Data Quality Policy. DOCUMENT CONTROL: Version: 4.0

Transcription

1 Data Quality Policy DOCUMENT CONTROL: Version: 4.0 Ratified By: Risk Management Sub Group Date Ratified 27 August 2013 Name of Originator/Author: Head of Information Services Name of Responsible Risk Management Sub-Group Committee/Individual: Date Issued: 23 September 2013 Review Date August 2016 Target Audience Operational Management, Clinical, Medical and Administrative Support staff and all Trust staff who are responsible for the collection and storage of data and information.

2 CONTENTS SECTION PAGE NO INTRODUCTION PURPOSE 3 3. SCOPE 5 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 5 5. PROCEDURE/IMPLEMENTATION 6 6. TRAINING IMPLICATIONS 8 7 MONITORING ARRANGEMENTS 8 8. EQUALITY IMPACT ASSESSMENT SCREENING 8.1 Privacy, Dignity and Respect 8.2 Mental Capacity Act LINKS TO ANY ASSOCIATED DOCUMENTS REFERENCES 10 Page 2 of 11

3 1 Introduction 1.1 Rotherham Doncaster and South Humber NHS Foundation Trust recognises the importance of reliable information as a fundamental requirement for the delivery of effective treatment for service users. The availability of complete and up to date information is essential in ensuring service users receive effective ongoing care. Data quality underpins Clinical and Research Governance, Information Governance, management, planning and accountability for service level agreements. 1.2 The importance of good data quality cannot be over-estimated. Poor quality data can lead to wasted time, financial loss and in the most extreme cases of inaccurate clinical information, death. 1.3 Data Quality is also important for legal reasons. The Data Protection Act 1998 provides a legal obligation on organisations to ensure that information is accurate, complete and up to date and applies to both electronic and paper records. 1.4 The Data Quality Policy ensures a positive impact on equality and diversity due to robust data collection principles. 2 Purpose 2.1 The purpose of this Data Quality Policy is to set out the principles the Trust adopts to ensure that its data collection processes deliver high quality data that conforms to NHS Data Standards. These principles will be adopted and supported by data quality procedures. While the focus of this policy is on the two main corporate clinical information systems (Silverlink) and TPP, it is expected that any other data collection within the Trust should conform to the same stated principles. 2.2 Trusts have frequently been criticised for poor clinical performance when the reality is that data quality is poor and therefore gives an inaccurate picture of performance. 2.3 Reliable information is vital in supporting the Trust to achieve its goals. Specific areas include: Clinical and Research Governance Clinical Governance is essentially about ensuring NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care. It is also a collective term for the quality of various component activities that aim to improve the experience of patients, carers and the public. These include: Page 3 of 11

4 Patient, carer and public involvement Risk Management Clinical Audit Research and clinical effectiveness Staffing and staff management Education and continuous personal and professional development. Use of information to support clinical governance. NHS Litigation Authority (NHSLA) Risk Management Standards Rather like Clinical Governance, Research Governance is a framework that aims to ensure research is of high quality, safe, and meets agreed scientific and ethical standards. Both Clinical and Research Governance are dependant on high quality information in order to be effective and continuously improve the quality of service provision. See Research Governance Policy Business and Performance Management Accurate service user based data is essential both for internal management and external scrutiny of the Trust s activities. It is important for the effective running of the Trust s services to have accurate information about both the volume and quality of services that we provide. In addition to supporting the day to day running of the Trust, such information is essential in the development of new services. From an external monitoring perspective the Trust requires accurate information to monitor and manage legally binding contracts with commissioners and partner organisations, and data to meet the national reporting requirements; as well as meeting legislative requirements, some of which are listed below National Requirements Care Quality Commission (CQC) Monitor Compliance Framework Statutory Returns and Data Sets o Mental Health Minimum Data Set (MHMDS) o Commissioning Data Sets (CDS) o Quarterly Monitoring Returns eg: VSMR Local Development Plan Returns External Inspections, eg: CQC and Audit Commission Data Protection Act 1998/Freedom of Information Act 2000 Improved Access to Psychological Therapies (IAPT) National Drug Treatment Monitoring System (NDTMS) Commissioning for Quality and Innovation Indicators (CQUIN) Green Light for Mental Health Page 4 of 11

5 3 Scope Audit CAMHS Mapping Contribution to Local Authority Key Performance Indicators Community Information Data Set (CIDS) The Trust is regularly audited to ensure that: Applicable legislative Acts are complied with NHS and Trust Policies and Standards are complied with Suitable processes are used, and controls put in place, to ensure data is Complete, Accessible, Relevant, and Accurate and entered in a Timely (CARAT) way whilst maintaining its security and confidentiality Information Governance Data quality is an element of the broader Information Governance remit. The Caldicott directive now also falls within Information Governance and this reinforces the need for accurate service user demographic and clinical data, which provides the Trust with high quality information. 3.1 This policy is predominantly related to the collection of patient electronic health records. However, it is important to understand that all other business information, eg; financial and personnel records, should following the CARAT principles to be able to support the business of the Trust. 4 Responsibilities, Accountabilities and Duties 4.1 All Trust staff that collect, manage or use patient data, or have line management responsibility for functions and/or staff that handle information, are responsible and accountable for the accuracy of that data Operational Management The Director of Mental Health and Forensic Services and the Director of Children s, Community and Substance Misuse Services will ensure that good data quality practices are embedded throughout Operational Services Business Divisions There are seven Business Divisions currently identified within the Operational Service and these are: Adult Mental Health Services Children and Young Peoples Services Page 5 of 11

