Information Governance Strategy To whom this document applies: All Trust staff, including agency and contractors Procedural Documents Approval Committee Issue Date: January 2010 Version 1 Document reference: 292 Date(s) reviewed: March 2011 Version 2 Approved by: Procedural Documents Approval Committee October 2011 Version 2a March 2012 Version 3 Date approved: March 2014 March 2014 Version 4 Next Review date: March 2016 Version No: 4 Responsibility for review: Head of Information Governance Contributors: Please See Procedural Development, Consultation Proposal Form page 2 Archiving information held by the secretary of the Procedural Documents Approval Committee Strategy: 292 Page 1 of 12
Procedural Development Consultation Proposal Form Title: Information Governance Strategy Policy Procedure Guideline Protocol Standard Strategy Name of person presenting document: Rees Millbourne Head of Information Governance Reason for document development/review: Review of document, minor changes made due to organisational changes. Names of development team (including a representative from all relevant disciplines): Rees Millbourne Head of Information Governance Who has been consulted? Medical Director (Caldicott Guardian) Director of Finance (Senior Information Risk Owner (SIRO)) Deputy Director of Finance Associate Director of ICT Does this document require presentation and agreement from Health and Safety Committee or Staff Partnership Forum prior to PDAC approval? Yes No Specify groups of staff to whom the document relates: All Trust staff, including agency and contractors Source of supporting evidence (references etc.): See Evidence Base. Are there resource implications? Yes No If yes please detail them: Does the Procedure/Guideline meet latest NHSLA, Risk Management Standards, Essential Standards of Quality and Safety (CQC)? Yes No Does this Procedure/Guideline include children, if applicable? 1. Does this document apply to children? Yes No 2. Are there aspects of this document that differ with regard to the treatment of children? Yes No If yes, please state who has been consulted A Trust review will occur every two years unless national guidance states otherwise. Date: March 2014 Procedure: 292 Page 2 of 12
Contents Review, Updating and Archiving of the Document 1 Document Development and Consultation Process 2 Contents 3 Introduction 4 Related Documents 4 1. Definition of Terms 5 2. Roles and Responsibilities 6 3. Process Core Measures to Protect Information Culture Stronger Accountability Stronger Scrutiny Implementation Information Governance Assurance Framework Confidential Information Steering Group Corporate Records Group Health Records Group Key Objectives 4. Training 11 5. Evidence Base 11 6. Monitoring Compliance and Audit 11 7. Dissemination, Implementation and Access to the Document 12 Page No. 8 8 9 9 9 10 10 10 10 Procedure: 292 Page 3 of 12
Statement of Intent Effective use of information is absolutely central to the challenges faced by the Trust to improve the clinical management of individual patients or efficient management of services and resources in order to achieve Trust business objectives. The Trust needs to keep person identifiable and sensitive data secure, in order to build public confidence. This is essential to strengthen greater data sharing with other health organisations and other agencies in a controlled manner for the provision of healthcare to patients and in some circumstances for public interest. The Trust cannot guarantee that it will never experience loss of data but the organisation will ensure that high standards are implemented and maintained to protect information and meet public expectations. The document sets out how the Trust will: implement core measures to protect information, including personal data, to enhance consistency of protection and transparency of protection to others. develop a culture that properly values, protects and uses data both in planning and delivery of Trust services. implement strong accountability mechanisms, recognising that individual divisions, services and departments need to understand and address risks to information, including personal data in their areas; and implement processes of strong scrutiny of performance, to build confidence and ensure that lessons are learned and shared. Introduction This document sets out the approach Colchester Hospital University NHS Foundation Trust will take to develop and implement a robust Information Governance framework for the future management of information. The vision of the strategy is: To enable the Trust and its provider services to assure itself, its service users and its partners that information used, particularly person identifiable data, whatever its form or content, and whatever its context, will be processed in accordance with prevailing legislation and standards of best practice. During the implementation of electronic health records and Trust IT systems coupled with increased public concern and public awareness about safeguarding personal data, that Information Governance policies, processes and procedures are transparent, robust, safe and secure. To ensure that public confidence and trust in handling and processing person identifiable data is maintained and confirmed. To improve and assure its Information Governance related activities and to deliver year on year consolidation and improvements in its Information Governance Toolkit scores. Related Documents 239 Data Protection Procedure 297 Data Quality Policy 311 Data Transfer and Removable Media Policy 189 Health Records Procedure 238 Information Governance Procedure 291 Information Security Policy 314 Internet Policy 315 Internet Procedure Procedure: 292 Page 4 of 12
