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OPERATIONAL DIRECTIVE
Enquiries to: Karen Lopez Tel.: (08) 9222 4135 Number: OD 0107/08
Date: 19 February 2008
Supersedes: File No: 07-00218
Subject: Health Data Management Policy
WA Health, like most organisations, is becoming increasingly dependent on information to support decision-making. There are a vast number of data collections throughout WA Health used for both operational and corporate decision-making that must be managed with regard to the quality of data collected, custodianship of the data, processes undertaken to justify collection of the data and the associated costs in maintaining these collections.
The objective of this policy is to ensure accountability in the management of data throughout WA Health by:
• formalising the establishment of new data collections and enhancements to existing data collections;
• establishing custodianship for data collections, with associated responsibilities; and
• ensuring that information is of the highest possible quality for both patient care and effective decision-making.
Dr Peter Flett
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HEALTH DATA MANAGEMENT POLICYSCOPE
This policy applies to all electronic Data Collections containing either patient, corporate, financial or workforce information within WA Health regardless of size where one or more of the following conditions are met:
• The data collection is used to meet business, operational or legislative requirements; or
• The State of Western Australia has a strategic need for the data; or
• The data collection contains personal information; or
• The data collection is used for reporting at a state level, national level or external to the health service where the data collection resides; or
• The data collection is used across multiple health services. Ad hoc data collections are excluded from this policy.
POLICY
The following rules shall apply to Data Collections within scope:
• All new data collections must be approved by the State Health Executive Forum (SHEF) Performance and Reporting Governance Sub-Committee before data collection may commence.
• Substantial changes in the scope and/or volume of data being collected will require approval by the SHEF Performance and Reporting Governance Sub-Committee. Regardless of the scope and nature of modifications, approval must initially be sought from the data custodian.
• Before a new collection or change to an existing data collection will be approved:
à a data custodian must be assigned to the collection;
à a data quality management plan must be completed;
à the data elements to be collected must be identified, defined and described;
à all existing collections must be checked to ensure the required data is not already collected; and
à the establishment / enhancement proposal must be completed, documenting the above details and justifying the basis for the collection, the impact of the
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new/changed collection on WA Health, the cost, the issues and how these issues will be resolved.
• All data collections will be subject to a regular review process to ensure relevance of the collection. Collections will be authorised for a three-year period, and at the end of this period a review must be conducted before the authorisation will be renewed. Approval to renew will be based on clear demonstration of the following:
à a data custodian being assigned to the collection;
à a completed data quality management plan;
à the data elements being collected have been identified, defined and described.
• All currently existing data collections will be initially listed as authorised, but must be reviewed within one year of the listing date or authorisation will not be renewed.
• Health Services and data custodians will not be required to provide data for any collection that does not have authorisation.
Changes proposed to existing ‘out of scope’ data collections which will result in the collection being ‘in scope’ will require approval as per the rules documented above.
DEFINITIONS
A Data Collection is a systematic gathering of data for a particular purpose from various sources, including manual entry into an application system, questionnaires, interviews, observation, existing records and electronic devices.
For the purpose of this policy Data Collection refers to a collection of data, which is undertaken for a specific business purpose. This includes both operational data collections and data repositories.
A Data Repository includes data that is collected from various sources, including operational data collections for the primary purpose of monitoring, evaluation, reporting and research. Examples of Data Repositories include data held within the Hospital Morbidity Data System, Finance Data Warehouse and the Patient Electronic Analysis Reference Liaison System (PEARLS).
An Operational Data Collection includes data that is collected as part of the day-to-day activities of an area for the primary purpose of tracking and managing the operational aspects of the area. The operational data collection is typically a transaction-based system which contains detailed data elements to represent the activities of the area. Examples of operational data collections include data held within Patient Administration Systems, TRIM, Financial Systems and Human Resource Management Systems.
BACKGROUND
There are a number of data collections that have been established in WA Health including some that have been established without consideration or awareness of existing collections containing the same or similar information. The cost involved in the
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development and ongoing operation of data collections is significant, both financially and in terms of the burden that it imposes on Health Service staff. It is essential that processes be implemented to ensure accountability for expenditure on data collection.
Information is a critical resource to the Department and to the health system as a whole, and must be managed, with regard to the cost of collection, quality of data collected and process undertaken in establishing new collections and justifying the continuation of existing collections.
IMPLEMENTATION
The Information Management and Reporting (IMR) Directorate will be responsible for implementation of this policy.
A list of authorised data collections, the nature of the collection (including data elements), and the custodians of those collections, will be posted on the Health Intranet.
Data custodians will be advised that this initial authorisation is temporary and must be renewed within one year. The expiry date of the authorisation should be included on the list of authorised collections.
Data custodians will also be advised of the need to establish a data quality management plan which will be reviewed by IMR in line with the renewal of authorisation for the data collection.
All staff will be advised that data need not be provided to unauthorised data collections. To avoid staff confusion all core health systems (eg, TOPAS, Hcare, Oracle Financials, etc.) should be listed as authorised data collections for the life of the system.
REVIEW
In order to ensure currency and ongoing relevance to WA Health, this policy will be reviewed on a 2 yearly basis by the Information Management and Reporting Directorate.
RELEVANT POLICIES
IMR Directorate Data Custodianship Policy IMR Directorate Data Quality Standard
Business Case Guidelines for Information Systems
Information Systems Initiation, Development and Implementation Policy ICT Project Initiation Guideline
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ASSOCIATED REFERENCE TOOLSEstablishment / enhancement proposal Data Quality Template
Data Quality Questionnaire
RELEVANT LEGISLATION
Hospitals and Health Services Act 1927 Health Act 1911
Human Reproductive Technology Act 1991 Freedom of Information Act 1992
State Records Act 2000 WA Mental Health Act 1996 Financial Management Act 2006
SUPPORTING DOCUMENT
NSW Health. 2005. Process for Approval of New or Modified Data Collections. NSW: NSW Health. http://www.health.nsw.gov.au/policies/PD/2005/PD2005_155.html
