nhs business partners, commercial third parties, secondary use

IG Toolkit user guide: Completing your IG Toolkit assessment of 29

Completing your Information Governance Toolkit Assessment

This guide explains how to complete your Information Governance Toolkit (IG Toolkit) assessment if you are one of the following organisations:

NHS Business Partners

Commercial Third Parties

Secondary Use Organisations

Hosted Secondary Use Teams

NHS England

Health & Social Care Information Centre

Any Qualified Providers – Clinical

Any Qualified Providers – Non Clinical

To make the guide easy to follow it has been split into two main sections:

i. How to complete your IG Toolkit assessment….for the first time

ii. How to complete your IG Toolkit assessment….year after year (once you have completed the

initial assessment)

_________________________________________________________________________________

i. How to complete your IG Toolkit assessment….. for the first time

To complete your assessment you will need to:

A. Register for an account B. Log in C. Work on your assessment D. Publish your assessment __________________________________________________________________________________ If this is the first time you are completing an IG toolkit assessment, following the steps below should help you to navigate your way round the site and fully complete your assessment:

A. Register for an account

In order to be able to work on your assessment, you will need to be logged in as a user.

If you don’t have a user account you will need to obtain one first (refer to the ‘How to register’ help guide for details on how to do this). ______________________________________________________________________________

B. Log In

Once you have registered and have your user ID (which you will receive in an email) you will be able to login. To login, go to the IG Toolkit Home Page and enter your organisation code and your user details within the Registered Users section.

https://nww.igt.hscic.gov.uk/resources/UserGuide-HowToRegister.pdf


1. Click the 'Log In' button.

____________________________________________________________________________________


C. Work on your assessment

Once you have logged in, you will be able to access your assessment.

2. From your ‘At a Glance’ section, click on 'Go To The Assessments Section'

3. The system will display the Assessment Summary page. As this is your first assessment only the assessment you are now working on will be shown on the Summary page. In subsequent years this page will show a summary of all your IG Toolkit assessments, with the current assessment at the top and older ones below.


INFORMATION BOX 1

The Assessment Summary box shows the current status of various aspects of your assessment, in the following sections:

Headlines

Assessment Ref: a unique reference number relating to your assessment

Status: whether the assessment has been started or published

Next Deadline: the date that the assessment is due for publication

Audited: whether the assessment has been independently audited

Progress

Requirements Answered: This will show the number or requirements you have answered so far out of the total number of requirements in your IG Toolkit view.

Requirements Not Answered: This will show the number or requirements you have not yet answered out of the total number of requirements in your view.

Score

Current Score: This section shows two types of information; a percentage score and a textual ‘score’ (either Satisfactory or Not Satisfactory).

Percentage score is calculated by dividing the organisation’s actual total score by the highest potential score. The result is expressed as a percentage and rounded down.

Actual total score is equal to all the scores entered by the organisation added together.

Highest potential score is equal to the number of requirements in a particular IG Toolkit view multiplied by 3 (as 3 is the highest level of attainment possible), but excludes any requirements marked as Not Relevant (NR) or Exempt (EX).

For example, the highest potential score for Commercial Third Parties would be 17 requirements x 3 = 51. So if the CTP recorded actual scores that added up to 27, the calculation would be 27/51 = 52%; if one requirement was marked as NR, the calculation would be 27/48 = 56%


Textual ‘Score’ will either show Satisfactory which means level 2 attainment or above has been achieved on all requirements, or Not Satisfactory where level 2 or above has not been achieved on all requirements.

Target Score: Where you have set target scores on the system for your organisation as described below this section will appear showing a percentage score and a textual ‘score’ (either Satisfactory or Not Satisfactory). The section is not automatically completed by the IG Toolkit as other sections are. It is most useful as part of the improvement planning process, as if you have entered target information you will be able to automatically generate an Improvement plan from the system. To do this, enter a target score for each requirement for next year’s assessment, so if you marked level 2 on a requirement on this assessment the target score for that requirement for next year could be level 3 (or it could simply be to maintain level 2). You can also set a target date, e.g. three months, six months or 12 months from the date that you completed this assessment.

There is no obligation to set target scores or dates, but many organisations prefer to do so, as otherwise the percentages on the assessments page look a little odd (e.g. target score recorded as a low percentage and unsatisfactory). The target score is for your own purposes and is not used by the HSCIC External IG Delivery team.

Refer to the ‘How to use the improvement planning features’ help guide for more information.

4. In order to start working on your assessment, from the Assessment Summary page, click on 'Work on this Assessment'.

5. The system will display the Requirements List page, showing all the requirements you need to answer for your current assessment.

https://nww.igt.hscic.gov.uk/resources/UserGuide-HowToUseImprovementPlanning.pdf


INFORMATION BOX 2

You can answer the requirements in any order.

