Data Quality Policy. The Trust will aim to achieve and maintain the highest standards contained within the Information Governance Toolkit.

Trust Policy Department / Service: Information Department Originator: Information Governance Manager Accountable Director: Director of Finance/SIRO Approved by: Trust Management Committee Date of approval: 18 th February 2015 First Revision Due: 18 th February 2017 Target Organisation(s) Worcestershire Acute Hospitals NHS Trust Target Departments All Target staff categories All Policy Overview: The Trust is committed to pursuing a high standard of accuracy, completeness and timeliness within all aspects of data collection in accordance with NHS Data Standards. Policies and procedures are in place to cover all the major data collection activities and adherence to good practice is mandatory. All staff involved in data collection must be familiar with the aims and practices described in this policy. Data quality is the responsibility of all staff. Systems procedures and the routines of all data collection and data processing staff will therefore be subject to on-going monitoring and review as stated in this policy. The Trust will aim to achieve and maintain the highest standards contained within the Information Governance Toolkit. Key amendments to this Document: Date Amendment By: Mar 2006 Initial Draft IG Manager Oct 2006 Updated Draft IG Manager Dec 2006 Updated Draft IG Manager Sept 2009 Updated into Trust Format for policies IG Manager Sept 2011 Updated into new trust policy format IG Manager Dec 2013 Updated into new trust policy format IG Manager Jan 2015 Includes latest guidance and reflects organisational changes and the audit cycle. IG Manager WAHT-CG-443 Page 1 of 27 Version 3

Trust Policy Contents page: 1. Introduction 2. Scope of this document 3. Definitions 4. Responsibility and Duties 5. Policy detail 6. Implementation of key document 6.1 Plan for implementation 6.2 Dissemination 6.3 Training and awareness 7. Monitoring and compliance 8. Policy review 9. References 10. Background 10.1 Equality requirements 10.2 Financial Risk Assessment 10.3 Consultation Process 10.4 Approval Process Appendices Appendix 1: Patient Information Collection/Confirmation of Attendance Appendix 2: Right First Time Quick Reference Guide Appendix 3: Right First Time Top Tips Appendix 4: Data Quality Audit Cycle Supporting Documents Supporting Document 1 Supporting Document 2 Equality Impact Assessment Financial Risk Assessment WAHT-CG-443 Page 2 of 27 Version 3

Trust Policy 1. Introduction The Trust requires accurate, timely, relevant and standardised patient information to support both the delivery of its core business objectives and the monitoring of activity and performance for internal and external management purposes. A vital pre-requisite to the production of robust information is the availability of high quality data across all areas of the Trust. The improvement and promotion of all aspects of data quality is the responsibility of every Trust employee. In order to achieve this, staff must meet agreed standards by following the procedures laid down for data collection and reporting. Data quality will be measured against NHS data standards. The requirement for accurate patient data has increased due to a number of factors. These have included: Emphasis from central NHS management on performance targets, league tables and ratings The Data Protection Act 1998 setting a legal requirement for accurate and up to date personal data The introduction of Payment by Results The need to conform to National data quality standards; i.e. the Information Governance Toolkit and the Care Quality Commission. In order to address the above requirements, the Trust has introduced a data quality policy to achieve and maintain the continuing availability of high data quality. 2. Scope of this document The principles cover all patient related computer systems within the Trust where patient data can be demographic, administrative or clinical. The following systems are included: Patient Administration System A&E (Patient First) Radiology (CRIS) Pathology (WinPath) ICE Pharmacy (Ascribe) Bluespier Maternity Datix Each department must produce their own procedures to provide their staff with detailed guidance regarding data collection, recording and validation, in line with this policy. The data recorded on these systems is used to support: Patient care Achievement of local and national performance targets Measurement of patient activity. Maintenance of integrated patient records Risk management Clinical audit Production of commissioning datasets Payment by Results 3. Definitions WAHT-CG-443 Page 3 of 27 Version 3

