Records Management and Information Lifecycle Strategy

Transcription

1 LINCOLNSHIRE PARTNERSHIP NHS FOUNDATION TRUST Records Management and Information Lifecycle Strategy DOCUMENT VERSION CONTROL Document Type and Title: Strategy New or Replacing: Revised/Updated Version No: 3 Date Policy First Written: April 2010 Date Policy First Implemented: June 2010 Date Policy Last Reviewed and Updated: August 2014 Implementation Date: October 2014 Author: Records Management and Information Governance Approving Body: Board of Directors Approval Date: 23 September 2014 Review Date: May

2 Contents Section Title Page No. 1. Introduction 3 2. Purpose and Scope 3 3. Aims 4 4. Key Elements 6 5. Implementation 8 6 Review 8 7 References 8 App A Implementation Work Plan 9 2

3 1. Introduction 1.1 Information Lifecycle Management relates to the policies, processes, practices, services and tools used by an organisation to manage its information through every phase of its existence, from creation through to destruction 1.2 This document sets out an overarching framework for integrating current records management initiatives, as well as recommending new ones. It defines a strategy for improving the quality, availability and effective use of records in the Trust and provides a strategic framework for all records management activities. This will enable overall coordination of all records management activities and ensure alignment with the Trust s Integrated Business Plan and Quality Strategy. 1.3 The Trust has made clear its intention to enhance the electronic patient record into a fully integrated clinical system that covers all aspects of the patient s journey which will represent a significant step forward for the Trust by providing a mechanism for integrating the legacy paperwork with the current and emerging electronic healthcare record. 1.4 The Trust also intends to continue to develop the electronic document management system for Corporate and non-clinical records again providing a mechanism for integrating historical paper based systems with a mechanism for creating and storing electronic information. 1.5 This Strategy should be read in conjunction with the Records Lifecycle Management and Policy. (Policy 08). 2. Purpose and Scope 2.1 This Strategy relates to all clinical and non-clinical records held in any format by the Trust in all phases of the life of information: creation, retention, maintenance, use and eventual disposal or transfer into public archives, i.e.: all administrative records (e.g. human resources, estates, financial and accounting records, notes associated with complaints etc); and all service users health records for all specialties and including records for private patients treated on NHS premises. all research and audit data 2.2 These include records held in all formats, for example: paper records, reports, diaries and registers etc; electronic records; s x-rays and other images; microform (ie microfiche and microfilm); and audio and video tapes, including CD and DVD s artwork 3

4 2.3 An organisation wide Information Lifecycle Strategy is necessary for identifying the resources needed to ensure that records of all types are properly controlled, tracked, accessible and available for use and eventually archived or otherwise disposed of in line with the principles contained within the NHS Records Management Code of Practice. 3. Aims 3.1 The aims of the Trust s Records Management and Information Lifecycle Strategy are to ensure: a systematic and planned approach to records management covering records from creation to eventual disposal; development of records in a digital format to meet the NHS England directive of paper-free patient records by 2018 efficiency and best value through improvements in the quality and flow of information, and greater coordination of records and storage systems; compliance with statutory requirements; provision of staff training for record keeping standards awareness of the importance of records management and the need for responsibility and accountability at all levels; formal procedures for closure, disposal and retention of records; archiving of the Trust s important records or records with an historical value. 4. Key Elements 4.1 The records management and information lifecycle strategy comprises the following key elements: Responsibility and Accountability To provide a clear system of accountability and responsibility for record keeping and use It is important that all individuals in the Trust appreciate the need for responsibility and accountability in the creation, amendment, management, storage of and access to all Trust records. A major target is therefore to have a clear chain of managerial responsibility and accountability for all records created by the Trust. This is the prerequisite for an effectively coordinated records management strategy. This is defined within the Records Lifecycle Management and Policy Record Quality To create and keep records which are adequate, consistent, and relevant for statutory, legal and business requirements Trust records should be accurate and complete, in order to facilitate audit, fulfil the Trust s responsibilities, and protect its legal and other rights. Records should show proof of their validity and authenticity so that any evidence derived from them is clearly credible and authoritative. 4

