Information Governance in NHSScotland - NES · Information Governance in NHSScotland: ... The importance of good information governance practice is recognised by the ... 6 Chapter

Information Governance in NHSScotland: A Competency Framework

2nd Edition | December 2011

Contents

Foreword 1

by Malcolm Wright, NHS Education for Scotland

Executive Summary 2

Chapter 1. Why? Information Governance and Workforce Development 3

1.1 InformationGovernance 41.2 Workforcedevelopment 41.3 Whyeducateforinformationhandling? 51.3 Usingthisdocument 6

Chapter 2. What? Information Governance Competencies 7

2.1UnderstandingInformationGovernancecompetencies 82.2Levelsofcompetence 82.3Usingcompetencies 92.4TheInformationGovernancecompetencies 10

Chapter 3. How? Analysing Training Needs and Monitoring Quality and Outcomes 19

3.1Educationandtrainingneeds 203.2Monitoringqualityandoutcomes 21

Chapter 4. Who? Education and Training for All, and Developing Partnerships 23

4.1 Educationandtrainingforall 244.2 Developingpartnerships 26

AppendicesAppendix1.EditorialGroup 30Appendix2.Policycontext 30Appendix3.Educationandtrainingneedsanalysis 32Appendix4.AgendaforChange 33Appendix5.ScottishCreditandQualificationsFramework 34Appendix6.Glossary 35

Workforce Education Planning Template 37

Contact details 38

©NHSEducationforScotland2011.YoucancopyorreproducetheinformationinthisdocumentforusewithinNHSScotlandandfornon-commercialeducationalpurposes.UseofthisdocumentforcommercialpurposesispermittedonlywiththewrittenpermissionofNES.

ISBN:978-0-85791-019-6

Information Governance in NHSScotland: A Competency FrameworkForeword 1

Foreword by Malcolm Wright, Chief Executive, NESThe NHSScotland Information Governance Competency Framework was published in 2008 in response to the escalating volume of information handled by the service, and the associated challenges to safe and effective information handling.

SinceitspublicationtheIGCompetencyFrameworkhasbeenwidelyusedbyNHSBoardsandotherhealthcareorganisationswhereithasbeenakeypointofreferenceforworkforcedevelopmentinthisimportantdimensionofservice.WearegratifiedtolearnthattheFrameworkhasalsobeenusedbyhealthcarestaffinotherUKcountriesandfurtherafield.ThesecondeditionoftheFrameworkretainsmostofthecontentoftheoriginaledition,includingthecompetenciessetoutinChapter2.Itneverthelessbringsthedocumentfullyup-to-datebylinkinginformationgovernancetotheNHSScotlandQualityStrategyandotherkeyserviceandpolicydevelopments.WehopethattheCompetencyFrameworkwillalsoassisttheserviceinaddressingtheopportunitiesandrisksarisingfromnewwaysofworkingandnewtechnologies,includingtheincreasinguseofmobiledevicesinhealthcareandsocialnetworking.

Asthevolumeandcomplexityofinformationincreases,wedemandthehigheststandardsofprobityinthewayitisprocessed.TheserequirementsaresetoutinlegislationsuchastheDataProtectionAct1998,theHumanRightsAct1998andtheFreedomofInformation(Scotland)Act2002.Whilethisgivesthepublicandserviceusersgreaterconfidencethattheirpersonaldatawillbeusedappropriately,itpresentsconsiderablechallengesandriskstoNHSBoards,primarycareprovidersandtheirstaff.SuchchallengesareclearlyevidentintheScottishGovernment’sstrategyfordevelopmentofaneHealthcultureinNHSScotland,centredontheintroductionofanelectronicHealthRecord.

Modernisationandredesignprojectswillhaveimplicationsforthewaystaffwork,communicateanduseinformation.Webelieveitiscrucialtooursuccessthatwehaveacohesive,integratedapproachtoeducationandtrainingoninformationgovernance.ThesecondeditionofInformation Governance in NHSScotland: a Competency Framework marksourcontinuingdeterminationtoensurewehavesuchanapproachinplace.WeareconfidentthatitwillremainofsignificantbenefittoNHSBoards,staffandserviceusers.

Information Governance in NHSScotland: A Competency FrameworkExecutive Summary2

Executive SummaryHigh quality information is crucial to the delivery of safe and effective health care. NHSScotland is putting in place modern and efficient information and communications systems to ensure that the right information is available at the right time, in the right place, to enable staff to provide the best possible care and keep clear, accurate and legible records. We also need to ensure that the benefits which information technology brings to patients and health care professionals, such as improved co-ordination of care, are delivered within a culture which respects, values and keeps data secure. The provision of good quality education and training in information governance is an important method of effective information management. It also assists Boards in meeting their statutory responsibilities and policy obligations in information governance.

TheInformationGovernanceCompetencyFrameworkprovidesafirmfoundationforthedevelopment,commissioningandreviewofeducationandtrainingtosupporteffectivepractice.Itisalsoausefulreferencepointforworkforceplanningandjobdesigninthisaspectofservice.TheFrameworkisorganisedinfive‘domains’reflectingdifferentaspectsofinformationhandling,andfourlevelseachdescribingadifferenttypeofresponsibilityinthisarea.Thisapproachisdesignedtoenabletrainingcommissioners/providerstotailoreducationforthespecificneedsofindividuals,groupsandorganisations.

Inadditiontospecifyingthecompetencesrequiredforeffectiveinformationgovernancepractice,thedocumentwillassisthealthcareorganisationsinimplementingrelatededucationanddevelopment.AstartingpointforanyeducationalprogrammeisaLearningNeedsAnalysistoidentifyworkforcerequirements.TheguidanceonlearningneedsanalysiscontainedinthisFrameworkwillhelpthoseinvolvedinco-ordinatinglearninganddevelopmenttodesignorcommissioneducationalinterventionsforparticularstaffgroupsandwillindicateresourcerequirements.

NHSScotlandorganisationsandindividualstaffmembersalreadycommitsignificanttimeandresourcestotraininganddevelopment.CurrentimperativesforeducationincludetheKnowledgeandSkillsFrameworkandpersonaldevelopmentplanningforstaffcoveredbytheNHSAgendaforChange,professionalCPDandlocal‘learningplans’.EffectiveandsafeinformationhandlingalsoplaysanimportantpartinhelpingNHSBoardsmeettheambitionssetoutintheNHSScotlandQualityStrategy,astheyrelatetopersoncentredcareandeffectivegovernance.ThisambitionisreinforcedbytheprovisionsofthePatientsRights(Scotland)Act2011,whichstatesthat‘Privacy and confidentiality will be respected’.(Schedule1)asaprincipleunderpinningapatientfocusedservice.

Itisimportantthatinformationgovernanceeducationandtrainingformspartofanorganisations’broadstrategicapproachtoworkforcedevelopment.TheWorkforceEducationPlanningTemplateprovidedattheendofthedocumentprovidesonesuggestedapproachtoimplementingeducationalsupportonthisvitaltopic.


Chapter 1Why? InformationGovernanceandWorkforceDevelopment

Information Governance in NHSScotland: A Competency FrameworkChapter 1 Why? Information Governance and Workforce Development4

1.1 Information governance Information is crucial to safe and effective care, and a key objective for NHSScotland is to improve its availability to NHSS staff: ensuring the right information is available to the right people at the right time.

NHSScotlandistransformingthewayitusesinformation,sharingconsiderableamountsofdataandjoiningupservicesandsystemsonanunprecedentedscale.Againstthisrapidlyadvancingandchangingenvironment,NHSBoardsrecognisetheimportanceoftheavailability,integrityandconfidentialtyofinformationanditsdutyofcareinrelationtotheinformationituses.TheserequirementsreflectwhatisdefinedasInformationGovernance1.

Thefundamentalobjectivesofinformationgovernanceareto:

●supporthigh-qualitycarebypromotingthesafe,effectiveandappropriateuseofinformationinNHSScotland

●encouragecloserworkingwithinNHSScotlandandcontractingorganisationstopreventduplicationofeffortandenableamoreefficientuseofresources

●enablestafftodischargetheirresponsibilitiestoconsistentlyhighstandardsandcomplywiththelawandprofessionalcodesofethicsbydevelopingsupportarrangementsandprovidingappropriatetools.

Byachievingtheseaims,NHSScotlandwillgainthefollowingbenefits:

●anintegratedwayofthinkingandworking

●betterunderstandingwithinNHSserviceprovidersoftheirperformance

●thecreationofconnectionsbetweenclinicalandcorporategovernance

●effectiveuseoflimitedresources

●sharingofgoodpractice

●effectivemanagementofrisksassociatedwiththeuseofpersonalandotherconfidentialdata

●increasedpublicconfidenceregardingdatahandlinginNHSScotlandandpartnerorganisations.

Inadditiontothesesignificantbenefits,organisationsprovidingNHSScotlandservicesaresubjecttolegalandpolicyimperativesforsafeandeffectivepracticeinthisimportantaspectofpracticeforexample:DataProtectionAct1998,FreedomofInformationAct(Scotland)2002,PublicRecords(Scotland)Act2011andthePatientRights(Scotland)Act2011.

1.2 Workforce educationOngoing workforce education plays a major part in preparing NHS staff and staff employed by contractor organisations to deliver effective, high-quality services. It is needed to maintain performance, and to enable individuals to achieve personal aspirations and meet professional requirements and for teams and organisations to achieve their objectives.

Thisdocumentprovidesaroutemaptomulti-professionaleducationandtrainingininformationgovernance,althoughitisrecognisedthattherewillbeoccasionswhenuni-disciplinaryactivitywillbemoreappropriate.Itoffersorganisationsa‘directionoftravel’foreducationandtrainingactivityininformationgovernancefromwhichtheycandesignlocalactionplanstoensuretheirstaffcanaccesstherighteducationpreparationtoenablethemtocontributeeffectivelytoinformationgovernancepracticesandinitiativeslocally.

‘Inclusivity’isthewatchword.Educationandtrainingopportunitiesmustbemadeavailabletostaffinalllocationswithintheorganisation,basedonanoverallethosthatpromotes:

●increasedaccesstoeducationandtrainingopportunities

●equalopportunitiesforall

●recognitionoftheindividuallearningneedsofpeoplewithdisabilitiesandtheimplicationsofpromotingeducationandtrainingtostafffromdiversesocialandeducationbackgrounds

●developingpeopletotheirfullpotential

●thedeliveryofqualityeducationandtraining.

