Flow Mapping of Patient Identifiable Information

Flow Mapping of Patient Identifiable Information

July 2002 – July 2003

PROJECT CLOSURE REPORT

1.  INTRODUCTION

The aim of this report is to provide an overview of:-

·  How this Project has developed

·  How it has been implemented

·  What has been achieved

·  How it has been closed

And to recommend a plan of action to launch the second stage of flow mapping patient identifiable information as dictated by the Caldicott report.

It is intended, therefore, that this report will provide sufficient information to close this project and to provide a reference document to assist with the on-going process of flow mapping information across the Trust.

2.  PROJECT CONCEPT

2.1  Background Information

This project was initiated as a result of the Caldicott Management Audit Out-turn report 2001/02 and subsequent Improvement Plan 2002/3, which identified that information flows of patient identifiable information were not being controlled or monitored and that breaches of confidentiality have occurred as a result.

The Caldicott Report (Ref: www.gov.doh.gov.uk/nhsexipu/ confiden/guard/cginflows.htm.07/09/01) and Caldicott Audit Criteria number 8 requires that:-

·  Every flow of patient identifiable information within and from an organisation should be tested against the Caldicott principles and that each item of information containing patient identifiable details should be justified.

·  The mapping of these information flows should fall into three key stages:-

1.  Mapping information flows (Stage 1) (This Project)

2.  Prioritising mapped flows for review purposes (Stage 2)

3.  Rolling program of review (2,3,4 or 5 year program) (Stage 3)

The Commission for Health Improvement (CHI) Review of 2002 also identified that urgent action was required to improve the quality of data produced across the Trust. Required improvements included establishing effective information flows.

2.2  Purpose of Project

To produce information flow maps of patient identifiable information throughout the Trust in order that:-

·  An accurate baseline of the current position is established in order to achieve compliance with the Caldicott recommendations.

·  Potential breaches of confidentiality and or Data Protection can be reduced.

·  Patient privacy can be enhanced

·  We can encourage standardisation of working practices throughout the Trust, thereby improving process efficiency and effectiveness.

In line with Caldicott recommendations (2.1) this project focused on the first of the three key stages outlined above. It was accepted that immediate action would be taken if areas of risk were identified during this stage.

2.3  Objectives

·  To produce comprehensive flow maps of patient identifiable information contained within manually completed forms, print outs from systems and electronically exchanged data across the Trust.

·  To use these completed flow maps to provide baseline evidence against which future assessment will be reviewed and to inform Directorate managers of issues requiring corrective action

·  To report on areas which fail to meet Caldicott and Data Protection guidelines and to share details where the use of best practise is identified in order to assist weaker areas.

·  To identify processes to support a rolling programme of flow maps for review

2.4  Scope

All areas of the hospital (clinical and non-clinical), which are involved with handling patient identifiable information. The external flow of information (i.e. to PCTs, Community support groups, Contractors, etc) to be identified but excluded from the detailed mapping process at this stage.

2.5  Deliverables

·  Production of comprehensive flow maps of patient identifiable information

·  Co-ordination of Action Plans identifying areas of risk

·  Achievement of compliance with Caldicott Principles throughout the Trust

2.6  Constraints and Risks

·  Evidence available from other Trusts identified that the quantity of problems discovered had a knock on effect on the time required to project completion. Production of a reliable milestone schedule was therefore difficult.

·  Although the Caldicott Report provided broad guidelines relating to assessing data flows, an approved National Standard has yet to be published and therefore the implementation and commissioning of this project has been open to personal interpretation.

3.  DESIGN AND PLANNING

3.1  Project Management Board (PMB) and Quality Review Panel

To ensure a Trust wide commitment and support for this project and in order to maximise the potential benefits, a high level Project Management Board was appointed as follows:-

·  Eric Waters, Caldicott Guardian (Chair)

·  Dr Brian Bentley, Information Governance Chair

·  Laurence Arnold, Head of Planning & Service Development

·  Erica Hayde, Information Governance Manager

·  Sue Garner, Directorate Manager

·  Gill Clothier, Process Redesign Manager

PMB meetings were held on a quarterly basis (Appendix 1)

Members of the Quality Review Panel were:-

·  Erica Hayde, Information Governance Manager (Chair)

·  Frank Harsent, Chief Executive

·  Eric Waters, Caldicott Guardian

Following the inaugural PMB meeting and meeting with the Chief Executive it was agreed that during the project:-

·  Immediate remedial action should only be taken where high risks or quick fix solutions were identified

·  Action Plans requiring significant redesign to be annotated and deferred to a later date to avoid major disruption to staff work.

