document title… · cntw(o)26 2 cumbria northumberland, tyne and wear nhs foundation trust...

Document Title Data Quality Policy

Reference Number CNTW(O)26

Lead Officer Lisa Quinn

Executive Director of Commissioning and Quality Assurance

Author(s)

(name and designation)

Anna Foster- Deputy Director of Commissioning and Quality Assurance

Alison Paxton, Commissioning and Quality Assurance Manager

Ratified by Business Delivery Group

Date ratified May 18

Implementation Date May 18

Date of full implementation

May 18

Review Date May 21

Version number V05.1

Review and Amendment Log

Version Type of Change

Date Description of Change

V05 Update May 18 Review

V05.1 Review Oct 19 Governance changes

This policy supersedes the following Policy which must now be destroyed:

Number Title

CNTW(30) – V05 Data Quality Policy

Data Quality Policy

Section

Contents

Page No.

1 Introduction 1

2 Purpose 1

3 Duties, Accountability and Responsibilities 2

4 Definition of Terms Used 5

5 Data Quality 6

6 Measurement and Audit 10

7 Quality Report and Information Governance 11

8 Incident Reporting 12

9 Identification of Stakeholders 12

10 Fair Blame 12

11 Equality Impact Assessment 13

12 Training 13

13 Implementation 13

14 Standards and Key Performance Indicators 13

15 Associated Documents 14

16 References 15

Standard Appendices – attached to Policy

A Equality Analysis Screening Toolkit 16

B Training Checklist and Training Needs Analysis 18

C Audit Monitoring Tool 20

D Policy Notification Record Sheet - click here

Appendices – attached to the Policy

Appendix No:

Description

Appendix 1 Schedule of National, Local and Internal Reports

Appendix 2 Data Quality Kite Mark

https://www.cntw.nhs.uk/about/policies/appendix-d-policy-notification-record-sheet/

CNTW(O)26

1 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust CNTW(O)26 – Data Quality Policy – V05.1 Oct 19

1 Introduction 1.1 The importance of reliable quality data is fundamental for all involved in the

safe care and effective treatment of service users and the on-going development and service planning of quality services.

1.2 Complete, accurate and timely data is also crucial in terms of having secure

and legally acceptable Information and Governance arrangements and compliance in terms of the organisations internal and external contractual and associated performance obligations.

1.3 The use of any computerised system provides greater facility to store and access many types of data. This is essential to deliver effective and safe care for service users and gives the Trust more opportunities to analyse data to inform future service delivery. With the implementation of RiO across the organisation as the Trust’s main clinical system, there is an even greater impetus to improve and maintain the quality of the data held by the Trust.

2 Purpose 2.1 The purpose of the Policy is to:

Establish Cumbria Northumberland, Tyne and Wear NHS Foundation Trust’s (the Trust / CNTW) commitment to data quality, its approach to ensuring adherence to the data quality standards and the maximisation around the accuracy, timeliness and quality of data recorded on the organisations computer systems and clinical documentation

Identify the roles and responsibilities of both the Trust and staff with regards to data quality

Outline principals, standards, legislation and measurement of good data quality

Improve clinical and management decision making through the provision and development of effective information

2.2 The Policy refers predominantly to quality and standards relating to the

collection, processing and exchange of data relating to clinical service delivery. However, the principles are generic and therefore apply equally to all Trust Information Systems.

2.3 The Policy is intended to cover all information that is recorded within the Trust

with the main emphasis, but not exclusively on RiO the Trust’s clinical information system, the documents used to feed this system and data extracted from it.

CNTW(O)26


2.4 The Policy is aimed at all staff involved in the collection, gathering, processing, or use of service user-related data no matter what their level within the organisation.

3 Duties, Accountability and Responsibilities 3.1 Good data quality is not an optional extra. It is fundamental to the operation of

the Trust. As such, it must always be considered at the centre of any current records kept, and all future developments and must therefore be constantly under review.

3.2 It is therefore imperative that data quality is included in relevant job descriptions

and forms part of the post holder’s appraisal and Personal Development Plan (PDP). All appropriate job descriptions must support the responsibilities and requirements within this Policy for ensuring accuracy and completeness of data. This must also include adherence to the detailed operational / working procedures and clinical standard practice notes.

3.3 Executive Officers and Assurance

Responsibility for implementation and compliance to this Policy lies with the Chief Executive

The Executive Director of Commissioning and Quality Assurance has delegated responsibility from the Chief Executive. This Executive Officer position has a dual role as the Trust’s Senior Information Risk Officer (SIRO)

Assurance will be provided via the Quality and Performance Committee, Trust-wide Caldicott and Health Informatics Group and the North, Central and South Clinical Locality Care Group Quality Standards meetings.

