Ref No: DATA QUALITY POLICY Version: 4e Ratified by: Policy Ratification Group Date ratified: 15 December 2010 Name of author: Head of Information & Performance Name of responsible committee: Quality Committee (Approved by the Corporate Safety and Experience Committee) Date issued: December 2010 Review date: June 2011 Target audience: All Staff Copyright 2010 The Rotherham NHS Foundation Trust Version 4e Please check the intranet to ensure you have the latest version Page 1 of 16
Version Date Author Status Comment 1.0 22/04/04 Approved Initial approved policy 2.02 25/08/05 Approved Updates in line with review schedule 3.01 10/10/07 Head of Information 3.02 30/11/07 Head of Information 3.03 19/12/07 Head of Information 3.04 02/04/08 Head of Information 3.05 16/04/08 Head of Information 4a 08/07/10 Information Governance Manager 4b 22/9/10 Head of Information 4c 4d 4e 14/10/10 Head of Information 03/12/10 Head of Information & Performance 22/12/10 Head of Information & Performance Draft Draft Approved Draft Approved Draft Draft Draft Draft Approved Re-formatted inline with new Trust policy template and group responsibilities Modified following discussion at System Managers Meeting Further modifications following System Managers Meeting Responsibilities of Health Records Group Incorporated Comments from HISC incorporated Changed to new format Modified to reflect changes in organisation structure, responsibilities and EPR implementation A monitoring point included to ensure all audit requirements to meet the IGT are actioned Modified following discussion at the Quality Committee Modified following discussion at the Policy Ratification Group Version 4e Please check the intranet to ensure you have the latest version Page 2 of 16
Contents Section Title Page 1 Introduction 5 2 Purpose 6 3 Duties 6 3.1 Duties within the Organisation 6 3.2 Consultation and Communication with Stakeholders 8 3.3 Approval of the Policy 8 3.4 Ratification of the Policy 8 4 Definitions and Abbreviations 8 5 Equality Impact Assessment 9 6 Review and Revision Arrangements 9 7 Procedural Information 9 8 Dissemination and Implementation 10 8.1 Dissemination 10 8.2 Implementation Plan Including Training 10 9 Monitoring Compliance 10 10 References 11 11 Associated Documentation 11 Appendices Appendix 1 Equality Impact Assessment 12 Appendix 2 Data Quality Standards 14 Appendix 3 System Specific Information Policy Outline 16 Version 4e Please check the intranet to ensure you have the latest version Page 3 of 16
The 10 Golden Rules of this Policy 1 Data quality is everyone s responsibility and can negatively impact patient care and the finances of the Trust 2 Errors in data shall be corrected at source, normally by the staff responsible for the original data entry 3 Information Asset Owners must ensure a System Specific Information Policy is in place for their electronic system 4 The NHS number is the only way of identifying patients across systems, and the Trust is committed to using this in all patient systems where it is available 5 The Trust will maintain a Data Assurance Document (DAD) which will contain details on quality indicators, where data comes from and any calculations undertaken. A copy of the DAD can be found at: I:\Management\Quality Accounts\Data Assurance Documentation\Data Assurance Document_master.xls 6 Appendix 2 contains details on the standards that support good data quality 7 Principle 4 of the Data Protection Act 1998, requires that personal data shall be accurate and, where necessary, kept up to date 8 Line Managers must ensure their staff are aware of their responsibilities in relation to data quality and have received appropriate training 9 Information Asset Owners must ensure that appropriate data quality procedures are in place (relevant to the specific system) and staff are aware of and follow them 10 The policy covers all data recorded across the Trust, both in electronic and paper format Version 4e Please check the intranet to ensure you have the latest version Page 4 of 16
1 INTRODUCTION 1.1 This policy defines the Data Quality agenda in the period leading up to the MEDITECH EPR implementation. Whilst many aspects will remain the same, the overall policy will be revised in line with the EPR implementation date to reflect required modifications. It is for this reason that the policy has a 6 month review period. 1.2 The primary aims of the policy are: To define the framework for capturing and improving the quality of data held on the Trust s information systems (both clinical and nonclinical) To ensure compliance with the Data Protection Act 1998, Principle 4 that personal data shall be accurate and, where necessary, kept up to date. To ensure the reliability (fitness for purpose) of all data used in patient care, governance, planning and service agreements. To ensure the Patient Administration System (PAS) index is utilised as the Patient Master Index, utilising the NHS number where available. Access to the patient data held on the PAS Index shall be made available to other systems via an electronic interface wherever it is cost effective to do so, to improve the data in those systems. 