Policy Information Management Document Title: Policy Information Management Issue date: October 2013 Document Status: Approved IGC 23 Oct 2013 Review date: October 2014 Page 1 of 17
Document control Document Information Document Name: Directorate: Consultation: Policy Information Management Governance Information Governance Steering Group Approved by: Integrated Governance Committee Date: 23 October 2013 Supersedes: Description: Not Applicable Policy outlining the organisational approach and objectives for the management of Information held and used by NHS Lambeth Clinical Commissioning Group Audience: Contact details: All staff. South London Commissioning Support Unit, Information Governance Function Email: slcsu.information.governance@nhs.net Change History Version Date Author Approver Reason 0.1 May-13 SL CSU,IG Manager, SL CSU, Head of IG, 1 st Draft H Thomas D Stone 0.1 Oct 2013 SL CSU,IG Manager, SL CSU, Head of IG, Final draft Ian Allsup D Stone 0.1 Oct 2013 SL CSU, IG Business Manager, SL CSU, Head of IG, D Stone Final draft Ratified at NHS Lambeth CCG Integrated Governance Committee 1.0 Mar 2014 SL CSU IG Manager A Ford Minor Amendments Page 2 of 17
Table of Contents 1 Introduction... 5 1.1 Policy statement and aim... 5 1.2 Objectives... 6 1.3 Promoting Equality... 6 2 Scope of this Policy... 6 2.1 NHS Lambeth Clinical Commissioning Group Clinical Commissioning Group Members... 7 2.2 Information Lifecycle Stages... 7 2.3 Types of Information... 7 3 Governance... 7 3.1 Accountability and Responsibility... 7 4 Information Lifecycle... 8 4.1 System Design... 8 4.2 Creation... 8 4.3 Use... 9 4.4 Maintenance... 9 4.5 Scanning... 9 4.6 Disposal... 9 5 Record... 10 5.1 Definition of a Record.... 10 5.2 Declaration of a Record... 10 6 Measures... 10 6.1 Measurement of Documents, Information and Data... 10 6.2 Measurement of Records... 11 7 Audit and monitoring criteria... 11 7.1 Monitoring and Reporting of compliance... 11 7.2 Non Compliance... 12 8 Review... 13 8.1 Next formal review... 13 8.2 Latest Version... 13 9 Statement of evidence/references... 13 9.1 Key Legislative and Regulatory Environment... 13 9.2 Other References... 13 10 Implementation and dissemination of document... 13 Annexe A -Equality & Equity Impact Assessment Checklist... 14 Annexe B - Definitions... 15 Page 3 of 17
Document Consultation Record Version Date Name Post Organisation Comments 0.1 20-Jun-13 C Tapping IG Support Officer CSU 0.1 09 Oct-13 I Allsup IG Manager CSU Quality Assurance review 0.1 Oct 2013 IGSG IGSG Lambeth CCG Grammar and spelling Page 4 of 17
1 Introduction 1.1 Policy statement and aim The policy of NHS Lambeth Clinical Commissioning Group is to manage all the information within its remit to the standards required by law and regulation. In doing so, supports high quality commissioning and healthcare, through accurate, accessible and appropriately governed information. This policy and commitment extends to the services we commission, ensuring their appropriate use and control of information to deliver high quality healthcare and to support our patients and our organisation. This policy outlines the legal, regulatory and best practice framework that this organisation works to and the methods we will use to deliver and maintain this policy. Background Information is the key resource of the National Health Service (NHS) and the wider health economy; it enables the effective treatment of patients and the management of the NHS system and the services we commission. Information Management requires the management from its creation and use all, the way through to destruction or archival retention. Appropriate management of information enables an organisation, to reduce costs, improve efficiency and enhance the ability to monitor the performance of contracts and commissioned services. Understanding the information we hold and the way our organisation uses it helps us to manage our responsibilities under legislation, such as the Data Protection Act. As a commissioner of services we require information to be appropriately created, managed and utilised by those we commission. The Organisation is responsible for driving improvements in Information Governance from these services. This ensures an efficient, effective and accountable service supporting high quality healthcare and appropriate clinical decision making. In those instances where we appropriately share or publish information, we must ensure that this done in a lawful and appropriate manner. This policy sets out NHS Lambeth Clinical Commissioning Group s information management principles, controls and standards are in place for each stage of the information s lifecycle. Staff are responsible for maintaining these controls and standards. The policy is part of a suite related to Information Governance which set out the expected standards and controls around its use. They are: Information Governance, Information Quality, Information Management and Information Security. The concepts and standards are interrelated. It is important to consider all of our obligations and intentions across the suite of policies. Page 5 of 17
