Information Governance Policy Version 1.1 Responsible Person Information Governance Manager Lead Director Head of Corporate Services Consultation Route Information Governance Steering Group Approval Route Applies To HSCB Senior Management Team All HSCB Staff, Contractors and Relevant Third Parties Approval Date Senior Management Team 27 May 2014 Review Date June 2017 HSCB Information Governance Policy Page 1
Amendment / Change Control Date Version Action Amendment 15/05/14 1.0 27/05/14 1.1 Comments from HSCB SMT received and amended accordingly Additional Principle added in relation to Appropriate data Sharing HSCB Information Governance Policy Page 2
Equality, Good Relations and Human Rights SCREENING This policy has been screened for equality implications as required by Section 75 of Schedule 9 of the Northern Ireland Act 1998. It has been concluded that the policy does not in any way have an impact on the nine equality groupings or the three good relations duties. This policy will therefore not be subject to an Equality Impact Assessment. Human Rights This policy has been considered under the terms of the Human Rights Act 1998, and was deemed compatible with the European Convention Rights contained in the Act. This policy will be included in the Health and Social Care Board s Register of Screening documentation and maintained for inspection whilst it remains in force. HSCB Information Governance Policy Page 3
CONTENTS 1.0 Introduction... 5 2.0 Policy Statement... 5 3.0 Scope... 5 4.0 HSCB Principles... 6 4.1 Openness... 7 4.2 Legal Compliance... 7 4.3 Information Security... 7 4.4 Information Quality Assurance... 8 4.5 Appropriate Information Sharing... 8 5.0 Information Governance Framework... 8 6.0 Roles and Responsibilities... 9 6.1 Chief Executive... 9 6.2 Senior Information Risk Owner (SIRO)... 9 6.3 The Personal Data Guardian (PDG)... 9 6.4 Information Asset Owners (IAO)... 9 6.5 Information Asset Assistants (IAA)... 9 6.6 Information Governance Team... 9 6.7 All Staff... 10 7.0 Monitoring and Compliance... 10 8.0 Review and revision arrangements... 10 9.0 Training Requirements... 11 10.0 Policy Distribution... 11 Appendix One Information Governance Framework... 12 HSCB Information Governance Policy Page 4
1.0 Introduction Information is a vital asset, both in terms of the clinical management of patients and the efficient management of services and resources. It plays a key part in corporate governance, service planning and performance management. It is therefore of paramount importance to ensure that information is efficiently managed and that appropriate policies, procedures and management accountability provide a robust governance framework for information management. The Information Governance (IG) framework for the Health and Social Care Board (HSCB) is formed by those elements of law and policy from which applicable information governance standards are derived and the activities and roles which individually and collectively ensure that these standards are clearly defined and met. 2.0 Policy Statement Information Governance is an overarching term used to describe all aspects of information management. This Information Governance Policy is therefore a statement of the HSCB approach and intentions to fulfilling its statutory and organisational responsibilities in relation to the management of information. It will enable management and staff to make correct decisions, work effectively and comply with relevant legislation and the organisations aims and objectives. This document sets out the high level principles across the HSCB for confidentiality, integrity and availability of information to promote and build a level of consistency across the HSCB on these principles. Failure by any employee of the HSCB to adhere to this policy and its associated procedures and guidelines will be viewed as a serious matter and may result in disciplinary action. 3.0 Scope This Information Governance Policy should be considered alongside the supporting suite of policies and guidance covering the key aspects of Information Governance. The main policy documents are as follows: HSCB Information Governance Policy Page 5
Data Protection and Confidentiality Policy Records Management Policy Retention and Disposal Schedule ICT Security and Associated Policies Freedom of Information Procedures Information Risk Procedures The policy applies to all HSCB staff, Agency staff, third party contractors/service providers and any other individual or organisation processing information for or on behalf of the HSCB. It is applicable to all processing activities on information held in any format and type such as (but is not limited to): Patient/client/service user information Staff and personnel information Organisational, business and operational information Research, audit and reporting information It is the responsibility of the HSCB Directors, Assistant Directors and Senior Managers to ensure that this Information Governance Policy is brought to the attention of all staff and that staff have appropriate training on information governance and related policies on induction and annually thereafter. 4.0 HSCB Principles The HSCB recognises the need for an appropriate balance between openness and confidentiality in the management and use of information. The HSCB fully supports the principles of corporate governance and recognises its public accountability but equally places importance on the confidentiality of, and the security arrangements to safeguard both personal information about service users and staff and commercially sensitive information. Whilst meeting legislative and statutory requirements the HSCB also recognises the need to share (disclose) patient information with other health organisations and other agencies in a controlled manner to support better care, consistent with the consent of the patient and, in rare circumstances, the public interest. HSCB Information Governance Policy Page 6
