1. No category

NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST
PATIENT DATA QUALITY POLICY
Documentation Control
Reference
Approving Body
Date Approved
Implementation Date
Version
Summary of Changes from
Previous Version
Supersedes
Consultation Undertaken
Date of Completion of
Equality Impact Assessment
Date of Completion of We
Are Here for You
Assessment
Date of Environmental
Impact Assessment (if
applicable)
Legal and/or Accreditation
Implications
Target Audience
Review Date
GG/INF/019
Directors’ Group
23 April 2103
23 April 2013
3
Update of definitions and Process Flows
appendix as part of Policy review date
expiring.
PATIENT DATA QUALITY POLICY
Version 2.0
Approved 1st February 2012
Information Governance Committee
Deputy Director of Operations
8th February 2013 – see separate template
attached at Appendix 3
7th February 2013 – see separate template
attached at Appendix 5
N/A
N/A
All Trust staff who collect or process patient
data
April 2015
Lead Executive
Director of Finance and Procurement
Chief Operating Officer
Author/Lead Manager
Name : Steve Baxter
Job title : Head of Information
Extension : 62009
Further Guidance/Information Name : Jim Hatton
Job title : Deputy Director of Operations
Extension : 76141
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CONTENTS
Paragraph
Title
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Introduction
Executive Summary
Policy Statement
Definitions (including Glossary as needed)
Roles and Responsibilities
Policy and/or Procedural Requirements
Training, Implementation and Resources
Impact Assessments
Monitoring Matrix
Relevant Legislation, National Guidance
and Associated NUH Documents
Flow charts relating to section 6
Data Output Standards
Equality Impact Assessment
Environmental Impact Assessment
Here For You Assessment
Certification Of Employee Awareness
Appendix (1)
Appendix (2)
Appendix (3)
Appendix (4)
Appendix (5)
Appendix (6)
Page
3
3
4
5
5
6
8
11
12
13
14
19
21
24
26
28
1.0
Introduction
1.1
Nottingham University Hospitals NHS Trust requires the collection,
storage and management of patient data to be accurate, timely,
relevant and secure in order to support the delivery of effective and
efficient patient care and the achievement of the Trusts’ core
business objectives and statutory obligations.
Good quality data is not an optional extra; it is a fundamental
requirement for the delivery of high standard services.
2.0
Executive Summary
2.1
This policy applies to the administrative and clinical patient related
data contained within the Trusts’ electronic and paper based
systems.
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This policy is a statement of intent which members of staff are
expected to follow and should be regarded as mandatory by all staff.
Failure to follow a trust policy could result in disciplinary action being
taken, up to and including dismissal.
Patient data is collected and processed by many staff across the
Trust. Data quality may be affected by a wide range of activities; the
need for good quality data must therefore be embedded in the
culture, values and actions of Trust staff.
This policy compliments the following Trust policies:
Health Records Management Policy
Health Records Keeping Policy
Information Security & Data Protection Policy
Information Governance Policy
Corporate Data Validation Policy
3.0
Policy Statement
3.1
The Trust will:
Ensure that operational and clinical staff are aware of the
importance and value of good quality patient data.
Continue to identify and implement ways of achieving and
sustaining improved data quality through training, technical and
process developments and collaborative working between staff.
Adhere to standards set out in the NHS Data Dictionary and will
ensure that locally developed standards are consistent with the
NHS Data Dictionary.
Continue to set standards for patient data quality that are
challenging and consistent with national targets.
Maintain and regularly review its Information Security & Data
Protection Policy to ensure that it continues to underpin data
quality principles. Staff must abide by the principles contained
in the Information Security & Data Protection Policy, in
particular, be familiar with the principles set out in the Data
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Protection Act (1998).
Have a nominated Information Governance Manager and
Caldicott Guardian. Data Custodians will be identified
throughout the Trust to ensure that Data Protection and
Caldicott principles are fully observed and complied with. The
roles and responsibilities of these officers will be set out in the
Trusts Information Security & Data Protection Policy.
Ensure staff abides by the Trust policy for the communication of
personal and sensitive data in the process of rectifying data
quality issues. All personal and sensitive data must be
transferred by either NHS Mail, or if using NUH mail systems,
encrypted to NHS standards using software approved by the
Trust in accordance with the Trusts E-Mail Policy.
