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CALDICOTT Flow Mapping of Patient Identifiable Information

CALDICOTT Flow Mapping of Patient Identifiable Information. Shirley Ledingham Project Manager July 2003. AIM OF THE SESSION. Background Information How the Project was implemented Examples of Action Plans & Risks Stages 2 & 3 Outcomes and Achievements Conclusion.

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CALDICOTT Flow Mapping of Patient Identifiable Information

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  1. CALDICOTT Flow Mapping of Patient Identifiable Information Shirley Ledingham Project Manager July 2003

  2. AIM OF THE SESSION Background Information How the Project was implemented Examples of Action Plans & Risks Stages 2 & 3 Outcomes and Achievements Conclusion

  3. The Annual Caldicott Out-turn Report Linked to the Trust’s Star Rating THIS PROJECT Exchanges of Patient identifiable information should be mapped and reviewed regularly Caldicott …… What is it? A framework of principles which protect the use of patient identifiable information in NHS/Social Care organisations

  4. Reminder of Caldicott Principles Person-identifiable information should be: • clearly defined and justified • only used when absolutely necessary • kept to a minimum • accessed on a need-to-know basis • Staff should be aware of their responsibilities and obligations to respect confidentiality • Every use of person-identifiable information must be lawful

  5. Flow Mapped STAGE 1 • Reviewed STAGE 2 • Rolling review established STAGE 3 CALDICOTT RECOMMENDATIONS A Staged Approach

  6. Chief Executive and Project Management Board Recommendations • CHI REVIEW • IMMEDIATE ACTION PLANS • LONG TERM ACTIONS

  7. Investigation • Caldicott Guidelines • Other Trusts Planning • Gathering Information Question Bank Questionnaire • Storing Information Electronic Tracking system • Reports Templates • Flow Maps Visio Training PREPARING TO FLOW MAP

  8. What areas WANT/NEED to be flow mapped? THE DIRECTORATE MANAGERS FEEDBACK FEEDBACK AGREE AREAS TO BE MAPPED FEEDBACK AGREE KEY STAFF TO BE APPROACHED FEEDBACK FLOW MAP? READY STEADY MAPBUTWHERE TO START? FLOW MAPPING

  9. Tracking System • Detailed Report • Summary Report • The Visio Flow Map Reports and flow maps

  10. DATAFLOW Receipt of Medical Records for Clinic MEDICAL RECORDS MEDICAL RECORDS Medical records delivered to clinic (+ 2 clinic lists) PROCESS Search for missing records PROCEDURE BREACH OF CALDICOTT PRINCIPLES Not clearly defined or justified, Not necessary, Not kept to a minimum, Not accessed on a need-to-know basis ACTION Example – Immediate Action Plan Records ready to be prepared

  11. DATAFLOW Arranging inpatient Nurse led follow up clinic PROCESS Ward round to collect details Send appointment letters NO PIMS PROCEDURESCAN INCLUDE Clinic List DIARY BREACH OF CALDICOTT PRINCIPLES DATA QUALITY Not kept to a minimum Needs updating! ACTIONS Example – Long Term Action Plan Request Medical Records Non Consultant Led Clinics Project Patient Document Tracking Project ATD Project EPR

  12. ELECTRONIC • Not networked • Unreliable • Unsafe havens PAPER SYSTEMS • Duplication • Insecure • Split records • Medical Notes VERBAL SYSTEMS • Telephone • Answer machines COMMON RISKS

  13. Risk Reports Review & feedback to Information Governance Manager Directorate Managers Head of Modernisation Information Governance Manager Cascade to project leads Completion of Caldicott Out-turn Report March 04 & sign off by Caldicott Guardian Repeat above for Out-turn report in March 05 Completion of Caldicott Out-turn Report March 06 & sign off by Caldicott Guardian Review & Update Feedback to Information Governance Manager Cascade flow map templates to Directorate Managers March 07 Rolling review by exception reporting LAUNCH OF STAGES 2 & 3 Prioritising mapped flows for review (Stage 2) & Rolling review (Stage 3)

  14. OUTCOMES & ACHIEVEMENTS Achieved an Out-turn report Criteria 8 score of 2 Project objectives have been met :- Baseline of current position Breaches of confidentiality reduced Patient privacy enhanced Work towards standardisation of working practices Processes identified to support review programme Immediate action plans complete Long term actions assigned to Projects Recognition from the NHSIA

  15. CONCLUSION In line with the Data Protection Act and Caldicott Principles this project has endeavoured to:- • Raise the profile of confidentiality issues across the Trust • Recommend processes to support on-going improvements

  16. CALDICOTT Flow Mapping of Patient Identifiable Information Shirley Ledingham Project Manager July 2003

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