South East Coast Ambulance Service NHS Trust Information Governance Working Group
Terms of Reference
1. Constitution
1.1. The Board hereby resolves to establish a Working Group of the Risk Management & Clinical Governance Committee (RMCGC) to be known as the Information Governance Working Group (IGWG), referred to in this document as ‘The Group’.
2. Purpose
2.1. The purpose of the Group is to decide and report to the RMCGC that best practice mechanisms are in place within the Trust with regard to information governance.
3. Membership
3.1. The Group shall have no fewer than three members, appointed by the Board from amongst senior managers of the Trust. The IM&T Director and Medical Director will be appointed joint Chair of the Group by the RMCGC.
3.2. The membership will comprise: IM&T Director
Medical Director/ Caldicott Guardian Director of Business Development/ SIRO Head of Information Governance
Assistant Director Distribution
Head of Clinical Controls and Assurance Head of System Information & Development Senior Education Manager
Human Resources Manager
Records and Data Quality Manager
Information Security/ Registration Authority Manager IT Manager
Health Records Manager Complaints Manager
Information Governance Officer Management Accountant
Staff Side
Local Security Management Specialist Patient Representative
4. Quorum
4.1. The quorum necessary for formal transaction of business by the Group shall be three members and shall include representatives from three directorates. The Medical Director may be represented by the Head of Audit and Assurance. 5. Attendance
5.1. Other organisational managers and officers may be invited to attend meetings for specific agenda items or when issues relevant to their area of responsibility are to be discussed.
5.2. The IG Administrator will provide secretarial duties to the Group and shall attend to take minutes of the meeting and provide appropriate support to the Chair and Group members.
5.3. Members and officers unable to attend a meeting are required to send a fully briefed deputy or provide a written update to the Group members at least two
working days beforehand. Members and officers are required to attend 75% of these Group meetings.
5.4. The Chair of the Group will follow up any issues related to the unexplained non attendance of members. Should non attendance jeopardise the functioning of the Group the Chair will discuss the matter with the members and if necessary seek a substitute or replacement.
5.5. Attendance at Group meetings will be disclosed in the Group’s Annual Report to the Risk Management and Clinical Governance Committee (RMCGC).
6. Frequency
6.1. Meetings of the Group will be held every two months and in advance of the next RMCGC meeting to ensure timely reporting. Meeting dates will be diarised on a yearly basis and Extraordinary meetings may be called between regular meetings to discuss and resolve any critical issues arising.
7. Authority
7.1. The Group has no executive powers.
7.2. The Group is authorised by the Board to investigate any action within its Terms of Reference. It is authorised to seek any information it requires from any employee and all employees are directed to cooperate with any request made by the Group. 7.3. The Group is authorised by the Board to request outside legal or other
independent professional advice via the relevant senior Committee, and to secure the attendance of outsiders with relevant experience and expertise if it considers necessary.
8. Duties
8.1. The subject matter for meetings will be wide-ranging and varied but in particular it will cover the following:
8.1.1. Act as a forum for examining, co-ordinating and monitoring compliance with the Information Governance agenda;
8.1.2. Make recommendations to the Risk Management and Clinical Governance Committee;
8.1.3. Creating and reviewing relevant policies and procedures; and
8.1.4. Disseminating information on information governance submitting an annual self assessment for external scrutiny.
8.1.5. This Working Group has delegated authority from the Trust Board to approve and ratify documents that support strategies and policies (such as
procedures, guidance etc.). The Working Group may also review and recommend policies and strategies for approval by Committee. All such decisions will be recorded in the notes of meetings.
8.2. The key duties of the Working Group are to;
8.2.1. inform the review of the Trust’s management and accountability arrangements for Information Governance (IG);
8.2.2. develop an IG policy and associated IG implementation strategy and/or maintain the currency of the policy;
8.2.3. review and agree the annual IG assessment for sign off by the RMCGC; 8.2.4. review and monitor the Trust’s IG work programme;
8.2.5. ensure that the Trust’s approach to information handling is communicated to all staff and made available to the public;
8.2.6. coordinate the activities of staff given data protection, confidentiality, security, information quality, records management and Freedom of Information responsibilities;
8.2.7. monitor the Trust’s information handling activities to ensure compliance with law and guidance;
8.2.8. ensure that training made available by the Trust is taken up by staff as necessary to support their role;
8.2.10. review issues/incidents related to IG in accordance with national guidance;
8.2.11. review impact analysis for all new systems/processes to ensure that functionality and data quality are not adversely affected;
8.2.12. manage risks and review the adequacy of risk and control measures; 8.2.13. offer support and guidance to the Caldicott function and data protection programme within the Trust.
9. Reporting
9.1. The Group shall be directly accountable to the RMCGC. The Chair of the Group shall report a summary of the proceedings of each meeting at the next meeting of the RMCGC and draw to the attention of the Committee any significant issues that require disclosure.
9.2. The IGWG will monitor progress of the IG Toolkit standards within the Trust. 10. Support
10.1. The Group shall be supported by the IG Administrator and duties shall include: 10.1.1. Agreement of the meeting agendas with the Chair of the Group;
10.1.2. Providing timely notice of meetings and forwarding details including the agenda and supporting papers to members and attendees in advance of the meetings;
10.1.3. Enforcing a disciplined timeframe for agenda items and papers, as below: i. At least twelve working days prior to each meeting, agenda items will be due from Group members;
ii. At least seven working days before each meeting, papers will be due from Group members;
iii. At least five working days prior to each meeting, papers will be issued to all Group members and any invited Directors, managers and officers.
10.1.4. Recording formal minutes of meetings and keeping a record of matters arising and issues to be carried forward, circulating approved draft minutes within five working days from the date of the last meeting;
10.1.5. Advising the Chair and the Group about fulfilment of the Group’s Terms of Reference and related governance matters.
11. Review
11.1. The Group will undertake a self-assessment at the end of each meeting to review its effectiveness in discharging its responsibilities as set out in these Terms of Reference.
11.2. The Group shall review its own performance and Terms of Reference at least once a year to ensure it is operating at maximum effectiveness. Any proposed changes shall be submitted to the RMCGC for approval.
11.3. These Terms of Reference shall be approved by the RMCGC and formally reviewed at intervals not exceeding two years.
Approved: RMCGC 10 September 2010 Review Date: July 2012
