1 Welcome to the twentieth edition of the information governance bulletin Our regular bulletin about information governance and the work of the IG transition programme Publication Gateway Reference: Information Governance Bulletin In this Edition Page 2: NHS Number survey About this Bulletin Page 2 Update on SIRIs Page 4: Feedback sough This bulletin sets out the work that NHS England is carrying out on behalf of the NHS to overcome the information governance (IG) issues created by the legal and organisational changes introduced by the Health and Social Care Act This bulletin is written for anyone who uses data for secondary uses, such as commissioners inside NHS England and within CCGs, data analytics providers, those working in clinical audit, researchers, managers, clinicians, and patients.
2 Welcome to the 20 th edition of the IG Bulletin With the long nights drawing in, what better time to curl up with a few information governance consultation papers? We ve three to bring to your this month covering records management, data sharing, and working with the voluntary sector. We also have updated on SIRI management and the results of the NHS Number programme. A Merry Christmas and a Happy New Year to all our readers! Stuart A Notholt Editor England in their use of the NHS Number when sharing information for direct care. The NHS Number Survey was launched on 1 July 2014 and aimed at Trusts across all services in England. A 100% response rate was received. The survey results have enabled NHS England to build a comprehensive picture by Trusts across England of use of the NHS Number in direct care. The results have highlighted a number of areas to be taken forward in improving the use of the NHS Number. NHS England will now work with regional teams, CCGs and Trusts to further drive the widespread adoption of the NHS Number as the primary identifier in all clinical correspondence. Checklist guidance for reporting, managing and investigating SIRIs The Health & Social Care Information Centre has recently published Checklist guidance for reporting, managing and investigating information governance Serious incidents requiring investigation (IG SIRIs) This guidance covers the reporting arrangements and describes the actions that need to be taken in terms of communication and follow up when an information governance SIRI occurs. It supports health, public health and adult social care service commissioners, providers, suppliers and staff in ensuring that: NHS Number Programme Survey results published NHS England has published the NHS Number Survey Report, a national baseline report across all Trusts in Further information can be found at /nhs-number/ the management of IG SIRIs conforms to the processes and procedures set out for managing all Serious Incidents Requiring Investigation; there is a consistent approach to evaluating IG SIRIs; Information Governance Bulletin, No.20, December
3 early reports of IG SIRIs are sufficient to decide appropriate escalation, notification and communication to interested parties; appropriate action is taken to prevent damage to patients, staff and the reputation of healthcare, public health or adult social care; all aspects of an IG SIRI are fully explored and lessons learned are identified and communicated; and that appropriate corrective action is taken to prevent recurrence; Caldicott 2 recommendations are addressed; there is transparent reporting of incidents; contractual obligations are adhered to with regards to managing, investigating and reporting IG SIRIs in a standardised and consistent manner, including reporting to commissioners. The checklist guidance should be embedded within local processes and procedures which in turn are used by all staff involved in managing information governance SIRIs. It is important to note that much of this checklist will also be applicable to near misses. Staff should be encouraged to report IG SIRI near misses and the opportunity taken to identify and disseminate any lessons learnt. The checklist guidance is available at https://nww.igt.hscic.gov.uk/resources/ IGIncidentsChecklistGuidance.pdf IG Toolkit V12.2 enhancements to the IG SIRI Incident Reporting Tool The Health & Social Care Information Centre s external information governance delivery team have been working with the IG SIRI Design Group to review the functionality, content, and guidance that supports the IG Incident Reporting Tool. The aim in the new release of the tool is to enhance user experience, advance the reporting capability and improved understanding of the sensitivity factors that determine the severity of the incident. The full list of enhancement in the new release can be downloaded from: The IG Incident Reporting Tool is the Department of Health and Information Commissioner s Office solution for reporting both personal and confidential data breaches. It is an online product hosted on the secure Information Governance Toolkit and is accessible by all organisations registered with the IG Toolkit website, once access permissions have been granted. All organisation administrators can set themselves up and grant permissions for additional incident reporting users via the Organisation Admin section of the website. Information Governance Bulletin, No.20, December
4 The IG Toolkit website is at: https://nww.igt.hscic.gov.uk/ Records Management: Review of NHS Code of Practice The Department of Health issued the Records Management: NHS Code of Practice in 2006, with a revision of the part 2 retention guide in Given the recent changes in health and social care practice and the law, the Information Governance Alliance has decided to review and update the Code of Practice. A consultation has been opened, which runs until the end of January 2015, to enable those involved in Records Management, to comment upon the old Code, and suggest what they would like to see in the revised Code, which is due to be published towards the end of Specific consultations will take place with professional bodies and other organisations who are directly impacted by this review. Please follow the link below to take part in this consultation. https://www.igt.hscic.gov.uk/newsartic le.aspx?tk= &lnv=1& cb=f5383dd8-a764-40f8-add6-6a7b6ddca1c5&artid=125&web=yes Feedback sought on data sharing guidance Draft short guidance to help care professionals make good data sharing decisions has been published by the Department of Health in conjunction with the Information Governance Alliance. There is a duty on frontline workers to share information between health and care professionals so that patients experience good, safe and seamless care. This guidance aims to ensure that care professionals understand when they should share information and how to do it safely, and where to turn if in doubt. It sets out five rules for sharing information, designed to protect confidentiality while making sure people get the best care and don't fall between gaps in different services. Comments are welcomed from staff, patients and carers on how the guidance may be improved to make it even more useful for those making decisions about sharing information to support the care of individuals. Please visit this link to take part in the consultation. https://www.gov.uk/government/consul tations/data-sharing-for-health-careprofessionals-guidance-leaflet Information Governance Bulletin, No.20, December
5 Sharing information with the voluntary sector All those involved in healthcare have a duty of care. This duty requires that information about individuals is shared with all those involved in care where this may result in improved outcomes. This is especially true with regards to Voluntary and Community Sector (VCS) organisations, which often work with the most disadvantaged communities and are an invaluable resource for delivering integrated care. A new document from the Information Governance Alliance aims to develop guidance on how information should be shared with the voluntary sector. The document is currently for consultation and can be downloaded at /whatsnew/sharing.pdf The Information Governance Alliance exists to bring information governance resources together and provide a single source of authoritative and credible guidance to the health and social care sector. The founder organisations of the IGA are the Department of Health, NHS England and the Health & Social Care Information Centre (HSCIC). There are more details of the work of the Information Governance Alliance at: And finally From over the pond: the challenges of clinical coding in the US US commentators have been having fun with a new system of medical diagnostic codes (denominated in from 4 to 10 digits each) that is scheduled to take effect in October The Healthcare Dive blog had its laughs in a July post. The codes for "problems in relationship with in-laws" and "bizarre personal appearance" are quixotic enough, they say, but the most "absurd" codes are "subsequent encounters" (that is, at least the second time the same thing happened to a patient) for events like walking into a lamppost, or getting sucked into a jet engine, or receiving burns from on-fire water skis, or having contact with a cow beyond being bitten or kicked (since those contacts have separate codes). Also notable was S10.87XA, "Other superficial bite of other specified part of neck, initial encounter," which seems to describe a love bite (or hickey as our American cousins call it). (Acknowledgements to HealthcareDive.com, 15/7/2014) Information Governance Bulletin, No.20, December