Information Quality Policy V1.0
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Information Governance:
Information Quality Policy
Policy Title: Information Quality Policy Version: 1.0 Draft Approved by: Date of Approval: Policy supersedes Name of originator/author: Balbir Bhogal; Deputy Director of Informatics Information and Patient Services Name of responsible Alison Dailly; Director of Informatics committee/individual: Date issued: Review date: Target audience: Accountability - Executive Directors Responsibility - senior managers in corporate functions and senior operational managers Implementation - all Trust staff Contents
Section Page Summary 4 1 Introduction 5 2 Definition of Information Quality 5 3 The Importance of High Information Quality 6 4 Information Reporting 7 4.1 - Responsibility 7 4.2 - Internal Reporting 7 4.3 - External Reporting 7 5 Responsibility for Information Quality 8 6 How can Information Quality be Improved 8 6.1 - Key Elements 8 6.2 - Procedures 8 6.3 - NHS Number 9 6.4 - Review of Procedures 9 6.5 - Training 9 6.6 - Responsibility for Training 9 6.7 - Staff Awareness 10 6.8 - Trust’s Internal Information Systems 10 7 Identifying and Correcting Errors and Omissions 10 7.1 - Information Quality Reports 10 7.2 - Information Analysts 11 7.3 - Strategy 11 7.4 - Poor Data Quality 11 7.5 - Errors 11 8 Measurement of Accurate Information Quality 11 9 Requirements for Accurate Information Quality 12 9.1 - Accurate Data 12 P/Information Governance/Information Quality/Information Quality Policy 2 Author: Balbir Bhogal Section Page
9.2 - Information Staff 12 9.3 - Timely information 12 9.4 - Variances 12 9.5 - ISN’s 12 9.6 - Data Dictionary 13 9.7 - PAS Master Files 13 9.8 - New Services 13 10 Links to other Information Governance Initiatives 13 10.1 - Health Records 13 10.2 - Caldicott Guardians 13 10.3 - Safe Havens 13 11 Dealing with enquiries about Information Quality 14 12 Information Quality Group 14 13 Equality Impact Assessment 14 14 Conclusion 16
P/Information Governance/Information Quality/Information Quality Policy 3 Author: Balbir Bhogal P/Information Governance/Information Quality/Information Quality Policy 4 Author: Balbir Bhogal Information Quality - Good Practice Guidelines
Summary
This policy is an overarching document covering all aspects of Information Quality. The Trust will act in compliance with current legislation and best practice to provide high quality and accurate information.
Information Quality Assurance is a key element of Information Governance.
Responsibility for good Information Quality lies with all staff who record patient information, whether clinical, technical or clerical. The management of Information Quality will be within the remit of the Director of Informatics through the Information Quality Group.
P/Information Governance/Information Quality/Information Quality Policy 5 Author: Balbir Bhogal 1. Introduction
Information Quality Assurance is a key element of Information Governance. The Trust recognises the importance of reliable information to the delivery of patient care. All decisions, whether clinical, managerial or financial; need to be based on information which is of the highest quality.
Good quality information relies on accurate data but also on informed interpretation and presentation in line with national definitions. The Trust’s patient activity information is derived from individual data items, collected from a number of sources. Patient activity information comes from a centralised Informatics Department, to ensure that consistent interpretations are placed on the data obtained from the Patient Administration System.
All staff have a responsibility for Information Quality and this in turn, should be reflected in the Policies and Procedures documented and practiced in the Trust at all levels
The purpose of this policy is to draw together the requisites for a high standard of information quality in one policy. The policy‘s main emphasis is on the Trust’s PAS system and the information derived from it. More information can be obtained from various procedures within the Informatics Department.