Trust Policy Data Quality Patient Data National guidelines Defined as the maintenance of demonstrably accurate, consistent, electronic patient activity data conformant with national guidelines. Refers to demographic and clinical data held within all Trust systems. Include those laid out in the NHS Data Manual and Data Standards and the application of the principles and processes detailed in the National Data Accreditation Standards. 4. Responsibility and Duties 4.1 The Trust Management Committee - Each month the Trust Board Performance Dashboard is produced for the Trust Board meeting. It contains a wide variety of key performance indicators covering Quality, Workforce, Finance, Performance, Maternity and Contractual elements. This includes dashboards detailing monthly numbers of patients on the waiting list, outpatients DNA rates and day case admissions. Many of the indicators are RAG rated giving an indication of performance over time. TMC approves trust policies. 4.2 The Risk Executive Group receives its authority from the Board and its membership consists of Board members, senior managers, clinicians and other senior clinical representatives. The committee receives six monthly updates and ad hoc reports from the Information Governance Steering Group. 4.3 The Information Governance Steering Group receives its authority from the Risk Executive Group and is chaired by the Director of Finance, who is the Senior Information Risk Owner (SIRO) for the trust. Members include the Head of ICT and Asset Management (Vice-Chair), the Caldicott Guardian, Information Governance Manager, Deputy Director of Nursing, Secretary to the Trust Board, Head of Clinical Governance and Risk Management, Head of Legal Services, Assistant Director of HR and Information Governance Officer. The purpose of the group is to ensure the trust produces year-on-year improvement in the standards contained within the Information Governance Toolkit and its own annual work programme. The group receives 6 monthly Information Governance reports which contain a section on Data Quality. 4.4 The Data Quality Group receives its authority from the Information Governance Steering Group and is chaired by the Head of Information. Membership includes Information Governance Manager/Officer, Information Analyst, Senior Health Records Manager and Clinical Applications Manager. The purpose of the group is to produce year-on-year improvements in the timeliness and quality of the Trusts data. An annual review of effectiveness is achieved against set data quality standards within an annual work programme. The group receives data set change notices, coding reports, audit reports, data quality report and reviews PAS enhancements. This group will take primary operational responsibility for the development and implementation of the Trusts data quality policies and procedures including: To ensure Policy and Procedure Documents surrounding data collection, processing and validation are in place, up-to-date and conform to National Standards. To ensure all staff are receiving appropriate training, are adhering to trust policies and procedures regarding data collection and have an understanding of the importance of the data they are responsible for entering onto the system. To communicate any changes in practice, standards and any national changes in data / information collection. To ensure the correct processes are in place to maximise income. To identify any data errors and agree remedial plans. WAHT-CG-443 Page 4 of 27 Version 3

Trust Policy To commission audits / monitoring of information processes and feedback results / recommendations through the team and onto the Information Governance Steering Group. To work with the Clinical Application Team to improve the set up / functionality of patient systems, in order to reduce the possibility of entering data incorrectly. To review and prioritise proposed enhancements to the PAS system. To liaise with other trust working groups and committees in order to promote data quality issues. Encourage clinical involvement in the provision and use of Trust data. To use forums such as the Executive team, Senior Nurse Operational Forum and Divisional Operational Group as a means of communicating trust-wide data quality issues. 4.5 All System Users - all users of systems employed for the collection of patient activity data have responsibility for ensuring that the data they collect and record is timely, accurate and consistent and that Trust policies and procedures relating to this data are adhered to. Appendix 1 sets out the minimum set of patient demographic details that should be updated at every attendance 4.6 Data Audit Clerk Information Governance Standard 506 is a requirement for all trusts to have a documented procedure and a regular audit cycle for accuracy checks on service user data (see appendix 4 for this document). The results of these audits should be reported to the Data Quality Group and the Information Governance Steering Group. 4.7 Data Quality Clerks - Data quality reports provided by the information department are updated daily and patients found with missing patient data such as GP, Postcode, DOB and NHS number are updated using the national databases before matching and updating patient information locally. 4.8 Departmental/Corporate Systems it is the responsibility of local departmental managers (and managers responsible for data collection areas on corporate systems such as PAS) to ensure the data recorded on the system is accurate and timely. Validation processes need to be in place to check the data and departmental procedures which give clear instructions to staff as to how and why the information is collected. The procedures must also include processes for updating demographic data from departmental systems to the Patient Administration System (PAS). Copies of the procedures should be available within the department or on the trust intranet. 4.9 The Information Department the teams within the department consists of; Development and processing team which includes a senior developer and Analysis team which includes a senior performance analyst. The teams are managed by the Information Manager. The Information Team are responsible for the production of regular reports to trust management boards, committees and groups, the completion of statutory external returns and data submission and the production of both ad-hoc and routine reports developed to support clinical directorate management and decision making. Systems development create and support databases in order to process, validate and report on trust data, to ensure its accurate and timely production. The role of information governance is to ensure trust data is held securely and confidentially, obtained fairly and efficiently, recorded accurately and reliably, used effectively and ethically and shared appropriately and lawfully. All reports should be based on national dataset standards and the information department takes responsibility for the implementation of any changes to these standards. Data used in the production of these reports is extracted from patient systems and the information staff take responsibility for the validation (identifying and reporting the errors) once extracted. Regular and some ad-hoc data error reports are sent to the data quality team managed by the Information Governance Manager to be corrected. Any immediate errors are resolved in liaison WAHT-CG-443 Page 5 of 27 Version 3

