Document control: Name and role Contact details Document Completed by Debbie Hibbert, Programme Manager, NHS Benchmarking Network team debbie.hibbert@nhs.net Data Protection Officer name (Data Controller - HQIP) Hewitt Data Protection Officer Sasha.hewitt@hqip.org.uk Data Protection Officer name (Data Processor - NHSBN) Curtiss Green, Data Protection Officer curtiss@grgserv.co.uk Document approved by Claire Holditch, Director, NHS Benchmarking Network team cholditch@nhs.net Organisation’s ICO registration number (Data Controller - HQIP) Z1780946 Organisation’s ICO registration number (Data Processor - NHSBN) This DPIA is completed by the NHS Benchmarking Network team, subcontractor to East London NHS Foundation (ELFT) (host of the Network) on behalf of HQIP. The Network (via ELFT) is contracted by HQIP to provide NACEL. The Network team’s ICO number is Z1624069. Date Completed Version Summary of changes 16th April 2018 V1.0 HQIP pilot template 24th April 2018 V2.0 Revised HQIP template 25th April 2018 V3.0 30th April HQIP submission 2nd May 2018 V4.0 Additional sections and comments from HQIP 17th May 2018 V5.0 Approved by Steering Group (16/5/18) 20th June 2018 V6.0 Update at request of HQIP on potential use of data for clinical audit, service evaluation & research purposes
Income / Financial / Tax Situation NO Email Address NO Physical Description NO General Identifier e.g. Hospital No NO Home Phone Number NO Online Identifier e.g. IP Address/Event Logs Yes (CNR & CRM) A unique audit code will be generated to link the Case Note Review and Carer Reported Measure. The Network will not be able to link this code to any patient identifiable information. The attempt to link the data is a requirement of the HQIP contract. Website Cookies NO Mobile Phone / Device No NO Device Mobile Phone / Device IMEI No NO Location Data (Travel / GPS / GSM Data) NO Device MAC Address (Wireless Network Interface) NO Sensitive Personal Data Physical / Mental Health or Condition Yes (CNR & CRM) Required to provide a profile of the cause of death for the audit sample. Assessment can then be made as to whether end of life care varies for different medical conditions. Sexual Life / Orientation NO Family / Lifestyle / Social Circumstance NO Offences Committed / Alleged to have Committed NO Criminal Proceedings / Outcomes / Sentence NO Education / Professional Training NO Employment / Career History NO Financial Affairs NO Religion or Other Beliefs Yes (CNR & CRM) Required to provide a profile of the religious affiliations for the audit sample. Assessment can then be made as to whether end of life care varies for different religious groups. Trade Union membership NO
Categories of data processed Included in participating Trust Privacy notices Recipients or categories of recipients N/A The source of the personal data N/A To know the period for their data will be stored (or the criteria used to determine that period) N/A The existence of, and an explanation of the logic involved in, any automated processing that has a significant effect on data subjects (if applicable)
Privacy and Actions Table Please see appendix 2 for additional guidance on completing this table What are the potential risks to the individuals whose personal data you hold? Likelihood of this happening 1 Very unlikely 2 Unlikely 3 Possible 4 Likely 5 Very Likely (See guidance below for definition)) Impact 1 2-Minor 3-Moderate 4-Major (See guidance below for definition) Overall risk score (likelihood x impact = score) Will risk be accepted, reduced or eliminated? Mitigating action to reduce or eliminate each risk OR Where risk is accepted give justification. Explain how this action eliminates or reduces the risk Expected date Responsible Illegitimate access, undesired modification and disappearance of data 1 1 1 Eliminated No patient identifiable data will be held. No patient identifiable data will be transferred. Any loss of anonymised data would not result in harm to any individual, since they can’t be identified. Data is protected by the BMC Network and Data Security Policy. This includes that all BMC staff are Data Protection trained. BMC are in the process of completing the new Data Security and Protection toolkit Ensures that staff are aware of data protection risks and work within an agreed policy framework Director Accidental receipt of patient identifiable data (e.g. carer such as a carer writing a name in a text box on the 1 1 1 Eliminated Random samples of the data will be scanned for any personal data. Programme Manager NHSBN
Carer Reported Measure online form Any breaches will be identified at the validation and review stage and dealt with on a case by case basis. However, it should be noted that such a breach could only happen by the carer themselves disclosing the information and hence gave consent. Corporate risks & compliance risks section Reputational risk to the NHSBN if any personal data is ever inappropriately accessed 1 1 1 Eliminated No patient identifiable data will be held. No patient identifiable data will be transferred. Any loss of anonymised data would not result in harm to any individual, since they can’t be identified. Data is protected by the BMC Network and Data Security Policy. This includes that all BMC staff are Data Protection trained. BMC are in the process of completing the new Data Security and Protection toolkit Ensures that staff are aware of data protection risks and work within an agreed policy framework Director