1 Information governancereferstothepracticeofhandlingthisinformationinaconfidentialandsecuremanner,followingappropriateethicalandqualitystandards.

Information Governance in NHSScotland: A Competency FrameworkChapter 1 Why? Information Governance and Workforce Development 5

1.3 Why educate for information handling?There are numerous reasons for providing education and training in information handling. These include obvious reasons such as the maintenance and improvement of services, respect for service users and the need to comply with legislation on the way information is collected, stored and used.

Butgoodinformationhandlingalsoconfersanumberofbenefitsforindividualstaffmembers,organisationsandserviceusers.TheimportanceofgoodinformationgovernancepracticeisrecognisedbytheScottishGovernmentHealthandSocialCareDirectoratesandotherorganisations,whichhavesoughttoenhancepracticeinthisareathrougharangeoflegislativeandpolicyinitiatives(seeAppendix2).Staffeducationandtrainingisidentifiedconsistentlyinpolicystatementsasakeycomponentinensuringthedeliveryofhigh-quality,effectiveservices.

ThisCompetencyFrameworkreflectstheimportanceofoptimalsupportandsupervisionbeingprovidedforallstaffinvolvedinprovidinghealthcareservices,eachofwhomworksinachallengingenvironment.Thiswillhelptoensurethatstaffareappropriatelysupportedtocarryouttheirrolesinrelationtoinformationgovernanceeffectivelyanddeveloptheirskillsandknowledge.

ForstaffcoveredbyAgendaforChange,theKnowledgeandSkillsFramework(KSF)providesthebasisofaframeworkforsupportandsupervisionthatpromotesacompetency-basedapproachtolifelonglearning.Otherstaffcoveredbyprofessionalcodesofconductareequallyresponsibleforensuringthattheirskillsandknowledgeinsafeinformationhandlingarekeptuptodatethroughouttheirworkinglife.

Learninginrelationtoinformationgovernanceandservicedeliverygohand-in-hand.Learningneedsareconstantlyevolvinginrelationtochangesinservicedelivery,andservicedeliveryisconstantlybeinginformedbynewlearning.AllNHSBoardsandpartnerorganisationsshouldremainalerttochangesinservicedeliverythathaveanimpactoninformationgovernance(forexample,theintroductionofElectronicHealthRecords,ortheincreaseduseofsocialmedia).

Healthcareorganisationsshouldthereforeprovideeducationandtrainingforappropriatestaffinresponseto:

●newlegislation,guidelines,protocolsandstandardsastheyemerge

●newequipmentandhealthtechnologiesthatbecomeavailable.

Theaimistoensurestaffreceiveappropriatesupportthroughouttheircareersthatwillenhancetheirabilitiesinrelationtoinformationgovernance.

Information Governance in NHSScotland: A Competency FrameworkChapter 1 Why? Information Governance and Workforce Development6

1.4 Using this documentThe Information Governance Competency Framework provides broad guidance on the recommended content, delivery and governance of education and training to support effective information governance practice across a range of staff groups. Its principles and practices can be applied at the level of a whole NHS board or by smaller units or organisations, such as GP Practices.

Bydrawingfromanumberofimportantreferencepointsandthroughconsultationwitharangeofstaffandstakeholders,thedocumentidentifiesrelevantareasofskillsandknowledgetobedevelopedthroughin-houseeducationandtrainingorcommissionedexternalprovision.Theseskillsandareasofknowledgearepresentedinanumberof‘domains’representingkeyareasofactivityforhealthservicestaff.ItishopedthatthisFrameworkwillprovideNHSboardsandpartnerorganisationswithafirmfoundationforidentifyinglearningneeds,evaluatingexistingcourses,commissioningorevaluatingnewprovision,anddesigningnewin-houseeducationandtraining.TheCompetencyFrameworkisalsodesignedtoaidmanagersindesigningjobrolesastheyrelatetoinformationhandling.

Inadditiontoprovidingguidanceonindicativeeducationcontent,theplanningdocumentbroadlyoutlinestheprocessesrequiredforeffectiveimplementationofmulti-disciplinarytraininganddevelopmenttosupportinformationgovernance.Theseprocessesincludetheidentificationandanalysisofeducationandtrainingneeds(linkedwithPersonalDevelopmentPlanningandongoingdevelopmentprocesses),goodcommissioningpracticeandmonitoringandevaluation.

ThedocumentindicatesthecompetencesthatorganisationsdeliveringNHSScotlandservicesshouldseektodevelopamongstafftoensureeffectiveandsafeinformationhandling.ItrecognisesthatmanysuchorganisationsalreadyoffertraininginsubjectssuchasDataProtectionandFreedomofInformationandprovidesthebasisforaconsistentapproachtothistypeofeducation.

ThecompetencyframeworkpresentedinChapter2recognisesthattheneedsofindividualsandgroupsofstaffdifferwidelydependingonroleandcontext.Itisclear,however,thatabroadrangeofstaffareresponsibleforprocessingsensitivedataasasignificantpartoftheirwiderclinicaloradministrativerole.Thisincludesstaffgroupsasdiverseasreceptionists,doctors,alliedhealthprofessionals,medicalsecretaries,healthcareassistantsandmanagementaccountants.

Finally,thedocumentincludesaWorkforceEducationPlanningTemplatetoassistorganisationsincollectingandpresentinginformationabouteducationneeds,planningeducationsolutionsandtrackingprogress.


Chapter 2What? InformationGovernanceCompetencies

Information Governance in NHSScotland: A Competency FrameworkChapter 2 What? Information Governance Competencies8

2.1 Understanding information governance competenciesThe information governance competencies presented in this Chapter specify the knowledge, skills and understanding required for the competent handling of information to recognised ethical, legal and quality standards.

Theyreflectthatdifferentlevelsandareasofcompetenceareneededfordifferentjobroles,accordingtopostholders’levelofresponsibility,therange,sensitivityandcomplexityofinformationhandled,andtheriskstoservice-usersandhealthserviceorganisations.ItisexpectedthatcompetenciescanbematchedtospecificjobrolesusingKnowledgeandSkillsFrameworkoutlines(whererelevant),professionspecificcodesofconductandcompetencyframeworks,occupationalstandards,localandnationalpolicies,andotherreferencepoints.Theyarealsoinformedbythefollowing(HORUS2)principlesofinformationhandling:

●Holdinginformationsecurelyandconfidentially

●Obtaininginformationfairlyandefficiently

●Recordinginformationaccuratelyandreliably

●Usinginformationeffectivelyandethically

●Sharinginformationappropriatelyandlawfully

Thecompetenciessetoutbelowdescribewhathealthservicestaffshouldknowandbeabletodotoperformtheirjobsatacompetentstandardintheinformationgovernancerelatedaspectsoftheirwork.Theythereforeindicatetherequiredlearningoutcomesofeducationandtrainingactivitiesofvarioustypes,andindicatethebreadthoflearningneededandassociateddescriptorsofcompetentperformance.Inthisway,theFrameworkwillguidethedesignofeducationandtrainingforindividuals,departments,organisationsandNHSScotlandasawhole.

NotallofthecompetenciesareneededforallNHSjobs.Theyarethereforesetoutin‘domains’,‘learningoutcomes’and‘competences’,whichmaybecombinedaccordingtolocalneedsandpreferences.

2.2 Levels of competenceThe information governance competencies are set out in four levels, reflecting that most NHSScotland staff have responsibility for handling personal data and other confidential information in at least part of their job role.

Thefourlevelsofcompetenceininformationgovernancearedescribedverybroadlyinthefollowingtableandareaguidetotheeducationandtrainingrequiredforeffectiveperformance.AnindicativeScottishCreditandQualificationsFrameworklevelhasbeenassignedtoeachcompetencylevelasabroadguidetoanylearningrequired.Itisassumedthatcompetencemaybedevelopedthoughavarietyofmeansrangingfromon-the-jobexperiencetowork-basedtraining,formaleducationcoursesoracombinationofthese.

Level Description Examples

Advanced knowledge and skills

Developspolicy,proceduresandpracticeinownorganisationasitrelatestoinformationgovernance.

Maintainsownawarenessofchangesinlegislation,caselaw,bestpractice,policyandguidance.SCQF level 10

HeadsofHealthRecords

InformationGovernanceManagers

Intermediate level 2

Appliesdataprotectionprinciplesandkeylegislationtoownworkroleandworkofothers.

Monitorscompliancewithpolicies/procedures SCQF level 8

Clinicians

Supervisoryroles

Middlemanagers

Intermediate level 1

Understandingofdataprotectionprinciplesandawarenessofkeylegislationandpolicy.SCQF level 5

AdministratorsMedicalRecordsstaffClinicalCodingstaffHealthcareSupportWorkers

Foundation level competence

Understandingoftheneedforsecureandconfidentialinformationhandlinginrelationtoownworkrole.Awarenessofsourcesofinformation,referral,adviceandguidance(includinglocalpolicies).SCQF level 3

Supportstaffincludingthoseprovidingdomesticservices

2 ConnectingforHealth,DepartmentofHealth

Information Governance in NHSScotland: A Competency FrameworkChapter 2 What? Information Governance Competencies 9

2.3 The information governance competenciesThe following information governance competencies are set out under five main domains which link related competences under one of the HORUS areas of practice described in 2.1.

Eachdomainincludesoneormorelearning outcome,eachofwhichdescribewhatstaffshouldknowandbeabletodoasaresultoftheirlearning.Thelearningoutcomesareakeyfeatureforthoseinvolvedinthedesignoflearningactivities/programmes,andforeducationalsupervisors,tutors,trainersandassessors.Theyarealsoveryusefulforlearnersinunderstandingwhattheyandtheirtutorsareaimingtoachieve.

Competenciesarecloselyrelatedtothelearningoutcomesand,asdescribedabove,specifytheknowledge,skillsandunderstandingrequiredforcompetentperformanceintheworkplaceindefinedareasofactivity.Thecompetencystatementssetoutbelowrecognisethatdifferentlevelsofcompetencewillberequiredfordifferentpostsandthatthesamelevelwillnotnecessarilyapplytoapostacrosseachdomainandcompetency.Eachpostwillrequirecompetenceinseveraloftheareasdescribedbelowalthoughtherewillbefewpostswhereallaredirectlyrelevant.ThecompetenciesarelinkedtorelevantKnowledgeandSkillsFrameworkdimensionsinsomeareas,andrelatetocurriculaandcodesofethicsandpracticespecifiedbythehealthcareprofessionalbodies.