Trust Policy with departments / directorate staff, validation clerks and longer term issues are raised through the Data Quality Group. Examples of Data Quality reports: 18 week activity and waiting list validation lists Activity outcomes validation lists A&E waiting time s validation Patient Master Index DQ DQ indicators report SUS dashboard Completeness and validity reports 4.10 Divisional/Directorate Management Teams - have responsibility for ensuring that data quality is regarded as a key issue within their teams, that suitable representation is made on the relevant data quality groups aimed at the implementation of this policy and that those responsible for the dissemination of policies, training and the investigation of issues are provided with the required access to users. Additionally Directorates must ensure that case notes are available to the coding teams the day after discharge for completion of the coding process. 4.11 Clinical Coding have the primary responsibility for ensuring all inpatient episodes are fully and correctly assigned with appropriate diagnosis and procedure codes (ICD10 & OPCS coding rules and conventions),to meet the trust deadline in regard to timeliness. Included in the coding process is the validation of admission data in relation to consultant, specialty, admission, transfer and discharge dates. One off errors are corrected and returned to the original user, persistent errors are reported by the Coding Manager to the Directorate Team or Head of Department. The Coding Manager will take responsibility for conducting clinical coding audits in order to monitor and review practice and will liaise directly with medical staff regarding the continued improvement of the quality of source documentation used in the coding process. 4.12 Clinicians have the responsibility for completing the trust source documentation for coding (key documents being patient notes, TTO, KMR1 in conjunction with EDS and access to departmental systems such as pathology and radiology). The source documentation should be completed according to the guidelines contained with the Coding Booklet, available on the intranet under the main heading of policies and procedures or the Information website. 4.13 The Clinical Applications Support Team are part of the Acute ICT service that provides support for the trusts PAS and other systems such as A&E and their Users. They provide advice on system usage and liaise with the system suppliers to resolve errors and to clarify the effects of changes in system usage. 4.14 Information Technology Trainers - are part of the Acute ICT services provided by the Trust. The IT Trainers are responsible for delivering system training which includes materials to support the recording of accurate and timely data in all systems. Access to systems will not be granted until satisfactory completion of training. Where other departments deliver training, this will be with the agreement of the Training Department, who will be responsible for ensuring it is to the required standard. 5. Policy Detail The Trust is committed to pursuing a high standard of accuracy, completeness and timeliness within all aspects of data collection in accordance with NHS Data Standards. Policies and procedures are in place to cover all the major data collection activities and adherence to good practice is mandatory. All staff involved in data collection must be familiar with the aims and practices described in this policy. WAHT-CG-443 Page 6 of 27 Version 3

Trust Policy Data quality is the responsibility of all staff. Systems procedures and the routines of all data collection and data processing staff will therefore be subject to on-going monitoring and review as stated in this policy. The Trust will aim to achieve and maintain the highest standards contained within the Information Governance Toolkit. Details of systems in scope of this policy This section lists the systems and procedure documents covered by this policy. These documents cover the major aspects of data collection and how data collection is managed. All staff will be aware of the procedures that relate to their work and must adhere to them. 5.1 The NHS Number This nationally used number is the necessary and preferred identifier when transferring data across NHS organisations. All clinical documentation, both paper and electronic, must include the NHS number when it is known. It is mandatory for inclusion in all admitted patient care commissioning dataset transmissions and when present other patient identifiers are removed. For clinical documentation it is used as a check on patient identification. Every effort will be made via use of the NHS Summary Care Record to improve and maintain the completeness, accuracy and verification of this identifier both by individual enquiries and by a programme of batch tracing. For further information, refer to the guidance on the NHS Summary Care Record 5.2 The Patient Administration System (PAS) PAS is the corporate system for the trust and has a number of modules that cover the large administrative processes which include, the patient master index, inpatients, outpatients and waiting list data. This data is directly used to invoice our purchasers under the Payment by Results system. Therefore it is essential that all patient related activity is recorded in an accurate and timely manner and according to national data standards. The system administrator is responsible for high level system documentation and procedures: : In association with the Acute ICT Services Department who provide support, guidance, access controls and Maintenance of table files Release, Change and Problem Manager ensures upgrades are tested and released to users It is the responsibility of divisions/departments to ensure that procedures are in place to cover the following areas of data input: Master Patient Index Registering a patient Making changes to a patient registration Recording deaths Outpatients Recording of a referral Use of the waiting list module (including booking) Making an appointment WAHT-CG-443 Page 7 of 27 Version 3

Trust Policy Recording attendance, or otherwise, and outcomes Inpatient and Day Case Waiting Lists Adding patients to the lists Managing the lists and recording periods of suspension Offering dates of admission and recording attendance, removal or otherwise Admitted Patient Care Recording an admission Entering any ward or consultant transfers or periods of home leave Recording discharges Case note Tracking Recording the location and movement of health care records The Patient Administration System must be regarded as the principal source of patient information and where departmental systems are in place, care must be taken to ensure that any updates in demographic data recorded on the departmental system are also entered on the Patient Administration System. Other Systems; Accident and Emergency Recording arrival of patient in department ting patient s progress through department Clinical coding Recording outcome of attendance Clinical Correspondence Preparing and editing clinical correspondence Marking correspondence complete Maternity Module Registering community midwifery booking details Entering labour and delivery details Recording postnatal discharge 5.3 Information Procedures The Information Department staff are the processors of data and hold procedures which cover the following: The handling of Data Set Change tices The setting up and maintenance of new data flows and collection processes (In partnership with the Clinical Applications Support) Commissioning data set validation and production Meeting targets for completion of all outputs and reports The production of routine information Procedures for dealing with queries about activity and data quality Submission of all regional and national data requirements The handling of requests for information, including following Caldicott Guidelines for supplying of patient identifiable information. WAHT-CG-443 Page 8 of 27 Version 3