You do not have to answer all the requirements in one session; as long as you have clicked the ‘Save’ button before you leave the relevant Requirement Details page(s) the system will remember your answers even after you have logged out.

6. To answer a requirement click on the ‘Answer’ button under the Action column, you will then be taken to the main requirement page.


The main requirement page has a number of expandable sections: click on the + sign next to a heading to open

the section.

INFORMATION BOX 3

Requirement Description: This section contains a brief description of the overall content of the requirement.

Guidance: This section contains all the relevant guidance for the requirement, which may include useful web links. You should read the guidance section before you start to answer a particular requirement so that you fully understand the content of the requirement and what you need to do to fulfil that requirement.

Attainment Levels: This section outlines what needs to be done to fulfil each attainment level, including examples of evidence that organisations should have to support their scores.

Knowledge Base Resources: This section is split into three types of resources. 1. Key Resources – often guidance documents from Dept of Health, Professional bodies and other agencies; 2. Exemplar Documents – these are documents that can be downloaded and adapted by your organisation or used as a guide to develop your own documents; 3. Useful Links – useful links to various website containing pertinent information to that requirement.

Training: This section outlines any relevant training modules in the IG Training Tool developed by the Department of Health.

Requirement Origins: Provides details of the origins of the requirement.

Changes: This section will detail any significant changes in the requirement between IG Toolkit versions.


7. ‘Actions’ section of the ‘Assessment Summary’ screen to allow you to specify the purpose of the assessment. This pop-up and information collected will inform the HSCIC team of the specific purpose for your organisation completing the IG Toolkit assessment. This is mandatory for the following organisations – Any Qualified Provider-Clinical and Non Clinical/Commercial Third Party/NHS Business Partner/Community Health Provider/Voluntary Sector Organisation/Secondary Use Organisation/Local Authority and Hosted Secondary Use Team/Project and optional for all others.

8. Once you have read through the guidance, you can start scoring a requirement by clicking on the + sign

next to the Attainment Levels heading. This will expand the attainment levels section to allow you to see levels 0, 1, 2 and 3.

9. Next click on the + sign next to attainment level 1 and then on the + sign next to criteria level 1a to

display the type of ‘Evidence required’ that will demonstrate attainment. Do this for the remaining level 1 criteria (i.e. levels 1b, 1c and 1d depending on how many criteria there are for that attainment level).


Read each of the attainment levels and evidence to determine where your organisation is currently in relation to those levels and then score appropriately. ***Please note that the attainment levels are cumulative and you can therefore only score at the higher levels if you have met the criteria for everything in the lower levels***.

For example, if you feel that on requirement 202 you have everything in place to support level 2, you must have everything outlined in level 1 also.

10. To score the requirement, at level 2 for example, you need to tick the check boxes for criteria a, b, c, d

(depending on how many criteria there are for that level, in some cases, there may only be a and b, or just a) for level 1, this will automatically tick the main check box next to the level 1 statement. Then do the same for level 2, this will automatically tick the main check box next to the level 2 statement, and will also mark the ‘Current Level’ box at the bottom of the attainment levels section with a 2.


When scoring the requirements you also have the option to add evidence in the yellow ‘Evidence required’ section of the IG Toolkit. Whilst this is not mandatory for your organisation-type, it is recommended as it helps you to collect all your evidence all in one place (for example to provide assurances to NHS Commissioners, and auditors should you be audited during the year).

INFORMATION BOX 4

If you choose not to use the yellow evidence section then you must use the white General Comments fields to provide detailed information about your evidence for each attainment criteria you have achieved. If you publish your assessment with insufficient information (i.e. appropriate detail on each requirement on each criteria of the levels attained), when it is reviewed you will be informed that the assessment has been unpublished to enable you to add additional information to demonstrate the scores claimed.

The comments should contain sufficient detail to enable reviewers/auditors to ask for the evidence by name and be assured that it relates to the correct requirement - e.g. the name of a procedure, how it meets the evidence requirement, where it is located and who is responsible for it.

If you choose to complete the yellow evidence section, you can provide evidence in four different ways, you can:

o upload a copy of a document, for example a copy of an IG Policy

o provide an internet link, for example a link to a document that is published on your organisation's public website, e.g. an FOI policy

o provide an intranet link, this may link to a document that is held locally on your organisation's intranet

o specify another form of evidence, this may be useful for documents that are not in an electronic format.

