QUALITY AND SAFETY COMMITTEE 12 SEPTEMBER 2013 AGEND ITEM 3.2a INFORMATION GOVERNANCE COMMITTEE (IGC) - UNCONFIRMED MINUTES OF THE MEETING HELD ON 29 JULY 2013 Report of Director of Therapies & Health Science Paper prepared by Information Governance Manager Purpose of Paper The purpose of this paper is to submit the unconfirmed minutes of the IGC Action/Decision required The Quality & Safety Committee is asked to RECEIVE the unconfirmed minutes of the IGC meeting held on 29 July 2013 and NOTE the 4 highlighted issues. Link to Doing Well, Doing Better: Standards for Health Services in Wales : Link to Health Board s Corporate Plan Standard 1: Governance & Accountability Standard 19: Information Management Standard 20: Records Management Striving for Excellence (delivery) Acronyms and abbreviations IG Information Governance IGC Information Governance Committee Page 1 of 7
UNCONFIRMED MINUTES OF THE IGC MEETING HELD ON 29 JULY 2013 Background The unconfirmed minutes of the IGC meeting held on 29 July 2013 have been submitted to the Quality & Safety Committee to demonstrate the information governance work being undertaken in the Health Board. In particular the following issues should be noted: 1. Progress Report in Respect of the 2011/12 Internal Audit Recommendations Work to address the outstanding recommendations was progressing in line with the agreed action dates with the exception of the launch of IG Training. However subsequent to the meeting, the mandatory IG e-learning modules were implemented on 8 August 2013 and appraisers requested to ensure that all employees complete them by 31 March 2014. 2. IG Policy Creation and Updating With the exception of 4 documents all required policies have been created and updated. Most are in draft form and are currently in the consultation stage. It is envisaged that this task will be completed no later than 31 December 2013. 3. Robert Powell Investigation Recommendations Progress against the Health Board s Action Plan was noted and a further update will be submitted to the next Committee meeting. Discussions also included reference to 3 related ICT projects and it was agreed that the implementation timetable for these would be presented to the next meeting. 4. Review of Medical Records Storage The review highlighted concerns regarding the secure storage of records throughout the Health Board. Subsequent to the Committee meeting the Executive Directors requested a risk assessment of the situation and this was submitted to the Risk Management Committee. Three significant risks were indentified and it was agreed that these must be recorded in the Corporate Risk Register. A report regarding these risks and proposals for their mitigation will be included on the agenda of the Board of Directors meeting scheduled for 28 August 2013. Recommendation The is requested to RECEIVE the unconfirmed minutes of the IGC meeting held on 29 July 2013 (Appendix 1) and NOTE the 4 highlighted issues Page 2 of 7
Report prepared by: Philip Trocki Information Governance Manager Presented By: Amanda Smith Director of Therapies & Health Sciences Page 3 of 7
Appendix 1 Information Governance Committee Minutes (unconfirmed) 2 4pm Monday 29 July 2013 Basil Webb Hall, Bronllys Hospital Present: Mark Baird Gyles Palmer Amanda Smith Philip Trocki Amanda Smart Brendan Lloyd Apologies: Wendy Morgan David Long Ian Ruse Non-Officer Member MB (Chair) Non-Officer Member GP (Vice-Chair) Director of Therapies AS Information Governance Manager PT Records Manager AS2 (secretariat) Medical Director BL Head of Quality and Safety WM Assistant Director of Workforce & OD DL ICT Project Manager IR Ref No. Subject Issues / Action required By Whom IGC1.1 Welcome and Apologies for Absence Noted as above. IGC1.2 Declarations of Interest None declared. IGC1.3 Minutes of previous meeting held on 25 April 2013 The Committee approved the minutes of the meeting held on 25 April 2013. The Chairman requested that the Secretariat minuted agreed changes to documents considered by the Committee in order to provide assurance that these have been actioned. Action: Ensure future minutes reflect Chairman s request. AS2/AS IGC1.4 Matters arising from previous meeting IGC 5.1 update from PT. Approval has been received for two of the IG Training Tool modules to form part of the mandatory training for all Powys staff. The Workforce and OD Development Team will launch these modules as part of the UK Core Skills Framework Training. There have been delays in developing the other areas involved. PT advised that confirmation had been received from the Assistant Director, Workforce Development that the IG modules should be launched this week. Action: Update on progress to be reported to the next Committee meeting. PT Page 4 of 7