Trust Policy 5.4 All Systems The system administrator is responsible for the high level system documentation and procedures: : Acute ICT Services Department provide support and ensure look up tables are kept up to date Release, Change and Problem Manager ensure upgrades are tested and released to users 5.5 Information Governance Toolkit and NHS Data Quality Standards The Trust will achieve and maintain high standards against the Information Governance Toolkit and the Trust s corporate data quality requirements. The Information Governance Manager will ensure year-on-year improvements in the standards in conjunction with the senior leads within the Information Governance Steering Group. The Information Governance Manager in conjunction with the members of the Data Quality Group will be responsible for on-going monitoring against the relevant NHS Data Standards and Trust policies and procedures. Additionally of staff performance in relation to data input, and for instigating remedial action as appropriate. The roll out of the online Information Governance training tool, will inform all trust staff of their responsibility to record data correctly and manage the data according to the Data Protection Act and Caldicott Principals. The service, workforce and financial frameworks include data quality targets and expected timeliness. The achievement of high scores against the Information Governance Toolkit will provide assurance for all external agencies that the Trust takes data quality seriously and that the data is fit for the intended purpose. 5.6 Payment by Results (PbR) The Trust will adhere to the code of conduct for payment by results Good quality information is integral to the effective running of PbR, and that same information underpins the delivery of effective patient care. Ultimate responsibility for the quality of data rests with the organisation producing it. Providers and commissioners should work together to improve data quality by understanding and addressing the issues causing poor quality data. Any changes to coding and counting practices, other than those contained in the annual PbR guidance or NHS Classifications Service (NCS) guidance will be subject to standard notice periods as set out in the NHS standard contracts; unless an alternative notice period is agreed between provider and commissioner. In addition, any changes shall be demonstrably in line with best practice. There is a national PBR audit covering inpatients, out patients and coding on a rolling 3 year program. The Trust will organise an audit of its coded inpatient data and coding auditor will carry out audits with clinicians on a rolling basis. These audits validate the quality of the data recorded on the PAS and the source documentation written in the case notes. 5.7 SUS (Secondary Uses Service) Data collected within the Trust is submitted to SUS (monthly/weekly). Quality checks on this data are performed prior to the submission by the information team. Data Quality dashboards returned from SUS show both the Trusts current standards and national standards. WAHT-CG-443 Page 9 of 27 Version 3

Trust Policy 6. Implementation 6.1 Plan for implementation This policy sets out good practice for data quality within the Trust. All specific systems are managed within either the department or by the Clinical Applications team. Each department head/staff are responsible for the quality and timeliness of the data within the system. This policy will be made available to all heads of departments and it is their responsibility to ensure their staff adheres to the policy. All heads of department, with staff who use data collection systems must ensure their staff have access to this policy and local processes comply with this policy. Guidelines for Data Quality, Right First Time are included in appendix 2 and 3 and are also published on the DQ webpage on the intranet and support the collection of complete and accurate data. The data quality group will ensure that issues with poor data quality are discussed and investigated. 6.2 Dissemination This updated policy will replace all other versions held on the Trust Intranet site. The updated policy, once approved, will be included in a Daily Brief Article and published on the Trusts Intranet Document Finder. 6.3 Training and awareness Training for all trust systems is arranged via the IT training Department and all training sessions will ensure staff are aware of the importance of good quality and the timely collection of data. The guidance Right First Time will be used as part of the training. Support on data quality matters can be sought from the data quality group or the Information Governance Manager. 7. Monitoring and compliance The table below should help to detail the Who, What, Where and How for the monitoring of this policy. WAHT-CG-443 Page 10 of 27 Version 3

Trust Policy Page/ Section of Key Document Key control: Checks to be carried out to confirm compliance with the policy: How often the check will be carried out: Responsible for carrying out the check: Results of check reported to: (Responsible for also ensuring actions are developed to address any areas of noncompliance) Frequency reporting: of Page 5 4.6 Page 9 5.6 Page 9 5.7 WHAT? HOW? WHEN? WHO? WHERE? WHEN? Information Governance requirement 506 Data Quality Audit Clerk audits national Monthly Data Quality Information Governance Bi-Monthly details the need to have a documented required percentages of staff on a Audit Clerk Steering Group procedure and a regular audit cycle for monthly basis accuracy checks on service user date. The results of the audits should be reported to the Data Quality Committee and the Information Governance Steering Group Payment by Results Audits: This is a national audit covering inpatients, out patients and coding on a rolling 3 year program. SUS (Secondary Uses Service): Data collected within the Trust is submitted to SUS (monthly/weekly). The Trust will organise an audit of its coded inpatient data. These audits validate the quality of the data recorded on the PAS and the source documentation written in the case notes. Quality checks on this data are performed prior to the submission by the information team. Yearly External Auditor Information Governance Steering Group Audit Committee Monthly/weekly Information Team Data Quality Group review the SUS Data Quality dashboards Yearly 10 times a year Page 5 4.9 Page 5 4.7 The information department provide many reports throughout the Trust. These may be for all or some of the directorates, individual departments or ad hoc reports when requested. Missing demographic data from PAS Directorate validation of data quality reports such as: 18 week activity waiting list validation lists Activity outcomes validation lists A&E waiting times validation Patient Master Index DQ DQ indicators report Updating data, such as: NHS Number PMI Details Monthly/weekly Weekly Directorate staff/directorate validation staff Data Quality Clerks Reported directly back to directorate managers Reported through the Data Quality Group Validation is an on-going process Validation is an on-going process WAHT-CG-443 Page 11 of 27 Version 3