Ensure users sign a confidentiality clause and an undertaking
to take reasonable steps to ensure the accuracy of information
they enter on the computer system. Users will only be given
access to the menus and access levels that are appropriate to
their job. If a user changes their job within the hospital, access
to hospital systems will be reviewed, to ensure that they do not
have any inappropriate access.
Systematically monitor, review and report on compliance with
this policy.
4.0
Definitions
4.1
CSA – Clinical Spine Application
CCG – Care Commissioning Group
SUS – Secondary Uses Service
HRMG – Health Records Management Group
CNST – Clinical Negligence Scheme for Trusts
EMIAS – East Midland Internal Audit Services
5.0
Roles and Responsibilities
5.1
Committees
The Trust Board is responsible for ensuring that arrangements are in
place so that it can be assured about patient data quality and
compliance with this policy.
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The Information Governance Committee is responsible for
overseeing implementation of data quality improvement plans as part
of the NHS Information Governance programme.
5.2
Individual Officers
The Chief Operating Officer is responsible for promotion and
implementation of this policy.
The Director of ICT is responsible for the technical integrity of
electronic systems used for recording patient data and for delivery of
training in the use of these systems.
The Deputy Director of Information is responsible for:
providing support and advice about NHS Data Standards, their
interpretation and implementation
corporate monitoring, validation and reporting of patient data
quality
taking remedial action where patient data quality is found to be
below acceptable standards
monitoring, reviewing and reporting on compliance with this
policy
Departmental managers are responsible for monitoring patient data
quality and for ensuring that their staff:
are aware of the importance of good quality patient data
have access to and apply local Standard Operating Procedures
that set out the standards and procedures for patient data
recording
have sufficient training and understanding in the use of systems
(paper and electronic) used for recording patient data
All staff are responsible for ensuring that they record patient data
promptly and accurately with reference to the latest procedures and
definitions.
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6.0
Policy and/or Procedural Requirements
6.1
System users must have up to date written departmental procedures
available which include procedures for the collection, validation and
entry of data. The procedures will be available to staff in all
appropriate locations and will be updated in accordance with
changes to guidelines and data definitions.
As a minimum the following procedures will be documented:
Registering a patient
GP Referral to Outpatient Clinic or Test
Attendance, Cancellation, DNA at outpatient clinic and outcome
Add patient to Inpatient Waiting List
Emergency or Elective admission
Attendance in the Emergency Department
All service user and associated data must be entered in accordance
with defined standards.
Staff who collect and enter service user data have a responsibility to
ensure that its accuracy is validated with service users at every
opportunity and that any necessary corrections are made promptly.
Inaccurate demographics may result in important letters being
mislaid, or incorrect identification of a service user.
All reference tables, such as GP, Specialty and Postcodes, will be
updated within a month of publication unless there are doubts about
the quality of the data supplied.
All data items held on Trust computer systems must be valid. Where
codes are used, these must comply with national standards or map to
national values. Wherever possible, computer systems will be
programmed to only accept valid entries.
Regular validation of compliance and processes will be undertaken
on service user data to assess its accuracy. For example Waiting List
validations, Duplicate Records, checks for logical errors. Internally a
regular program of daily, weekly and monthly error reports from key
Trust systems is produced.
In addition departmental processes for data validation are outlined in
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the Trusts ‘Corporate Data Validation Policy’. Accredited external
sources of information e.g. Clinical Spine Application (CSA), will be
used to assist with the validation of service user records.
Internal Data Quality reports will be produced and communicated to
directorates and CCG’s. These reports will be used to inform
management, improve service user processes, ensure focused
training, enhance documentation, and enable complete data capture
on computer systems.
Accredited external organisations will be used to assist in the
communication of data quality assurance issues and may include the
following:
Secondary Uses Service (SUS) Data Quality/Completeness
Reports
Data Quality Audits
Performance Indicators (Annual Health Check)
NHS Choices Indicators
Service User Queries
Commissioner Complaints
7.0
Training and Implementation
7.1
Training
As part of the Trusts information systems training courses for staff,
the Trust requires all trainers to address the requirement for accurate
data and to undertake procedures necessary to achieve this goal.
Staff must attend appropriate training to ensure an adequate level of
competency in the patient administration functions used in their role.
Refresher training will be offered as required. All training should
include evaluation of its effectiveness in terms of staff feedback
forms:
Appropriate staff will receive training on record keeping and
management.
All data entry systems should have an audit trail that is
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activated and used.