308 Network Security Policy 288 Release of Data to Outside Agencies Procedure (Police forces etc.) 318 Registration Authority Procedure 287 Responding to Requests made under the Freedom of Information Act 2000 and Environmental Information Regulations 2004 Procedure 350 Third Party Requests for Clinical and Personal Information Procedure (including patients and relatives) 1. Definition of Terms Information Governance Information Governance is a framework to ensure necessary safeguards for, and appropriate use of, personal information for both patients and staff. Information Governance Assurance Framework The NHS Information Governance Assurance Framework is the mechanism by which: Information Governance policies and standards are set regulators can check an organisation s compliance, and an organisation can be performance managed. The framework therefore includes an annual assessment using the Information Governance toolkit. Information Governance Toolkit (IGT) A tool with which the Trust self-assesses its compliance with current legislation, Government directives and other national guidance relating to information handling. The initiatives include: Information Governance management. confidentiality and data protection assurance. information security assurance. clinical information assurance. secondary use assurance. corporate information assurance. The NHS Health and Social Care Information Centre (HSCIC) Information Governance Statement of Compliance revised edition 2 (IGSoC2) NHS HSCIC is supporting the NHS to deliver better care, safer care, for patients by introducing new information technology systems and services which improve the way information is stored and shared in the NHS. All organisations wishing to access and use HSCIC systems and services, including the N3 network, must meet the terms and conditions in the IGSoC2. Information Assets Information assets come in many shapes and forms. It is generally sensible to group information assets in a logical manner e.g. where they all related to the same information system or business process. Person Identifiable Data/Information (PID/I) Information that allows the identification of an individual to be revealed, either explicitly or by implication. Identifiable data/information includes: name, address. Procedure: 292 Page 5 of 12
full postcode. date of birth. pictures, photographs, video, audio-tapes or other images of patients. NHS number and local patient identifiable codes. any grouping term such as baby, new-born baby. National Insurance numbers for staff. pay or sickness details for staff. anything else that may be used to identify an individual directly or indirectly. For example, rare diseases, drug treatments or statistical analyses which have very small numbers within a small population may allow individuals to be identified. N3 Network N3 is the name for the National NHS Network, which provides fast broadband networking services to the NHS. 2. Roles and Responsibilities Board of Directors In his communication to the Chief Executive, the NHS Chief Executive has made it clear that ultimate responsibility for Information Governance in the NHS rests with the Board of Directors for the organisation, who should note that: Information Governance must be explicitly referenced within each organisation s statement of internal controls. from 2009/10 onwards, the major NHS organisations must baseline their performance within the toolkit by the end of July each year and should update the assessment with improvements at end of October to enable performance and actions to be tracked by commissioners and other monitoring bodies. organisations must sign the Information Governance Statement of Compliance (IGSoC)2 to provide assurance that they are meeting these key requirements and must have robust improvement plans to address any shortfalls against other requirements. details of serious untoward incidents involving actual or potential loss of personal data or breach of confidentiality must be published in annual reports and reported to the Clinical Commissioning Group (CCG) and to the Information Commissioner, where appropriate. Foundation Trusts are subject to the same requirements, set out by Monitor. The contractual arrangements with independent sector NHS providers also contain strengthened Information Governance requirements. Chief Executive The Chief Executive as the Accounting Officer for the Trust has ultimate responsibility for ensuring that processes are in place. Senior Information Risk Owner (SIRO) The SIRO is an executive who is familiar with and takes ownership of the organisation s information risk policy and acts as advocate for information risk for the Board of Directors. The Director of Finance is the designated SIRO for the Trust and they will: be accountable. foster a culture for protecting and using data. provide a focal point for managing information risks and incidents. be concerned with the management of all information assets. Procedure: 292 Page 6 of 12
Caldicott Guardian The Caldicott Guardian is a senior person responsible for protecting the confidentiality of patient and service-user information and enabling appropriate information-sharing. The Guardian plays a key role in ensuring that NHS, Councils with Social Services responsibilities and partner organisations satisfy the highest practical standards for handling patient identifiable information. The Medical Director has been designated Caldicott Guardian for the Trust and they will: be advisory. be the conscience of the organisation. provide a focal point for patient confidentiality and information sharing issues. be concerned with the management of patient information. Head of Information Governance The Head of Information Governance is responsible for: overseeing the Information Governance systems and processes within the Trust. collating the evidence required for the Information Governance toolkit. developing the improvement plan for the following year s submissions. providing the organisation with Information Governance advice. carrying out operational duties on behalf of the Caldicott Guardian and SIRO. Directors and Associate Directors Directors and Associate Directors will have responsibility for the protection of person identifiable data and for identifying and managing any risk associated with this, within their own sphere of responsibility. Audit and Risk Assurance Committee/Executive Team The strategy will go to the Audit and Risk Committee for approval if there is a major