3.4 All Staff 3.4.1 All staff are responsible for ensuring adherence to data standards and ensuring

good data quality. The NMC (Nursing and Midwifery Council) makes it clear in “Guidelines for records and record keeping” (August, 2004) that good record keeping is a reflection of professional practice, stating that “the same basic principles which apply to manual records must be applied to computer-held records”.

3.5 All Staff must

Ensure the timely, accurate and complete input of data onto the appropriate trust information system

CNTW(O)26


Ensure that they have the appropriate level of knowledge and skills for using the information systems;

Undertake regular validation checks of data collection and input, to confirm that the demographic data and key personal data such as GP, ethnicity, etc., is accurate and up to date

Ensure that they have the appropriate level of knowledge and skills for using the information systems

Monitor the data held for any data quality issues and reporting any concerns to the appropriate Information Asset Owner (IAO) or information Asset Administrator (IAA).

3.6 Individual Clinical Staff must

Ensure timely, accurate and complete input of their own clinical data

Regularly check service user demographic data with service users and update any inaccuracies

Monitor and escalate any data quality issues appropriately

Be aware of and comply with documented policies, procedures and regulatory and professional standards.

Monitor own competencies and access basic Informatics and appropriate clinical system training prior to beginning use of RiO and update when necessary

3.7 Administration Staff inputting on behalf of Clinicians must

Ensure timely, accurate and complete input of data from clinical notes / completed forms

Regularly check service user demographic data with service users and update any inaccuracies

Ensure timely, accurate and complete input of appointment details and outcomes

Monitor and escalate any data quality issues appropriately

Be aware of and comply with documented Policies and Procedures

Monitor own competencies and access basic Informatics and appropriate

CNTW(O)26


clinical system training prior to beginning use of RiO and update when necessary.

3.8 Service, Line and Administration Managers must

Ensure that all staff input accurate and complete data in a timely manner

Ensure that all staff are aware of their responsibilities with regard to checking and updating any inaccuracies in service user demographic data

Address any data quality issues as quickly as possible and escalate where appropriate;

Ensure that all local data collection working procedures are documented, updated regularly, and available to all staff

Ensure that all staff are familiar with and adhere to current policies and operational / working procedures

Ensure Data Quality is part of the Trust’s performance appraisal methodology and includes the monitoring of staff competencies, identification of training / awareness needs and attendance at relevant sessions

3.9 Group Directors must

Ensure that all staff are aware of their responsibilities with regard to data quality under the terms of current guidance and legislation

Ensure that Policies are disseminated appropriately and any changes to Policy are reflected in current practice

Ensure implementation of Policy

Ensure that lines of communication between operational and support staff are well established so that data quality issues are addressed appropriately

Ensure resolution of data quality issues

Ensure that all job descriptions contain reference to the responsibility of the role with respect to recording information and ensuring accuracy and completeness of data

3.10 Information Asset Owner (IAO) must 3.10.1 In conjunction with the respective Information Asset Administrator (IAA),

ensure that information risk assessments are performed routinely on all

CNTW(O)26


information assets where they have been assigned ‘ownership’, following guidance from the SIRO on assessment method, format, content and frequency.

3.11 Caldicott and Data Protection staff must

Liaise with all staff regarding relevant trust policy, national guidance, legislation and professional standards, and to provide the appropriate support to staff around this

Disseminate any changes to all staff regarding relevant Trust policy, national guidance, legislation and professional standards

3.12 Commissioning and Quality Assurance staff must

Interpret requirements of the Data Dictionary and Data Manual and ensure compliance of all Trust data

Monitor and disseminate changes to requirements as notified via Information Standard Board Notifications (ISBNs) or other official channels

Ensure that all systems support robust data collection acting appropriately

on any data quality issues in a timely manner

Produce or enable production of exception reporting to monitor data quality

Raise awareness and provide support and training where appropriate to staff

Develop operational / working procedures and monitor and ensure adherence

3.13 Informatics Customer Operations Staff must

Ensure systems are ‘fit for purpose’ by implementing Informatics developments through the utilisation of appropriate project management methodology

Standardise documentation and processes in accordance with business change requirements and update accordingly in line with version upgrades and RPIW changes

4 Definition of Terms Used

HES - Hospital Episode Statistics is the data source for a wide range of healthcare analysis for the NHS, Government and many other organisations and individuals.