To use the yellow evidence table (which appears once you have expanded the Attainment Levels section - see step 8):


11. Mark the evidence as obtained by ticking the check box in the ‘Obtained’ column.

12. Upload the evidence document by clicking the 'pencil' icon in the Location column and following the instructions, or you can select ‘Internet’, ‘Intranet’ or ‘Other’ and specify an internet/intranet link or some other comments e.g. kept in policy folder in shared drive. Prior to uploading an evidence document you should ensure that the filename of the document uploaded is reflective of the document title. This will enable easier future management of evidence documentation.

13. Additionally, if it is not self explanatory (e.g. where the link or filename does not reference the name of the document), you should add details about the document contents in the Details column.

14. You can also add your own evidence that might be supplementary to or an alternative to the default evidence listed. To do this, click the link Add other evidence, add some meaningful text to describe the evidence and tick the check box in the ‘Obtained’ column. Then follow steps 11 and 12 to specify the location and details.

15. Any document uploaded as evidence may be disclosed under a “Freedom of Information” request unless an exemption applies.

16. Whenever the dustbin icon is clicked to remove an evidence source you will be presented with the

following pop-up window.


***Please note: if you upload a document that is relevant to more than one IG Toolkit requirement, there is no need to upload the document more than once. You can link the same document to several requirements and even to several attainment or criteria levels by selecting ‘upload file’ and then selecting the required document from the ‘select a previously uploaded file’ drop-down list against the relevant requirement / attainment or criteria level***

17. Click ‘Save’ and then ‘Next’ if you wish to continue answering requirements.


18. If you need to log out and come back the assessment later you simply need to click the ‘Save’ button and then click the ‘Log Out’ button on the top left hand menu list.

INFORMATION BOX 5 The initial upload of evidence documentation or links must be carried out from the ‘Attainment Level’ section on the assessment screen. The linking of evidence to relevant requirement criteria can only be carried out from this area too. Ongoing maintenance of evidence can then be carried out from the ‘Maintenance and Planning’ area found on the assessment summary screen (please see screenshot below). From this area evidence can be replaced with updated versions or deleted if no longer applicable. Guidance on how to use the evidence management tools is available in the Viewing and Managing Evidence user guide.

https://194.189.27.36/resources/Viewing%20and%20managing%20your%20evidence%20User%20Guide.pdf

https://194.189.27.36/resources/Viewing%20and%20managing%20your%20evidence%20User%20Guide.pdf


___________________________________________________________________

D. Publish your assessment

19. Once you have answered all the requirements (outlined in steps 8 -18) and your assessment has been signed off by Senior Management you should then be able to ‘Publish’ your assessment. The yellow ‘Publish’ button will appear on the Assessment Summary Page. ***Please note that this button will only appear once all requirements have been answered***

20. If the “View Information Governance Senior Management Details” link is selected then the resulting

popup window has a single button with the text “Close” which closes the window.


It is mandatory for the following organisations – Acute Trust/Ambulance Trust/Mental Health Trust/ NHS Business Services Authority/NHS Direct/HSCIC /NHS England/Data Service for Commissioners/Public Health England and Area Team/Region/Hosted Body to enter Senior Management information. For all other organistions it is optional.

You can also complete or update the Organisation Profile from the ‘Admin’ page - click on Admin on the left hand menu to access this. For further information see the ‘How to use admin functions’ help guide.

https://nww.igt.hscic.gov.uk/resources/UserGuide-HowToUseAdminFunctions_ForIGTAdministrators.pdf


INFORMATION BOX 6

By clicking ‘Publish’ you are confirming that your Board/Owners/Senior Management team has signed off this assessment and no other changes are required. Clicking the publish button means that your assessment will immediately be published on the IG Toolkit website via the IG Toolkit Reports section and your scores (not the comments or evidence) will therefore be accessible to others.

21. The “Compare with Previous” drop down shows versions appropriate to the chosen organisation regardless of whether you have published or started an assessment for that version.

22. Context help is available for assessment report history.


To publish your assessment:

23. Navigate to the Assessment Summary page, (by clicking ‘Assessments’ on the left hand menu). 24. Click the 'Publish' button. 25. If the most recent review for the assessment report has been marked as ‘Complete’ with the status

‘Satisfactory with Improvement Plan’ then the current grade column will display the ‘Satisfactory with Improvement Plan’ in a green cell.

26. The current grade for an assessment is shown as ‘n/a’ if no review has taken place by the IG External Delivery Team.


27. Read the ‘IG Assurance Statement’, and scroll down the page to ‘Accept’ the Statement. Once you have accepted, your assessment will be fully published.


