Information Governance Steering Group

Meeting

/ Bexley Formal Clinical Commissioning Cabinet

Agenda Heading

For Decison

Enclosure

G 131/11

Date of Meeting

27th October 2011

Title of report / Approval of the IGSG Terms of Reference
Next Steps /

Revised and approved at the IGSG on 20th September 2011
Approval required by Bexley BSU Corporate Meeting October 2011
Ratification required by Clinical Commissioning Cabinet October 2011

Executive summary

The Terms of Reference for the IGSG have been reviewed and amended in view of the following;

Changes in the organisational structure committees
Details relating to job titles and positions have been updated
Quoracy issues have been discussed and amended to reflect this.
Information Governance management details updated to reflect changes relating to the new SIRO and IAO Cluster arrangements.

The BSU Corporate Team are requested to APPROVE the terms of reference before ratification by the Bexley Clinical Commissioning Cabinet.
Organisational implications
Financial / No issues have been identified
Equality and Diversity / No issues have been identified
Risk (governance and/or clinical) / No issues have been identified
Patient impact / No issues have been identified
NHS constitution / The principles of the NHS Constitution have been considered when preparing this report.
Which objective does this paper support? / Insert Tick ()
Improve choice and access to integrated health services for Bexley patients
Reduce the level of health inequalities across Bexley
Improve care for patients with long term conditions & increase the range of services offered within the community
Improving the health & wellbeing for people in Bexley
Maximizing the opportunities of joint working (APoH, JSNA, Wellness agenda etc)
Using our resources in the most efficient & effective manner (organisational & financial)
Report Author / Alison Pryor
Date / 5th October 2011
Contact Details / 020 8 298 6007
Executive sponsor / David Parkins
SE LONDON
BEXLEY BUSINESS SUPPORT UNIT
Title: Information Governance Terms of Reference / Reference No:
Version: V 2.3
Originating Department: / ICT
Sponsor: Information Governance Steering Group / Date Issued:
30th September 2011
Authors: Nisha Wheeler
Approved by: Information Governance Steering Group / Date approved:
21 September 2011
Approved by: Bexley BSU Corporate Meeting / Date:
Ratified by: Bexley Clinical Commissioning Cabinet / Date:
Target Audience: All Bexley BSU Staff / Next Review Date: Sept 2012

INFORMATION GOVERNANCE TERMS OF REFERENCE

Version Control Sheet

Version / Date / Author / Status / Comment
1. / February 2011 / Nisha Wheeler / Approved / Review of current ToR
2. 1 / July 2011 / Nisha Wheeler / DRAFT / Membership review and committee changes
2.2 / August 2011 / Nisha wheeler / DRAFT with amendments / Changes completed further check
2.3 / Sept 2011 / Nisha Wheeler / Draft with further amendments re quoracy / Changes and Compliance re Sector IAO

Consultation page

Nisha Wheeler / Assistant Director of ICT
Sponsor: / IG Steering Group
Authors: / Nisha Wheeler

Consultation Panel

Name / Designation
Pam Creaven / Director of Operations and Total Health/Medical Director /Lead Information Asset Owner
David Parkins / Clinical Quality Lead and Caldicott Guardian
Nisha Wheeler / Assistant Director of ICT
Michael Fairbairn / Clinical and Corporate Risk Manager
Pin Bhandal / Head of ICT
Mary Stoneham / Corporate Office Manager
Sue Sitch / Information Analyst
Julie Witherall / Assistant Director of Finance Performance and Information
Sue Flanagan / Primary Care Systems Manager
Janet Reid / Project Manager
Louise Hart / Business Support Officer

Information Governance Steering Group

“Information Governance is the framework by which the NHS safeguards information about patients and employees – in particular, personal and sensitive information. It allows individuals and NHS and partner organisations to ensure that personal information is dealt with legally, securely, efficiently and effectively in order to deliver the best possible care.”[1]

Terms of Reference:

Summary:

Information is a vital asset, both in terms of the clinical management of individual patients and the efficient management of the Trust’s services and resources. It plays a key part in both clinical and information governance, as well as service planning and performance management. It is therefore of paramount importance to ensure that information is efficiently managed, and that appropriate policies, procedures and management accountability provide a robust governance framework for information management.

