1. Information Governance for Practice Staff1

2. Introduction Confidentiality; including Caldicott Data Protection
Information Sharing
Freedom of Information
Records Management
IM&T Security

3. The consequences of not considering Information Governance in GP surgeries
2007
April: Patient info found in skip behind building when GP branch being renovated
November: Patient Data losses at GP surgery – 3000
2008
Jan: Dictaphone holding patient identifiable information stolen from GP practice room.
June: GPs laptop stolen from home containing patient records
July: Back up Tape lost from GP surgery containing 11,000 records

4. ICO research into social concerns
Environmental issues
Preventing crime
Improving education
The National Health Service
Equal rights
National security
Protecting personal information
Protecting freedom of speech
Unemployment
Access to information held by public authorities

5. ICO research into social concerns
Preventing crime 94%
Protecting personal information 92%
The National Health Service 91%
Equal rights 89%
National security 89%
Improving education 88%
Protecting freedom of speech 86%
Environmental issues 86%
Unemployment 80%
Access to information held by public authorities 79%

7. for example - patient to clinician or carer to social worker
Confidentiality
A duty of confidence arises when one person discloses information to another;
for example - patient to clinician or carer to social worker
in circumstances where it is reasonable to expect that the information will be protected and held in confidence.

8. The Duty of Confidentiality continues after the death of a patient
TRUE or FALSE

9. TRUE
Any information provided in confidence, for example, within a health record, must remain confidential following a patient’s death

10. Confidentiality - Mail
Envelopes – Marked Private & Confidential, For Addressee Only
Royal Mail - Special Delivery
Courier – Trusted, Tracked, with a Signed Confirmation
Delivery Confirmation
Mail Opening Process

11. Confidentiality – Fax Could it go by safer means
Use Safe Haven or Secure fax number
Mark as Private and Confidential to a named person
Confirm recipients fax number
Transmit in 2 parts -
Confirm receipt of first faxed sheet
Confirm receipt of remaining sheets

12. Confidentiality – Email ISMS Section 6
PII must only be sent in a password protected or encrypted file
DO NOT send PII in the ‘subject’ or content of
Sent High Priority and Confidential
If possible use NHS Number
Use Safe Haven addresses
Confirm receipt

13. Confidentiality - Telephone
Avoid exchanging sensitive PII unless it is a matter of life and death
Only exchange PII in a closed (Safe Haven) room
If you cannot prevent someone from giving you PII over the telephone:
Take the callers full details
Verify who the caller is
Record the PII carefully
Read back to confirm the details
Ask for written confirmation using agreed anonymised identifier

14. Confidentiality – Public Areas
Always be aware who is in the vicinity
Who can listen to telephone calls
Who can listen to conversations
Who can see personal identifiable information on desks
Who can see personal identifiable information on monitors
Respect the privacy of individuals

15. Consent & Confidentiality
ISMS Section 3
Obtaining consent for treatment or for the disclosure of personal information;
Consent is specific to the uses defined in the information process;
3 types of consent - Implied, Informed and Explicit;
Some laws override the need for consent, e.g. Children’s Act, Vulnerable Adults, Tax and Benefits; Crime and Disorder Act s115.

16. Consent ISMS Section 3
Consent is voluntary and even if it is signed it can be withdrawn at any time;
Consent must be revisited regularly;
Consent must be gained for any new use of personal information

18. You always need consent before doing anything with personal information
TRUE or FALSE

19. FALSE
There are various conditions (other than consent) in the Data Protection Act which allow you to process personal information.

20. Balance
Healthcare employees are entrusted with patients’ confidence and have a legal obligation to protect their privacy.
The need for confidentiality must be balanced against the need for NHS staff to have access to patient information.

