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INFORMATION GOVERNANCE POLICY &
FRAMEWORK
Version 1.2
Committee Approved by Audit Committee Date Approved 5 March 2015
Author: Associate IG Specialist, YHCS Responsible Lead: Corporate & Governance Manger
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Version Control Sheet
Document Title: Information Governance Policy and Framework Version: 1.1
The table below logs the history of the steps in development of the document.
Version Date Author Status Circulation
1.0 Oct 13 Associate IG Specialist, YHCS
Draft Corporate & Governance Manager, Senior Management Team
1.0 Nov 2013 Approved Approve by Audit and Committee 1.1 Oct 2014 Associate IG
Specialist, CSU
Under review
Corporate & Governance Manager, Senior Management Team
1.2 5 March 2015 Associate IG Specialist, CSU Approved by Audit Committee CCG Staff
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Contents Section
1 Introduction 4
2 Aims and Objectives 4
3 Scope of the Policy 4
4 Accountability 5
5 Definition of Terms 5
6 Procedure 6
7 Training & Guidance 7
8 Implementation and Dissemination 8
9 Monitoring Compliance with and the Effectiveness of the policy 9
11 References 9
12 Associated Documentation 9
Appendix List appendices below
Appendix A IG Framework 11
Appendix B IG Training Strategy 22
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1 INTRODUCTION
1.1 NHS Calderdale Clinical Commissioning Group, hereafter referred to as the CCG, recognises the importance of reliable information, both in terms of the clinical management of individual patients and the efficient management of services and resources. Information governance plays a key part in commissioning quality services, supporting clinical governance, service planning and performance management that will improve local patients’ experiences of care and their health outcomes.
1.2 Information Governance addresses the demands that law, ethics and policy place upon information processing – holding, obtaining, recording, using and sharing of information. It is crucial to ensure that staff are aware of these demands and the implications for patient care.
2. AIMS AND OBJECTIVES
2.1 The aim of this policy is to ensure that all staff understand their obligations with regard to any information which they come into contact with in the course of their work and to provide assurance to the Governing Body that such information is dealt with legally, securely, efficiently and effectively.
2.2 The CCG will establish and maintain policies and procedures linked to this policy to ensure compliance with the requirements of Data Protection Act 1998, Records Management Guidance, Information Security Guidance and other related legislation and guidance, contractual responsibilities and to support the assurance standards of the Information Governance Toolkit. These standards are:-
Information Governance Management
Confidentiality and Data Protection Assurance Information Security Assurance
Clinical Information Assurance
2.3 This policy supports the CCG in its role as a Commissioner of Health Services and will assist in the safe sharing of information with its partner and agencies.
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3 SCOPE
3.1 This policy must be followed by all staff who work for or on behalf of CCG
including those on temporary or honorary contracts, secondments, pool staff and students.
The Information Governance policy is applicable to all areas of the organisation and adherence should be included in all contracts for outsourced or shared services. There are no exclusions.
This policy covers:
all aspects of information within the organisation, including (but not limited to):
Patient/Client/Service User information Personnel/Staff information
Organisational information
All aspects of handling information, including (but not limited to): o Structured record systems - paper and electronic
o Transmission of information – fax, e-mail, post and telephone
o All information systems purchased, developed and managed by/or on behalf of, the organisation
o Photographic images, digital, text or video recordings o CCG information held on paper, floppy disc, CD,
USB/Memory sticks, computers, laptops, tablets, mobile phones and cameras
The processing of all types of information, including (but not limited to):
o Transmission of information – verbal, fax, e-mail, post, text and telephone
o Sharing of information for clinical, operational or legal reasons
o The storage and retention of information o The destruction of information.
3.2 The CCG recognises the changes introduced to information management as a result of the Health and Social Care Act 2012 and will work with national bodies, member practices and partners to ensure the continuing safe use of information to support services and clinical care.
3,4 Failure to adhere to this Policy may result in disciplinary action and/or referral to the appropriate regulatory bodies including the police and professional bodies.
