Flow Mapping of Patient Identifiable Information
July 2002 – July 2003
PROJECT CLOSURE REPORT
1. INTRODUCTION
The aim of this report is to provide an overview of:



How this Project has developed
How it has been implemented
What has been achieved
How it has been closed
And to recommend a plan of action to launch the second stage of flow
mapping patient identifiable information as dictated by the Caldicott report.
It is intended, therefore, that this report will provide sufficient information to
close this project and to provide a reference document to assist with the ongoing process of flow mapping information across the Trust.
2. PROJECT CONCEPT
2.1 Background Information
This project was initiated as a result of the Caldicott Management Audit
Out-turn report 2001/02 and subsequent Improvement Plan 2002/3, which
identified that information flows of patient identifiable information were not
being controlled or monitored and that breaches of confidentiality have
occurred as a result.
The Caldicott Report (Ref: www.gov.doh.gov.uk/nhsexipu/
confiden/guard/cginflows.htm.07/09/01) and Caldicott Audit Criteria
number 8 requires that:

Every flow of patient identifiable information within and from
an organisation should be tested against the Caldicott
principles and that each item of information containing
patient identifiable details should be justified.
The mapping of these information flows should fall into three
key stages:1. Mapping information flows (Stage 1) (This Project)
2. Prioritising mapped flows for review purposes (Stage 2)
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3. Rolling program of review (2,3,4 or 5 year program)
(Stage 3)
The Commission for Health Improvement (CHI) Review of 2002 also
identified that urgent action was required to improve the quality of data
produced across the Trust. Required improvements included establishing
effective information flows.
2.2 Purpose of Project
To produce information flow maps of patient identifiable information
throughout the Trust in order that:



An accurate baseline of the current position is established in
order to achieve compliance with the Caldicott
recommendations.
Potential breaches of confidentiality and or Data Protection
can be reduced.
Patient privacy can be enhanced
We can encourage standardisation of working practices
throughout the Trust, thereby improving process efficiency
and effectiveness.
In line with Caldicott recommendations (2.1) this project focused on the
first of the three key stages outlined above. It was accepted that
immediate action would be taken if areas of risk were identified during this
stage.
2.3 Objectives




To produce comprehensive flow maps of patient identifiable
information contained within manually completed forms, print
outs from systems and electronically exchanged data across
the Trust.
To use these completed flow maps to provide baseline
evidence against which future assessment will be reviewed
and to inform Directorate managers of issues requiring
corrective action
To report on areas which fail to meet Caldicott and Data
Protection guidelines and to share details where the use of
best practise is identified in order to assist weaker areas.
To identify processes to support a rolling programme of flow
maps for review
2.4 Scope
All areas of the hospital (clinical and non-clinical), which are involved with
handling patient identifiable information. The external flow of information
(i.e. to PCTs, Community support groups, Contractors, etc) to be identified
but excluded from the detailed mapping process at this stage.
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2.5 Deliverables



Production of comprehensive flow maps of patient
identifiable information
Co-ordination of Action Plans identifying areas of risk
Achievement of compliance with Caldicott Principles
throughout the Trust
2.6 Constraints and Risks


Evidence available from other Trusts identified that the
quantity of problems discovered had a knock on effect on
the time required to project completion. Production of a
reliable milestone schedule was therefore difficult.
Although the Caldicott Report provided broad guidelines
relating to assessing data flows, an approved National
Standard has yet to be published and therefore the
implementation and commissioning of this project has been
open to personal interpretation.
3. DESIGN AND PLANNING
3.1 Project Management Board (PMB) and Quality Review Panel
To ensure a Trust wide commitment and support for this project and in
order to maximise the potential benefits, a high level Project Management
Board was appointed as follows:





Eric Waters, Caldicott Guardian (Chair)
Dr Brian Bentley, Information Governance Chair
Laurence Arnold, Head of Planning & Service
Development
Erica Hayde, Information Governance Manager
Sue Garner, Directorate Manager
Gill Clothier, Process Redesign Manager
PMB meetings were held on a quarterly basis (Appendix 1)
Members of the Quality Review Panel were:


Erica Hayde, Information Governance Manager (Chair)
Frank Harsent, Chief Executive
Eric Waters, Caldicott Guardian
Following the inaugural PMB meeting and meeting with the Chief
Executive it was agreed that during the project:
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Immediate remedial action should only be taken where high
risks or quick fix solutions were identified
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
Action Plans requiring significant redesign to be annotated
and deferred to a later date to avoid major disruption to staff
work.
3.2 Project Planning and documentation
The project commenced at the end of July 2002. Following investigative
visits to Luton and Poole NHS Trusts, the following documentation and
tracking system was approved by the PMB in September 2002:



