To ensure that the Trust has in place the systems and processes to effectively manage data quality.

Transcription

1 DATA QUALITY POLICY Document Summary To ensure that the Trust has in place the systems and processes to effectively manage data quality. DOCUMENT NUMBER POL/002/064 DATE RATIFIED June 2014 DATE IMPLEMENTED June 2014 NEXT REVIEW DATE June 2017 ACCOUNTABLE DIRECTOR Director of Strategy and Support Services POLICY AUTHOR Health Records and Data Quality Manager Important Note: The Intranet version of this document is the only version that is maintained. Any printed copies should therefore be viewed as uncontrolled and, as such, may not necessarily contain the latest updates and amendments.

2 TABLE OF CONTENTS 1 SCOPE Introduction Statement of Intent Definitions Duties Key themes DATA QUALITY STANDARDS MONITORING AND REPORTING DATA QUALITY ISSUES RISK MANAGEMENT LEGISLATION AND DATA STANDARDS PROFESSIONAL OBLIGATIONS Training Monitoring compliance with this document References/ Bibliography Related Trust Policy/Procedures/Guidance Conclusions Approved June 2014 Page 2 of 15 Our Ref: POL/002/064

3 1 SCOPE The purpose of this policy is to reinforce Cumbria Partnership NHS Foundation Trust s commitment to data quality. The policy will provide our staff working in every service area with clear guidelines as to their roles and responsibilities in respect of data quality. The scope and the principles set out in this policy are applicable to all information systems including both clinical and administrative This policy applies to: All information that is held in either paper or electronic format. The development and implementation of any new information systems. All staff employed by or working on behalf of Cumbria Partnership NHS Foundation Trust who collect, use, input or report on information contained within the Trust information systems. A failure to follow the requirements of this policy may result in investigation and management action being taken as considered appropriate. This may include formal action in line with the Trust disciplinary or capability policies and procedures. In relation to any one working on behalf of the Trust may lead to termination of an assignment, placement, secondment or honorary arrangement. Noncompliance may also lead to criminal action being taken. 2 INTRODUCTION Reliable information is a fundamental requirement for the Trust to conduct its business efficiently and effectively. This applies in all areas of activity including the delivery of care to service users, service management, performance management, corporate governance, internal and external accountability and communication. Data is used to manage and improve the ways in which the Trust achieves its business objectives. Data quality is therefore a crucial pre-requisite to information that is complete, relevant, accurate and timely. Poor data quality may lead to: Avoidable serious incidents occurring. Staff and service users being put at risk through invalid or incorrect decisions being made about a service user s care. Lack of confidence in the validity of the recorded/reported information. Adverse results from the Care Quality Commission Poor management decisions relating to the trust both internally and externally. Loss of income to the trust (through current commissioning reports and future payment-by-results). Lack of credibility of the organisation and by implication of its profile and standing in the eyes of its peers, service users and carers and the public sector. The aim therefore is to provide and sustain a high level of data quality in order to provide meaningful information for corporate purposes, patient care and the delivery Approved June 2014 Page 3 of 15 Our Ref: POL/002/064

4 of external performance standards and targets. Ensuring information is robust is therefore vital to meeting the Trust s business needs. In order to achieve and maintain a high level of quality data it is important that the Trust puts in place processes for assessing, measuring, reporting, reacting to and controlling the risks associated with poor data quality. The aim of this policy therefore is to provide the framework for establishing, maintaining and improving the quality of data across Cumbria Partnership Trust. Data can only be regarded as fit for purpose if it is: Valid Complete Consistent Accurate and up to date Relevant Available when required Secure in compliance with Data Protection Act and Caldicott Guidelines 3 STATEMENT OF INTENT The Trust requires accurate timely, relevant and standardised patient information in order to support both the delivery of its core business objectives, and to monitor activity performance for both internal and external management purposes. A vital pre requisite for the production of robust information is the availability of high quality data across all areas of the Trust. The requirement of accurate patient data has become more prominent in recent years because of a growing emphasis within the NHS for the measuring performance against nationally set standards and targets. In addition legislation through the Data Protection Act 1998 requires the Trust to ensure that it meets the fundamental principle of ensuring that personal data held by the Trust is accurate, relevant, complete and up to date. In order to achieve the above requirements therefore the Trust will; Focus on data quality that will underpin the local business needs and fit with key strategic developments. Ensure that data quality is a fundamental feature within the development of care pathways, and clinical governance. Commit to the delivery of the electronic patient record. Ensure compliance with legal and statutory requirements, and NHS good practice guidelines and requirements. Approved June 2014 Page 4 of 15 Our Ref: POL/002/064

