National Workforce Data Definitions Inherited Information Standard. Human Behavioural Guidance Version 1.0

Transcription

1 Inherited Information Standard Human Behavioural Guidance Version 1.0

2 Purpose of this document The purpose of this document is to provide human behavioural guidance for the implementation and use of the National Workforce Dataset Version History Version Date Brief Summary of Change Owner s Name Draft 0.1 First draft Isis Hreczuk-Hirst Draft /03/08 Minor amendments following review by Ally Butler Draft /03/08 Amendments following Appraiser Disposition /04/08 Amendments following Appraisal Board Ally Butler Isis Hreczuk-Hirst Isis Hreczuk-Hirst For more information on the status of this document, please see the covering letter or contact: The NHS Information Centre for health and social care National Datasets Programme 4 th Floor, 1 Trevelyan Square Boar Lane Leeds LS1 6AE Tel: Fax: datasets@ic.nhs.uk Internet: Date of Issue 8th April 2008 Document Reference G:\DS\ICDS004 National Workforce Dataset\Working\ISB working\nwd - Human Behavioural Guidance v1.0.doc Copyright 2008 The NHS Information Centre for Health and Social Care, National Datasets Service. All Rights Reserved. Copyright This work remains the sole and exclusive property of The NHS Information Centre and may only be reproduced where there is explicit reference to the ownership of The NHS Information Centre. This work may only be reproduced in a modified format with the express written permission of The NHS Information Centre Author: Isis Hreczuk-Hirst i

3 Contents 1. Introduction Background Guidance Scope Approval Status Occupation Codes Collection and reporting Audit Audit Committee Standards for Better Health Quality Assurance of Data Organisational and cultural issues Contractual Issues Education and development Training Needs Kbase (ESR Knowledge Management System) Health Care Workforce Skills for Health Further Information and Support... 8 Appendix A - What Makes Good Quality Data... 9 Appendix B Standards for Better Health...10 Author: Isis Hreczuk-Hirst ii

4 1. Introduction This document outlines the issues that may need to be considered when using the National Workforce Definitions Dataset (NWDD) as an information reference tool. The NWDD sets out common definitions for people who plan workforce at strategic, national and local levels. 2. Background The National Workforce Dataset data definitions were developed in partnership with all key stakeholders across the workforce planning community from the original Körner review of workforce information (1984), the workforce data manual (1995), and Department of Health central returns, following comprehensive consultation and testing exercises over many years. The NWDD is designed to help NHS colleagues and deaneries to identify the many workforce data items that have been in existence since the Körner review, and to show how the data items have been mapped to influence the creation of the Electronic Staff Record (ESR) solution. The NWDD demonstrates not only how the workforce data items interrelate with the ESR solution, but how the data items have evolved over the years to fit the needs of Department of Health central returns. The review of information needs (as a result of A Health Service of all the Talents: Developing the NHS Workforce April 2000) recommended and received Ministerial support in 2001 for action on improving workforce planning information by stating: There is a pressing need for a national workforce dataset and dictionary. This should be centered on the workforce information requirements of WDCs (Workforce Development Confederations) and Deaneries. A common dictionary of definitions is also needed so that terms are used consistently and appropriately across the NHS and, so far as possible, the wider health care sector. 3. Guidance 3.1. Scope The NWDD is not a data collection, however it exists to support workforce data collections. It should not be used as or instead of an operational HR dataset as many more data items are needed for workforce planning. The NWDD sets out those data items required for planning, not for employee administration or HR management. It is not a replacement for the Deans Dataset or the PWA and INTREPID systems used by Deaneries. Deaneries are responsible for postgraduate medical and dental training in regional / geographical locations. They are tasked with improving the quality of patient care by ensuring a supply of doctors and dentists who are educated, trained and motivated to play their part in a first class modern health service. They do this by being responsive to the government's national objectives for health and social care, the local context in which these doctors and dentists work, and the changing needs and expectations of the patients they serve. To be able to do this they have collected an agreed minimum dataset through the use of such systems as INTREPID that contains the key data items that have Author: Isis Hreczuk-Hirst 1