2. Definition of Information Quality
The Trust defines Information Quality as being reflected in the following criteria
Accurate - data must be correct and accurately reflect the patients’ activity within the Trust. All reference tables including GPs and postcodes will be updated regularly. Every opportunity will be taken to check a patient’s demographic details with the patient themselves. Complete – data should be captured in full. All mandatory data items within a data set should be completed and default codes will only be used where appropriate, not as a substitute for real data. The use of mandatory data items on the computer systems is to be encouraged but only where this would not cause undue delay. For key data items which are not mandatory on the computer system, it is vital that a list of records with missing data items can be produced. Valid - data should be within an agreed format which conforms to recognised national standards. Codes must map to national values
P/Information Governance/Information Quality/Information Quality Policy 6 Author: Balbir Bhogal and wherever possible, computer systems should be programmed to only accept valid entries. Timely – data should be collected at the earliest opportunity; recording of timely data is beneficial to the treatment of the patient. All data will be recorded to a deadline which will ensure that it meets national reporting and extract deadlines. Defined / Consistent – the data being collected should be understood by the staff collecting it. Data definitions should be reflected in procedure documents. Coverage – data will reflect the work of the Trust and not go unrecorded. Spot checks and comparison of data between months can highlight potential areas of data loss.
3. The Importance of High Quality Information
The Information team brings together raw data to turn it into meaningful information. This information is essential for:
Efficient delivery of patient care Clinical governance and minimising clinical risk. Management information to enable decisions to be made on the basis of sound information – both operational and strategic, local and national. Attracting the correct level of funding from Payment by Results (PbR) and local commissioning agreements. Performance measurement against national trends and trends over time, so that we can continually plan improvements for our patients. Clinical and Performance Indicators, in addition to Care Quality Commission assessments, are all largely based on HES data which is obtained from the Contract Data Set (CDS) data the Trust sends to the Secondary Uses Service (SUS). As a foundation on which future investments will be based. To support clinical audit and research and development, with a view to improving patient care in the future. Payment by Results to ensure that the Trust correct level of payment is secured from Commissioners and to monitor performance against Service Level Agreements. This is particularly important under the PbR system, where payment for spells varies according to e.g. clinical coding and length of stay As a foundation on which future investments will be based
P/Information Governance/Information Quality/Information Quality Policy 7 Author: Balbir Bhogal 4. Information Reporting
4.1. Responsibility The Trust’s Information reporting function is the responsibility of the Head of Information Governance and Patient Services, reporting to the Director of Informatics. The Head of Information Governance and Patient Services is supported by a team including information analysts, data quality officers, and the PAS Manager and team.
4.2. Internal Reporting
4.2.1. The majority of this is via the in-house information systems which give aggregate information regarding activity and waiting times and lists. It is recognised that consistency is key to high quality information so the key to these systems is that as many reports as possible are pulled from one data source.
4.2.2. In addition to the various monthly reports, weekly reports are produced to assist in enabling managers to meet the various waiting times targets.
4.2.3. Ad hoc information requests are also received and should be dealt with, where possible within 2 weeks of receipt. Such requests are made e.g. to support clinical audit, research and development, and operational and strategic management. Information analysts need to be aware of the confidentiality aspects of patient information and the appropriateness of information requests at all times. If in doubt, they must discuss with the Head of Information Governance and Patient Services.
4.3. External Reporting
4.3.1. It is a requirement for all Trusts to submit Inpatient and Outpatient CDS (Commissioning Data Sets) to SUS from where it is distributed to the relevant PCT.
4.3.2. In the regime of Payment by Results, good data and information quality have never been more important to the Trust. It is particularly important that clinical coding on PAS is as up to date at possible; this is greatly assisted by high quality recording of diagnoses and operations in the casenotes.
4.3.3. Apart from the provision of CDS, there are numerous reporting requirements both nationally and to the local Strategic Health Authority and PCTs. Information is obtained, as above from PAS and many of the performance indicators used to produce the Department of Health performance management framework, Monitor Compliance Framework and the annual Care Quality
P/Information Governance/Information Quality/Information Quality Policy 8 Author: Balbir Bhogal Commission assessment for Trusts are derived from these returns or from SUS data itself. It is vital that the data contained within these returns is accurate and that they are submitted to meet the strict deadlines.