CNTW(O)26


MHSDS – Mental Health Service Dataset contains record level data about the care of adults and older people using secondary Mental Health Services. Information Standard Board Notifications (ISBNs) – Data Set Change Notices are a mechanism for introducing an information requirement or standard to which the NHS and its partners must conform. SUS – Secondary Uses Service is a single source of data to enable a range of reporting and analysis for the NHS and its partners. RiO – Trust Patient Information System provided by CSE Servelec. Caldicott - Health Service Guideline HSG98 (89) on the use and protection of patient information. Caldicott Guardian - A Caldicott Guardian is a senior person (usually the Medical Director) in NHS and Social Care who is responsible for ensuring protection of the confidentiality of patient and service-user information and enabling appropriate information-sharing. SIRO - A Senior Information Risk Officer is an Executive Officer who is responsible for advising the Board on the on-going development and management of the risk management programme. Connecting for Health – A Directorate of the Department of Health which supports the delivery of new computer systems and services.

5 Data Quality 5.1 Legislation, Data Standards and Data Quality Principles 5.1.1 Data Protection Act 5.1.1.1 The Data Protection Act 1998 (the Act) came into force in March 2000. This

was replaced by the Data Protection Bill 2017 via the General European Data Protection Regulation. The provisions of this bill apply to both computerised and manual records relating to personal information about living individuals. The Bill covers an individual’s rights to access their own records as well as the six, legally enforceable principles relating to the processing of personal data which all organisations must adhere. These principles are particularly relevant to this Policy with regard to the standards to be applied when obtaining, recording and maintaining service user data.

5.1.1.2 Under the Bill service users, or those acting on their behalf, have a right to see

or receive copies of their personal data (with certain exceptions.)

CNTW(O)26


5.1.1.3 The Trust encourages informal access to their clinical records where possible. If a service user requires formal access to their records this can be done through the Trust’s Individual Rights Policy and Procedures.

5.2 Data Standards 5.2.1 Adherence to Data standards ensures that clinical data sets and data flows are

consistent across NHS organisations and are comparable at a national level. The Data Dictionary, Data Manual and ISBNs are the vehicles through which data standards are established and maintained both locally and nationally by the Department of Health and other agencies

5.3 Principles of Good Quality Data 5.3.1 Although there are many aspects to good quality data, the general principles

are data must have the following attributes:

Validity

All data items held on trust computer systems must be valid. Where codes are used, these will comply with national standards; locally defined code sets will map to national values. Wherever possible, computer systems will be programmed to error-trap invalid entries and these integrated controls will be reviewed annually

Completeness

All internally agreed data items within a data set must be completed. Computers must be programmed to force the input of mandated fields for national requirements. Use of default codes will only be used where appropriate and not as a substitute for real data. If it is necessary to bypass a data item in order to admit or treat a service user, the missing data must be reported for immediate follow up

Reliability

Data items must be reliable and internally consistent. Service users with multiple episodes must have consistent dates and where multiple referrals exist, interventions must be linked to the appropriate referrals.

Relevance

Data will reflect all the clinical work carried out by Trust staff. All Data captured must be appropriate for the purpose it is to be used, for example, Admissions, outpatient attendances, community contacts. Nursing and Allied Health Professional contacts must also be recorded as well as those provided by Social Service staff where they work in joint teams with the Mental Health

CNTW(O)26


sector. Where applicable, joint-working arrangements will be agreed and technical solutions implemented to aid with data collection for all relevant organisations. Correct operational / working procedures are essential to ensure complete data capture. Spot checks, exception reports and audits must be used to identify missing data

Granularity

Data recorded, whether in case notes or on RiO must accurately reflect the care and treatment provided to the service user. All reference tables, such as General Practitioners (GPs) and postcodes will be updated regularly.

Every opportunity must be taken to check demographic details with the service users themselves. Inaccurate demographics may result in important letters being mislaid, the incorrect identification of individuals and, ultimately, poor quality information

Timeliness

Recording of timely data, in accordance with operational / working procedures and clinical standard practice notes, is beneficial to the care and treatment of the service user. Inputting details of contacts and interventions makes that information available to all Mental Health professionals providing care to the service user. All data will be recorded to specified deadlines, which will enable that data to be included in national, local & internal reports. See Appendix 1.

5.4 Use of Clinical Information Systems

The Trust uses RiO as the single electronic patient record. The Clinical Standards Practice Notes documentation has been produced to ensure effective and accurate use of the system.

5.4.1 Stand-alone Systems must not be used to Record Service User Data 5.4.1.1 Stand-alone Systems are defined as any system that is used to record and / or

retrieve service user data whether developed in-house or provided by third parties. The definition is not limited to applications developed in databases but covers any searchable front-end including spreadsheet and word processing packages and manual systems. The Data Protection Act has strict definitions of ’relevant filing systems’ and the Trust is responsible for ensuring its compliance under the terms of the Act.