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4. ACCOUNTABILITY
4.1 Governing Body
The Governing Body is responsible for ensuring that the necessary support and resources are available for the effective implementation of this Policy.
4.2 The Audit Committee
The Audit Committee is responsible for the review and approval of this policy and IG related work plans, procedures and will receive regular updates on compliance and any related issues and risks.
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4.3 Accountable Officer
The Chief Officer is the Accountable Officer of the CCG and has overall accountability and responsibility for Information Governance within the CCG and is required to provide assurance, through the Statement of Internal Control that all risks to the CCG, including those relating to information, are effectively managed and mitigated.
4.4 Senior Information Risk Owner
The Chief Finance Officer is the Senior Information Risk Owner (SIRO) and has organisational responsibility for all aspects of Information Governance, including the responsibility for ensuring CCG has appropriate systems and policies in place to ensure that the organisation has robust Information Governance procedures in place.
4.5 Caldicott Guardian
The Caldicott Guardian for the CCG is Dr Matt Walsh, Governing Body Member. The Caldicott Guardian plays a key role in ensuring that the CCG satisfies the highest practical standards for handling patient identifiable information.
4.6 Senior Management Team
The Senior Management Team will received IG progress reports, contribute to polices reviews and help manage the resolution of IG operational issues.
4.7 Information Governance Lead
The Senior Level Information Governance Lead for the CCG is the Corporate and Governance Manager. The IG Lead is accountable for ensuring effective management, accountability, compliance and assurance for all aspects of IG. Some key tasks may be delegated to the Information Governance Team from commissioning support services. They are also responsible for reviewing the policy and ensuring it is updated in line with any changes to national guidance or local policy.
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4.8 Information Asset Owners
Information Asset Owners (IAO) are directly accountable to the SIRO and must provide assurance that information risk is being managed effectively in respect of the information assets that they are responsible for, and that any new or changes introduced to their business processes and systems undergo a privacy impact assessment.
4.9 Heads of Service
Heads of Service are responsible for ensuring that they and their staff are
adequately trained, and are familiar with this policy and its associated guidance. They must ensure that any breaches of the policy are reported, investigated and acted upon.
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4.10 Employees
Information Governance compliance is an obligation for all staff. Staff should note that there is a Non-Disclosure of Confidential Information clause in their contract and that they are expected to participate in induction training, annual refresher training and awareness sessions carried out to inform/update staff on information governance issues. Any breach of confidentiality, inappropriate use of health, business or staff records or abuse of computer system is a disciplinary offence, which could result in dismissal or termination of your employment contract, and must be reported to the SIRO and (in the case of health or social care records) the Caldicott Guardian.
All employees are personally responsible for compliance with the law in relation to Data Protection and Confidentiality
5. Definition of terms
The words used in this policy are used in their ordinary sense and technical terms have been avoided.
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6. PROCEDURE 6.1 Openness
The CCG recognises the need for an appropriate balance between openness and confidentiality in the management and use of information. Information will be defined and where appropriate kept confidential,
underpinning the principles of Caldicott and legislation as laid out in the Data Protection Act and Freedom of Information Act.
Information about the organisation will be available to the public through the Freedom of Information Act, Environmental Information Regulations and Protection of Freedoms Act unless an exemption applies. The CCG will establish and maintain a Publication Scheme in line with legislation and Guidance from the Information Commissioner.
Patients will have access to information relating to their own health care, options for treatment and their rights as patients. There will be clear procedures and arrangements for handling queries from patients and the public.
Integrity of information will be developed, monitored and maintained to ensure that it is appropriate for the purposes intended.
Availability of information for operational purposes will be maintained within set parameters relating to its importance via appropriate procedures and computer system resilience.
Legislation, national and local guidelines will be followed.
The CCG will undertake annual assessments and audits (through the Information Governance Toolkit) of its policies, procedures and arrangements for openness.
6.2 Legal Compliance
The CCG regards all identifiable personal information relating to patients as confidential and compliance with legal and regulatory framework will be achieved, monitored and maintained.
