Policy: D9 Data Quality Policy

Transcription

1 Policy: D9 Data Quality Policy Version: D9/02 Ratified by: Trust Management Team Date ratified: 16 th October 2013 Title of Author: Head of Knowledge Management Title of responsible Director Director of Finance / Deputy Chief Executive Governance Committee Informatics Sub-Committee Date issued: 18 TH November 2013 Review date: September 2017 Target audience: All staff Trust wide NHSLA relevant? No Disclosure Status B Can be disclosed to patients and the public EIA / Sustainability N/A Implementation Plan G:\St Bernards Shared\Trust Policies Other Related Procedure or Documents: West London Mental Health NHS Trust Page 1 of 16

2 Equality & Diversity statement The Trust strives to ensure its policies are accessible, appropriate and inclusive for all. Therefore all policies will be required to undergo an Equality Impact Assessment and will only be approved once this process has been completed Sustainable Development Statement The Trust aims to ensure its policies consider and minimise the sustainable development impacts of its activities. All policies are therefore required to undergo a Sustainable Development Impact Assessment to ensure that the financial, environmental and social implications have been considered. Policies will only be approved once this process has been completed West London Mental Health NHS Trust Page 2 of 16

3 Version Control Sheet Version Date Title of Author D9/0.1 Apr 10 Head of Information D9/0.1.1 May 10 Head of Information D9/0.1.2 Jun 10 Head of Information D9/0.1.3 Jul 10 Head of Information D9/0.1.4 Aug 10 Head of Information N/A Status New Policy drafted Comment N/A Draft Policy reviewed at 11 th May 2010 Finance and Performance Committee. N/A Draft Policy circulated for consultatio n Amended Policy for approval Revision made: Reformatting, minor changes and addition of Glossary of Terms. Consultant periods ends 23/7/2010 Minor amendments to policy following consultation period including comments from Information Governance Manager relating to Information Governance Toolkit 8 new requirements and reference to other policies. Submitted to Trust Policy Review Group 17/8/2010 policy approved, subject to update of Section 11. D9/ Head of Information D9/ Head of Knowledge Management D9/ Head of Knowledge Management D9/ Head of Knowledge Management NEW Policy Issued Policy review Policy review Policy review 7 th Feb 11 - Update to Section 11 Monitoring and Review Policy review and amendments made Policy to be reviewed DARG 11/7/2013 ISC 18/7/2013 Policy review and amendments made DARG 11/7/2013 Policy review and amendments made ISC 18/7/2013. Trustwide consultation ending Presented to October 2013 TMT Uploaded onto Exchange 18 th Nov 2013 West London Mental Health NHS Trust Page 3 of 16

4 Content Page No. 1. Introduction (includes purpose) 5 2. Scope 5 3. Definitions Duties Chief Executive Accountable Director Managers Policy Author Local Policy Lead Specific Staff for Policy All Staff Escalation of Data / Quality Issues 9 6. Control Processes Training Monitoring Fraud Statement References (External Documents) Supporting Documents Glossary of Terms / Acronyms Monitoring Template 16 West London Mental Health NHS Trust Page 4 of 16

5 1. INTRODUCTION 1.1 West London Mental Health Trust (WLMHT) recognises the importance of reliable information as a fundamental requirement for the effective, safe treatment of its service users and for the efficient operation of its business. 1.2 The availability of complete, comprehensive, accurate and timely data is an essential component in the provision of high quality mental health services, risk management, compliance with external scrutiny requirements and in performance improvements against national and local targets, standards and contractual/statutory requirements. 1.3 The Trust also recognises that reliable information can only be produced if good quality data is captured at source, regardless of the methods used to capture this data. It is therefore the aspiration of the Trust that 100% data accuracy is achieved by its employees when collecting and transcribing data items, and that the Trust will support the development of individuals, processes and systems to minimise the risk of data errors. 1.4 The purpose of this policy is to ensure that the relationship between good quality data, good quality information, and good quality decisions is clearly understood and that the responsibilities for the management of that relationship are identified. 1.5 It is intended to raise awareness of the increasing reliance of the organisation on good data quality and the responsibilities of staff to support the information requirements of the wider organisation as well as meet their local needs. 2. SCOPE 2.1 This policy applies to all authorised staff involved in the collection of data are responsible for accuracy and timeliness to ensure Trust information is correct and available. 2.2 This policy details the responsibilities of all staff regarding the quality and timeliness of recording data. It covers all type of data collected and recorded. 2.3 The policy applies key systems, electronic or otherwise, which collect, store or report on all data related to the activities of the Trust e.g. RiO, ESR, IR It applies to such data for the entire period during which it is held, not just when it is first recorded, and also to any amendments made subsequently. 3. DEFINITIONS 3.1 The trust is committed to the common standard for good data quality as defined by the Audit Commission: West London Mental Health NHS Trust Page 5 of 16

