff are updated in regard to any changes in this Policy. 4.4 All Trust Staff All staff must adhere to this policy. There is a named individual responsible for the quality of data held on each system. Responsibilities concerning data quality will be stated in their job description and of all staff involved in the collection or processing of data that is input to relevant information systems. 5 Implementing the Policy for Data Quality 5.1 Data Quality Principles Accuracy All data recorded must accurately reflect the actual state that is being described. Every opportunity must be taken to check demographic details to avoid misidentification or correspondence being misdirected. Validity All data items held on Trust computer and other record systems must be valid and correct. Where possible free-text fields will be avoided and standard codes or options used which comply with national standards. Wherever possible, computer systems will be programmed to only accept valid entries. Data will be captured as close to the patient and as timely as possible in order to reduce errors. E.g. the patient s casenotes will be used as the source document for Clinical Coding in order to capture a comprehensive record of the patient s condition and treatment. Consistency All reference tables and codes will be audited and updated regularly with reference to national and local data sources. Trust Policy for Data Quality v2.3 March 2016 Page 4

5 Consistency of patient data must be maintained across all patient-based systems. In order to achieve this, mechanisms must be put in place to ensure details are updated such as change of address or GP or notification of death. The individual responsible for Data Quality will ensure that these mechanisms are effective and are reviewed on a regular basis. Completeness Every effort will be made to ensure that data in a record is complete. It is required that all mandatory data items within a dataset are populated. Use of default codes will only be permitted where appropriate. If it is necessary to bypass a data item in order to progress the delivery of care such an event will be notified to the appropriate authority immediately for corrective action. Coverage Every effort will be made to ensure that recorded data reflects all of the Trust s activity. Systems and processes will be reviewed to ensure complete data capture. Audit procedures will be developed and routinely applied to identify missing data. Timeliness The timely recording of data is essential to the efficient and effective delivery of care. Data needs to be present at the time that processes require it. Staff must be aware of relevant deadlines. 5.2 Controls Assurance Data quality will be subject to internal control processes within the Trust and through external scrutiny. Internal Controls All information systems and processes will have routines developed and designed to systematically identify errors and poor data quality. Data quality reports will be generated monthly via Data Quality Support Officers. They will be reviewed regularly and will make recommendations regarding the improvement of data quality. Data quality reports will be routinely fed back to operational managers with advice regarding any corrective action necessary. Audit of casenotes and data quality by internal auditors on a rolling basis as part of the regular clinical coding audits. External Controls Data quality reports from SUS HES CDS data quality indicators Queries from commissioners Queries from service users Audit of casenotes and data quality by external auditors such as the Audit Commission. Communication of patient information to non NHS organisations is subject to protection according to the Trust s Information Security Policy, Caldicott Guardianship and Data Protection Act requirements. Trust Policy for Data Quality v2.3 March 2016 Page 5

6 6 Monitoring Compliance and Effectiveness Monitoring Requirement : The Information Governance Toolkit has several requirements that require monitoring to take place: Data Quality Clinical Coding audits Dashboard Monitoring Monitoring Method: Internal audits will be undertaken on data quality and clinical coding. Information will be summarised in a report. Dashboard data provided by the Information Centre will be analysed and a summary will be provided of salient points. Report by: Prepared Data Quality Manager Monitoring Report presented to: Information Governance Action Group (IGAG) Information Governance Steering Group (IGSG) Frequency Report of IGAG every meeting IGSG every 6 months 7 References Data Protection Act (1998): Guidance manual and right of access. Caldicott Guardianship Principles Freedom of Information Act Trust Policy for Data Quality v2.3 March 2016 Page 6