1.2 Objectives The organisation must ensure that it manages information throughout its lifecycle and as it flows internally and externally with partners alongside those we commission. The protocol applies to all stages of the lifecycle; it sets out the minimum requirement for staff at each stage of information processing. These must be met alongside the provision of security, confidentiality and the use of information to discharge the functions of the organisation. The right information, to the right people at the right time Best Practice guidelines for information and records management across all formats To reflect the relevant NHS Records Management standards To maintain the confidentiality, integrity and availability of information To support the information and records management strategy and review The requirements for on-going monitoring, reviews and regular audits of information and records 1.3 Promoting Equality Information Governance promotes the fair, equitable and opens access to high quality healthcare. By promoting better management of information this organisation can meet its statutory duty to address health inequality and commission high quality healthcare. 2 Scope of this Policy This policy is applicable to: All records, information and data held and processed by NHS Lambeth Clinical Commissioning Group. All information must be managed and held within a controlled environment. This includes personal data of patients and staff, non-identifiable patient level data, as well as corporate information. It applies to records, information and data regardless of format, in addition to legacy data held by the organisation; The standards expected from services commissioned by our organisation for healthcare and non-healthcare purposes; All permanent, contract or temporary personnel and all third parties who have access to NHS Lambeth Clinical Commissioning Group premises, systems or information. Any reference to staff within this document also refers to those working on behalf of the Organisation on a temporary, contractual or voluntary basis. This includes Members of the Clinical Commissioning Group discharging obligations, roles or work on behalf of the organisation; Information systems, data sets, computer systems, networks, software and information created, held or processed on these systems, together with printed output from these systems All means of communicating information, both within and outside the Cluster and both paper and electronic, including data and voice transmissions, emails, post, fax, voice and video conferencing. This document will refer to information to encompass the terms information, data and records. The Cabinet Office defines data as qualitative or quantitative statements or numbers that are assumed to be factual, and not the product of analysis or interpretation and Information as Page 6 of 17
output of some process that summarises interprets or otherwise represents data to convey meaning. This definition will be used throughout this document. See Annex B for definitions 2.1 NHS Lambeth Clinical Commissioning Group Clinical Commissioning Group Members Those members undertaking roles or work for the Clinical Commissioning Group are required to work to this policy alongside the related protocols and procedures. In doing so they are fulfilling a different role and obligations to those within their normal duties. They will be supported in doing so in line with this policy. 2.2 Information Lifecycle Stages The protocol applies to all stages of information and records management lifecycle, from the initial identification of a requirement through to its ultimate disposal: System Design Creation Use Maintenance Disposal An overview of the stages of the Information lifecycle is contained in Section on Information Lifecycle s below. 2.3 Types of Information The following is a list of information and systems within the scope of this protocol, the list is not exhaustive: digital or hard copy patient health records (including GP medical records); digital or hard copy administrative information (including, for example, personnel, estates, corporate planning, supplies ordering, financial and accounting records); digital or printed X-rays, photographs, slides and imaging reports, outputs and images; digital media (including, for example, data tapes, CD-ROMs, DVDs, USB disc drives, removable memory sticks, and other internal and external media compatible with NHS information systems); computerised records, including those that are processed in networked, mobile or standalone systems; portable communications devices such as mobile phones, Blackberry s, Personal Digital 3 Governance 3.1 Accountability and Responsibility Responsibility and accountability ultimately resides in the Accountable Officer for NHS Lambeth Clinical Commissioning Group, the Chief Officer They are supported in this role by the work of the Governing Body and delegated sub-committees as outlined in the Information Governance Framework. Page 7 of 17
The Senior Information Risk Owner (SIRO) is a Governing Body appointee accountable to the Board for the appropriate management of risk associated with the organisation s use and holding of information. The organisation s SIRO is Chief Officer Andrew Eyres. The Caldicott Guardian (CG) is responsible for leading the assurance agenda for the use of personal information within NHS Lambeth Clinical Commissioning Group. They are responsible for advising the Governing Body on the standards expected for maintaining the expected standards of confidentiality and data protection. The Organisation s Caldicott Guardian is Ruth Wallis. Both the SIRO and Caldicott Guardian are responsible for ensuring that the Organisation s strategic objectives are met for their respective agendas, and that controls are in place to ensure appropriate standards are