21. What is Caldicott? ISMS Section 3
A set of principles and recommendations put forward by the Caldicott Committee in 1997 which apply to Health and Social Care Organisations to ensure Patient Identifiable information remains confidential and secure

22. Caldicott Principles ISMS Section 3
Justify the purpose
Use Patient Identifiable Information only if absolutely necessary
Only use the minimum amount necessary
Access only on a strictly need to know basis
Know your responsibilities
Understand and comply with the law

23. Key Requirements of Caldicott ISMS Section 3
Appoint a Caldicott Guardian or Lead (should be a Senior Clinician)
Definition of Guardian ‘one who protects’
Abide by Caldicott principles
Ensure Polices and Procedures to protect PII are in place and adhered to

24. The best person to undertake the role of Caldicott Guardian in my GP surgery is the Practice Manager
TRUE or FALSE

25. FALSE
The best person to undertake the role of Caldicott Guardian would be a senior clinician as they would be expected to advise on individual cases where there are concerns about patient information

26. ICO’s Video ‘The lights are on’

27. Comply with the Law ISMS Section 3
Data Protection Act 1998 – It is your responsibility to understand the principles in relation to your role and your organisation
Activity (takes around 15 minutes to complete):
Split in to 2 groups
Read the Data Protection Act 1998 principles handout
Match the principles with scenarios A to H on the following slides. There is only one scenario considered to be correct in this exercise but you may find that more than one principle may apply.

28. Scenario A Scenario B Activity
Which Principle does the scenario breach relate to?
Scenario A
Scenario B
Mr X receives a call from Wrexham hospital to tell him that his pregnant wife has been admitted. Mr X was shocked as they have been divorced for 10 years and his ex-wife remarried with his best friend. Mr X informed the hospital that he is no longer her Next of Kin.
A Mother asks to see her 16 year old daughter’s School Nurse reports as she suspects her daughter is sexually active. The School Nurse says no problem, asks for the request to be in writing and she will provide a copy of recent notes within 21 working Days.

29. Scenario C Scenario D Activity
Which Principle does the scenario breach relate to?
Scenario C
Scenario D
A health records assistant has been tasked with checking 100 random health records to see whether they are labelled with the correct NHS Number. She decides that there is not enough space in her department to do this task comfortably, so she finds a quiet meeting room in the Post Grad Centre to do this. She pops out for lunch for 1hr leaving the notes unattended and room unlocked.
Mrs Y moves from Mold to Swansea and registers herself with a new GP in Swansea. The GP goes through her records to get familiar with his new Patient’s health history. He finds abbreviations such as HT and NLW in the notes. When he asks the previous GP to explain – he laughs and says oh that means ‘Hot Totty’ and ‘Nice Looking Woman’.

30. Scenario E Scenario F Activity
Which Principle does the scenario breach relate to?
Scenario E
Scenario F
Nurse Hughes is approached by PC Jones asking how his Brother (also a Police Officer) is doing after having been shot in the line of duty. Nurse Hughes mentions that he is stable in terms of the gun wound, but they have found that his cancer has spread. When the Brother regained consciousness he was surprised to find that his Brother (PC Jones) knew about the cancer. Only his wife knew until now.
HR were approached by the their Trusts communications team asking for all staff home addresses to do a mail shot regarding the benefits for staff and training opportunities available when the implementation of the new National Programme for IT is complete at their Trust. HR agree to the staff database to the communications team a.s.a.p.

31. Scenario H Scenario G Activity
Which Principle does the scenario breach relate to?
Scenario H
Scenario G
A Finance Assistant is tasked with disposing of any old requisitions filed. Her colleague tells her to get rid of any cleared requisitions which are more than 18 months old. The assistant found 50+ requisitions nearly 3yrs old which exceeds the recommended retention period in the DH Records Management NHS: Code of Practice
A USA Social Services team heard that a UK Social Care team were using new and successful techniques to handle manic depressive young teenagers. USA team ask for a report on the methodology supported by real life case reports so that they can learn from UK findings. UK send case notes and reports via to the USA team.

32. Subject Access Requests ISMS Section 3
Gives patients and staff the right to know what personal information the organisation holds on them
Requests must be in writing
The requester may not and need not quote the DPA
The organisation must respond within 40 days. The clock starts as soon as the request is received by the organisation

33. Sharing Personal Information ISMS Section 3
Sharing information about an individual within and between partner agencies is vital to the provision of co-ordinated and seamless care to that individual. This care includes:
Improving the health and social care of people;
Arranging and delivering services;
Supporting the people in need;
Investigating complaints.