Trust Policy 8. Policy Review This policy will be reviewed every 2 years by the Information Governance Manager unless changes to national requirements are released. 9. References: NHS Data Standards Information Quality Assurance Program (Data Quality) Information Governance Toolkit Code: 10. Background 10.1 Consultation This policy has been created by the Information Governance Manager in conjunction with key staff from the Information department, the Clinical Coding Manager and Health Records staff. Consultation has been sought from the Data Quality Group. 10.2 Approval process After consultation this policy will be sent for approval to the Information Governance Steering Group and then on to the Trust Management Committee. Further development of the policy will be an ongoing process, often following newly released national guidance and any changes to national requirements. 10.3 Equality requirements The equality impact assessment tool has been completed and shows no equality risks. A copy of this policy including the relevant appendix can be requested from the Information Governance Manager. (Supporting Document 1) 10.4 Financial risk assessment The financial risk assessment has been completed and shows no financial risks. A copy of this policy including the relevant appendix can be requested from the Information Governance Manager. (Supporting Document 2) WAHT-CG-443 Page 12 of 27 Version 3

Patient Information Collection/Confirmation on Attendance When a patient attends the Trust for any episode of care, the following information is required The patient may make you aware of a name change on arrival Please confirm your address (inc postcode) Please confirm your telephone number Update the patients Name Address Telephone Number GP Practice Please confirm your GP Practice Would you be willing to receive appt reminders via text message? Mark the relevant box when patient gives/does not give consent (if applicable to system) If the patient has no ethnic origin recorded Ask the patient to please point to the number on the sheet that matches your ethnic origin (if applicable to system) If you have updated any information on PAS (OASIS) Print off new Front Sheet and labels and file within case notes Admin Process 2013 WAHT-CG-443 Page 13 of 27 Version 3

Right First Time Quick Reference Guide 1 ALWAYS ASK THE PATIENT to state their: a. Address b. DoB c. Postcode d. GP e. Ethnic origin (if not already on the system) f. NHS number (if not already on the system) 2 Use the INSERT facility to change a patient s address 3 Overseas patients - Record overseas address in permanent field. 4 Carry out a thorough check before you register a patient to ensure the patient isn t on the system. Use the Summary Care Record (SCR) to assist you by using the NHS number in the search. 5 Record new appointments and follow up correctly, using correct clinic type. 6 At the end of each clinic check all patients are on the system with the correct details and have been outcomed. 7 Ensure any unspecified WL entries are updated with full details. 8 Always check you have selected the correct TCI to ensure the correct episode details are recorded for the patient. 9 Check all admission, ward and consultant transfer and discharge details especially recording dates correctly. 10 Only use the transfer transaction when patients move between the 3 acute sites (WRH, ALX & KTC), otherwise the patient should be discharged. 11 Use the ward leave facility to record patients on home leave. 12 Maternity Mothers estimated date of delivery MUST be recorded on PAS. Mother and baby episodes need to be linked correctly. 13 Clinical Coding - If you add a late admission to the system please notify the coding staff on your site. 14 It is essential to ensure notes are retained on the wards for the coders to collect or sent to coding, (whichever is the process for your site). 15 New / Change of Service form Need to be used to record all new or changes to any activity on Oasis and the Information Department must be copied in regarding all changes. These forms are now available electronically, please refer to the intranet. WAHT-CG-443 Page 14 of 27 Version 3

Right First Time Top Tips 1 Demographic Details If patients and GPs are to receive correspondence and the trust to receive payment it is essential that Demographic Details must be checked each time the patients attends. Patients must be asked to give their address, DOB, postcode, GP and (ethnic origin if not already completed). For administrative purposes please check telephone numbers, next of kin and NHS number. It is both a clinical risk and a breach of the 1998 Data Protection Act if the casenotes do not reflect the same up to date information as the PAS system or any other hospital system; therefore casenotes must be updated at the same time as the system you are using, particularly PAS. N.B. Patient addresses Use the insert address facility to change a patient s address. Only type over the address if it was incorrect in the first place. Overseas patients Please use overseas address in permanent address field, if they have temp address whilst here in the UK use temp address in temp field. This will ensure the patient receives the appointments and the trust the income for the treatment. 2 Demographic Details Double Registrations can increase the clinical risk for patients. Also, in order for the trust to move onto the national PAS system, we have to reduce the number of duplicate registrations and prevent further ones being created. A thorough check must be completed to ensure that a patient is not already known to the system, before proceeding to register a patient. Please use the Summary Care Record (SCR) to assist. 3 Out-Patients The trust receives three times the amount of money for a new out-patient appointment in comparison to a follow up appointment. Therefore please ensure you are recording new and follow up appointments correctly for every patient, checking it is the correct appointment type as well as the correct clinic type. The trust can only invoice for patients entered onto the PAS system with the correct demographic/appointment details and who have been outcomed at the end of the clinic. Therefore, at the end of every clinic session PAS must be checked to ensure all patients are on the system and each appointment is complete including the outpatient coding. 4 Waiting List/TCI It is vital to ensure patients are on the correct waiting list with correct details in order that patients receive their treatment/procedures to meet their clinical need and for the trust to meet government targets. Therefore if you enter unspecific WL entries in order to get the basic details entered onto the system to ensure the entry is not lost, the full details must be updated shortly afterwards. 5 Booked admission TCI s When admitting a patient who has a booked admission (TCI), please select the correct TCI for the admission. Old TCIs should be taken off the system. If an incorrect TCI is selected this can set in motion a whole catalogue of errors with serious consequences both for the patient and the trust. Log a call with IT if you experience any issues. 6 Admission, Discharge & Transfers Check all admission, ward and consultant transfer and discharge details especially recording dates. If we wish to retain services at this trust then we need to get this data right, as it is used directly to receive payment for the trust and to monitor our performance as part patient choice. 7 Transfers Patients being physically transferred to community hospitals or any hospital other than Kidderminster, Worcester Royal or the Alexandra Hospital, must be discharged from the system (using the code to reflect they have been transferred to another hospital). WAHT-CG-443 Page 15 of 27 Version 3

