Document Title: Written Control Document
Development and Approval Procedure
Reference Number: UHB001/01
Version Number: 1
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Reference Number: UHB xxx/xx
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DATA QUALITY POLICY
Policy Statement
High quality data in all settings is critical for improving patient and service user care,
performance monitoring, and planning services. In relation to personal data this is in line
with Principle 4 of the Data Protection Act 'Personal data shall be accurate and where
necessary kept up to date' and is an important aspect of the Information Governance
agenda. The Health Board is committed to implementing programmes of work within the
organisation to address data quality, and ensure that where data is processed within the
organisation, controls are in place to ensure the data is kept accurate and where
necessary up to date. The Health Board will deliver this through the management
accountabilities and responsibilities framework. The Board will be given assurance as to
whether the UHB is meeting its obligations by reporting through its information governance
assurance framework.
The ability of the Health Board to generate, use and share good quality data effectively and
to demonstrate this objectively is paramount to the business of healthcare. High quality
data gives the Health Board assurance that all data and derived information is reliable,
supports decision making and the delivery of the best possible care.
The Health Board aims through this policy to give a clear statement of intent as to how it
will organise and meet its obligations in processing data to the highest standards.
Policy Commitment
Key components of data quality include; accuracy, completeness, validity, timeliness, free
from duplication or fragmentation, defined and consistent. Data from all areas should be
recorded and processed at all levels in the Health Board using relevant skills and
knowledge.
The Health Board has set 8 key objectives in order to achieve the policy aims. They are:

Data is accurate and up to date:
Correct and accurately reflects what actually happened
Precise and includes all data processed in the organisation

Data is complete: Data should be captured in full and where applicable a valid and
traced NHS number must be included to support operational use.

Data is valid
Data should be held in a format which conforms to recognised national
standards
Document Title: Written Control Document
Development and Approval Procedure
Reference Number: UHB001/01
Version Number: 1
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Must be mapped by codes to national values where these are in existence
Held in computer systems that are programmed to only accept valid entries
wherever possible
Data is timely
Data should be collected at the earliest opportunity, preferably at the time
and place of the activity taking place
Data is available when required for its intended use
 Data is free from duplication and fragmentation: Patients must not have duplicated
or confused patient records e.g. should not have two or more separate records held
on Patient Management Systems.

Data is defined and consistent: The data being collected should be understood by
the staff collecting and interpreting it.

Coverage: Data from all areas of activity - clinical or corporate should be recorded in
the appropriate place and format.

Data quality management: At every level across the Health Board those managing
data quality must have the appropriate skills and knowledge.
All employees are required to adhere to this policy. Inappropriate use of data may lead to
disciplinary action. Serious breaches, for example disclosure of person identifiable
information, theft and misuse of information technology may constitute gross misconduct
and lead to dismissal and possibly police involvement.
Supporting Policies, Procedures and other Written Control Documents
This policy and the supporting guidance together with its supporting procedures describes
the UHB’s aim, objectives and operational organisation in regard to discharging its
obligations in respect of the quality of information and data it processes.
Scope
This policy applies to all Health Board staff whether permanent, temporary, or contracted
including students, contractors or volunteers in all locations and those with Honorary
Contracts.
Equality Impact
Assessment
An Equality Impact Assessment has been completed for the
overarching Information Governance Policy one element of
which is Data Quality. The assessment can be found [insert
hyperlink when approved] An action plan has been developed
to address those areas.
Documents to read
alongside this
Procedure
Data Quality Operational Management and Responsibilities
Records Management Policy
Records Management Retention and Destruction Protocol
Validation at Source System (VASS) checks mandated by
Welsh Government.
