Presentation on theme: "Information Governance for Practice Staff. Introduction Confidentiality; including Caldicott Data Protection Information Sharing Freedom of Information."— Presentation transcript:
Information Governance for Practice Staff
Introduction Confidentiality; including Caldicott Data Protection Information Sharing Freedom of Information Records Management IM&T Security
Information Governance for Practice Staff 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 – 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
Information Governance for Practice Staff 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
Information Governance for Practice Staff 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%
Information Governance for Practice Staff
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.
Information Governance for Practice Staff The Duty of Confidentiality continues after the death of a patient TRUE or FALSE
Information Governance for Practice Staff TRUE Any information provided in confidence, for example, within a health record, must remain confidential following a patients death
Information Governance for Practice Staff 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
Information Governance for Practice Staff 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
Information Governance for Practice Staff Confidentiality – 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
Information Governance for Practice Staff 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
Information Governance for Practice Staff 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
Information Governance for Practice Staff 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. Childrens Act, Vulnerable Adults, Tax and Benefits; Crime and Disorder Act s115. Consent & Confidentiality ISMS Section 3
Information Governance for Practice Staff 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
Information Governance for Practice Staff Information Leaflets/Posters What information is held on Patient? Who Information will be shared with? Records treated with respect and confidentiality Use of record for local clinical/ performance audits Information given by patient will be recorded Why information is collected? Right of patients to have access to Health records
Information Governance for Practice Staff You always need consent before doing anything with personal information TRUE or FALSE
Information Governance for Practice Staff FALSE There are various conditions (other than consent) in the Data Protection Act which allow you to process personal information.
Information Governance for Practice Staff 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.
Information Governance for Practice Staff 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
Information Governance for Practice Staff 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
Information Governance for Practice Staff 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
Information Governance for Practice Staff The best person to undertake the role of Caldicott Guardian in my GP surgery is the Practice Manager TRUE or FALSE
Information Governance for Practice Staff 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
Information Governance for Practice Staff ICOs Video The lights are on
Information Governance for Practice Staff 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. 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
Information Governance for Practice Staff Scenario A 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. Scenario B Activity Which Principle does the scenario breach relate to? A Mother asks to see her 16 year old daughters 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.
Information Governance for Practice Staff Scenario C 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. Scenario D Activity Which Principle does the scenario breach relate to? 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 Patients 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.
Information Governance for Practice Staff Scenario E 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. Scenario F Activity Which Principle does the scenario breach relate to? 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.
Information Governance for Practice Staff Scenario G 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. Scenario H Activity Which Principle does the scenario breach relate to? 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
Information Governance for Practice Staff 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
Information Governance for Practice Staff 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.
Information Governance for Practice Staff 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 –Childrens 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
Information Governance for Practice Staff 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)
Information Governance for Practice Staff 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.
Information Governance for Practice Staff 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.
Information Governance for Practice Staff 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
Information Governance for Practice Staff FALSE You still need to ensure all the legal requirements have been met before sharing information
Information Governance for Practice Staff 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.
Information Governance for Practice Staff A Policewoman turns up at reception and demands a copy of Mr As medical notes immediately for an investigation. TRUE or FALSE The Police have that power.
Information Governance for Practice Staff 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
Information Governance for Practice Staff They can request records under DPA S.29 or under S.115 of the Crime & disorder Act 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. Requests from the Police ISMS Section 3
Information Governance for Practice Staff Thought……… Treat other peoples information as you would like your own to be treated – with respect and confidentiality
Information Governance for Practice Staff Break
Information Governance for Practice Staff 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
Information Governance for Practice Staff ICO's Tick Tock Video
Information Governance for Practice Staff 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 informationwww.ico.gov.uk
Information Governance for Practice Staff The contents of an can be disclosed under the Data Protection Act and Freedom of Information Act? TRUE or FALSE
Information Governance for Practice Staff TRUE s are corporate records of an organisation and therefore they may be disclosable by any public body
Information Governance for Practice Staff 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
Information Governance for Practice Staff 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.
Information Governance for Practice Staff 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
Information Governance for Practice Staff 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.
Information Governance for Practice Staff Determine whether records are worthy of permanent archival preservation Record Lifecycle Creation Using Retention Create & log Quality information Use/handle in accordance with Data Protection Act Keep/maintain in line with NHS recommended Retention Schedule Dispose appropriately according to policy AppraisalDisposal Close Record Record Lifecycle
Information Governance for Practice Staff 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
Information Governance for Practice Staff 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 youll 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 youll be from your desk for a significant period.
Information Governance for Practice Staff 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 DONT REMOVE SENSITIVE INFORMATION FROM SITE UNLESS ABSOLUTELY NECESSARY
Information Governance for Practice Staff 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 Physical Infrastructure ISMS Section 7
Information Governance for Practice Staff 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
Information Governance for Practice Staff 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 DONT SAVE SENSITIVE INFORMATION ONTO PORTABLE DEVICES OR MEDIA UNLESS ABSOLUTELY NECESSARY Portable Media Devices
Information Governance for Practice Staff The IG Confidentiality eLearning Toolkit
Information Governance for Practice Staff 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
Information Governance for Practice Staff Further Information ISMS Website m?orgid=542 m?orgid=542 ISMS Procedures, Policies & Toolkit FAQs Training Materials Leaflets & Posters Forum News, Events and Hot Topics
Information Governance for Practice Staff Any Questions?