Right First Time Top Tips 8 Ward leave Use the ward leave transaction to record if a patient is on ward leave. It is important to record a patient is on ward leave so the trust is aware of what beds are available at any time and also to ensure data is accurate for patients and the trust to use. Please refer to the PAS guidance for further information. 9 Maternity All patient who attend for maternity appointments must have their estimated date of delivery (EDD) recorded on PAS. This will allow any episodes of care to link and the eventual birth to be linked to the pregnancy. If mothers and baby data is not linked correctly, it is extremely difficult to correct it on the system retrospectively and could pose a clinical risk at some point during the treatment. See guidance for further information. 10 Clinical Coding If you add a late admission to the system please notify the coding staff on your site and ensure all ADT s are completed each day so the coders can collect and code the notes on a daily basis. It is essential to ensure notes are retained on the wards for the coders to collect or sent to coding (Whichever is the process for your site). Coders can only code accurately if they have the full set of notes from which to code. 11 New / Change of Service Need to be used to record all new or changes to any activity on Oasis and the Information Department must be copied in regarding all changes. These forms are now available electronically, please refer to the intranet. 12 Why is Right First Time so important- - To ensure patients receive the best possible care from our trust. - Saves you or someone else time / effort and the cost involved in correcting the information. - To ensure data is credible so it can be used internally and externally to make managerial and financial decisions for the trust. - To maximize income for the trust and retain services for patients. - To be ready to move onto national systems, where correcting data after the event will be very difficult and not always possible. - To ensure we comply with best practice and the law (Data Protection Act) - Where to go for further information/training The IT Training Department The intranet site Team Leader / Manager The Information Team The Coding Manager or Teams WAHT-CG-443 Page 16 of 27 Version 3

Data Quality Audit Cycle Contents 1. Background 2. Accuracy Checks 2.1 Admitted Patient Care 2.2 Outpatient Data 2.3 Elective Admission List 3 Approach to Audit 4. Method for Audit 5. Accuracy Scoring 5.1 Admitted Patient Care score 5.2 Elective Admission List score 5.3 Outpatient Data score 6. Generic Fields 6.1 Admitted Patient Mandated Fields 6.2 Outpatient Data Mandated Fields 6.3 Elective Admission Mandated Fields WAHT-CG-443 Page 17 of 27 Version 3

Data Quality Audit Cycle 1. Background The Department of Health has for a number of years placed requirements on acute trusts to ensure they hold good quality data and required Trusts to have in place process and procedures to provide assurances to themselves as well as external users of their information, that their information of high quality. Data quality is a significant issue both locally and nationally. Data therefore needs to be accurate, credible and reliable. The Trust holds patient information in both paper format (case notes) and electronic format (Bluespier clinical letters/eds etc). The Trust is due to commence with scanned electronic records (eznotes) in July 2012 and the auditor will then use these records rather than paper case notes to audit against. 2. Accuracy Checks 2.1 Admitted Patient Care Sample Sizes The sample size must be 0.5% of a Trust s total annual Finished Consultant Episode (FCE). The sample size is taken from the total of FCE for the previous financial year eg. 2013/15. 0.5% of this total provides the sample size. Eg. 111,400 / 0.5% = 557 The sample size that the Trust must undertake for the year is 557. The Trust will take a 12 th of the total sample size to be checked each month. 557 / 12 = 46.4. Each month 47 case-notes must be checked against the fields listed in point 6.1 for accuracy. 2.2 Out Patient Data Sample Sizes The sample size must be 0.2% of total annual number of outpatient appointments. The sample size is taken from the total number of outpatient appointments for the previous financial year eg. 2013/15. 0.2% of this total provides the sample size Eg. 485,000 / 0.2% = a sample size of 970 episodes. The sample size that the Trust must undertake for the year is 970. The Trust will take a 12 th of the total sample size to be checked each month. 970 / 12 = 80.8. Each month 81 case-notes will be checked against the fields listed in point 6.2 for accuracy. 2.3 Elective Admissions Sample Sizes The sample must be 5% of total annual planned elective admissions. The Trust will take the total of people on the elective admission list for the previous financial year eg. 2013/15 5% of this figure provides the sample size. Eg, 14,260 / 5% = sample size of 713 WAHT-CG-443 Page 18 of 27 Version 3