The CCG regards all identifiable personal information relating to staff as confidential except where national policy on accountability and openness requires otherwise.
The CCG will establish and maintain policies and procedures to ensure compliance with the Data Protection Act, Human Rights Act, the common law duty of confidentiality and the Freedom of Information Act and Environmental Information Regulations.
9 Awareness and understanding of all staff, with regard to responsibilities, will be routinely assessed and appropriate training and awareness provided.
Risk assessment, in conjunction with overall priority planning of organisational activity will be undertaken to determine appropriate, effective and affordable information governance controls are in place.
6.3 Information Security
The CCG will establish and maintain policies for the effective and secure management of its information assets and resources.
Audits will be undertaken or commissioned to assess information and IT security arrangements.
The CCG will ensure IG incidents are managed in accordance with the Checklist for Reporting, Managing and Investigating Information Governance Serious Incidents.
The CCG will ensure that the security of the information it holds complies with national guidelines.
Gain assurance from IT service providers as to the integrity of CCG’s IT systems and that controls are in place to reduce exposure to potential cyber-crime through maintenance of robust information and
network security practices
6.4 Information Quality Assurance
The CCG will establish and maintain policies for information quality assurance and the effective management of records.
Audits will be undertaken or commissioned of CCG’s quality of data and records management arrangements.
Managers will be expected to take ownership of, and seek to improve, the quality of data within their services.
Wherever possible, information quality will be assured at the point of collection.
The CCG will promote data quality through policies, procedures/user manual and training.
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6.4 Clinical Information Assurance
The CCG will establish and maintain policies for quality assurance of clinical information and the effective management of records.
7 TRAINING & GUIDANCE 7.1 Mandatory Training
Information Governance training will be mandatory for all staff. This will include awareness and understanding of Caldicott principles and confidentiality, information security and data protection. Information Governance will be included in induction processes for all new staff. The necessity and frequency of any further training will be Personal Development Review (PDR) based.
All staff will receive Information Governance Training via the CCG’s
Mandatory Training Programme and new starters will undertake IG training within 2 months of their starting date. All new starters will be issued with an IG User Handbook and they must sign an IG declaration as part of their induction process.
7.2 IG Training Principles:
Undertaking of information governance training will be mandatory and will run on an annual basis
Information governance training will be undertaken using the online Connecting for Health IG Training Tool (IGTT) or through attendance of a formal IG classroom based session.
Based on their responsibilities and roles and required training needs outcomes, other staff groups may be resourced to undertake additional training as required
Quarterly monitoring and reporting of uptake and completion of information governance training will be provided to the Audit Committee.
8 Implementation and dissemination
Following ratification by the Audit Committee this policy will be
disseminated to staff via the CCG’s intranet and communication through in-house staff briefings.
11 This Policy will be reviewed every year or in line with changes to relevant legislation or national guidance.
9 Monitoring compliance with and the effectiveness of the policy
An assessment of compliance with requirements, within the Information Governance Toolkit (IGT), will be undertaken each year. Annual reports and proposed work programme will be presented to the Audit Committee for approval prior to submission to Health & Social Care Information Centre.
11 References
Freedom of Information Act 2000 Data Protection Act 1998
Human Rights Act 1998
Common Law Duty of Confidence
12 ASSOCIATED DOCUMENTS
(Policies, protocols and procedures)
12.1 The CCG will produce appropriate procedures and guidance relating to information governance as required by related policies. This will include an Information Governance handbook which will be updated annually and which will be given to all staff.