Eachofthelearningoutcomessetoutbelowissupportedbystatementsdescribingthecore contentoflearningundertheheading.Thissectionofthecompetencyframeworkisprovidedasaguidetotheknowledgeunderpinningcompetentperformanceinaspecifiedareaofactivity.Itwillhelplearnersidentifythedetailedknowledgerequiredforcompetence,andguidecurriculumdesigners,andtutors/educationalsupervisorsetc.


Domain 1 Holding information securely and confidentially

Learning outcome H.1 Store,transportandtransferhealthrecordsandotherpersonalorothersensitivedatasecurelyandeffectively.

Core content●Meaningofpersonalandsensitivedata

●Importanceofsecureandconfidentialinformationhandlingtopatientprivacyanddignity

●Securephysicalandelectronicstorage,transportationandtransferofsensitivedata

●Legalandethicalrequirementsandprinciples–DataProtectionAct1998,FreedomofInformation(Scotland)Act2002,AccesstoHealthRecordsAct1990,codesofethics/practice,

●ScottishGovernmentRecordsManagementNHSCodeofPractice(Scotland)2010

●LocalpoliciesandproceduresincludingHealthRecordsManagementStrategy

●Risks–patientcarefordifferentindividualsandsocialgroups(includingthoseforwhomconfidentialityisparticularlyimportantsuchasindividualswithmentalhealthissuesanddependentchildrenpresentingwithsensitivehealthproblems),legal,reputational,financial

●Traininganddevelopment,communication,andpolicydevelopment

●Organisationalandpersonalresponsibilitiesandaccountabilities–e.g.DataController,CaldicottGuardian

Knowledge and Skills Framework dimensions for staff covered by Agenda for Change

Core 1: Communication

Core 2: PersonalandPeopleDevelopment(especiallyat‘Advanced’levelofcompetence)

Core 3: Health,safetyandsecurity

Core 4: ServiceImprovement(especiallyat‘Advanced’levelofcompetence)

Core 5: Quality

Core 6: Equalityanddiversity

IK2: Informationcollectionandanalysis

IK3: Knowledgeandinformationresources


Competencies Foundation Intermediate 1 Intermediate 2 Advanced

H.1.1 Treat patient/personal information with confidentiality

Inrelationtoownrole,understand:

●individuals’rightstoconfidentiality

●differentformatsandtypesofsensitivedata

●risksassociatedwithpoorpractice

●whoisentitledtoaccessrecords/data.

Beawareofsourcesofadviceinrelationtopatientconfidentiality.

Beawareofprofessional,ethical,legalandpolicyrequirementsforpatientconfidentiality.

Useappropriatesourcesofinformation,adviceandguidancetomaintainpatientconfidentiality.

Applyprofessional,ethical,legalandpolicystandardsinthestorageofpatientinformation.

Understanddifferenttypesofriskassociatedwithpatientconfidentiality,includingtheimplicationsfordifferentindividualsandsocialgroups.

Developcapacityofteam,departmentand/ororganisationformaintainingpatientconfidentialitythroughpolicydevelopment,reviewofprocedures/governanceandstafftraining.

Provideaccurateandeffectiveadviceandguidancetocolleaguesinrelationtopatientconfidentiality.

H.1.2 Maintain the security of personal data

Undersupervision,useestablishedprocedurestomaintainsecurityofpaperbaseddata,computerfiles,andoralcommunicationasitrelatestorecords/data.

Applyorganisationalprotocolsandprinciplesforthestorageandsecurityofpersonaldata.

UnderstandtheroleoftheDataControllerandotherswithresponsibilityandaccountabilityforthecontrolofrecords/data.

Understandnationalinformationgovernancestandardsapplicabletothestorageofrecords/data,includingthesafeandeffectiveretentionanddisposalofrecords/data.

Monitordatasecuritypracticesinteam,departmentororganisation.

Developteam,departmentalororganisationpolicies,practiceandcapacityinrelationtosafeandeffectivestorageofconfidentialdata.

Managebreachesofconfidentialityeffectively.

H.1.3 Transfer and transport records/ data securely

Undersupervision,useestablishedproceduresforthemanualtransportandelectronictransferofrecordsanddataincludingidentifyingassociatedrisksandapplyinganappropriatesolution.

Applyorganisationalprotocolsandprinciplesforthetransferandtransportofrecords/data.

Understandthetechnicalandoperationalrisksassociatedwiththetransferandtransportationofrecords/data.

Understandnationalinformationgovernancestandardsapplicabletothetransfer/transportationofrecords/data.

Monitorapplicationofpolicies/procedures/protocolsinteam,departmentororganisation.

Developteam,departmentalororganisationpolicies,practiceandcapacityinrelationtosafeandeffectivetransfer/transportationofconfidentialdata.

Managebreachesofpolicies/proceduresandprotocolseffectively.


Learning outcome H.2 Usetechnologysafelywhenhandlingpersonalandothersensitivedata.

Core content●Staffidentificationandauthenticationprinciples(UserIDandpassword)

●CommunityHealthIndex(CHI)numberasuniquepatientidentifier

●Usingtechnology


H.2.1 Understand the safe use of technology

Understandneedforstaffidentificationandauthentication.

Understandtheneedforaconfidentialenvironmenttoshareinformationorimages.

Undersupervision,useestablishedproceduresforuseandcontrolofpasswordaccess.

UnderstandneedforCHInumberonallclinicalcommunicationandpatientidentification.

Uselocalproceduresforidentificationandauthenticationtoaccesspersonaland/orconfidentialinformation

Protectconfidentialityandprivacyduringtelehealthcareencounters

UseCHInumberforallclinicalcommunicationandpatientidentification.

Monitoruseoftechnologyinteam,departmentororganisationtocheckthatinformationishandledsafelyinlinewithlocalprocedures

Provideadviceandguidanceonuseoftelehealthcare

PromoteuseofCHInumbersbyteam,departmentororganisation

Developteam,departmentalororganisationpolicies,practiceandcapacityinrelationtosecuredatahandlingusingIT.

InterpretnationalITSecuritystandardsandapplylocally.

PromoteembeddingofCHInumberuseinallsystemdevelopment.




EF1: Systems,vehiclesandequipment

IK1: Informationprocessing



Domain 2 Obtaining information fairly and efficiently

Learning outcome O.1 Obtainpersonaldataeffectivelyandlawfully.

Core content●Rightsandresponsibilitiesinrelationtopersonaldata

●Consent–definition,types,duration,recording,capacity

●Sourcesofpersonalinformation

●Accuracyofdata




Core 5: Quality




O.1.1 Inform individuals about the use of their data

Understandthecontentofrelevantpatientinformationleafletsrelatingtotheuseofpersonaldata.

Explainthecontentofpatientinformationleafletsrelatingtotheuseoftheirdata.

Makecleartoindividualswheninformationisrecordedandwheninformationisaccessed/shared.

Provideexplanationofhowinformationwillbeusedaccordingtocontext.

Checkthatpatientshavenoconcernsorqueriesabouthowtheirinformationisused.

Answerqueriesaboutuseofdataordirectpatientstoothersourcesofinformation.

Respectpatients’decisionstorestrictthedisclosureoruseofinformation,explainingimplications.

Provideadviceandguidancetocolleaguesrelatingtoconsentandobtainingpersonaldata.

Table continues overleaf



O.1.2 Understand the circumstances when consent should be sought prior to obtaining and recording personal data

Understandthatpatientsandotherindividualshaverightsinrelationtotheirownpersonaldata.

Understandthatpersonaldataisobtainedonthebasisofconsent.

Undersupervision,obtainpersonaldatausingorganisationalproceduresand/orprofessionalguidancerelatingtoconsent.

Beawareofappropriatepointsofassistanceforthecollectionofpersonaldata.

Understandprocessforsubjectsaccessingtheirownrecords/data.

Understandtheneedforreliableandvalidsourcesofpersonaldata.

Identifyrangeofsourcesofinformationforobtainingpersonalinformation.

Understandtypesofconsentandtheconditionsthatapplytoitsscope.

Asappropriate,andinaccordancewithlegalrequirements,professionalguidanceandlocalprocedures,recordconsentforuseofpersonaldata.

Communicateseffectivelywithpatientsandcarerstoexplainthepurposeforwhichpersonaldatawillbeused.

Providebasicguidanceandadviceonthecollectionofpersonaldata.

Applytherequirementsforobtainingconsentincasesofchildren,vulnerableadultsorotherswherecapacityisanissue.

Developteam,departmentalororganisationpolicies,practiceandcapacityinrelationtothecollectionofpersonaldata

Provideadviceandguidancetocolleaguesrelatingtoconsentandobtainingpersonaldata.

Monitorpracticeinobtainingpersonaldata.

Table continued from previous page


Domain 3 Recording information accurately and reliably

Learning outcome R.1Ensurerecordscontainingpersonaldataandotherinformationisaccurate,relevant,notexcessiveandup-to-date.

Core content●Contextsforrecordkeepinganddutytorecordwithinprofessionalguidance

andlegislation

●CaldicottandDataProtectionprinciples

●Authorityandresponsibility

●Relianceofselfandothersonaccurateandcompleteinformation

●Positivepatientidentification

●Verificationofinformation

●Recordkeepingstandards(technical,datadefinitionsandprofessionalstandards)






Core 5: Quality



●Auditofadministrativeandclinicalcontentinaccordancewithdataqualitystandards

●Reportingincidentsandinaccuracy


R.1.1 Verify recorded data

Ensureanycontactwithpatientsisbasedonaprocessofpositiveidentification.

Positivelyidentifypatientsateachcontactorintervention.

Routinelyupdaterecords.

Nearmisses,non-matchesandexceptionsarereported

Establishprotocolsforpatientidentification

Encourageverification

Monitorverificationpractice

R.1.2 Record personal information accurately and consistently

Understandtheneedforaccurate,completeandup-to-daterecords.

Applyrelevantrecordkeepingstandardsforrecordingallpersonalinformation(manualorelectronic).

Identifyinaccuracies,inconsistencies,andomissionsandreporttheneedforcorrectiveaction.

Understandtheprinciplesandprocessforauditingrecordedinformation.

Understandtherelationshipbetweenadministrativeandclinicalrecordaudit.

Monitorcompliancewithrecordkeepingstandards,recommendingcorrectiveaction.

Leadprogrammeofauditand/ordataqualityassurance.

Developlocalstrategiestosupportrecord-keeping.

R.1.3 Ensure that information recorded is relevant and not excessive

Understandthesignificanceofgatheringrelevant,adequateinformationthatisnotexcessiveforitspurpose.

