Data Quality Policy Associate Director for Corporate Information

Transcription

1 Title: Data Quality Policy Developed by: Associate Director for Corporate Information Document type: Policy Policy library: Information Governance Sub Section: Document status: Date of ratification: 10 th August 2015 Ratified By: IGSC Date to be reviewed: 10 th August 2018 HISTORY Revisions: (Enter details of revisions below) Date: Author: Description: June 2009 P Curnow New Policy Ratified March 2011 P Curnow Amended and updated April 2011 P Curnow Amendments post consultation with IGSC August 2012 B Gallagher Amended to Kernow Clinical Commissioning Group (KCCG) August 2015 K Proctor Amended and updated Distribution Methods:

2 Data Quality Policy Contents 1. Introduction 2 2. Aims 2 3. Principles 2 4. Responsibilities 3 5. Objectives 4 6. Training 4 7. Monitoring 5 8. Validation 5 9. Data Quality Standards Implementation of the Policy Related Policies & Strategies Dissemination and Implementation Audit 7 2

3 1.0 Introduction 1.1 Good quality information underpins the quality of services and operational effectiveness of an organisation. KCCG recognise that monitoring and enhancing the quality of data within KCCG is essential to the provision of patient care and the management of its services. 1.2 The effective use of information and information technology is critical to improving the quality of care given to patients. Every decision in the planning of services and the provision of care to patients should be informed and evidence based. One source of evidence is derived from the information collected about individual patients and informed decisions will depend on the availability of complete, accurate, consistent, relevant and timely data. 1.3 Significant time and effort may be wasted, and incorrect decisions about patient care may be made, unless the data available is of sufficient quality. It is vital that everyone involved in collecting, processing and using data understands the importance of maintaining data quality. 1.4 A specific programme of audits has been developed to monitor the adherence to the policy. 2.0 Aims 2.1 The purpose of this document is to set out a clear policy framework for maintaining and improving data quality within KCCG. The way in which data is collected and analysed can influence results and it is, therefore, important to have a clear and open framework in place which supports the data collection process and accurately reflects the practice of KCCG. 2.2 The Data Quality Policy sets out how KCCG will collect analyse and report data from the moment a patient or referral is received into the system to the point of discharge or death. The retention and disposal of records should be consistent with KCCG Records Management Policy. 3.0 Principles 3.1 The over arching principles of the policy are; Data must be accurate (in terms of correctness). Complete (in terms of having been captured in full). Valid (it should be within an agreed format which conforms to recognised national standards and coding). Timely (collected at the earliest possible opportunity). Stored securely and confidentially inline with the Data Protection Act and Records Management Policy Used effectively and ethically Appropriately recorded 2

4 Retained and destroyed appropriately in line with KCCG Records Management Policy. 3.2 These principles apply to all data and information systems, whether paper based, or stored on computer, film, tape or any other media. All personal identifiable data must be stored in line with KCCG IT security policy. 3.3 The fundamental principle is that data quality must be built in from the moment that a system is introduced or information captured. 4.0 Responsibilities 4.1 All staff 4.2 Data quality is a key part of any information system that exists within KCCG. All staff members will be in contact at some point with a form of information system, whether paper or electronic. As a result, all staff members are responsible for implementing and maintaining data quality and are obligated to maintain accurate information legally (Data Protection Act), contractually (contract of employment) and ethically (professional codes of practice). 4.3 Data Quality is the responsibility of everyone; therefore all staff must be aware of, and follow KCCG procedures relating to Data Quality, and have attended any relevant training or awareness sessions. All staff should be aware of the importance of good data quality and their own contribution to achieving it. 4.4 Teams should have comprehensive procedures in place for identifying and correcting data errors, such that information is accurate and reliable at time of use. 4.5 Management 4.6 The Chief Executive, Directors and Senior Managers are personally accountable for Data Quality within KCCG. 4.7 All line managers are required to ensure that their staff, whether clinical or administrative, are adequately trained and apply the appropriate procedures and guidelines. Managers have an additional responsibility to ensure that local processes and documents are updated regularly, and changes cascaded to staff in the event of changes to national or local standards or guidance. 4.8 Data Quality accountability must be included in the Job descriptions of staff who have specific responsibilities for data quality. Consideration must also be given to data being supplied to external parties where there may be a risk of fraud or breach of security. 3

