Information Quality Policy V1.0

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 committee/individual: / Alison Dailly; Director of Informatics
Date issued:
Review date:
Target audience: / Accountability - Executive Directors
Responsibility - senior managers in corporate functions and senior operational managers
Implementation - all Trust staff

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
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

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.

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 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

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 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

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

· 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

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.

Contents

Information Quality - Good Practice Guidelines