5 4 DEFINITIONS Data Protection Act The provisions detailed within the Act provide the statutory guidance for the protection and use of personal information. Commissioning data sets Minimum data sets containing information relating to patient care and are used by commissioners and other external bodies such as monitor and CQC for monitoring activity and performance. Information Assets The primary information systems used for the capture and maintenance of data within the Trust. Information Asset Owner (IAO) The individual with responsibility for the management of an information system. Information System Administrator (IAA) The individual with responsibility for the day to day administration and operation of an information system. The Information Governance Toolkit This provides a framework for assuring information quality requiring the monitoring of key data items against national definitions. Information Set Change Notices (ISCNs) Guidance produced by the Information Centre to inform Trusts about and planned changes to national data standards. System Level Security Policy (SLSP) Document setting out the operational arrangements for the management of an information asset or system. 5 DUTIES Chief Executive The Chief Executive has overall responsibility for data quality. Board of Directors The Board of Directors have responsibility for setting the strategic context and for the formal review and endorsement of Information Governance policies and procedures including data quality. Director of Strategy and Support Services The Director of Strategy and Support Services has Executive responsibility to the Trust Board for ensuring that the appropriate systems and processes are in place to Approved June 2014 Page 5 of 15 Our Ref: POL/002/064

6 manage data quality. The Director of Strategy and Support Services is the Trust Senior Information Risk Officer (SIRO). Deputy Director of Information The Deputy Director is the senior manager responsible to the Director of Strategy and Support Services for the overall strategic an operational direction of information management sand technology services within the Trust which includes health records and data quality The Head of Information Management The Head of Information Management is responsible for overseeing the management of data quality and for ensuring compliance with the legal obligations and NHS standards. The Health Records and Data Quality Manager The health records and data quality manager has operational management for the health records and data quality team and ensuring that the systems and processes for delivering good data quality are in place within all services areas The Health Records and Data Quality Group The Data quality and Systems Board is responsible for: Directing and performance managing the development and implementation of data quality strategy and policy as part of the wider information governance agenda. Monitoring the Trust s information handling activities to ensure compliance with the law and NHS policy and guidance. Ensuring that training and awareness on data quality is made available for all staff where this is required to support their role. General Managers, Heads of Service and Senior Managers Ensure that staff are aware of and comply with appropriate trust policies and procedures and changes within policies are reflected in practice. Ensuring staff are aware of their responsibilities. Ensuring that support is provided to enable the timely, accurate and complete input of data onto the appropriate trust information system. Ensuring that all staff are aware of their responsibilities with regard to checking and maintaining up to date demographic and data. Ensuring that any data quality issues identified are addressed quickly and reported to the IAO and IAA. Ensuring that all working procedures are fully documented regularly updated and available to all staff. Monitoring staff knowledge and skills for using the information systems and identifying any training needs. Monitoring compliance with this policy and appropriate use of information systems as detailed in the system level security policy (SLSP). Ensuring that communication flows exist between the clinical and corporate services to facilitate the resolution of data quality issues. Approved June 2014 Page 6 of 15 Our Ref: POL/002/064

7 Ensuring that any data quality issues identified are addressed quickly and reported to the information asset owner. Ensuring that all job description support the responsibilities within this policy and enforce the role s responsibility on ensuring accuracy and completeness of data. All staff working within Cumbria Partnership NHS foundation Trust All staff who record patient information whether on paper or within electronic system have a responsibility to take care to ensure that the data is accurate, and complete as possible. All staff including temporary or agency staff are responsible for: Compliance with relevant policies. Failure to comply may result in disciplinary action being taken. Co-operating with the development and implementation of policies and as part of their normal duties and responsibilities. Compliance with polices and supporting documents. Ensuring the timely accurate and complete input of data onto the appropriate trust information system or data recording sheets. Ensuring that they have the appropriate level of knowledge and skills for using the information systems. Where staff have responsibility for maintaining information but do not enter the data themselves they must provide input staff with the fully completed data sheets in a timely manner and ensure that the data entered is accurate and complete. Undertake regular validation checks of data collection and input to confirm that the data for which they have responsibility for is accurate, complete and up to date. Monitoring the data held for any data quality issues and reporting any concerns to the appropriate information asset owner or administrator. Identifying the need for a change in policy as a result of becoming aware of changes in practice, changes to statutory requirements, revised professional or clinical standards and local or national directives and advising their line manager accordingly. Identifying training needs in respect of policies and procedures and bringing them to the attention of their line manager. Attending training and awareness sessions as required or completing training materials when provided. Information Asset Owner (IAO) Maintaining data standards in accordance with national developments in relation to the system for which they are responsible. Ensuring that the system facilitates the collection of high quality data in accordance with national standards. Monitoring and disseminating changes implemented by information change notices. Establishing and disseminating monitoring reports from the system to appropriate staff and service detailing key data quality issues. Reporting any concerns to the appropriate service manager. Approved June 2014 Page 7 of 15 Our Ref: POL/002/064