5 5.0 Objectives 5.1 KCCG aims to maximise the accuracy, quality and availability of data within KCCG through: The development and implementation of policies and procedures to support the data quality policy. Clear procedures for the identification, reporting, and correction of erroneous data. Compliance with National Service Frameworks, guidelines and legislation Identified data owners for information systems, with accountability for data quality Implementation of Connecting for Health (formerly known as National Programme for IT) to integrate systems and processes, and remove the need for small systems Development of secure information sharing protocols and Service Level Agreements between partner organisations including internal/external audit to ensure that the data is kept secure at all times. Use of data quality methodologies and tools for improving data quality. This should include routine validation and data checking/cleansing of data recorded, where appropriate. Reconciliation of data held on separate systems. Regular risk analysis and audit to track progress, and identify gaps. Improved culture of data quality in all staff through training and awareness. Lost data should be reported following the KCCG incident management processes. 6.0 Training 6.1 Staff will receive instruction and direction regarding Data Quality advice and information from a number of sources:- o KCCG Policies and Procedure Manuals o Line manager o Training on induction and Information Governance o Other communication methods (e.g. Team Brief/team meetings) 6.2 KCCG has a responsibility to ensure that staff are aware and are sufficiently trained to maintain high standards of data quality and confidentiality. 6.3 KCCG will assess its training programmes regularly to ensure that training is provided for all staff involved in data collection and management. Similarly training needs analysis will be carried out to identify and address the training needs of staff, particularly those involved in the collection and management of patient related data. 4

6 7.0 Monitoring 7.1 KCCG will as a matter of routine, monitor performance in collecting and processing data according to defined standards, and provide appropriate feedback to staff involved in the process of data collection. 7.2 KCCG is regularly audited to ensure that applicable legislative Acts and NHS Policies and Standards are complied with. Suitable processes are used, and controls put in place, to ensure the completeness, relevance, correctness and security of data through the Data Quality Audit carried out by the Audit Commission. 8.0 Validation 8.1 Validation should be accomplished using some or all of the following methods: 8.2 On submission of data returns, procedures will exist to ensure the completeness and validity of the data sets used. This can be done by comparing to historical data sets, looking at trends in the data and also by cross checking the data with other staff members. 8.3 Regular spot checks by staff members; which involve analysis of a random selection of records against source material, if available. Spot checks should be conducted on an ongoing basis (at least quarterly) to ensure the continuation of data quality, and is the responsibility of line managers, 8.4 KCCG will endeavour to ensure that timescales for submission of information are adhered to, and that the quality and accuracy of such submissions is of the highest standard. Internal deadlines for the completion of data sets, to ensure national timescales are achieved, will be explicit and monitored. 8.5 KCCG routinely receives activity information from its service providers. This information is used to monitor the performance of contracts and to contribute to the service planning and development process. Sufficient and appropriate checks are made by the service providers to ensure that the information received is accurate and complete. Where data falls outside anticipated ranges a more detailed evaluation and validation is undertaken. 8.6 KCCG conduct regular monthly Technical Group meetings with its local trusts, to ensure that any data discrepancies are picked up and any corrections are made as required. 9.0 Data Quality Standards KCCG staff should adhere to the following set of data quality standards: 5

7 9.1 Validity 9.2 All data items held on KCCG 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. 9.3 Completeness 9.4 All mandatory data items within a data set should be completed. Use of default codes will only be used where appropriate, and not as a substitute for real data. 9.5 Consistency 9.6 Data items should be internally consistent. 9.7 Coverage 10.8 Data will reflect all the work done by KCCG. Correct procedures are essential to ensure complete data capture. Spot checks and comparisons between systems should be used to identify missing data. 9.9 Accuracy 9.10 Data recorded in notes and on computer systems must accurately reflect what actually happened to a patient. All reference tables, such as GPs, postcodes, teams will be updated regularly Every opportunity should be taken to check patient s demographic details with the patient themselves. Inaccurate demographics may result in important letters being mislaid, or incorrect identification of patient Inaccurate data must be reported and dealt with initially through members of staff line managers. Line Managers must report inaccuracies though to the Corporate Information Team. It is their role to identify potential operational or reporting issues that may be affected, and to ensure the data has been corrected in a timely manner. Line managers need to determine any further training requirements or disciplinary procedures that are necessary. The Data Quality lead should maintain a register of data inaccuracies and feed into the annual audit programme Breaches of the Data Quality policy must be taken seriously. Serious incidents should be recorded on the KCCG s incident reporting system and may be subject to disciplinary process Timeliness 9.15 All data will be recorded to a deadline this does vary dependant on data type. 6