1.3 Data held on Trust Information Systems is required for many purposes: Operationally: to provide an efficient service to patients and ensure appropriate treatment Clinically: to produce reliable clinical indicators and to inform clinical audit Strategically: the PAS Index contains the patient data which will form the core of future electronic records (This will be fulfilled by the MEDITECH Master Patient Index once the EPR is in place) Financially: under Payment by Results (PbR), the Trust s income depends on the reliable recording and reporting of patient activity Managerially: data is used to produce performance indicators and assess the achievement of national targets, as well as to support local targets and service improvements 1.4 The risks associated with poor data quality include sub-standard patient care or harm to patients, loss of income and poor management decisions. Version 4e Please check the intranet to ensure you have the latest version Page 5 of 16
2 PURPOSE 2.1 The policy sets out the roles and responsibilities for staff to enable data quality to be maximised and maintained over time. 2.2 The policy sets out the principles to be used in more detailed System Specific Information Policies (SSIPs). A template for developing a SSIP is shown in Appendix 2. SSIP will be completed by Information Asset Owners of electronic systems. 2.3 The policy covers all data recorded across the Trust, both in electronic and paper format. 3 DUTIES 3.1 Duties within the Organisation 3.1.1 The Chief Executive has overall responsibility for the maintenance and implementation of the policy. 3.1.2 The Quality Committee has delegated responsibility for the maintenance and implementation of this policy. 3.1.3 The Chief Financial Officer is the Lead Executive Director for data quality across the Trust 3.1.4 Line Managers shall be responsible for ensuring that staff with data quality responsibilities: Have an understanding of the importance of data quality as it relates to them Are supported, especially when there are time constraints Receive appropriate training Have access to relevant procedures and guidance Have this responsibility documented in their job description 3.1.5 All Staff must ensure that they read, understand and comply with this policy and any relevant local procedures. Staff who record patient information must ensure that data is accurate, complete and documented in a timely manner. Errors in patient data shall be corrected at source, normally by the staff responsible for the original data entry. See Appendix 2 for the data quality standards. 3.1.6 Clinical Staff have a professional responsibility for the quality of any information they collect, use or submit. They will work with clinical coding staff as appropriate to ensure data quality is maximised and maintained. Version 4e Please check the intranet to ensure you have the latest version Page 6 of 16
3.1.7 Information Asset Owners (IAO) / Information Asset Administrators (IAA) are responsible for ensuring that: 3.7.1 System Specific Information Policies are developed and maintained for systems they oversee. 3.7.2 Appropriate data quality procedures are in place (relevant to the specific system) and staff are aware of and follow them. 3.1.8 The Information Services Manager is responsible for the following: 3.8.1 Provision of advice and interpretation on Data Standards issues and for disseminating changes, e.g. in DSCNs, to appropriate staff. 3.8.2 The maintenance of reference files on the PAS and for distribution to other Trust systems (via IAO / IAA). 3.8.3 Submission of all activity data for reporting purposes. 3.1.9 The Information Department shall be responsible for providing data quality reports / information required by: Trust Directors and Managers CSUs and other internal management groups in order to validate and correct data as required The Performance Team to feed into dashboard reports 3.1.10 The Contract Compliance Group is responsible for ensuring conformance to national and local rules/definitions in the recording and reporting of Trust activity. Any change to how activity is recorded shall be agreed by this group. 3.1.11 The Health Records Manager is the Information Asset Owner for the Patient Administration System (PAS) and is responsible for submitting local data to the Demographics Batch Service (DBS) for obtaining/validating the NHS Number and other administrative data. The NHS number is the only way of identifying patients across systems, and the Trust is committed to using this in all patient systems where it is available. 3.1.12 The Health Records Group is responsible for ensuring the data quality of health records. This will be accomplished through the implementation and ongoing monitoring of the health records policy and health records strategy. 3.1.13 The IT Trainers are responsible for undertaking initial and follow-up training on the use of the PAS and going forward the EPR. Version 4e Please check the intranet to ensure you have the latest version Page 7 of 16