8 Ensuring that any data quality issues are reflected in the System level security policy when information assets are implemented upgraded or changed. Logging any information security issues relating to data quality with the Information Governance Department. Data Quality Team The data quality team are responsible for identifying and assessing any data quality issues and to work with information asset owners and managers and members of staff to ensure that data issues are resolved To monitor data quality issues and to validate data reports for internal and external submissions To provide mangers with tools to enable them to monitor data quality To support staff in delivering good quality data Ensuring that all managers and staff are kept up to date with current guidance on data quality 6 KEY THEMES 6.1 Data Quality Standards Trust Systems must be kept up to date. This is essential to ensure that they accurately reflect the activity undertaken by the Trust and to accurately reflect changes to national standards and data definitions. Mechanisms will be established to ensure that updates are disseminated efficiently and effectively. Standard operating procedures These will be put in place for each information asset to facilitate the capture of data. The following standard operating procedures should be followed in order to ensure that data captured meets the data quality standards defined within the Information Governance Toolkit. As a minimum the following procedures will be documented: Registering a referral Recording activity, contacts, appointments, failures to attend and cancellations, outcomes from attendance and the referrals to treatment (RTT) status of all patients on the 18 weeks pathway Adding patients to waiting lists Recording details of clinical activity and clinical coding Recording discharge arrangements Managing duplicate and confused records Procedures are detailed descriptions of the processed by which policies are carried out and should contain details of: The person in overall control of the policy or process Other persons involved Approved June 2014 Page 8 of 15 Our Ref: POL/002/064

9 Any definitions appropriate to the document The data quality elements of any procedure must be defined in a way that is clear and unambiguous to any person expected to carry out the tasks. They should reflect nation and local standards Procedures should be reviewed at least once a year to take account of any changes in national standards and definitions. Tight version control is essential so that staff in all parts of the trust are using the same procedures which reflect current data definitions. Procedures should be published on the Trust intranet NHS Number This is the primary patient identifier in the NHS. The NHS Number should be used as the key identifier to reference patients who have their data stored electronically. The NHS Number should be quoted in all correspondence about a particular named patient. The only exceptions are for patients who do not have an NHS Number (e.g. patients from Scotland or Overseas) when a suitable alternative means of identification shall be used. The use of the NHS number should greatly reduce the number of duplicate system records for patients. Training All users of computer systems will be trained on the system or systems appropriate to their clinical needs. Training is given within the Information Management Department. Users must agree as part of their contract of employment to maintain confidentially in line with local, national, professional and legal requirements. Job descriptions These should for each member of staff reflect the specific and general responsibilities for encouraging good data quality. Responsibility should be assigned and monitored through the supervision d appraisal system. This should provide an important mechanism for increasing staff awareness of their role in improving data quality. Validity All data items held on trust computer systems must be valid. Where codes are used, these will comply with national standards or will map to national values. Wherever possible, computer systems will be programmed to only accept valid entries. Validity has two meanings The data must be clinically valid that is the correct clinical information such as the appropriate diagnoses must be recorded within the patients case notes and reflected on the electronic patient record system. The correct coding structures must be used to record the data and these muse comply with national standards and guidelines. Approved June 2014 Page 9 of 15 Our Ref: POL/002/064