3.2  Project Planning and documentation

The project commenced at the end of July 2002. Following investigative visits to Luton and Poole NHS Trusts, the following documentation and tracking system was approved by the PMB in September 2002:-

·  Project Initiation Document (PID)

·  Project plan to the end of the year 02 (Initial phase of Stage 1)

·  Pilot questionnaire

·  Electronic Tracking system

3.3  The Pilot

In October 2002, the Speech and Language Therapy Department agreed to act as the Pilot site for flow mapping, as this area was currently involved in process redesign.

The pilot was completed in November 2002 and as a result the questionnaire and tracking system were restructured and improved. The questionnaire was replaced with an “Information Gathering pack” (Appendix 2) and a “Question Bank” (Appendix 3). The electronic tracking system is available through the Information Governance Manager (DIT\Information Governance\Caldicott\information flows\Reports\tracking system\date).

4.  IMPLEMENTATION

4.1  Agreeing Areas to be Mapped

Many areas of the Trust are undergoing some form of process redesign and/or modernisation. It was, therefore, important from the outset that the flow mapping process could compliment on-going work or provide the necessary information/evidence required for anticipated future plans. As a result Directorate Managers prioritised the areas to be flow mapped. Every two months meetings were arranged with each Directorate Manager and an action plan for flow mapping established and reviewed.

j

4.2  The mapping Process

4.2.1  Meeting Area/Specialty Manager

Having identified the area to be mapped a meeting was set up with the area/speciality manager. The objectives of the flow mapping project were discussed and a plan of action and list of key staff to be interviewed or shadowed was agreed.

4.2.2  The Detailed Report

At all times it was made clear that if staff workloads were exceptionally high the flow mapping exercise would be rescheduled. To maintain momentum this resulted in several areas of the Trust being flow mapped at any one time. This flexibility ensured quality time with staff when they did not feel under undue pressure. The detailed report was produced as follows:-

·  The first stage of the mapping process was to agree a logical start or entry point of information/patients into an area. The route of this information and any exit routes were then tracked. The flow mapping process was annotated solely by the Project Manager and assisting staff were not required to complete any documentation.

·  Dataflow details were entered on the tracking system and a detailed report was produced by the Project Manager. In order to gain ownership from departments, staff in the relevant area were then invited to check, amend or add to the report. Again, complete flexibility was given to the timescale for these reports to be checked, thus ensuring quality feedback. (Appendix 4).

4.2.3  The Visio Flow Map

As Visio was considered to be the most appropriate IT package to present the information, the dataflow information contained in the detailed report was then copied and précised as required onto a Visio Flow Map (Appendix 5). .

4.2.4  The Summary Report

As each dataflow was entered on the tracking system it was assessed against the Caldicott Principles and Data Protection Regulations. If a dataflow appeared to breach these principles it was annotated as a potential “risk” or if it appeared to adhere to recommendations it was annotated as evidence of “good practice”. Relevant ad hoc remarks by staff were annotated as “comments”.

A Summary Report was produced for discussion with the Area/Specialty Manager (Appendix 6). Each potential risk was either justified or a plan of action and timescale agreed. The Project Manager completed the details of the agreed Summary Report on the tracking system and added the name of the Area/Specialty Manager to the bottom of the Summary Report as evidence of “sign off” and completion of the flow mapping process within that area.

4.2.5  Distribution of Reports

Copies of the Detailed Report and flow map were offered to members of staff in the area that had been flow mapped and copies of these reports together with the Summary report were given to the Area/Speciality Manager.

Copies of reports were provided to Directorate Managers on request. Some Directorate Managers preferring to have an overview feedback from the Project Manager (Appendix 7).

Electronic copies of all reports and flow maps are stored in the Information Flows Directory and held by the Information Governance Manager.

4.3  Linking with other Projects

By November 2002 the importance of incorporating long-term action plans into on-going process redesign, modernisation and other projects within the Trust became apparent.

Although mapping flows of patient identifiable information has not been completed throughout the entire Trust, assessment of the problems identified to date clearly indicates repetition of data flow risks within similar areas. It can be assumed, therefore, that outcomes of continuing the flow mapping exercise can already be anticipated.

Implementation of the projects listed below will resolve the majority of data flow issues identified in the action plans. This transfer of action points into other Projects has formed the basis of how this project will be closed, thus ensuring that the responsibility for completion of agreed actions is clearly assigned to another recognised project. In effect this commences Stage 2 of the overall Project by “prioritising mapped flows for review purposes” (1.1 Background Information).