UnderstandCaldicottandDataProtectionprinciplesinrelationtotherelevance,quantityandqualityofinformation.

DevelopprocessestocapturerelevantinformationinaccordancewithCaldicottandDataProtectionprinciples.

Leadprogrammeofauditand/ordataqualityassurance.

Developlocalstrategiestosupportrecord-keeping.


Domain 4Using information effectively and ethically

Learning outcome U.1Usepersonaldatasecurely,ethicallyandeffectively.

Core content●Dutyofconfidence

●Rightpatient,rightrecord,rightplace,righttime

●Useofrecordsforthedeliveryofhealthcare

●Secondaryuses(research,diseaseregisters,audit,clinicaltrials,statisticalmonitoring)

●ProfessionalcodesofpracticeandNHSScotlandCodeofConfidentiality

●Understandingconsent


U.1.1 Use patient related data to support the delivery and management of direct and indirect healthcare

Understandethical/professionalcodesofpracticerelatingtouseofinformation.

Userecordsmanagementpoliciesandprocedurestoensure:

●timelyavailabilityofrecords/data

●informationiscompleteandup-to-date

●informationisavailabletothosethatneedit

●informationisprotected●informationisusedwithin

limitsofobtainedconsent.

Developpoliciesandprocedurestosupporteffectiveuseofinformation.

Leadprogrammeofauditand/ordataqualityassurance.(AlsoinLearningOutcomeR.1.3)

Developlocalstrategiestosupporttheeffectiveandappropriateuseofinformation.

U.1.2 Use information for secondary purposes

Understandthecircumstancesinwhichdatais/maybeusedforsecondarypurposes.

Beawareofsourcesofadviceinrelationtosecondaryuseofdata.

Maintainindividuals’rightstoconfidentialitybyensuringcompliancewithnationalandlocalpolicyandguidance,includingseekingapprovalofCaldicottGuardianifapplicable.

Developlocalstrategiestosupporttheeffectiveandappropriateuseofinformationforsecondarypurposes.





Core 4: ServiceImprovement(especiallyat‘Intermediate2’and‘Advanced’levelofcompetence)




Domain 5Sharing information appropriately and lawfully

Learning outcome S.1Understandtheconditionsunderwhichpersonaldatacan,shouldandmustbeshared.

Core content●Informationsharingprotocols(internalandexternal)

●Jointworking(ManagedClinicalNetworks,RegionalServices,Inter-agency)

●Statutoryobligations(childprotection,vulnerableadults,publichealth,police)

●Secondarypurposes

●Bodieswithstatutoryinvestigativepowers(e.g.ProcuratorFiscal,GeneralMedicalCouncil,ScottishPublicServicesOmbudsman)

●CourtOrders*

●Solicitorsandotherlegalrepresentatives#

●SubjectAccess(DPA1998/AccesstoHealthRecordsAct1990)

●HumanFertilisationandEmbryologyAuthorityandothersimilarbodies


S.1.1 Identify circumstances when personal data can, should and must be shared

Understandthatthereisarangeofcircumstancesunderwhichpersonaldatacan,shouldandmustbeshared.

Understandthecircumstancesunderwhichdatacan,shouldandmustbeshared,includingrelevantstandardsandprocedures.

Provideadviceandguidancerelatingtothecircumstancesunderwhichdatacan,shouldandmustbeshared.

Leaddevelopmentofpoliciesforinformationsharinginaccordancewithnationalguidance/relevantlegislation.

*Indicatescircumstancesinwhichpersonaldatamustbeshared.#Inthecaseof‘Solicitorsandotherlegalrepresentatives,’healthcareorganisationsareobligedtoshareinformationonlywithpatients’representativesandwhereconsenthasbeengiven.








Learning outcome S.2UnderstandthedutiesofpublicsectorhealthcareorganisationsforcompliancewiththeFreedomofInformation(Scotland)Act2002.

Core content●Typesofinformationrequest

●Processinginformationrequests

●RelationshipbetweenFreedomofInformation(Scotland)Act2002(FOISA)andDataProtectionAct1998

●Gatheringofinformation

●Publicationscheme

●Formulationofresponse

●Risksofnon-response

●Applicationofexemptions

●Timelimitsforrespondingtorequests


S.2.1Respond timeously and effec-tively to requests for informa-tion

UnderstandingoflocalFOISAarrangements/proceduresincludingwhotocontact.

Beabletointerpretarequestandcompileadraftresponse.

Beabletofullyrespondifnocontentiousissues–businessasusual.

Understandescalationprocedureforcontentiousissues.

BeabletoassessresponsesinlinewithFOISAexemptions.

Beabletodealwithescalatedissues.

UnderstandtheroleoftheInformationCommissionerandwiderimpactofFOISAontheorganisation.

DeveloplocalstrategiestosupporttheeffectiveandappropriatemanagementofFOISA.







Chapter 3How? AnalysingTrainingNeedsandMonitoringQualityandOutcomes

Information Governance in NHSScotland: A Competency FrameworkChapter 3 How? Analysing Training Needs and Monitoring Quality and Outcomes20

3.1 Education and training needsWhile local, area, regional and national3 policies will always be important drivers of education and training, the needs of staff as they perceive them will also have a significant impact on the education and training activity developed at local level within NHSScotland.

Conducting an education and training needs analysis (ETNA)Conductingaformaleducationandtrainingneedsanalysis(ETNA)ininformationgovernancemaybeofbenefittoNHSBoardsandcontractororganisations,andtheyareencouragedtoconsiderwhetherthiswouldbeappropriate.Higherandfurthereducationinstitutionsmaybeabletoofferadviceandsupportontakingthisforward.

Newlegislation,policiesandguidancerelatingtoinformationgovernanceshouldbereflectedintheeducationandtrainingneedsanalysisastheyappear,particularlythosethathavecoreeducationandtrainingimplications.

ThekeyelementsofconductingatypicalETNAaresetoutinAppendix3.NHSBoardsandotherorganisationsmaywishtofollowtheprocesssetoutthere,butitshouldbeemphasisedthatthereareotherequallyeffectivemodelsofconductinganETNAthatmaybepursued.SuchapproachesincludetheanalysisofKnowledgeandSkillsFrameworkoutlines(whererelevant),andPersonalDevelopmentPlanstoproduceorganisationallearning/workforcedevelopmentplans.

Options in keeping up-to-dateIndividualhealthcareworkersarejointlyresponsiblewiththeiremployersforensuringthatskills,knowledgeandcompetenceremainup-to-dateandappropriatefortheirwork.Healthcareworkersareaccountablefortheirperformancetoserviceusers,theiremployerand,whereappropriate,theirprofessionalregulatorybody.Managershaveaparticularresponsibilityandopportunitytocreateacultureinwhichlearningisvaluedanddiverseeducationandtrainingmethodsarerecognisedandused.

Clearly,alllearningactivitydoesnotneedtobe‘course’based.Therearemanywaysinwhichindividualhealthcareworkerscanupdatetheirknowledgeandskillsinrelationtoinformationgovernance–accessingjournals,onlinesources,librariesandopenlearningcentres,meetinganddiscussingissueswithcolleagues,participatinginin-servicetrainingactivities,attendingprofessionaleventsandlearningexperientiallythroughday-to-daywork.Opportunitiesforflexiblelearningshouldbeactivelyencouraged,includingworkplacelearning,e-learningand‘shadowing’opportunities.

3 Inthisplanningdocument:‘local’equatestocommunityhealth/healthcarepartnershiplevel;‘area’withNHSBoards;‘regional’withWest,NorthorSouthEastScotland;and‘national’withtheScottishGovernment.

4 http://www.knowledge.scot.nhs.uk/ig.aspx

Anumberoforganisationsandresourceshavebeenintroducedinrecentyearstosupporthealthcareworkersinkeepingup-to-datewithcurrentknowledgeanddevelopingtheirpracticeinarangeofsubjectsthroughtheapplicationofreliableresearchevidence.TheseincludetheNHSScotlandKnowledgeNetwork,whichincludesaspecialistinformationgovernanceportal,4accessibletoallNHSstaff.

AllthecommunicationmechanismsatNHSorganisations’disposal,includingmeetings,newsletters,noticeboards,e-mailandtheintranet,shouldbeusedtoincreasestaffawarenessofeducationandtrainingopportunities.

Personal development planning and education and training needsPersonaldevelopmentplanning(PDP)isoneofthemeansthroughwhichstaffinNHSScotlandcanreflectontheireducationandtrainingneedswiththeirlinemanagersandsupervisorsandalsofocusonorganisationalobjectives.AsignificantpartofthePDPprocessfocusesonindividuals’perceptionsoftheirownneedsandhowtheyrelatetoteam,local,area,regionalandnationalneedsandpriorities.

AllNHSScotlandstaffshouldhaveopportunitiestoaddresseducationandtrainingininformationgovernancethroughpersonaldevelopmentplanningbasedontheprinciplesoffairness,opennessandtransparency.Theyshouldalsohaveopportunitiesforstructuredreflectiontoenablethemtoidentifystrengthsandweaknessintheirperformanceandknowledgebase.

TheKnowledgeandSkillsFramework(KSF)(seeAppendix4)significantlysupportspersonaldevelopmentplanningandprovidesaframeworkforcareerdevelopmentandreviewforallNHSstaffgroupsexceptdoctorsanddentists.

http://www.nhsemployers.org/PayAndContracts/AgendaForChange/KSF/Simplified-KSF/Pages/SimplifiedKSF.aspx

Information Governance in NHSScotland: A Competency FrameworkChapter 3 How? Analysing Training Needs and Monitoring Quality and Outcomes 21

External courses and training programmesLearningismuchmorethancoursesinhigherandfurthereducationinstitutions.Theworkplace,forinstance,isbecomingincreasinglyrecognisedasacoresettinginwhichlearningtakesplace.Therewillbeoccasions,however,wherethelearningrequirementsofidentifiedmembersofstaffwillindicateaneedtoundertakecoursesandtrainingprogrammesrelevanttoinformationgovernancewhichleadtofurtherorhighereducationawards.SupportforstafftoaccesstheseprogrammesshouldbemadeavailablebyNHSorganisationsandotherhealthcareserviceprovidersaccordingtoexplicitcriteriabasedonarangeoffactors,includingidentifiedlocalandserviceneeds/priorities,levelofrelevancetotheapplicant’scurrentpostand/orfuturecareer,andbudgetallocationsforthatyear.

Accesstorelevantnon-accreditedcourses,seminarsorconferencesmayalsobesupportedthroughlocaltrainingbudgets.

