Information Governance Toolkit Policy

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1 Information Governance Toolkit Policy UNIQUE REF NUMBER: AC/IG/014/V1.2 DOCUMENT STATUS: Approved by Audit Committee 19 June 2013 DATE ISSUED: June 2013 DATE TO BE REVIEWED: June P age

2 AMENDMENT HISTORY VERSION DATE AMENDMENT HISTORY V1 June 2013 Version approved by Audit Committee 19 June 2013 AC/IG/014/V1.1 December 2013 Addition of branding and formatting in line with Policy for Development of Policies AC/IG/014/V1.2 February 2014 Addition of unique reference number prior to publication REVIEWERS NAME DATE TITLE/RESPONSIBILITY VERSION Donna Dallaway June 2013 CSU Information Governance Officer V1 Matthew Hartland June 2013 Chief Finance Officer V1 Julia Dixon June 2013 Staff Side Representative V1 APPROVALS This document has been approved by: NAME DATE TITLE/RESPONSIBILITY VERSION CCG Audit 19 June 2013 Delegated authority from the Board V1 Committee NB: The version of this policy used on the intranet must be a PDF copy of the approved version. DOCUMENT STATUS This is a controlled document. Whilst this document may be printed, the electronic version posted on the intranet is the controlled copy. Any printed copies of the document are not controlled. RELATED DOCUMENTS These documents will provide additional information: REFERENCE NUMBER AC/IG/008 AC/IG/020 DOCUMENT TITLE Complaints Procedure Corporate Records Policy Safe Haven Policy Subject Access Request Procedure VERSION APPLICABLE LEGISLATION Data Protection Act 1998 Freedom of Information Act 2000 Access to Health Records Act 1990 (where not superseded by the Data Protection Act) GLOSSARY OF TERMS TERM ACRONYM DEFINITION Senior Information Risk Officer SIRO Takes ownership of information risk and is a key factor in successfully raising the profile of information risk and to embedding information risk management in Dudley CCG s culture. 2 P age

3 CONTENTS PAGE NO POLICY OVERVIEW Introduction Purpose Who this Policy applies to Legal Considerations 5 THE POLICY Objectives Requirements Roles Assessment Steering Group Monitoring Compliance 6 Appendix 1 Procedure Flow Chart 3 P age

4 POLICY OVERVIEW 1.0 Introduction 1.1. The Information Governance Toolkit is an assessment framework to which Dudley CCG can measure its compliance with the Information Handling requirements, current legislation and national guidance The Information Governance Toolkit gives a Statement of Assurance which is monitored through a self- assessed checklist process through the NHS Connecting for Health Information Governance Toolkit website. This statement not only provides the NHS Connecting for Health a report on Dudley CCG s current status but also gives the CCG an assessment of its current work. 2.0 Purpose 2.1 The purpose of this policy is to provide NHS Dudley CCG (Dudley CCG) in respect of meeting the national information governance requirements of the Connecting for Health Information Governance Toolkit. 2.1 The Information Governance Toolkit is essentially an online tool produced by the NHS Connecting for Health and the NHS information Authority. The Toolkit is currently on Version The Information Governance Toolkit is a mandatory requirement across all areas of the NHS. 2.3 The Information Governance Toolkit comprises of various legislation and NHS policies. These legislation, policies and procedures are incorporated into four initiatives, which overarch the assessment questions. These initiatives aim cover all aspects of information governance. The Toolkit s current initiatives are: Information Governance Management Confidentiality and Data Protection Assurance o The Confidentiality NHS Code of Practice o Data Protection Act 1998 Information Security Assurance o Information Security Management HNS Code of Practice Clinical Information Assurance 3.0 Who this Policy applies to 3.1 It is the responsibility of all Dudley CCG s staff to comply with the Common Law Code of Confidentiality, Data Protection Act 1998, Access to Health Records Act 1990 and Freedom of Information Act A failure to adhere to this policy and its associated procedures may result in disciplinary action. Managers at all levels are responsible for ensuring that the staff for whom they are responsible are aware of and adhere to this policy. Managers are also responsible for ensuring staff are updated in regard to any changes in this policy. 4 P age

