POLICY DOCUMENT Burton Hospitals NHS Foundation Trust DATA QUALITY POLICY Approved by: Trust Management Team On: 22 January 2016 Review Date: December 2018 Corporate / Directorate Clinical / Non Clinical Department Responsible for Review: Distribution: Essential Reading for: Corporate Non Clinical Information Department All staff Information for: Policy Number: Version Number: 8 7 Signature: Chief Executive Date: 22 January 2016 Data Quality Policy / Version 7/ December 2015
Burton Hospitals NHS Foundation Trust POLICY INDEX SHEET Title: Data Quality Policy Original Issue Date: October 2002 Date of Last Review: December 2015 Reason for amendment: Periodic Review Responsibility: Chief Information Officer Stored: Linked Trust Policies: Information Department home drive \Information Governance\Data Quality & Coding folder Information Governance Policy Records Management Policy Health Record Keeping Policy Data Quality Management Strategy E & D Impact assessed EIA 019 Consulted Executive Directors, Associate Directors, Departmental Heads, Senior Managers, Information Governance Steering Group. Data Quality Policy / Version 7/ December 2015
REVIEW AND AMENDMENT LOG Version Type of change Date Description of Change 6 Updated November 2013 7 Review December 2015 Periodic review Periodic review Data Quality Policy / Version 7/ December 2015
DATA QUALITY POLICY CONTENTS Paragraph Number Subject Page Number 1 Introduction 1 2 Scope 1 3 Policy Statement and Objectives 1 4 Roles and Responsibilities 2 5 Data Quality Standards 3 6 Training 4 7 Monitoring and Enforcement 4 Data Quality Policy / Version 7/ December 2015
Burton Hospitals NHS Foundation Trust DATA QUALITY POLICY 1. INTRODUCTION 1.1 The data contained within Trust systems are used to support decision making by clinicians and managers and for monitoring and research purposes by a range of external organisations. It is essential that the data are accurate, relevant and of sufficient quality to produce information that is fit for purpose. The aim of this Policy is to set out a framework within which this can be achieved 1.2 Data Quality is encompassed by the NHS Information Governance initiative. Within the Trust the key overarching document is the Information Governance Policy which sets out the direction of travel for Data Quality 2. SCOPE 2.1 This Policy encompasses all clinical and non clinical data contained in the Trust s clinical and administrative computer systems. This includes but is not limited to financial, staffing and patient related data. 2.2 Data is collected, stored, and processed within the Trust s key IT systems. These include patient and financial data on the Meditech system, staffing data on the Electronic Staff Record system, and other key data contained in departmental systems. A complete list of relevant systems is maintained within the Trust s Information Asset Register. 3. POLICY STATEMENT AND OBJECTIVES 3.1 The achievement of good data quality is the result of many staff across the Trust taking care in how they use the system on a day to day basis; it should not be seen as a separate or remote activity but concerns all users. 3.2 The Trust will ensure that all staff appreciate the importance and value of good quality data. 3.3 The Trust will continue to explore ways of improving quality through training, system development and collaborative work between corporate departments and operational staff. 3.4 The Trust will consistently produce data to the required standard in a timely and accurate manner. 3.5 Adherence to a common set of definitions and standards is essential; the standard reference for the Trust will be the NHS Data Dictionary and Model. 3.6 The Trust will maintain and improve where possible its data quality ratings on national indexes, e.g. NHS Number completeness. Data Quality Policy / Version 7 / December 2015 1
3.7 The Trust will work to improve its performance against the data quality standards set by the NHS Executive as part of the Information Governance initiative. 3.8 In order to maintain and improve data quality the Trust will utilise external benchmarking, other comparative data, independent and internal audit. 3.9 Where data are found to be incorrect, for example as the result of validation or queries, the Trust will resolve the problem in a timely manner and in accordance with agreed deadlines and standards. 3.10 Risks associated with IT systems will be reviewed as part of the Information Risk Management Programme and will be reported to the Information Governance Steering Group. 4. ROLES AND RESPONSIBILITIES 4.1 The Chief Executive has overall responsibility for data quality within the Trust. The director with responsibility for corporate reporting is the Director of Finance who will take a lead role in ensuring data quality. The Chief Information Officer supported by the Information Manager is responsible for ensuring systems are in place to quality assure data used for corporate reporting. 4.2 Executive and Associate Directors are responsible for the overall quality of data contained in systems within their respective remit. 