6 Accuracy: Data recorded on systems must accurately reflect true or exact values for its intended purpose, representing clearly and in sufficient detail the interaction provided at the point of activity. Validity: Data is not valid unless it meets format and content standards in compliance with relevant requirements. Data must be recorded in an agreed format which conforms to recognised national and local standards, including correct application of any rules or definitions and data collection procedures and processes. Reliability: Reliability of the data is a key feature of accuracy and should reflect stable and consistent data collection processes across collection points and over time. Timeliness: Data must be recorded and be available as soon as possible after the event. Relevant: Data captured should be relevant to the purposes for which it is used. Completeness: Data requirements should be clearly specified based on the information needs of the organisation and data collections matched to those requirements. Defined: All relevant staff must be able to understand data and it must be consistent across the trust. 4. DUTIES 4.1 Chief Executive The Chief Executive is responsible for ensuring that the Trust has policies in place and complies with its legal and regulatory obligations. 4.2 Accountable Director The Finance Director/ Deputy Chief Executive is the accountable director for this policy and is responsible for the development of relevant policies and to ensure they comply with NHSLA standards and criteria where applicable. They must also contain all the relevant details and processes as per P3. They are also responsible for trust wide implementation and compliance with the policy. 4.3 Managers Managers are responsible for ensuring policies are communicated to their teams / staff. They are responsible for ensuring staff attend relevant training and adhere to the policy detail. They are also responsible for ensuring policies applicable to their services are implemented. 4.4 Policy Author Policy Author is responsible for the development or review of a policy as well as ensuring the implementation and monitoring is communicated effectively throughout the Trust via CSU / Directorate leads and that monitoring arrangements are robust. 4.5 Local Policy Leads Local policy leads are responsible for ensuring policies are communicated and implemented within their CSU / Directorate as well as West London Mental Health NHS Trust Page 6 of 16

7 co-ordinating and systematically filing monitoring reports. Areas of poor performance should be raised at the CSU / Directorate SMT meetings. 4.6 Specific Staff Information Asset Owners (IAO) and Information Asset Administrator (IAA). See glossary for further information on roles. IAO should be aware of what information is held and the nature and justification of information flows to and from the assets i.e. systems. They are responsible for. Whilst responsibility for implementing and managing Information Assets controls may be delegated to IAA, accountability will remain with the nominated owner of the asset. The IAO and IAA must ensure robust data quality controls and compliance are in place. Must ensure key electronic systems have validation programmes built in that are conformant with, or mapped to: NHS standards or agreed standards by WLMHT where they exist, or at least minimise the scope for data errors where there are none. Information Asset Registers must be kept up to date and audited and local system documentations should be updated as standards develop. The IAO for specialist applications that are supported directly by expert users within departments in conjunction with 3rd party arrangements with an external supplier, must ensure appropriate measures and controls are in place to escalate issues for resolution. Feedback any analysis on data quality from the data entered on the systems where it is available and develops appropriate data quality monitoring tools. Identified issues should be escalated through agreed channels and where appropriate advise clinical teams, managers and the board on Information issues. See Section 5 for the Escalation Process. Interpret and advise requirements of the Data Dictionary, monitor and disseminate changes of requirements as notified via ISB (Information Standards Board) or other official channels as appropriate (This applies in full to key electronic systems, but paper based systems should also include national standard definitions and codes, where they exist). Ensure appropriate documented processes are in place and are shared and communicated through the department s e.g. training material, procedures, SLA agreements, logs of issues and resolutions, guidances or templates. Manage validation programmes used routinely on data entry to ensure completeness and validity of national data set submissions as appropriate. Performance and Information staff must: Interpret requirements of the; Data Dictionary, external and internal data definitions and monitor compliance of the Trust data. West London Mental Health NHS Trust Page 7 of 16