12.2 This policy should be read in conjunction with: Confidentiality & Data Protection Policy Information Sharing Protocol
Information Security Policy
Incident Reporting Policy and procedure
Record Management Policy Access to Records Procedure Risk Management Framework Freedom of Information Policy System Level Security Policies Network Security Policy
Privacy Impact processes
Disciplinary Policy and Procedure Business Continuity Plan
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Appendix A INFORMATION GOVERNANCE MANAGEMENT FRAMEWORK
1. ORGANISATION CHART
2. Outline of Roles and Responsibilities 2.1 The CCG Caldicott Guardian will:
ensure that the CCG satisfies the highest practical standards for handling identifiable/confidential information
act as the ‘conscience’ of the CCG
facilitate and enable information sharing and supported by expert advice from the commissioning support services’ IG Team, advise on options for lawful and ethical processing of information
represent and champion Information Governance requirements and issues at executive level
ensure that confidentiality issues are appropriately reflected in organisational strategies, policies and working procedures for staff
SIRO J. Lawreniuk
CALDICOTT GUARDIAN Dr M Walsh
Senior Management Team Progress updates and resolution of
operational issues INFORMATION ASSET OWNERS (IAOs) INFORMATION ASSET ADMINISTRATORS (IAAs) AUDIT COMMITTEE
Assurance and approval of policies
13 oversee all arrangements, protocols and procedures where confidential patient information may be shared with external bodies both within, and outside, the NHS
The Caldicott Guardian also has a strategic role, which involves representing and championing confidentiality and information sharing requirements and issues at senior management level and, where appropriate, at a range of levels within the organisation’s overall governance framework.
2.2 Caldicott Function
In CCG the Caldicott Function will be undertaken by CCG’s IG Lead with additional support from the commissioning support services’ IG Team.
The key responsibilities of the Caldicott Function are to:
support the Caldicott Guardian Function and Implementation Plan (Appendix B).
ensure the confidentiality and data protection work programme is successfully co-ordinated and implemented
ensure compliance with the principles contained within the
Confidentiality: NHS Code of Practice and that staff are made aware of individual responsibilities through policy, procedure and training
complete the Confidentiality and Data Protection Assurance component of the Information Governance Toolkit, contributing to the annual
assessment
provide routine reports to senior management on Confidentiality and Data protection issues as required
review information sharing agreements for approval.
2.3 CCG Senior Information Risk owner (SIRO) will: be an Executive Director
take overall ownership of the Organisation’s Information Risk Policy act as champion for information risk within the CCG executive function
and provide written advice to the Accountable Officer on the content of the Organisation’s Statement of Internal Control in regard to information risk.
understand how the strategic business goals of the Organisation and how other client organisations’ business goals may be impacted by information risks, and how those risks may be managed.
implement and lead the CCG Information Governance (IG) risk assessment and management processes within the organisation advise the CCG Executive on the effectiveness of information risk
management across the organisation
receive training as necessary to ensure they remain effective in their role as SIRO.
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2.4 CCG Information Asset Owners (IAO) will:
know what information comprises or is associated with the asset, and understands the nature and justification of information flows to and from the asset
know who has access to the asset, whether system or information, and why, and ensures access is monitored and compliant with policy
understand and address risks to the asset, and providing assurance to the SIRO
ensure any systems (or new business processes) which hold and use person identifiable information (patient or staff information) are tested for data protection and confidentiality compliance before they are procured or implemented
assist in the development of Business Continuity Management arrangements for key information assets
2.5 CCG Information Governance Lead will:
ensure that there is top level awareness and support for IG resourcing and implementation of improvements
act as the organisational lead for Data Protection including subject access request, Freedom of Information, Information Security and Records Management.
maintain comprehensive and appropriate documentation that demonstrates commitment to and ownership of IG responsibilities. Provide direction in formulating, establishing and promoting IG policies work the with the commissioning support services’ IG team to maintain
an awareness of information governance issues within the CCG
ensure appropriate IG training is made available to staff and completed as necessary to support their duties
in conjunction with the commissioning support services’ IG Team
review and audit all procedures relating to this policy where appropriate on an ad-hoc basis
ensure that CCG team leaders are aware of the requirements of the policy
ensure IG training requirements are included in overall mandatory and statutory training plans and monitor and report on IG Training
compliance
work with the commissioning support services’ IG Team to ensure that the IG Toolkit requirement evidence is collated and uploaded to the IG Toolkit website
ensure that the IG Toolkit assessment is submitted by the 31st March annually.