5 been necessary to aid planning and commissioning of postgraduate education. The developers of the INTREPID system (developed circa 1996) have been working closely with the ESR project team to develop an interface between the systems. This interface will enable Deaneries and Trusts to share and exchange personnel and appointment information (eliminating the need for dual keying) and ensuring that data is captured at the appropriate source. These systems contain many additional items that are needed for the day to day management of doctors and dentists training programs. Therefore the NWDD does not cover: Frequency of collections Technical specifications of collections Volume or coverage of collections Systems / system requirements of collections 3.2. Approval Status This document forms part of the documentation needed to gain approval from the Information Standards Board for Health and Social Care (ISB HaSC) as an Inherited Standard. Although the NWDD does not at present have Review of Central Returns (ROCR) approval as it is only a reference dataset, it can be used by NHS organisations when completing central workforce returns such as the following: Non medical workforce census (ROCR/OR/0086/WEIS/FT6/009) Medical and dental workforce census (ROCR/OR/0085/FT6/008) Earning survey (ROCR/OR/0088) Sickness/absence collection (This is part of "Workforce Collection - FIMS T12, T13, PCT17, PCT18, SHA14, SHA14A - ROCR/OR/0185) Workforce Monitoring Database (Not ROCR approved) HR Balanced Scorecard (Not ROCR approved) 3.3. Occupation Codes Occupation codes are the traditional way of identifying numbers of staff in particular work sectors of the NHS in a consistent way. Occupation codes cover all staff in the Hospital and Community Health Service (HCHS), both medical and non-medical. In April 1995 a simplified set of codes was introduced which were not dependent on payscale information to classify staff. The manual covers NHS staff by their main functional groupings and is arranged into nine sections. The manual has been prepared as an aid to the coding of staff to these new occupation codes and is subject to continuing review. This can be found at: Author: Isis Hreczuk-Hirst 2

6 3.4. Collection and reporting With the NWDD data items being made available for collection through the implementation and national rollout of the ESR, IT training in the use of the system will be needed for all data entry staff. For many organisations, the implementation of ESR / electronic systems will be phased in over a period of time with due reference to the finances available to support development. All members of staff within the relevant department will need to be involved to ensure that the data is captured via an integrated approach, at the appropriate time and that all staff can benefit from use of the NWDD. Regardless of whether or not the NWDD is collected electronically, training needs to ensure data definitions are clearly understood (knowledge and interpretation of new dataset items) and training should cover data abstraction techniques including capturing source workforce data. Awareness of coding levels / responsibilities must be widely and appropriately disseminated. The collection of the dataset will, in practice, be the responsibility of the whole team with different members responsible for the capture of different sections. Underlying this is the understanding that the people providing the data are motivated to provide correct data and that the benefits of collecting the data outweigh any costs involved. Data collection must be: Focused on the organisation s assessment and improvement needs Flexible to take advantage of any data source or method that is feasible and costefficient Simple and aligned with the organisation s needs to provide clear, relevant information Consistent to allow comparisons and easy transition from one dataset to the next 3.5. Audit A general definition of an audit is an evaluation of a person, organisation, system, process, project or product. It is performed to ascertain the validity and reliability of information, and also provide an assessment of a system's internal control. Most NHS organisations will have a policy for non-clinical audit which assists in creating best practice within the workplace. The term non-clinical audit is used to encourage individual departments across organisations to assess whether their identified activities are achieving standards, for example the recruitment process or outcomes for training. There can be many stages to an audit such as the following: Select priority Topic and Objectives / Problem Identification Review Literature for criteria Set Standards Design Audit / Determine methodology Collect & Analyse data / compare performance with standards Feedback Findings Make an Action plan Author: Isis Hreczuk-Hirst 3

7 Review Standards Re-Audit Or it can be as simple as Planning, Documenting, Evaluating, Testing and Reporting. The 2005 NHS Audit Committee Handbook provides a model Terms of Reference; it recognises that the requirement for a Statement on Internal Control, informed by an embedded system of assurance, is joined by a clear public declaration on the Standards for Better Health, that requires Boards and Audit Committees to consider the whole system of internal control Audit Committee The Codes of Conduct and Accountability (April 1994) set out the requirement for every NHS Board to establish an Audit Committee. This reflects established best practice and the constant principle that the existence of an independent Audit Committee is a central means by which a board ensures effective internal control arrangements are in place. The primary role of the Audit Committee is to conclude upon the adequacy and effective operation of the organisation s overall internal control system. It predominantly focuses on the risks, controls and related assurances that underpin the delivery of the organisations objectives The duties of the Audit Committee can be categorised: Governance, Risk Management and Internal Control Internal Audit External Audit Management Financial Reporting Reporting Other Assurance functions Standards for Better Health Standards for Better Health ( represented the Government s response to the consultation on the health care standards. It puts quality on the agenda for the NHS and for private and voluntary providers of NHS care. The standards describe the level of quality that healthcare organisations, including NHS Foundation Trusts, and private and voluntary providers of NHS care are expected to meet, in terms of safety, clinical and cost effectiveness, governance, patient focus, accessible and responsive care, care environment and amenities, and public health. Core standards are based on a number of standards or requirements that already exist and describe a level of service which is acceptable and which must be universal. Healthcare organisations must comply with these standards. Developmental standards are broad based and comprehensive in their scope and are framed so as to provide a dynamic force for continuous improvement. Organisations are assessed through national review against their progress for achieving these standards. Appendix B references the domain of Governance, as this looks at probity, quality assurance and quality improvement to ensure they are central components of all the activities of the health care organisation. The development of Actions Plans may identify the need to analyse current workforce requirements in line with service planning. This would, for example, help in achieving Author: Isis Hreczuk-Hirst 4

