Title: Date Approved: Approved by: DATA QUALITY POLICY Review Date: Policy Ref: Issue: Jan 2010 Sherwood Forest Hospitals Oct 2011 Information Governance Group Division/Department: Policy Category: ISP_03 4 Information Governance Author (post-holder): Information Governance Manager Corporate Information Sponsor (Director): Chief Executive CONTENT SECTION DESCRIPTION PAGE 1 Introduction 2 2 Policy Statement 2 3 Definitions 3 4 Roles and Responsibilities 4 5 Scope of Policy 4 6 Consultation 5 7 Consequences of Poor Data Quality 5 8 Measurement of Data Quality 5 9 Local Data Quality Procedures 6 10 General Guidance/Standards 7 11 Good Practice 7 12 Notification of Change 7 13 Breach of the Policy 8 14 Evidence Base 8 15 Monitoring Compliance 8 16 Training 8 17 Distribution 9 18 Communication 9 19 Author and Review Details 9 Appendix A Data Quality Responsibilities Chart 10 The issue of this page is the overall issue of this procedure. The current issue of individual pages are as follows: PAGE 1 2 3 4 5 6 7 8 9 10 ISSUE 4 4 4 4 4 4 4 4 4 4 DATE 01/10 01/10 01/10 01/10 01/10 01/10 01/10 01/10 01/10 01/10
1. Introduction 1.1 This document defines the for Sherwood Forest Hospitals NHS Foundation Trust. 1.2 The Trust gathers and stores large amounts of data both manually and electronically, with increasing reliance being placed on this data to validate delivery of improved patient care and inform service planning. It is therefore imperative that we achieve and maintain the highest possible data quality standards whilst remaining focused on the predetermined need for that data. 1.3 Data Quality applies to all data encountered in the day-to-day working environment, not just that relating to financial, safety issues or patient care. 1.4 Data collection should always have a clear purpose and should be the by-product of service provision and not just collected for collection s sake. 1.5 Data must be sufficiently robust to ensure fulfilment of all national and local audit requirements and delivery of high quality patient care. In order to facilitate this, all data collection processes should be clearly documented and regularly reviewed. 1.6 The information requirements of the Trust must be met and therefore data should be readily available and fit for purpose at all times. 1.7 This policy is issued and maintained by the Chief Executive on behalf of the Trust, at the issue defined on the front sheet, which supersedes and replaces all previous versions. 2. Policy Statement 2.1 Information is the life-blood of any major organisation, and within the NHS timely access to the right information can literally save lives. Less dramatically, accurate information is required to underpin efficient and fair service provision and management. 2.2 Sherwood Forest Hospitals recognises the importance of high quality data in ensuring continued delivery of improved patient care and the Trust is committed to improving data quality standards. Author: Information Governance Page 2 Review Date: 2011
2.3 This policy describes the measures that all the Trust s information systems must implement to achieve appropriate levels of quality in normal operation. 2.4 For the purpose of this policy where the term System Manager is used, it applies to both electronic and manual data collection System Managers. 2.5 This policy should be read in conjunction with the Trusts Information Security Policy and comply with all relevant guidance that underpins this policy. 3. Definitions 3.1 Data quality is defined by the following criteria: Complete that all required data is present, with no omissions; Accurate - that the recorded data are factually correct; Consistent that data are expressed in, or coded to, agreed standards; Relevant data should only be collected as a by-product of patient care and should be regularly reviewed to ensure data collection requirements are being met; Timely up to date and recorded as near as possible to the data source; Unambiguous - that recorded data have only a single valid interpretation; Unique data is not unnecessarily duplicated, either in whole or in part. 3.2 As it is not always possible, for a variety of reasons, to adhere to all the principles in every case, a judgement must be made by the Trust as to the relative importance of individual data items. This will depend on the intrinsic nature of the data, as well as the use to which the application is put. High priority items could include important clinical details such as allergies, chronic disease factors or current medication. Other examples might include identification data, financial transactions, etc. However, lower priority items should not be considered as optional for data collection (unless defined as such), merely that the consequences of being unable to collect the data are less serious. 3.3 Certain key measures of overall data quality within Trusts are now measured nationally and published by the Department of Health. These include Clinical Information Assurance, Secondary User Assurance and Confidentiality and Data Protection Assurance, which forms part of the Information Governance Toolkit and contribute to the Annual Health Check and Data Quality Indicators (DQIs), which are extracted from the Hospital Episode Author: Information Governance Page 3 Review Date: 2009