Project Initiation Document (PID)
Project plan to the end of the year 02 (Initial phase of Stage
1)
Pilot questionnaire
Electronic Tracking system
3.3 The Pilot
In October 2002, the Speech and Language Therapy Department agreed
to act as the Pilot site for flow mapping, as this area was currently
involved in process redesign.
The pilot was completed in November 2002 and as a result the
questionnaire and tracking system were restructured and improved. The
questionnaire was replaced with an “Information Gathering pack”
(Appendix 2) and a “Question Bank” (Appendix 3). The electronic tracking
system is available through the Information Governance Manager
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4. IMPLEMENTATION
4.1 Agreeing Areas to be Mapped
Many areas of the Trust are undergoing some form of process redesign
and/or modernisation. It was, therefore, important from the outset that the
flow mapping process could compliment on-going work or provide the
necessary information/evidence required for anticipated future plans. As
a result Directorate Managers prioritised the areas to be flow mapped.
Every two months meetings were arranged with each Directorate
Manager and an action plan for flow mapping established and reviewed.
j
4.2 The mapping Process
4.2.1 Meeting Area/Specialty Manager
Having identified the area to be mapped a meeting was set up with
the area/speciality manager. The objectives of the flow mapping
project were discussed and a plan of action and list of key staff to be
interviewed or shadowed was agreed.
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4.2.2 The Detailed Report
At all times it was made clear that if staff workloads were
exceptionally high the flow mapping exercise would be rescheduled.
To maintain momentum this resulted in several areas of the Trust
being flow mapped at any one time. This flexibility ensured quality
time with staff when they did not feel under undue pressure. The
detailed report was produced as follows:

The first stage of the mapping process was to agree a
logical start or entry point of information/patients into
an area. The route of this information and any exit
routes were then tracked. The flow mapping process
was annotated solely by the Project Manager and
assisting staff were not required to complete any
documentation.
Dataflow details were entered on the tracking system
and a detailed report was produced by the Project
Manager. In order to gain ownership from
departments, staff in the relevant area were then
invited to check, amend or add to the report. Again,
complete flexibility was given to the timescale for these
reports to be checked, thus ensuring quality feedback.
(Appendix 4).
4.2.3 The Visio Flow Map
As Visio was considered to be the most appropriate IT package to
present the information, the dataflow information contained in the
detailed report was then copied and précised as required onto a
Visio Flow Map (Appendix 5). .
4.2.4 The Summary Report
As each dataflow was entered on the tracking system it was
assessed against the Caldicott Principles and Data Protection
Regulations. If a dataflow appeared to breach these principles it
was annotated as a potential “risk” or if it appeared to adhere to
recommendations it was annotated as evidence of “good practice”.
Relevant ad hoc remarks by staff were annotated as “comments”.
A Summary Report was produced for discussion with the
Area/Specialty Manager (Appendix 6). Each potential risk was
either justified or a plan of action and timescale agreed. The Project
Manager completed the details of the agreed Summary Report on
the tracking system and added the name of the Area/Specialty
Manager to the bottom of the Summary Report as evidence of “sign
off” and completion of the flow mapping process within that area.
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4.2.5 Distribution of Reports
Copies of the Detailed Report and flow map were offered to
members of staff in the area that had been flow mapped and copies
of these reports together with the Summary report were given to the
Area/Speciality Manager.
Copies of reports were provided to Directorate Managers on
request. Some Directorate Managers preferring to have an
overview feedback from the Project Manager (Appendix 7).
Electronic copies of all reports and flow maps are stored in the
Information Flows Directory and held by the Information
Governance Manager.
4.3 Linking with other Projects
By November 2002 the importance of incorporating long-term action plans
into on-going process redesign, modernisation and other projects within
the Trust became apparent.
Although mapping flows of patient identifiable information has not been
completed throughout the entire Trust, assessment of the problems
identified to date clearly indicates repetition of data flow risks within similar
areas. It can be assumed, therefore, that outcomes of continuing the flow
mapping exercise can already be anticipated.
Implementation of the projects listed below will resolve the majority of data
flow issues identified in the action plans. This transfer of action points into
other Projects has formed the basis of how this project will be closed, thus
ensuring that the responsibility for completion of agreed actions is clearly
assigned to another recognised project. In effect this commences Stage 2
of the overall Project by “prioritising mapped flows for review purposes”
(1.1 Background Information).
The following chart lists the various projects throughout the Trust that will
assume ownership for long-term action plans identified during the Flow
Mapping Project. Each individual action point is linked accordingly on the
Tracking System so that follow up and review can continue in Stage 2.
TRANSFER OF RESPONSIBILITY FOR LONG TERM ACTION PLANS
Short
Long Description
Description Ownership
Responsibility
Patient Records
Clinical Documentation Group
CMG
Committee
Destruction Policy and
Patient Records
Process
DP
Committee
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TRANSFER OF RESPONSIBILITY FOR LONG TERM ACTION PLANS
Patient Records
Patient Document Tracking
PDT
Committee
Health Records Process
Patient Records
Redesign
MRM
Committee
Head of
Non Consultant Led Clinics
NCC
Modernisation
Head of
ATD Project
ATD
Modernisation
Electronic Booking
Head of
Management Service
ABC
Modernisation
Modernisation of Secretarial
Head of
Role
MSR
Modernisation
Head of
Outpatient Improvement Group
OI
Modernisation
Head of
EPR Project
EPR
Modernisation
Head of Planning &
Data Accreditation
DA
Service Development
Freedom of Information
FOI
Trust Secretary
Area Redesign - On-going
project currently addressing
Relevant Directorate
identified problems
AR
Manager
NOTE: Short Term Actions completed during flow mapping project are marked as
"COMPLETED" in the FOLLOW UP COLUMN on the electronic Tracking System
5. EXAMPLES OF ACTION PLANS AND COMMON PROBLEMS
5.1 Examples of Common Problems identified
Electronic Risks
Duplication of electronic systems (PiMS and local
databases)
Faxes being sent to open areas
Computer systems not linked to PIMS or networked
Computer systems slow, drip feed from PiMS regularly
crashes
Screen savers switched off locally by staff and
passwords shared
Lack of knowledge and understanding of computer
system
Screens visible by patients and unauthorised staff
Paper/Hard data Risks
Unnecessary duplication of paper systems (registration,
diaries, lists, questionnaires, forms, reports)
Unnecessary retention of duplicated patient information
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Insecure patient information
No protocols for destroying information
Verbal Risks
Telephone discussions in open areas
Messages left on answer phones
Miscellaneous Risks
Duplication of electronic and hard systems
Incomplete medical details (some details stored in clinic
and some in medical records)
Problems locating medical records (separate mapping
exercise is on-going)
5.2 Examples of Action Plans
ACTIONS
TIMEFRAME
Restricting access levels to databases
Removing unnecessary patient identifiable
information on invoices
Raising staff awareness of Caldicott
Principles and Data Protection Regulations
(posters, meetings, additional training
provided by Information Governance Officer)
Purchase of cordless phones to enable
sensitive conversations in a secure area
Purchase of number lock pads to improve
security of medical records
Creating fax safe havens (moving fax
machines etc)
Amalgamating forms, questionnaires etc
Short term
Short term
Additional IT training, use of personal
passwords
Process Redesign
Increasing reliance on computer systems (as
they become more robust)
Patient Document Tracking to track medical
records to locations currently not on PiMS
Streamlining of appointment procedures to
avoid duplication of appointment letters
Service Development bids for equipment (i.e.
IPAQS)
Integration of computer systems
Short term
6. OUTCOMES
6.1 Purpose of Project
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Short term
Short term
Short term
Short term
Short term
On-going
On-going
Long term
Long term
Long term
Long term
Purpose of Project (2.2)
 An accurate baseline
of the current position
is established in order
to achieve compliance
with the Caldicott
recommendations.
Outcome of Stage 1
An accurate baseline now exists for all areas
of the Trust that have been flow mapped.
These areas include clinical and non-clinical
areas and can be used as a template for the
rolling review programme in Stage 3.
(Appendix 8)

Immediate action taken during this stage has
reduced potential breaches of confidentiality
and the long-term plans now in place will
continue to address confidentiality issues. (5.2)
Immediate action taken during this stage has
enhanced patient privacy and the long-term
plans now in place will continue to do this.
(5.2)
Stage 1 of this project has identified areas
where standardisation of working practices
could be improved. The long term plans,
particularly the Secretariat Process Redesign
Project and Outpatient Improvements will use
the evidence gathered during flow mapping to
assist with process redesign. (4.3)