8 Produce or enable production of exception reporting to monitor data quality. Be aware of and comply with legislation and Trust policies and procedures (See policies within Section 11 Supporting Documents) Work in partnership with corporate and clinical services to improve the quality of data. Report on Key Performance Indicators (KPIs) to monitor data quality compliance. Incorporate data quality KPIs within the performance reporting framework. Escalate and feedback any data quality issues identified via local escalation channels and procedures. See Section 5 for Escalation Process. Information Governance Ensure the Trust is aware of its obligations under the Information Quality Assurance initiative as part of information governance and Information Governance Toolkit (IGT) compliance. Responsible for monitoring the implementation of and compliance with the Trusts Data Quality policy and all other information related policies (see policies within Section 11 Supporting Documents) Collate evidence which demonstrates progress against the information governance strategy and action plan. Report incidents relating to data e.g. data loss of data or significant inaccuracies of patient data and escalate via local escalation procedures. Where relevant, register incidents on the risk register. Escalate where relevant data quality issues to the Caldicott guardian as outlined in Policy I5 information governance. Assure compliance with relevant legislation and legal compliance to relevant governing committees. Data Quality Leads Utilise data quality tools where available to improve the quality of data e.g. IDT tools and dashboards. Regularly check and resolve inaccuracies and support users in improvement of quality of data. Ensure corrective actions and measures are implemented within deadlines for reporting submissions. Set up local procedures and supporting guidelines. Where trust wide systems exist the local procedures must be consistent across all areas. West London Mental Health NHS Trust Page 8 of 16

9 Take local responsibility for the quality of data and feed back particular issues for training or update of procedures, including resolution of data subject s issues. Address data quality issues as soon as possible and escalate appropriately through agreed formal channels. See Escalation Process in Section 5. Produce or enable production of exception reporting to monitor data quality. 4.7 All Staff Data quality is every ones responsibility and staff must not rely on others to carry out their data quality responsibilities. All staff are responsible for ensuring adherence to the relevant data standards and for ensuring good data quality. They must: Ensure timely, accurate and complete data is recorded and entered appropriately. Identify errors and omissions should be identified as close to the point of entry as possible and be corrected at source. Escalate any data quality issues identified appropriately to their line manager and /or agreed formal channels. Monitor own competencies and access basic IM&T and appropriate training where necessary. Clinical coders (Applies to those staff who has been nominated as clinical coders) must have completed the clinical coding training. Where ever possible collect data once which can be used multiple times once entered on designated systems. Be aware of and comply with legislation, Trust policies and procedures Deal with any form of data and or/information they are responsible for by ensuring data quality is consistently maintained o Legally under the 1998 Data Protection Act o Contractually under their contract of Employment o Ethically under professional codes of practice o Discharge any relevant duties under the legislation for data subjects. 5. ESCALATION OF DATA QUALITY ISSUES 5.1 Identifying and correcting errors Errors created by an individual through inaccurate data entry should be rectified as soon as they are discovered. If staffs are unable to correct at West London Mental Health NHS Trust Page 9 of 16