Listening to service users and carersNHSScotlandhasapositivefocusonreceivingandrespondingtoserviceusers’andcarers’commentsandsuggestions.Manysuchcontributionswillindicateimportantstaffinformationgovernancetrainingneedsthatcansubsequentlybeaddressedatlocallevel.Formalsurveysofserviceusers’andcarers’viewswillalsocontributetodeterminingeducationandtrainingneeds.

Theeducationandtrainingneedsofstaffwhohaveresponsibilityforrespondingtoserviceusers’andcarers’commentsandsuggestionsshouldalsobeaddressedbyNHSorganisationsonanongoingbasis.

3.2 Monitoring quality and outcomes Selectivity about the kinds of information governance-related education and training activities provided or facilitated is essential.

Factorsthatshouldbetakenintoaccountinrelationtoallpotentialeducationandtrainingactivitiesincludeavailableresourcesandservice,teamandpersonalneeds,aswellasthefollowing:

●Whatarethepotentialbenefitstoserviceusers/carers,staffandservicesofofferingorfacilitatingtheeducationandtrainingactivityforstaff?

●Whattypeofeducationandtrainingactivityisappropriateforthesubject,andwhatisitsdurationandfrequency?

●Shouldparticipants’learningbeassessed?

●Isthelearningactivityandassessmentqualityassured?

●Forwhichstaffwouldtheactivitybemostappropriate?

●Howshouldtheactivitybeevaluated?

●Whatkindofresourceswillberequiredovertheshort,mediumandlongtermsasaresultoftheactivity?

●Wherewilltheactivitytakeplace,andhowfrequently?

●Howreadilycanstaffbereleasedfromregulardutiestotakepartintheactivity?

●Whatarethefinancialandotherresourceimplicationsofrunningtheactivity?

●Istheactivitymorecost-effectiveifarrangedlocallyorcollectively?

●Whatlevelofcompetence(Foundation,Intermediate1,Intermediate2,Advanced)isrequiredofstaff?

●Howdoestheactivityrelatetothelearningoutcomesspecifiedintheinformationgovernancecompetencyframeworks?

Information Governance in NHSScotland: A Competency FrameworkChapter 3 How? Analysing Training Needs and Monitoring Quality and Outcomes22

Theaimofmonitoringqualityandoutcomesistomakethebestuseofresourcestoensuremaximumeffectiveness.Educationandtrainingactivityshouldthereforebelinkedwithlocalandnationalobjectivesandbequalityassuredandevaluated.CentraltothisactivitywillbecompliancewiththeexpectationssetoutinNHSHealthDepartmentLetter(2006)36(EducationandPolicyStatementforNHSScotland),whichstatesthattheScottishExecutiveanticipatesthatthosecommittingexpenditureoneducationandtrainingshallensurethat,wherepossible,commissionedactivity:

●isserviceuser/personfocused,evidencebasedandriskassessed,andthatdecisionstotargetresourcesareopenandtransparent

●focusesoncapabilities(competencies,skills,knowledge,behaviours,attitudesandvalues),notprofessions

●complieswithlegislationandexistingpolicyframeworks,includingthePartnershipInformationNetwork(PIN)policyandpracticeguidelinesontraining

●recognisesandaccreditspriorlearningwhereappropriate

●promotesflexiblelearningpathwayswhereappropriate

●encouragesdevelopmentandtrainingthatsupportsinter-disciplinaryworkingandlearningandisdeliveredinwaysthatpromotemulti-disciplinarylearningandworking

●hasitssafetyandeffectivenessconfirmedthrougheducationalgovernance

●equipsallstafftodealconfidentlyandsensitivelywiththemultipleidentitiesofpublic,serviceusersandfellowstaff

●isunderpinnedbyastatementoutliningthemutualexpectationsofemployersandemployees.

Education and training activity evaluationsIncomplyingwiththeScottishGovernment’sexpectations,NHSorganisationsshouldstrivetoensurethat:

●eacheducationandtrainingactivitywillhavedefinedlearningoutcomes,whereappropriate

●participantswillbeaskedfortheirviewsonissuessuchas:appropriatenessoftheactivitytotheirneedsandexpectations;processandcontentoftheactivity;qualityofdelivery;potentialimpactoftheactivityonservices;furthereducation/training/activityrequired

●theeffectivenessofactivitiesforindividualstaffwillbeassessedthroughpersonaldevelopmentplanningandreviewprocessesandteam,service,localandarealearningplansreview,toensuretheactivities’continuingfitnessforpurpose

●thepublic’sevaluationofserviceswillbemonitored,therebyassessingtheappropriatenessofeducationandtrainingactivitiesinmeetingtheirneeds;commentsandcomplaintsreceivedwillalsobemonitoredforindicationsofhoweducationandtrainingactivityshoulddevelop

●evaluationsoflearningwillbeexploredandusedtoaffectimprovement

●optionsinconductingcost-benefitanalysesofeducationandtrainingactivitywillbeexplored.

Recording education and training activityEducationandtrainingactivitythatisrecordedandaccreditedistransferablebetweenorganisations/systems.Someprofessionalgroupshaveastatutoryrequirementtorecordtheirongoingeducationandtrainingactivity,butnotall.Infutureacentralised,standardised,secureelectronicsystemforrecordinghealthcareworkers’participationininformationgovernance-relatededucationandtrainingactivitieswillbeusedbyNHSorganisations.


Chapter 4Who? EducationandTrainingforAll,andDevelopingPartnerships

Information Governance in NHSScotland: A Competency FrameworkChapter 4 Who? Education and Training for All, and Developing Partnerships24

4.1 Education and training for all… The overall objective is to establish a framework of education initiatives to support staff providing NHS services in the safe and effective management of information, including service user-sensitive data. The framework follows a stepped approach, with the level of education and training offered being commensurate with the professional background, existing skills and role responsibilities of staff members. A range of education activities relevant to each level of the framework should be designed and delivered, and these should be set out in NHS organisations’ local action plans.

Foundation training for allAlargeproportionofNHSBoardscurrentlyprovidetrainingtostaffontheprinciplesandpracticeofconfidentialityanddataprotection.Whilesuchtrainingisundoubtedlyuseful,theCompetencyFrameworkmayassistNHSScotlandandpartnerorganisationstoreviewexistingprovisionand,insomecases,makeadjustments.Itisalsointendedtohelpotherstodesignorcommissionnewfoundationtraininginthisareabysettingoutlearningoutcomesandcompetencies.

Training for statutory obligations Statutory trainingactivitiesarethoserequiredbylaw.Mandatory trainingactivitiesarethosethegovernment,NHSScotlandand/orparticularNHSorganisationsdecreearecompulsoryforallstaff(orgroupsofstaff).

Atpresent,therearenospecificreferencestostatutorytrainingrelatingtoinformationgovernance.Principle7oftheDataProtectionAct1998,however,requiresthatappropriate technical and organisational measures shall be taken against unauthorised or unlawful processing of personal data and against accidental loss or destruction of, or damage to, personal data; theUKinformationCommissionerhasindicatedthatthese“organisationalmeasures”includestafftraining.

TheNHSScotlandCodeofPracticeonProtectingPatientConfidentialitysetsouttheexpectationsoftheScottishGovernmentHealthandSocialCareDirectoratesrelatingtostaffresponsibilities.TheCodeindicatesthatallstaffmust be aware of where to seek support, further information and training, and be able to demonstrate that they are making every reasonable effort to comply with the relevant standards.Italsostatesthatfailure to comply with the Code of Practice may lead to a disciplinary offence.Atorganisationallevel,NHSBoardsaremustbeabletodemonstratecomplianceagainstrelevantlegislationandSGpolicyandcodesofpractice.

Aconsistentandinclusiveapproachtostatutorytrainingobligationsinrelationtoinformationgovernance,basedonaneffectiveassessmentandrecordingsystemwhichwillidentifythosewhoneedtraining,inwhichareasandwhen,andwhichaffordsstaffaccesstorelevanttraining,shouldbetheaimofNHSorganisations.

Localactionplansshoulddefinethestatutorytraininginitiativesrequiredforspecificgroupsofstaffandsetoutspecificrecallsystemsforre-training,whereappropriate.Thisprocesscanbefacilitatedbyaneducationandtrainingneedsanalysis(ETNA)referredtoinChapter3,whichwouldprovideguidanceformanagers.

Flexiblemeansofdeliveringstatutorytrainingusing,forexample,video,onlinesources,CDsandDVDsandvideo-conferencingfacilitiesshouldbeexplored,andopportunitiesforjointstatutorytrainingactivitieswithotherhealthcareorganisationsandexternalagenciesshouldalsobereviewed.Topicareasforstatutorytrainingchangeovertime,andservicesshouldremainresponsivetonewneedsastheyarise.

Formanyhealthcareprofessionsregulatedbyastatutorybody,informationgovernancerequirementsarespecifiedinstandardsandcodesofethics.Regulatorybodies5suchastheGeneralMedicalCouncilandNursingandMidwiferyCouncilpublishclearguidelinesonthemessuchasconfidentiality,informationsharingandrecordkeeping.Traininganddevelopmentoninformationgovernanceissuesthereforedemonstratescommitmenttocontinuingprofessionaldevelopmentforthesestaffgroups.

5 TheRegulatoryBodiesinclude:theGeneralMedicalCouncil,NursingandMidwiferyCouncil,theGeneralDentalCouncil,GeneralPharmaceuticalCouncil,theHealthProfessionsCouncilandtheGeneralOpticalCouncil

Information Governance in NHSScotland: A Competency FrameworkChapter 4 Who? Education and Training for All, and Developing Partnerships 25

Intermediate education and training for manyManyNHSScotlandstaffareresponsiblefortheeffectiveandsafehandlingofserviceuser-identifyinginformationandothersensitivedataaspartofawiderclinicalorsupportrole.Thisinformationiscollected,usedandstoredforarangeoflegitimatereasons,butitshugevolumeandcomplexityexposesserviceusers,individualstaffmembersandhealthcareproviderstoconsiderablerisk.

Theprovisionoftargetededucationandtrainingisconsequentlyviewedasawayofmanagingthisriskbyensuringthatstaffunderstandpersonalandorganisationalresponsibilitiesandhavetherequiredskillsandknowledgetohandleinformationwithconfidence.TheknowledgeandskillsrequiredforcompetentinformationhandlingisspecifiedintheKSFprofileforeachpostcoveredbyAgendaforChange.