review of the document. Minor changes can be approved by the SIRO or by the Executive Team. Divisions, Services and Departments Are responsible for: making Information Governance and measures to protect information, including personal data part of normal/everyday activity. setting and driving forward a culture that properly values, protects and uses data both in planning and delivery of Trust services. providing evidence for the IGT. adhering to Information Governance related procedures. ensuring breaches/near misses relating to Information Governance are reported using the organisations incident reporting procedure. informing the Head of Information Governance, Caldicott Guardian or SIRO of any Information Governance risk related information that needs urgent attention. All Staff For Information Governance, it is the responsibility of all staff to: be aware that they have a duty under legislation to protect information, especially Person Identifiable Data. report Information Governance incidents, including near misses, using the Trust s incident reporting system and learn from Information Governance incidents to reduce risks in the future. be familiar with the Trust s Information Governance Strategy and associated procedures and comply with these. Procedure: 292 Page 7 of 12
actively participate in the Trust s induction training and complete the mandatory IG e-learning and subsequent annual updates. report to line management any perceived Information Governance issues in their area of work. Information Asset Owners (IAO) Information Asset Owners are senior individuals involved in running the relevant business. Their role is to understand and address risks to the information assets they own and to provide assurance to the SIRO on the security and the use of those assets. Service Managers, Heads of Department or Associate Directors will be nominated as IAOs. Information Asset Administrators (IAA) Information Asset Administrators ensure that policies and procedures are followed, recognise actual or potential security incidents, consult their IAO on incident management, and ensure that information asset registers are accurate and up to date. The IAA will be a member of Operational staff responsible for one or more information assets as nominated by the IAO for the area of responsibility. 3. Process Core Measures to Protect Information The Department of Health (DH) has issued policy advice on how the Trust must manage information. The Trust must implement processes to: specify which data is person identifiable and requires higher levels of protection. A risk assessment should be performed if the level of data cannot be identified as to whether the higher level of protection should be applied to all information. ensure, where possible, such information should not be transferred, but it should be accessed on its home system or remotely via a secure channel. ensure, where transfer must occur, that this is done through secure electronic transfer so that discs are phased out where possible. ensure, where data has to be put onto removable media such as discs or laptops that the information transferred is minimised and uses encryption. secure disposal for paper or electronic records. use independent penetration testing to test Trust systems. put controls in place on access to information systems and logging and monitoring of use. increase the use of the accreditation process, developed to provide assurance to the Trust for systems holding personal data. Culture High levels of data security must be underpinned by a culture that values, protects and uses information. This culture is important both when services are being planned and when they are being delivered. This has to be led by the Board of Directors, but individual service areas/departments will be responsible for their own data security. Senior Managers will need to understand and actively manage any day to day operational processes that may wrongly lead staff to cut corners and expose information, in whatever form, to an unacceptable risk. Procedure: 292 Page 8 of 12
The Trust will regard any data loss as a cause for concern, and take immediate action to improve matters for the future. When problems occur, the culture has to be one in which losses are identified and learned from. This should apply to near misses as well as actual incidents. The Trust will take the following action: Introduce Privacy Impact Assessments, which ensure that privacy issues are factored into plans from the start, and those planning services are clear about their aims. These will be carried out in accordance with the Trust s Risk Management Strategy and Policy, document number 118. Information Governance elearning annual training will be completed by all Trust staff. Use existing processes such as the incident reporting system or the whistleblowing procedure by which individuals can bring concerns to the attention of senior management. Amend Trust policies and procedures where necessary to make clear that failing to apply to controls in handling personal data could result in disciplinary action. Stronger Accountability The onus is on the Trust to plan and secure the information it uses. The protection and use of data is part and parcel of organisational business. The Trust should aim to increase accountability by: establishing a process by which information assets are identified and allocated to a responsible owner. using the Information Governance toolkit and the incident reporting system to form part of an annual assessment to support the Chief Executive s judgement for the Statement on Internal Control for the Trust. Stronger Scrutiny The Trust will cover information assurance in its annual report and will report on information security annually via the Information Governance Toolkit submission. The commitment to stronger scrutiny will now be reinforced through: development and publication of an Information Charter, which will set out the standards that patients and staff can expect from the Trust when requesting, or holding their personal information, how they can get access to their personal data and