10 Completeness All mandatory data items within a data set should be completed. Use of unknown or not stated codes will only be used as a last resort, and not as a substitute for real data. If it is necessary to bypass a data item (for example, in order to admit a patient into hospital), the missing data should be added as soon as practical. Consistency Data items should be internally consistent. Patients with multiple episodes must have consistent dates. Diagnoses and treatments must be consistent for ages and sex and must be coded in line with clinical coding guidance and in line with the clinical coding policy. Coverage Data will reflect all the work done by the Trust. Admitted patient care (inpatients), outpatient attendances, and community contacts should all be recorded. Correct procedures are essential to ensure complete data capture. Data Quality reports will be used to identify any missing data. Accuracy Data recorded in paper clinical notes and on computer systems must accurately reflect both what and when activity happened to a patient. Reference tables will be updated regularly. Every opportunity should be taken to check patient s demographic details with the patient themselves. Inaccurate demographics may result in records being mislaid, or incorrect identification of patient. Checks on patient data should be done at every appointment or review to ensure that the most up to date information is held by the Trust. Timeliness Recording of timely data is beneficial to the treatment of the patient. Recording diagnosis and treatments makes that information available to all staff treating the patient, even if they do not have access to the paper notes. All data will be recorded to a deadline, which will enable that data to be included in the national deadlines. The accurate recording of data items must, however, not be allowed to delay urgent treatment of patient. Information Reporting A significant amount of information is reported through the trust reporting systems (ipm reporting tool, provider reporting tool, CHIPS, Community dashboard). These are updated at regular intervals. Depending on which systems is in place managers and clinicians can access a range of data relating to their area of work. Anomalies in data or variances in trends or activity levels should be identified and investigated Identifying and Correcting Errors and Omissions Issues relating to data quality will be identified and mechanisms will be in place to deal with these. Support to manage data quality issues will be managed through the Data Quality Team. Approved June 2014 Page 10 of 15 Our Ref: POL/002/064

11 Routine Quality Checking The Data Quality Team run regular validation checks as part of the overall data quality improvement procedures Omissions Coding Completeness report Monthly review of finished consultant episode (FCEs) which have not been clinically coded Missing data reports Monthly report showing patients with no NHS number, no registered GP, post code or ethnic status Outcome an attendance reports - Report s showing where patients have not been seen within specific periods of time Errors Validation reports identifying RTT errors Validation reports on consistency between paper and electronic information Information analysis will highlight significant variations in activity levels an investigate to ensure that the variations are real rather than the result of poor data capture The strategy is to move away from this retrospective checking ad correction and strive as far as possible to identify an eradicate poor practices with robust procedures, guidance, awareness and training The general approach to the correction of data should be that where examples of poor data quality are uncovered the audit trail should be used to identify the member of staff responsible for the error or omission. The identified person should then be asked to take corrective action and be made aware of the implications of the errors and the importance of accuracy Errors should be amended as soon as possible after they have been identified Measurement of good data quality Apart from internal measures there are a number of tools available to assist the trust in assessing performance regarding data quality HES data quality indicators SUS data quality indicators Coverage reports available through SUS Complaints and queries Internal and external audit reports on data quality Information Governance Toolkit Approved June 2014 Page 11 of 15 Our Ref: POL/002/064

12 6.2 Monitoring and reporting data quality issues Documented Procedures Careful monitoring and error correction can support good quality data, but it is more effective and efficient for data to be entered correctly first time. In order to achieve this, good procedures must exist so that staff can be trained and supported in their work. Details of these procedures, training and processes are available within each Service and from the Data Quality Team. The Trust will aim to be significantly above average in all indicators and will strive for 100% accuracy. The Trust will act on all enquiries and complaints from commissioners or patients. Measurement of Good Data Quality Data quality will be subject to control processes within the Trust and also be assessed externally as part of audit scrutiny. The Health Records and Data Quality Manager will report to the Health Records and Data Quality Group on data items, which have been identified as causing concern. Internal monitoring reports will be used to inform operational managers to target and improve processes, identify training needs and develop further documentation and guidance to support clinical and administrative staff responsible for capturing data at its source. The trust will regularly monitor an audit its data quality practices for compliance with this policy The audit will:- Identify areas of operation that are covered by the Trust s policies and identify which procedures and or guidance should comply to the policy Follow a mechanism for adapting the policy to cover missing areas if these are critical to processes and develop a plan if there are major changes to be made Set an maintain standards by implementing new procedures including obtaining feedback where the procedures do not match the desired levels of performance Highlight where nonconformance to the policy is occurring and suggest a tightening of controls and adjustment to related procedures 6.3 Risk Management Information collected on the trust s information systems is used to inform clinical care, manage resources, record financial flows and to improve services within the trust. If data is not collected efficiently and effectively a number of risks can occur. Incomplete or inaccurate demographic details can impact on patient care. The inconsistent collation of key data items may result in unsuccessful and ill informed decisions for service improvement. The inaccurate recording of contact information can impact on resources. Approved June 2014 Page 12 of 15 Our Ref: POL/002/064