10 source, then the error should be escalated to their line manager and/or via agreed formal channels for correction Where persistent data quality issues need to be raised and escalated, the Trust where possible will go through the appropriate assurance and performance sub committee. If in doubt, send to the Data Assurance and Reporting Group (DARG). See Escalation Process below. Data Quality Escalation Process 8. If DQ impacts patient care or significant risk to Trust reputation log on risk register 7. If actions not completed within 2 deadlines must be escalated as per governance structure 6. Action plan is owned and reviewed and relevant committee/meeting 5. Action plan created to improve quality of data 4. Reports reviewed at meetings (as per Trust governance structure) 3. Data Quality issues identified 2. Reports created e.g. KPIs, Performance, Scorecards 1. Data entered on systems West London Mental Health NHS Trust Page 10 of 16

11 Data Quality Reporting & Resolution Process Ensure a solution is found and implemented Escalate to Senior Management If Issues cannot be resolved via standard operational procedures Resolve DQ Issues Analyse and Determine Cause Review Exception Reports highlighting DQ Issues 5.2 System errors Latent/ systematic errors i.e. where a process or system encourages or allows routine errors to occur, should be identified and escalated by all staff through the agreed formal channels and addressed by the Information Asset Administrator and Owner. 5.3 Caldicott Guardian Data quality issues directly affecting patient care or treatment must be referred to the Caldicott Guardian and the Information Governance Manager as outlined in Policy I5 information Governance. 6. CONTROL PROCESSES 6.1 Internal Controls Data quality will be subject to internal control processes within the Trust Internal controls: Electronic information systems and processes will have procedures developed, designed to systematically identify errors and other aspects of poor data quality. Data quality reports will be locally generated regularly and considered by the appropriate monitoring leads e.g. local data West London Mental Health NHS Trust Page 11 of 16

12 quality leads or IAA which will make recommendations on data improvement. Data quality reports will be routinely fed back to operational managers with advice as to corrective action to be taken such as improving processes, systems and staff training and development. Audit of case records and data quality by internal audits. 6.2 External Control Data quality will also be subject to external control processes: External controls: Publication and analysis of data quality reports from Secondary Use Service and the Health and Social Care Information Centre (HSCIC), CQC Quality and Risk Profiles, Queries from Commissioners and external stakeholders Audits of Information systems and data quality by external auditors The Trust will aim to achieve the target compliance requirements and act on all enquiries, recommendations and performance within agreed timescales. 7. TRAINING Data Quality awareness forms part of the secondary induction and where relevant via role based training. Access to systems will not be granted until appropriate training has been completed. No staff should use a system on which the Trust relies for information without appropriate system training Managers must ensure enough advance notice is given for new starters to ensure appropriate training can be delivered to the required timescales. Existing staff must have access to on-going training to keep up to date with new processes and changes to data definitions. It is vital to create a get it right the first time culture within the organisation with regard to data collection and recording. This objective will be supported by ensuring data quality awareness is always maintained and staffs are supported through training and development appropriate to their role and by direct management encouragement. West London Mental Health NHS Trust Page 12 of 16

13 8. MONITORING 8.1 The process for monitoring and evaluating the effectiveness of this policy, including obtaining evidence of compliance will be monitored and reviewed by: Ensuring Information Governance Toolkit requirements relating to data quality are met. IGT requirements will be monitored by the Information Governance manager and performance below required attainment level will be actioned by nominated leads. Quarterly completeness and validity checks will be completed by the Knowledge Management Team (IM&T). Any non compliance relating to attainment levels will be reviewed and escalated to the Information Governance Manager. The Knowledge Management Team (IM&T) will utilise the QRP published by CQC to support internal monitoring of quality by identifying areas of lower than average performance and, where necessary, taking action to address them. Internal Data Quality reports will be produced and communicated by CSU via scorecards and/or performance reports developed by the CSU Information team. These reports will be used to inform management, improve staff processes, ensure focused training, enhance documentation, and enable complete data capture on computer systems. In addition, annual planned data quality audit and review will be lead by the internal Audit team and reported back to the Audit Committee for review. 9. FRAUD STATEMENT Not applicable to all policies (N/A) 10. REFERENCES (EXTERNAL DOCUMENTS) This policy should be read in conjunction with the following: Data Protection Act SUPPORTING DOCUMENTS (TRUST DOCUMENTS) H8 Health Records Policy I2 IM&T Security Policy D5- Data Protection Policy F5- Freedom of Information Act I5 Information Governance R9 Records Management and Information Lifecycle Policy M10 Mobile Working West London Mental Health NHS Trust Page 13 of 16

