Information Governance Management – Primary Care Trusts
How would you assess your PCT’s ability to access expertise across the
Information Quality and Records Management agenda?
The PCT should ensure that it allocates responsibility for information quality
and records management appropriately throughout the PCT and that these
responsibilities are formalised in all relevant job descriptions.
Information Quality and Records Management expertise
Information quality is all about the accuracy, completeness and reliability of
information, in other words, its “integrity”.
The PCT should ensure that it allocates responsibility for information quality and
records management (clinical and corporate) ‘appropriately’ throughout the PCT. The
most ‘appropriate’ way to achieve this may be different depending on the size and
make-up of the PCT and may need to recognise, in some cases, that individuals in
some organisations may be called upon to perform more than one key role .
The following guidance contains key elements which should be included in the
consideration of the management of the agenda. Where an organisation chooses to
manage its responsibilities for information quality and records management in a
different way, they will need to be able to justify this, and demonstrate that their
mechanisms are robust.
1. Responsibilities for Information Quality Assurance
The PCT should ensure that there are individuals within the PCT that have clear
responsibility for patient data quality across all key systems. There should be a lead
strategic focus for information quality assurance through the PCT Board (or
delegated sub-committee), with a key individual empowered to make operational
decisions at director level.
Each person with such responsibility, including those nominated to lead on
information quality within new system implementations, must be clear about their
roles and the accountability they have in this regard. To this end, job descriptions
associated with this role should clearly define accountability and responsibilities for
data quality including monitoring and correction of errors.
The individuals with responsibility for information quality below Board level should be
sufficiently empowered to make differences at IT system or information management
process level. They should also closely liaise with the organisation’s’ Risk Manager,
Education, Training & Development Managers and Department Heads to identify
regular or consistent errors by individuals or staff groups, so that retraining needs
can be identified and provided for as necessary.
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2. Responsibilities for Clinical Information Assurance (The Health Record)
The role of a Health Records Manager is:
To identify current arrangements for managing health records, including a
survey of existing Health records management systems
To draft an organisational Health Records Management Strategy and
To liaise and work with other employees responsible for information handling
activities, e.g. the Freedom of Information Lead, the DPO and the Caldicott
To raise awareness of the importance of health records management
throughout the organisation through profile raising and a publicity campaign
To promote health records management awareness throughout the
organisation by providing training and written procedures that are widely
disseminated and available to all staff
To assess the need for support staff
To assess the health records training requirements of support staff and
indirectly managed staff (e.g. ward clerks, medical secretaries) and to ensure
the provision/arrangement of that training
To submit quarterly reports on performance and improvements to the health
records service to the Board
The Health Records Manager must liaise with the Caldicott Guardian to ensure that
the Health records management strategy and implementation programme is in line
with current guidance and protocols on confidentiality. The Caldicott Guardian should
review Health records management processes annually to ensure that the PCT’s
Health Records Strategy and all aspects of the implementation plan are developed in
line with local and national guidance on confidentiality.
The Health Records Manager must also work closely with the Data Protection Officer
to ensure that subject access arrangements comply with the Data Protection Act
Freedom of Information
The Health Records Manager should work closely with the Freedom of Information
Lead to ensure the PCT’s compliance with the overall records management strategy.
3. Responsibilities for Corporate Information Assurance (Including FOI 2000)
PCTs must ensure that all staff members are aware of their personal responsibilities
for compliance with the Freedom of Information Act 2000 and adhere to PCT
policies and procedures on this issue so that organisational compliance can be
achieved and maintained.
Ideally, each PCT should allocate overall responsibility for Freedom of Information
issues to a senior member of staff who can pull together and oversee the diverse
requirements of the law.
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The Chief Executive
The Chief Executive has the ultimate responsibility for PCT compliance with the Act
and should ensure that:
Responsibility for bringing Freedom of Information issues to the Board is
delegated to an appropriate Director.
An individual has been appointed/designated to lead on the implementation of the
Freedom of Information work programme and report directly to this Director.
The Freedom of Information Lead has a key role in ensuring procedures and
processes are in place to enable the PCT to comply with the Freedom of Information
Act. The Lead’s key responsibilities are:
To ensure that the organisation complies with all aspects of the Freedom of
Information Act and related provisions and provide reports to the Board
To draft and/or maintain the currency of the organisation's FOI policy
To promote FOI awareness throughout the organisation by providing training
and written procedures that are widely disseminated and available to all staff
To ensure the general public has access to information about their rights
under the FOI Act
To assist with investigations into complaints and appeals about decisions
To encourage the setting up of a FOI group with representatives from across
To liaise and work with other employees responsible for information handling
activities, e.g. Caldicott Guardian, DPO, Information Security Manager
These staff members are responsible for:
Carrying out the aspects of the work programme delegated to them by the Lead
Attendance at training identified through training analyses to keep their skills and
knowledge up to date
Support staff should receive basic training in FOI issues, with particular attention paid
to records management matters.
