Shirley Ledingham Project Manager July 2003 CALDICOTT Flow Mapping of Patient Identifiable...
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Transcript of Shirley Ledingham Project Manager July 2003 CALDICOTT Flow Mapping of Patient Identifiable...
I n f o r m a t i o n G o v e r n a n c e T e a mI n f o r m a t i o n G o v e r n a n c e T e a m
Shirley Ledingham
Project Manager
July 2003
CALDICOTT CALDICOTT Flow MappingFlow Mapping
of of Patient Identifiable Patient Identifiable
InformationInformation
AIM OF THE SESSIONAIM OF THE SESSION Background Information Background Information How the Project was implementedHow the Project was implemented Examples of Action Plans & Risks Examples of Action Plans & Risks Stages 2 & 3Stages 2 & 3 Outcomes and AchievementsOutcomes and Achievements ConclusionConclusion
A framework of principles which protect A framework of principles which protect the use of patient identifiable information the use of patient identifiable information
in NHS/Social Care organisationsin NHS/Social Care organisations
The Annual Caldicott Out-The Annual Caldicott Out-turn Reportturn Report
Linked to the Trust’s Star Linked to the Trust’s Star RatingRating
THIS PROJECTTHIS PROJECT Exchanges of Patient Exchanges of Patient identifiable information identifiable information should be mapped and should be mapped and reviewed regularlyreviewed regularly
Caldicott …… What is it?Caldicott …… What is it?
Reminder of Caldicott PrinciplesReminder of Caldicott Principles
clearly defined and justified clearly defined and justified only used when absolutely necessaryonly used when absolutely necessary kept to a minimum kept to a minimum accessed on a need-to-know basisaccessed on a need-to-know basis
Staff should be aware of their responsibilities and Staff should be aware of their responsibilities and obligations to respect confidentialityobligations to respect confidentiality
Every use of person-identifiable information must be Every use of person-identifiable information must be lawfullawful
Person-identifiable information should be:Person-identifiable information should be:
A Staged ApproachA Staged ApproachPHOTOCOPYING ROOM - SDH
NORTH
EntryRoutes
Procedure/Process Data Details
ALL AREAS
PhotocopyRequests
Distributionof copies
Copying materialcontaining patient
information (i.e.Medical Notes), are
hand delivered to thephotocopying room.When possible Notesare locked in drawer.
PII = ALL
ALL AREASOF THETRUST
Flow MappedFlow Mapped
STAGE 1STAGE 1
Reviewed Reviewed
STAGE 2STAGE 2
Rolling review establishedRolling review established
STAGE 3STAGE 3
CALDICOTT RECOMMENDATIONSCALDICOTT RECOMMENDATIONS
IMMEDIATE ACTION PLANSIMMEDIATE ACTION PLANS
LONG TERM ACTIONSLONG TERM ACTIONS
Chief Executive and Chief Executive and Project Management Board Project Management Board
RecommendationsRecommendations
CHI REVIEWCHI REVIEW
PREPARING TO FLOW MAPPREPARING TO FLOW MAP
InvestigationInvestigation Caldicott GuidelinesCaldicott Guidelines
Other TrustsOther Trusts
PlanningPlanning
Gathering InformationGathering Information Question BankQuestion Bank
QuestionnaireQuestionnaire
Storing InformationStoring Information Electronic Electronic Tracking systemTracking system
Visio TrainingVisio Training Flow MapsFlow Maps
ReportsReports TemplatesTemplates
FLOW MAPPINGFLOW MAPPING
READY STEADY MAPREADY STEADY MAPBUTBUT
WHERE TO START?WHERE TO START?
FLOW MAP?
What areas What areas WANT/NEEDWANT/NEED to be flow mapped? to be flow mapped?