Someprofessionalgroupshaveprioreducationintheseareasofprofessionalpractice,acquiredthroughpre-andpost-registrationtraining.

Advanced practice education and training for a fewAllNHSScotlandBoardsandprimarycareorganisationsemploystafftoprovidespecialistInformationGovernanceservices.InNHSBoardstheseincludeDataProtectionOfficers,InformationGovernanceManagers,RecordsManagers,FreedomofInformationLeadsandotherswithresponsibilityfordevelopingpolicy,monitoringpractice,providingspecialistadviceandguidance,trainingothersetc.PracticeManagersalsohaveakeyroleinthesafeandeffectivemanagementofsensitivedatainGeneralPractice.TheseindividualsareakeyresourceforNHSBoardsandPrimaryCareOrganisationsanditisthereforeessentialthattheirskillsandknowledgearedevelopedandmaintained.Therangeofspecialisteducationandtrainingavailabletosupporthighlevelinformationgovernancepracticeisincreasingandcurrentlyincludesthefollowing:

●specialistprofessionalconferencesindefinedareasofInformationGovernancepractice

●postgraduatecoursesrangingfromindividualmodulestofullmastersdegrees(someofwhichareavailableine-learningformats)

●specialistcoursesofferedbylawfirms.

FurtherdetailsaboutcoursesareavailablefromtheInformationGovernanceportaloftheNHSScotlandKnowledgeNetwork6.TosupportInformationGovernanceSpecialistsintheirtrainingrolesitisrecommendedthattheycontactlocalOrganisationDevelopment/LearningandDevelopmentmanagerstodiscusstheirneedsandavailabletraininganddevelopment.StaffbasedinPrimaryCareOrganisations/CommunityHealthPartnershipsmaybeabletoaccesssuchtrainingthroughprofessionalnetworksorlocaleducationproviders.

6 http://www.knowledge.scot.nhs.uk/ig.aspx


4.2 Developing partnershipsInformation Governance in NHSScotland: A Competency Framework is all about making the best use of resources to provide education and training opportunities that will help staff to deliver quality, effective services to service users and carers directly and indirectly. This can be achieved through the measures set out in the previous chapters, by sharing good practice and by tapping into the wealth of knowledge, skills and experience possessed by staff, particularly those with specialist expertise.

Butwhilethetalentthroughouthealthcareorganisationsisrecognisedandrespected,linksandpartnershipsbuiltwithanumberofoutsideagenciesarealsogreatlyvalued.Thesepartnershipsshouldbestrengthenedandimprovedtopromotequalityin,andwidenaccessto,educationandtrainingopportunitiesnotonlyforNHSstaff,butalsoforthestaffofotheragenciesandformembersofthepublic.Theyincludethefollowing:

The Scottish Government Health and Social Care DirectoratesProvidesthepolicyframeworkwithinwhichHealthBoardsandotherhealthcareorganisationsaddresstheirobligationsforeffectiveinformationgovernance.

NHS Education for Scotland (NES)NEShasanimportantroleinsupportingeducationandtraininginitiativesforallstaffatlocalandregionallevelandinhelpingNHSBoardsandindividualorganisationstobuildthequalityframeworkswithinwhichlocalactionplanscanbetakenforward.

NHS Healthcare Improvement Scotland7 (NHS HIS)NHSHealthcareImprovementScotlandisresponsibleforhelpingNHSScotlandandindependenthealthcareprovidersdeliverhighquality,evidence-based,safe,effectiveandperson-centredcare;andtoscrutiniseservicestoprovidepublicassuranceaboutthequalityandsafetyofthatcare.

Skills for HealthSkillsforHealthworkswithemployersandotherstakeholderstoensurethatthoseworkinginthepublicsectorthroughouttheUKareequippedwiththerightskillstosupportthedevelopmentanddeliveryofhealthcareservices.TheyareresponsiblefordevelopinganddisseminatingNationalOccupationalStandards(NOS)andNationalWorkforceCompetences(NWC)andanumberofeducationandtrainingprogrammesthatsupportworkforcedevelopmentacrossthehealthsector.

7 FormerlyNHSQualityImprovementScotland(NHSQIS)

Higher and further education institutionsPartnershipswithhigherandfurthereducationinstitutionsshouldbefurtherdevelopedbyworkingwiththemto:

●developinformationgovernance-relatedcurriculathatensurethecoursestheyprovidecomplementlocalandareaserviceandpolicydrivers;

●developmulti-disciplinary,multi-sectoraleducationactivities;

●developnewandinnovativewaysofdeliveringeducationtostaff.

Professional expertsWhereappropriate,professionalexpertswithinandoutwithNHSBoardsshouldbecommissionedtoprovideeducationandtrainingopportunitiesconsistentwithlearningneed,professionalexpertise,accessandavailabilityofresources.

NHS BoardsPartnershipswithavarietyofgroupsandorganisationsshouldbedevelopedandstrengthenedwithaviewtoimprovingthequalityofeducationandtrainingactivityprovidedandfacilitated.OfparticularimportanceisthedevelopmentopportunitiespresentedbyotherNHSBoards,inpartnershipwithrelevantstakeholderssuchasserviceusers,carersandsupportagencieswhereappropriate.

Information Governance in NHSScotland: A Competency FrameworkChapter 4 Who? Education and Training for All, and Developing Partnerships 27

NHS24 and Scottish Centre for Telehealth and Telecare NHS24andtheScottishCentreforTelehealth(SCT)aretakingforwardaneducationandtrainingprogrammetodevelop,orfacilitatethedevelopmentofeducationandtrainingintelehealthincludingteachingmaterials/standardstoprovideinstructioninthephysicalusageoftelehealthequipment;activelypromotingtheinclusionoftelehealthteachinginthecorecurriculumofallpre-registrationtrainingfordoctors,nursingandalliedhealthprofessionals.PartoftheprogrammeincludesaCompetencyFrameworktoensurethathealthandsocialcareprofessionalswhowillusetelehealthcareareadequatelytrained.ATelehealthcarePortalisalsoavailablewhichhostsresourcesandactsasaprimarysourceofcredibleeducationalcontent.

UK Caldicott Guardian CouncilTheUKCaldicottGuardianCouncilisanelectedbodymadeupofCaldicottGuardiansfromhealthandsocialcare.TheobjectsoftheCouncilincludepromotionoftherole,exchanginginformation,representingmembers’viewsinpolicymatters,arranginglearningopportunitiesandactingasaresourcecentre.

Consumer Focus Scotland ConsumerFocusScotland isastatutoryorganisationcampaigningforafairdealforconsumersinScotland.TheyareinvolvedinarangeofworkandprojectswhichaimtocontributetoimprovingScotland’shealthanddiet.ItsHealthRightsInformationScotlandprojecthasaparticularfocusonconfidentiality,consent,informationsharingandrecordkeeping.

Professional regulatory bodies and Royal CollegesWorkforceeducationinitiativesmustcomplywithprofessionalregulatoryrequirementsfromprofessionalbodiesandRoyalColleges.Reviewsofpost-registrationeducationareregularlycarriedoutbysuchbodies.

Professional organisations and trade unionsNHSScotlandalreadyhasstronglinkswithprofessionalorganisationsandtradeunionsacrossarangeofwork-relatedissues,anditaimstoincreasethemutualbenefitstobegainedfromjointworkingoneducationandtrainingactivity.Mosthealthcare-relatedprofessionalandstatutorybodiespublishprofessionalstandardsandcodesofethicswithastrongemphasisoninformationgovernancethemes.


References GeneralDentalCouncil(Oct2009):StandardsforDentalPractitioners

GeneralDentalCouncil(Oct2009):PatientConfidentialty

GeneralMedicalCouncil(2009):ConfidentialtyandConfidentialtySupplementaryguidance

GeneralPharmaceuticalSociety(Sept2010):Standardsforconduct,ethicsandperformance

HealthProfessionsCouncil(July2008):StandardsofConduct,PerformanceandEthics

HealthRightsInformationScotland(2010):Confidentiality,ConsentandAccesstoHealthRecords

InformingHealthcareWales:HealthInformaticsCareerFramework

NursingandMidwiferyCouncil(2008):TheCode:StandardsofConduct,PerformancesandEthicsforNursesandMidwives

NursingandMidwiferyCouncil(Aug2009):RecordKeeping

ScottishGovernment(Jan2011):NHSSCaldicottGuardians:PrinciplesintoPractice

ScottishGovernment:NHSSCodeofProtectingPatientConfidentiality(revised)duetobepublishedAutumn2011

ScottishGovernment(Aug2010):RecordsManagement:NHSCodeofPractice(Scotland)V2

ScottishGovernmentHealthDirectorates:CEL23(2010)HealthcareSupportWorkers–MandatoryinductionStandardsandCodeOfConductForHealthcareSupportWorkersandMandatoryCodeofPracticeforEmployersofHealthcareSupportWorkers

http://www.gdc-uk.org/Newsandpublications/Publications/Publications/StandardsforDentalProfessionals%5b1%5d.pdf

http://www.gdc-uk.org/Newsandpublications/Publications/Publications/PatientConfidentiality%5b1%5d.pdf

http://www.gmc-uk.org/guidance/ethical_guidance/confidentiality_contents.asp

http://www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp

http://www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp

http://www.pharmacyregulation.org/pdfs/other/gphcstandardsofconductethicsandperflo.pdf

http://www.pharmacyregulation.org/pdfs/other/gphcstandardsofconductethicsandperflo.pdf

http://www.hpc-uk.org/assets/documents/10002367FINALcopyofSCPEJuly2008.pdf

http://www.hpc-uk.org/assets/documents/10002367FINALcopyofSCPEJuly2008.pdf

http://www.hris.org.uk/index.aspx?o=1027




http://www.hicf.org.uk/

http://www.nmc-uk.org/Documents/Standards/The-code-A4-20100406.pdf

http://www.nmc-uk.org/Documents/Standards/The-code-A4-20100406.pdf

http://www.nmc-uk.org/Documents/Guidance/nmcGuidanceRecordKeepingGuidanceforNursesandMidwives.pdf

http://www.scotland.gov.uk/Resource/Doc/340362/0112733.pdf

http://www.scotland.gov.uk/Publications/2010/04/NHS-record-management

http://www.sehd.scot.nhs.uk/mels/CEL2010_23.pdf


Appendices

Information Governance in NHSScotland: A Competency FrameworkAppendices30

Appendix 1: Editorial GroupProject Managers:Rob Coward,EducationalProjectsManager,NES

Kim Kingan,IGLead,ScottishGovernmentHealthandSocialCareDirectorate

Angela McCulloch,ProjectCo-ordinator,NES

Thedocumenthasbeenrevisedbyaneditorialgroupofsubjectexperts(seebelow)andwassubjecttowideconsultation,ensuringthatitispractical,relevantandhasgainedwidespreadsupport.