set and implemented, and that relevant risks are identified. Supporting the Board and office holders, the Information Governance Steering Group, a Governing Body sub-committee and the delegated authority, is responsible and accountabilities are outlined in its terms of reference. The Governing Body is responsible for approving the policy and strategy framework. The Information Governance Steering Committee reports to Governing Body, which monitors the implementation of policy and approves necessary supporting controls such as protocols and procedures. Senior managers are responsible for identifying and managing information risks in their remit. Staff nominated as Information Risk Owners (Information Asset Owners) and those responsible for operating Information Assets as Information Risk Administrators (Information Asset Administrators) are accountable to the SIRO for the appropriate identification and management of risks. All staff are responsible for maintaining the controls for the use of information. This includes operating policy, protocol and procedures, completing mandated training and ensuring they are aware and comply with legal obligations. Line managers are responsible for ensuring the required standards are met. 4 Information Lifecycle 4.1 System Design One of the key elements of Information management throughout the lifecycle of information is the design of systems to capture information and records, It is important that the procurement, commissioning or system design process completes a thorough analysis. 4.2 Creation Information when created must be authentic, accurate, accessible, complete, compliant, effective and secure and its integrity must be protected over time. At the point of creation, the relevant metadata (breakdown details of the data) needs to be captured to ensure its on-going value and evidential weight. Page 8 of 17
Within a records management environment these highlighted terms have a specific meaning which is defined in Annexe B. 4.3 Use All information must be used consistently, only for the intentions for which it was intended and never for an individual employee s personal gain or purpose. If in doubt employees should seek guidance from their line manager and the Information Governance function. Evidential weight relies upon a clear audit trial and the ability to demonstrate that the context and content of information can be relied upon. The following are key components of use: Retrieval information must be accessible throughout its lifecycle for staff with authorised access and in line with access controls, Naming Conventions a clear, systematic and consistent standard for naming information is required Version Control a clear, systematic and consistent method of controlling version of information is vital for effective management and efficient working Storage - all information must be stored in systematic and consistent to be of use. Storage must also be Secure. Further details are provided in the Policy on Information Security and the policies and procedures for the relevant systems. Mapped Information Flows - All Flows of personal confidential data must be in accordance with legal, regulatory and organisational requirements. Routine flows of information within the organisation and with external bodies will be mapped, ensured as lawful and the risks involved understood. 4.4 Maintenance All information needs to be maintainable through time. The qualities of availability, accessibility, interpretation and trustworthiness must be maintained for as long as the information is needed, perhaps permanently, despite changes in the format. 4.5 Scanning An important element in meeting the requirement for accessibility and completeness of records is considering which records should be scanned. This is a process that will be addressed on a case by case basis given the expenses involved. However, it is the objective of the Organisation to ensure all records are in one format (e.g. no hybrid paper electronic records) with appropriate reference to relevant NHS strategies. 4.6 Disposal Disposal is defined as the management intent for a record once it is no longer required for the conduct of current business. Data and information, not classified as a record, may be destroyed once its business value is concluded. There are a number of stages in the disposal phase of a corporate record which will be outlined in the Protocol on Records Management. These include: Page 9 of 17
Closure - records are made inactive and transferred to secondary storage Retention - the retention period varies dependant on the type of information being stored. Destruction - all information and records must be destroyed appropriately. This applies across all media and to the systems that hold information (such as servers and encrypted memory sticks). Archiving - upon the end of a retention period, information must be assessed for whether it is requires archiving or destroyed. Any service that takes over legacy records must manage their disposal. Those that find records within their remit or office space must; register the collection with the Information Governance Team and inform the relevant senior manager for their function to ensure the appropriate Information Risk Owner is identified ensure that it is managed appropriately 5 Record 5.1 Definition of a Record. The definition of a recorded by this organisation documentary evidence, regardless of form or medium, created, received, maintained and used by NHS Lambeth