Data Quality Policy. March 2015 POLICY DEVELOPMENT PROCESS. Data Quality Policy Page 1

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Data Quality Policy Page 1

Data Quality Policy

March 2015

POLICY DEVELOPMENT PROCESS

Author: Lynda Harris, Head of Information Governance

LyndaHarris2@nhs.net

Responsibility: All Staff Effective Date: March 2015

Review Date: March 2017

Reviewing/Endorsing committees Risk Management Group. Approved by Risk Group 13 April 2015

Date Ratified by Executive Management Team

23 April 2015

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Names of those involved in policy development

Name Designation Email Lynda Harris Head of Information

Governance, Bedfordshire CCG

Susan La Rosa Lamar

Head of Validation and Clinical Coding Audit, Bedfordshire CCG

Susan.LaRosaLamar@bedfordshireccg.nhs.uk

Names of those consulted regarding the policy approval

Date Name Designation Email

Equality Impact Assessment prepared and held by

Date Name Designation Email 31st December

2012

Lynda Harris Head of Information Governance,

Bedfordshire CCG

Committee where policy was discussed/approved/ratified

Committee/Group Date Status Governance and Risk

Group

12 May 2013 Approved Risk Management Group 13 April 2015 Approved Executive Team 23 April 2015 Ratified

Equality Impact Assessment

Bedfordshire Clinical Commissioning Group is committed to promoting equality in all its responsibilities – as commissioner of services, as a provider of services, as a partner in the local economy and as an employer. This policy will contribute to ensuring that all users and potential users of services and employees are treated fairly and respectfully with regard to the protected characteristics of age, disability, gender, reassignment, marriage or civil partnership, pregnancy and maternity, race, religion, sex and sexual orientation.

Discussions took place as to whether an Equality Impact Assessment was required and it was agreed that one was not required in this instance.

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Contents page

Introduction 4

Purpose 4

Definitions 4

Responsibilities 5

Development Process 5

Validation 5

Clinical Staff 5

Training 5

Monitoring 6

External Controls 6

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Introduction

The CCG recognises that decision making at every level within the NHS whether financial, clinical or managerial needs to be based on information which is of the highest quality. Information is derived from individual data items which are collected from a number of sources either on paper or more increasingly with the advent of the electronic patient record and electronic health records on electronic systems.

Purpose

Data quality is crucial and the availability of complete, accurate, relevant, accessible and timely data is important in supporting patient care, clinical governance, management and service agreements for healthcare planning and accountability. A data quality policy and regular monitoring of data standards are a requirement of the NHS Information Governance toolkit.

This policy is one of the key policies supporting the overarching information governance strategy and works in conjunction with other relevant legislation and policies:

Data Protection Act 1998 Information Lifecycle Policy

Confidentiality Policy including Caldicott Information Governance Policy

Information Security Policy Safe Haven Policy

Privacy Impact Assessment Guidance This policy sets out:

 The standards required for data quality

 The importance of using the NHS number as the unique patient identifier

 How data quality is validated

 The importance of data standards

 Involvement of clinicians in validation

Definitions Data should be:

 Complete (in terms of being captured in full)

 Accurate (the proximity of the figures to the exact or true values)

 Relevant (the degree to which the data meets current and the potential users needs)

 Accessible (data must be retrievable in order to be used and in order to assess its quality)

 Timely (recorded and available as soon after the event as possible)

 Valid (within an agreed format which conforms to recognised standards – either national or local)

 Defined (understood by all staff who need to know and reflected in procedural documents)

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 Appropriately recorded (in either paper or electronic format)

Responsibilities

Overall responsibility for information governance sits with the Chief Operating Officer. Managers are responsible for ensuring staff members have received the relevant training that is conducive to achieving data quality.

Data quality is a key part of any information system which exists within the organisation’s structure. All staff members will be in contact with a form of information system, whether paper or electronic based and are obligated to maintain records accurately and legally (Data Protection Act 1998), contractually (contract of employment) and ethically

(professional code of conducts).

Validation

Refer to the Information Validation Policy.

The CCG should routinely undertake the following for validation:

 Validate contracted provider data using validation rules following NHS PbR rules,

 Ensure clinical coding is validated in line with up to date national clinical coding guidance, payment by result and locally agreed policy,

 Monitor coded activity in line with the national acute contract and locally agreed schedules,

 Ensure acute provider compliance with locally agreed low priority guidance,

 Ensure compliance of specialist commissioning activity against agreed standards

 Support the contracting process in the development and monitoring of measurable standards in quality and in achieving value for money.

Clinical Staff

Clinicians should be involved in validating data that may have been entered into the system by clinical coding staff. This may involve the clinical manually reviewing the data that has been entered to confirm its integrity. Regular spot checks will help to ensure that

discrepancies are minimised. Clinical input should be sought in situations where the data amended is held within medical records. In the case of auditable software, suitable amendments should be made and the necessary explanation recorded on the system.

Training

Training is required to ensure the necessary members of staff have the appropriate

understanding in order to satisfy the requirements of information governance. With suitable guidance data quality processed will be improved as information will be collected and recorded correctly at the point of entry. This then reduces the requirement for lengthy validation procedures at later dates.

Line Managers are responsible for identifying the training requirements of their staff and working with training providers to ensure these needs are met. Staff must be enabled to attend the appropriate training as it is an integral part of records management. Training is given at corporate induction. Training will be given to staff on how to use electronic systems

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such as TPP SystmOne and Medeanalytics. Staff must be enabled to attend the

appropriate training courses allowing them an adequate level of proficiency in order to carry out their functions effectively.

Monitoring

Data quality will be subject to internal control processes with the CCG and to external scrutiny. All information systems and processes will have routines developed designed to systematically identify errors and other aspects of poor data quality. Departments should undertake an internal audit of their records annually.

External controls

 Data quality reports from Department of Health

 Hospital episode statistics data quality indicators

 Queries from service users and commissioned services

 Audit of case records and data quality by external auditors

References

Department of Health (2004) A Strategy for NHS Information Quality Assurance.