Health Data

How to Build a Health Data Governance Plan

Starting a health data governance project/plan is a complex undertaking for an organization that requires a lot of preparation. Healthcare organizations collect a tremendous amount of data. Knowing where, how, why, and what data is collected is vital for an organization as data is a vital asset.

Data has many purposes, including, but not limited to: strategic planning; clinical decision making and patient care; financial; population health purposes; and federal, state, and local reporting. The data may have not have uniform definitions throughout the organization, as each department may apply their own definitions to some of the data collected and used.

For additional information, please see the AHIMA Healthcare Data Governance Practice Brief.

The first step in the plan should be the creation of a charter based on organizational approval and support for the project/plan. This article will discuss what is needed: starting the project/plan and selecting a committee; setting goals; creating metrics; and establishing rules and guidelines for communication.   

Initiation Phase

The initiation phase begins the journey to health data governance in the organization, and the first step is to create a charter.

Identifying Information

The first tasks are to complete basic information, such as selecting the team name, identifying a  senior stakeholder, creating a project name, and determining the time frame to complete the project. The senior stakeholder should be a member of the leadership/executive team and serve as a champion for the data governance project/plan. A project name might be simple such as “Committee Kickoff and Plan.” The time frame should have specific start and completion dates.

Purpose

The purpose details the “why” of the project/plan. An example might be developing a plan and strategy for a health data governance plan, such as:

“To provide oversight for the use, management, and integrity of healthcare data across its 

life cycle with a focus on supporting data quality, regulatory compliance, and the organization’s mission and goals.”

The next steps include creating the vision, mission, responsibilities, tasks, and deliverables.

Vision Statement

A vision statement is a brief statement of what you are trying to achieve. The statement will help guide the project and assist with focus and achieving its goal. This is similar to a vision statement for the organization.

Mission Statement

As with the vision statement, it is imperative to establish a strong mission statement to anchor the project. The mission should describe how to achieve the vision and why it is essential. The more focused the project is, the more likely it is to succeed. 

Responsibilities and Tasks   

The responsibilities and tasks relate to the project’s purpose and is where the work starts being defined and organized. At this stage, the responsibilities and tasks will only relate to starting the project/plan, and include decisions such on committee members and the tasks. Below are some examples.

  • Create a health data governance vision, mission, strategic plan, and charter.
  • Appoint a health data governance committee and provide oversight, guidance, and a plan.
  • Determine the scopes of the steering and health data governance committees.
  • Conduct an environmental scan of all health data collected, captured, and retained by the organization (this is a significant undertaking).
  • Create an education plan for the organization.
  • Define “data governance” and the “health data governance plan.”
  • Determine metrics for the team.

Include critical objectives to guide the vision and mission achievement. Those objectives should consist of team building, communication, creating the charter, appropriate leadership (chair), and appropriate communication, such as email, Slack, or other messaging platforms. All of the above components are very important, and a document such as this needs sufficient detail for clarification and direction so all team members know the project/plan and can stay focused.

Deliverables

Deliverables are essential, as they clearly state what the team needs to accomplish as the project/plan starts. They should be clear so the team knows the responsibilies, expectations, and outcomes. Some examples of deliverables:

  • Finalized charter with the vision, mission, and scope
  • Finalized communications plan
  • Completed educational plan
  • Completed environmental scan
  • Identify members of the health data governance committee

Clearly defined deliverables will allow easier completion and planning of determined timelines and deadlines as the project/plan begins.   

Team Membership

Establishing the committee, the structure, and how it will function is essential to the project/plan. Data governance affects the entire organization; it may be best to have all the departments within the organization represented in some form. Specific tasks may need to be handled by others rather than the primary membership. Below is an example structure, starting with executive leadership; from there, a data governance office made up of data owners and data stewards. The executive leadership team creates a data governance committee, which should consist of department leadership. A chair within the committee should be the project champion. The data owners and data stewards would make up ad hoc committees as needed. It is important to recognize the valuable insight the end user can provide to the data governance project/plan. 

Communication information should be provided, including team members’ names, phone numbers, and email addresses. 

Roles

Assigning roles to each member appointed to the committee should assist in keeping the project/plan organized and the structure intact. The example structure above is very general and may need to be more specific to meet the organization’s needs and allow for a clear assignment of roles for all those involved.   

Responsibilities

As the roles are defined and assigned, the entire team needs responsibilities . Some examples responsibilities are:

  • Successfully achieving our mission and vision goals
  • Team charter and communications plan
  • Develop and implement a project plan
  • Stakeholder analysis

Authority

Succeeding with a health data governance project/plan, which may encompass many people in different positions, requires authority. Authority may be required to complete some of the tasks for the project/plan, as it may affect workflow and processes. An example of some of that authority is as follows:

  • Establish team operating procedures to promote effective team performance.
  • Communicate with stakeholders as necessary.

This authority will provide a more cohesive culture within the organization and within the team. 

Operating Agreement

An operating agreement ensures all the team members work cohesively together and remain respectful throughout the project, especially in today’s environment where many meetings and events are virtual. Some examples of what to include in the operating agreement are:

Team communication rules

  • Listen and respect all contributors.
  • Be open to all ideas (there are no bad ideas).
  • Trust each other.
  • Come prepared to all meetings.
  • Complete assignments on time.
  • Be committed and dedicated to the team’s objectives.
  • Understand the “why.”
  • Timely communications are essential.
  • Email communications rules: remove any emotional accusatory language; don’t take things personally.