5.4.1.2 In accordance with the Informatics Strategy, there will be no further

developments of Stand-alone Systems, without prior agreement from the Integrated Business Development Group (IBDG).

5.4.1.3 Where stand-alone databases are to be used for research purposes approval

CNTW(O)26


must be sought via the Research and Development Group, following the agreed procedures, before any service user data is stored on Stand-alone Systems. For any other purpose, written approval must be sought from the Caldicott Guardian and the Senior Information Risk Officer (SIRO).

5.5 Identifying and Correcting Errors and Omissions 5.5.1 Errors and omissions must be identified as close to point of entry as possible

and rectified accordingly. 5.5.2 Where standard reports are available from systems for use by clinical,

managerial and admin staff these must be used to check for inaccurate, incomplete or untimely data.

5.5.3 Recipients of scheduled weekly or monthly information must check all reports

for inconsistency of information or missing data. Any errors and anomalies must be corrected locally by the respective user.

5.5.4 The appropriate department or individual will investigate queries, gaps in data

items, and anomalies raised by Informatics staff as a result of report production. 5.5.5 Errors and omissions will be corrected within agreed timescales. 5.5.6 External data quality reports, such as those produced by SUS, will be checked

by IM and T staff and any issues addressed before the next return deadline. 5.6 Clinical Coding 5.6.1 It is vital that the coding of clinical data is accurate and complete. The code

should be agreed by the respective Consultant and entered at source in a timely fashion. Sample data will be validated by trained Informatics staff and errors rectified accordingly. The Trust adopts the standards as applied in National Guidance and the Information Governance Toolkit. Adherence to Operational / Working Procedures and Clinical Standard Practice Notes is paramount.

5.6.2 The overall requirements include an annual clinical coding audit carried out in

accordance with the criteria laid down within the NHS Connecting for Health Clinical Coding Methodology. This will be supplemented by internal ‘spot checks’ carried out by appropriate Informatics staff on a quarterly basis.

5.7 Dashboards 5.7.1 The Trust’s information dashboards and associated reporting continues to

contribute to improve the quality of key information across the organisation and the speed and reliability of internal reporting. Current live dashboards provide a near real-time view of information and include:

CNTW(O)26


Workforce

Clinical

Quality and Performance

Safety and Patient Experience

Staff, Service User and Carer Experience

Medical Performance

Time and Attendance

Finance

My Dashboard (an individual view of each member of staff’s performance against key targets and Workforce specific information).

5.7.2 Subject to security, the Dashboards allow managers and operational staff to

see key information and performance data summarised at Board level and drill down through organisational layers to the lowest level such as patient / staff member. All staff have access to a ‘my dashboard’ screen showing their individual performance against key indicators.

6 Measurement and Audit of Good Quality Data 6.1 Responsibility for monitoring compliance and ensuring good data quality lies

locally with Service and Line Managers. 6.2 Compliance will be monitored through observation, spot checks and through

incident management in line with the Trust Incident reporting process. 6.3 Data quality will be subject to control processes within the Trust and to internal

and external scrutiny. Commissioning and Quality Assurance are standing agenda items on the Business Development Group (BDG) and the Corporate Decision Team Quality Group (CDT-Q) and reports are regularly presented, discussed and action agreed to ensure improvement and overall compliance. The Trust’s Quality and Performance Committee and Groups also continually review data quality.

6.4 There is also a requirement to produce an annual quality report for scrutiny by

the Trust Board, Internal Audit and Monitor, via External Auditors, to provide external assurance.

CNTW(O)26


6.5 Internally

Locally defined measures will be used by the Trust to monitor data quality, which will be performance managed via the Group Performance Management agenda

Internal monitoring reports will be used to inform management, improve processes and documentation, and identify training needs

Data quality kite marks will be developed and introduced on a phased roll out basis to provide visual assurance on the quality of the performance indicator displayed within the Trust internal dashboards. This will be in the form of a visual indicator which acknowledges the variability of the data whilst making an explicit assessment of the quality of evidence on which the performance measurement is based. Each measure will be assessed as

‘sufficient’, ‘insufficient’ or ‘not yet assessed’ using the data quality elements

attached on described under Section 5.3.1. and detailed in Appendix D. Each measure will have an equal weighting and will be displayed on the Trust dashboards.