5 To support the Trust Quality Strategy priorities there also needs to be a focus on the CQC Essential Standard of Quality and Safety Outcome 21. The Trust has committed to progress the ability to audit records electronically and monitor care and record keeping compliance remotely with the introduction of electronic patient records. To be able to provide prompts for staff within the systems to ensure compliance with pathways of care and support complete and timely record keeping through mobile and offline working. To provide compliance reports for staff and managers to support continuous improvement Management To achieve systematic, orderly and consistent creation, retention, appraisal and disposal procedures for records throughout their life cycle Record-keeping systems should be easy to understand, clear, and efficient in terms of minimising staff time and optimising the use of space for storage. Records Management is a discipline which utilises an administrative system to direct and control the creation, version control, distribution, filing, retention, storage and disposal of records, in a way that is administratively and legally sound, whilst at the same time serving the operational needs of the Trust and preserving an appropriate historical record. The future for clinical records involves health and social care services using digital technology to ensure that vital patient related information and clinical decision and support tools can be viewed by an authorised user in a joined up manner in any single instance Security To provide systems which maintain appropriate confidentiality, security and integrity for records in their storage and use Records must be kept securely to protect the confidentiality and authenticity of their contents, and to provide further evidence of their validity in the event of a legal challenge. Records must be held securely to protect them from unauthorised or inadvertent alteration or erasure, access and disclosure are properly controlled and audit trails will track all use and changes. To ensure that records are held in a robust format which remains readable for as long as records are required Access To provide clear and efficient access for employees and others who have a legitimate right of access to Trust records, and ensure compliance with Access to Health Records, Data Protection and Freedom of Information legislation Access is a key part of any records management strategy. Fast, efficient access to records unlocks the information and knowledge they contain. In line with the Francis Inquiry Report patients need to be granted user friendly, real time and retrospective access to read their records and a facility to enter comments. They should be enabled to have a copy of records in a form useable by them, if they wish to have one. 5

6 4.1.6 Audit To audit and measure the implementation of the records management strategy against agreed standards The records of the organisation must be regularly checked against agreed standards to ensure that the records management systems and processes are robust and properly applied within the organisation to ensure that we can be certain our records are fit for purpose and legally sound Training To provide training and guidance on legal and ethical responsibilities and operational good practice for all staff involved in records management Effective records management involves staff at all levels. Training and guidance enables staff to understand and implement policies, and facilitates the efficient implementation of good record keeping practices. Records Management training is mandated for all staff every three years and training is an annual refresh requirement. 5. Implementation 5.1 The action points, in the table below, have been developed from the Trust s Records Lifecycle Management and Policy which requires the following fundamentals to be present: existence of an overall policy statement on how records (including electronic records) are to be managed; endorsement of policy by senior management; dissemination of policy to staff at all levels; provision of corporate mandate for the performance of all records and information functions; organisational commitment to create, keep and manage records which document activities; definition of roles and responsibilities; definition of responsibility of personnel to document actions and decisions in the records and to dispose of obsolete records; provision of framework for supporting appropriate standards, procedures and guidelines; provision of monitoring mechanisms to ascertain compliance with appropriate standards, procedures and guidelines; and review of policy at regular intervals. 6. Review 6.1 This strategy will be reviewed every two years (or sooner if new legislation, codes of practice or national standards are to be introduced). 7. References Records Management: NHS Code of Practice Lincolnshire Partnership NHS Foundation Trust Records Lifecycle Management and Policy (Policy 08) 6

7 LPFT Clinical Strategy LPFT Strategic Objectives Safer Hospitals Safer Wards Achieving an Integrated Digital Care Record. NHS England July

8 APPENDIX A RECORDS MANAGEMENT WORK STRATEGY 2014/15 Strategic Goal Objective Action Responsibility & Progress 1 Responsibility and Accountability Target Date 1.1 To provide a clear system of accountability and responsibility for records 1.2 Review resource for records function Establish a records management strategy with processes for ongoing monitoring and review Allocate appropriate resources across the Trust to enable the maintenance of the records management function. Records Manager and Services to determine if resources are adequate for records management. Risk to be assessed through datix incidents. Records team to support where issues identified. 18/11/2013 to be addressed as part of 1.10 (see above) Due for Review in May 2014 work commenced July 2014 to be sent to September IM&T for ratification Ongoing 8

