Data Quality
BACKGROUND
The purpose of this report is two-fold : to give the Board assurance regarding the quality of patient data both in terms of accuracy and completeness and to inform the Board of the current status of data quality and capture within the Community Services.
Ensuring that information is of the highest possible standard is crucial to:
• Effective delivery of patient care.
• Efficient service delivery, performance management and future planning.
• Compliance with legislative and mandatory requirements, eg – Data Protection Act, Information Governance Toolkit and Freedom of Information Act.
The Board must have confidence in the patient data that is utilised throughout the Trust and within the papers and reports that are provided to the Board and on which the Board will make its decisions.
How Data Quality is Achieved
The Trust has a Data Quality Strategy (attached) that recognises the need for information to be collected, managed and used in accordance with sound principles that ensure information is:
• Justified, relevant and not excessive.
• Accurate and not misleading.
• Complete, consistent and reliable.
• Inspires confidence in the user.
• Goes to the right person at the right time and at the right level of detail.
• Is fit for purpose.
• Is comprehensive.
The Data Quality Strategy sets out aims and objectives that will achieve these principles. To deliver against these aims and objectives, the Strategy sets out the roles, responsibilities and reporting structures, how those responsibilities are applied through the Data Quality Steering Group, for example, and the specific responsibilities of individuals such as the data quality leads.
There are a range of associated policies that support the implementation of this Strategy, including:
• Data Quality Policy.
• IT and Information Security Strategy.
Audit & Assessment of Data Quality
The Strategy sets out the multi-tiered approach that is adopted to assess the Trust’s compliance with the Strategy and its associate policies and ultimately gain assurance of its data quality.
The Strategy details the role of each organisation or group in providing assurance. Fundamentally, the audit of existing policies and procedures is critical in providing assurance of individual and systems compliance by ensuring that policies and procedures are comprehensive operational and embedded within the day to day activities of the Trust and its staff.
The Trust’s internal auditors undertake a number of data quality audits as determined by SEMT.
External audit reports and those undertaken by the Trust’s internal auditors are managed and monitored through the Audit Committee which in turn will provide assurance to the Board regarding data quality. For example, most recently an audit of the Trusts procedures and processes in relation to the 18 Week Referral To Treatment data capture and reporting was subject to external audit and received significant assurance. In addition, it is proposed that a 6 monthly data quality report is included within the Integrated Performance Report to Board. It is the responsibility of the Data Quality Steering Group to establish an annual audit plan of departmental systems.
The implementation and compliance with this Strategy will ensure the Trust has patient data that is valid, reliable and comprehensive.
Community Services Data Capture and Accuracy
With the creation of the Integrated Care Organisation on 1st April 2011, Southport & Ormskirk NHS Trust inherited 35 community services, providing a range of services across West Lancashire and North Sefton, inclusive of a large Sexual Health Service. Both community services use the National Programmes for IT (NPFIT) ‘IPM’ patient administration systems; however, they are two different versions.
The roll-out of the IPM system has been disparate across both Sefton and West Lancashire, with the Trust having inherited services with only 50% of the users directly utilising the system. In some services, paper based returns are completed and submitted to data input clerks for retrospective input, leading to significant backlogs. There are, therefore, a number of services with a full IPM system, a number with partial implementation and a small number of services with non-IPM systems.
The responsibility for the IPM system remains with the original owners (Informatics Merseyside and NHS Central Lancashire/Lancashire Care). As such, the Trust has no immediate ability to access its own data and must rely on third parties to generate and handle extracts. At present, the Trust has a chargeable SLA in place with Greater Manchester Business Intelligence Services (GMBIS) to process and handle the data extract to ensure the Trust can discharge its responsibilities with regards to information and utilise the data available. This has been available from Central Lancashire since merger. However, Sefton has only been available from this month and is currently being assessed for data completeness. (Data has been received from Sefton although it has not been in a format that is easy to manage and extract reports).
