Northampton General Hospital NHS Trust Quality Account 2016-2017

An action plan, work schedule and a comprehensive confidentiality/information governance audit
programme is being developed for a more proactive and robust approach to the Information
Governance Toolkit, with particular attention paid to the above areas. This will be monitored
through the Information Governance Group chaired by the Director of Corporate Development
Governance and Assurance (the Senior Information Risk Owner- SIRO) with regular reports to the
Assurance, Risk and Compliance Group and the Quality Governance Committee as required.
Clinical coding error rate
Background
An audit was internally commissioned by Northampton General NHS Trust to fulfil the Information
Governance (IG) Toolkit requirement 505 and the associated objectives are clearly defined to
support this purpose. The toolkit requirement states that there should be established procedures in
place for regular quality inspections of the coded clinical data using the Clinical Classifications
Service (CCS) Clinical Coding Audit Methodology to demonstrate compliance with the clinical
classifications OPCS-4 and ICD-10 and national clinical coding standards and the organisation’s
commitment to continual improvement of its coded data. The clinical coding audits are undertaken
by a CCS approved clinical coding auditor.
In the audit, each of the 3 bed-holding clinical Divisions have been selected for audit which
included all associated inpatient sub-specialties. This represents a snapshot of all inpatient coded
data.
In addition to this yearly audit, there is a cycle of audit both random (individual coders quarterly)
and targeted (monthly) undertaken by management staff which covers a minimum of 100
Consultant episodes each month.
NGH was not subject to an externally commissioned clinical coding audit at any time during the
reporting period.
Objectives
To assess Trust-wide inpatient coding performance against recommended achievement
levels for Information Governance Toolkit Requirement 505.
To review the coded information for accuracy and adherence to national standards.
To identify a baseline measure of accuracy for continuous improvement.
To analyse the information provided to the coders at the time of the coding with the
information contained in the case notes at the time of audit.
To make recommendations where appropriate, to improve the quality of the coded clinical
data.
Methodology
The individual episode data was selected at random across each of the Division’s activity. The
sample period was quarter 2 of 2016-17 and comprised 120 spells for each Division. A total of 5
excess notes were pulled per Division in case folders were unable to be audited.
The auditors carried out the audit strictly adhering to the Clinical Coding Audit Methodology
Version 10.0 in order to satisfy the Information Governance requirement 505.
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