Other staff members
All staff who hold, obtain, record use and store PCT information should be made
aware of their own personal responsibilities, especially for records they create. They
Attend the available training and awareness programmes
Adhere to all PCT policies and procedures and guidance issued by the DH
Comply with the law
Awareness and training
This requires that a programme of on-going training is put in place for all those with
Freedom of Information responsibilities in the PCT.
Training should be provided to the manager with overall responsibility for Freedom of
Information issues in all aspects of the FOI Act and supporting initiatives.
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This training should ideally cover:
o Recognising and responding to a request for information
o Adopting and maintaining a Publication Scheme
o Records management
o Exemptions – public interest and absolute exemptions
o The interface between Freedom of Information and data protection
Support staff, such as those charged with locating and collating information should
receive basic training in FOI issues, with particular attention paid to records
The PCT should appoint (or be able to demonstrate access to) skilled Information
Quality and Records Managers/Officers and establish a Board approved plan to
support both agendas.
The PCT should ensure that responsibilities for Information Quality and Records
Management are identified in various staff roles and co-ordinated by the lead
The PCT should ensure that Information Quality and Records Management
arrangements are coordinated by the lead manager/officers but incorporated within
broader IG arrangements. The PCT's IG Steering Group should receive routine
reports from the Information Quality and Records Management Functions and sign
off the appropriate components of the IG assessment before its submission to the
Key Guidance Document(s):
IHRIM (UK)- Institute of Health Records and Information Management
IHRIM was established in 1948, primarily as an educational body. Its objectives,
then as now, were to provide qualifications at different levels, as well as career and
professional assistance for members working in the field of health records,
information, clinical coding and related professions.
The Institute offers support for students studying for professional qualifications and it
provides the routes to qualification at a number of levels by way of examinations at
Foundation Certificate, Intermediate Certificate and Diploma levels, the National
Clinical Coding Qualification (UK) and the Certificates of Technical Competence in
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Health Records Practice at Basic and Advanced levels, which are assessed
The National Archives
The National Archives (TNA) has developed and published a significant amount of
guidance for use by records managers within the public sector. Although some of the
earlier publications were written specifically for a central government audience, a lot
of the guidance is generic and should assist records managers in the health and
social care setting. The National Archives produces standards and guidance on all
aspects of records management.
The Records Management Society of Great Britain
This website is intended for Information and Records Managers and members of the
Records Management Society of Great Britain to use as a reference site and single
point of contact for discussion and the exchange of ideas. The Society is also
developing its own training programmes and extending its range of technical and
NHS Records Management Advisory Group Membership and terms of reference.
The role of this centrally run group is to support and assist the development of quality
assurance of best practice guidance and other exemplar materials to be available
electronically via the Department of Health website for reference and use in the
management of NHS records.
DH: Records Management NHS Code of Practice
The Code is a guide to the required standards of practice in the management of
records for those who work within or under contract to NHS organisations in England.
It is based on current legal requirements and professional best practice. The
guidance applies to all NHS records and contains details of the recommended
minimum retention period for each record type. HSC 1999/053 has now been
The Records Management Roadmap
The Roadmap comprises of ‘how to’ materials in the form of templates and checklists
to assist organisations in developing and implementing solid records management
NHS Connecting for Health Information Quality Assurance Programme
NHS CFH MODEL Job description for Freedom of Information Lead 2006
NHS CFH MODEL content for Records Manager Job Description
NHS CFH MODEL IG Steering Group Terms of Reference
NHS CFH IG Toolkit User Guide
The following are not model publications but examples of real documents in
use by organisations that represent elements of good practice. They have been
made available for organisations to adapt, use and improve on as they see fit.
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Royal Cornwall Hospital NHS Trust Corporate Records Manager Job
Information Governance Training Tool
The Digital Information Policy team at NHS CFH in conjunction with the UK Council
of Caldicott Guardians and a third party supplier has developed an Information
Governance Training Tool. The main body of the tool comprises a structured e-
learning programme with Introductory, Foundation and Practitioner level modules.
As well as the interactive e-learning the tool has several other features, including
Trainer tool, comprising PowerPoint presentations, tutor notes and audio clips
Resource Library with further reading documents and links to useful websites
Ability to obtain a certificate on successful completion of an assessment
Reporting function for Department of Health / NHS Connecting for Health
The Tool is available at: www.connectingforhealth.nhs.uk/igtrainingtool
Dr FOI service of Dilys Jones Associates
NHS CFH General Practice - Data Quality Support (QOF)
NHS CFH Secondary Uses Service web page
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