Document Title: Written Control Document
Development and Approval Procedure
Reference Number: UHB001/01
Version Number: 1
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Data Standard Change Notifications (DSCNs) issued by the
National Wales Informatics Service
Other relevant documents mandated by Welsh Government
such as the “Rules for Managing Referral to Treatment Waiting
Times”
UHB Standard Operating Procedures for routine Data Quality
checks linked to the 8 key objectives as described in the Data
Quality Operational Management and Responsibilities
Procedure
Approved by
People, Performance and Delivery Committee
Accountable Executive
or Clinical Board
Director
Executive Director of Finance
Author(s)
Head of Information Governance and Assurance and Senior
Manager, Performance and Compliance
Disclaimer
If the review date of this document has passed please ensure that the version you are using is the most
to date either by contacting the document author or the Governance Directorate.
Summary of reviews/amendments
Version
Number
1
Date of
Review
Approved
Date Published
Summary of Amendments
Document Title: Written Control Document
Development and Approval Procedure
Reference Number: UHB001/01
Version Number: 1
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Reference Number: UHB 001/01
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Data Quality
Operational Management and Responsibilities
Introduction and Aim
The University Health Board (UHB) has a Data Quality Policy that was developed by the
Information Governance Sub Committee (IGSC) and approved by the People,
Performance and Delivery (PPD) Committee.
This supporting document provides some of the detail to support the implementation of the
policy including individual responsibilities. It clearly sets out the organisation and
responsibilities of staff in the day to day management of data quality (DQ) to ensure that all
data processed in all formats is demonstrably of the highest quality.
Definitions
Data
Data are numbers, words or images that have yet to be organised or analysed to answer a
specific question.
Information
Information is produced through processing, manipulating and organising data too answer
questions, adding to the knowledge of the receiver.
Knowledge
Knowledge is know by a person or persons and involves interpreting information received,
adding relevance and context to clarify the insights the information contains.
Data Quality Principles
Good quality information is derived from data that is:
 Accurate and up to date
 Complete i.e. captured in full
 Valid i.e. held in a format which conforms to recognised national standards
 Timely i.e. data should be collected at the earliest opportunity, preferably at the time
and place of the activity taking place.
 Free from duplication and fragmentation. Patient must not have duplicated or
confused patient records e.g. should not have two or more separate PMS records.
 Defined and consistent. i.e. The data being collected should be understood by the
staff collecting it.
 Reflects full coverage i.e. data from all areas of activity clinical or corporate should
be recorded by electronic or manual means.
 Subject to quality management. Data must be managed by adequate skills and
knowledge at every level across the Health Board
Document Title: Written Control Document
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Reference Number: UHB001/01
Version Number: 1
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All employees are required to adhere to these principles. Inappropriate management of
data may lead to disciplinary action. Serious breaches, for example disclosure of person
identifiable information, theft and misuse of information technology through acts and
omissions of staff may constitute gross misconduct and lead to dismissal and possibly
police involvement. All staff, whether permanent, temporary or contracted (including
students, contractors or volunteers and those on honorary contracts) are responsible for
ensuring they are aware of IG requirements and that they comply with these on a daily
basis on a daily basis.
Data Standards
Processes and procedures must be in place to ensure that where new services are
provided or system changes are made, the appropriate action is taken to notify system
administrators of changes and ensure that all users are aware of the impact of those
changes to maintain information quality.
All departmental data collection procedure documents should ensure that staff
responsibilities in relation to the quality of the data entered onto patient systems, are
clearly referenced and managers must ensure that these are regularly reviewed and
updated.
Formal notifications such as Data Set Change Notices (DSCNs) must be logged and
disseminated appropriately within the UHB.
Data Quality Monitoring
Procedures must be in place to ensure that staff routinely checks information with the
source and that corrections are routinely made. Liaison should take place with outside
organisations with regard to data quality issues.
Awareness of data quality throughout the UHB will be provided by the deputy SIROs and
supported by the activities of the Data Quality Sub Group (DQSG) and UHB training
programme. Data quality will, in all cases, (as a minimum requirement) be compliant with
the data quality standards laid down by the Welsh Assembly Government and monitoring
of compliance will be performed.
Data Quality Reporting
Annual and quarterly performance reports will be submitted to Information Governance
Sub Committee (IGSC). Significant issues will be escalated to the Board via the PPD.
Security
All data must be held securely in line with the IT security policy and procedures. Also the
Data Protection Act Policy and procedures must be adhered to in order to ensure the
confidentiality of personal identifiable information.