4.3 The Information Governance Steering Group has specific responsibilities for Data Quality contained within its Terms of Reference. The Group ensures that improvement plans for Data Quality are produced and implemented and compliance with Information Governance requirements are maintained. Data Quality is a standing agenda item and reports are received quarterly. Clinical Coding Data Quality is monitored via a quarterly report. The Group monitors Data Quality via Key Performance Indicators that measure the completeness of the following data items: NHS Number Postcode Registered GP Practice Code Ethnic Category Primary Diagnosis The Steering Group routinely reports to the Finance and Performance Committee on a quarterly basis. Where appropriate, this will include the escalation of risks and serious issues. 4.4 The Information Department produces reports for a wide range of internal and external purposes. This is achieved both by the extraction and processing of data from a range of systems and by the coordination of reports from other departments. In either case, data checking and validation is essential and is detailed in departmental procedures. The Information Department has a vital role in the identification of errors and their resolution. Remedial action includes liaising Data Quality Policy / Version 7 / December 2015 2
with operational staff, requesting system changes and amending procedures. The Department will also be the contact point for data collection issues that cannot be resolved at local level and will be responsible for carrying out the annual Information Governance Completeness and Validity Check. 4.5 Heads of department are responsible for ensuring that procedures are drawn up that comply with the Data Quality Standards contained within this Policy. 4.6 Departmental managers are responsible for ensuring that staff who use the system have been properly trained and that departmental procedures are up to date and are actively in use. They will also be the initial point of contact for resolving data collection problems and queries. 4.7 Line managers will assess staff compliance with data quality standards as part of the annual performance appraisal process. To assist with the process, Competence Assessment forms can be located within Appendix B of the Data Quality Management Strategy v1. 4.8 All system users have a personal responsibility to record data promptly and accurately with reference to the latest procedures and definitions. 5. DATA QUALITY STANDARDS 5.1 Validity Data entered onto the Trust s systems must be valid. Coded data must comply with national standards. Where possible validation will be carried out automatically at the point of data entry. 5.2 Completeness All mandatory data items within a data set must be completed. Where possible such data fields will be made required within systems without the ability to bypass them. Default or dummy codes, e.g. GP Unknown will only be used appropriately and after genuine attempts to ascertain the correct value have been made. 5.3 Consistency Data items will be internally consistent with other items in the same data set. For example time out of theatre will be after time arrived in theatre, operation / diagnoses will be consistent with age and sex of the patient. 5.4 Coverage Data must cover the whole of an area of activity and not just a sub set. Measures to ensure complete coverage include spot checks and comparisons between systems and modules. Data Quality Policy / Version 7 / December 2015 3
5.5 Accuracy Data must record the actual value or true position. For example, checks with the patient to confirm demographic details must be made at each attendance. System reference files and tables must be kept up to date and be regularly checked. Regular audits of data quality will be carried out. 5.6 Timeliness Data must be recorded in a timely fashion as this will aid accuracy and make it available to other users accessing the system. This will include the recording of transactions, e.g. adding a patient to the inpatient waiting list. Data should not be routinely backlogged for input at a later date unless for a legitimate reason, e.g. system downtime due to computer failure. 5.7 Procedures All departments involved in data collection, data handling, and reporting activities must produce and maintain a set of operating procedures that ensure compliance with the above standards. 6. TRAINING 6.1 All staff will be trained on induction in basic record keeping and accurate recording of data. 6.2 Training in Data Quality will be integral to computer system training rather than as a separate activity. For example, training for the Health Information Management module of Meditech will include the definition of what is an emergency or elective case. 6.3 Staff will be required to undertake training and complete refresher courses on an annual basis. 7. MONITORING AND ENFORCEMENT 7.1 The Information Governance Steering Group will monitor the overall arrangements for data quality including the implementation and review of this Policy. 7.2 Internal Audit will be responsible for reviewing compliance with Policy and procedures relating to data quality and recommending remedial action where required. 7.3 The Information Department will carry out routine validation checks and report on completeness of key data items. Examples of this include diagnoses coding and NHS numbers. Data Quality Policy / Version 7 / December 2015 4