Data Quality Management Strategy 2013-16

Document Information
Board
Document Document
Library
Type
Subject
Reference
Strategy
Data
Quality

Original
Document
Author
Head of
Information
&
Performance
Management

Scrutinised Review Cycle

by
ET, Q&S
Committee

3 years

Document Version Tracking

Ref Date
1.0 1/11/13

Revision description
First Draft

1.1

11/11/13

Amended First Draft

1.2

15/11/13

1. Re-title to Data Quality Management

Strategy
2. Provide links to Francis report
3. Provide definition of data vs.
information
4. Timescales for future tasks
5. Provide direct reference to data entry
policies in place
6. Reference to need to develop and
Information Strategy

Editor(s)
Head of Info &
Performance
Interim Director
of Finance
Executive Team

Status
Draft
Draft
Draft

Key terms
Name
RiO
IAPTUS / PC-MIS
MLE
ESR
Agresso
PaCMAN
CPMG
IQ

Description
Electronic Patient Record used widely across the Trust
Electronic Patient Record used in IAPT services
Managed Learning Environment
Electronic Staff Record
Finance system
Performance & Contract Management Meeting
Contract & Performance Management Group
Trusts Quality Information System
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1. Introduction
High quality and meaningful information enables people at all levels in the Trust (and
external stakeholders), from the frontline to Board to:

Judge our service quality and outcomes; and monitor progress

Make strategic and service decisions, based on evidence
Investigate or diagnose suspected problems, or evaluate service/practice changes
Benchmark the Trust, against other Trusts, or internally across services

Information derived from the Trusts electronic systems is a key component of this,
and thus assuring the quality of the data held by the Trust is of crucial importance.
1.1 Francis report: recommendations
The Francis report (2013) contains a number of recommendations where the use
of high quality information is crucial. Some of the key recommendations are
included below, however the full report should be referred to in order to gain the full
context:

The regulator should have a duty to monitor the accuracy of information

disseminated by providers and commissioners
A coordinated collection of accurate information about the performance of
organisations must be available to providers, commissioners, regulators and
the public, in as near real time as possible
Trust Boards should provide, through quality accounts, and in a nationally
consistent format, full and accurate information about their compliance with
each standard which applies to them
Commissioners must have the capacity to monitor the performance of every
commissioning contract []:
o Such monitoring may include requiring quality information generated by
the provider
o The possession of accurate, relevant, and useable information from
which the safety and quality of a service can be ascertained is the vital
key to effective commissioning, as it is to effective regulation
Metrics need to be established which are relevant to the quality of care and
patient safety across the service, to allow norms to be established so that
outliers or progression to poor performance can be identified and accepted as
needing to be fixed
The only practical way of ensuring reasonable accuracy is vigilant auditing at
local level of the data put into the system. This is important work, which must
be continued and where possible improved

2. Purpose
The purpose of this document is to set out the Trusts approach to data quality
management and the strategic direction for the next three years.

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3. Scope
The principles outlined in this strategy are applicable to all data held on all electronic
systems. Examples include:

Electronic Patient Record (e.g. RiO, IAPTUS, PC-MIS, Theseus)

Staff Record Systems (e.g. ESR, MLE)
Agresso (Finance system)
Ulysses (Incident reporting tool)

4. Defining Data Quality

4.1 Definitions
For the purpose of this document the following distinction is applied:
Data - what is entered on a system and any unanalysed data reported out
Information the analysed, presented or interpreted output from data entered
4.1 Figures you can Trust
The Audit Commission provide a useful framework for defining and then managing
data quality in their Figures you can Trust report published in 2009. In this
document, six dimensions of data quality are identified which, when suitably
addressed, will support an organisation to achieve good levels of data quality.
These dimensions are included in the table below.
This strategy outlines how each of these dimensions is attended to, drawing on
explicit examples, and identifies where gaps are known and actions underway to
address.
In addition, it should be noted that there is no absolute standard for data quality
that can be applied universally, therefore these principles will need to be applied as
part of a continuous improvement approach, reviewed and evaluated regularly.
Table 1: Dimensions of Data Quality
Timeliness
Data captured quickly after the event, and made available for use as
quickly as possible
Completeness

The extent to which data is complete (e.g. how many missing records
are there)

Validity

Data is recorded and used in accordance with any rules / definitions

(allowing for comparison)

Relevance

Data should be relevant for the purpose for which it is being used

Reliability

Data should be based on stable and consistent collection processes

(danger that improvements in performance reflect changes in
collection, rather than practice)

Accuracy

How correct is the data

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4.2 Information Governance Toolkit

