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