Clinical Commissioning Group in pursuance of its legal obligations or in the transaction of business. This definition draws a distinction between a record and a document. A record is a final version that may be retained, while a document can be changed and will not normally be retained except for audit trail purposes where necessary. The purpose of a record is to preserve information in a form that is trustworthy and, once declared, should not be changed. A record is only created when there is a need to remember the details of an event, decision or action. Creation is supported by a process of lodging a document into a record keeping system, including the registration and classification of the record and assigning metadata to describe the record and place it in context. The life of a record from its creation/receipt through the period of its active use, then into a period of inactive retention (such as closed files which may still be referred to occasionally) and finally either preservation or confidential destruction. 5.2 Declaration of a Record Where required, information will be declared a record through application of the relevant process. At which point an unalterable version meeting standards of legal admissibility will be created and the relevant metadata captured. Further details are outlined in the relevant Protocol 6 Measures 6.1 Measurement of Documents, Information and Data Measurement of documents, information and data will be related to the functions they support and the infrastructure that supports them. Management will be measured through the principles of security, quality and governance as outlined in the relevant Policies and Protocols. Page 10 of 17
The extent, the period covered and the annual accumulation rate will be measured for information via appropriate measures defined in the relevant protocols. Appropriate management is through the Information Asset Register. 6.2 Measurement of Records The measurement of records will be through the capture of record series and data about them, the timely disposal of records in accordance with the agreed retention schedule. The Information Asset Register will be used to record relevant data about the records and where they are held. All directorates, teams and functions are expected to maintain clear measures of the records they hold covering the extent and period they cover, in addition to the annual accumulation rate. 7 Audit and monitoring criteria 7.1 Monitoring and Reporting of compliance This policy and the associated controls will be monitored through the Information Risk Management system for the organisation. The Information Risk Register will be reviewed on a monthly basis, in response to any information incident or enforcement action by the Information Commissioner s Office. Information Risk Management will be a key component of wider assurance and control in setting the priorities for the information governance work plan for Information Quality. Control Audit and Monitoring Table Monitoring requirements What in this document do we have to monitor? Monitoring Method Monitoring prepared by The management of information risks (Information Risk Management) Compliance with the law Compliance with the Information Governance Toolkit Incidents related to the breach of this policy Information Risks will be monitored through the Information Risk Register and management system. Compliance with law will be monitored through audit, work directed by the Information Governance Toolkit and as directed by Information Risk Management The Information Governance Toolkit will be monitored by assessment of evidence against the objective of the relevant requirement. In addition, the IGT will be audited by the organisation s internal audit function before the annual submission. Incident reporting and management requirements Information Governance Function SL CSU supporting the IG Lead for NHS Lambeth Clinical Commissioning Group and Information Governance Steering Group Incident reports will be produced by the nominated investigation officer Page 11 of 17
Monitoring presented to Frequency of Review Information Governance Steering Group Senior Information Risk Owner Caldicott Guardian Governing Body and Accountable Officer Monthly updates will be provided to the IG Steering Group, the SIRO and the CG Relevant Information Risks will be added to the Corporate Risk Register and reported in line with Risk Management system Annual (as a minimum) updates to the Governing Body will be provided. The internal audit report on IGT performance will be provided to the Governing Body or delegated sub-committee. Incident Reports will be reviewed on an annual basis and as directed by the seriousness of the incident Further assurance will be provided through the Information Governance Toolkit (IGT) and the associated audit. Reviews of the current controls and their operation will be undertaken in line with a quarterly timescales, as a minimum, and in line with the expectations of the Information Governance Toolkit. It is noted that the Toolkit may supplementary work to ensure broader assurance. Information Risk Owners, assisted by Information Risk Administrators, will be required to routinely review the Risks and Information Flows associated with the Information Assets utilised to fulfil the business functions and activities within their remit. Further monitoring will be undertaken through the change control process. 7.2 Non Compliance Failure to comply with the standards and appropriate governance of information as detailed in this policy, supporting protocols and procedures can result in disciplinary action. All staff are reminded that this policy covers several aspects of legal compliance that as individuals they are responsible for. Failure to maintain these standards can result in criminal proceedings against the individual. These include but are not limited to: Common law duty of confidentiality Computer Misuse Act 1990 Data Protection Act 1998 Freedom of Information Act 2000 Human Rights Act 1998 Public Records Act 1958 For a full list of relevant legislation and guidance see the Information Governance Framework. Page 12 of 17
