CCH - Corporate Privacy Policy

Corporate Privacy Policy

SECTION: PRIVACY
POLICY NUMBER: PV 05-010
SUB-SECTION: Introduction
EFFECTIVE DATE: 2005-03-02
SUBJECT: Corporate Privacy Policy
LAST REVISION DATE:

BACKGROUND:
Cornwall Community Hospital recognizes that the health information of our patients deserves to be treated with respect and sensitivity and our patients’ privacy must be protected. Access to personal health information is available to those who need to know to provide care, including physicians, nurses, technicians, therapists and other health professionals. Furthermore, when it comes to collecting and using personal health information, the hospital takes measures to ensure the privacy and confidentiality of the information is protected.
Accountability for Personal Information

Cornwall Community Hospital is responsible for personal information under its control and has designated an individual who is accountable for the hospital’s compliance.

Accountability for Cornwall Community Hospital’s compliance with the policy rests with the Chief Financial Officer, although other individuals within the hospital are responsible for the day-to-day collection and processing of personal information. In addition, other individuals are delegated to act on behalf of the Chief Financial Officer, such as the Privacy Contact.
The name of the designated Privacy Contact is a matter of public record.
Cornwall Community Hospital is responsible for personal information in its possession or custody, including information that has been transferred to a third party for processing. The hospital will use contractual or other means to provide a comparable level of protection while the information is being processed by a third party.
Cornwall Community Hospital will implement policies and procedures to give effect to this policy, including:
a. Implementing procedures to protect personal information.
b. Establishing procedures to receive and respond to complaints and inquiries.
c. Training staff and communicating to staff information about the hospital’s policies and procedures.
d. Developing information to explain the hospital’s policies and procedures.

Identifying Purposes for the Collection of Personal Information

At or before the time personal information is collected, the hospital will identify the purposes for which personal information is collected. The primary purposes are the delivery of direct patient care, the administration of the health care system, research, teaching, statistics, fundraising, and meeting legal and regulatory requirements.
Identifying the purposes for which personal information is collected at or before the time of collection allows the hospital to determine the information it needs to collect to fulfil these purposes.

The identified purposes are specified at or before the time of collection to the individual from whom the personal information is collected. Depending upon the way in which the information is collected, this can be done orally or in writing. A patient who presents for treatment is also giving implied consent for the use of his or her personal information.
When personal information that has been collected is to be used for a purpose not previously identified, the new purpose will be identified prior to use. Unless law requires the new purpose, the consent of the individual is required before information can be used for that purpose.
Persons collecting personal information will be able to explain to individuals the purposes for which the information is being collected.

Consent for the Collection, Use and Disclosure of Personal Information

The hospital requires the knowledge and consent of the individual or substitute decision-maker for the collection, use, or disclosure of personal information, except where inappropriate i.e. legal requirements, or serious illness.

Consent is required for the collection of personal information and the subsequent use or disclosure of this information. Consent with respect to use or disclosure will be sought after the information has been collected but before use (for example, when the hospital wants to use information for a purpose not previously identified).
The hospital will make a reasonable effort to ensure that the individual is advised of the purposes for which the information will be used. To make the consent meaningful, the purposes must be stated in such a manner that the individual can reasonably understand how the information will be used or disclosed.
The hospital will not, as a condition of the supply of a product or service, require an individual to consent to the collection, use, or disclosure of information beyond that required to fulfil the explicitly specified and legitimate purposes.
The form of the consent sought by the hospital may vary, depending upon the circumstances and the type of information.
In obtaining consent, the reasonable expectations of the individual are relevant. The hospital can assume that an individual's request for treatment constitutes consent for specific purposes.
The way in which the hospital seeks consent may vary, depending on the circumstances and the type of information collected. The hospital will generally seek express consent when the information is likely to be considered sensitive. Implied consent would generally be appropriate when the information is less sensitive. An authorized representative (such as a legal guardian or a person having power of attorney) can also give consent.
Individuals can give consent in many ways. For example:

a. An admission form may be used to seek consent, collect information, and inform the individual of the use that will be made of the information. By completing and signing the form, the individual is giving consent to the collection and the specified uses;
b. A check-off box may be used to allow individuals to request that their names and addresses not be given to other organizations. Individuals who do not check the box are assumed to consent to the transfer of this information to third parties;
c. Consent may be given orally when information is collected over the telephone, or
d. Consent may be given at the time that individuals use a health service.

An individual may withdraw consent at any time, subject to legal or contractual restrictions and reasonable notice. The hospital will inform the individual of the implications of such withdrawal.

We will not collect personal information indiscriminately. Both the amount and the type of information collected will be limited to that which is necessary to fulfil the purposes identified.
Personal information will be collected by fair and lawful means.

If using personal information for a new purpose, the hospital will document this purpose.
The hospital will develop guidelines and implement procedures with respect to the retention of personal information. These guidelines will include minimum and maximum retention periods.
The hospital is subject to legislative requirements with respect to retention periods.
Personal information that is no longer required to fulfil the identified purposes will be destroyed, erased, or made anonymous. The hospital will develop guidelines and implement procedures to govern the destruction of personal information.