Val Baker NHSLothian

Robert Bryden NHSGreaterGlasgowandClyde

Peter McKenzie NHSTayside

Frank Rankin NHSEducationforScotland

Trish Ruddy NHSNationalServicesScotland

Prof Liz Wilson eHealthProgrammeScottishGovernmentHealthandSocialCareDirectorates

Audrey Cowie HCNO:CNODPolicyUnit,ScottishGovernmentHealthandSocialCareDirectorates

Sara Weeden HealthRightsInformationScotland

Appendix 2: Policy driversThis appendix focuses on specific workforce development and information governance initiatives that have an immediate impact on this planning tool.

Key policies on lifelong learning, continuing professional development, workforce development and workforce assurance 1 Lifelong Learning and CPD Knowledge and Skills Framework (NHS KSF) The KSFdefinesanddescribestheknowledgeandskillsthatNHSstaffneed

forcompetentperformanceintheirwork.OneofthepurposesoftheKSFistosupporttheeffectivelearninganddevelopmentofindividualsandteams,ensuringtheyaresupportedtolearnandaregiventheresourcestodoso.EachmemberofNHSScotlandstaffwillhaveanagreedKSFprofileandaPersonalDevelopmentPlanbasedonareviewofdevelopmentneeds.

TheKSFcomprisessixcoredimensions(seeAppendix4)and25morespecialistdimensions,whicheachhavefourlevels.KSFprofilesareconstructedforeachpost,reflectingrequiredskillsandknowledgeinthecoredimensionsandanyrelevantspecialistdimensions.Anumberofthesedimensions(suchasCore3,Health, safety and security,andIK2,Information collection and analysis)relatedirectlytoinformationgovernancethemes.TheKSFconsequentlyemphasisesorganisationalandindividualneedsfortraininganddevelopmentinthisaspectofserviceprovision.

CPD for Health Professionals EachoftheregulatedprofessionsisrequiredtomeetCPDstandards.

Information Governance in NHSScotland: A Competency FrameworkAppendices 31

2 Workforce Development Education and Training Policy Statement for NHSScotland (SEHD HDL

[2006] 36) TheHDL isunderpinnedbyastatementoutliningthemutualexpectationsof

employersandemployees.Itstatesthat employeescanexpect:

●toworkinanenvironmentthatsupportslearning,educationandtraining

●tobeappropriatelyinductedtotheirroleandtheorganisation

●toreceiveongoingdevelopment

●tohaveaccesstosupervisionandcoachingtosupplementformallearning

●tobesupportedinseekingaccreditedlearningasappropriate

●theiremployerstoopenupaccesstolearningforallgroupsofstaff

●thatsomeparticipationmayinvolvereleasefromwork

●thatincreasinglyparticipationwillmovetowardse-learningandblendedlearning.

Itgoesontostatethat employers can expect employees to:●takeownershipoftheirownpersonalandprofessionaldevelopment

●takeadvantageoflearningopportunities

●maintainrecordsfortheirPersonalDevelopmentPlan

●supportcolleagues’learning,educationandtraining.

Staff Governance Standard, 2002 (SEHD,2002a)Underthisstandard,allstaffinNHSScotlandareentitledtobe:

●well-informed

●appropriatelytrained

●involvedindecisionswhichaffectthem

●treatedfairlyandconsistently

●providedwithanimprovedandsafeworkingenvironment.

NHSScotlandorganisationsfullyrecognisetheimportanceofthesestandardstostaff.TheWorkforceEducationPlanningTooladdressesthosepartsofthestandardwhichrelatetoeducationandtrainingspecificallyintheareaofinformationgovernance.

3 Workforce Assurance Regulation of Healthcare Professionals Inordertoprotectthepublicthereare8UKstatutoryregularitybodieswho

setstandardsforeducation,practice,conduct,performanceandethics.

Mandatory Induction Standards And Code Of Conduct For Healthcare Support Workers And Mandatory Code Of Practice For Employers Of Healthcare Support Workers (The Scottish Government Health and Social Care Directorate (2010)

Since31December2010,allnewstarthealthcaresupportworkersemployedinNHSScotlandarerequiredtoachieveasetofinductionstandardsandtocomplywithacodeofconduct,throughouttheiremploymentwhichincludesastandardonconfidentialty.Employersofhealthcaresupportworkersarealsorequiredtocomplywithacodeofpractice.

TheserequirementsarelaidoutinaDirectionfromScottishMinisters(the

equivalentofsecondarylegislation)undercoverofCEL23(2010).

Key legislation and policy initiatives relating to information governance

Patient Rights (Scotland) Act 2011ThePatientRights(Scotland)Act2011aimstoimprovepatients’experiencesofusinghealthservicesandtosupportpeopletobecomemoreinvolvedintheirhealthandhealthcare.ItwillhelptheScottishGovernment’saspirationforanNHSwhichrespectstherightsofbothpatientsandstaff.

NHSScotland Quality Strategy (The Scottish Government Health and Social Care Directorate, 2010)InformationGovernanceissuesrelatedirectlytotheNHSScotlandQualityStrategypublishedinMay2010.Althoughtherearenospecificreferences,severaloftheambitionsset-outinthedocumenthaveimplicationsfordataprotection,confidentialityandtraininganddevelopment.Confidentialityanddataprotectionarekeyaspectsofpatient-centredcare:akeycommitmentoftheQualityStrategy,whichisreinforcedbythePatientRights(Scotland)Act2011.


eHealth Strategy 2011-2017 TheeHealthStrategy8setsouthowweaimtobuildontheachievementsof2008-2011,bringingtogetherexistinginformationandsystemsthroughoutapatient’sjourneyofcareandspreadgoodpracticebetweenareasandclinicalfunctions. ThefollowingfivestrategiceHealthaimsareintendedtoenablequalityimprovementsacrossNHSSandsupportdeliveryofthethreeQualityStrategyAmbitions:- Touseinformationandtechnologyinacoordinatedwayto:

●maximiseefficientworkingpractices,minimisewastefulvariation,bringaboutmeasurablesavingsandensurevalueformoney

●supportpeopletocommunicatewiththeNHSS,managetheirownhealthandwellbeing,andtobecomemoreactiveparticipantsinthecareandservicestheyreceive

●contributetocareintegration,andtosupportpeoplewithlongtermconditions

●improvetheavailabilityofappropriateinformationforhealthcareworkers9andthetoolstouseandcommunicatethatinformationeffectivelytoimprovequality

●improvethesafetyofpeopletakingmedicinesandtheireffectiveuse

NHSScotland Information Assurance Strategy 2011- 2015 TheaimoftheInformationAssurancestrategy10istohelpNHSScotlandgetthebestoutifitsinformation,developitsuse,confidentthattherisksassociatedwithcollecting,recording,holding,usingandsharinginformationarewellmanagedandunderpintheeHealthStrategy2011-2017.

8 eHealthStrategy2011-2017isviewableat:http://www.scotland.gov.uk/Publications/2011/09/09103110/09 TheWorldHealthOrganisationdefinesahealthcareworkerasanyonewhosefocusoractivityistoimprovehealth.Thisdefinitionincludesproviders(e.g.,doctors,nursesandmidwives)aswellas

techniciansandmanagers10InformationAssuranceStrategyisavailableat:addinlinkafter14thSept

Appendix 3: Education and training needs analysisEducation and training needs analysisTheaimofeducationandtrainingneedsanalysisistoidentifytheeducationandtrainingneedsoftheorganisationandindividualsthroughaprocessofconsultationwithstaff,serviceusersandothers.Thiscreatestheopportunitytodesignanongoingeducationandtrainingprogrammethatissystematic,affordableandappropriatetotheneedsofserviceusers,theorganisationandtheworkforce.

Carryingoutthiskindofexerciserequiressophisticatedskillsandsignificanttimecommitment.Specialistexpertisemaythereforebeneededtosupportthiswork.Theexercisewillneverthelessprovideimportantinformationfromthefront-lineofcareservicesontheeducationandtrainingissuesstaffandserviceusersmostvalue.

Therearedifferentwaystoconductaneducationandtrainingneedsanalysis(ETNA)butmostincludesixkeyelements.

1. Consultation Managers,supervisors,healthcareworkers,serviceusersandcarerswillneedtofeeltheirviewsonthedesign,deliveryandevaluationofCPDactivityhavebeenproperlycanvassedandtakenintoaccount.Consultationcantakemanyforms–focusgroups,questionnairesandface-to-faceinterviews,forexample.Butitiswisenottoover-estimatehowwidetheconsultationprocesscanbe;smallerunitsmaybeabletoseekviewsfromallstaffandsomeserviceusers,butrepresentativesamplesmayhavetobeidentifiedforlargerorganisations.

2. Information analysisReliableandvalidmeansofsiftinginformationfromconsultationsareneededtoarriveatlogicalconclusionsforaction.Somedatacollectiontools(suchas‘tickbox’questionnaires)willrequireonlyarithmeticalskills,butmorecomplexmethods(suchassemi-structuredinterviews)willrequiresophisticatedanalysis.Therearewell-testedqualitativedataanalysissoftwarepackagesavailabletoallowanalysisofinterviewandquestionnaireinformation.OtherrelevantinformationiscollectedthroughKSFoutlinesandpersonaldevelopmentplans.

http://www.scotland.gov.uk/Publications/2011/09/09103110/0

http://www.scotland.gov.uk/Publications/2011/09/09103110/0


11KSFpostoutlinesdescribetheskillsandknowledgerequiredtoundertakedefinedroles.Theyhelppractitionersidentifydevelopmentneeds&provideguidanceonpaybandsforindividualjobs.

12Ninepaybandsaredescribedinthepaygateways,eachwiththreepartsconsistingofaseriesofprogressivesteps.

3. Feeding back to interested partiesWhentheinformationhasbeengatheredandanalysed,itisimportantthatconclusionsarefedbacktotheparticipantstocheckforaccuracyandvalidity.Alloftheorganisation’scommunicationsystems–staffmeetings,educationalseminars,newsletters,memos,intranetandteambriefings,forinstance–canbeusedforthispurpose.Allowanceshouldalsobemadefortimeforpeopletorespondtoideas.