The Information Governance Toolkit has a number of requirements that relate to
data quality assurance and the approach within this strategy ensures compliance
with these requirements which in doing so further promotes the quality of the
Trusts data. These requirements are:
502: External data quality reports are used to monitor and improve data quality
504: Use of local & national benchmarks to identify data quality issues
506: Regular audit cycle for accuracy of service user records
507: Completeness & Validity check
508: Clinical staff are involved in validating information relating to clinical care
514: Audit of clinical coding
4. Links to the Performance and Quality Management Strategy
This strategy sets out the approach to supporting the delivery of good data quality
across the Trust. Where issues of poor data quality are identified, improvement will be
delivered in accordance with the principles set out in the Trusts Performance &
Quality Management Strategy and therefore this document should be viewed as
supporting / underpinning that strategy. Key principles, in brief:

IQ underpins the quality / performance conversation

Monthly review / challenge of data, via:

o Internal: Quality Huddle, PaCMAN, Locality Meetings, Team / ward
meetings, supervision
o External: CPMG, Local CPMG

5. Ensuring Data Quality

5.1 Timeliness
5.1.1 Timelines (data entry)
The Trust has set a standard for the timeliness of data entry for all of its
electronic patient record systems as follows:

Inpatient / intensive services: within 24hrs of the event

Community services: within 3 working days of the event

This standard will be monitored via a Data quality: timeliness metric within the
Quality Information System (IQ) and reported both internally and externally, via
the Quality and Performance Report, on a monthly basis. A target of 95% has
been set for this metric. The full list of data quality metrics used by the
Trust is detailed in Appendix A.
5.1.2 Timeliness (reporting)
The Trust will consider the time taken to report whenever information is due to
be published and aim to minimise the delay between data collection and
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publication as much as possible. IQ, which contains a range of metrics from a

range of systems, is updated monthly as a minimum and in some cases more
frequently. For example:

Friends & Family, Records Management & CQC Compliance audits: these
domains are all updated on a monthly basis, within 3 working days of the
end of the previous month
Monitor & Contract Compliance & Supervision: both these sections are
updated daily

5.2 Completeness
The Trust will monitor all nationally defined completeness metrics. In addition, the
completeness of records in the systems that underpin key local reports / indicators
will be considered, and where necessary a metric will be introduced to monitor this
aspect of data quality (which will be reported monthly internally and externally).
Examples of the above already in place include:
5.2.1 Monitor Compliance
The Trust uses the two data completeness metrics detailed by Monitor, these
are:

Data quality: identifiers (which monitors the completeness of core fields

within the patient record, e.g. date of birth, GP, postcode)
Data quality: outcomes (which monitors the completeness of key outcomes
fields)

5.2.2 CQC Compliance, Records Management and Friends and Family

The Trust underpins the scores achieved for these quality indicators by
publishing completeness metrics alongside the scores, in the form of the
percentage of teams and wards that submitted a return for the first two, and the
response rate by service users for Friends and Family.
5.2.3 Staff related indictors (sickness, supervision, appraisals)
The Trust reports these indicators based on whole population, rather than a
sample basis, to ensure all staff are included in the reporting.
5.2.24 Completeness & Validity check (507)
In order to support delivery of the IG toolkit, the Trust will monitor performance
against the Completeness and Validity check and report progress to the
Information Governance Management Group.
5.3 Validity / relevance
The Performance and Quality Management Strategy sets out the requirement for
an annual review of the high level domains within IQ, as well as a review of all
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Contractual indicators. This process will ensure the validity and relevance of the
reports in place.
5.4 Reliability
The Trust will ensure that all data entry into clinical and business systems is
supported by suitable guidance documentation to ensure reliability. This will be
supported by a centrally coordinated training programme where necessary (e.g.
RiO training), where training packages are constructed around the core guidance
available.
5.4.1 Clinical Systems Management
For clinical systems, this process coordinated by the Clinical Systems Manager
(and team) to ensure that all guidance and training that support clinical systems
is synchronised and fit for purpose. Links to guidance / policy are included in
Appendix B.
5.4.2 Clinical Academy
The Clinical Academy provide high level oversight of clinical system usage and
will ensure that processes included in guidance and training are clinical
intuitive, and importantly support quality improvement across the Trust.

