IGPOL76 Data Quality Policy by Provide Community

Data Quality Policy

Version: V6

Ratified by:

Quality Reference Group

Date ratified: 15/12/2023

Job Title of author:

Reviewed by Committee or Expert Group

Equality Impact Assessed by:

1. Introduction

The organisation recognises that all its decisions, whether clinical, managerial or financial; need to be based on information which is of the highest quality. All this information is derived from individual data items which are collected from a number of sources either on paper, or more increasingly, on electronic systems.

Data quality is crucial and the availability of complete, accurate and timely data is important in supporting patient care, integrated governance, management and service agreements for healthcare planning and accountability.

2. Purpose

This policy is intended to cover all data entered onto computerised or paper systems. It applies to all clinical and non-clinical data.

This policy is designed to ensure that the concept and importance of data quality to Provide CIC and Group companies is disseminated to all staff. It will describe the meaning of data quality, who is responsible for its maintenance and how it can continue to improve in the future.

This policy applies to those members of staff who are directly employed by Provide CIC and Group companies and for whom the organisation has legal responsibility.

3. Definition of Data Quality

Data quality is a measure of the degree of usefulness of the data for a specific purpose. Data needs to be:

• Complete (in terms of having been 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 potential user’s 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 national standards)

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

• Appropriately sought (in terms of being collected or checked only once during an episode)

• Appropriately recorded (in both paper and electronic records)

4. Core Principles

As with other NHS Health care providers, Provide CIC and Group companies is required by NHS Digital and Department of Health to achieve certain levels for Data Quality as set out in the Data Security and Protection Toolkit.

Data Protection Legislation requires that information is accurate and up-to date.

Data quality is a key part of any information system that exists within the Organisation’s structure. All staff members will be in contact at some time with some form of information system, whether paper or electronically based. As a result, all staff members are responsible for implementing and maintaining data quality and are obligated to maintain accurate records legally (Data Protection Legislation), contractually (contract of employment) and ethically (professional code of practice).

There will be identified individuals within the organisation with particular responsibility for data quality issues (e.g. Business Intelligence, Information Governance/ Caldicott Guardian and Data Protection Officer). Their specific responsibility will be explicitly stated in their job descriptions.

Responsibilities concerning data quality will be explicitly stated in the job descriptions of staff involved in the collection or processing of data that is input to information systems.

Responsibility for the strategic management of data quality in the organisation will lie with the Group Chief Finance Officer.

Responsibility for the operational management of data quality will lie with the operational managers of all services to which this policy applies.

The importance of achieving good data quality will be addressed with all relevant staff as part of the induction process at commencement of their employment. All data collection and input processes will have an audit trail and any training and development needs will be addressed.

All users will be made aware of their individual and the organisation’s corporate responsibility for confidentiality and security of data through the organisation’s Information Governance Policies and mandatory Information Governance training for all employed staff and those staff on a fixed term contract of more than 3 months.

5. Importance of Data Quality

Quality information is essential for:

• Patient care – to deliver effective, relevant and timely care, and minimise clinical risk.

• Efficient administrative and clinical processes, such as communication with patients, their families and other carers involved in the patient’s treatment.

• Management and strategic planning, requiring accurate data about the volume and type of previous patient activity and the population health needs to Provide CIC and Group companies appropriate allocation of resources and future service delivery.

• Establishing acceptable service agreements for healthcare provision.

• Clinical governance, which depends on detailed, accurate patient data for the identification of areas where clinical care could be improved.

• Providing information for NHS Commissioners who depend on the information that we send them and need to have confidence in its quality.

• Providing a foundation on which future investments will be based.

• Effective health protection (e.g. immunisation and vaccination)

• The identification of appropriate target populations to improve health and help reduce health inequalities through health and well-being programmes.

• Being able to benchmark the organisation against other organisations nationally and to ensure that we are hitting the required standards.

• To facilitate and maintain the accurate flow of information between the organisation and external agencies.

6. NHS Numbers

In order to ensure that a patient’s NHS Number is recorded accurately it should be retrieved and recorded as near to their first contact with Provide CIC and Group companies as possible.

The use of TPP SystmOne across Provide CIC and Group companies services has ensured that both national and contractual requirements are met and will also provide assurances from a patient safety perspective as key mandatory data sets have been implemented as part of this roll out process including the mandatory use of the NHS Number.

On the rare occasion where a Patient has been registered on SystmOne without an NHS number, this can be matched to the spine so long as staff have the appropriate access rights on their smartcard.

Where the patient’s NHS Number is not known or is not validated it is recommended that staff utilise either the Personal Demographic Service (PDS) through the NHS Spine or Open Exeter to retrieve NHS Numbers.

It is important that regular data quality checks are made on NHS Numbers.

6.1 Electronic Health Records

It is important that all electronic health record systems, comply with this Policy in respect of NHS Number usage and coverage.