8 Review 8.1 Next formal review Review will take place of the 1 st anniversary of adoption and subsequently every three years until rescinded or superseded. 8.2 Latest Version The audience of this document should be aware that a physical copy may not be the latest version. The latest version, which supersedes all previous versions, is available in the policy register for the organisation. Those to whom this policy applies are responsible for familiarising themselves periodically with the latest version and for complying with policy requirements at all times. 9 Statement of evidence/references A full list of guidelines, evidence and references will be provided and maintained in the Information Governance Framework. 9.1 Key Legislative and Regulatory Environment The following is a list of the Key legislative and regulatory framework Data Protection Act 1998 Freedom of Information Act 2000 Computer Misuse Act 1990 Common law duty of confidentiality Human Rights Act 1998 Health and Social Care Act 2012 NHS Constitution Information Commissioner Offices guidance, passim. Care Quality Commission Requirements (for commissioned healthcare services) A full list of current guidance will be maintained in the Information Governance Framework. 9.2 Other References Other relevant policies are: Information Governance Information Quality Information Security A list of related protocols and procedures will be maintained in the Information Governance Framework 10 Implementation and dissemination of document The Policy, once approved will be shared with all staff through the all staff email, updated on the intranet, included in staff briefings and place in the policy register. A team and management briefing will be provided to support this dissemination. In addition to the monitoring detailed above, awareness of the policy will be checked through a staff survey and spot checks on at least an annual basis. Page 13 of 17
Annexe A -Equality & Equity Impact Assessment Checklist This is a checklist to ensure relevant equality and equity aspects of proposals, policy or guidance have been addressed either in the main body of the document or in a separate equality & equity impact assessment (EEIA)/ equality analysis. It is not a substitute for EEIA/ equality analysis which is normally required unless it can be shown that a proposal has no capacity to influence equality. The checklist is to enable the policy lead and the relevant committee to see whether the EEIA has covered the ground and to give assurance that the proposals will not only be legal but also fair and equitable and lead to reduced health inequality. Challenge questions Yes/No/D Comments K/NA 1. 2. Does the document set out the health care needs of the groups intended to benefit from the proposal, including any differences in need in terms of the legally protected or other characteristics (such as socioeconomic position) Does the document set out any known existing inequality in access, quality, experience and outcome of care for populations relevant to the proposal (ie as defined in 1. and in relation to the existing health or care service)? 3. Are there any particular public concerns about equality about the policy area that need to be addressed? 4. Has the policy described any gaps in knowledge about 1-3, and any action taken to fill gaps (or recommendations for action) 5. Does the document set out risks to equity of access, quality, experience and outcomes including risk of direct or indirect discrimination, and risk to good relations between people of different groups? 6. Does the document describe any specific opportunities to promote equality and human rights, good relations between people of different groups, to enhance participation, etc? 7. Does the document describe how the proposal, policy etc will address the identified inequalities? 8. Does the document make recommendations to mitigate risks and enhance the opportunities to promote equality and equity? 9. Does the document describe how monitoring and reporting will take place to assure equality and equity in the future including to stakeholders. [audit and monitoring table may be used] N/A N/A No No No No No Yes No Within the policy is a section on Promoting Equality. Information Governance promotes the fair, equitable and opens access to high quality healthcare. By promoting better management of information this organisation can meet its statutory duty to address health inequality and commission high quality healthcare. * Race/ ethnicity, gender (including gender reassignment) age, religion or belief, disability, sexual orientation, marriage or civil partnership, pregnancy and maternity. This will include groups such as refugees and asylum seekers, new migrants, Gypsy and Traveller communities; and people with long term conditions, hearing or visual impairments, mental health problems or learning disability Page 14 of 17