Statistics (HES). These measures are mandatory and systems contributing to these such as PAS, data entered or accessed via Orion and GP community systems must make every effort to ensure maximum compliance with all relevant guidance. 3.4 All data collection processes whether clinical, administrative or financial, electronic or manual, should be clearly documented and regularly audited. Development of data collection processes is the individual departments responsibility and must be complete, up to date and available in all work areas. When new systems are implemented it is the department and projects joint responsibility to develop appropriate data collection processes prior to implementation. Such processes must be underpinned by suitable training to ensure ownership, understanding and compliance. 4. Roles and Responsibilities 4.1 The Chief Executive of the Trust has overall responsibility for Data Quality. 4.2 All system managers must ensure that procedures are upheld for each patient based system. 4.3 All data users must adhere to local data quality procedures at all times. 4.4 It is the responsibility of the organisation to ensure an audit programme is in place to assess compliance with the policy and to ensure training requirements are identified and actioned. 4.5 It is the responsibility of Line Managers to ensure staff compliance with local data quality procedures. This will guarantee that all staff are trained to an acceptable standard on data entry, collection and storage processes and procedures on all relevant systems whether electronic or manual. 4.6 It is the responsibility of Line Managers to ensure that all staff are compliant with good practices with regard to data quality. 4.7 Reference to the responsibility towards data quality will be included in relevant job descriptions. 4.8 All users must comply with this policy and other related policies and guidance and attend appropriate training programmes. 4.9 It is the responsibility of the Trust to provide support and advice to their independent contractors on request. See also Section 15 Data Quality Responsibilities Chart. Author: Information Governance Page 4 Review Date: 2011
5. Scope of Policy 6. Consultation The applies to all employees of the Trust, including temporary staff and contractors. The Policy will be considered and approved by the: Data Quality Group Information Governance Group Risk Management Group (non-clinical) Board of Directors. 7. Consequences of Poor Data Quality 7.1 The consequences of poor data quality vary depending on the nature and complexity of that data. However, some typical examples of common problems are given below: 7.1.1 Patient care could be compromised through data either being inaccurate or unavailable at the point of care 7.1.2 Financial loss through inaccurate or misleading recording of information 7.1.3 Inappropriate influence on service planning 7.1.4 Operational problems additional time and effort expended due to inaccurate and incomplete records 7.1.5 Monitoring of local and national targets could be compromised through failure to collect appropriate data, or inappropriate coding of that data. 8. Measurement of Data Quality 8.1 The assessment of whether data quality is of sufficiently high standard is dependent on the data in question and the purpose for which it is collected and utilised. Typical measures may include the following: 8.1.1 All mandatory data collection is complete, accurate and up to date 8.1.2 Manual data is readable and stored in a structured filing system Author: Information Governance Page 5 Review Date: 2009
8.1.3 Duplication of records is minimised 8.1.4 Data is collected in accordance with documented procedures and guidelines meeting national/local standards 8.1.5 Percentage of completed and valid coded data regularly monitored 8.1.6 Random audits on data for accuracy and completeness 8.1.7 Cross-referencing with other trusted systems (e.g. NHS Number tracing via the NHS Clinical Spine Application). 9. Local Data Quality Procedures 9.1 All local procedures should comply with and/or map back to national data standards and coding and will be subject to control processes within the Trust as well as to external scrutiny. 9.2 Each information system must implement well documented and clearly understood local data quality procedures with a view to ensuring that high level of data quality is maintained at all times. 9.3 It is the responsibility of the relevant named System Manager to ensure that local data quality procedures are produced and maintained and monitored. Manual recording of data is not excluded from this process. 9.4 Procedures should assess levels of risk associated with different data items, identifying high priority data items and noting the consequences of missing data. 9.5 Procedures must specify where applicable what enforcement mechanisms are available to ensure adherence. 9.6 Data quality procedures should be reviewed on a regular basis to ensure that they still meet the business requirements of the Trust. 9.7 Regular auditing against local internal targets to monitor data quality compliance, and clear processes on handling poor data quality outcomes to ensure improvement. 9.8 Where data errors and/or corruption of data are identified, clear processes must be in place to identify implications and immediate correction of such data. 9.9 In certain circumstances, systems may have specific resources allocated for the maintenance of data quality. Local data quality procedures must specify under what circumstances those Author: Information Governance Page 6 Review Date: 2011