4. Setting an action plan Havingachievedgeneralagreementthattheanalysishasidentifiededucationandtrainingneedsthatwillhelptoimproveservicesandassisttheorganisationtomeetitsgoals,acourseofactioncanbeplanned.Keypeoplewithinandoutwiththeorganisationcanbeidentifiedtoassist.Managers,supervisors,workforcerepresentatives,tradeunionofficials,healthandsafetyofficials,humanresourcesstaffandfinancemanagers,serviceusers,carers,educationinstitutionsandaccreditingbodiesallhaveacontributiontomakeinidentifyingprioritiesanddevelopingactionplans.

5. Dissemination and consultationTheactionplanwillbemoresuitedtotheneedsoftheorganisation,theworkforceandserviceusersifithastheirendorsement.Afurtherperiodofconsultation,inwhichtheactionplanisdisseminatedtorepresentativeindividualsforanalysisandcomment,willhelptoensurethatthefinalversionoftheplanistrulyfitforpurpose.

6. Delivery and evaluationTheplancanthenbeputintoactionandtheresultantCPDprogramme(andindividualactivitieswithinit)evaluated.Furtheractivitytomatcheducationneedstoservice-userandorganisationneedscanbelaunchedperiodically,beginningwiththeprocessofconsultation.

Appendix 4: Agenda for ChangeAgenda for Change (AfC), is the UK wide NHS pay and conditions framework for all staff except very senior managers and medical staff. The system introduced the Knowledge and Skills Framework (KSF) as a tool to describe and identify the knowledge, skills and development that staff need to do their job. KSF focuses on the individual practitioner and his/her knowledge, skills and development potential.

TheWorkforceEducationDevelopmentStrategysupportsAfCandtheKSFoutlinesastheyrelatetoinformationgovernancethemes.Together,KSFpostoutlines11andpaygateways12,theannualreviewandpersonaldevelopmentplanningmechanisms,andtheWorkforceEducationDevelopmentStrategyprovidethefoundationforprofessionaldevelopmentforallaffectedstaff.

AfCandtheKSFarebasedonsix‘coredimensions’relevanttoallpostsand24dimensionsspecifictoparticularjobroles.Thefollowingdimensionsarerelevanttoinformationgovernance:

●CoreDimension1: Communication

●CoreDimension2: Personalandpeopledevelopment

●CoreDimension3: Health,safetyandsecurity

●CoreDimension4: ServiceImprovement

●CoreDimension5: Quality

●CoreDimension6: Equality,diversityandrights

●SpecificDimensionEF1: Systems,vehiclesandequipment

●SpecificDimensionIK1: Informationprocessing

●SpecificDimensionIK2: Informationcollectionandanalysis

●SpecificDimensionIK3: Knowledgeandinformationresources

●SpecificDimensionG1: Learninganddevelopment

●SpecificDimensionG2: Developmentandinnovation


Appendix 5: Scottish Credit and Qualifications FrameworkThe call for the development of the SCQF came in 1998’s Government Green Paper on lifelong learning, Opportunity Scotland.

Itsetoutaten-pointactionplanthatincludedtheimplementationoftheSCQFaspartofalifelonglearningstrategyforScotland.ThedevelopmentoftheSCQFisajointventureinvolving:

●theScottishExecutive

●theQualityAssuranceAgencyforHigherEducation

●UniversitiesScotland

●theScottishQualificationsAuthority.

TheSCQFisbasedona12-levelscalethatreflectsthecurrentScottishsystemofeducationandtrainingandhasbeendevisedto:

●provideanationalframeworkforrecognisingalllearning,regardlessofwhetheritislinkedtoaformalqualificationornot,providedithas(orcanbe)subjecttovalid,reliableandquality-assuredassessment

●clarifyrelationshipsbetweendifferentScottishqualificationsandbetweenScottishqualificationsandthoseoftherestoftheUK,Europeandbeyond

●enhanceflexibilitybybuildingmorecreditlinksbetweendifferentkindsofqualifications

●provideacommonmeansofdescribingandrecordingallindividuallearningachievements.

Theframeworklevelsareshownbelow,andtheframeworkareavailableat:http://www.scqf.org.uk/The%20Framework/

SCQF level

SQA national units, courses and group awards Higher educationScottish Vocational

Qualifications

12 Doctorates

11 Masters SVQ5

10 Honoursdegree/GraduateDiploma/Certificate

9 Ordinarydegree/GraduateDiploma/Certificate

8HigherNationalDiploma HigherNationalDiploma

DiplomainHigherEducationSVQ4

7AdvancedHigher HigherNationalCertificate HigherNationalCertificate

CertificateinHigherEducation

6 Higher SVQ3

5 Intermediate2CreditStandardGrade SVQ2

4 Intermediate2CreditStandardGrade NationalCertificates SVQ1

3 Access3FoundationStandardGrade

2 Access2

1 Access1

http://www.scqf.org.uk/The Framework/


Appendix 6: GlossaryAnonymised data Informationfromwhichindividualscannotreasonably

beidentified.Names,addresses,fullpostcodesoridentificationnumbers,aloneortogetherorinconjunctionwithanyotherinformationheldbyoravailabletotherecipient,canbeusedtoidentifypatients.

Consent Directionsexpressedbyanindividualindicatingthetermsonwhichtheirpersonalinformationmaybedisclosed,andwhatandwheredatamaynotbedisclosed.Consentfordisclosuremaybeexpressedorally,inwritingorimpliedwheretheindividualhasopportunitiestowithholdconsentbutdeclinestodoso.

Data Controller Person(s)whodeterminesthepurposesforwhichandmannerinwhichanypersonaldatamaybeprocessed.

Data disclosure Anyaccesstopersonalinformationgiventoanindividual,whetheritbeaccesstoadatafloworstoredrecords,orwithinanorganisationoracrossorganisationboundaries.

Data processor Person(s)(otherthananemployeeoftheDataController)whoprocesses(e.g.obtains,holds,recordsoranalyses)dataonbehalfoftheDataController.

Data subject Anindividualwhoisthesubjectofpersonaldata.

eHealth Theuseofinformation,computersandtelecommunicationsinsupportofmeetingtheneedsofpatientsandthehealthofcitizens.

Records Theprocessofmanagingrecordsthroughouttheirlifecycle,fromtheircreation,usage,maintenanceandstoragetotheirultimatedestructionorpermanentpreservation.

management

Patient identifiable Datasetwhichmayincludesomeorallofthe‘Personaldata’isthetermusedintheDataProtectionAct1998.TheActtreatsmuchhealthinformationas‘SensitivePersonalData’–withadditionalprotections.Keyidentifiableinformationincludes:

●person’sname,address,fullpostcode,dateofbirth

●pictures,photographs,videos,audio-tapesorotherimagesofindividuals

●CHInumberandlocalpatientidentifiablecodes

●anythingelsethatmaybeusedtoidentifyapersondirectlyorindirectly.Forexample,rarediseases,drugtreatmentsorstatisticalanalyseswhichhaveverysmallnumberswithinasmallpopulationmayallowindividualstobeidentified.

Personal data Relatestoalivingindividualwhocanbeidentifiedfromdata,includinganyexpressionsofopinionabouttheindividual

Public interest Exceptionalcircumstancesthatjustifyoverrulingtherightofanindividualtoconfidentialityinordertoserveabroadersocietalinterest.Decisionsaboutthepublicinterestarecomplexandmusttakeaccountofboththepotentialharmthatdisclosuremaycauseandtheinterestofsocietyinthecontinuedprovisionofconfidentialhealthservices.

Records ‘Informationcreated,received,andmaintainedasevidenceandinformationbyanorganizationorperson,inpursuanceoflegalobligationsorinthetransactionofbusiness’.(InternationalStandardsOrganisation)

information

http://en.wikipedia.org/wiki/Organization

http://en.wikipedia.org/wiki/Person


Sensitive data Personaldataconsistingofinformationregarding:raceorethnicorigin,religiousbeliefs,tradeunionmembership,mentalandphysicalhealth,sexuallifeortheactualorallegedoffences.

Telehealth Referstotechnologicalapplicationswhichareusedindifferentsettingsbyavarietyofcommunitycareprofessionals.Telehealthisfrequentlyusedasanumbrellatermfortelemedicineandtelecare.

Telecare Therangeoftechnologiesusedinahomeorcommunitysetting.Telecareisusedprimarilytosupportindividualswitharangeofhealthand/orsocialneedstolivemoreindependentlyandremainathomesafely.

Information Governance in NHSScotland: A Competency FrameworkWorkforce Education Planning Template – Information Governance 37

Workforce Education Planning Template – Information Governance

Issue Action required Responsibility(staff/group)

Timescale

GeneralIdentify workforce education and training needs in relation to Information Governance

●Consultationwithstaffandserviceusersthroughsurveysetc.●Analyseconsultationdatatoproduceaworkforce‘profile’.●Feedbacktointerestedpartiestocheckvalidityetc.●Developaneducationandtrainingactionplan.●Disseminationandconsultation.●Deliveryandevaluation.

Ensure action plan links with other organisational initiatives

Reviewactionplaninrelationto:●HealthcareGovernanceagenda●BoardStrategicPlan●HumanResourcesStrategy●OrganisationalDevelopment/LearningandDevelopmentStrategy●Nationalandlocalpolicydrivers.

Prepare a prospectus of current organisational CPD provision relevant to information governance themes

Reviewexistingprovisioninrelationtoidentifiedneeds.

Undertake an inventory of training and development resources

Review:●classroomprovision●E-learningaccess●learningcentres●personnelavailabletoprovidetraining●IT/libraryfacilities.

Examine capacity systems Reviewsystemsfor:●identifyingeducationandtrainingneeds●costingprovisionandmaintainingbudgets.

Monitoring workforce development Monitorworkforcedevelopmenttoensure:●personaldevelopmentplansareupdated●widespreadparticipationinrelevantparticipation●intendedlearningoutcomesareachieved.

Evaluate education and training Evaluate:●staffsatisfactionwithtrainingprovided●effectsonserviceprovision●returnoninvestment.

Plan revision of education and training ‘portfolio’ and quality improvements

Asappropriate,useevaluationdatato:●discontinueprovision;●commission/designnewprovision;●reviseexistingeducationandtraining.

Information Governance in NHSScotland: A Competency FrameworkForeword38

RobCowardEducationalProjectsManagerNHSEducationforScotlandFloor5,ThistleHouse91HaymarketTerraceEdinburghEH125HE

Tel:01313138095Fax:01313138001

Email:[email protected]:www.nes.scot.nhs.ukISBN:978-0-85791-019-6