5. Responsibility for Information Quality
Responsibility for good Information Quality lies with all staff who record patient information, whether clinical, technical or clerical. The management of Information Quality will be within the remit of the Director of Informatics through the Information Quality Group.
There are posts within the Information Department, Waiting List team, Medical Records and Emergency Department with specific responsibilities for Information Quality issues in their areas. Divisional staff have a responsibility to inform Medical Records and the Information Department when changes need to be made to the PAS System, to allow for data capture regarding new consultants or changes to clinic templates, waiting lists etc. They also have a responsibility to notify the Information Department of any Ward or Service changes which could impact on how data is captured on PAS.
All staff within the Trust have a responsibility for recording accurate and complete information.
6. How can Information Quality be improved?
6.1. Key Elements
Two key elements to improving data quality are ensuring a high standard of training and adherence to standard operating procedures. Good quality data can be achieved by careful monitoring and error correction but it is more effective and efficient for data to be entered correctly the first time. In order to achieve this, standard operating procedures must exist so that staff can be trained and supported in their work.
6.2. Procedures
As a minimum, the following procedures must be fully documented: Registering a referral for an outpatient clinic, test or other healthcare activity Recording outpatient attendances, cancellations and DNAs, the outcome from the attendance and the RTT status of patients on an 18 week pathway. Adding a patient to an Inpatient waiting list Admitting a patient
P/Information Governance/Information Quality/Information Quality Policy 9 Author: Balbir Bhogal Recording an A&E attendance. Recording Radiology examinations Recording all Pathology tests.
Procedures are detailed descriptions of the processes by which policies are carried out and should contain details of:
The person in overall control of the policy or process Persons responsible for any other aspects Any definitions appropriate to the document
The data quality elements of any procedure must be defined in such a way so as to be unambiguous to those who are expected to carry out the tasks. They should reflect national and local standards. The Trust has standard templates which can be used for creating SOPs (Standard Operating Procedures).
6.3. NHS Number
Where possible the patient’s NHS Number should be used within systems as the nationally unique ID for English and Welsh patients as recommended by Connecting for Health. Use of the NHS number should greatly reduce the number of duplicate system records for patients and is key to the national Connecting for Health modernisation programme.
6.4. Review of procedures
Procedures need to be reviewed at least on an annual basis, to take account of any changes in national standards and definitions, including PbR definitions. Tight version control is essential to ensure that staff within all areas of the Trust, are using the same procedures which reflect current data definitions. Publication of procedures on the Intranet is to be encouraged
6.5. Training
All Users of computer Systems will be given training on the functionality required for them to perform their role in an efficient manner. PAS training is undertaken by the Core Training Team from within the Informatics Department. Users must sign a confidentiality clause and fully understand its implications before being issued with a password. Training in using all other Systems is carried out within the relevant departments
P/Information Governance/Information Quality/Information Quality Policy 10 Author: Balbir Bhogal 6.6. Responsibility for training
The Trust recognises the importance of training to ensure understanding with regard to quality issues. The responsibility for arranging training and for day to day adherence to policies and procedures rests firmly with the team leaders, supervisors and managers whose areas of responsibilities have been identified in each individual policy. It is their role to ensure that staff are resourced, motivated and listened to in respect of quality issues. A no blame culture should operate, so that mistakes can be avoided in the future. Users should be informed by their line managers where and who to report errors or duplicates on PAS.
6.7. Staff Awareness
Job Descriptions should also reflect specific and general responsibilities for encouraging good quality. Responsibility for the quality of data should be assigned and monitored under the core KSF competency of Quality. The appraisal system provides an important mechanism for increasing staff awareness of their role in improving data quality.
6.8. Trusts internal information systems
A significant amount of information is reported on the Trust’s internal information systems which are regularly updated. Managers and clinicians can access data regarding their own specialties and consultants and from the information presented readily identify variances or apparent anomalies. These should be investigated, particularly if there is no obvious cause or trigger for the variance in activity levels or trends.