resources should be used. 10. General Guidance/Standards 10.1 Where appropriate, local standards should conform to or map back to standards defined in the NHS Data Manual. 10.2 NHS Number is the mandated identifier for all information systems as per DSCN 32/2008. Where this is not consistent, a unique local identifier should be used but work towards the national standards must be progressed. The NHS number will become a mandatory data requirement with the implementation of the NHS Care Record. 10.3 Clinical coding should be consistent with the following standards, where applicable: ICD10 OPCS4 Read codes Snomed CT 10.4 To ensure data quality is maintained. Records must be completed at the time of treatment and not left for completion at a later date. 11. Good Practice 11.1 All data should, wherever possible, be derived from the original source. Patient demographic data should be obtained directly from the patient, and not through an intermediary, unless the patient s medical condition precludes this. 11.2 High priority data that is likely to change over time should be checked and verified at every opportunity (e.g. patient address, GP details and telephone numbers). 11.3 Record facts clearly and ensure that statements made within records are clear, correct, concise and not misleading. 12. Notification of Change 12.1 The Information Department must ensure that notification of changes via Data Set Change Notices (DSCN s) and other Department of Health routes are monitored, and any impact identified and appropriate actions taken by the relevant data quality forum. Author: Information Governance Page 7 Review Date: 2009
12.2 Changes in service provision, where there is or could be an impact on data collection standards/definitions must be identified prior to change via the relevant data quality forum to enable correct guidance to be issued. 12.3 Changes in the way information is collected where there could be an impact on Data Collection Standards/definition must be identified prior to change and approved by the Data Quality Group, to enable correct guidance and processes to be issued. 13. Breach of The Policy 13.1 If a data user is found to be in breach of the data quality policy then the Line Manager must assess the training needs of the user prior to any further action. 13.2 Disciplinary action may be taken against users who wilfully and/or maliciously infringe local data quality procedures. Malicious intent includes deliberate alteration, deletion, erasing or destruction of any data on any system containing data. 14. Evidence Base This Policy has been developed using the following Information Governance Initiatives: Data Protection Act Caldicott Guidelines Confidentiality Code of Conduct Information Sharing Protocols Information Quality Assurance Information Security Policy. 15. Monitoring Compliance 15.1 The policy will be maintained by the Information Governance Manager. 15.2 The following should act on the policy to ensure that correct procedures for maintaining data quality are followed at all times: 16. Training System Managers (electronic and manual) Senior Managers Line Managers Users Author: Information Governance Page 8 Review Date: 2011
16.1 Line Managers are responsible for ensuring that all staff are given appropriate training in order to comply with the Trust s data quality policy and procedures, and this includes training on new/existing systems. 16.2 System Managers are responsible for ensuring that appropriate training is available to support all users in meeting their obligations under local data quality procedures. 16.3 It is the responsibility of Line Managers to ensure staff are trained to competently use the appropriate information systems. 16.4 It is the responsibility of Line Managers to ensure staff are aware of and have access to this policy. 16.5 Where relevant, data quality procedures and processes should be incorporated into staff training and induction programmes along with yearly refresher sessions. 17. Distribution The Policy, once approved, will be included within the Governance Policy Section of the Trust s Intranet. http://sfhnet.nnotts.nhs.uk/corporateinfo/cmsbrowse.aspx?recid=8&ho meid=1 18. Communication All Directors and Divisional General Managers will be informed of the Policy and will be asked to ensure that all members of their staff have access to the Policy for implementation purposes. 19. Author and Review Details Date issued: Jan 2010 Date to be reviewed by: Jan 2012 To be reviewed by: Executive Sponsor: Information Governance Manager Chief Executive Author: Information Governance Page 9 Review Date: 2009
Appendix A Data Quality Responsibilities Chief Executive and Board of Directors Executive Director - Data Quality Lead Senior Management Responsibilities HIS Information Governance Advice & Guidance Line Management Responsibilities Users Users Users Users Users END OF DOCUMENT Author: Information Governance Page 10 Review Date: 2011