Information Governance Health Care Unit

Information Governance – Health Care Unit

Guidance

Requirement PH 105

An Information Governance Policy

The Policy should be a high level statement of the Health Care Unit’s intended approach towards effectively implementing Information Governance.

It is possible that the PCT with responsibility for the Health Care Unit may have an appropriate template policy and procedure documents. The Health Care Unit should then decide whether the template is sufficient for its needs and adopt or amend the document as necessary. All procedures referenced within the IG Policy for use by Health Care Unit staff should be readily available.

The following is suggested key content that an IG policy should contain:

Key content

• A section specifying why the Policy is required
• An description of how information will be handled by the Health Care Unit – see below
• A description of accountability and responsibility for the policy
• A process for monitoring the Policy
• Health Care Unit staff duties and responsibilities for IG
• A description of how the initiatives within IG link together
• Actions to be taken if the Policy is breached

The Health Care Unit should review current policies and determine whether the ones in place / available from the PCT can be adapted to form an IG Policy.

The IG Lead should ensure the policy:

• Is a statement of the Health Care Unit’s overall information governance goals and should perhaps be no more than 3 – 4 pages long

• Outlines the procedures in place (to be put in place) that underpin the policy
• Sets out what is expected of Health Care Unit staff in order to ensure compliance
• Takes into account and reflects central guidance (above)

The IG Lead should take responsibility for considering whether any template policy from the PCT fully meets the needs of the Health Care Unit:

• Does it reflect the way in which information is handled within the Health Care Unit?
• Does the template require any amendment / removal of non-applicable detail?
• Does the template require any additions to reflect differing internal procedures?
• Which information handling initiatives are addressed within the policy? Areas that should initially be addressed are information quality, security and confidentiality. Records management and Freedom of Information duties should be added as soon as possible

The IG Policy should be made available to all members of Health Care Unit staff. Particular attention should be drawn to the section of the policy setting out staff responsibilities for compliance and also to the procedures that underpin the policy. There should be evidence that staff understand and comply with the policy.

Information Governance Strategy

An Information Governance Strategy describes the way in which improvements to the performance of the Health Care Unit will be carried out. To develop an Information Governance Strategy the Unit must understand both scope and approach. Key elements should include:

• How the Health Care Unit’s Information Governance Policy will be supported in terms of both resources and operationally? Ensuring resources devoted to Information Governance are adequate to deliver the work programme
• How existing systems and processes will be impacted
• How ownership of the Strategy will be ensured
• What mechanism will be used to review the Strategy
• How the Health Care Unit’s Strategy will link to the PCT’s IG Strategy

Improvement plans

• Level 1

The Health Care Unit has an IG Policy and Strategy approved by the Partnership Board or delegated sub-group, which addresses information quality, security and confidentiality. The Strategy includes an improvement plan for the Health Care Unit and links with the PCT's overall IG Strategy.

• Level 2

The Health Care Unit has begun to implement the IG Strategy and improvement plan including establishing links to the PCT's Risk Management processes.

• Level 3

The Health Care Unit has begun to implement the IG Strategy and improvement plan and provides progress reports to the Partnership Board or delegated sub-group. The Board annually reviews and signs off the IG Policy, Strategy and improvement plans.

Requirement checklist

IGM_PH_105_V5_Checklist_07-08-27.doc

Key Guidance Document(s)

DH: Confidentiality NHS Code of Practice

The Code is a guide to required practice for those who work within or under contract to NHS organisations concerning confidentiality and patients' consent to use their health records.

DH: Records Management NHS Code of Practice

The Code is a guide to the required standards of practice in the management of records for those who work within or under contract to NHS organisations in England. It is based on current legal requirements and professional best practice. The guidance applies to all NHS records and contains details of the recommended minimum retention period for each record type. HSC 1999/053 has now been superseded.

The Records Management Roadmap

The Roadmap comprises of ‘how to’ materials in the form of templates and checklists to assist organisations in developing and implementing solid records management processes.

DH: Information Security NHS Code of Practice

The code is a guide to the methods and required standards of practice in the management of information security for those who work within or under contract to, or in business partnership with NHS organisations in England. It is based on current legal requirements, relevant standards and professional best practice and replaces HSG 1996/15 – NHS Information Management and Technology Security Manual.

Exemplar materials:

NHS CFH MODEL Information Governance Policy

The following are not model publications but examples of real documents in use by Organisations that represent elements of good practice. They have been made available for Organisations to adapt, use and improve on as they see fit.

Heatherwood and Wexham Park Hospital IG Strategy (Acute).pdf

South West Staffordshire PCT IG Policy and Strategy

St George's Strategy Policy Improvement Plan

Useful websites:

IC: Use and Disclosure of Health Data