7. Identifying and Correcting Errors and Omissions
Lapses in Information Quality will occur and mechanisms need to be in place to identify and deal with these.
7.1. Information Quality Reports
The Information Quality Team, run regular validation reports as part of their procedures. Some examples are given below:
Omissions: Coding Completeness Report – List of FCEs in the financial year which have not been clinically coded. (See Clinical coding Policy and procedures) PAS missing Data Reports – Reports showing patients with no registered GP; no postcode, no contract ID etc. (See CDS Policy and procedures) P/Information Governance/Information Quality/Information Quality Policy 11 Author: Balbir Bhogal Missing NHS number reports from the DBS Outcomes or Attendance Reports - Reports showing clinics with outpatient outcomes not yet recorded on PAS. No outcome reports for waiting list patients who have passed their TCI date but are still active on the waiting list. Errors: Validation reports on outpatient long waiters, which are investigated to remove any administrative errors. CDS error reports from PAS system which identifies data items in error. Clinical coding department notification of admission errors to Medical Records. Reports identifying patient episodes with no consultant. Reports identifying errors in RTT data.
7.2. Information Analysts
In addition, Information Analysts will highlight significant variations in data and investigate to ensure that the variations are accurate rather than the result of data recording errors.
7.3. Strategy
The strategy of the Trust is to move away from this retrospective checking and correction of data, and strive as far as is possible to identify and eradicate poor practices with robust procedures, additional resources and/or continuation of training.
7.4. Poor Data Quality
The general onus of data correction should be that where examples of poor data quality are uncovered, the audit trail should be used to identify the member of staff responsible for the error or omission. The identified person should then be asked to make any corrective entry, or at least informed of the error, so that they can be made aware of the implications of their action and the importance of data items.
7.5. Errors
Errors should be amended as soon as possible after they have been identified and certainly by month end.
P/Information Governance/Information Quality/Information Quality Policy 12 Author: Balbir Bhogal 8. Measurement of Accurate Information Quality Apart from the internal measures, there are various tools available to enable the Trust to assess its performance re data quality: HES Data Quality Indicators SUS Data Quality reports DQRS reports taken from SUS data Coverage reports regarding presence of patients’ NHS numbers on PAS Complaints & Queries Internal and external audit reports CHI Inspections comment on data quality. Information Governance Toolkit Health Records accreditation
9. Requirements for Accurate Information Quality
9.1. Accurate Data
Accurate data recorded on all patient systems. This is the responsibility of all Trust staff and is aided by good training and documentation of data collection procedures.
9.2. Information Staff
Fully trained Information staff who are capable of extracting the required data accurately and are able to interpret it and present it to Trust staff in a meaningful way.
9.3. Timely information
This is dependent not only on the availability of analytical resources but also on the timeliness of recording data on PAS and on the timeliness of clinical coding.
9.4. Variances
Information analysts should check regularly produced reports against previous reports and investigate any large variances prior to submission.
9.5. ISN’s
Staff awareness of changes to national reporting requirements and definitions. Changes are notified by ISNs (see ISN Procedure.) It is the responsibility of the Head of Information Governance and Patient P/Information Governance/Information Quality/Information Quality Policy 13 Author: Balbir Bhogal Services to ensure that managers across the Trust are kept informed of relevant changes.
9.6. Data Dictionary
The online Data Dictionary should be used by information staff to ensure that the latest versions are referenced at all times.
9.7. PAS Master Files
PAS Master Files need to be up to date with national requirements and other reference files be regularly updated. This is the responsibility of the PAS Manager.
9.8. New Services
Any new services should be notified to the Information Manager so that it can be determined how the data should be recorded on PAS and support can be given regarding implications for training. Services should not be re-categorised without discussion with the Information Manager, to ensure that the way they are recorded complies with National and Commissioning Standards.