Annexe B - Definitions Term Definition Source Data Data is used to describe qualitative or quantitative statements or numbers that are assumed to be factual, and not the product of analysis or interpretation. The Information Governance Review, Mar 2013 (Gateway Ref: 2900774) 1 based on the Cabinet Information Personal Confidential Data or PCD Information is the output of some process that summarises interprets or otherwise represents data to convey meaning. This term describes personal information about identified or identifiable individuals, which should be kept private or secret. For the purposes of this review personal includes the Data Protection Act definition of personal data, but it is adapted to include dead as well as living people and confidential includes both information given in confidence and that which is owed a duty of confidence and is adapted to include sensitive as defined in the Data Protection Act. Office definition The Information Governance Review, Mar 2013 (Gateway Ref: 2900774) The Information Governance Review, Mar 2013 (Gateway Ref: 2900774) Sensitive Personal Information Sensitive Information There is a precise definition of sensitive information within the Data Protection Act 1998 for Personal Data. It includes information about the health of an individual; within the NHS it is safe to assume that most information about patients can be considered sensitive if it includes any details of health conditions or treatment. For more information see the Data Protection Protocol This is information such as financial or security information that should be considered sensitive. Access to this information needs to be controlled and restricted to specific post holders. Data Protection Act 1998 and The Information Governance Review, Mar 2013 (Gateway Ref: 2900774) Data Protection Act 1998 and The Information Governance Review, Mar 2013 (Gateway Ref: 2900774) 1 See https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/192572/2900774_infogovernance_accv2.pdf, p. 24 Page 15 of 17
Protected Personal Data Category A Protected Personal Data Category B Safe Haven Records Management This is information if wrongly released or lost could cause harm or distress to individuals. These need to be afforded the highest protection and most restricted access. Category A Any information that links one or more identifiable living person with information about them which, if released, would put them at significant risk of harm or distress. See Information Governance Toolkit Requirement 308 for more background information Any information about 21 or more identifiable individuals, other than information sourced from the public domain. This is a minimum standard, information on a smaller number of individuals will warrant protected personal data status because of the nature of the individuals or source of information, for example vulnerable adults or children. A Safe Haven is a term used to explain either a secure physical location or the agreed set of administration arrangements that are in place within the organisation to ensure confidential patient or staff information is communicated safely and securely. It is a safeguard for confidential information, which enters or leaves, or is transmitted within the organisation by any means. Any members of staff handling confidential information, whether paper based or electronic must adhere to the Safe Haven protocol and relevant procedure. as defined by ISO 15489 The field of management responsible for the efficient and systematic control of the creation, receipt, maintenance, use and disposition of records, including processes for capturing and maintaining evidence of and information about business activities and transactions in the form of records. Data Protection Act 1998 and The Information Governance Review, Mar 2013 (Gateway Ref: 2900774) Data Protection Act 1998 and The Information Governance Review, Mar 2013 (Gateway Ref: 2900774) Data Protection Act 1998 and The Information Governance Review, Mar 2013 (Gateway Ref: 2900774) ISO 15489 and NHS Code of Practice: Records Management Page 16 of 17
Record Records Life Cycle Vital Records Information Security Documentary evidence, regardless of form or medium, created, received, maintained and used by the Cluster in pursuance of its legal obligations or in the transaction of business. This definition draws a distinction between a record and a document a record is a final version that may be retained, while a document can be changed and will not normally be retained except for audit trail purposes where necessary. The purpose of a record is to preserve information in a form that is trustworthy and, once declared, should not be changed. The life of a record from its creation/receipt through the period of its active use, then into a period of inactive retention (such as closed files which may still be referred to occasionally) and finally either preservation or confidential destruction. Records containing information essential to the survival and recovery of an organisation in the event of a disaster Securing, safeguarding and protecting the confidentiality, integrity and availability of all information, electronic or otherwise ISO 15489 and NHS Code of Practice: Records Management ISO 15489 and NHS Code of Practice: Records Management ISO 15489 and NHS Code of Practice: Records Management ISO 27001 and NHS Code of Practice: Information Security Page 17 of 17