3.1.14 For other information systems, training is the responsibility of the Information Asset Owner or Information Asset Administrator and will be documented in the System Specific Information Policy for that system. 3.1.15 The Clinical Coding Department are responsible for maintaining and improving the quality of the coded (diagnostic and procedure) information held on the PAS. They will undertake audits with CSUs (defined in the audit plan) which will highlight improvements for coding which will be discussed at CSU meetings. The Clinical Coding Manager will provide induction training to junior doctors on clinical coding. 3.1.16 The IT Department is responsible for: Development (or project manage the development) of interfaces between patient systems Advice and support on data quality issues Technical support shall be provided for: PAS as set out in the PAS Management Policy PAS data extraction software (MSM SQL) Updating the PAS Data Dictionary with new releases The Data Warehouse 3.2 CONSULTATION AND COMMUNICATION WITH STAKEHOLDERS The policy is discussed with staff holding key data quality responsibilities prior to submission to the Quality Committee. 3.3 APPROVAL OF THE POLICY The Corporate Safety and Experience Committee has responsibility for approving the policy. 3.4 RATIFICATION OF THE POLICY This policy will be ratified by the Trust s Policy Ratification Group. 4 DEFINITIONS AND ABBREVIATIONS CSU Clinical Service Unit DBS Demographics Batch Service: This is the means by which patient information is submitted to the national Spine for tracing against the Personal Demographics Service. Version 4e Please check the intranet to ensure you have the latest version Page 8 of 16
DSCN Data Set Change Notice: Give notification of changes to information requirements which will be included as appropriate in the NHS Data Dictionary, and the NHS Commissioning Data Set Manual. EPR Electronic Patient Record System IAA Information Asset Administrator: Provides support to the Information Asset Owner. IAO Information Asset Owner: Is a senior member of staff who is the nominated owner for one or more identified information assets, and monitors what information is held, managed over time, and access to it. PAS Patient Administration System PbR Payment by Results: The funding methodology used in the NHS SSIP System Specific Information Policy: These are policies covering a wide range of topics for a given IT system SUS Secondary Uses Service 5 EQUALITY IMPACT ASSESSMENT 5.1 The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. 5.2 A completed copy of the Equality Impact Assessment tool is attached as Appendix 1. 6 REVIEW AND REVISION ARRANGEMENTS 6.1 The policy will be reviewed by the Quality Committee within the timescales listed on the coversheet. 6.2 The Head of Information & Performance, as the Author of this policy will be the lead officer for ensuring the policy is reviewed and approved according to the method identified. 7 PROCEDURAL INFORMATION 7.1 Relevant procedure documents are listed in section 11. Version 4e Please check the intranet to ensure you have the latest version Page 9 of 16
8 DISSEMINATION AND IMPLEMENTATION 8.1 The Head of Information & Performance will ensure the policy is added to the Trust document management system located on the Intranet site. 8.2 The policy will be communicated to staff. As a minimum: 8.2.1 An electronic version of the policy document will be emailed to all Heads of Departments/Matrons/Ward Managers/Clinical Directors by the Head of Information. 8.2.2 Line Managers must ensure that new policy documents are communicated to all relevant staff and that arrangements for training and support are identified. 8.2.3 The approval of the policy will be printed in relevant Team Brief documents. 9 MONITORING COMPLIANCE 9.1 This policy will be monitored through the development and implementation of a series of Information Governance policies and through the use of internal and external data quality reports. 9.2 The Trust will maintain a Data Assurance Document (DAD) which will contain details on quality indicators, where data comes from and any calculations undertaken. A copy of the DAD can be found at: I:\Management\Quality Accounts\Data Assurance Documentation\Data Assurance Document_master.xls 9.3 The Quality Committee will ensure that all required data quality checks are undertaken as required by the IG Toolkit (i.e. the completeness and validity checks). 9.4 Compliance with Data Set Change Notices (DSCNs) will be assessed via audits of individual systems. 9.5 Trust performance against the Quality Assurance Standards in the IG Toolkit shall be assessed annually through the Quality Committee and the results reported to the Information Governance Steering Group. 9.6 Internal monitoring of data quality shall be undertaken on key data items as specified in System Specific Information Policies. 9.7 Accuracy of clinical coding data will be monitored from audits of specialty and individual coder activity. Version 4e Please check the intranet to ensure you have the latest version Page 10 of 16