6 Learning Disability Services Doncaster Community Integrated Services Forensic Services Older People s Mental Health Services Substance Misuse Services The Assistant Director and/or Clinical Director of each Business Division, acting as Information Asset Owners are responsible for the data quality issues within their remit. It is their responsibility to ensure that each area has staff identified who will ensure that data quality issues are communicated to their teams and action taken to correct any problems. 4.2 The Trust s Information Services Department has a responsibility to ensure that systems are configured to collect data according to agreed standards and to undertake maintenance at system level. The department also has a responsibility to provide a framework of policies and procedures designed to promote data quality. It will monitor and audit data quality and publish this information to relevant staff and managers for their action, and provide training where appropriate. 4.3 The Director of Finance and Information will oversee development and implementation of data quality policies and promote a data quality culture within the Trust; supported by the Information Services Department. 5 Procedure/Implementation 5.1 NHS Guidance The NHS Data Dictionary gives common definitions and guidance to support the sharing, exchange and comparison of information across the NHS. The common definitions, known as data standards, make up the base currency of Commissioning Data Sets. 5.2 NHS Data Standards NHS Data Standards are presented as a logical data model, ensuring that the standards are consistent and integrated across all NHS business areas. Changes to the content of the NHS Data Dictionary are published as Data Set Change Notifications (DSCNs). 5.3 Errors Careful monitoring and error correction supports good data quality. However it is more effective and efficient for data to be entered correctly in the first instance. In order to help achieve this, procedures must exist within the Trust so that staff can be trained and supported in their work Correct Data Entry Page 6 of 11

7 To facilitate an understanding of the data requirements and for what purpose they are used, there have been two documents published. The Protocol for the Collection of Service User Information Into Clinical Information Systems, and more recently to support the development of the Care Pathways and Packages work in moving towards mental health Payment by Results, the Protocol for Input of Activity Data Into the Silverlink System. It is anticipated all services will have data entry manuals to support the data entry process Error Identification The use of the Data Quality Dashboard is essential to identify data quality issues for individuals and listings where necessary, i.e.: when consistent errors are identified which impact on performance and contracting information. Errors within information should be identified and corrected as close to the point of entry as possible. No level of inaccuracy should be viewed as acceptable. 5.4 Correction of error records will be a continuous process Timescales for the Correction of Errors and Omissions Individual Staff The Trust has invested in a data warehouse which facilitates refreshed data quality reports on a daily basis via the Data Quality Dashboard. It is the responsibility of operational staff to access these reports frequently (once per week as a minimum standard), and make use of the information to correct any problem records in the clinical information system. Each error record shown on the Data Quality Dashboard has an indicator which points at where to find the information on how to correct the problem within the Data Quality Guide (which is published on the Intranet) Data Quality Lists With the development of electronic Business Division dashboards, and as data quality reports are developed relating to specific performance data, lists will be published on the dashboard associated to the identified data problem. Identified staff within Operational teams will access data quality tables to check for issues and make the necessary Page 7 of 11

8 validation check and update records within the clinical information system. 6 Training Implications 6.1 A detailed training analysis is not required for this policy. 6.2 Training on the clinical information system is mandated prior to staff being allocated with a log in and password for the system. 6.3 Basic computer skills and Information Governance training will be provided prior to training being delivered for the clinical information system. 6.4 In addition to system training, staff will have access to one to one support via telephone contact or at their base-point when requested and according to the availability of support and training staff. 6.5 When new functionality is developed and published in the clinical information system, workshops will be provided in all geographical areas to raise awareness of the changes. If additional support and training is requested, training sessions will be made available in each geographical area. In addition to workshops, training sessions and support, up to date, training materials are available via the Trust Intranet, along with newsletters that are published regularly giving hints and tips and providing an analysis of support requests recorded during the previous 4 to 8 week period. Training materials will be reviewed and updated. 6.6 Where error problems appear recurrent, training programmes and supporting documentation will be reviewed to provide assurance that these potential problem areas are given focus at initial training and in on-going support meetings. 7. MONITORING ARRANGEMENTS Area for Monitoring How Who by Reported to Frequency Data quality and report validation Review performance and commissioning reports and data quality issues at Business Intelligence Group Director of Finance/Director of Business Assurance/Director of Mental Health and Forensics Services/ Director of Children s, Community and Substance Misuse Finance Information and Business Development Group 2 weekly Page 8 of 11

9 meetings Services 8. EQUALITY IMPACT ASSESSMENT SCREENING - The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website click here 8.1 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi s review of the NHS, identifies the need to organise care around the individual, not just clinically but in terms of dignity and respect. Indicate how this will be met Not applicable As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). 8.2 Mental Capacity Act Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible. Indicate How This Will Be Achieved. All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act (Section 1) Not applicable Page 9 of 11

10 9 Links To any associated Documents Electronic link to Silverlink and TPP Training Manuals Research Governance Policy Rotherham Doncaster and South Humber NHS Foundation Trust. Data Quality Dashboard +ADMIN&rs:Command=Render Rotherham Doncaster and South Humber NHS Foundation Trust. Data Quality Guide Rotherham Doncaster and South Humber NHS Foundation Trust. Protocol for the Collection of Service User Information Into Clinical Information Systems Rotherham Doncaster and South Humber NHS Foundation Trust. Various Informatics Security Policies 10 References Department of Health. Commissioning for Quality an Innovation (CQUIN) uidance/dh_ Department of Health. Improving Access to Psychological Therapies (IAPT) uidance/dh_ Information Commissioner s Office. Data Protection Act Information Commissioner s Office. Freedom of Information National Drug Treatment Agency. National Drug Treatment Monitoring System (NDTMS) NHS Connecting for Health. Commissioning Datasets NHS Connecting for Health. Information Governance Toolkit NHS Connecting for Health. NHS Data Dictionary Page 10 of 11

11 NHS Information Centre. Mental Health Minimum Dataset (MHMDS) Page 11 of 11