(Refer to Training and User Guides for detailed training
documentation)
7.2
Implementation
Health Records Management
7.2.1 There will be a Health Records Management Group (HRMG)
with multi-disciplinary membership. The groups terms of
reference will include achievement of Clinical Negligence
Scheme for Trusts standards (CNST).
7.2.2 The Health Records Management Group will work in
conjunction with partnership agencies and will determine policy
for health records management and specify standards for the
performance of the health records service.
7.2.3 The Health Records Management Group will review health
records policies and procedures and ensure consistency in the
operation and performance of the Trusts records stores.
Data Quality Standards
7.2.4 The Trusts service users will expect that all data held on them
will be 100% accurate.
7.2.5 Service user data held by the Trust must be ‘fit for purpose’.
There are many aspects to good quality data:
Completeness
All mandatory data items within a data set should be
completed. Use of default codes should only be used where
appropriate, and not as a substitute for real data. If it is
necessary to omit a data item in order to admit that patient, the
missing data should be reported for immediate follow up.
Consistency
Data items should be internally consistent. Patients with
multiple episodes should have consistent dates. Operations
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and diagnoses will be consistent for ages and/or sex.
Coverage
Data must reflect all the work done by the Trust. A&E
attendances, Admissions, Outpatient attendances and
procedures must be recorded. Correct procedures are essential
to ensure complete data capture. Spot checks and
comparisons between systems will be used to identify missing
data.
Accuracy
Data recorded in notes and on computer systems should
accurately reflect what actually happened to a patient.
Timeliness
Recording of timely data is beneficial to the treatment of the
patient. Entering test results into the computer or recording
diagnoses and procedures makes that information available to
all treating the patient even if they do not have access to the
paper notes. All data must be recorded promptly. The accurate
recording of data items must not be allowed to delay the urgent
treatment of a patient.
(Standards for service user data quality are contained in
Appendix 2)
Accountability
7.2.6 All staff are responsible for assuring the quality of data and
information held on service users with whom they are in
contact. Managers are accountable for the data quality within
the services that they provide.
7.2.7 The lead director reporting to the Trust Board on data quality is
the Chief Operating Officer.
Audit & Monitoring
7.2.8 The Trust will undertake audits and data quality checks. These
will include:
External clinical coding audits
Internal audits (topics to be agreed)
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Accuracy checks
Completeness and validity checks
Compliance checks
The Trust has undertaken a review of integrated performance
reporting with the East Midland Internal Audit Services (EMIAS), the
results of which gave ‘significant assurance’ regarding data quality
processes. The reports are available from the NUH Information
Services website:
http://nuhnet/operations/info_services/dataquality/reports/
ReportsLibrary/Forms/current.aspx
7.2.9 Additionally the Trust will use available external reports to
monitor data quality and rectify issues identified wherever
possible. Information Services will produce and monitor
progress against an annual data quality work programme,
reporting progress and issues to the Information Governance
Committee.
Communication on data quality issues to all staff will be
maintained through the Trusts Data Quality Newsletter and
through the Trusts team brief mechanisms.
7.3
Resources
No additional resources needed
8.0
Trust Impact Assessments
8.1
Equality Impact Assessment
An equality impact assessment has been undertaken on this draft
and has not indicated that any additional considerations are
necessary.
8.2
Environmental Impact Assessment
An environmental impact assessment has been undertaken on this
draft and has not indicated that any additional considerations are
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necessary.
8.3
Here For You Assessment
A Here For You assessment has been undertaken on this document
and has indicated the need for additional considerations which have
been duly incorporated.