10. Links to other Information Governance Initiatives
10.1. Health Records Information quality relies on good data quality which in terms of PAS data is the responsibility of all PAS users. Many of these users deal with Health Records, so high standards in Health Records are the bed rock of good information.
10.2. Caldicott Guidelines All Trust staff should be aware of Confidentiality of Patient identifiable information. They should be aware of the Caldicott Guidelines governing access to patient identifiable information and need to keep the 6 Caldicott Principles in mind when dealing with information requests. The Caldicott Policy is available through the Information Governance Office.
10.3. Safe Havens Information staff should understand the importance of Safe Haven Principles with regard to security of confidential data and keep information security issues in mind, in all aspects of their work. P/Information Governance/Information Quality/Information Quality Policy 14 Author: Balbir Bhogal Guidance on the use of Safe Havens is available through the Information Governance Office.
11. Dealing with Enquires about Information Quality Any Queries received by the Information department are passed to the most appropriate person to deal with and should be dealt with in a timely manner. Queries received from external sources are minimal and should be sent through to the Head of Information Governance and Patient Services. The members of staff who work within the information departments of our main PCTs are aware of this and the Head of Information Governance and Patient Services is also the contact point for National Returns. If errors are found in CDS data or on any returns, these should be corrected before the final submission. Complaints by individuals regarding any inaccuracy in their data on PAS will be brought to the attention of the Head of Information Governance and Patient Services by the Complaints department or the Patient Access Manager. These should be dealt with in a timely manner and may involve looking at the audit trail on PAS.
12. Information Quality Group Queries from Trust staff on Information Quality need to be investigated, appropriate action taken and staff informed of this action. An Information Quality Group exists to identify areas where improvements to Data Quality could be made, identify and initiate corrective action and monitor the situation to ensure improvements are made. Minutes of the Information Quality Group are electronically sent to the Information Governance Group so that senior managers are kept informed of the work to improve Information Quality and will support it. It is planned that periodic updates regarding the achievement of quality targets will also be reported to this group.
13. Equality Impact Assessment
The Leeds Teaching Hospitals Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflect individual needs, promote equality and does not discriminate unfairly against any particular individual or group.
The development of Trust policies must comply with equalities legislation which is to promote equality and eliminate unlawful discrimination. Guidance on Equality Impact Assessment of policies is available on the Trust intranet.
P/Information Governance/Information Quality/Information Quality Policy 15 Author: Balbir Bhogal 1. Screening
P/Information Governance/Information Quality/Information Quality Policy 16 Author: Balbir Bhogal How relevant is this policy and its associated procedures to promoting equality and human rights and to eliminating discrimination?
Not relevant Partly relevant (say Very relevant which parts)
Race/ethnic group: X
Disability X
Gender including X transsexuals:
Age: X
Sexual Orientation: X
Religion: X
Human Rights X
Carers or other group X (please state)
2. Assessing Impact ( To be completed where the policy and associated procedures has been determined as relevant in the screening process)
Please specify, in the rows below, anything that you have included in this policy and its associated procedures to ensure that equality is promoted and that no one will be unlawfully disadvantaged (discriminated against) as a result of this policy
Race/ethnic group:
Disability: .
Gender:
Age:
Sexual Orientation:
P/Information Governance/Information Quality/Information Quality Policy 17 Author: Balbir Bhogal Religion:
Human Rights
Carers or other group (please state):
14. Conclusion Information Quality Assurance is critical to many area of the Trust’s business. It is important to the efficient working of the Trust as well as being fundamental to Payment by Results. Meaningful information has to be based on accurate data. The emphasis on improving data quality should be on identifying inaccuracies and preventing their reoccurrence through up to date procedural documentation and refresher training. Training policies should make staff aware of the importance of the data they collect and why good data quality is therefore so vital. With over 3,000 members of staff now using PAS, the task of assuring Information Quality is an increasing one but one to which the Trust is fully committed.
P/Information Governance/Information Quality/Information Quality Policy 18 Author: Balbir Bhogal