Information Governance and Internal audits will be carried out on systems, processes and data quality to ensure continued compliance with National and local Trust standards

6.6 Externally

Where Commissioners and external agencies receive or have access to Trust information and produce Data Quality Reports and Indicators, the Trust will aim to achieve or exceed the agreed targets

The Care Quality Commission inspections rely on information based on good quality data and it carries out regular and appropriate audits. Monitor governance risk ratings can be influenced by Data Quality issues

Designated staff will address issues highlighted by reports or indicators that demonstrate poor quality data. Recommendations made as a result of data quality audits will be acted upon within agreed timescales

7 Quality Report and Information Governance 7.1 The Trust will adhere to the Quality Account Regulations and use the Data

Quality Audit Report produced by External Auditors for assurance. The Trust will ensure that the performance information reported in the report is reliable and accurate and that there are proper internal controls over the collection and reporting measures of performance. The data underpinning the measures will be robust, reliable and conform to the specified data quality standards and

CNTW(O)26


prescribed definitions via clear policies and procedures 7.2 Information Governance has a much wider focus than pure data quality

including areas covered in other Trust Policies such as Data Protection, Records Management, and Confidentiality. It provides a framework to bring together all the requirements, standards and best practice that apply to the handling of personal information. Adopting the framework and implementing the Information Governance Toolkit criteria will ensure that the Trust and its staff are using and handling data in compliance with the law and with current guidance.

8 Incident Reporting

All incidents involving data quality must be reported immediately to the Commissioning & Quality Assurance Team and Information Governance Departments and dealt with in accordance with the Trust Incident Reporting Policy - CNTW(O)05.

9 Identification of Stakeholders 9.1 This is an existing Policy which has only minor changes that do not relate to

operational and / or clinical practice therefore does not require a full consultation process.

North Locality Care Group

Central Locality Care Group

South Locality Care Group

North Cumbria Locality Care Group

Corporate Decision Team

Business Delivery Group

Safer Care Group

Communications, Finance, IM&T

Commissioning and Quality Assurance

Workforce and Organisational Development

NTW Solutions

Local Negotiating Committee

Medical Directorate

Staff Side

Internal Audit

10 Fair Blame

The Trust is committed to developing an open learning culture. It has endorsed the view that, wherever possible, disciplinary action will not be taken against

CNTW(O)26


members of staff who report near misses and adverse incidents, although there may be clearly defined occasions where disciplinary action will be undertaken.

11 Equality Impact Assessment 11.1 In conjunction with the Trust’s Equality and Diversity Officer, this Policy has

undergone an Equality and Diversity Impact Assessment (see Appendix A) which has taken into account all human rights in relation to disability, ethnicity, age and gender. The Trust undertakes to improve the working experience of staff and to ensure everyone is treated in a fair and consistent manner.

12 Training 12.1 Regular exception reporting, careful monitoring and error correction can

support good quality data, but it is more effective and efficient for data to be entered correctly first time. In order to achieve this, on the job training and induction programmes for all new staff must include training in the use of appropriate computer systems that is relevant to their role. Access to systems will not be granted until appropriate training has been completed. Existing staff must have access to on-going training to keep them up-to-date with new processes and changes to data definitions.

12.2 A full training needs analysis will take place for all staff. Basic IT skills and other

relevant training will be completed prior to RiO training taking place. All training will be recorded and monitored by the Training and Development Department.

12.3 Training must be backed up by regularly reviewed procedures. These must be

properly documented and accessible to all appropriate staff. Staff must be made aware of where these are stored and how to access them.

12.4 Where additional training is required it is the responsibility of both managers

and staff to ensure that this is undertaken and that attendance is verified and recorded

13 Implementation 13.1 The Policy will be monitored by the Quality and Performance Committee in

terms of its overall acceptance and implementation. If at any stage there is an indication that the objectives are not being met, then further consideration will be given to the implementation of an approved Action Plan.

13.2 Taking into consideration all the implications associated with this Policy, it is

considered that a target date of February, 2015 is achievable for the contents to be implemented across the Trust.

CNTW(O)26


14 Standards and Key Performance Indicators 14.1 The criteria set out in this Policy is based on International Auditing and

Assurance Standards and also draws on standards for data quality published by the Local Public Sector Audit Agencies and CIPFA. The standards cover key areas including; Governance and Leadership, Policies, Systems and Processes, People and Skills and Data Use and Reporting (See Appendix 2 for more detail).

14.2 Key National and local Performance Indicators are assessed against mandated

returns to ‘key’ stakeholders and to National Databases for example; Hospital Episode Statistics (HES) and the Mental Health Minimum Dataset (MHMDS) via Secondary Uses Service (SUS). Timeliness, consistency and compliance with National and local standards are therefore essential as Trusts are measured and judged on the data they produce. Health Service Indicators are also heavily dependent on good quality data, which is a measure in its own right.