5.5 Accuracy
The Trust will ensure that records within clinical and business systems are
regularly validated to ensure accuracy.
5.5.1 The electronic patient record (Records Management Audit)
The Trust has in place a monthly Records Management audit that requires
each team and ward to manually audit 5 randomly selected service user
records. Each record is audited against 10 centrally defined elements. Team /
ward level results are then included within IQ and monitored as part of the
Performance and Quality Management monthly cycle. These audits are
undertaken by frontline clinicians. Estimate for 2013-14 is that 750 individual
records are review each month, which equates to 7,500 individual elements of
the care record being clinically assessed for quality and accuracy on a monthly
basis.
This element of the data quality assurance process underpins the Trusts
compliance with IG Toolkit requirements 506 (cycle of audits) and 508 (clinician
involvement in validating records).
5.5.2 Auditing the quality of clinical coding
To support compliance with IG Toolkit requirement 514, audit of clinical coding,
the Trust will include an audit of clinical coding as part of the CQC Compliance
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element of IQ requiring 10 records to be audited each month, for each team

and ward, and checked for accuracy. This information will be made available
via the IQ system so that performance can be monitored and issues of
accuracy addressed.
5.5.3 The Quality Information System (IQ): total transparency
The IQ system provides the organisation with opportunity to view, and
challenge, information being presented using local knowledge and experience.
This openness allows for opportunity to check accuracy and make corrections
where necessary. Relevant features of the system are:

Open access: any member of the Trust can access any part of IQ and view
the information therein (except areas that contain patient level data, where
access restrictions are in place)
Drillable: the system provides reports that can be drilled into, from Trust, to
local delivery unit, to team or ward and onto patient / staff level.
Range of information: the system combines information from different
systems (e.g. RiO, Agresso, ESR, MLE) and shows them alongside each
other delivering transparency and validation across multiple systems, no
just the electronic patient record.

5.6 Benchmarking
5.6.1 Internal Benchmarking
The IQ system has been designed to allow for internal benchmarking across all
high level domains and their sub-components. The system allows:

Benchmarking at locality & team type level.

Users can self-select their peers. For example, a Recovery team manager
may choose to benchmark themselves against other teams in their
geographic area, or Recovery teams in other parts of the Trust.

5.6.2 External Benchmarking (including external data quality reports)

The Trust is a number of the NHS Benchmarking Network, and sits on the
Mental Health Reference Group which develops the annual benchmarking
exercise. The results of this annual exercise will be analysed and shared
internally and where applicable, the IQ system will be expanded to add national
benchmarks as further context to the information presented.
In addition, the Information Governance Management Group received a
quarterly Data Quality Report that provides an update on all internal data
quality metrics, as well as nationally reported data quality metrics (i.e. to
provide assurance that internally created data is accurate).
The combination of 5.6.1 and 5.6.2 underpin the Trusts compliance with IG
Toolkit requirements 502 (external data quality reports) and 504 (internal and
external benchmarking).
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6. Next steps for further improvement

6.1 Corporate Systems & Data Quality
The Trust will seek to strengthen the data quality monitoring for corporate systems
to ensure that levels of assurance are comparable to clinical systems. Including,
where appropriate, centralising the reporting of corporate information to maximise
efficiency, develop a reporting brand, and to reconcile core data across multiple
systems. Timescale: by April 2014
6.2 Peer review within clinical records auditing
The Trust will implement a systematic peer review process to underpin the
assurance reported via the Records Management and CQC Compliance domains
within IQ (both of which are self-reported at team and ward level). Timescale:
agree approach by Dec 2014, implement during Q4, 2013-14.
6.3 Development of an Information Strategy
The Trust will develop and Information Strategy to set out the Trusts approach in
this area. Specifically to:

Develop a systematic approach to understanding the Trusts information

needs
Ensuring information systems are utilised to their full potential and
duplication / redundancy is removed

Time scale: Q4, 2013-14

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Appendix A: list of data quality metrics (for 2013-14)

Source
Monitor
Monitor
Local
PbR
PbR
PbR
PbR
Local
Local

Description
Completeness of outcomes
Completeness of identifiers
Timeliness
Cluster: completeness of cluster
Cluster: timeliness of review for clusters
Cluster: compliance with transition protocols
Cluster: compliance with red rules
Completeness of ethnicity
Completeness of protected characteristics

Appendix B: links to clinical systems guidance / policy

How to use RiO (home page)
http://ourspace/Systems/RiO/Pages/Home.aspx
User training guides
http://ourspace/Systems/RiO/Pages/UserGuides.aspx
RiO usage process maps
http://ourspace/Systems/RiO/Pages/Processmaps.aspx
RiO WIKI (procedures for recording and accessing clinical information)
http://ourspace/Systems/RiO/ClinicalSupport/Wiki%20Pages/Home.aspx

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