Data Quality Policy
March 2017
Author:
Lynda Harris, Head of Information Governance
[email protected]
Responsibility:
All Staff
Effective Date:
March 2017
Review Date:
March 2018
Reviewing/Endorsing committees
Risk Management Group.
Approved by Risk Group
6 March 2017
Date Ratified by Executive Team
23 March 2017
Version Number
4
POLICY DEVELOPMENT PROCESS
Data Quality Policy
Page 1
Names of those involved in policy development
Name
Lynda Harris
Susan La Rosa Lamar
Designation
Head of Information
Governance, Bedfordshire
CCG
Head of Validation and
Clinical Coding Audit,
Bedfordshire CCG
Email
[email protected]
Susan
[email protected]
Names of those consulted regarding the policy approval
Date
16th February
2015
Name
Susan La Rosa
Lamar
Designation
Head of
Validation,
Clinical Coding
Audit,
Bedfordshire
CCG
Email
Susan.La Rosa
[email protected]
Equality Impact Assessment prepared and held by
Date
31st December
2012
Name
Lynda Harris
Designation
Head of Information
Governance,
Bedfordshire CCG
Email
[email protected]
Committee where policy was discussed/approved/ratified
Committee/Group
Governance and Risk
Group
Governance & Risk Group
executive Management
Team
Date
12 May 2013
Status
Approved
6 March 2017
23 March 2017
Approved
Ratified
Equality Impact Assessment
Bedfordshire Clinical Commissioning Group is committed to promoting equality in all its
responsibilities – as commissioner of services, as a provider of services, as a partner in the
local economy and as an employer. This policy will contribute to ensuring that all users and
potential users of services and employees are treated fairly and respectfully with regard to
the protected characteristics of age, disability, gender, reassignment, marriage or civil
partnership, pregnancy and maternity, race, religion, sex and sexual orientation.
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Discussions took place as to whether an Equality Impact Assessment was required and it
was agreed that one was not required in this instance.
Contents page
Introduction
4
Purpose
4
Definitions
4
Responsibilities
5
Development Process
5
Validation
5
Clinical Staff
5
Training
6
Monitoring
6
External Controls
6
References
6
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Introduction
The CCG recognises that decision making at every level within the NHS whether financial,
clinical or managerial needs to be based on information which is of the highest quality.
Information is derived from individual data items which are collected from a number of
sources either on paper or more increasingly with the advent of the electronic patient record
and electronic health records on electronic systems.
Purpose
Data quality is crucial and the availability of complete, accurate, relevant, accessible and
timely data is important in supporting patient care, clinical governance, management and
service agreements for healthcare planning and accountability. A data quality policy and
regular monitoring of data standards are a requirement of the NHS Information Governance
toolkit.
This policy is one of the key policies supporting the overarching information governance
strategy and works in conjunction with other relevant legislation and policies:
Data Protection Act 1998
Information Lifecycle Policy
Confidentiality Policy including Caldicott
Information Governance Policy
Information Security Policy
Safe Haven Policy
Privacy Impact Assessment Guidance
This policy sets out:
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The standards required for data quality
The importance of using the NHS number as the unique patient identifier
How data quality is validated
The importance of data standards
Involvement of clinicians in validation
Definitions
Data should be:
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Complete (in terms of being captured in full)
Accurate (the proximity of the figures to the exact or true values)
Relevant (the degree to which the data meets current and the potential users needs)
Accessible (data must be retrievable in order to be used and in order to assess its
quality)
Timely (recorded and available as soon after the event as possible)
Valid (within an agreed format which conforms to recognised standards – either
national or local)
Defined (understood by all staff who need to know and reflected in procedural
documents)
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
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Appropriately sought (in terms of being collected or checked once during an episode)
Appropriately recorded (in either paper or electronic format)
Responsibilities
Overall responsibility for information governance sits with the Accountable Officer.
Managers are responsible for ensuring staff members have received the relevant training
that is conducive to achieving data quality.
Data quality is a key part of any information system which exists within the organisation’s
structure. All staff members will be in contact with a form of information system, whether
paper or electronic based and are obligated to maintain records accurately and legally
(Data Protection Act 1998), contractually (contract of employment) and ethically
(professional code of conducts).
Validation
The purpose of validation is to ensure that the quality of data provided to the CCG is
accurate, timely and adheres to national guidelines. The process of validation enables the
CCG to check hospital activity data to ensure accuracy and in turn, ensure cost
effectiveness. Monthly validation is undertaken by the CCG and incorporates both
automated bulk validation of data using specific rules and manual data checks for coding
anomalies.
The CCG should routinely undertake the following for validation:
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Validate contracted provider data using validation rules following NHS PbR rules,
Ensure clinical coding is validated in line with up to date national clinical coding
guidance, payment by result and locally agreed policy,
Monitor coded activity in line with the national acute contract and locally agreed
schedules,
Ensure acute provider compliance with locally agreed low priority guidance,
Ensure compliance of specialist commissioning activity against agreed standards
Support the contracting process in the development and monitoring of measurable
standards in quality and in achieving value for money.
Clinical Staff
Clinicians should be involved in validating data that may have been entered into the system
by clinical coding staff. This may involve the clinical manually reviewing the data that has
been entered to confirm its integrity. Regular spot checks will help to ensure that
discrepancies are minimised. Clinical input should be sought in situations where the data
amended is held within medical records. In the case of auditable software, suitable
amendments should be made and the necessary explanation recorded on the system.
Training
Training is required to ensure the necessary members of staff have the appropriate
understanding in order to satisfy the requirements of information governance. With suitable
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guidance data quality processed will be improved as information will be collected and
recorded correctly at the point of entry. This then reduces the requirement for lengthy
validation procedures at later dates.
Line Managers are responsible for identifying the training requirements of their staff and
working with training providers to ensure these needs are met. Staff must be enabled to
attend the appropriate training as it is an integral part of records management. Training is
given at corporate induction. Training will be given to staff on how to use electronic systems
such as TPP SystmOne and Medeanalytics. Staff must be enabled to attend the
appropriate training courses allowing them an adequate level of proficiency in order to carry
out their functions effectively.
Monitoring
Data quality will be subject to internal control processes with the CCG and to external
scrutiny. All information systems and processes will have routines developed designed to
systematically identify errors and other aspects of poor data quality. Departments should
undertake an internal audit of their records annually.
External controls
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Data quality reports from Department of Health
Hospital episode statistics data quality indicators
Queries from service users and commissioned services
Audit of case records and data quality by external auditors
References
Department of Health (2004) A Strategy for NHS Information Quality Assurance.
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