The system will send you an email to confirm your assessment publication has been received. You will receive a response from a member of the HSCIC External IG Delivery team once your assessment has been reviewed. Please note that response times may be extended during busy periods, for instance around the annual assessment publication deadline.


__________________________________________________________________________________

ii. How to complete your IG Toolkit assessment……year after year

To complete your assessment you will need to:

A. Log in B. Work on your assessment C. Publish your assessment ________________________________________________________________________________

A. Log in

From the Home Page, enter your organisation code and your user details (as received by email) within the Registered Users section.

1. Click the 'Log In' button.

__________________________________________________________________________________

B. Work on your assessment

Once you have logged in, you will be able to access your assessment.

2. From your ‘At a Glance’ section, click on 'Go To The Assessments Section'.


The system will display the Assessment Summary page. This shows a summary of all your IG Toolkit assessments, with the current assessment at the top and older ones below. The ‘rollover’ functionality (introduced in v9) will mean that the new/latest assessment is populated with the scores, evidence and comments from the previous assessment.

3. From the Assessments page, click on 'Work On This Assessment' within the topmost assessment.


The system will display the Requirements List page, showing all the requirements you need to Answer or Review for your current assessment.

INFORMATION BOX 1 You can review/answer the requirements in any order. You do not have to review/answer all the requirements in one session; as long as you have clicked

the ‘Save’ button before you leave the relevant Requirement Details page(s) the system will remember your answers even after you have logged out.

Mark a requirement as ‘Reviewed’

All requirements that have been rolled over from the previous assessment will, as mentioned, contain the scores, evidence and comments that were entered for the previous assessment.

4. To view this click on the ‘Review’ button, this will give you the requirement details page.


5. To familiarise yourself with the requirement and also to note any changes to the guidance click on the + sign next to the Guidance heading, this will expand the guidance section.

6. Click on + next to ‘Attainment Levels’ to expand the attainment levels section.


7. Next click on the + signs next to the attainment levels and then on the + signs next to the criteria levels

to display the scores, comments and, where relevant, any evidence you entered for the previous assessment.

8. Review the score and comments (and where relevant the evidence), and decide whether these are still an accurate record of your attainment against the requirement. If so, tick the ‘Requirement Reviewed’ check box, which can be found under the Level 3 attainment section. Click inside the check box and then ‘Save’ the requirement.

Changing scores

9. If you need to change a rolled over score to a lower score you simply need to un-tick the check boxes for the criteria level (e.g. the boxes at 2a, 2b, 2c etc.), this will then default the score to the next level down.

10. If you used the yellow evidence section to add evidence (upload, link to Intranet/Internet site etc) and you need to lower a score, you can also un-tick the ‘Obtained’ check boxes for the appropriate level.

11. When you have finished, tick the ‘Requirement Reviewed’ check box, which can be found under the Level 3 attainment section. Click inside the check box and ‘Save’ the requirement.

12. Click ‘Done’ to return to the requirement list screen or,

13. Click ‘Next’ if you wish to continue reviewing/answering requirements.

Changing/Providing evidence

INFORMATION BOX 2

Even if evidence is rolled over from the previous version of your assessment it can be updated within the current assessment, but the previous version of the assessment (accessible via the ‘Assessment Summary’ screen will always have a copy of the evidence submitted to that version as a record. Documents that have been uploaded to a previous version of the IG Toolkit CANNOT be deleted


from that version of your assessment.

If you added evidence text to the General Comments field in the last version of the IG Toolkit, you will see that this has also rolled over. You can edit, delete or add to the comments as appropriate.

You also have the option to add additional evidence in the yellow ‘Evidence required’ section of the IG Toolkit. Whilst this is not mandatory for your organisation-type, it is recommended as it helps you to collect all your evidence all in one place (for example to provide assurances to NHS Commissioners, and auditors should you be audited during the year). You can also change / provide additional evidence via the ‘Maintenance and Planning’ section (new for version 11) as detailed in information box 4:

If you choose to complete this section, you can provide evidence in four different ways, you can:

o upload a copy of a document, for example a copy of an IG Policy

o provide an internet link, for example a link to a document that is published on your organisation's public website, e.g. an FOI policy

o provide an intranet link, this may link to a document that is held locally on your organisation's intranet

o specify another form of evidence, this may be useful for documents that are not in an electronic format.

To use the yellow evidence table to change or provide additional evidence (the table appears once you have expanded the Attainment Levels section - see steps 6 - 7):

14. Mark the evidence as obtained by ticking the check box in the ‘Obtained’ column

15. Upload the evidence document by clicking the 'pencil' icon in the Location column and following the instructions, or you can select ‘Internet’, ‘Intranet’ or ‘Other’ and specify an internet/intranet link or some other comments e.g. kept in policy folder in shared drive. Prior to uploading an evidence document you should ensure that the filename of the document uploaded is reflective of the document title and version number. This will enable easier future management of evidence documentation.