4.1 Openness Information on the HSCB and its services should be available to the public through a variety of media, in line with the HSCB Freedom of Information procedures (subject to it not being exempt from disclosure). What constitutes exempt information is defined by law and decisions by the Information Commissioner and/or the Information Tribunal. The HSCB will undertake or commission annual assessments and audits of its information governance processes and arrangements for openness. Patients, clients and members of the public should have access to personal information including their own health care, their options for treatment and their rights as patients. Staff will have access to personal information including their rights as employees. 4.2 Legal Compliance The HSCB regards all identifiable personal information as confidential. Personal information relating to staff will be treated as confidential except where national policy on accountability and openness requires otherwise and in the public interest. The HSCB will establish and maintain policies to ensure compliance with the Data Protection Act, Freedom of Information Act, the DHSSPS Code of Practice on Protecting the Confidentiality of Service User Information and the common law duty of confidentiality. The HSCB will undertake or commission annual assessments and audits of its compliance with legal requirements in relation to information governance primarily the Information Management Controls Assurance Standard. The HSCB will investigate all breaches of confidentiality and security, and failure to comply with key information governance policies in line with HSCB incident reporting processes. 4.3 Information Security The HSCB, in partnership with the Business Services Organisation (BSO), will establish and maintain policies for the effective and secure management of its information assets and resources. The HSCB will promote effective confidentiality and security practices to its staff through the dissemination of its policies, the establishment of local procedures, and staff training and awareness. HSCB Information Governance Policy Page 7
The HSCB, in partnership with the Business Services Organisation (BSO), will undertake or commission annual assessments and audits of its information and IT security arrangements. The HSCB will establish and maintain incident reporting procedures and will monitor and investigate all reported instances of actual or potential breaches of confidentiality and security. 4.4 Information Quality Assurance The HSCB will establish and maintain policies and procedures for information quality assurance and the effective management of records. In compliance with the DHSSPS Information Management Controls Assurance Standard, the HSCB will undertake annual assessments and audits of its information quality and records management arrangements. Managers are expected to take ownership of, and seek to improve, the quality of information within their services. Wherever possible, information quality should be assured at the point of collection. The HSCB will promote information quality and effective records management through policies, local procedures/user manuals and staff training and awareness. 4.5 Appropriate Information Sharing Appropriate sharing of some personal Health & Care information for direct care purposes is essential for achieving faster, safer decisions for better care outcomes. The HSCB will take account of The Data Protection considerations associated with the electronic processing of personal data for direct care purposes, DHSSPS, February 2012 and ICO Data Sharing Code of Practice, May 2011 and establish and maintain Data Sharing Agreements when appropriate to allow the secure and safe sharing of patient identifiable information with due consideration given to patient consent, arrangements for controlled access and governance arrangements for the shared data. 5.0 Information Governance Framework Appendix one provides the Information Governance Framework for the HSCB. The framework provides a high level summary of the key Information Governance roles, policies, reporting and oversight HSCB Information Governance Policy Page 8
arrangements, training and incident management processes in place for the HSCB. 6.0 Roles and Responsibilities The main roles are identified as follows: 6.1 Chief Executive The Chief Executive, as Accountable Officer, has responsibility for ensuring that sound systems of Corporate Governance are in place within the HSCB and to ensure compliance with legal and statutory obligations. 6.2 Senior Information Risk Owner (SIRO) The SIRO (Director of PMSI and Corporate Services) is the focus for the management of information risk at Board level. The SIRO will advise the Accounting Officer on the Information Risk aspect of the Statement of Internal Control and will own the overall information risk and risk assessment process. 6.3 The Personal Data Guardian (PDG) The PDG (Director of Integrated Care) has responsibility for ensuring that HSCB processes satisfy the highest practical standards for handling personal data. The PDG is the conscience of the organization in respect of patient information, and will also promote a culture that respects and protects personal data. The PDG works closely with the SIRO and Information Asset Owners where appropriate, especially where information risk reviews are conducted for assets which comprise or contain patient/service user information. 6.4 Information Asset Owners (IAO) The IAOs primary role is to manage and address risks associated with the information assets within their function and to provide assurance to the SIRO on the management of those assets. Each IAO for their function sits on the Information Governance Steering Group. 6.5 Information Asset Assistants (IAA) IAAs may be identified in each function to support the IAO. 6.6 Information Governance Team The Information Governance Team will support the above roles and provide expert advice, guidance and support to all staff on all elements of Information Governance. HSCB Information Governance Policy Page 9