34. Sharing Personal Information ISMS Section 3
The principles underpinning the sharing of person identifiable information are governed by legislation, including:
Data Protection Act 1998
Access to Health Records Act 1990
Human Rights Act 1998
Freedom of Information Act 2000
Children’s Act 1989
Computer Misuse Act 1990
Human Fertilisation and Embryology Act 1990
Health and Social Care Act 2001
NHS Venereal Diseases Regulation 2000
Abortion Act 1967, regulations 1991

35. Examples of Information Sharing
For health care purposes
With NHS staff involved in the provision of care
Parents and Guardians (generally children under 16)
For purposes other than direct health care
Social care
Researchers
Bodies with statutory Investigative Powers – GMC, audit commission
Non health care purposes
Police (with a valid request)
Solicitors (with explicit consent from the patient)

36. Information Sharing Protocols – what are they? ISMS Section 3
A written agreement, between parties, i.e. different groups of people who are involved in sharing patient information, that:
Documents how information should be shared;
Ensures information is shared consistently, appropriately and lawfully;
Clearly defines individuals’ responsibilities when sharing information to uphold patient confidentiality.

37. Information Sharing Protocols – the benefits? ISMS Section 3
Protocols go a long way in reducing the risks of breaches because:
They provide clear guidelines on how much and what way and to whom information should be shared;
They allow individuals to make informed, confident and timely decisions about sharing information, to allow better patient care.

38. The organisation I work for has signed up to a local information sharing protocol therefore I can share personal information with any organisation that has also signed the protocol
TRUE or FALSE

39. FALSE
You still need to ensure all the legal requirements have been met before sharing information

40. When should Information Sharing Protocols not be used?
If there are concerns relating to child or adult protection issues, they should refer to the relevant documents:
All Wales Child Protection Procedures;
The Multi-agency Inter-agency Information Sharing Protocol for the Assessment of Children in Need and in Need of Protection;
Policy and procedures for responding to the alleged or confirmed abuse of vulnerable adults.

41. The Police have that power.
A Policewoman turns up at reception and demands a copy of Mr A’s medical notes immediately for an investigation.
The Police have that power.
TRUE or FALSE

42. FALSE
Unless you are provided with a copy of a court order for release, the police must provide a written request under a relevant act which should be considered by the practice prior to release

43. Requests from the Police
ISMS Section 3
They can request records under DPA S.29 or under S.115 of the Crime & disorder Act 1998.
They must provide an official written request signed by the S.I.O. (DCI or above).
You only need to disclose what is ‘Minimum and Relevant’ and get a signed receipt.
You may have to make an immediate release if they have a dated Court Order – you must obey a Court Order to the letter so read it carefully.
If their case or a Court Order requires you to release the original records, you MUST make a numbered ‘best’ copy of the records to retain.

44. Thought………
Treat other people’s information as you would like your own to be treated – with respect and confidentiality

45. Break

46. Freedom of Information Act 2000 ISMS Section 4
Gives individuals the right to access information
Have you got it? May I see it?
NON Personal Identifiable Information (PII)
The Act does not have to be quoted when making a request
20 working days to process
Exemptions apply

47. ICO's ‘Tick Tock’ Video

48. GP Publication Schemes ISMS Section 4
Under the FOI Act it is the duty of every public body to adopt and maintain a publication scheme
Demonstrate a commitment to openness
A new model publication scheme developed specifically for GP practices Jan 09 (Guide to Information)
The new guide contains details on how information can be obtained and what the costs are
Visit for more information

49. The contents of an can be disclosed under the Data Protection Act and Freedom of Information Act?
TRUE or FALSE

50. TRUE
s are corporate records of an organisation and therefore they may be disclosable by any public body

51. Why do we need Records Management ISMS Section 4
Meeting legal/statutory requirements
Supporting administrative and managerial decision-making
Efficiency within the surgery
Promoting professional image

52. Definition: Record ISMS Section 4
Recorded information regardless of media or format, created or received in the course of individual or organisational activity, which provides reliable evidence of policy, actions and decisions.