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9.0
Policy / Procedure Monitoring Matrix
Minimum
requirement
to be
monitored
Responsible
individual/
group/
committee
Process
for monitoring
e.g. audit
Frequency
of monitoring
Responsible
individual/
group/
committee for
review of
results
Daily, Weekly
and Monthly
Validation
reports
Directorate
Managers
Error Reports,
Audit of
Casenotes
Daily, Weekly
and Monthly
Relevant staff
members and
Directorate
Managers
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Responsible
individual/
group/
committee
for
development
of action plan
Directorate
Governance
Forums
Responsible
individual/
group/
committee
for monitoring
of action plan
Directorate
Governance
Forums
12
10.0
Relevant Legislation, National Guidance and Associated NUH
Documents
10.1
Equal Pay Act (1970 and amended 1983)
Sex Discrimination Act (1975 amended 1986)
Race Relations (Amendment) Act 2000
Disability Discrimination Act (1995)
Employment Relations Act (1999)
Rehabilitation of Offenders Act (1974)
Human Rights Act (1998)
Trade Union and Labour Relations (Consolidation) Act 1999
Code of Practice on Age Diversity in Employment (1999)
Part Time Workers - Prevention of Less Favourable Treatment
Regulations (2000)
Civil Partnership Act 2004
Fixed Term Employees - Prevention of Less Favourable
Treatment Regulations (2001)
Employment Equality (Sexual Orientation) Regulations 2003
Employment Equality (Religion or Belief) Regulations 2003
Employment Equality (Age) Regulations 2006
Equality Act (Sexual Orientation) Regulations 2007
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APPENDIX 1
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APPENDIX 2
Data Output Standards
Admitted Patient Care
NHS Number
Patient Pathway (PPI)
Postcode of Usual Address
Ethnic Category
GP Practice (registered)
Date of Birth
Sex
Source of Admission
Method of Admission
Admission date
Discharge Destination
Discharge Method
Discharge Date
Episode Start Date
Episode End Date
Intended management
Consultant Code
Treatment Specialty
Primary Diagnosis
Healthcare Resource Group Code (HRG)
Percentage
Complete & Valid
98
100
100
95
99
99
100
99
99
99
99
99
99
99
99
98
100
100
99
99
Outpatients
NHS Number
Patient Pathway (PPI)
Postcode of Usual Address
GP Practice (registered)
Date of Birth
Sex
Source of Referral
Referral Request Received date
Attended or Did Not Attend
First Attendance
Outcome of Attendance
Attendance Date
Consultant Code
Treatment Specialty
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100
100
99
99
99
99
99
99
99
99
99
100
100
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Emergency Department
NHS Number
Postcode of Usual Address
GP Practice (registered)
Date of Birth
Sex
Ethnic Group
Source of Referral
Discharge Destination
Primary Diagnosis
First Investigation
First Treatment
Attendance Date
Departure Time
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Percentage
Complete & Valid
98
100
99
99
99
99
99
99
99
99
99
100
100
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APPENDIX 3
Equality Impact Assessment (EQIA) Form (Please complete all sections)
Q1. Date of Assessment: 8th February 2013
Q2. For the policy and its implementation answer the questions a – c below against each characteristic (if
relevant consider breaking the policy or implementation down into areas)
a) Using data and supporting
b) What is already in place in c) Please state any
Protected
information, what issues,
the policy or its
barriers that still need to
Characteristic
needs or barriers could the
implementation to address
be addressed and any
protected characteristic
any inequalities or barriers to proposed actions to
groups experience? i.e. are
access including under
eliminate inequality
there any known health
representation at clinics,
inequality or access issues to
screening
consider?
The area of policy or its implementation being assessed:
Race and
No Impact Identified
Ethnicity
Gender
No Impact Identified
Age
Religion
Disability
Sexuality
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No Impact Identified
No Impact Identified
No Impact Identified
No Impact Identified
21
Pregnancy and
Maternity
Gender
Reassignment
Marriage and
Civil Partnership
Socio-Economic
Factors (i.e.
living in a poorer
neighbour hood
/ social
deprivation)
No Impact Identified
No Impact Identified
No Impact Identified
No Impact Identified
Area of service/strategy/function
Q3. What consultation with protected characteristic groups inc. patient groups have you carried out?
Following the above initial assessment, this policy does not have an impact either positively or negatively on any of
the above strands of equality as the policy sets out the importance of the quality of data collection, for example the
appropriateness on the electronic systems used to collect and record patient data not what data is actually being
collected.
Q4. What data or information did you use in support of this EQIA?
Not Applicable
Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from
surveys, questionnaires, comments, concerns, complaints or compliments? None
Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups
identified or to create confidence that the policy and its implementation is not discriminating against any
groups
Not Applicable
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What
By Whom
By When
Resources required
Q7. Review date
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APPENDIX 4
Environmental Impact Assessment
The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the
significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b)
implement mitigating actions.
Area of
Environmental Risk/Impacts to consider
impact
Waste and
Is the policy encouraging using more materials/supplies?
materials
Is the policy likely to increase the waste produced?
Does the policy fail to utilise opportunities for
introduction/replacement of materials that can be recycled?
Soil/Land
Is the policy likely to promote the use of substances
dangerous to the land if released (e.g. lubricants, liquid
chemicals)
Does the policy fail to consider the need to provide adequate
containment for these substances? (e.g. bunded containers,
etc.)
Water
Is the policy likely to result in an increase of water usage?