Potential breaches of
confidentiality and or
Data Protection can
be reduced.
Patient privacy can be
enhanced
To encourage
standardisation of
working practices
throughout the Trust,
thereby improving
process efficiency and
effectiveness.
6.2 Objectives
Objectives (2.3)
To produce
comprehensive flow
maps of patient
identifiable information
contained within manually
completed forms, print
outs from systems and
electronically exchanged
data across the Trust
Outcome of Stage 1
Comprehensive flow maps of patient
identifiable information have been produced for
all areas of the Trust that have been flow
mapped. (Appendix 8) Each dataflow is
identified on the tracking system as “hard
copy”, “electronic” and/or “verbal”. Graphical
analysis of risks identified in each of these
dataflow formats has been on going
throughout the Project. Examples of analysis
are available in the Project Report file and
Information Flows Directory held by the
Information Governance Manager.
To use these completed
The completed flow maps, reports and details
flow maps to provide
of issues requiring corrective action have been
baseline evidence against disseminated to Directorate Managers and
which future assessment Project Leads throughout the project. This
will be reviewed and to
information has been used to take immediate
inform Directorate
corrective action if required and forms the
managers of issues
basis for long-term action. (8, 8.1, 8.2)
requiring corrective action
To report on areas which On completion of each flow map, a Summary
fail to meet Caldicott and Report has been produced (4.2.4) and
Data Protection
distributed to relevant staff (4.2.5). Evidence
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Objectives (2.3)
guidelines and to share
details where the use of
best practise is identified
in order to assist weaker
areas.
To identify processes to
support a rolling
programme of flow maps
for review
Outcome of Stage 1
of Good Practise within an area is detailed on
the summary report and details shared with
other areas as applicable.
The processes recommended to support a
rolling programme of flow maps for review are
provided in detail at 8 and Appendix 9. To
summarise, these involve a cascade approach
supported by the Caldicott Guardian and led
by the Information Governance Manager.
6.3 Areas flow mapped within the Trust
An accurate calculation of the areas that have been flow mapped as a
percentage is difficult, as an area may be found to consist of several
areas each requiring a separate flow map (e.g. Medical Records is split
into four distinct areas, Medical Records Library, Subject Access, Clinical
Coding and Amalgamations). It is however, estimated that the flows
completed at the end of Stage 1 of the project represent 57% of the
Trust. Appendix 8 provides details of all the areas mapped during this
stage.
6.4 Using flow mapping to assist with specific modernisation/change agendas
Managing and implementing any planned change generally requires
significant detailed investigation into the existing situation. With many
areas of the Trust currently involved in some form of change an
unquestionable benefit of flow mapping has been to provide the initial
process mapping required to produce a baseline against which
changes/redesign can be based.
Some examples of how flow mapping has assisted with this work in
specific areas (as opposed to linking with other Trust wide project as
detailed in 3.3 above) are as follows:-
AREA
A&E
Breast Service
Cancer Office
Colorectal Cancer
Clinic
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FLOW MAPPING REPORTS HAVE
PROVIDED:Evidence to support business plan for new
computer system and the review and
streamlining of working processes
Details to assist with the review of Patient
Care Pathway
An overview of administrative processes for
rapid referrals to enable review
Process mapping to enable review of
processes and redesign of patient care
10
AREA
Maternity
Department
ICU - Radnor
FLOW MAPPING REPORTS HAVE
PROVIDED:pathway
Evidence to support business plan for new
computer system and streamline existing
working processes
Evidence to support the initiation of an
elective operations booking project
Medical Records
Details to assist with redesign of working
processes
Medical secretariat Baseline details to be used in forthcoming
modernisation of the Secretarial Role
Project
Medical Surgical
Information to be considered in forthcoming
Out Patients
redesign and work with on-going patient
improvements and appointment booking
service
Orthopaedics
Information to be incorporated with current
pre operative assessment project
Speech Therapy
Information to be used with current process
redesign and modernisation
Urology
Details to assist with current assessment of
working practices
6.5 Data Accreditation and Freedom of Information
It is anticipated that the information gathered during this project can be
integrated with Data Accreditation and Freedom of Information projects
recently started within the Trust.
7. ACHIEVEMENTS
7.1 Caldicott Annual Return 2003
Achieved a score of 2 in the Caldicott Annual Return for mapping flows of
Information thus meeting one of the main objectives for the Project.
7.2 Recognition by the NHS Information Authority (NHSIA)
Feedback from the NHSIA stated that this flow mapping project was the
most extensive to date nationally and is to be used as exemplar material
with the new Information Governance Toolkit. The tracking system has
also been passed to the Department of Health and is being considered for
use with on-going work with the Commission for Health Improvement
(CHI) and a new initiative for “Reducing bureaucracy in the NHS”.
7.3 Sharing information with other NHS Trusts
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The NHSIA have recommended the approach used for this project to
other NHS Trusts and a number of Trusts have visited and contacted SDH
to obtain details. Currently the Isle of Wight, Somerset and Northampton
NHS Trusts are considering using this format.
8. CONTINUING FLOW MAPPING BEYOND THIS PROJECT
8.1 Aim
As outlined at 3.3 above the closure of this stage and transfer of
responsibility for actions into modernisation projects launches the start of
Stage 2 (“Prioritising mapped flows for review purposes”). The aim of this
section is to recommend how this stage should be completed and how
Stage 3 (“Rolling program of review 2,3,4 or 5 year program”) should be
launched. Refer to The plan for Continuation (Appendix 9).
8.2 Stage 2 - Monitoring Progress
At project closure each Directorate Manager and Project lead will receive
a report detailing either the previously agreed action or action to be
incorporated within a specific project. (Appendix 10.11.12.13). A copy of
these reports will be held by the Information Governance Manager and
electronic copies stored in the Information Flows Directory held by the
Information Governance Manager.
As explained in the covering Memorandum (Appendix 10, 12) details of
any action completed should be reported back to the Information
Governance Manager by March 2004. This information will be included in
the annual Information Governance Performance Indicator report in March
2004.
Updating the existing flow maps will be the ultimate responsibility of the
Directorate Managers to cascade to appropriate staff. Electronic copies of
all reports and flow maps are stored within the Information Flows
Directory. It should be noted that there is a training and resource
implication for the collection and updating of this information.
It is anticipated that full implementation of many of the projects listed at
3.3 will not be complete until 2005 and therefore a realistic target to
commence Stage 3 is 2006.
8.3 Stage 3 – Rolling program of review
This project has flow mapped a cross section of clinical and non-clinical
areas within the Trust and it is recommended that these reports and flow
maps be used as templates for Stage 3. This will ensure the quality of
flow maps produced and minimise the additional workload impact on staff.
A cascade approach to this exercise is suggested.
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9. SUMMARY
9.1 Time, Cost and Quality
This project can be summarised in terms of Time, Cost and Quality as
follows:
Time
As identified at the outset the major constraint to this project
was time. The impact of this time limit has resulted in the flow
mapping exercise not having been carried out in all areas of the
Trust. However, the success of the project could not have been
greater if the timescale had been increased as the holistic
approach now to be taken regarding remedial action to improve
data flows will resolve issues on a Trust wide basis.