The following has been identified as key to ensuring compliance with this Policy:

• Use of Data Quality minimum data sets to ensure standards of 95% verified NHS Number for all active patients registered on existing systems and to ensure compliance with the agreed Data Quality Plan with our main Commissioners

• Where it is identified that an NHS Number is missing from a Patient Record it must be entered within 1 week of notification

• The organisation’s annual record keeping audit covers the recording of NHS Number in electronic systems

Where new patient systems are to be implemented these must be able to record the NHS Number and be Spine enabled to assure data quality standards are maintained.

6.2 Paper Health Records

Although most services are now computerised and most patient information is held electronically, some health records are still paper based. The format of these paper records varies and some are more compliant with the use of NHS Number than others. The Format of Records section within the Health Record Keeping Policy states that there should be a space for the NHS Number on every paper health record where the service being delivered is an NHS Service

The following has been identified as key to ensuring compliance with this Policy:

• Staff are appraised of the need to record NHS Number through Mandatory Information Governance training; and

• The organisation’s annual record keeping audit covers the recording of NHS Number in paper records.

6.3

Clinical Correspondence

The Department of Health specifies that verified NHS Numbers must be used routinely on all clinical communications, i.e. referrals forms and letters.

In order to satisfy this requirement any patient letter templates submitted to the Systems team must include a merge field for inclusion of the NHS Number. Any letters that do not allow this will be rejected.

6.4

New Births

The Child Health Department ensures that new birth information is entered onto SystmOne, including NHS Number.

For Home Birth’s the Child Health team will generate a new NHS number using the NHS Numbers for Babies (NN4B) system once a New Birth Notification is received. This information will then automatically be uploaded to the Spine and captured in SystmOne.

For Birth’s in Hospital, the Child Health team will upload the new birth information on to SystmOne, including the child’s NHS Number once received from the midwife. The NHS number is generated by the hospital.

Access to the NN4B system is obtained from the national NN4B helpdesk.

To ensure that this process is controlled only the Child Health team can allocate an NHS Number to a child. For adult records this must be referred to the Patient’s General Practice.

If any issues are identified with the use of an NHS Number staff should contact the National Back Office to resolve this. (0300 303 5035). Duplicate NHS numbers for children should be investigated by Child Health first before contacting the National Back Office.

6.5 Difficulties in registering a patient with an NHS Number

There are specific services where allocating an NHS Number to a patient may be more difficult due to the patient group they serve, e.g. sexual health services. These services need to be identified and consideration given to any further, or different, mechanisms needed for ensuring NHS Number or other unique identifiers are used on their records.

7. Validation of Data

7.1

Importance of Validation

Validation encompasses the processes that are required to ensure that the information being recorded is of good quality. These processes deal with data that is being added continuously and also can be used on historical data to improve its quality.

It is imperative that regular validation processes be undertaken on data being recorded to assess its completeness, accuracy, relevance, accessibility and timeliness. Such processes may include checking for duplicate data, validating waiting lists, ensuring that national definitions and coding standards are adopted and NHS number is used and validated.

7.2 Validation Methods

Validation should be accomplished using either of the following methods:

• Bulk reporting which involves a large single process of data analysis to identify all areas where quality issues exist and correct them.

• Regular spot checks which involves data analysis on a random selection of records against source material if available.

• Bulk reporting can be used as an initial data quality tool as this will quickly highlight any areas of concern, however further investigation will be required to identify more specific issues. Spot checks must be completed on an ongoing regular basis to ensure the continuation of data quality.

7.3 Data Standards

7.3.1 The use of data standards within systems can greatly improve data quality. These can be incorporated into systems either using electronic selection lists within computer systems or manually generated lists for services that do not yet have computer facilities. Either method requires the list to be generated from national or locally agreed definitions and must be controlled, maintained and updated in accordance with any variations that may occur. Any documentation that refers to the data standards must also be updated as needed and disseminated to all relevant parties.

7.3.2 A minimum data set has been implemented within Provide CIC and Group companies services to ensure that clinical information is routinely captured.

7.3.3 Data quality is an essential part of the overall information governance (IG) framework and is a requirement of the Data Security and Protection Toolkit for all data providers.

7.3.4 The legislative framework within which data standards should comply includes:

• Data Protection Act (2018)

• UK General Data Protection Regulation (2018)

• Freedom of Information Act (2000)

• Human Rights Act (1998)

• Access to Health Records Act (1990)

• Computer Misuse Act (1990)

• National Health Services Act (1977)

• NHS Information Governance: Guidance on Legal and Professional Obligations (2007)

7.4 Involving Clinical Staff

Clinicians must be involved in validating data that may have been entered into the system by other (authorised) staff. This may involve the clinician 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 to be amended is held within medical records. In the case of records held on electronic patient records any amendments are fully auditable. Suitable amendments should be made and the necessary explanation recorded on the system.

7.5

External Sources of Data

The validation process should use accredited external sources of information, for example, Open Exeter should be used for checking NHS number etc. Submitting externally we use data pertaining to Secondary Uses Services (SUS), Payment by Results (PBR) and Commissioning coming from providers and/or information services (including the Health Informatics Service [HIS] and Commissioning).