8 10.0 Implementation of the Policy 10.1 The Director of Commissioning will have overall responsibility for implementing the Policy ensuring that the following action is taken: That the Information Governance sub-committee reviews the Policy every 3 years so that it continues to reflect best practice and the statutory, legal and business needs of KCCG; That the Policy is promoted and circulated appropriately within KCCG. Training needs are assessed and agreed during induction and appraisal. Monitoring and audit to be identified and completed at appropriate intervals Related Policies & Strategies Freedom of Information Policy Information Security Policy Records Management Policy Information Governance Policy Data Dictionary guidelines to ensure data quality NSTS (to be replaced by Personal Demographic Service (PDS) as part of the Clinical Spine Applications CSA Pseudonymisation Policy Safe haven Policy Incident reporting 12.0 Dissemination and Implementation 12.1 All new employees will be given a copy of this policy through the Induction Process and published on KCCG s Intranet Document Library Policy Distribution List: Head of Information Governance Corporate Information Managers Associate Director of Primary Care (Contracting) Associate Directors of Commissioning Associate Director for Continuing Healthcare Deputy Head of Prescribing and Medicines Management HR Managers 13.0 Audit 13.1 In order to evidence compliance with this policy, the following Training procedures annual spot checks on departmental procedures to be carried out, facilitated by corporate information department 7

9 Data Quality Audits rolling programme of departmental DQ audits to be facilitated by Corporate Information Team. 8

10 Initial Equality Impact Assessment Screening Form Initial Equality Impact Assessment Pro Forma 9

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12 Section Commissioning Officer responsible for the assessment Paula Curnow Name of Policy to be assessed Data Quality Policy Date of Assessment 28 th April, 2011 Is this a new or existing policy? Existing 1. Briefly describe the aims, objectives and purpose of the policy. 2. Are there any associated objectives of the policy? Please explain. 3. Who is intended to benefit from this policy, and in what way? 4. What outcomes are wanted from this policy? Set out a clear policy framework for maintaining and increasing high levels of data quality within KCCG Improvement in Data Quality All Staff Understanding of principles and practice of Data Quality, leading to improvement in data recording. 5. What factors/forces could contribute/detract from the outcomes? None 6. Who are the main stakeholders in relation to the policy? Staff and patients 7. Who implements the policy, and who is responsible for the policy? Associate Director for Corporate Information 8. Are there concerns that the policy could have a differential impact on RACIAL groups? What existing evidence (either presumed or otherwise) do you have for this? The policy identifies that ethnicity data will be recorded on patients both Y within the community services directorate and commissioned services. This is to ensure that analysis can inform decision making within the organisation. Collecting ethnicity data will inform decision making and ultimately have a positive affect on health inequalities. 11

13 9. Are there concerns that the policy could have a differential impact due to GENDER (including TRANSGENDER)? What existing evidence (either presumed or otherwise) do you have for this? 10. Are there concerns that the policy could have a differential impact due to DISABILITY? What existing evidence (either presumed or otherwise) do you have for this? 11. Are there concerns that the policy could have a differential impact due to SEXUAL ORIENTATION? What existing evidence (either presumed or otherwise) do you have for this? 12. Are there concerns that the policy could have a differential impact due to their AGE? What existing evidence (either presumed or otherwise) do you have for this? N Gender information is collected routinely to gain a sound picture of the population served and to help inform commissioning decisions. All key datasets are able to be analysed by gender. N To be devised. N Staff and patients with learning disabilities may require easy read version of the policy. The policy does not specifically identify collation of information on sexual orientation. Sexual Orientation is not currently collected on our systems and is not part of the current minimum data set. This could be borne in mind on the commissioning of new systems. Age data will be collected through a patient s date of birth are there N differential impacts for the handling of data concerning children or the elderly if so this could be incorporated here All key datasets are able to be analysed by age. 13. Are there concerns that the policy could have a differential impact due to their RELIGIOUS BELIEF? N Data on religion and belief is collected on our main systems. What existing evidence (either presumed or otherwise) do you have for this? Although religion is available as a data item, analysis by religious belief is only prepared on an ad hoc basis. Ward level staff can request a religion print to identify the beliefs of patients currently receiving care. 12

14 14. Could the differential impact identified in 8 13 amount to there being the potential for adverse impact in this policy? 15. Can this adverse impact be justified on the grounds of promoting equality of opportunity for one group? Or any other reason? 16. Should the policy proceed to a full equality impact assessment? N N N Identified actions are positive with improved outcomes, there will be no adverse impact Only if no adverse impact identified. Only if adverse impact identified 17. If Yes, describe why, then proceed to a full EIA. 18. If No, are there any minor further amendments that should take place? See comments 19. If a need for minor amendments is identified, what date were these completed and what actions were undertaken. Signed (completing officer).. Signed (Head of Section).. Date Date Please ensure that a signed copy of this form is sent to both the Policies Lead and the Equality and Diversity lead to be placed on KCCG website. 13