9 2 Record Quality 12/5/14 Issues continue to be experienced with resource in the records management team due to the ever expanding role of subject access. Added to risk register. 2.1 Review and reduce the use of paper records to ensure that the organisation can achieve the aim of digitalised patient records by Reduce the duplication of records to improve information sharing, reduce cost and save space. Develop processes for centralising all paper notes into Records libraries from team locations as part of the digitalisation of records project (Scanning). X-ref 3.7 and create workplan to deliver scanning bureau function and remove historical paper notes from team locations. To commence March Management of records 3.1 Ensure that the Trust holds robust and up to date information on records held, their format, location to comply with national standards and achieve compliance with the Toolkit. Undertake an inventory of all Trust records, both health and corporate records held in either hard copy or electronic formats. (This is to ensure that all record collections/information sets are identified along with the volume of records held, the type of media on which they are held, their physical condition, their location, the environmental conditions in which they are stored and the responsible manager. See Records Management Roadmap: Records Inventory Guidance ) Deputy Records Manager/ Officer Data to be captured from Data Flow mapping work commenced August 2014 and then to be further interrogated to achieve level 3 compliance for IG Toolkit Commenced August 2014 to be delivered by 31 December

10 Further work to be undertaken during 2014/15 to finalise audit of corporate records as part of Corporate Records project X-reference to item Ensure that the Trust can manage the creation and use of records in a systematic and planned approach. Establish procedures for the continuous monitoring of the records management process to ensure that legal and statutory requirements are met and new types of records have a lifecycle determined at the point of creation. Development of an archive function on Silverlink for electronic records which are no longer current but which need to be accessed in accordance with retention schedules. Records Manager and to review existing process to ensure non-clinical records are included. X-reference item 3.5. Records Manager and /Head of Informatics Commenced to be delivered by 31 March 2015 To be progressed during Ensure that the Trust can demonstrate that it manages records through the Records lifecycle. Establish procedures for the closure of records when no longer current; arrange secure storage of archived records, and effective disposal, as soon as appropriate. Review archiving arrangements and ensure value for money and Statutory obligations are met by approved contractor. During 2013/14 work will need to be commenced on the reduction of microfiche Records Manager and Records schedules of information held at TNT now being reviewed to identify records which are ready for destruction. 31 March

11 held in archive which is beyond DPA retention requirements and can be transferred to historical archive. The same will apply to information held on the archive database and CD Roms. 12/5/14 work incomplete due to resource issues. Placed on risk register 3.4 To develop the functionality of the electronic patient record to enable the move towards a paper-light health records system and further progress to paper free records by To develop the functionality of Sharepoint (SHARON) to offer the Trust an electronic document management system for non-clinical records to progress the move towards a paper-light organisation. The Trust intends to further develop the electronic patient records (Silverlink, IAPTus, SystmOne and WebBomic) into fully integrated clinical systems that cover all aspects of the patient s journey which will represent a significant step forward for the Trust by providing a mechanism for integrating the legacy paperwork with the current and emerging electronic healthcare record. The Trust intends to continue to develop the electronic document management system for Corporate and non-clinical records again providing a mechanism for integrating historical paper based systems with a new mechanism for creating and storing electronic information utilising the functionality of Sharepoint. Records Management and and Head of Informatics The final trust system which needs capacity for scanning and attaching documentation and creation of letters is WebBomic. Functionality is now available and the project needs to be launched in September 2014 IM& T Programme Development Manager Records Manager and / /Deputy Records Manager System went live 22 October 2010 but now needs a thorough review Partially completed In progress to be delivered by March

12 Further work to be undertaken to progress to during 2014/ To develop the Electronic Staff Record to enable scanning and attaching of documentation to enable the trust to move towards paper light payroll and human resources records. To ensure that any functionality implemented complies with BIP 0008 and Trust policy. Head of Payroll Services Human Manager Resources 18/11/2013 Further work being progressed between IM&T Programme Development manager/head of Payroll and Workforce Lead in respect of travel claims and employment documentation. 12/5/14 Excellent progress made in 2013/14 with HR records moving to an electronic medium. Payroll records moved to electronic from in respect of starter, change and termination forms. Work to be continued in respect of remaining forms which will require investment in esr and e- rostering for timesheets Already Met Part delivered in 2012/13. Further development progressing November 2013 also achieved. Ongoing 12