Who is responsible for what?
Executive Director responsible for Information - The executive director responsible for
information is the accountable director for data quality and works closely with the SIRO on
assurance matters.
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Senior Information Risk Officer (SIRO) - The SIRO is responsible for providing the
Board with assurance that arrangements are in place to deliver and maintain high quality
data. The quality of data within the Health Board is one of the key areas within the SIROs
portfolio and will:
 Require assurance from the deputy SIROs in the clinical boards and executive
teams in respect of data quality that they have arrangements in place as set out in
the policy and this associated document.
 Chair the Data Quality Group (DQG)
 Advise the Information Governance Sub Committee on Data Quality matters
 Act as an advocate for data quality /information risk on the Board and in internal
discussions
Caldicott Guardian (Medical Director) – responsible for ensuring that the UHB
operational systems and processes satisfy the highest practical standards for processing
personal identifiable information (PII) which is fundamental to the processing of high quality
data and information flowing from that data. The Medical Director will:
 Work closely with the SIRO and the Data Quality Group to discharge his obligations.
Information Governance Sub Committee (IGSC)
In respect of data quality the purpose of the IGSC is to receive evidence based and timely
advice from the SIRO to assist in discharging their functions and meeting their
responsibilities. The role of IGSC is to assure PPD and onwards to the Board
The IGSC will require a number of reports as standing items. These reports will be
generated by the Data Quality Sub Group and shared routinely with the clinical boards and
corporate services for information and action. Summary reports will be presented routinely
to the IGSC for assurance.
Data Quality Group (DQG)–The group reports to the IGSC through its chair the SIRO. The
purpose of the DQG is to provide a corporate forum for the coordination of all activities
related to data quality, data collection and data entry working practices across the UHB.
These activities must comply with requirements mandated by WG and other third parties
as appropriate.
Communication with Clinical Boards and Corporate Services - Effective
communication between the clinical boards and executive teams and the Data Quality Sub
Group is achieved through its membership and the IG data quality sub group that ensures
two way communication flows.
Data Quality: Operational management
Data Quality is managed operationally by the clinical boards and corporate services. The
accountable officers are the Clinical Board Directors and Executive Directors respectively
and they work closely with the SIRO as deputy SIROs. The Head of Information
Governance and team are responsible for advising on strategic direction, compliance and
development of policy and guidance in respect of data quality. The Senior Manager for
performance and compliance (data quality manager) in conjunction with the Head of
Information Governance is responsible for operational guidance and advice and supports
the SIRO in delivery of continuous improvement action plans developed by the Data
Document Title: Written Control Document
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Quality Group.
Clinical boards Clinical Board Directors are the accountable officers and act as deputies
to the SIRO for their areas. The Clinical Directors discharge the role of Information Asset
Owners (IAOs) and Directorate Managers Information Asset Administrators (IAAs)
Corporate Services Corporate directors are the accountable officers and deputies to the
SIRO. The Assistant Directors or equivalent discharge the role of Information Asset
Owners (IAOs) and Section Managers Information Asset Administrators (IAAs)
The data owner/information asset owner is responsible for ensuring that specific
information assets are processed confidentially, safely, securely and lawfully. This means
making sure that data quality is properly delivered and that its value to the organisation is
fully exploited. They usually will
 Lead and foster a culture that understands and values data quality
 Monitor the standard of data quality within their areas and take appropriate action.
 Identify staff responsible for poor data quality and ensure that training or other
appropriate action is taken
 Understand, record and address risks to data quality, and provide assurance to the
SIRO
 Work with the Health Board Data Quality Manager and the Data Quality Group to
deliver a corporate improvement plan for data quality.
Corporate Information Services. This is part of the performance and information
department. This team is made up of professionally qualified and experienced information
professionals. This department is made up of professionally qualified and experienced
information professionals. Its role is to ensure that the information processed consistently
provides accurate, timely and appropriate information in accordance with nationally
mandated requirements and are responsible for the transfer of a range of data to the
Welsh Government and elsewhere. They advise healthcare professionals on their
information requirements to support service delivery and assist them use information to
gain the maximum benefit from departmental systems. It is professionally responsible for
data standards across the UHB and advises on areas of non-compliance. It is responsible
for monitoring a range of data standards.