7.6

Source Data

Staff involved with recording data need to ensure that it is performed in a timely manner and that the details being recorded are checked with the source at every opportunity. The organisation strongly supports patient involvement and this could be by cross checking with patient records or by asking the patients themselves.

7.7

Synchronising Information Systems

In situations where data is shared between systems it is imperative that the source data be validated initially. Any modifications made to this data must then be shared with other related systems ensuring there are no inconsistencies between them. These systems must then be examined and authenticated in turn. Continuous synchronisation between systems is required to guarantee that all data sources reflect the same information.

7.8 Timescales for Validation

Where inconsistencies are identified these must be acted on immediately and documented. Note: Under Data Protection Legislation (Subject Access), patients are entitled to have their own version of events included in their health records

8. Reporting of Data

An area of Data Quality that can often be overlooked is the validation of the reports we design and use to extract and show our data. If we had completely accurate data but the report was wrong, the data we submit to commissioner and use to make judgements on could be of poor quality and incorrect.

To minimise the chance of incorrect reporting, the following principles must always be followed:

i) Building of reports that are used wider than internal use for a single department should be done by a member of staff with the relevant skillset and training, or should be done under supervision.

a. Advice should be requested from the BI Team or Systems Team where there are not trained and experienced staff within the service. The request should be made through the appropriate process, for the BI Team this is the ‘Information Request From – Internal’.

b. The service manager is responsible for arranging any required training

ii) Reports that are used wider than internal use for a single department must be thoroughly reviewed by a minimum of two employees:

a. The person that has built the reports should present the construct of the reports and should not fulfil any other role in the review

b. The review should include at least one subject matter expert

c. The review should include at least one reporting expert

d. The panel must also review and approve any amendments or deletions of reports

iii) The review and approval process should be documented in a SOP by the relevant service

9. Fraud and Bribery

Any records or information contained therein that is used, passed on misappropriated for criminal purposes by any person whether connected to Provide CIC and Group companies or not should be reported to either the Counter Fraud team for Provide CIC and Group companies at enquiries@gatewayassure.com, 01634 334697 or 07940 589263, or to the Executive Finance Director and Company Secretary at the earliest opportunity.

Staff must familiarise themselves with the Anti-Crime Policy (EFPOL01) which provides further details about Fraud and Bribery.

10.Training and Communication

10.1 Training

Training is necessary to ensure the relevant members of staff have the appropriate understanding in order to satisfy the Information Governance agenda. With suitable guidance, data quality processes 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.

As a minimum staff must complete the mandatory Information Governance training.

Line managers are responsible for identifying any additional training requirements of their staff. 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.

It is vital that all staff working with clinical and business information have received training on data quality and understand the importance it commands within the organisation both for the management and provision of patient care.

Use of a smartcard in order to access clinical records is subject to Mandatory Systems training to ensure policy compliance e.g. Record Keeping Policy, and appropriate use of the system to ensure accurate patient records. This will also ensure that staff are trained in how to record information relevant to Commissioner requirements for reporting purposes.

10.2 Communication

Copies of this policy will be made available to staff via the policy distribution process and will be on MyCompliance for staff to access. The Data Quality Policy is a mandatory requirement for all Clinical Staff to read through Metacompliance.

All new starters will receive a de-brief after attending mandatory SystmOne training which will include a link to the Data Quality policy.

11.Non-Compliance

Non-compliance with the terms of this policy could result in disciplinary action, which may ultimately lead to dismissal or criminal prosecution.

12.Monitoring and Review

All staff are responsible for monitoring their compliance with this policy: line managers and supervisors should also monitor compliance on a regular basis.

A review of this policy will be initiated every 3 years by the Information Governance Manager. Earlier review may be required in response to exceptional circumstances, organisational change or relevant changes in legislation.

13.References

Data Security and Protection Toolkit: https://www.dsptoolkit.nhs.uk/ (accessed online 21/11/2023)

NHS Digital: https://digital.nhs.uk/ (accessed online 21/11/2023)

Data Protection Legislation: https://ico.org.uk/ (accessed online 21/11/2023)

NHS Information Governance: Guidance on Legal and Professional Obligations (2007): https://assets.publishing.service.gov.uk/media/5a7c3bd6e5274a1b0042262b/NHS_In formation_Governance_Guidance_on_Legal_and_Professional_Obligations.pdf (accessed online 21/11/2023)

EQUALITY IMPACT ASSESSMENT

TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

Data Quality Policy

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

Project/Policy Manager: Information Governance Manager Date: 21/11/2023

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

Neutral

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

Neutral

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

No. Monitoring will be carried out by Governance team.

Policy is reviewed every 3 years in response to local and national requirements.

Guidelines: Things to consider

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

N/A

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

N/A

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

N/A

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

Policy reviewed every 3 years to take into account both local and national initiatives

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised.

It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative.

The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action.

If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.disabilitynow.org.uk – online disability related newspaper www.womenandequalityunit.gov.uk – Gender issues in more depth www.opportunitynow.org.uk - Employer member organisation (gender) www.efa.org.uk – Employers forum on age www.agepositive.gov.uk – Age issues in more depth