9.8 The following external data quality services/reports shall be used by the Information Department to identify data quality problems: CHKS Data Quality Reports SUS (Secondary Uses Service) Data Quality Dashboards Audit Commission PbR Coding Audits (or other relevant audit reports) 10 REFERENCES Guidance to Support Duplicate Record Management http://www.connectingforhealth.nhs.uk/systemsandservices/data/dataquali ty/resources/dqm000409.pdf Procedures for Migration Analysis Cleansing Service (MACS) http://www.connectingforhealth.nhs.uk/systemsandservices/data/dataquali ty/resources/dqm010705.pdf CSA Migration Strategy - Demographics http://nww.connectingforhealth.nhs.uk/demographics/docs/nsts- migration/npfit-fnt-to-dsd-0045%2003csadeploymentstrategy- Demographicsv2.doc Demographics Batch Service http://nww.connectingforhealth.nhs.uk/demographics/dbs 11 ASSOCIATED DOCUMENTATION Information Governance Policy Health Records Policy PAS Management Policy Policy on the Use and Protection of Patient Information System Specific Information Policies Version 4e Please check the intranet to ensure you have the latest version Page 11 of 16
EQUALITY IMPACT ASSESSMENT (EIA) INITIAL SCREENING TOOL Document Name: Data Quality Policy Date/Period of Document: 1 year review cycle Lead Officer: Scott Reid, Head of Information Directorate: Finance Reviewing Officers: John Francis APPENDIX 1 Function x Policy Procedure Strategy Joint Document, with who? Describe the main aim, objectives and intended outcomes of the above: The policy sets out the roles and responsibilities for staff to enable data quality to be maximised and maintained over time. You must assess each of the 7 areas separately and consider how your policy may affect people s human rights. 1. Assessment of possible adverse impact against any minority group How could the policy have a significant negative impact on equality in relation to each area? Response Yes No 1 Age? x 2 Gender (Male, Female and Transgender)? x 3 Disability (Learning Difficulties/Physical or Sensory Disability)? x 4 Race or Ethnicity? x 5 Religious, Spiritual Belief? x 6 Sexual Orientation? x 7 Socio-economic groups? x If yes, please state why and the evidence used in your assessment You need to ask yourself: Will the policy create any problems or barriers to any community of group? Yes/No Will any group be excluded because of the policy? Yes/No Will the policy have a negative impact on community relations? Yes/No If the answer to any of these questions is Yes, you must complete a full Equality Impact Assessment 2. Positive impact: Could the policy have a significant positive impact on equality by reducing inequalities that already exist? Explain how will it meet our duty to: Response 1 Promote equal opportunities x 2 Get rid of discrimination x 3 Get rid of harassment x 4 Promote good community relations x 5 Promote positive attitudes towards disabled people x 6 Encourage participation by disabled people x 7 Consider more favourable treatment of disabled people x 8 Promote and protect human rights x Yes No If yes, please state why and the evidence used in your assessment 3. Summary On the basis of the information/evidence/consideration so far, do you believe that the policy will have a positive or negative adverse impact on equality? Positive Please rate, by circling, the level of impact Negative HIGH MEDIUM LOW NIL LOW MEDIUM HIGH Date assessment completed:30.09.10 Is a full equality impact assessment required? Yes (documentation on the intranet) x No Version 4e Please check the intranet to ensure you have the latest version Page 12 of 16
WEBSITE SUMMARY FORM Please ensure that you complete this form for publishing on our website APPENDIX 1 DETAILS OF COMPLETED EQUALITY IMPACT ASSESSMENT Directorate Finance KEY FINDINGS FUTURE ACTIONS TIMESCALES No areas identified that will have either a positive or negative impact on equality. Name of Function or Policy DATA QUALITY POLICY Brief description of aims of the Policy/Function This policy outlines how data quality will be managed. Status of Function or Policy (i.e. new, changing, existing) Revised policy Name of Lead Officer Completing the Assessment IG Manager Date of Assessment 30.09.10 We are required to publicise the results of all Equality Impact Assessments, could you please forward a copy of your completed screening tool and website summary form to webmaster@rothgen.nhs.uk for uploading on the intranet/internet. Version 4e Please check the intranet to ensure you have the latest version Page 13 of 16