13 Poor data quality presents a risk to planning and performance management. Failure to record key data items may result in a lack of payment for trust services by commissioners and the ability to obtain the correct funding under payment by results. The Health Records and Data Quality Group will monitor and ensure that appropriate action is being taken against any risks that are identified relating to data quality issues. Data quality risks will be included in the quarterly report on information governance submitted to the Governance, Quality and Risk Committee. 6.4 Legislation and Data Standards The Data Protection Act 1998 This legislation applies to computerised and manual records for living individuals. Under the provision of the Act individuals have a number of rights including the right of access and the right to take steps to rectify or destroy inaccurate data. Principle 4 of the act states that personal data shall be accurate and kept up to date. This provides a legal requirement to maintain and update all patient records to ensure that they correctly reflect the patient's demographic details and clinical care. Confidentiality The NHS Confidentiality Code of Practice 2003 emphasises the importance of maintaining comprehensive records to patient care. If records are inaccurate, future decisions may be wrong and harm the patient. If information is recorded inconsistently then records are harder to interpret resulting in delays and possible errors. The information may be needed not only for the immediate treatment of the patient and the audit of care but also to support future research that can lead o better treatments in the future. Information Set Change Notices (ISCNs) These are issued on a regular basis to inform about and support changes to national standards. Trust must ensure that information systems support the decisions established within the data dictionary and the ISCNs and that these are also reflected within care pathways. Clinical Coding Processes to support the standards established within the NHS Clinical Coding Manual must be in place to ensure that the coding of clinical data is accurate, complete and timely and complies with ICD!0-4 and OPCS Professional Obligations The General Medical Council The GMC code of professional conduct states that [in] providing care [medics] must Keep clear, accurate and legible records. Approved June 2014 Page 13 of 15 Our Ref: POL/002/064

14 The Nursing and Midwifery Council The NMC requires that nurses must keep clear and accurate records of the discussions you have, the assessments you make, the treatment and medicines you give and how effective these have been. 7 TRAINING Mandatory training relating to data quality will be provided in accordance with the Trust s Training Needs Analysis. Attendance at mandatory training will be managed in accordance with the Trust s Learning and Development Policy. Specific staff that are identified as the Information Asset Owners of record systems will be provided with additional ad hoc training that outlines their responsibilities and provides them with the tools necessary for setting up and managing a record system. 8 MONITORING COMPLIANCE WITH THIS DOCUMENT The table below outlines the Trusts monitoring arrangements for this policy/document. The Trust reserves the right to commission additional work or change the monitoring arrangements to meet organisational needs. Aspect of compliance or effectiveness being monitored Compliance with data quality standards Data quality completeness Data Quality benchmarking Monitoring method Data quality and validation plan Data Quality KPIs Report Individual responsible for the monitoring Health Records and Data Quality Manager Health Records and Data Quality Manager Health Records and Data Quality Manager Frequency of the monitoring activity Monthly Monthly Monthly Group / committee which will receive the findings / monitoring report Health Records and Data Quality Group Health Records and Data Quality Group Health Records and Data Quality Group Group / committee / individual responsible for ensuring that the actions are completed Head of Information Management Head of Information Management Head of Information Management 9 REFERENCES/ BIBLIOGRAPHY Data Protection Act 1998 The NHS Confidentiality Code of Practice 2003 General Medical Council, Professional Standards Guide Good Medical Practice 2006 Approved June 2014 Page 14 of 15 Our Ref: POL/002/064

15 Nursing and Midwifery Council Code of Professional Conduct 2008 Information Governance Toolkit, Connecting for Health 10 RELATED TRUST POLICY/PROCEDURES/GUIDANCE POL/002/018 Data Protection Policy POL/002/038 Confidentiality Policy POL/002/008 Information lifecycle and Records Management Policy Procedure for dealing with confused and duplicate records POL/002/064/001 Standard Operating procedure for data validation and Benchmarking 11 CONCLUSIONS Data quality will continue to increase in importance as we move towards the new age of the electronic health record (epr). The answer to improved data quality cannot lie in increasing the amount of data routinely corrected before being sent to SUS or for other internal or external performance monitoring and commissioners. The emphasis should be on greater awareness an ownership of procedural documentation and increased opportunities for training and awareness and support through the Information Management Service. Training should make staff ware of the importance of the data they collect, why good data quality is important and of the potential cost implications to the trust and the time wastage caused by having to correct poor data quality. Improving data quality will be critical to the migration towards the electronic patient record and the increasing emphasis on recording data in real time. Approved June 2014 Page 15 of 15 Our Ref: POL/002/064