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3.0 Resources
3.1 Commissioning Support Service Information Governance Support
The commissioning support service has an Information Governance team that provides expert advice and guidance to CCG staff on all elements of Information Governance. The team is will provide the following support to NHS Calderdale CCG:
advice and guidance on Information Governance
advice and template resources relating to the CCG’s Information Governance Toolkit requirement
ensuring the consistency of information governance across the organisation.
developing information governance policies and procedures. establishing protocols on how information is to be shared. developing information governance awareness and training
programmes
supporting organisational compliance with Data Protection, Freedom of Information and other information security related legislation.
implementing NHS Commissioning Board, NHS Information Centre for Health and Social Care and Department information governance guidance and policy.
provide support to the Caldicott Guardian and SIRO.
The commissioning support services’ IM&T and Information Governance Teams have Specialists that hold professional certification in Data Protection, Freedom of Information and information security. They will support the CCG IG Lead in fulfilling the following specific roles:
Data Protection Officer – The Data Protection Officer is tasked with providing advice on all aspects of the Data Protection Act and NHS Code of Confidentiality, utilising their own expertise and, where necessary, external advice. They are also responsible for co-ordinating the work of other staff with data protection
responsibilities
Information Security Lead - The Information Security Lead is tasked with
providing advice on all aspects of information security management, utilising their own expertise and, where necessary, external advice.
Records Management Lead - The Records Management Lead is tasked with providing advice on all aspects of records management and lifecycle of
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4.0 Governance Framework 4.1 Staff Contracts
All CCG staff contracts currently contain Information Governance related clauses within them (see Appendix A).
4.2 Non-NHS Third Party Contract Confidentiality Clause
Any non-NHS third party with whom the organisation contracts should include as a minimum a confidentiality clause. The CCGs also requests all third party
contractors to sign a declaration that they are registered with the Information Commissioner for Data Protection Purposes and that they encrypt all mobile devices to minimum standard required by the NHS. (See Organisation of Information Security)
4.3 Information Assets and Asset Owners
Each asset has been allocated an Information Asset Owner (IAO) and an
Information Asset Administrator (IAA). The Information Asset Owner will review their asset entries on the Information Asset Register annually and undertake regular risk assessments of these assets and report their findings to the SIRO.
5.0 IG Training
5.1 Mandatory IG Training
The NHS Operating Framework requires that all staff must undergo Information Governance training. The CCG will strive to meet this requirement. The CCG includes Information Governance as part of its mandatory training for all staff annually. All new staff is required to complete the Introduction to Information Governance training module via the online IG Training Tool, when they first join the organisation unless they have completed appropriate IG Training within the last year and can evidence this.
The CCG also requires all existing staff to complete online IG Training annually, if they have previously completed the ‘Introduction to Information Governance’ then they can complete the Refresher Module thereafter.
5.2 Role Specific Training
The CCG has identified other recommended training for staff members whose role has information governance responsibilities and requires further role specific training, also referred to as a training needs analysis. This can be delivered through the online training tool or suitable alternatives such as workshops, face to face training and keeping up to date through briefing materials and
newsletters.
Details of the specific training requirements are included in the CCG’s IG Training Strategy (Appendix B).
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5.3 Adhoc Training
In addition to the above any member of staff involved in an Information
Governance related incident may be required to undertake one or more modules of the IG Training Tool, the modules to be taken will depend on the type of incident and the outcomes of any investigations into the incident.
6.0 Information Security Incidents
Information security incidents are any event that has resulted or could have resulted in the disclosure of confidential information to an unauthorised individual, the integrity of the system or data put at risk or the availability of the system or information being put at risk. Incidents may include theft, misuse or loss of
equipment containing confidential information or other incidents that could lead to unauthorised access to data all of which will have an adverse impact to patients and to the organisation e.g.
· embarrassment to the patient/patients/organisation · threat to personal safety or privacy
· legal obligation or penalty
· loss of confidence in the organisation · financial loss
· disruption of activities
Whenever an incident, near miss or hazard occurs it must be reported using the incident reporting system. Information security incidents will be highlighted to the CCG IG Lead and the commissioning support services’ IG Team for investigation and advice.