IPM requires users to be trained by “accredited trainers” to be able to access and use the system. Under TCS, the Trust received no resource to be able to carry out this function. Training must be delivered at additional cost from Informatics Merseyside, NHS Central Lancashire or Lancashire Care, at an additional cost to the Trust.
There are currently few nationally mandated returns required from community Services (Sexual Health/Chlamydia Screening, Smoking Cessation, Breast-feeding). The fragmented nature of data capture and lack of “mandated” requirements has led to significant variability in the quality and coverage of community data. This situation exists nationally as well as locally. At present, data is presented with varying caveats. “Movement” in data volume cannot easily be distinguished between better/worse capture and actual service change.
Current Position
The Trust is intending to complete roll-out of the IPM system to services that currently have partial roll-out or where the system exists in one locality and not the other. This will ensure consistency within services.
Assessment is being made of non-IPM systems and whether they are fit for purpose.
The Trust is currently considering its options for a replacement Patient Administrative System (PAS) as the current system will no longer be supported from April 2014. This system will be Trust wide and will ultimately replace all existing PAS.
There is a national requirement for all Trusts to implement a Community Information Dataset (CIDs) by April 2014. In addition, Monitor requires FTs to be able to complete community data returns by 2014 and the Trust is reporting on its compliance with this requirement on its monthly Monitor compliance return. The Trust expects to meet both requirements within the specific timeframe.
Currently the following Community Services are reported on within the Integrated Performance Report:
• Skelmersdale WIC activity – within the integrated A&E Report.
• Community Paediatrics 18 Weeks Performance – within the integrated 18 Week RTT Report.
• Complaints and Compliments.
• Patient Falls.
• Community Pressure Sores – within the integrated Strategic Stretch targets. In addition, the following are reported to PCT/Commissioners.
• Sexual Health Reporting.
• Chlamydia Screening.
• Smoking Cessation.
For the Community Contract, activity plans and contractual variances are reported. However, they are heavily caveated regarding data capture. There are a range of information requirements specified within the information schedule that are currently under development.
The Community & Long Term Conditions CBU and Urgent Care CBU receive this community data at CBU level within their Quality & Performance Dashboards. Currently under development are:
• Integrated Active Case Management pathway reports.
• Direct access audiology reporting.
• Integrated Paediatric reporting.
• Reporting within services for Any Qualified Provider (AQP).
Moving Forward
To resolve the issues that exist in respect of data capture and quality within the community the Information Department have the following proposed programme of work.
• Verify data completeness for Southport Community Services
• Remove the backlog of data inputting
• Agree an SLA for iPM accredited training provision
• Complete iPM rollout to identified services
• Undertake assessment of non iPM services
• Provide gap analysis and actions for resolution, identifying any resource requirements
• Action plan to achieve Community Information Dataset (CIDs) by 2014.
• Provide Service Line Reports for each Community Service to verify activity levels, commencing with iPM users
July 12 October 12 July 12 December 12 December 12 December 12 March 2014 March 2013
To implement this programme of work the following resources are required.
• Administrative support for iPM rollout (3rd party)
• SLA for accredited training provision
• Continued data management support from GMIBS
• Additional data warehouse hardware
• Staffing (data clerk) to clear backlog of data input
10k 10k 20k 20k 15k 75k CONCLUSION
The Trust has a Data Quality Strategy that sets out the framework for managing data quality. Through this ‘deep dive’ the Board has reviewed the Strategy, reporting mechanisms, responsibilities and assessment processes. The review of community data quality has identified the work programme and resources required to ensure data completeness, capture and accuracy are fit for purpose and support the decision making of the Trust.
RECOMMENDATIONS
The Board are asked to:
• Support the proposed work programme.
• Approve investment in the resources to facilitate the programme.
• Be assured of the systems in place to ensure data quality assurance.
Sheilah Finnegan Toni Vaughan
Chief Operating Officer Business Intelligence Analyst July 2012
