Annual Report and Accounts - The Great Western Hospital

Great Western Hospitals NHS Foundation Trust will be taking the following actions to improve data
quality:
- The Trust Data Quality Group will continue to manage and monitor a work programme that
targets identified areas of poor data quality and progress will be reported to the Trust’s
Information Governance Steering Group
- The actions from internal and external audits and benchmark reports associated with data
quality will be acted on and monitored by the Trust Data Quality Group
- Development of refresher training programmes for staff involved in data collection and data
entry will continue
Great Western Hospitals NHS Foundation Trust was subject to the Payment by Results clinical
coding audit during the reporting period by the Audit Commission. The summary results of the audit
were
Auditor
PbR Audit
Commission
Primary
Secondary Primary Procedure Secondary
Diagnosis Diagnosis
Procedure
91.5% 91.0% 91.1% 94.7%
These results achieved level 2 in the Information Governance Toolkit. The audit identified areas for
improvement and these have been included in an action plan that will be implemented in the course
of the year.
The Trust continues to work towards developing compliance with the pseudonymisation initiative and
has re-audited patient identifiable data flows from key departments. The audit serves both to log the
flows and to audit their compliance with pseudonymisation and data protection rules. This work will
maintain its level of focus as changes to data flows are requested by Clinical Care Commissioning
Groups as they become established as Commissioners.
Information governance
Information is a key asset, both in terms of the clinical management of individual patients and the
management of services and resources throughout the Trust. It is therefore of utmost importance
that appropriate policies, procedures and management accountability provide a robust governance
framework for the efficient management of information. There is corporate leadership of information
governance, the Finance Director having overall responsibility. The Information Governance Steering
Group oversees information governance issues, with responsibilities delegated from the Audit, Risk &
Assurance Committee on behalf of the Trust Board.
The Information Governance Management Framework is documented within the Information
Governance Strategy and Policy. The four key principles are openness, information quality,
information security and legal compliance. Confidentiality, security, and data quality play an
important role in the safeguarding of information within the Trust. This includes organisational and
staff information as well as patient information. The Trust has agreements for the sharing of patient
information with healthcare organisations and other agencies in a controlled manner, which ensures
the patients’ and public interests are upheld. It is essential for the delivery of the highest quality
health care that accurate, timely and relevant information is recorded and maintained. As such it is
the responsibility of all staff to promote data quality and confidentiality.
The Trust’s Information Governance Steering Group undertakes an Information Governance Work
Programme covering the full range of information governance elements, and ensures that appropriate
policies and management arrangements are in place. The Data Quality Group, which reports to the
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