All IT security incidents should be reported to the Health Informatics Service Desk upon detection to obtain support with preserving data, preventing an incident being prolonged, and enabling an audit trail and technical investigations to commence without delay. These will be highlighted to the CCG IG Lead and the commissioning support services’ IG Team. The service desk will advise of any additional steps that are required to make the information secure, including initiating policy and procedure.
Incidents classified at an IG SIRI severity level 2 are those that are classed as a personal data breach (as defined in the Data protection Act) or high risk of reputational damage that are reportable to the Department of Health and the
Information Commissioner’s Office. These incidents will be detailed individually in the annual report.
7.0 Communication
7.1 Communication with Staff
The Information Governance operational policies and procedures will be made available in electronic format and will be located on CCG Intranet. Any updates/ new policies / procedures are approved by the Audit Committee and are communicated to staff via the intranet. Information Governance email alerts will be issued by the commissioning
18 support services’ IG team as appropriate, authorised by the IG Lead at NHS Calderdale CCG.
Every new member of staff will be issued with the Information Governance user handbook about handling patient information as part of the recruitment process. All staff are reminded to re-read the Information Governance booklet on an annual basis.
The commissioning support services’ IG Team will support the CCG to continue to raise the profile and understanding of Information Governance through
mandatory and ad hoc training, IG Alerts, staff newsletters, emails, intranet sites and staff briefings.
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APPENDIX A
STAFF CONTRACT CLAUSES
CONFIDENTIALITY OF INFORMATION
1. You are subject directly or indirectly to the Data Protection Act. This Act covers the confidentiality of personal information held on computer and manual systems. Every employee is now personally liable to respect and protect the confidentiality of the information they enter, process and encounter and should not discuss this information or disclose it to any unauthorised person or company.
2. Anyone who discloses personal information, intentionally or otherwise, can be sued for damages by the individual affected and the person concerned may be subject to disciplinary procedures.
3. NHS Calderdale CCG reserves the right to monitor telephone calls and e-mails in circumstances that may warrant such action.
4. By signing this contract you consent to both NHS Calderdale CCG and the commissioning support service, both manual and by electronic means your personal and sensitive data for the purposes of the administration and management of your employment and/or NHS Calderdale CCG business. You also agree to comply with the relevant Confidentiality/Data Protection Policy.
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Appendix B
CALDICOTT FUNCTION SPECIFICATION AND IMPLEMENTATION PLAN
In accordance with the Information Governance Toolkit requirements the Caldicott function has been established to support the Caldicott Guardian. The Caldicott Guardian is required to be at Director Level and have a clinical
background. The CCG’s should also appoint a deputy Caldicott Guardian, also with clinical expertise, who will act on behalf of the main post holder in their absence.
The Caldicott Guardians will perform the functions as laid down in the Caldicott Guardian Manual, available on the Health & Social Care Information Centre website, and will be responsible for protecting patient and service user
confidentiality and enabling information sharing. The Caldicott Guardian will also have a strategic role in representing and championing Information Governance requirements and issues at Board level.
The role of the Caldicott Guardians will be specified and promoted throughout the IG Management Framework documentation and will be made readily accessible to staff via the CCG’s staff intranet. This role will be primarily supported by the NHS Code of Confidentiality.
The Caldicott Guardians will be supported by the CCG’s Information Governance Lead with additional support available from the commissioning support services’ IG team on issues concerning data protection and will provide advice on the release of information to the Police and other agencies as appropriate. Where CCG and Commissioning Support Unit staff processing personal
confidential data on behalf of the CCG feel that meeting IG standards may cause operational difficulties or they feel that meeting IG standards would compromise patient care or safety, they can apply to the Caldicott Guardian for a decision on whether an acceptable risk status can be agreed.
