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

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. A framework of principles which protect the use of patient identifiable information in NHS/Social Care organisations 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?

4. Reminder of Caldicott Principles  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 Person-identifiable information should be:

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

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

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

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

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

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

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

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

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

14. Achieved an Out-turn report Criteria 8 score of 2  Achieved an Out-turn report Criteria 8 score of 2 Project objectives have been met :-  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  Immediate action plans complete  Long term actions assigned to Projects  Recognition from the NHSIA OUTCOMES & ACHIEVEMENTS

15. 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 CONCLUSION

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