Data Quality Audit Cycle The sample size that the Trust must undertake for the year is 713. The Trust will take a 12th of the total sample size to be checked each month. 713 / 12 = 59.4 Each month 60 case-notes will be checked against all the fields listed in point 6.3 for accuracy. 3. Approach to Audit Specialities will be randomly covered within the audit with the auditor keeping a running total of each specialty and the amount of sample records audited. The auditor will select patient records that are accessible so as to not hold case notes within a non-clinical area s that may be needed for clinical care prior to go live for electronic records (eznotes) 4. Method for Audit The information department will supply a spreadsheet/database of all mandated fields data from the Patient Administration System (PAS) following submission to SUS. All fields contained within the spreadsheet must provide the written codes rather than the numerical codes. The auditor will record all information following the patient records checks within a local database If the case-notes for the patient cannot be located, this must be recorded in the Comments column. The appropriate Health Records Manager must be informed and assist in location the case-notes. The Health Records Manager must ensure that the missing case-notes are recorded as per the Medical Records procedure. All case-notes for accuracy checks must be correctly tracked on the PAS. For each field within the spread sheet, confirmation that the data within the case notes matches PAS must be recorded by a YES answer. If the data in the case-notes is different to the data on the PAS, this must be recorded beneath the appropriate data field on the spreadsheet. Once all the case-notes have been checked for accuracy, all case-notes must be returned to the appropriate location. The accuracy spreadsheet must be returned to the Data Quality Manager for scoring. In all instances if the PAS is updated, a new front sheet must be printed off and filed in the casenotes. 5. Accuracy Scoring If the field on PAS is exactly the same as the field in the case-notes, an accuracy score of 1 is recorded (For any data that is not applicable to the patient a N/A will be recorded and a YES score used). WAHT-CG-443 Page 19 of 27 Version 3

Data Quality Audit Cycle If the field on the PAS is not exactly the same as the field in the case-notes, an accuracy score of 0 is recorded. If the data is missing from a field on either the PAS or in the case-notes, an accuracy score of 0 must be given. 5.1 Admitted Patient Care Score The Trust will be checking 20 fields for Admitted Patient Care data, providing a total score of 20 for each patient episode. The total score the Trust could achieve for each months accuracy checks is: sample size x admitted patient care score Eg. 25 x 20 = 500. Total accuracy score / Total Possible score = % accuracy score for data set Eg. 18 x 20 = 360. 360 / 500 = 72% 5.2 Outpatient Data Score The Trust will be checking 17 fields for Outpatient data, providing a total score of 17 for each patient episode. The total score the Trust could achieve for each months accuracy checks is: sample size x admitted patient care score Eg. 45 x 17 = 765 Total accuracy score / Total Possible score = % accuracy score for data set Eg. 40 x 17 = 680. 680 / 765 = 89% 5.3 Elective Admission Score The Trust will be checking 16 fields for Elective Admission List data, providing a total score of 16 for each patient episode. The total score the Trust could achieve for each months accuracy checks is: sample size x admitted patient care score Eg. 27 x 16 = 432. Total accuracy score / Total Possible score = % accuracy score for data set WAHT-CG-443 Page 20 of 27 Version 3

Data Quality Audit Cycle Eg. 20 x 16 = 320. 320 / 432 = 74% te: Where it has not been possible to check the accuracy of the data field from the PAS against the case-notes, then this field has been excluded from the total accuracy score. 6. Generic Fields If any fields within do not match (PAS or case notes) then the auditor must obtain the correct demographics and ensure that either the PAS or the case notes are updated For all patient demographics listed below: NHS Number Postcode Code of Registered GP/Practice Birth Date Sex Staff must use the National Summary Care Record (SCR) to obtain the correct patient demographics. In all instances the information on the SCR must be taken as correct and the patient details updated on the PAS. Checking the PAS against the case-notes for accuracy has proven difficult for the following reasons and a number of assumptions have been made. When it is unclear from the case-notes whether the information on the PAS is accurate, then staff must obtain the correct information. For inpatient episodes staff should consult either the: Ward Clerk Nursing Staff Consultants Secretary Consultant or Clinical Coding. For outpatient episodes staff should consult either the: Booking Services Team Leaders Outpatient clerks Outpatient/Medical Records Manager For waiting list episodes staff should consult either the: Waiting List office Admission Office Waiting List Manager Medical Secretary Ward Clerk Consultant or Clinical Coding. WAHT-CG-443 Page 21 of 27 Version 3

Data Quality Audit Cycle Staff must also ensure any issues with data quality are escalated the both the Data Quality Manager and the departmental manager. Some fields are not routinely recorded in patient s case notes. The tables below record the fields that will not be audited against (for this audit) for each category and the reasons why. Alternate auditing or data checking is listed. WAHT-CG-443 Page 22 of 27 Version 3