14.3 The Policy also upholds the Principles of the Data Protection Act 1998, the

Caldicott report HSG 98(89), as well as guidance issued by the Care Quality Commission.

15 Associated Documents

This Policy should be read in conjunction with the following:

CNTW(O)05 - Incident Reporting Policy;

CNTW(O)06 - Non-Attendance Policy;

CNTW(O)36 - Data Protection Act 1998 Policy; CNTW(O)43 - Freedom of Information Act 2000 Policy;

CNTW(C)22 - Waiting Time and Access Policy;

CNTW(C)20 - Care Co-ordination Policy;

CNTW(C)48 - Care Co-ordination in Children and Young People Specialist Services Policy;

CNTW(O)55 - Information Risk Policy;

RiO User Guides and associated documents; Clinical Standard Practice Notes; Data Quality Operational / Working Procedures

CNTW(O)26


16 References

- http://content.digital.nhs.uk/ - http://nww.unify2.dh.nhs.uk/unify/interface/homepage.aspx - www.doh.gov.uk - http://www.connectingforhealth.nhs.uk/systemsandservices/sus - http://www.cqc.org.uk/

http://content.digital.nhs.uk/

http://nww.unify2.dh.nhs.uk/unify/interface/homepage.aspx

http://www.doh.gov.uk/

http://www.connectingforhealth.nhs.uk/systemsandservices/sus

http://www.cqc.org.uk/

CNTW(O)26


Appendix A

Equality and Diversity Impact Assessment Screening Tool

Equality Analysis Screening Toolkit

Names of Individuals involved in Review

Date of Initial Screening

Review Date Service Area / Locality

Alison Paxton Christopher Rowlands

May 18 May21 Trust-wide

Policy to be analysed Is this policy new or existing?

CNTW(O)26 Data Quality Policy Existing

What are the intended outcomes of this work? Include outline of objectives and function aims

To identify the Trust and staff roles and responsibilities regarding quality and standards for the collection, processing and exchange of user-related data. To support the on-going development of quality clinical service delivery and monitoring.

Who will be affected? e.g. staff, service users, carers, wider public etc.

ALL STAFF

Protected Characteristics under the Equality Act 2010. The following characteristics have protection under the Act and therefore require further analysis of the potential impact that the policy may have upon them

Disability N/A

Sex N/A

Race N/A

Age N/A

Gender reassignment

(including transgender)

N/A

Sexual orientation. N/A

Religion or belief N/A

Marriage and Civil Partnership

N/A

Pregnancy and maternity

N/A

Carers N/A

Other identified groups N/A

CNTW(O)26


How have you engaged stakeholders in gathering evidence or testing the evidence available?

Though standard Policy consultation mechanisms.

How have you engaged stakeholders in testing the policy or programme proposals?


For each engagement activity, please state who was involved, how and when they were engaged, and the key outputs:


Summary of Analysis Considering the evidence and engagement activity you listed above please summarise the impact of your work. Consider whether the evidence shows potential for differential impact, if so state whether adverse or positive and for which groups. How you will mitigate any negative impacts. How you will include certain protected groups in services or expand their participation in public life.

Now consider and detail below how the proposals impact on elimination of discrimination, harassment and victimisation, advance the equality of opportunity and promote good relations between groups. Where there is evidence, address each protected characteristic

Eliminate discrimination, harassment and victimisation

N/A

Advance equality of opportunity N/A

Promote good relations between groups N/A

What is the overall impact? N/A

Addressing the impact on equalities N/A

From the outcome of this Screening, have negative impacts been identified for any protected characteristics as defined by the Equality Act 2010? NO

If yes, has a Full Impact Assessment been recommended? If not, why not?

Manager’s signature: Alison Paxton Date: May 18

CNTW(O)26


Appendix B

Communication and Training Check List for Policies

Key Questions for the accountable committees designing, reviewing or agreeing a new Trust Policy

Is this a new policy with new training requirements or a change to an existing policy?

No this is an existing policy

If it is a change to an existing policy are there changes to the existing model of training delivery? If yes specify below.

N/A

Are the awareness/training needs required to deliver the changes by law, national or local standards or best practice?

Please give specific evidence that identifies the training need, e.g. National Guidance, CQC, NHS Resolutions etc.

Please identify the risks if training does not occur.

In order to comply with Data Protection Legislation, a directive has been issued by the NHS nationally, and encryption of removable media mandated

Please specify which staff groups need to undertake this awareness/training. Please be specific. It may well be the case that certain groups will require different levels e.g. staff group A requires awareness and staff group B requires training.

Trust-wide

Is there a staff group that should be prioritised for this training / awareness?