8 developmental standard D5 a) Having an appropriately constituted workforce with appropriate skill mix across the community Quality Assurance of Data Data quality can be defined as the extent to which information remains accurate, complete and fit for purpose across the organisation. There is often a need to raise awareness amongst staff of the need for accurate recording of administrative or organisational information whether it is via employee notes or electronically. If the NWDD is used to inform any organisational decisions, then certain fields need to be verified or entered by suitably trained staff. National guidelines may be needed for data checking to ensure consistent quality is maintained. To ensure that data collection and analysis is applicable to the decisions that will be made from the analysis, it is important to verify and validate the data. Verification ensures that the data collected represents the data desired that a dataset meets a specified set of criteria. Validation is the comparison of the data with the requirements specification. Together, verification and validation check for any oversights or deviations from requirements, and identifies them. It is recommended that organisations provide awareness days or internal management meetings to raise awareness of the impact of data quality issues and promote the principles of data validation and data quality. Staff with the greatest interest in the data are most likely to enter information with completeness and accuracy. There is a great deal of duplication of data collection on various systems. With duplication there is a risk, especially where data is being input manually, of inconsistency across the Trust and error in interpretation. Systems for collecting or carrying the NWDD will need to integrate with existing systems to pull across information without the need for manually re-inputting. To allow for consistent data quality in the collection of the NWDD, organisations could: Build data quality assessment into normal work processes, including ongoing reviews or inspections Use software checks and edits of data on computer systems and review their implementation Use feedback from data users and other stakeholders Compare with other sources of similar data In this case, any data that is incorrect can potentially impact the quality of the data and any decision made from that data. Thus, poor quality data can have a negative impact on an organisation since many management decisions are based on quantitative analysis. There is also a danger that good performance may not be recognised and rewarded. The level of data quality can be measured against four criteria: Accuracy (rate of error) Completeness (reporting of data as required) Consistency (application of criteria yields similar results) Currency (age of data relative to time of collection and collection frequency) The Audit Commission however sets out six key characteristics that can be used to define good quality data: Author: Isis Hreczuk-Hirst 5

9 Accuracy Validity Reliability Timeliness Relevance Completeness For further details on this please see Appendix A What Makes Good Quality Data. Incomplete, inaccurate, or missing data increases the risk of incorrect reporting of findings and trend analysis. Moreover, having to erase data to fix a particular problem is expensive and time consuming. Implementing a data quality process leads to improvements in data quality and can lead to more informed management, strategic planning, and decision-making. Assuring data quality must be a planned activity. The use of the NWDD through the NHS Data Dictionary will help to ensure proper data standardisation and consistent use across the NHS and other identified sectors. The process undertaken for the development of the NWDD as an ISB Inherited Standard ensures that validation and verification has been undertaken on the items that form the reference dataset Organisational and cultural issues Any usage of the NWDD through manual implementation may take a significant amount of time to set up initially, and this would have to be considered through departmental resources and job roles, and would depend on the skills of the staff involved. There needs to be clear identification of the roles and responsibilities for organisations and personnel involved collecting each part of the dataset. Near real time entry needs to be the goal. This requires systems to be constantly available, and they therefore have to have high levels of resilience. A Trust or Deanery may feel that they need to gather more information than that currently contained within the ESR or through current workforce censuses. The financial implications of undertaking a needs analysis, local collections or surveys using the NWDD to gather further requirements would need to be investigated both in terms of spending and savings at local organisational level. It is noted that any costs incurred would have to be met by the Trusts directly. Funding may need to be made available for equipment hardware and software, to train all levels of staff, to plan and manage changes to local data collection processes and to cover the continuing maintenance of the process. However, with the ongoing implementation and rollout of the ESR, these costs would substantially be reduced. The NHS Information Centre for health and social care s ESR Data Warehouse Utilisation Programme aims to exploit the information accessible through the Electronic Staff Record and its Data Warehouse. It provides an opportunity to modify current ways of working and develop new solutions to significantly improve the collection of data and the delivery of workforce information. This would in future negate the need for trusts to maintain locally developed legacy systems. It is important that data collection should not depend on a single individual. There need to be contingency plans to manage circumstances of sickness. Author: Isis Hreczuk-Hirst 6