14 12. GLOSSARY OF TERMS / ACRONYMS Data: Data are numbers, words or images that have yet to be organised or analysed to answer a specific question. Information: Information is produced through processing, manipulating and organising data to answer questions, adding to the knowledge of the receiver. Data Dictionary - The NHS Data Model and Dictionary provides a reference point for assured information standards to support health care activities within the NHS in England. It has been developed for everyone who is actively involved in the collection of data and the management of information in the NHS. Information Standards Board (ISB): - Approves information standards for the NHS and adult social care in England. Information Asset Owners (IAO) Are senior individuals involved in running the relevant business. Their role is to understand and address risks to the information assets they own and provide assurance to the SIRO on the security and use of these assets. Information Asset Administrator (IAA) Provide support to their Information Asset owners and ensure that policies and procedures are followed and information assets registers and accurate and up to date. Assets: Assets are defined as Information assets that come in many shapes and forms and can consist of personal/other information (databases, data files), System,/Process Documentation (Procedure, training, systems), Software (Applications, system software), Hardware (PCs, laptops, communication devices). Information Governance Tool kit compliance: The Information Governance Toolkit is a performance tool produced by the Department of Health (DH). It draws together the legal rules and central guidance set out above and presents them in one place as a set of information governance requirements the Trust must comply with. Information Governance: Information Governance is to do with the rules that should be followed when we process information. It allows organisations and individuals to ensure information is processed legally, securely, efficiently and effectively Caldicott Guardian: A senior person responsible for protecting the confidentiality of patient and service user information and enabling appropriate information sharing. Caldicott Guardians were mandated for NHS organisations by Health Service Circular HSC 1999/012 and later for social care by Local Authority Circular LAC 2002/2. General practices are required by regulations to have a confidentiality lead. Senior Information Risk Owner (SIRO): A SIRO is an Executive Director or member of the Senior Management Board with overall responsibility for the organisation s information risk policy. The SIRO will also lead and implement the information governance risk assessment West London Mental Health NHS Trust Page 14 of 16

15 and advise the Board on the effectiveness of risk management across the organisation. Exemption Reporting: Exemption reporting enables you to identify immediately any results that deviate from the expected results. Where exemption reporting is used, a explanation of why and actions to rectify should be included. DARG ISC WLMHT NHSLA CSU SMT SLA KPI IGT QRP IM&T HSCIC CQC SIRO HSC LAC Data Assurance & Reporting Group Information Security & Confidentiality West London Metal Health Trust National Health Service Litigation Authority Clinical Service Unit Senior Management Team Service Level Agreements Key Performance Indicator Information Governance Toolkit Quality Risk Profile Information Service & the Health and Social Care Information Centre Care Quality Commission Senior Information Risk Owner Health Service Circular Local Authority Circular West London Mental Health NHS Trust Page 15 of 16

16 APPENDIX 1 MONITORING TEMPLATE POLICY / PROCEDURE: D9 Data Quality Policy MONITORING TEMPLATE Minimum Requirement to be Monitored Where Described in the Policy WHO (which staff / team / dept) HOW MONITORED (Audit / process / report / scorecard) - list details HOW MANY RECORDS (No of records / % records) FREQUENCY (monthly / quarterly / annual) REVIEW GROUP (which meeting / committee) Escalation process Sect 5 KMT Report to DARG 100% Bi monthly DARG Informatics Data quality Scorecards / Monthly / SMT / TMT / Internal controls leads / Audit report / audit Quarterly Commissioners Sect 6.1 team / KMT 100% Board External controls Sect 6.2 KMT Electronic Submissions Scorecards / report 100% Monthly / Quarterly SMT / TMT / Commissioners OUTCOME OF REVIEW / ACTION TAKEN (Action plan / escalate to higher meeting) Board West London Mental Health NHS Trust Page 16 of 16