Caldicott Issues Log -Any incidents relating to patient confidentiality will be recorded and monitored through the existing CCG incident management system. Other patient confidentiality or information sharing issues will be managed by the Caldicott function and where necessary, escalated to Caldicott Guardian and recorded on the Caldicott Issues Log, the IG Lead will support the Caldicott Guardian to ensure that the CCGs benefit from lessons learned by sharing with senior managers and, where relevant, within appropriate CCG Quality and Governance (or equivalent) Committees.
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INFORMATION GOVERNANCE
TRAINING STRATEGY
This Training Strategy is in support of the Information Governance Toolkit.
The strategy links directly to the following legislation, NHS commitments and best practice:
Principle 7 of the Data Protection Act 1998
Schedule I Part II paragraph 10 of the Data Protection Act 1998
Caldicott: Report on the Review of Patient Identifiable Information 1997: Recommendation 2
Protecting and Using Patient Information, Caldicott Management Audit points 3, 4 and 5: Confidentiality and Security Training Needs
NHS Care Record Guarantee, Commitment 9
Confidentiality: NHS Code of Practice Page 3, paragraph 7
Links to Other Associated Documents:
This strategy is supported by a range of policies relating to various aspects of Information Governance. These are:-
Information Governance Policy and Framework Confidentiality and Data Protection Policy Information Security Policy
Records Management Policy
Incident and Serious Incident Reporting Procedure
Overall Aim of Training:
To ensure that all staff, including new starters, temporary, student and contract staff members complete basic level information governance training. Additionally a secondary aim is to ensure that specialist information governance training is targeted at specific staff groups across the organisation to comply with a number of the Information Governance Toolkit requirements.
Training Objectives:
Overall the training objectives for Information Governance are: To ensure compliance with the Data Protection Act 1998
To ensure the confidentiality and legitimate use of personal or medical Information
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fully aware of the uses of their personal data
To ensure the accuracy, availability and integrity of records held by the organisation
To ensure appropriate technical and organisational measures are in place to protect information against security threats
Endorsed By:
This strategy is endorsed by the Organisation’s Audit Committee and has sponsorship from the Caldicott Guardian and Senior Information Risk Owner (SIRO). The Corporate and Governance Manager is responsible for monitoring the IG Training compliance.
Requirements
The basic mandatory information governance training requirement which links to job role is one of the following e-learning modules:-
Introduction to Information Governance – for all staff
Refresher Module – a shorter refresher training module for subsequent
years
Written training materials and class room training can be provided to staff locally (and will meet the mandated training requirement) by commissioning support services.
Specialist/Advanced Training
The Information Governance Toolkit sets out minimum additional training requirements for specific staff groups/roles, these are:-
Requirement 12-230 The Information Governance agenda is supported by
adequate confidentiality and data protection skills, knowledge and experience which meet the organisation’s assessed needs.
Element 2b All staff assigned responsibility for co-ordinating and implementing the confidentiality and data protection work programme have been appropriately trained to carry out their role
Requirement 12-234 There are appropriate procedures for recognising and
responding to individuals’ requests for access to their personal data
Element 2a All staff assigned responsibility for processing subject access requests have been appropriately resourced and trained to do so
Requirement 12-340 The Information Governance agenda is supported by
adequate information security skills, knowledge and experience which meet the organisation’s assessed needs
Element 1a The role of Information Security Manager/Officer has been appropriately assigned. The appropriateness of the assignment will be in formal qualifications, or post holders membership of a relevant professional body, or certificates of training attendance records.
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Requirement 12-345 An effectively supported Senior Information Risk Owner
takes ownership of the organisation’s information risk policy and information risk management strategy.
Element 2a The SIRO and all other staff assigned responsibility for co-ordinating and implementing information risk management (Information Asset Owners - IAOs) have been appropriately trained to carry out their role.
Requirement 12-420 The Information Governance agenda is supported by
adequate information quality and records management skills, knowledge and experience.
Element 2b All staff assigned responsibility for Information Quality and Records Management Assurance have been appropriately trained to carry out their role.
Structure:
* See Table 1 over the page “Additional Information” Who needs to do this training?