ICG2.1 Progress Report To RECEIVE the IG work programme based on the 2011/12 internal audit report recommendation progress as at 14 February 2013 The Committee received and noted the IG Work Programme and progress to date. 1894/1900/1880 The Chairman asked for confirmation that a Training Needs Analysis had been completed to include staff with specific information responsibilities. This was confirmed by PT. The Chairman requested assurance that the training would be given to all staff. PT confirmed that the IG modules would be included in the Health Board s corporate induction programme and a refresher would also be provided every 2 years to all staff. GP asked if access issues for some staff areas would be a problem PT confirmed that all staff should have access to a computer, for example there are internet cafes in all hospitals. The Chairman asked if there are specific modules for specialist areas PT confirmed this is the case and advised that the IG Team would be targeting these staff independently. Action: A training progress report is to be presented to the November Committee meeting. PT 1901/5 The Chairman asked for update on how work was progressing in relation to mapping information flows. PT advised that the first stage would be setting up an information asset register. Compilation would need to be phased starting with major systems and larger geographical areas such has the Localities. 1902 The Chairman asked for confirmation on who was Powys DPA co-ordinator, PT confirmed it was his role. 1904 The Chairman requested a future agenda item in respect of IT Security Management. This should provide: Assurance that the Health Board is measuring itself against the national standards (ISO2700 and the NHS Code of Connection) Evidence of the technical safeguards in place. PT advised the Chairman that he has asked the IT Operations Manager for a report to be presented to the November 2013 Committee meeting 1899 The Chairman requested regular Information Governance performance reporting as separate agenda item covering areas such as compliance with SAR, FOI legislation and the level of security incidents. Page 5 of 7
Action: Assurance report to be provided by the IM&T Department covering recommendation 1904 and for this report to become a separate agenda item. IT Operations Manager IGC3.1 Policies - To RECEIVE the schedule of Information Governance Policies and their current status Action: Assurance report on compliance with SAR, FOI and Security Incidents and to become a separate agenda item for future meetings. PT updated the Group on progress and advised there were 4 outstanding policies to update or produce. The Chairman asked how assurance is given that Powys has all the necessary policies in place. PT advised that checks are made against other Health Boards in Wales and England. The Chairman asked how the Internet and Email Acceptable Use polices are monitored and requested feedback on this at the next meeting. PT/AS2 IGC4.1 INCIDENTS & RISKS To RECEIVE an update on action plan in response to recommendation of the Robert Powell investigation Action Feedback on how the Internet and Email Acceptable Use Policy is monitored and incidents to be provided to the Chairman. The Committee received an update on the Robbie Powell investigation and Welsh Government recommended actions from BL. BL presented the reports and updated the Committee on current actions. Further progress to be submitted to the next meeting Action: Further progress report will be SUBMITTED to the next Committee meeting. PT/IT Operations Manager BL Chairman asked for a progress report on the implementation timetable for the 3 national systems to be presented at the next meeting; The new GP system, IHR and the WCP. It was felt all these systems are necessary to satisfy the recommendations of the Robert Powell report. IGC5.1 To RECEIVE the Review of Medical Records Storage Action: progress report will be SUBMITTED to the next Committee meeting. The Committee received an overview of the report on Medical Records Storage. AS advised that the report was on the agenda for the next Executive Team meeting for discussion and prioritisation of actions and an update on the decisions made would be brought to the next meeting. BL/ICT project Group IGC5.2 To RECEIVE a presentation on the Individual Health Record Project Actions: Update on the decisions made by Executive Team to be provided at the November meeting. The Committee received an overview of the IHR project from BL. AS Page 6 of 7
IGC6 Date of next meeting Thursday 7 November 2013 2.00pm 4.00pm, Training Room 2, Bronllys Hospital Page 7 of 7