13 3.7 To deliver a scanning bureau functionality for the Trust to commence the move of historical legacy paper healthcare records into a digitalised format which can be appended to the electronic patient record. Scale of project to be scoped during August/September 2014 and business case to be produced for discussion at IM&T Committee with funding streams identified. and travel claims. Records Manager and Commence August 2014 for implementation by 31 March Develop functionality for electronic signatures on patient administration systems Business case to be developed for project to implement electronic signatures functionality in line with Electronic Communications Act 2000 and Electronic Signatures Regulations 2002 Deputy Records Manager 18/11/2013 Position paper on functionality required prepared to be presented to IM&T Committee January /5/14 Business case sits with PMO, functionality rests with the implementation of the Single Sign on project being managed by the IM&T Programme Development Manager which is anticipated in 2014 and will see access to all computers being through smartcards which December

14 3.9 Implement project to review clinic letters functionality on Silverlink and streamline the document centre in line with feedback from users 4 Access to Records Business case to be developed to review letters available on Silverlink and update in line with current requirements following liaison with services. To include aspects from green group. Review to also look at design of the document centre and possible streamlining. will authenticate all system entries and enable digital signatures. Records Manager and 18/11/2013 Position paper on functionality required prepared to be presented to IM&T Committee January /5/14 part met with existing letters on silverlink being reviewed with medical secretaries. Next version of silverlink will bring function to develop individualised clinic letters which meets this requirement and expected Summer December To provide clear and efficient access for patients and their representatives who have a legitimate right of access to Trust records, and ensure compliance with current Access to Health Records Act 1990, Data Protection Act 1998 and Freedom of Implement policies and procedures to ensure that the Trust has a robust Access to Healthcare records function which enables service users and their representatives to access information in accordance with provisions of the Data Protection Act Ensure access requests are met within statutory timeframes and in accordance Records Management and Deputy Records Manager 12/5/14 Placed on risk register in respect of resource available to meet demand. New processes likely to 14

15 Information Act 2000 legislation 4.2 Patients need to be granted user friendly, real time and retrospective access to read their records and a facility to enter comments. They should be enabled to have a copy of records in a form useable by them, if they wish to have one 6 Audit of Records with confidentiality principles. Implement new ways of working to reduce amount of paper records being copied and processed within the team and move to a digitalised process to improve lean working and reduce costs. The Trust IM&T strategy outlines the plan to develop this functionality between 2016 and There will need to be strong links with Records Management to ensure that the final product meets the requirements for layered access and user authentication. Head of Informatics Records Management and mitigate this risk to be reviewed To be delivered Review clinical content of patient records for all teams to ensure that Trust Records Management standards are being adhered to. Raise action plans for areas which need improvement. To produce an annual audit programme for the review and check of healthcare records against Trust Policy to ensure that compliance is achieved for IG Toolkit, CQC and NHSLA standards. Develop standard audit tools for the measuring of key records management standards. Develop action plans for implementation of audit outcomes by teams. Report audit outcomes to RMG for sharing with IM&T Committee and the Board. Monitor compliance with audit action plans and subsequent implementation. Records Manager and Bespoke audit tools now created for each clinical system in use by the Trust. Programme set to deliver records audit for 2014/15 and additional support to be provided for Mock CQC audits to enable Trust to achieve level 3 IG Toolkit. Part completed. To achieve by 28 February

16 7 Training 7.1 To provide training and guidance on responsibilities and good practice for all staff involved with records. Develop training programmes and packages on records management and information governance to be targeted at new staff to ensure they are aware of basic standards for records management. Produce and deliver annual refresh packages to ensure that staff achieve compliance with mandatory training requirements. Develop and deliver more specialised training packages for specific target groups where for instance audit outcomes have highlighted concerns or there are enhanced requirements for training. Records Management and Packages are reviewed annually for mandatory training sessions to ensure that local messages from incidents can be built into the training. On-going Revised and updated August 2014 Signed Date Director of Finance 16