10 3.8. Contractual Issues These will vary, depending on the types of staff used for data collection. For example, staff involved in data entry with no human resources / personnel knowledge may require training. Job descriptions for various staff may need to change for job analysis / recruitment purposes. Where collection of the NWDD may involve different departments, it needs to be clarified where the composite record will reside and under whose responsibility Education and development It is important to develop the skills and knowledge of managers, and other professional staff to understand the cultural change that new technology and new ways of working will bring to their organisation. An important aspect of culture change is to ensure that workforce information management is seen as a key component of the role of human resources / payroll professionals. This means that relevant aspects such as the importance of datasets need to be embedded into human resources / payroll professionals' learning at an early stage of professional development, and continue as a theme throughout lifelong learning. If the dataset is implemented electronically, the European Computer Driving Licence (ECDL) is recommended to improve basic IT skills where paper-based systems are currently used. ECDL has been established as a standard for basic IT skills across the NHS. (Note: The European Computer Driving Licence (ECDL) Service offered by NHS Connecting for Health has been replaced by the Essential IT Skills Programme (EITS). See Training Needs The NHS realises that if it is to provide the healthcare services that people will need in the future, it has to plan ahead to ensure it has a workforce that is able to deliver these services. There are a range of government initiatives that are aimed at providing resources and development of solutions that will help to deliver a skilled and flexible UK workforce. There are many other resources available, including training courses, e- learning and diplomas available to those staff involved in workforce planning Kbase (ESR Knowledge Management System) Kbase ( is the Knowledge Management System for ESR which provides answers to all the commonly asked questions about ESR functionality and the implementation approach. It is a web based tool that enables the user to access a range of important information primarily relevant to local ESR implementation. It is aimed at Group Project Managers, HR and Payroll Leads in particular, but is available to anyone involved in the implementation of ESR. ESR Leads will have access to information about ESR training, contact details for members of the ESR Project team, as well as key lessons learnt Health Care Workforce The NHS healthcare workforce portal ( provides a one-stop access to NHS healthcare workforce planning information, knowledge, intelligence and practical tools. As part of a programme of work to improve workforce planning capability and capacity within the NHS, NHS National Workforce Projects has developed a selection of development menus for 2007/2008. Author: Isis Hreczuk-Hirst 7

11 This approach is designed to allow people from different career paths and roles that input workforce planning to select the educational resources and supporting tools that will suit them. It allows a programme to be developed that will support workforce planning at all levels - giving a range of core skills and competences. The levels that have been identified are 1) Introduction to Workforce Planning, 2) Operational, 3) Workforce Planning for Service Commissioners and 4) Workforce Planning for Directors and Leaders Skills for Health Skills for Health s ( specific aims are to: Develop and manage national workforce competences Profile the UK workforce Improve workforce skills Influence education and training supply Work with our partners Although aimed at skills training it is a good resource for retrieving information for those involved in workforce planning. One of the main functions of Skills for Health is to develop National Occupational Standards (NOS) and National Workforce Competences (NWC) for use within the health sector. The NOS / NWC development links, where applicable, to key government agendas, such as National Service Frameworks, key targets, and the Knowledge and Skills Framework (KSF) as part of Agenda for Change Further Information and Support Queries regarding Workforce can be directed to: The NHS Information Centre for health and social care Contact Centre: Tel: enquiries@ic.nhs.uk Workforce and Facilities : enquiries@ic.nhs.uk Standards and Classifications: datasets@ic.nhs.uk Queries on the Occupation Code Manual: enquiries@ic.nhs.uk NWDD v2.0 and Classifications and Codes v2.0 temid=82 Occupational Codes: Author: Isis Hreczuk-Hirst 8