5 4.0 Legal Considerations 4.1 Dudley CCG will use all appropriate and necessary means to ensure that they comply with the Common Law Code of Confidentiality, Data Protection Act 1998, Freedom of Information Act 2000 and other relevant legislation to meet these requirements. THE POLICY 5.0 Objectives 5.1 For compliance with the Information Governance Toolkit there are four objectives of this policy: Accountability - that staff are aware of their role within the implementation and completion of the Information Governance Toolkit. Quality - the assessment is complete and accurate and all evidence associated with the attainment levels is accurate and up-to-date. Accessibility - that the evidence can be quickly and effectively retrieved for audit purposes. Performance Management - that staff involved with the Information Governance Toolkit regularly monitor improvements and developments towards the Information Governance Toolkit attainment levels. Also communication between staff is vital as continuous changes are made and new guidance published in relation to the Toolkit. 6.0 Requirements 6.1 For compliance with the Information Governance Toolkit, Dudley CCG must complete a self-assessment against the four initiatives. These initiatives are broken down into a series of questions and requirements, against each question a rating or score must be given for Dudley CCG. 6.2 Dudley CCG has to provide evidence to support the requirement and score this by level from zero level (the lowest level) up to level three (the highest an organisation can achieve). To meet the NHS Connecting for Health Statement of Assurance, Dudley CCG must score an attainment level of level 2 or higher in all requirements in the Toolkit. 7.0 Roles 7.1 Administrator On initial use the Administrator must register Dudley CCG by completing the relevant online form; all sections must be completed. Upon completion of registration, the Administrator will be contacted via . The Administrator is the person who establishes and manages the Reviewers and Users. It is the Administrator who submits the final Toolkit attainment levels to be reviewed. 7.2 Reviewers There can be up to six Reviewers who verify the scores and can upload the evidence on to the Toolkit site. The Reviewer can enter and amend the attainment scores, enter relevant comments for the questions; once this has been completed, they confirm that the assessment is ready for the Administrator to finalise and submit. 7.3 Users Their role is to assess the score for each requirement, enter the correct evidence to show the attainment levels to the corresponding question and amend these if necessary. Once this is complete, the User would forward to the Reviewer to access the evidence in accordance to the given attainment level. 5 P age

6 8.0 Assessment 8.1 The overall assessment is completed by the Administrator. The Administrator is responsible for registering and creating the first assessment. In subsequent years, the assessment is automatically generated and the evidence from the previous assessment is automatically available for update/revision. It also shows Dudley CCG s status from the previous submission. 8.2 Once the Users and Reviewers have completed the requirements, the Reviewer has to confirm the completion. 8.3 The Administrator is then able to submit the assessment ready to be reviewed by NHS Connecting for Health. The Administrator should only submit the assessment scores once the evidence for each score is loaded and confirmed to be correct into the corresponding requirements by the Information Governance Department. 8.4 The Toolkit provides Dudley CCG with a score in a percentage and notes if this is satisfactory or unsatisfactory. As well as gaining an overall score, each key requirement is given a colour coding of red for unsatisfactory and green for satisfactory. If Red is scored, Dudley CCG is required to change and improve the initiatives with this rating, or if unsatisfactory is scored as a whole Dudley CCG needs to look at all of the initiatives for immediate improvement. The report is publishes on the NHS Connecting for Health Information Governance Toolkit webpage, on the link below: e b cf-6a0ae7a747ff&lnv=6&clnav=yes 9.0 Steering Group 9.1 The completion of the Information Governance Toolkit (and the assurance it provides to Dudley CCG and the public) is monitored by the Senior Information Risk officer (SIR) for Dudley CCG who reports to the Accountable Officer and provides reports to Dudley CCG Board. 9.2 Dudley CCG Information Governance Team are responsible for liaison with all the other areas of Dudley CCG in order to meet the requirements laid down in the Toolkit, as it encompasses the full scope of Information Governance and therefore it is not possible to identify a single member of staff or department to work towards the Information Governance Toolkit ratings. Therefore within Dudley CCG a collaboration of departments and staff is needed to give a complete assessment against the standards. 9.3 In order to achieve continuous improvement, Dudley CCG Information Governance Team will agree action plans with other areas of Dudley CCG to take forward operational and practical issues raised regarding the Toolkit and these will be in addition to the action plan. 9.4 Dudley CCG Information Governance Team will liaise closely with other areas of Dudley CCG to ensure that the improvement action plans are completed in a timely and appropriate manner, providing advice and guidance as required Monitoring Compliance 10.1 Staff are expected to comply with the requirements set out within the Information Governance Toolkit Policy and related policies. Compliance will be monitored via Manager and Information Governance reports, spot checks, completion of staff questionnaires, incidents reported, electronic audit trails and submission of Information Governance Toolkit. 6 P age

7 10.2 Non adherence to Information Governance policies may result in Dudley CCG s disciplinary policy being implemented. 7 P age

8 APPENDIX 1 PROCEDURE FLOW CHART Information Governance Toolkit Released Review Information Governance Toolkit and create Action Plan Evidence gathered from CCG Evidence loaded for initial submission for 31 st October Evidence reviewed by Information Governance Senior Officer Any required changes or updates made Evidence reviewed by Information Governance Manager Any required changes or updates made Initial evidence submitted Internal audit by Head of Information Governance Final submit/publish by 31 st March each year Any required changes or updates made Advise SIRO/Information Governance Lead at the CCG and provide final report 8 P age

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