APPENDIX 2 Data Quality Standards The key indicators to sound data quality are listed below, and staff must take every step to maximise these. Accuracy - All recorded data must be correct when the patient is registered and presents at the Trust and updated as appropriate thereafter to accurately reflect both the patient s details and clinical pathway. Staff must take every opportunity to check a patient s demographic details with the patient themselves. Inaccurate demographics may result in important letters being mislaid, or incorrect identification of the patient as well as incorrect/delayed income for the trust. There are specific codes that can be used on the PAS system for patients who are unable to give their demographic details, such as unconscious patients, stroke victims, etc. The Information Department regularly update reference tables which contain data items such as GPs and Postcodes. If reference tables are found to be incomplete then the user must inform the Information Services Manager so that the tables can be updated. The accurate recording of data items must however not be allowed to delay urgent treatment of the patient. Completeness - All mandatory data items within a data set must be completed. Default codes will only be used where appropriate and not as a substitute for real data. If it is necessary to bypass a data item in order to progress the delivery of care to a service user, the missing data must be reported by the user to the manager of the relevant system for immediate follow up. (In the case of data items on PAS, this must be reported as soon as possible to the PAS Administrator). Consistency - Data collection and recording must be consistent throughout the Trust so that national and local comparisons can be made. Operations and diagnoses must be consistent with age and sex. Duplicate data items between different systems must be consistent so as not to lead to any ambiguity between different data sources. The NHS Data Dictionary sets out common data definitions to be used across the NHS. NHS data standards must not just be seen as supporting the collection of data on a consistent basis throughout the NHS, but they also have an important role in supporting the flow and quality of information used in different parts of the NHS so that health care professionals are presented with the relevant information where and when it is required. Coverage - Data will reflect all the work done by the Trust; Admissions, outpatient attendances, operations, procedures, transfers and discharges must all be recorded. Correct departmental procedures are essential to ensure complete data capture and spot checks/audits must be undertaken to identify missing or inaccurate data. Comparisons between data systems must also be used to identify missing or inaccurate data when necessary. Version 4e Please check the intranet to ensure you have the latest version Page 14 of 16
Timeliness - Recording of data in a timely fashion is beneficial to the treatment of the patient. Entering test results into the computer, recording diagnoses and operations or up-to-date information of patient admissions/transfers/discharges makes that information available to all involved in treating patients even if they do not have access to the paper records. All data must be recorded in a locally agreed timescale that will enable the data to be submitted in line with national deadlines. If data entry is delayed in any system, the relevant activity may not be coded in time. This means that the data will not be submitted and payment will not be received by the Trust for activities carried out. Changes to the NHS Data Dictionary are conveyed via the DSCN (Data Set Change Notice) process, which is internally overseen by the Information Services Manager. Validity - All data items held on Trust computer systems must be valid. Where codes are used, these will comply with national standards or map to national values. Wherever possible, computer systems are programmed to only accept valid entries. Version 4e Please check the intranet to ensure you have the latest version Page 15 of 16
APPENDIX 3 SYSTEM SPECIFIC INFORMATION POLICY: OUTLINE 1. Scope and System Definition 2. Aims 3. Authorised Users (Caldicott) 4. Training (before use) Application Data quality Security 5. Data Quality Individual Responsibility Patient Index Reference Files Interfaces 6. Management Information 7. Security (Access controls) 8. Availability/Business continuity 9. Application Development/User Group Appendices Policy Framework System Definition Risk Assessment (Data sensitivity; disruption; patient harm) Authorised Users (List of posts) Procedures (List) Contingency Plans Version 4e Please check the intranet to ensure you have the latest version Page 16 of 16