It is essential that all staff groups working with confidential / personal data are made aware of the Policy and the personal responsibilities associated with the national directive

Please outline how the training will be delivered. Include who will deliver it and by what method. The following may be useful to consider: Team brief/e bulletin of summary Management cascade Newsletter/leaflets/payslip attachment Focus groups for those concerned Local Induction Training Awareness sessions for those affected by the new policy Local demonstrations of techniques/equipment with reference documentation Staff Handbook Summary for easy reference Taught Session E Learning

Team Brief, CEO Bulletin, Intranet, face to face training, E-learning

Please identify a link person who will liaise with the training department to arrange details for the Trust Training Prospectus, Administration needs etc.

Head of Information Governance and Medico Legal.

CNTW(O)26


Appendix B – continued

Training Needs Analysis

Staff / Professional Group

Type of Training Duration of Training

Frequency of Training

ALL STAFF Awareness of Data Quality and associated legislation

1 Hour Annually Information Governance Training

Should any advice be required, please contact:- 0191 245 6777 (internal 56777- Option 1)

CNTW(O)26


Appendix C

Monitoring Tool

Statement The Trust is working towards effective clinical governance and governance systems. To demonstrate effective care delivery and compliance, Policy Authors are required to include how monitoring of this Policy is linked to auditable standards / key performance indicators will be undertaken using this framework.

CNTW(O)26 – Data Quality Policy - Monitoring Framework

Auditable Standard / Key Performance Indicators

Frequency / Method / Person Responsible

Where Results & Any Associate Action Plan Will Be Reported To & Monitored; (this will usually be via the relevant Governance Group)

1. Data Quality will be monitored internally via Trust Dashboards

All staff will monitor through their individual dashboards The Commissioning and Quality Assurance Team also monitor the Dashboards on a daily / weekly / monthly / quarterly basis dependent upon metric and highlight any issues The Commissioning and Quality Assurance prepare a weekly exception report

Quarterly Report sent to Caldicott and Health Informatics Group Annual Report sent to Trust Board so they can check on compliance Weekly Exception Report goes to Business Delivery Group

The Author(s) of each Policy is required to complete this monitoring template and ensure that these results are taken to the appropriate reporting governance group as above in line with the frequency set out.

CNTW (O) 26

Appendix 1

1 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust Appendix 1 – Schedule of National, Local and Internal Reports sent by Cumbria Northumberland, Tyne and Wear NHS Foundation Trust Part of CNTW (O)26 – Data Quality – V05.1 Oct 19

Schedule of National, Local and Internal Reports sent by Cumbria Northumberland, Tyne and Wear NHS Foundation Trust Data Set

Agency / Organisation to which it is Submitted

Date Sent / Submitted

Frequency of Submission

Method of Submission

Date Received

How do we know it’s been received?

18 Week PTL

DH

Every Wednesday

Weekly NHS Improvement

Same Day Email confirmation received to submitter

18WksRTT (18 Weeks Referral to Treatment)

DH

Around 20 days after month end

Monthly Unify2 Same Day Flagged on Unify2 as received

KH03 V2 (Bed Availability and Occupancy)

DH

Varies from quarter to quarter

Quarterly

Unify2

Same Day

Flagged on Unify2 as received

MAR (Monthly Activity Return)

DH


Monthly

Unify2

Same Day


QAR-Prov DH

Varies during the second month after quarter end

Quarterly Unify2 Same Day Flagged on Unify2 as received

MSitDT (Monthly SitReps Delayed Transfers of Care)

DH


Monthly

Unify2

Same Day


CNTW(O)26 Appendix 1

Cumbria Northumberland, Tyne and Wear NHS Foundation Trust Appendix 1 – Schedule of National, Local and Internal Reports sent by Cumbria Northumberland, Tyne and Wear NHS Foundation Trust Part of CNTW(O)26 – Data Quality – V05.1 Oct 19

2

Data Set





Date Received


MHPrvCom

(Mental Health Provider Commissioner)

DH

Varies from quarter to quarter

Quarterly

Unify2

Same Day


MSA (Mixed Sex Accommodation)

DH


Monthly

Unify2

Same Day


Nurse Staffing Return

DH

15 days after month end

Monthly

Strategic data Collection Service (SDCS)

Same Day

Email Confirmation received to submitter

Friends and Family Test (FFT)

DH

By end of following month after Quarter end

Quarterly

Strategic data Collection Service (SDCS)

Same Day

Email Confirmation received to submitter

MHMDS (Mental Health Minimum Data Set)

HSCIC

On or around snap shot day

Monthly

Bureau Portal

Same Day

Email Confirmation sent to Bureau Portal users stating if submission has been accepted or not