How will we deliver it?
(See Table 1, ‘Method of Delivery’ column)
Caldicott Guardian Information
Governance Officer
Senior Information Risk Owner (SIRO) and Information Asset Owners
Records staff and those handling subject access requests All Staff IG Training Tool Information Security Examination Board (ISEB) IG Training IG Training IG Training IG Training Tool/written materials/class room Essential Level *
Awareness / Basis Level * Expert *
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Additional Information: Training Needs Analysis Table 1
Staff Group Level Training Objective/Aim Module/Course Name Method of Delivery Frequency of
Training
All Staff Basic Level An introductory level module aimed at all staff to inform them about good Information Governance.
Introduction to Information Governance
NB. In subsequent years ‘The Refresher Module’
NLMS (e-learning) or written materials or class room based learning
Yearly
Records Management staff
Basic Level A foundation level module designed to provide practical information to enable understanding of the importance of good records
management.
Records Management and the NHS Code of Practice
IG Training Tool (e-learning) or classroom based sessions 3 yearly Staff handling subject access requests
Basic Level A practitioner level module providing advice on dealing with requests for access to patient records, both from the patient themselves and their friends and family.
Access to Health Records
Information Security Guidelines IG Training (delivered by the commissioning support services’ IG Service) 3 yearly Information Asset Owners (IAOs)
Essential Level An introductory level that describes key responsibilities for the SIRO and IAO roles, and outlines the structures required within organisations to support those staff with SIRO or IAO duties.
NHS Information Risk Management for SIROs and IAOs Secure Transfers of Personal Data IG Training Tool (e-learning) or Classroom based sessions/one to one and issue of IAO Handbook (delivered by the commissioning support services’ IG Service)
3 yearly
SIRO Expert Level A foundation level module intended to assist staff whose roles involve responsibility for the confidentiality, security and availability of information assets, in understanding and
NHS Information Risk Management
Secure Transfers of Personal Data
IG Training Tool (e-learning) or
Classroom session (study day provided by external
25 fulfilling their duties.
NHS Information Risk Management for SIROs and IAOs
training provider)
Staff Group Level Training Objective/Aim Module/Course Name Method of Delivery Frequency of
Training
Caldicott Guardian
Expert level A practitioner level module aimed at newly appointed Caldicott Guardians and those needing to know more about the role of the Caldicott Guardian.
The Caldicott Guardian in the NHS and Social Care
Patient Confidentiality
IG Training Tool
(e-learning) or classroom learning (study day provided by external provider) 3 yearly Information Governance Support
Expert Level In depth understanding of the Data Protection Act 1998 (and associated legislation) and information security
Information Security Examination Board (ISEB) Data Protection, and Information Security courses.
Formal qualification in records management
Specialist Courses and examinations
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Training will Improve Patient Experience:
Training staff in Information Governance gives the public and patients greater confidence and assurance of organisational compliance with the law (i.e. Common Law Duty of Confidence, Data Protection Act 1998 and Freedom of Information Act 2000) and central guidelines relating to Information Governance and the confidence that their information will be handled responsibly and confidentially.
Diversity Issues Have Been Addressed Within This Strategy:
In relation to the provision of basic mandatory information governance training requirement to staff, one to one training can be commissioned from the Information Governance Service to meet the special requirements of specific members of staff.
Evaluation:
The effectiveness of the training will be demonstrated in a number of ways.
Reactive Evaluation - Training feedback forms assessing the trainers performance as well as whether training objectives were met, are provided at all class room based learning events.
Evaluating Learning - Increase in knowledge after the training is measured by post training assessment test (either online assessment test or paper based assessment test). 80% is the pass mark for the assessments. Successful achievement of the assessment test is recorded against the learners training record.
Behaviour - The extent to which Information Governance training has been put into practice will be subjectively measured by:
The results of regular staff IG spot checks (typically administered via questionnaire)
Results of service user satisfaction surveys where questions on confidentiality and information security are included
Numbers of Information Governance related incidents reported
Training Strategy Review Date: