Trust Informatics Policy Information Quality Department Information Quality Assurance Policy
Policy Reference: 3572
Royal Liverpool and Broadgreen University Hospital NHS Trust
Document Control Document Title Author/Contact
Information Quality Assurance Policy Information Quality Manager
Document Reference
3572
Document File Path
EQMS
Document impact assessed
Yes
Version
5.0
Status
Approved
Publication Date
09/08/2011
Review Date
03/07/2013
Approved by (Executive)
Dr P Williams
Date: June 2011
Ratified by (Relevant Group) Information Governance Group
Date: 04/07/2011 Date: 04/07/2011
Distribution: Royal Liverpool and Broadgreen University Hospitals NHS Trust Policy Website Please note that the Policy Website version of this document is the only version that is maintained. Any printed copies must therefore be viewed as “uncontrolled” and as such, may not necessarily contain the latest updates and amendments. Document History Version Date Comments Author Draft. 0.1 14/10/02 A Penketh Board agreed version. 1.0 04/11/02 A Penketh Review board. 1.2 31/03/04 A Penketh Document review. 2.0 10/11/05 A Penketh Update font size in Appendix b. 2.1 18/01/06 J Pepper Change to Clinical and Cost 2.3 18/01/06 J Pepper 3.0 Draft
07/11/06
3.1 4.0
29/01/07 01/03/2011
5.0
01/05/2011
Effectiveness sub group. Amendment to include adequacy of data and policy on policy amendments. Grammar update Policy Updated and Amended and inclusion of specific external data reporting section Policy reviewed and additional section regarding information quality dimensions added
Information Quality Manager Information Quality Assurance Policy IQA
J Pepper J Pepper S Carroll S. Carroll
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Royal Liverpool and Broadgreen University Hospital NHS Trust
Review Process Prior to Ratification NAME OF GROUP/DEPARTMENT/SPECIALIST
DATE
COMMITTEE Information Governance Group Information Governance Group Information Governance Group
Information Quality Manager Information Quality Assurance Policy IQA
13.10.06 March 2007 July 2011
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Royal Liverpool and Broadgreen University Hospital NHS Trust
Table of Contents 1.0 INTRODUCTION ............................................................................................5 2.0 OBJECTIVE....................................................................................................5 3.0 SCOPE ...........................................................................................................6 4.0 POLICY...........................................................................................................6 4.1 Information Quality Dimensions...................................................................6 4.2 Achieving the Information Quality Dimensions ............................................7 4.3 Analysis of Trust Data .................................................................................9 4.4 Use of External Data Services.....................................................................9 4.5 Information Quality Reporting....................................................................10 4.6 Information Quality Improvement Process.................................................10 4.7 Information Governance Toolkit (IG Toolkit)..............................................10 4.8 Communication .........................................................................................10 4.9 Accountability ............................................................................................11 5.0 ROLES & RESPONSIBILITIES....................................................................11 6.0 ASSOCIATED DOCUMENTATION AND REFERENCES............................12 7.0 TRAINING AND RESOURCES ....................................................................12 8.0 MONITORING AND AUDIT ..........................................................................12 APPENDIX A COMMISSIONING DATA SET SUBMISSION PROCESS ...........13 APPENDIX B DATA QUALITY IMPROVEMENT PROCESS AND MANAGEMENT REPORTING STRUCTURE. ....................................................14 APPENDIX C – LIST OF LOCATION OF KEY DATA ITEMS .............................15
Information Quality Manager Information Quality Assurance Policy IQA
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
1.0 Introduction The Royal Liverpool and Broadgreen University Hospitals NHS Trust recognises that for accurate and correct decisions to be made whether they be at a clinical, managerial or financial level, the data on which these decisions are based must be of the highest possible quality. Every decision in the planning and delivery of services is based on information collected about individual patients and informed decisions will depend on the availability of complete, accurate, consistent, relevant and timely data. Therefore, it is essential that the organisations approach to data quality is clearly defined and is easily accessed by all members of staff. 1.1 Equality and Diversity The Trust is committed to an environment that promotes equality and embraces diversity in its performance as an employer and service provider. It will adhere to legal and performance requirements and will mainstream equality and diversity principles through its policies, procedures and processes. This policy should be implemented with due regard to this commitment. To ensure that the implementation of this policy does not have an adverse impact in response to the requirements of the Race Relations (Amendment Act) the Disability Discrimination Act 2005, and the Equality Act 2006 this policy has been screened for relevance during the policy development process and a full impact assessment conducted where necessary prior to consultation. The Trust will take remedial action when necessary to address any unexpected or unwarranted disparities and monitor practice to ensure that this policy is fairly implemented. This policy and procedure can be made available in alternative formats on request including large print, Braille, moon, audio, and different languages. To arrange this please refer to the Trust translation and interpretation policy in the first instance. The Trust will endeavour to make reasonable adjustments to accommodate any employee/patient with particular equality and diversity requirements in implementing this policy and procedure. This may include accessibility of meeting/appointment venues, providing translation, arranging an interpreter to attend appointments/meetings, extending policy timeframes to enable translation to be undertaken, or assistance with formulating any written statements.
2.0 Objective The objective of this policy is to ensure that all relevant staff understand the Trust’s requirements for handling, obtaining, retrieving, using and sharing (HORUS) clinical information.
Information Quality Manager Information Quality Assurance Policy IQA
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
3.0 Scope This policy is intended to cover all types of patient information recorded within the Trust, regardless of the system and whether held in paper or electronic format. Further, this policy will cover all Royal Liverpool and Broadgreen University NHS Hospital Trust (RLBUHT) employees as well as all users in its partner organisations, or organisations that use systems which interface RLBUHT systems. 4.0 Policy 4.1 Information Quality Dimensions Data Quality needs to be addressed within existing working practices and work plans and be managed in a focused way. All department procedures must address all aspects of data quality. Data should be accessible and used by staff to improve the standard of patient care. It is important to specify what constitutes good data quality and a way this quality can be measured. The quality of information held on Trust systems will be monitored using the following information quality dimensions. 4.1.1 Validity All data items held on the Trust’s i.PM system will be valid and should map to the relevant national value specified in the NHS Data Dictionary, where applicable. Where updates and changes to the NHS data definitions are specified through Information Standard Notices (ISN), the Information Quality department or relevant system administrator is responsible for the implementation and compliance of these changes within their responsible systems. These changes should also be reflected in training materials. Organisational Data Service (ODS) reference files will be loaded into Trust systems at the earliest opportunity after being published to ensure that the most up-to-date reference data is available for staff. Where systems have in-built validations, these must be used as an additional check of data quality i.e. QAS postcode functionality built into i.PM The Information Quality department will also be responsible for the maintenance of local reference data such as wards and clinicians on the i.PM system in accordance with local policy. 4.1.2 Completeness Staff must ensure that they capture all mandatory data items required to ensure that a complete data set is captured for the activity they are recording, providing a complete record of the activity provided to the patient.
Information Quality Manager Information Quality Assurance Policy IQA
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
Where data items are not captured or cannot be determined, only default values specified in the NHS Data Dictionary will be used to complete the mandatory data set. Default values should only be used when all other available means of determining that data value have been exhausted. 4.1.3 Consistency The recording of activity must be captured in a consistent fashion. This can only be achieved by ensuring that all relevant staff are trained to capture data correctly. 4.1.4 Accuracy Accuracy is a measure of how correct a value recorded is. The recording of a valid value does not necessarily make that value accurate. All data recorded on Trust systems must be accurate; that is, reflective of the service provided that data is intended to capture. Trust staff must ensure that they accurately update existing data and record new data on Trust systems. 4.1.5 Timeliness All activity data should be recorded at the time, or as close to the time as possible that that event occurred, on all relevant systems. Failure to record activity in a timely manner can impact patient care and may result in financial implications to the Trust. All Clinical Coding (ICD-10 and OPCS-4) as well as Accident and Emergency coding should be recorded within 5 working days of the following month during which the attendance or discharge occurred. The Information Quality department will submit all activity recorded on the Trust i.PM Patient Administration system to the Secondary Uses Service (SUS) in accordance with the nationally agreed Payment by Results (PbR) reconciliation and post reconciliation dates as published by the Information Centre (IC). 4.2 Achieving the Information Quality Dimensions By achieving the information quality dimensions, the Trust will be provided with assurance that they are recording activity which is of high quality. The following outlines the processes which will support the Trust’s approach to data quality. 4.2.1 Validation and Quality Assurance Validation encompasses the processes that are required to ensure that the data being recorded is of high quality. It is imperative that regular validation processes are undertaken of data recorded on the i.PM system covering the information quality standards specified in section three of this document.
Information Quality Manager Information Quality Assurance Policy IQA
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
A combination of local validation reports using the Trust data warehouse Ardentia as well as the use of externally available reporting and local audit will assist in providing assurance of the quality of data recorded. 4.2.1.1 Internal Validation Trust data will be subject to regular validation through locally created validation reports. The internal validation reporting will be developed to encompass the following areas: • • •
Known system errors/bugs/issues User Errors Any other areas of concern
In order to comply with the Information Governance Toolkit, standard 507, the Trust is required to complete the Completeness and Validity check on Trust data submitted to the Secondary Uses Service (SUS). The checks provide a level of assurance that the data the Trust is submitting to SUS is of a acceptable standard and enables the identification of potential data quality issues (identified as ‘bad cases’). The checks will be completed by the Information Quality team on a monthly basis. Further details of the methodology are held locally within the department. Further internal validation will be completed on activity data held on SUS by the Trust, to ensure that the data held nationally is reflective of the services provided. Any new quality issues identified will be managed via the Data Quality Improvement Process and Management Reporting Structure outlined in Appendix B. 4.2.1.2 External Validation Data is securely submitted to the Secondary Uses Service (SUS) where it can then be accessed by relevant organisations. Any issues or queries identified by these organisations which are raised to the Information Quality team will be investigated fully and will be Data Quality Improvement Process and Management Reporting Structure outlined in Appendix B. 4.2.1.3 Benchmarking Where possible, the Trust should benchmark its data against national targets and other Trusts in an attempt to gauge its performance against peer organisations. This analysis will also assist in the identification of areas where the organisations data quality is failing or requires further investigation.
4.2.1.4 Audits
Information Quality Manager Information Quality Assurance Policy IQA
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
The quality of data recorded on Trust systems should be subject to local audit when possible. Areas for audit will be outlined in the Information Quality Audit Plan at the beginning of each financial year. The audit plan will incorporate the audits required in the Information Governance Toolkit standards such as the accuracy audit. Information quality audits are managed separately to the Clinical Coding audits, which are the responsibility of the Clinical Coding department. The Information Governance Group reviews all patient data quality and clinical coding audits. 4.3 Analysis of Trust Data 4.3.1 Use of Internal Analysis The regular monitoring and review of Trust data is undertaken by the Corporate Information and Audit team. Any discrepancies must be reported to the Information Quality team to investigate further. The Information Quality team will also analyse and review data on a regular basis in an attempt to identify any areas requiring further investigation. 4.3.2 Use of External Data Quality Reporting Services There are several national data quality tools available which are used to monitor data quality performance: o o o o
eDQRS Reporting Information Centre Data Quality Dashboards Secondary Uses Service reporting Dr. Fosters Analysis
In addition, there are regional reports which should also be used: o Liverpool PCT Completeness and Validity Checks 4.4 Use of External Data Services Nationally provided data sources will be used to assist in the validation of patient demographic data. These systems are, but not limited to: o o o o o
Summary Care Record (SCR) Electronic Reporting Service (ERS) Demographic Batch Service (DBS) Open Exeter Use of Patient Demographic Service (PDS) (i.PM interfaces directly to this service)
Other NHS organisations, both local and nationwide will also be contacted when required to ascertain patient demographic information when it is missing. Information Quality Manager Information Quality Assurance Policy IQA
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4.5 Information Quality Reporting 4.5.1 Trust Board Reporting The Information Quality team will report performance to the Trust Board on a quarterly basis. The indicators reported will be regularly reviewed and will use external and local data sources. 4.5.2 Divisional/Department Reporting Divisional and departmental reporting will be developed to advise these areas of their own data quality performance. Errors relating to specific members of staff will be reported to the appropriate line manager, who takes the appropriate action as per the Data Quality Improvement Process and Management Reporting Structure outlined in Appendix B. 4.5.3 Ad Hoc Reporting Ad hoc reporting will be used when a particular issue has been identified and an action plan has been formulated. The ad hoc reporting will continue on a frequent basis until the issues has been resolved, at which point the reporting will cease. 4.5.3.1 Submission of Commissioning Data Sets (CDS) The Information Quality team is responsible for submitting all CDS files to SUS by the nationally agreed Payment by Results reconciliation and post reconciliation dates. These dates enable the population of such data to the Hospital Episodes Statistics (HES). HES is the data source for a wide range of healthcare analysis for the NHS, Government and many other organisations and individuals. The process of submission is outlined in Appendix A. 4.6 Information Quality Improvement Process The data quality process and structure within the Trust which supports the continuous improvement of data quality is highlighted in Appendix B. 4.7 Information Governance Toolkit (IG Toolkit) The IG Toolkit provides best practice standards which the Trust should comply with to ensure that procedures and processes are in place to address the requirements of this performance tool. 4.8 Communication 4.8.1 Information Quality Team The Information Quality team will meet at least once a month to discuss any issues affecting data quality, and will take relevant actions to resolve such issues. The team will liaise with supervisors and Trust management to raise such issues on relevant agendas and will strive to address such issues.
Information Quality Manager Information Quality Assurance Policy IQA
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
The Information Quality team will ensure there are adequate processes for communicating and sharing data and information both internally and externally and that procedures are in place for the resolution of enquiries. 4.8.2 Information Governance Group Any data quality issues of significant impact will be raised to the Information Governance Working Group (IGG). IGG is a high-level group led by the Medical Director with the Director of IM&T and senior management. The Information Governance Group is situated within the Trusts formal Governance reporting structure. The Information Governance Group meets approximately once a quarter. The group considers new policies, data quality audits, records management audits amongst other issues. Items discussed at this meeting go both up and down the organisation. Further decisions or reporting will go up to the Clinical & Cost Effectiveness Sub Committee for further consideration and if required on to the Clinical Governance Committee. 4.9 Accountability Accountability for operational data quality issues is the responsibility of the Information Quality Manager. Responsibility for management of the Information Quality Agenda falls to the Information Governance Manager. The Director of Information is responsible for the overall Information Governance Agenda. The point of contact for information quality issues will be the Information Quality Department. Managers must ensure appropriate measures are taken in their area of responsibility to meet the Information Quality Assurance Agenda and address data quality issues if/when directed. 5.0 Roles & Responsibilities 5.1 General Every individual employee has responsibility for entering electronic data into key systems in a timely, accurate and secure method. This responsibility should be outlined in all job descriptions, regardless of the role. Each individual has a duty to understand the systems in use and use them effectively while maintaining knowledge and competency. Each individual should seek to identify the adequate amount of information required in order to properly fulfill the purpose the data is collected.
5.2 Author Information Quality Manager Information Quality Assurance Policy IQA
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Royal Liverpool and Broadgreen University NHS Hospital Trusts
This policy is the responsibility of the Information Quality Manager who will be responsible for its review and maintenance. 5.3 Department Managers All department managers are responsible for ensuring that their staff are aware of the policy and that they are trained to ensure they are able to comply with its content 6.0 Associated documentation and references This policy should be read in conjunction with all Trust Informatics Policies. All Trust policies are accessible via the Trust’s Intranet site. 7.0 Training and Resources All staff will be trained on Trust systems by the I.T. training team and will not receive access to such systems until training has been completed. As systems or processes change, related documentation and training must be reviewed and updated as necessary to ensure it accurately represents the changes implemented. The I.T. training team is responsible for updating training documentation as directed by the Trust. The Information Quality team will work closely with the I.T. training team to ensure that a training programme is developed and maintained to ensure that staff are empowered to make the right decisions when recording activity, assisting in the achievement of the organisations data quality dimensions. Any training delivered must encompass the recording of activity data as well as the reasoning for recording data in that way. Supervisors and Trust Managers are responsible for ensuring that their staff are fully trained in the use of Trust systems and that their staff training requirements are met. Refresher training will be provided to staff, or when there is a change to national/local guidance which results in a procedural change. Staff can access training materials as required via the Trust intranet or upon request. 8.0 Monitoring and Audit Audits are carried our as outlined in section 4.2.1.4 of this document. This Policy will be reviewed annually or if there are significant changes to how the Trust approaches and manages data quality.
Information Quality Manager Information Quality Assurance Policy IQA
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Appendix A Commissioning Data Set Submission Process
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Appendix B Data Quality Improvement Process and Management Reporting Structure.
Information Quality Manager Information Quality Assurance Policy IQA
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Appendix C – List of Location of Key Data Items CDS Primary location Option System generated (IPM) M
Key Data Item Local Patient Identifier NHS Number
O
IPM or Casenotes
NHS Number Status Indicator
M
System generated (IPM)
Post Code of Usual Address
O
IPM or Casenotes
Ethnic Category
M
IPM
Code of GP Practice (Registered GMP)
M
IPM
Birth Date
O
IPM or Casenotes
Sex
O
IPM or Casenotes
Administrative Category
M
IPM
Patient Classification
M
IPM
Start Date (Hospital Provider Spell)
M
IPM or Casenotes
Admission Method (Hospital Provider Spell)
M
IPM
Source of Admission (Hospital Provider Spell) Discharge Destination (Hospital Provider Spell) Discharge Method (Hospital Provider Spell)
M
IPM
M
IPM or Casenotes
M
IPM or Casenotes
Discharge Date (Hospital Provider Spell)
M
IPM or Casenotes
Start Date (Episode)
M
IPM or Casenotes
End Date (Episode)
M
IPM or Casenotes
Decided to Admit Date
O
IPM or Casenotes
Intended Management
M
IPM
Consultant Code
M
IPM
Treatment Function Code
M
IPM
Primary Diagnosis (ICD)
O
IPM or Casenotes
Secondary Diagnosis (ICD)
O
IPM or Casenotes
Primary Procedure (OPCS)
M
IPM or Casenotes
Procedure Date (Primary)
M
IPM or Casenotes
Health Resource Group (HRG)
M
System generated (IPM)
Source of Referral for Outpatients
M
IPM or Casenotes
Referral Request Received Date
O
IPM or Casenotes
Attended or Did Not Attend
O
IPM or Casenotes
First Attendance
M
System generated (IPM)
Outcome of Attendance
O
IPM or Casenotes
Attendance Date
M
IPM or Casenotes
Decided to Admit Date (for this provider)
M
IPM or Casenotes
Original Decided to Admit Date
M
System generated (IPM)
O = Optional
M = Mandatory
Information Quality Manager Information Quality Assurance Policy IQA
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