12 Appendix A - What Makes Good Quality Data Dimension Accuracy Validity Reliability Timeliness Relevance Completeness Data should be sufficiently accurate for its intended purposes, representing clearly and in sufficient detail the interaction provided at the point of activity. Data should be captured once only, although it may have multiple uses. Accuracy is most likely to be secured if data is captured as close to the point of activity as possible. Reported information that is based on accurate data provides a fair picture of performance and should enable informed decision making at all levels. The need for accuracy must be balanced with the importance of the uses for the data, and the costs and effort of collection. For example, it may be appropriate to accept some degree of inaccuracy where timeliness is important. Where compromises have to be made on accuracy, the resulting limitations of the data should be clear to its users. Data should be recorded and used in compliance with relevant requirements, including the correct application of any rules or definitions. This will ensure consistency between periods and with similar organisations. Where proxy data is used to compensate for an absence of actual data, organisations must consider how well this data is able to satisfy the intended purpose. Data should reflect stable and consistent data collection processes across collection points and over time, whether using manual or computer-based systems, or a combination. Managers and stakeholders should be confident that progress toward performance targets reflects real changes rather than variations in data collection approaches or methods. Data should be captured as quickly as possible after the event or activity and must be available for the intended use within a reasonable time period. Data must be available quickly and frequently enough to support information needs and to influence the appropriate level of service or management decisions. Data captured should be relevant to the purposes for which it is used. This entails periodic review of requirements to reflect changing needs. It may be necessary to capture data at the point of activity which is relevant only for other purposes, rather than for the current intervention. Quality assurance and feedback processes are needed to ensure the quality of such data. Data requirements should be clearly specified based on the information needs of the organisation and data collection processes matched to these requirements. Monitoring missing, incomplete, or invalid records can provide an indication of data quality and can also point to problems in the recording of certain data items. Source: Audit Commission ( Author: Isis Hreczuk-Hirst 9

13 Appendix B Standards for Better Health Governance - Domain Outcome Managerial and clinical leadership and accountability, as well as the organisation s culture, systems and working practices ensure that probity, quality assurance, quality improvement and patient safety are central components of all the activities of the health care organisation. Core standards C7 - Health care organisations a) apply the principles of sound clinical and corporate governance; b) actively support all employees to promote openness, honesty, probity, accountability, and the economic, efficient and effective use of resources; c) undertake systematic risk assessment and risk management; d) ensure financial management achieves economy, effectiveness, efficiency, probity and accountability in the use of resources; e) challenge discrimination, promote equality and respect human rights; and f) meet the existing performance requirements set out in the annex. C8 - Health care organisations support their staff through a) having access to processes which permit them to raise, in confidence and without prejudicing their position, concerns over any aspect of service delivery, treatment or management that they consider to have a detrimental effect on patient care or on the delivery of services; and b) organisational and personal development programmes which recognise the contribution and value of staff, and address, where appropriate, underrepresentation of minority groups. C9 - Health care organisations have a systematic and planned approach to the management of records to ensure that, from the moment a record is created until its ultimate disposal, the organisation maintains information so that it serves the purpose it was collected for and disposes of the information appropriately when no longer required. C10 - Health care organisations a) undertake all appropriate employment checks and ensure that all employed or contracted professionally qualified staff are registered with the appropriate bodies; and b) require that all employed professionals abide by relevant published codes of professional practice. C11 - Health care organisations ensure that staff concerned with all aspects of the provision of health care a) are appropriately recruited, trained and qualified for the work they undertake; b) participate in mandatory training programmes; and c) participate in further professional and occupational development commensurate with their work throughout their working lives. C12 - Health care organisations which either lead or participate in research have systems in place to ensure that the principles and requirements of the research governance framework are consistently applied. Author: Isis Hreczuk-Hirst 10

14 Developmental standards D3 - Integrated governance arrangements representing best practice are in place in all health care organisations and across all health communities and clinical networks. D4 - Health care organisations work together to a) ensure that the principles of clinical governance are underpinning the work of every clinical team and every clinical service; b) implement a cycle of continuous quality improvement; and c) ensure effective clinical and managerial leadership and accountability. D5 - Health care organisations work together and with social care organisations to meet the changing health needs of their population by a) having an appropriately constituted workforce with appropriate skill mix across the community; and b) ensuring the continuous improvement of services through better ways of working. D6 - Health care organisations use effective and integrated information technology and information systems which support and enhance the quality and safety of patient care, choice and service planning. D7 - Health care organisations work to enhance patient care by adopting best practice in human resources management and continuously improving staff. Author: Isis Hreczuk-Hirst 11