THE DIRECTORATE MANAGERSTHE DIRECTORATE MANAGERS
AGREE AREAS TO BE MAPPEDAGREE AREAS TO BE MAPPED
AGREE KEY STAFF TO BE APPROACHEDAGREE KEY STAFF TO BE APPROACHED
Detailed ReportDetailed Report
Summary ReportSummary Report
The Visio Flow MapThe Visio Flow Map
Reports and flow mapsReports and flow maps
Tracking SystemTracking System
Receipt of Medical Records for ClinicReceipt of Medical Records for ClinicDATAFLOWDATAFLOW
Records ready Records ready to be preparedto be prepared
Example – Immediate Action PlanExample – Immediate Action Plan
PROCESSPROCESS Medical records Medical records delivered to delivered to
clinic clinic (+ 2 clinic (+ 2 clinic lists)lists)
Search for Search for missing missing recordsrecords
Not clearly defined or justified, Not necessary, Not kept to a Not clearly defined or justified, Not necessary, Not kept to a minimum, Not accessed on a need-to-know basisminimum, Not accessed on a need-to-know basis
BREACH OF BREACH OF CALDICOTT CALDICOTT PRINCIPLESPRINCIPLES
PROCEDUREPROCEDURE
MEDICAL RECORDS
MEDICAL RECORDS
ACTION ACTION
Arranging inpatient Nurse led follow up clinic Arranging inpatient Nurse led follow up clinic DATAFLOWDATAFLOW
Request Request Medical Medical
RecordsRecords
Example – Long Term Action PlanExample – Long Term Action Plan
PROCESSPROCESSWard round to Ward round to collect detailscollect details
Send Send appointment appointment
lettersletters
Not kept to a minimumNot kept to a minimumBREACH OF BREACH OF CALDICOTT CALDICOTT PRINCIPLESPRINCIPLES
PROCEDURESPROCEDURESCAN INCLUDECAN INCLUDE
NO
PIMS
Clinic List
DIARY
DATA DATA QUALITYQUALITY Needs updating!Needs updating!
ACTIONS ACTIONS Non
Consultant Led Clinics
Project
ATD Project
Patient Document Tracking Project
EPR
ELECTRONICELECTRONIC
Not networkedNot networked
UnreliableUnreliable
Unsafe havensUnsafe havens
PAPER SYSTEMSPAPER SYSTEMS DuplicationDuplication
InsecureInsecure
Split recordsSplit records
Medical NotesMedical Notes
TelephoneTelephone
Answer machinesAnswer machines
VERBAL SYSTEMSVERBAL SYSTEMS
COMMON RISKSCOMMON RISKS
LAUNCH OF STAGES 2 & 3Prioritising mapped flows for review (Stage 2) & Rolling review (Stage 3)
Risk Reports
Cascade to project leads
Directorate Managers
Head of Modernisation
Information Governance Manager
Review & feedback to Information Governance Manager
Completion of Caldicott Out-turn Report March 04 & sign off by Caldicott Guardian
Repeat above for Out-turn report in March 05
Cascade flow map templates to Directorate Managers
Review & Update
Feedback to Information Governance Manager
March 07 Rolling review by exception reporting
Completion of Caldicott Out-turn Report March 06 & sign off by Caldicott Guardian
Achieved an Out-turn report Criteria 8 score of 2Achieved an Out-turn report Criteria 8 score of 2 Project objectives have been metProject objectives have been met :- :-
Baseline of current positionBaseline of current positionBreaches of confidentiality reducedBreaches of confidentiality reducedPatient privacy enhancedPatient privacy enhancedWork towards standardisation of working practicesWork towards standardisation of working practicesProcesses identified to support review programmeProcesses identified to support review programme
Immediate action plans completeImmediate action plans complete Long term actions assigned to ProjectsLong term actions assigned to Projects Recognition from the NHSIARecognition from the NHSIA
OUTCOMES & ACHIEVEMENTSOUTCOMES & ACHIEVEMENTS
I n f o r m a t i o n G o v e r n a n c e T e a mI n f o r m a t i o n G o v e r n a n c e T e a m
In line with the Data Protection Act and In line with the Data Protection Act and Caldicott Principles this project has Caldicott Principles this project has endeavoured to:-endeavoured to:-
Raise the profile of confidentiality Raise the profile of confidentiality issues across the Trustissues across the Trust
Recommend processes to support Recommend processes to support on-going improvementson-going improvements
CONCLUSIONCONCLUSION
I n f o r m a t i o n G o v e r n a n c e T e a mI n f o r m a t i o n G o v e r n a n c e T e a m
Shirley Ledingham
Project Manager
July 2003
CALDICOTT CALDICOTT Flow MappingFlow Mapping
of of Patient Identifiable Patient Identifiable
InformationInformation