6.7 All Staff It is the responsibility of all staff to make themselves familiar with and comply with policies and procedures issued by the HSCB, and aware that failure to comply may result in disciplinary action. All staff will work within the principles outlined in the Information Governance framework and undertake annual Information Governance training. 7.0 Monitoring and Compliance Actions to ensure compliance with this policy are detailed in the corresponding Information Governance Strategy. The strategy includes an action plan identifying key areas of work necessary to ensure compliance with this policy. Formal reporting arrangements are also outlined with expected timescales. Ultimately performance will be monitored on a six monthly basis by the HSCB Governance Committee. Compliance with the Information Governance Assurance Framework will also be assessed by the annual completion of the Information Management CAS. Formal reports will be provided to the SIRO for sign off prior to submission. The HSCB has in place an established incident reporting procedure and will monitor and investigate all reported instances of actual or potential breaches of confidentiality and security. As part of the training and awareness programme, employees and third party contractors will also be made aware of definitions of incidents and the process for dealing with them. 8.0 Review and revision arrangements This policy will be reviewed as per the review date on the policy front sheet. However, it will be reviewed when affected by major internal or external changes such as: Legislation Practice change or change in system/technology Changing methodology HSCB Information Governance Policy Page 10
9.0 Training Requirements Staff will be trained in the use of systems and procedures to ensure the quality and appropriate handling of information in order to minimize risks to the organisation from poor information governance. All staff will receive mandatory induction/awareness training covering all aspects of Information Governance. Various methods of delivery will be used including E-Learning where applicable. Annual refresher updates will also be provided to all staff. Awareness raising of the key information governance principles will be undertaken as necessary. A staff Code of Conduct for Information Security and Confidentiality will be developed and available to all staff via the Intranet and in hard copy where applicable. This will give staff the key points regarding confidentiality and information security and best practice guidance. Staff with key roles (e.g. SIRO/Personal Data Guardian/Information Asset Owner) will undertake regular training for their specific role. 10.0 Policy Distribution The Policy will be made available to all HSCB Staff via the HSCB Intranet site. A global notice will be sent to all staff notifying them of the release of this document. HSCB Information Governance Policy Page 11
Appendix One Information Governance Framework INFORMATION GOVERNANCE MANAGEMENT FRAMEWORK Heading Requirement Notes Senior Roles IG Lead The Chief Executive as Accountable Officer has overall accountability for IG and is required to provide assurance, that all risks to the HSCB are effectively managed. Senior Information Risk Owner (SIRO) SIRO for the HSCB is Director of PMSI and Corporate Services. Personal Data Guardian (PDG) PDG for the HSCB is Director of Integrated Care IAOs for the HSCB are Assistant Directors within each Directorate Key Policies Over-arching IG Policy Information Governance Policy (to be developed) Data Protection Act 1998/Confidentiality Policy Data Protection/Confidentiality Policy (March 2010) Organisation Security Policy Information Lifecycle Management (Records Management) Policy ICT Security Policy Secure Mobile ICT Equip (Sept 2012) Use of the Internet Policy (Sept 2012) Use of Electronic Mail Policy(Sept 2012) Use of ICT Equipment Policy (Sept 2012) Records Management Policy (June 2012) Key Governance Bodies Corporate Governance Policy Freedom of Information Policy (to be developed) IG Board/Forum/Steering Group HSCB Governance Committee (meet bi annual) HSCB Information Governance Steering Group (meet bi monthly) HSCB Records Management Working Group (meeting bi monthly) Resources Details of key staff roles and dedicated budgets IG Manager x 1 Assistant IG Manager x 1 IG Project Manager x 1 IG Officer x 1 HSCB Information Governance Policy Page 12
IG Support Officers x 2 Governance Framework Details of how responsibility and accountability for IG is cascaded through the organisation. All staff contracts include IG clauses Contractors Confidentiality Agreement Information Asset Register Examples of 3 rd party contractors Training & Guidance Staff Code of Conduct (see criteria 5, 13 and 12) Training for all staff Code of Conduct for Employees in Respect of Confidentiality (to be developed) IG E-Learning Training is mandatory for all staff Organisation Security Policy HSCB ICT Security Policy Training for specialist IG roles SIRO, PDG and IAO training completed Incident Management Documented procedures and staff awareness Information Risk Policy (to be developed) Information Sharing Protocol Guidance for reporting IG related incidents IG Leaflet HSCB Information Governance Policy Page 13