53. Types of Records ISMS Section 4
Health records
Administrative records
Photographs
Microfilm
Audio (telephone conversations)
tapes, cassettes, CD-ROM
Video, CCTV
Diaries
s, Text messages

54. Record Quality Information ISMS Section 4
All staff have a legal and professional obligation to be responsible for any records which they create or use in the performance of their duties
Users must ensure that records are:
Secure;
Accurate;
Up to date;
Complete;
Quick and easy to find;
Free from duplication;
Free from fragmentation.

55. Record Lifecycle Record Lifecycle Creation Using Retention Appraisal
Close Record
Retention
Appraisal
Disposal
Create & log Quality information
Use/handle in accordance with Data Protection Act
Keep/maintain in line with NHS recommended Retention Schedule
Determine whether records are worthy of permanent archival preservation
Dispose appropriately according to policy

56. Return of the Patient Medical Record ISMS Section 3
The LHBs are the Data Controllers for Patient Records no longer registered with a practice
Records must be returned to the BSC via Courier Bags
Complete record must be returned including clinical system prints
Checklist on ISMS website to aid process
BSC can provide copies for medical reports
Solicitors and Insurance requests are dealt with by the BSC

57. Simple things we can all do...
Computer Systems - Clear Screen Regime
Apply the screen lockdown when you are going away from your desk – CTRL+ALT+DEL and click on Lock Computer in the Computer Security Dialog Box
Log out if you’ll be away from your desk for a significant time - also at the end of the day
Ensure PII is saved to the practice network- not desktop or C drive
Manual Records - Clear Desk Regime
Lock PII files or papers away when you leave for the day, or if you’ll be from your desk for a significant period.

58. UNLESS ABSOLUTELY NECESSARY
Removing or Transporting of Patient or Person Identifiable Information ISMS Section 7
Inform the your Caldicott Guardian and Information Security Officer or Practice Manager
Risk Assessment undertaken
Authorisation must be obtained prior to removal off site
Records removed must be logged
DON’T REMOVE SENSITIVE INFORMATION FROM SITE
UNLESS ABSOLUTELY NECESSARY

59. Physical Infrastructure
ISMS Section 7
Entry control systems to buildings/corridors
Lockable filing cabinets etc
A Safe Haven Room with fax and phone
A confidential waste paper service
A confidentiality culture
A visitor monitoring process
A ‘key/card security’ process
An ‘exit’ process for leavers

60. Laptop Security ISMS Section 7
Ensure laptops, memory sticks and patient notes are locked in the boot of your car when being transported; and must be removed when the car is left unattended
Do not allow family members and friends to access any laptop belonging to the surgery
Ensure no PII is saved to the ‘C’ drive or desktop of laptop (or PC) unless encrypted
Ensure the laptop is regularly connected to the network for back up purposes
Laptops must only be used by the staff they were issued to

61. Portable Media Devices
PII must only be stored on encrypted devices
Encrypted sticks must not be used for long term storage of PII
PII must be transferred from devices onto the practice clinical system regularly
If sending PII on portable devices –only send the minimum necessary
Media devices containing PII must only be sent by Government Mail
DON’T SAVE SENSITIVE INFORMATION ONTO PORTABLE DEVICES OR MEDIA UNLESS ABSOLUTELY NECESSARY

62. The IG Confidentiality eLearning Toolkit

63. The eLearning Toolkit covers a range of key topics including:
Data Protection Act
Human Rights Act
Information Security
Disclosing and Sharing Information
Duty of Confidence
Caldicott

64. Further Information
ISMS Website
ISMS Procedures, Policies & Toolkit
FAQs
Training Materials
Leaflets & Posters
Forum
News, Events and Hot Topics

65. Any Questions?