This example is for communication but would also need to be followed for other aspects of the project/plan.

Critical Success Factors

These factors are vital as milestones for the project/plan. These factors will be advantageous in keeping the team motivated and working toward the goals. Some examples of critical success factors are:

  • Build and execute the project plan, assign leads and support, then utilize the plan to manage the effort.
  • Complete an environmental scan.
  • Design a comprehensive communications plan that is all-inclusive to ensure program success.
  • Build a requirements roadmap with performance objectives and performance standards.

It’s critical to make these factors measurable and, once achieved, celebrate them. By celebrating the success factors, the team will be motivated to continue. 

Charter Approval

The last piece needed to complete the charter is approval from senior leadership. There should be a signature of the individual completing the charter, such as the project chair or manager. There should also be a signature of the senior stakeholder, who should be a senior leadership team member. This signature indicates support and buy-in for the project/plan from the organization’s leadership and executive teams. A project such as this involves the entire organization; everyone and the team must provide support.     

Planning Phase

After the initiation phase and getting started, it is time to move to the next stage: the actual planning. In this phase, two main themes will include 1) metrics and goals and 2) communication. Each of the aspects of a project/plan will require a charter using the steps above and will become apparent as the planning phase takes place. 

Metrics and Goals  

With a health data governance project/plan, it is essential to have metrics and goals since data governance is an attempt to develop standards around the health data collected within the organization. Creating metrics makes it possible to determine how the organization is progressing with developing those standards and how the data is becoming more beneficial. Along with the metrics, it is essential to set goals for the team, stakeholders, and employees as the project/plan progresses. Goals are vital to breaking the project/plan into smaller parts, as health data governance across an entire organization can be overwhelming. 

Communication

Communication for a project/plan is critical, each team member needs to know and understand what the others are doing clearly and concisely. It is essential to work together as a cohesive unit and respect the other team members.

Identify Communication Methods and Timing

Technology offers different ways to communicate; thus, providing guidance is necessary. In specific scenarios, communication may include the use of email and an instant message platform such as Slack and/or Teams. A particular platform should be used for meetings, such as Zoom or Teams. If the meetings will be virtual, a dedicated meeting link should be clear and available to the entire team. There needs to be defined etiquette for all meetings to ensure the discussion remains on topic. Along with straightforward communication methods, determining the timing for status checks is also essential. The subcommittees may meet weekly, and the entire committee meets monthly, so everyone is aware of deliverables and deadlines. Establishing these guidelines at the start of the project/plan will keep meetings streamlined, and the committee should run smoothly.  

Increase Awareness (Identify Target Audiences)

Increasing awareness around the project/plan and identifying the target audiences for the various parts of the project/plan is fundamental. To achieve awareness, use a website, either a page added to an existing website for the organization or a different website. The website would include dashboards related to various pieces of the overall project. General status updates targeting the different departments within the organization will provide transparency. The site would need to be maintained regularly to include updates, requiring a dedicated individual or team to complete the necessary updates.

Cultivate “Ownership” in Health Data Governance Processes 

This project/plan will encompass many individuals across the entire organization, so it is imperative to create a culture of ownership and pride in the project/plan at hand. If every team member feels invested in health data governance, they will take more pride in the creation, and the culture will spread throughout the organization.

Reflect Corporate Values  

The organization should already have clear values, and the culture created and nurtured needs to incorporate them as the health data governance project/plan unfolds. The culture will also assist  with the team’s cohesiveness, allowing them to work better together.

Promote/Implement Health Data Best Practices 

As health data governance becomes apparent in the organization, best practices will emerge and form standards. The end users need to be influential so it doesn’t fall into the old saying, “that is how we have always done it.” The end users understand the data the most and can assist if needed to promote or implement the best practices necessary within the organization. 

Enforce Compliance with Policies and Standards

Once the charter is complete and rules and guidelines established, it is essential to enforce them. The rules and guidelines need to be understood and enforced if the committee is to be a cohesive unit working toward the goal of health data governance across the organization. Many individuals may not typically work together, and there may be times when the typical chain of command does not apply. Enforcement of the created policies and standards applies as the project/plan starts. Without enforcement, the organization will return to how it used to operate. An organization undertaking a health data governance project/plan aims to create standards around the health data generated within the organization. Once those standards are made but not followed, the project/plan fails, so enforcement is needed.   

Putting it All Together

Once the charter has been created and the plan in place, the team is ready to work. A health data governance project/plan is just the beginning; many smaller projects will occur. Each of those may require a charter and a smaller committee to work on it and report back to the main committee. Each department may have an area to work on that is specific to that department. The smaller projects that take place will all assist in achieving the overall goal. An organizational health data governance project/plan is not a one and done but needs to be reviewed and updated regularly. Change management will need to be interwoven into this as well, as it will affect all the employees throughout the organization and assist with establishing the health data governance culture.

Conclusion

Starting an organization-wide health data governance project/plan is a serious undertaking requiring much planning and resources.  It is crucial to begin by completing the charter with all the discussed steps. Once the project gets underway and the committee is working toward the goal, it is vital to stay motivated and not lose sight of the main goal as a health data governance culture is created. Health data governance is a project/plan that is never complete and always needs review and modification as things change within the organization. A health data governance project/plan is well worth the effort for an organization if handled correctly.    

Nicole Miller (millern@millerandmillerassociates.com) is independent consultant at Miller And Miller Associates.

Patty Buttner (patty.buttner@ahima.org) is the practice director of informatics, analytics, and data use at AHIMA

Tags: data governance