Roles and responsibilities (checklist)

Roles and Responsibilities of Project Supervisor (Checklist) (word document)

Guidance on data protection

• It is not necessary to seek data protection approval to pull data from Landspítali‘s health records for quality improvement purposes.

• It is permissible for junior doctors to look into patients‘ health records and to manually collect data on a separate data collection form or spreadsheet as long as they do not record kennitalas or other patient identifiable information.

• Always ask: do you absolutely need to include kennitalas in your data collection?

• Once kennitalas are recorded this data is no longer anonymised and may require approval from the data protection authority.

• The health informatics team (Hagdeild) will generally not provide patient identifiable information when data is requested for and they may ask for evidence of ethics approval.

• The HUT department may include kennitalas in their spreadsheets and may not ask for proof of data protection (or ethics) approval.

• Rules are gradually tighening up.

• Residents and QI project supervisors therefore have a responsibility to make a concerted effort to always protect the identity of patients when conducting QI projects.

Quality and ethics screening

It is not necessary for QI projects to receive ethics approval from the Bioethics Committee, however it is important for ethical issues to be considered before starting any project. The screening tool below provides a guide for trainees and supervisors to be able to carry this out in a structured way. The trainee and supervisor should complete this together and have it signed by the QI Lead for the training programme. A signed copy should then be kept by the trainee. This will then fulfill the ethics screening criteria if the trainee chooses to publish his/her work in the future.

Quality and ethics screening tool for quality improvement project (word document)

QI competency sign off and certification

• Checklist of QI Competency Sign-off (pdf)

• Quality Improvement Project Assessment Tool (QIPAT) (word document)