The work of the Clinical Boards and Executive Teams. Arrangements shall be in place
to achieve the UHBs objectives with regard to Data Quality. The key responsibilities are to
ensure that:
 Operational processes and procedures are documented and embedded
 Routine monitoring and audit are in place to include agreed standards.
 Effective training both induction and re-fresher is in place
 Incident reporting systems are understood, used and lessons learned
 Data Quality risk assessments are in place, actively managed and recorded as
appropriate in risk registers.
 Year on year improvement plans are produced and actively managed
The clinical board SIROs will periodically give assurance to the SIRO that they have these
arrangements in place as part of their wider IG responsibilities and they will produce an
Document Title: Written Control Document
Development and Approval Procedure
Reference Number: UHB001/01
Version Number: 1
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annual performance report for integration into a corporate report. This process will be
clearly tied into the performance reporting schedules required by the Health Systems
Management Board (HSMB) for clinical boards. The SIRO will periodically report
performance to the IGSC for assurance purposes.
Reporting Process for incidents and / or breaches
During office hours:
Data Protection Act related incidents: Follow incident reporting procedure and contact the
Information Governance Team who will ensure that the Caldicott Guardian is informed.
IT Security incident: Follow incident reporting procedures and contact IT Security Manager
Outside office hours:
Data Protection Act related incidents: Follow the incident reporting procedure. Escalate to
the Executive Director on call who is responsible for ensuring that the Caldicott Guardian is
informed.
Performance. Performance against a set of agreed national and local standards shall be
measured, monitored and acted upon and reported to the Quality and Safety Groups within
the clinical boards and corporate services. Routine performance reports shall be reported
at the HSMB and periodically provided to the IGSC for assurance purposes.
What are the Monitoring Arrangements? The UHB shall routinely monitor its
performance for.
 Overall compliance – the SIRO
 Local compliance - clinical boards and corporate services
 Corporate assurance arrangements - the IGSC
 Compliance by formal assessment–
- Health and Care Standards Wales 3.4 and 3.5. or any future equivalent
standard
- Caldicott annual assessment
- Internal Audits sponsored by UHB committees
- Annual and specific audits by the Welsh Audit Office
- Any other audits or assessments directed by the Welsh Government
Scope
This procedure applies to all UHB staff whether permanent, temporary, or contracted
including students, contractors or volunteers in all locations including those with Honorary
Contracts.
An Equality Impact Assessment has been completed on the
Equality Impact
overarching IG policy a major element of which is data quality.
Assessment
The assessment found that there was some impact on the
equality groups mentioned in relation to communication. An
action plan has been developed to address those areas.
Documents to read
alongside this
Procedure
Data Quality Policy
Validation at Source System (VASS) checks mandated by
Welsh Government|.
Data Standard Change Notifications (DSCNs) issued by the
Document Title: Written Control Document
Development and Approval Procedure
Reference Number: UHB001/01
Version Number: 1
6 of 7
Approval Date
Next Review Date
Date of Publication
National Wales Informatics Service
Other relevant documents mandated by Welsh Government
such as the “Rules for Managing Referral to Treatment Waiting
Times”
Standard Operating Procedures for routine Data Quality checks
linked to the 8 key objectives as described in the Data Quality
Operational Management and Responsibilities Procedure
Approved by
People, Performance and Delivery Committee
Accountable Officer
Executive Director of Finance
Author(s)
Head of Information Governance and Assurance and Senior
Manager, Performance and Compliance
Disclaimer
If the review date of this document has passed please ensure that the version you are using is the most
to date either by contacting the document author or the Governance Directorate.
Summary of reviews/amendments
Version
Number
1
Date of
Review
Approved
Date Published
Summary of Amendments
New policy – supplementary information
Document Title: Written Control Document
Development and Approval Procedure
Reference Number: UHB001/01
Version Number: 1
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