Aim:

To ensure that patient confidentiality and the security of personal or sensitive information remains uncompromised.
To ensure there is clear management accountability within the Trust that provides a robust governance framework for information management.
To ensure that the Trust’s policies and procedures are compliant with appropriate national guidance and best practice advice for Information Governance.
The Information Governance Steering Group reports into the BSU Corporate Team and when appropriate to the Clinical Commissioning Cabinet to provide assurance on matters relating to Information Governance and to highlight any risks associated with it.
To ensure that the annual submission of the Information Governance Toolkit on the 31st March shows an annually improving trend in the Trust’s RAG scores.

Objectives:

To ensure appropriate arrangements are in place for the confidentiality and management of patient records
To ensure appropriate arrangements are in place for the confidentiality of employee records
To oversee arrangements for the handling of Freedom of Information (FOI) requests
To support the work of the Caldicott Guardian in relation to the above
To ensure that the Trust has robust policies in place for all core components of the Information Governance framework
To develop quarterly highlight reports for the BSU Corporate Team meeting providing assurances as necessary with respect to Information Governance
.
To highlight to the BSU Corporate Team and Clinical Commissioning Cabinet any areas of high risk relating to the Trust with respect to Information Governance
To work collaboratively with NHS SE London Cluster and other London Trusts on the Information Governance Assurance Programme
To ensure all Trust staff have the necessary knowledge and training to ensure that they can fulfill their obligations with respect to Information Governance
To work closely to the Information Governance annual work plan in order to ensure the Trust meets it’s obligations with respect to Information Governance

To ensure that periodic vulnerability testing of the IG Framework is carried out in the organisation and the outcomes reported to the Information Governance Committee.

Core Components:

There are six core components of the Information Governance framework. The table below sets out each of these core components together with the name of the Trust Leads who have been assigned responsibility for them:

Core Components of the Information Governance Framework
Sponsor / Owner
Information Governance Management / Director of Operations and Total Health /Medical Director / AD of ICT
Confidentiality and Data Protection Assurance / Clinical Quality Lead / Head of ICT
Information Security Assurance / Chief Finance Officer / Head of ICT
Clinical Information Assurance / Clinical Quality Lead / Clinical and Corporate Risk Manager
Secondary User Assurance / AD of Finance Performance and Information / Information Analyst
Corporate Information Assurance / Chief Finance Officer / Corporate Office Manager

Information Governance and the Wider Trust Framework

It is acknowledged that the Information Governance Toolkit is assessed purely on the six components detailed above. The Trust, however, recognizes that its Information Governance obligations are wider than this and considers the safeguarding of employee information and sensitive data also within its remit as well as being responsible for monitoring Information Governance with respect to GP Practices.

To ensure that the Steering Group is able to advise on all aspects of Information Governance, the group membership has been extended to include those leads responsible for the core components of the Information Governance framework as well as other leads from the Trust whose areas of work may impact on staff and patients alike if either patient identifiable data, personal data or sensitive data were compromised.

The table below sets out the membership of the Information Governance Steering Group:

Membership of the Information Governance Steering Group
Director of Operations and Total Health/Medical Director and Lead Information Asset Owner with delegated authority from SE London Cluster
Clinical Quality Lead & Caldicott Guardian – Chair
Assistant Director of ICT – Deputy Chair
Clinical and Corporate Risk Manager
Head of ICT
Corporate Office Manager
Information Analyst
Assistant Director of Finance and Resources
Primary Care Systems Manager
IT Project Manager
Head of Communications
Public Health Representative
Clinical Redesign and Governance Representative
Medicines Management

Reporting:

The Information Governance Steering Group reports to the BSU Corporate Team and will raise key issues and risks to this committee and the Clinical Commissioning Cabinet.

Sub Groups:

Reporting and any new work streams which are necessary to be undertaken, will be carried out by a designated sub-group, with full reporting responsibilities to the Information Governance Steering Group.

Frequency of Meetings:

Monthly

Quorum agreed

The minimum requirements for the Information Governance Group to be quorate will be at least 5 members, including the Chair or Deputy Chair.

A partnership of Primary Care Trusts in Bromley, Greenwich, Lambeth, Lewisham, Southwark and Bexley Care Trust

Chair: Caroline Hewitt Chief Executive: Andrew Kenworthy

[1] Connecting for Health