what they can do if they think that these standards are not being met. consideration to be given for publicising material on specific information assets held, such as, what information is contained and used. Implementation The Trust will implement new technical protection for information as directed by the Government for information that it holds directly. The Trust will identify the protected personal data it holds, will roll out encryption to protect it in transit, and have minimised the use of removable media. The Trust should also work with delivery partners to ensure that they apply the same protections. It is acknowledged that it will take time to implement this strategy fully; some of the timescales have been set by Government and the Board of Directors should be informed in order to take appropriate action(s) if the timescales set by Government are at risk of not being achieved. Procedure: 292 Page 9 of 12
Information Governance Assurance Framework The central strategic responsibility for steering the Information Governance agenda forward within the Trust lies with the Audit & Risk Committee under its devolved responsibility from the Board of Directors, to whom it remains accountable. Audit & Risk Committee Confidential Information Steering Group Corporate Records Group Health Records Group Figure 1: Information Governance Assurance Framework Confidential Information Steering Group The Confidential Information Steering Group is a standing group accountable to the Audit & Risk Committee. Its purpose is to support and drive the broader Information Governance (IG) agenda and provide the Board with the assurance that effective information governance best practice mechanisms are in place within the organisation for the management of confidential information. Corporate Records Group This group is responsible to oversee and advise on all issues relating to corporate records within the Trust to support Information Governance which aims to ensure that corporate records, whether paper or electronic, are accessible and retrievable when and where required. The group escalates any issues, risks or noncompliance to the Confidential Information Steering Group. Health Records Group This group is responsible to oversee and advise on all issues relating to health records within the Trust to support the operational use of health records within the Trust and to support Information Governance. This group will also assist in the development of the Electronic Patient Record. Key Objectives for 2014 2015 Senior leadership must continue to be provided as it demonstrates the importance of Information Governance and is critical in obtaining resources: To implement robust Information Governance assurance systems and processes. For all designated groups/committees to meet as stated within their terms of reference. To show improvement between the July submission and the October submission of the IGT. To achieve an overall score for the IGT of Compliant or Satisfactory for the March submission. To achieve full assurance in internal/external audits against requirements which are audited within the IGT. Procedure: 292 Page 10 of 12
4. Training The Trust recognises the importance of effective training and education to maintain its position as a quality healthcare provider and fully realises the potential of its staff. From an Information Governance perspective, a systematic and comprehensive strategy and education programme is crucial. It underpins the entire Information Governance process by making all staff aware of their roles and responsibilities for information management. The Trust has developed an accredited in-house elearning package which supports central guidelines for topic content. Identified trends in IG incidents are included in the training material to promote learning from incidents in an effort to reduce the reoccurrence rate. 5. Evidence Base Common law duty of confidentiality Data Protection Act 1998 Human Rights Act 1998 Freedom of Information Act 2000 Access to Health Records Act 1990 (where not superseded by the Data Protection Act) Computer Misuse Act 1990 (amended in 2005) Copyright, Designs and Patents Act 1988 (as amended by the Copyright Regulations 1992) Crime and Disorder Act 1998 Electronic Communications Act 2000 Regulation of Investigatory Powers Act 2000 Re-use of Public Sector Information Regulations 2005 Records Management NHS Code of Practice 2006 Confidentiality NHS Code of Practice 2003 Information Security Management NHS Code of Practice NHS Information Risk Management Data Handling Procedures in Government: Final Report June 2008 Information Governance Toolkit Information Governance Assurance Programme Documentation: Gateway reference: 9912 Gateway reference: 10509 Closure Document Privacy Impact Assessment Handbook Version 2.0 (Information Commissioner) The Operating Framework for the NHS in England 2012/13 The Caldicott 2 Review Department of Health September 2013 A guide to confidentiality in health & social care, Health & Social Care Information Centre September 2013 6. Monitoring Compliance and Audit Information Governance is not a linear process and requires perpetual review and adjustment in order to provide maximum protection. The Trust will ensure that processes and activities outlined within the strategy and the strategy document itself is updated annually. The Trust will use its routine management monitoring and audit tools and processes to monitor compliance with this strategy. Audits will be undertaken a minimum of Procedure: 292 Page 11 of 12
quarterly. Non-compliance will be reported to the Confidential Information Strategy Group, which reports up to the Audit and Risk Committee. Tools will include: IGT self-assessment. Internal audit on IGT requirements. Production of an annual report of Information Governance activities. Identifying whether the key objectives of this document have been achieved. 7. Dissemination, Implementation and Access to the Document This strategy is available on the Trust intranet. Staff are notified via email, of the strategy and any amendments. Procedure: 292 Page 12 of 12