The following chart lists the various projects throughout the Trust that will assume ownership for long-term action plans identified during the Flow Mapping Project. Each individual action point is linked accordingly on the Tracking System so that follow up and review can continue in Stage 2.

TRANSFER OF RESPONSIBILITY FOR LONG TERM ACTION PLANS

/
Long Description / Short Description / Ownership / Responsibility
Clinical Documentation Group / CMG / Patient Records Committee
Destruction Policy and Process / DP / Patient Records Committee
Patient Document Tracking / PDT / Patient Records Committee
Health Records Process Redesign / MRM / Patient Records Committee
Non Consultant Led Clinics / NCC / Head of Modernisation
ATD Project / ATD / Head of Modernisation
Electronic Booking Management Service / ABC / Head of Modernisation
Modernisation of Secretarial Role / MSR / Head of Modernisation
Outpatient Improvement Group / OI / Head of Modernisation
EPR Project / EPR / Head of Modernisation
Data Accreditation / DA / Head of Planning & Service Development
Freedom of Information / FOI / Trust Secretary
Area Redesign - On-going project currently addressing identified problems / AR / Relevant Directorate Manager
NOTE: Short Term Actions completed during flow mapping project are marked as "COMPLETED" in the FOLLOW UP COLUMN on the electronic Tracking System

5.  EXAMPLES OF ACTION PLANS AND COMMON PROBLEMS

5.1  Examples of Common Problems identified

Electronic Risks
Duplication of electronic systems (PiMS and local databases)
Faxes being sent to open areas
Computer systems not linked to PIMS or networked
Computer systems slow, drip feed from PiMS regularly crashes
Screen savers switched off locally by staff and passwords shared
Lack of knowledge and understanding of computer system
Screens visible by patients and unauthorised staff
Paper/Hard data Risks
Unnecessary duplication of paper systems (registration, diaries, lists, questionnaires, forms, reports)
Unnecessary retention of duplicated patient information
Insecure patient information
No protocols for destroying information

Verbal Risks

Telephone discussions in open areas
Messages left on answer phones

Miscellaneous Risks

Duplication of electronic and hard systems
Incomplete medical details (some details stored in clinic and some in medical records)
Problems locating medical records (separate mapping exercise is on-going)

5.2  Examples of Action Plans

ACTIONS

/

TIMEFRAME

/
Restricting access levels to databases / Short term
Removing unnecessary patient identifiable information on invoices / Short term
Raising staff awareness of Caldicott Principles and Data Protection Regulations (posters, meetings, additional training provided by Information Governance Officer) / Short term
Purchase of cordless phones to enable sensitive conversations in a secure area / Short term
Purchase of number lock pads to improve security of medical records / Short term
Creating fax safe havens (moving fax machines etc) / Short term
Amalgamating forms, questionnaires etc / Short term
Additional IT training, use of personal passwords / Short term
Process Redesign / On-going
Increasing reliance on computer systems (as they become more robust) / On-going
Patient Document Tracking to track medical records to locations currently not on PiMS / Long term
Streamlining of appointment procedures to avoid duplication of appointment letters / Long term
Service Development bids for equipment (i.e. IPAQS) / Long term
Integration of computer systems / Long term

6.  OUTCOMES

6.1  Purpose of Project

Purpose of Project (2.2) / Outcome of Stage 1
·  An accurate baseline of the current position is established in order to achieve compliance with the Caldicott recommendations. / An accurate baseline now exists for all areas of the Trust that have been flow mapped. These areas include clinical and non-clinical areas and can be used as a template for the rolling review programme in Stage 3. (Appendix 8)
·  Potential breaches of confidentiality and or Data Protection can be reduced. / Immediate action taken during this stage has reduced potential breaches of confidentiality and the long-term plans now in place will continue to address confidentiality issues. (5.2)
·  Patient privacy can be enhanced / Immediate action taken during this stage has enhanced patient privacy and the long-term plans now in place will continue to do this. (5.2)
·  To encourage standardisation of working practices throughout the Trust, thereby improving process efficiency and effectiveness. / Stage 1 of this project has identified areas where standardisation of working practices could be improved. The long term plans, particularly the Secretariat Process Redesign Project and Outpatient Improvements will use the evidence gathered during flow mapping to assist with process redesign. (4.3)

6.2  Objectives