IAPT national submission

HSCIC

On or around snap shot day

Monthly

Bureau Portal

Same Day

Email Confirmation sent to Bureau Portal users stating if submission has been accepted or not



3

PSA Indicators Local Authorities

15 working days after month end

Monthly

Email

Same Day

Email Receipt

Data Set





Date Received


Audit Commission Benchmarking for Mental Health Trusts

Audit Commission

Date confirmed by Benchmarking Club

Annually

Email

Same Day

Email Receipt

CQUIN

North East Commissioning Body for MH

23 days after month end

Monthly

Email

Same Day

Email Receipt

Schedule 3 & 5 (Contractual Activity Requirements)



Monthly

Email

Same Day

Email Receipt

DQIP (Data Quality Improvement Plan)



Monthly

Email

Same Day

Email Receipt

Picker

Picker Institute

Date confirmed by Picker

Annually

FTP to a secure box

Same Day

Email Confirmation

SLAM contracting monitoring data

Local Commissioners

Before 23rd each month

Monthly

Email

Same Day

Email Confirmation



4

Note: DQIP is a subset of the Schedule 3 & 5 data set Please note UNIFY2 is in the process of being decommissioned during 2018-19, all returns will be submitted via NHS Improvement or the Strategic Data Collection Service (SDCS) following this.

decommissioned, all returns will go via

CNTW(O)26

Appendix 2

1 Cumbria Northumberland, Tyne and Wear NHS Foundation Trust Appendix 2 – Data Quality Kite Mark Part of CNTW(O)26 – Data Quality – V05.1 Oct 19

Data Quality Kite Mark

Each metric has been assessed using the seven elements listed in blue to provide assurance that the data quality meets the standard of sufficient, insufficient or Not Yet Assessed.

Sufficient

Insufficient

Not Yet Assessed

CNTW(O)26

Appendix 2


Data Quality Kite Mark – This page provides guidance relating to how the metrics have been assessed relaying to NHS

Improvements, Single Oversight Framework and Contract Standards

Data Quality Indicator

Definition Sufficient Insufficient What does it mean if the indicator is insufficient

Action if metric is insufficient

Timeliness Is the data the most up to date and validates available within the system?

Data will be recorded within the timescales as referenced in “Record Keeping Standards PGN”

Data is being input outside the referenced timescales within the “Record Keeping Standards PGN”

The data is not the most up to date and decisions may be made on inaccurate data

Understand why the data was not completed within given timeframes. Report this to relevant parties as required

Granularity Can the data be broken down to different levels e.g. Available at Trust level down to client level?

Where relevant the Trust has the ability to drill down into the data to the correct level

The Trust is unable to drill down into the data to the correct level

It is not possible to drill down to the relevant level of data to understand any issues

Work with relevant teams to ensure the data can be broken down to varying levels

Completeness Does the data demonstrate the expected number of records for that period?

There is assurance that effective controls are in place to ensure 100% of records are included within the metrics as required and no individual records

There is inadequate assurance or no assurance that effective controls are in place to ensure 100% of records are

Performance cannot be assured due to the level of missing data

Understand why the data was not complete and request data will be updated by. Report this to relevant parties as required

CNTW(O)26

Appendix 2





are excluded without justification

included within the metrics

Validity Is the data validated by the Trust to ensure the data is accurate and compliant with relevant rules and definitions?

The Trust have agreed procedures in place for the validation and creation of new metrics and amendments to existing metrics

A metric is added or amended to the dashboard without the correct procedures being followed

The data has not been validated therefore performance cannot be assured

The metrics are regularly reviewed and updated as appropriate

Audit Has the data quality of the metric been audited within the last three years?

The data quality of the metric has been audited within the last three years

The metric has not been audited within the last 3 years

The system and processed have not been audited within the last three years therefore assurance cannot be guaranteed

Ensure metrics that are outside the three year audit cycle are highlighted and completed within the next year

Reliability The process is fully documented with controls and data flows mapped

Mostly a computerised system with automated controls

Mostly a manual system with no It automated controls

Process is not documented and/or for manual data production controls and validation procedures are not adequately detailed

Ensure processes are reviewed and updated accordingly and changes are communicated to appropriate parties

Relevance The indicator is relevant to the measurement of performance

This indictor is relevant to the measurement of performance

This indicator is no longer relevant to the measurement of performance

The metric may no longer be relevant to the

Ensure dashboards are reviewed regularly and metrics displayed

CNTW(O)26

Appendix 2





against the Performance question, strategic objective, internal, contractual and regularity standards

measurement of standards

are relevant and updated or retired if no longer relevant