Information Governance for Practice Staff. Introduction Confidentiality; including Caldicott Data...

Information Governance for Practice Staff



Introduction

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


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

11000 patient records July: Back up Tape lost from GP surgery

containing 11,000 records


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


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%


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.


The Duty of Confidentiality continues after the

death of a patient

TRUE or FALSE


TRUE

Any information provided in confidence, for example,

within a health record, must remain confidential following

a patient’s death


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


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


Confidentiality – EmailISMS Section 6

• PII must only be sent in a password protected or encrypted file

• DO NOT send PII in the ‘subject’ or content of Email

• Sent High Priority and Confidential• If possible use NHS Number • Use Safe Haven Email addresses• Confirm receipt


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


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


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.

Consent & ConfidentialityISMS Section 3


ConsentISMS 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


You always need consent before doing anything with

personal information

TRUE or FALSE


FALSE

There are various conditions (other than consent) in the

Data Protection Act which allow you to process personal

information.


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.


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


Caldicott PrinciplesISMS 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


Key Requirements of CaldicottISMS 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


The best person to undertake the role of

Caldicott Guardian in my GP surgery is the Practice

Manager

TRUE or FALSE


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


ICO’s Video‘The lights are on’


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 LawISMS Section 3

Data Protection Act 1998 – It is your responsibility to understand the principles in relation to your role and your organisation


Scenario AMr 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 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.


Scenario CA 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


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’.


Scenario ENurse 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

ActivityWhich 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 email the staff database to the communications team a.s.a.p.


Scenario GA 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 email to the USA team.

Scenario H


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


Subject Access RequestsISMS 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


Sharing Personal InformationISMS 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.


Sharing Personal InformationISMS 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


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 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 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 muchand what way and to whom informationshould be shared;

• They allow individuals to make informed,confident and timely decisions about sharing information, to allow better patient care.


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


FALSE

You still need to ensure all the legal requirements have been

met before sharing information


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.


A Policewoman turns up at reception and demands a copy

of Mr A’s medical notes immediately for an investigation.

TRUE or FALSE

The Police have that power.


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


• 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.

Requests from the PoliceISMS Section 3


Thought………

Treat other people’s information as you would like your own to be treated – with respect and

confidentiality


Break


Freedom of Information Act 2000ISMS 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


ICO's ‘Tick Tock’ Video


GP Publication SchemesISMS 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 www.ico.gov.uk for more information

http://www.ico.gov.uk/


The contents of an email can be disclosed under the Data Protection Act and Freedom of

Information Act?

TRUE or FALSE


TRUE

Emails are corporate records of an organisation and therefore they may be disclosable by

any public body


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


Definition: RecordISMS 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.


Types of RecordsISMS Section 4

• Health records• Administrative records• Photographs• Microfilm• Audio (telephone conversations)• tapes, cassettes, CD-ROM• Video, CCTV• Diaries• Emails, Text messages


Record Quality InformationISMS 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.


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

Appraisal DisposalC

lose R

ecord

Record Lifecycle


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


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.


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


• 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 InfrastructureISMS Section 7


Laptop SecurityISMS 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


• 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 MailDON’T SAVE SENSITIVE INFORMATION ONTO PORTABLE DEVICES OR MEDIA UNLESS ABSOLUTELY NECESSARY

Portable Media Devices


The IG Confidentiality

eLearning Toolkit


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


Further Information

ISMS Website http://howis.wales.nhs.uk/sites3/home.cfm?orgid=542

• ISMS Procedures, Policies & Toolkit• FAQs• Training Materials• Leaflets & Posters• Forum• News, Events and Hot Topics

http://howis.wales.nhs.uk/sites3/home.cfm?orgid=542

http://howis.wales.nhs.uk/sites3/home.cfm?orgid=542


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Information Governance for Practice Staff. Introduction Confidentiality; including Caldicott Data...

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