The extent to which personal information will be accurate, complete, and up to date will depend upon the use of the information, taking into account the interests of the individual. Information will be sufficiently accurate, complete, and up to date to minimize the possibility that inappropriate information may be used to make a decision about the individual.
The hospital will not routinely update personal information, unless such a process is necessary to fulfil the purposes for which the information was collected.
Personal information that is used on an ongoing basis, including information that is disclosed to third parties, will generally be accurate and up to date, unless limits to the requirement for accuracy are clearly set out.

The security safeguards will protect personal information against loss or theft, as well as unauthorized access, disclosure, copying, use, or modification. The hospital will protect personal information regardless of the format in which it is held.
The nature of the safeguards will vary depending on the sensitivity of the information that has been collected, the amount, distribution, and format of the information, and the method of storage. A higher level of protection will safeguard more sensitive information, such as medical and health records.
The methods of protection will include:
Physical measures, for example, locked filing cabinets and restricted access to offices;
Organizational measures, for example, limiting access on a "need-to-know" basis, and
Technological measures, for example, the use of passwords, encryption, and audits.
The hospital will make its employees aware of the importance of maintaining the confidentiality of personal information. As a condition of employment, all new hospital employees/agents (e.g., employee, clinician, physician, allied health, volunteer, researcher, student, consultant, vendor, or contractor) must sign the hospital’s Confidentiality Agreement.
Care will be used in the disposal or destruction of personal information, to prevent unauthorized parties from gaining access to the information.

The hospital will be open about its policies and practices with respect to the management of personal information. Individuals will be able to acquire information about its policies and practices without unreasonable effort. This information will be made available in a form that is generally understandable.
The information made available will include:

The name or title, and the address, of the Privacy contact, who is accountable for the hospital’s privacy policies and practices, and to whom complaints or inquiries can be forwarded;
The means of gaining access to personal information held by the hospital;
A description of the type of personal information held by the hospital, including a general account of its use;
A copy of any brochures or other information that explains the hospital’s policies, standards, or codes, and
What personal information is made available to related organizations.

The hospital will make information on its policies and practices available in a variety of ways. For example, make brochures available in its place of business, post signs, provide online access.

Individual Access to Own Personal Information

Upon request, an individual will be informed of the existence, use, and disclosure of his or her personal information and will be given access to that information. An individual will be able to challenge the accuracy and completeness of the information and have it amended as appropriate.

Note: In certain situations, the hospital may not be able to provide access to all the personal information it holds about an individual. The reasons for denying access will be provided to the individual upon request.

Upon request, the hospital will inform an individual whether or not it holds personal information about the individual. The hospital will allow the individual access to this information. However, it may choose to make sensitive medical information available through a medical practitioner. In addition, the hospital will provide an account of the use that has been made or is being made of this information and an account of the third parties to which it has been disclosed, when it is reasonably possible.
An individual will be required to provide sufficient information to permit the hospital to provide an account of the existence, use, and disclosure of personal information. The information provided will only be used for this purpose.
In providing an account of third parties to which it has disclosed personal information about an individual, the hospital will attempt to be as specific as possible. When it is not possible to provide a list of the organizations to which it has actually disclosed information about an individual, the hospital will provide a list of the organizations to which it may have disclosed information about the individual.
The hospital will respond to an individual's request within a reasonable time at a reasonable cost.
When an individual successfully demonstrates the inaccuracy or incompleteness of personal information, the hospital will amend the information as required. Depending upon the nature of the information challenged, amendment involves the correction, deletion, or addition of information. Where required, the amended information will be transmitted to third parties having access to the information in question.
When a challenge is not resolved to the satisfaction of the individual, the hospital will record the substance of the unresolved challenge. When appropriate, the existence of the unresolved challenge will be transmitted to third parties having access to the information in question.

The hospital will put procedures in place to receive and respond to complaints or inquiries about its policies and practices relating to the handling of personal information. The complaint procedures will be easily accessible and simple to use.
The hospital will inform individuals who make inquiries or lodge complaints of the existence of relevant complaint procedures. A range of these procedures may exist.
The hospital will investigate all complaints. If a complaint is found to be justified, the hospital will take appropriate measures, including, if necessary, amending its policies and practices.

Appendices

REFERENCE DOCUMENTS: 1. University of Health Network – Privacy Policy
2. Guidelines for Managing Privacy, Data Protection and Security for Ontario Hospitals prepared by The Ontario Hospital eHealth Council Privacy and Security Working Group July 2003

REPEALED POLICIES:
CGH Administrative Policy No. 5-45

APPROVAL PROCESS: Privacy Committee – February 2005
Senior Administrative Team – March 2, 2005

APPROVAL SIGNATURE:
Jeanette Despatie
Chief Executive Officer