(estimate quantities)
Is the policy likely to result in water being polluted? (e.g.
dangerous chemicals being introduced in the water)
Does the policy fail to include a mitigating procedure? (e.g.
modify procedure to prevent water from being polluted;
polluted water containment for adequate disposal)
Air
Is the policy likely to result in the introduction of procedures
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Action Taken (where
necessary)
Not Applicable
Not Applicable
Not Applicable
Not Applicable
24
Energy
Nuisances
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and equipment with resulting emissions to air? (e.g. use of a
furnaces; combustion of fuels, emission or particles to the
atmosphere, etc.)
Does the policy fail to include a procedure to mitigate the
effects?
Does the policy fail to require compliance with the limits of
emission imposed by the relevant regulations?
Does the policy result in an increase in energy consumption
levels in the Trust? (estimate quantities)
Would the policy result in the creation of nuisances such as
noise or odour (for staff, patients, visitors, neighbours and
other relevant stakeholders)?
Not Applicable
Not Applicable
25
APPENDIX 5
We Are Here For You Policy and Trust-wide Procedure Compliance Toolkit
The We Are Here For You service standards have been developed together with more than 1,000 staff and
patients. They can help us to be more consistent in what we do and say to help people to feel cared for, safe and
confident in their treatment. The standards apply to how we behave not only with patients and visitors, but with all
of our colleagues too. They apply to all of us, every day, in everything that we do. Therefore, their inclusion in
Policies and Trust-wide Procedures is essential to embed them in our organization.
Please rate each value from 1 – 3 (1being not at all, 2 being affected and 3 being very affected)
Value
1.
Polite and Respectful
Whatever our role we are polite, welcoming and positive in the face of adversity, and are always
respectful of people’s individuality, privacy and dignity.
2.
Communicate and Listen
We take the time to listen, asking open questions, to hear what people say; and keep people
informed of what’s happening; providing smooth handovers.
3.
Helpful and Kind
All of us keep our ‘eyes open’ for (and don’t ‘avoid’) people who need help; we take ownership of
delivering the help and can be relied on.
4.
Vigilant (patients are safe)
Every one of us is vigilant across all aspects of safety, practices hand hygiene & demonstrates
attention to detail for a clean and tidy environment everywhere.
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Score (1-3)
3
3
2
2
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5.
On Stage (patients feel safe)
We imagine anywhere that patients could see or hear us as a ‘stage’. Whenever we are ‘on
stage’ we look and behave professionally, acting as an ambassador for the Trust, so patients,
families and carers feel safe, and are never unduly worried.
6.
Speak Up (patients stay safe)
We are confident to speak up if colleagues don’t meet these standards, we are appreciative when
they do, and are open to ‘positive challenge’ by colleagues
7.
Informative
We involve people as partners in their own care, helping them to be clear about their condition,
choices, care plan and how they might feel. We answer their questions without jargon. We do the
same when delivering services to colleagues.
8.
Timely
We appreciate that other people’s time is valuable, and offer a responsive service, to keep
waiting to a minimum, with convenient appointments, helping patients get better quicker and
spend only appropriate time in hospital.
9.
Compassionate
We understand the important role that patients’ and family’s feelings play in helping them feel
better. We are considerate of patients’ pain, and compassionate, gentle and reassuring with
patients and colleagues.
10. Accountable
Take responsibility for our own actions and results
11. Best Use of Time and Resources
Simplify processes and eliminate waste, while improving quality
12. Improve
Our best gets better. Working in teams to innovate and to solve patient frustrations
TOTAL
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2
1
3
3
3
3
3
30
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APPENDIX 6
CERTIFICATION OF EMPLOYEE AWARENESS
Document Title
Version (number)
Version (date)
Patient Data Quality Policy
3
23 April 2013
I hereby certify that I have:
Identified (by reference to the document control sheet of the above
policy/ procedure) the staff groups within my area of responsibility to
whom this policy / procedure applies.
Made arrangements to ensure that such members of staff have the
opportunity to be aware of the existence of this document and have the
means to access, read and understand it.
Signature
Print name
Date
Directorate/
Department
The manager completing this certification should retain it for audit and/or other
purposes for a period of six years (even if subsequent versions of the
document are implemented). The suggested level of certification is;
Clinical directorates - general manager
Non clinical directorates - deputy director or equivalent.
The manager may, at their discretion, also require that subordinate levels of
their directorate / department utilize this form in a similar way, but this would
always be an additional (not replacement) action.
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