Data Quality Audit Cycle 6.1 Inpatient Mandated Fields Data Field Local Patient Identifier NHS Number NHS Number Status Indicator Postcode of Usual Address Ethnic Category Code of Registered GP/Practice Birth Date Sex Administrative Category Patient Classification Start Date Admission Method Source of Admission Discharge Destination Discharge Method Discharge Date Last Episode in Spell Indicator Start Date (Episode) End Date (Episode) Decided to Admit Date Intended Management Consultant Code Treatment Function Code Primary Diagnosis (ICD) Secondary Diagnosis (ICD) Primary Procedure (OPCS) Procedure Date (Primary) Operation Status Healthcare Resource Group Comments PAS ID number t recorded in case notes so excluded from manual audit Will be audited via information department checks t routinely recorded in case notes (unless KMR1 is present) so excluded from manual audit If the written GP is the same as the GP on the PAS, then this is marked as accurate, regardless of whether this is written or printed on the front sheet. t routinely recorded in case notes (unless KMR1 is present) so excluded from manual audit t recorded in case notes so excluded from manual audit Will be audited via information department checks Admit from Assumed as home unless written in notes as other Treated or not treated/died t recorded in case notes so excluded from manual audit Will be audited via information department checks Only elective patients Only elective patients - day case or inpatient etc As long as the main consultant is correct and the speciality is correct, this field is being marked as accurate when the consultants team reply to the GP etc Recorded speciality t included in manual audit Audited as part of yearly PBR audit t recorded in case notes so excluded from manual audit Will be audited via information department checks t recorded in case notes so excluded from manual audit Will be audited via information department checks WAHT-CG-443 Page 23 of 27 Version 3

Data Quality Audit Cycle 6.2 Outpatients Data Mandated Fields Data Field Local Patient Identifier NHS Number NHS Number Status Indicator Postcode of Usual Address Organisation Code (PCT of residence) Code of Registered GP/Practice Birth Date Sex Administrative Category NHS/PP Source of Referral for Outpatients Referral Request Received Date Attended or Did t Attend First Attendance Outcome of Attendance Attendance Date Priority Type Last DNA or Patient Cancelled Date Referrer Code Consultant Code Treatment Function Code Comments Pas ID Number t recorded in case notes so excluded from manual audit Will be audited via information department checks t recorded in case notes so excluded from manual audit Will be audited via information department checks If the written GP is the same as the GP on the PAS, then this is marked as accurate, regardless of whether this is written or printed on the front sheet. t routinely recorded in case notes so excluded from manual audit Date stamped letter Letter to GP or history sheet note GP referral or seen before etc PAS outcome clinic letter description Clinic letter Urgent/Routine recorded on the letter t recorded in case notes so excluded from manual audit Will be audited via information department checks Name not code will be recorded in the case notes As long as the main consultant is correct and the speciality is correct, this field is being marked as accurate when the consultants team reply to the GP etc Recorded speciality WAHT-CG-443 Page 24 of 27 Version 3

Data Quality Audit Cycle 6.3 Elective Admission Mandated Fields Data Field Local Patient Identifier NHS Number NHS Number Status Indicator Postcode of Usual Address Organisation Code (PCT of Res) Code of Registered GP/Practice Birth Date Sex Administrative Category Elective Admission Type Priority Type Decided to admit date (for this provider) Original Decided to admit date Intended management Intended Procedure Last DNA or Patient Cancelled Date Count of Days Suspended Offered for Admission Date Admission Offer Outcome Referrer Code Consultant Code Treatment Function Code Healthcare Resource Group Comments PAS ID Number t recorded in case notes so excluded from manual audit Will be audited via information department checks t recorded in case notes so excluded from manual audit Will be audited via information department checks If the written GP is the same as the GP on the PAS, then this is marked as accurate, regardless of whether this is written or printed on the front sheet. t routinely recorded in case notes (unless KMR1 is present) so excluded from manual audit Letter to GP may include if date was booked in clinic but not otherwise recorded in the case notes Urgent, routine etc Letter to GP should indicate if decision was made in clinic but otherwise not recorded in case notes Only recorded if patient has been referred by other provider Day case etc Reason for adding to the WL t recorded in case notes so excluded from manual audit Will be audited via competency checks on users/inputters Name not code will be recorded in the case notes As long as the main consultant is correct and the speciality is correct, this field is being marked as accurate when the consultants team reply to the GP etc Recorded speciality t recorded in case notes so excluded from manual audit Will be audited via information department checks WAHT-CG-443 Page 25 of 27 Version 3

Data Quality Audit Cycle Supporting Document 1 - Equality Impact Assessment Tool To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. Yes/ Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? If you have identified a potential discriminatory impact of this key document, please refer it to Assistant Manager of Human Resources, together with any suggestions as to the action required to avoid/reduce this impact. For advice in respect of answering the above questions, please contact Assistant Manager of Human Resources. 5. If so can the impact be avoided? N/A 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A WAHT-CG-443 Page 26 of 27 Version 3

Data Quality Audit Cycle Supporting Document 2 Financial Impact Assessment To be completed by the key document author and attached to key document when submitted to the appropriate committee for consideration and approval. Title of document: 1. Does the implementation of this document require any additional Capital resources 2. Does the implementation of this document require additional revenue Yes/ 3. Does the implementation of this document require additional manpower 4. Does the implementation of this document release any manpower costs through a change in practice 5. Are there additional staff training costs associated with implementing this document which cannot be delivered through current training programmes or allocated training times for staff Other comments: ne If the response to any of the above is yes, please complete a business case and which is signed by your Finance Manager and Directorate Manager for consideration by the Accountable Director before progressing to the relevant committee for approval WAHT-CG-443 Page 27 of 27 Version 3