16. Additionally, if it is not self explanatory (e.g. where the link or filename does not reference the name of the document), you should add details about the document contents in the Details column.

17. You can also add your own evidence that might be supplementary to or an alternative to the default evidence listed. To do this, click the link Add other evidence, add some meaningful text to describe the evidence and tick the check box in the ‘Obtained’ column. Then follow steps 15 and 16 to specify the location and details.


18. When you have finished, tick the ‘Requirement Reviewed’ check box, which can be found under the Level 3 attainment section. Click inside the check box and ‘Save’ the requirement.

19. Click ‘Done’ to return to the requirement list screen or,

20. Click ‘Next’ if you wish to continue reviewing/answering requirements.


INFORMATION BOX 3 If you have additional evidence but you choose not to use the yellow evidence section then you must use the white General Comments fields to provide detailed information about your additional evidence for each attainment criteria you have achieved. If you publish your assessment with insufficient information (i.e. appropriate detail on each requirement on each criteria of the levels attained), when it is reviewed you will be informed that the assessment has been unpublished to enable you to add additional information to demonstrate the scores claimed. The comments should contain sufficient detail to enable reviewers/auditors to ask for the evidence by name and be assured that it relates to the correct requirement - e.g. the name of a procedure, how it meets the evidence requirement, where it is located and who is responsible for it.

INFORMATION BOX 4 The initial upload of evidence documentation or links must be carried out from the ‘Attainment Level’ section on the assessment screen. The linking of evidence to relevant requirement criteria can only be carried out from this area too. Ongoing maintenance of evidence can then be carried out from the ‘Maintenance and Planning’ area found on the assessment summary screen (please see screenshot below). From this area evidence can be replaced with updated versions or deleted if no longer applicable. Guidance on how to use the evidence management tools is available in the Viewing and Managing Evidence user guide.

Mark a requirement as ‘Not Relevant’ or ‘Exempt’

Requirements that were marked as either ‘Not Relevant’ (NR) or ‘Exempt’ (EX) for the previous assessment will not rollover any scores or comments, as these markings apply for one assessment only.

21. If you marked a requirement as ‘Not Relevant’ for your previous IG Toolkit assessment and having reviewed the requirement you think this marking still applies, then you should score the requirement as ‘Not Relevant’ (providing this option is still available). If you wish to enter any comments, you need to do so before you select the NR option.

https://nww.igt.hscic.gov.uk/resources/Viewing%20and%20managing%20your%20evidence%20User%20Guide.pdf

https://nww.igt.hscic.gov.uk/resources/Viewing%20and%20managing%20your%20evidence%20User%20Guide.pdf


22. If a requirement was previously marked as ‘Exempt’ (granted by the HSCIC IG External Delivery Team after discussions) you will need to review the requirement again in relation to the services you are providing. If you still feel this requirement does not apply to you and cannot mark it as ‘Not Relevant’ you will need to apply again for an exemption to the HSCIC IG External Delivery Team (via the Exeter Helpdesk at [email protected])

23. When you have finished click ‘Done’ to return the requirement list screen, or

24. Click ‘Save’ and then ‘Next’ if you wish to continue reviewing/answering requirements.

____________________________________________________________________________________________

C. Publish Your Assessment

25. Once you have reviewed/answered all the requirements and your assessment has been signed off by Senior Management you should then be able to ‘Publish’ your assessment. The yellow ‘Publish’ button will appear on the Assessment Summary Page. ***Please note that this button will only appear once all requirements have been reviewed/answered***

INFORMATION BOX 5

By Clicking ‘Publish’ you are confirming that your Board/Owners/Senior Management team has signed off this assessment and no other changes are required. Clicking the publish button means that your assessment will immediately be published on the IG Toolkit website via the IG Toolkit Reports section and your scores (not the comments or evidence) will therefore be accessible to others.

To publish your assessment:

mailto:[email protected]


26. Navigate to the Assessment Summary page, by clicking on the Assessments tab on the left hand menu.

27. Click the 'Publish' button.

28. Read the ‘IG Assurance Statement’, and scroll down the page to ‘Accept’ the Statement. Once you have accepted, your assessment will be fully published.

The system will send you an email to confirm your assessment publication has been received. You will receive a response from a member of the HSCIC External IG Delivery team once your assessment has been reviewed. Please note that response times may be extended during busy periods, for instance around the annual assessment publication deadline.

____________________________________________________________________________________