Cost
The project came in within budget

Quality
External feedback in the methodology used to run this project
exceeds the expectations of both the objectives and deliverables
and can therefore be viewed as an additional benefit.
9.2 Value Added
On assessing this project two key factors emerge as pivotal to its
success:1. Actions Planning
Short-term actions have been immediately beneficial to staff
whilst also improving data flows in relation to Caldicott and
Data Protection guidelines.
Longer term actions are now firmly embedded in
modernisation plans; the depth of detail available from the
flow mapping exercise providing real evidence of issues and
problems that have previously been purely anecdotal.
2. Flexibility to staff during flow mapping
By interviewing staff only when their workload was lighter
ensured a much better quality of resultant flow map. On
occasions this meant delays in completion by many weeks
and even months but it was always worth it.
9.3 Reflection
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The flexible approach to gathering the information helped to build good
relationships between the Project Manager and staff and enabled staff to
have the time to fully digest the significance of the project in relationship
to their work. It also allowed the Project manager the opportunity to learn
and understand the reasons for many frustrations relating to working
practices that currently exist and gently encourage the benefits of change.
10. CONCLUSION
This has been a worthwhile, interesting and successful project. The outcome
of which should provide an effective and highly efficient mechanism for
information flows to be improved and reviewed as an on-going activity
throughout the Trust.
Appendix Number
1
2
3
4
5
6
7
8
9
10
11
12
13
Description
PMB Terms of Reference
Gathering Information Pack
Question Bank
Detailed Report
Visio Flow Map
Summary Report
Directorate Manager Summary Report
Areas flow mapped during Stage 1
Plan for continuation of Flow Mapping
Example Memorandum to Directorate Managers for feedback
Example report to Directorate Managers for Review
Example Memorandum to Project Lead for feedback
Example report to Project Lead for Review
Shirley Ledingham
Patient Identifiable Information Flow Mapping Project Manager
5 July 2003
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