The North Simcoe Muskoka Self-Management Program is committed to the principles set out in this legislation, which requires that we safeguard and protect your information. As part of our commitment, we believe that our patients should know what personal health information we collect, how we use it, how we protect it, and how to contact us. 

Scope

This policy applies to all South Georgian Bay Community Health Centre (SGBCHC) and North Simcoe Muskoka Self Management Program (NSMSMP) staff, volunteers, students and contracted out services.

Definitions

Personal Information:

This policy addresses the uses of personal information belonging to clients, staff and volunteers. Personal information is any factual or subjective information, recorded or not, about an identifiable individual. Employee personal information does not include the name, job title, work telephone number or work address, or anything that might appear on a business card.

Personal Health Information:

Personal Health Information is defined in the Person Health Information Protection Act (PHIPA, 2004) as identifying information relating to the physical or mental health of an individual, the provision of health care to an individual, the identification of the substitute decision-maker for the individual and the payment or eligibility of an individual for health care or coverage for health care, including the individual’s health number. For the purpose of abbreviation, the terms “personal information” and “personal health information” will be interchangeable in this document

Purpose

In order to provide quality care and services to our clients, we are required to collect and use personal information. The SGBCHC and NSMSMP is committed to protecting the privacy, confidentiality and security of all information gathered from clients, staff and volunteers. The purpose of this policy is to ensure compliance with relevant legislation (PHIPA), and therefore preventing the inappropriate collection, use and disclosure of personal information.

SGBCHC and NSMSMP recognizes the dignity and self-worth of every person and their right to a safe, secure and trusting care environment. The client has the right to culturally safe, considerate and respectful care. The client also has the right to participate in decision making affecting their health. Personal information is given to the SGBCHC or NSMSMP in trust. It is mandatory that the information remains confidential. It is important that information not circulate outside of the SGBCHC or NSMSMP in an unauthorized manner and it also should not pass between staff for reasons other than appropriate consultations.

Accountability

The South Georgian Bay Community Health Centre and North Simcoe Muskoka Self Management Program is responsible for personal information under its control and must maintain its confidentiality at all times. All SGBCHC/NSMSMP staff share this responsibility. Our responsibilities in protecting information also entail the assurance that third parties maintain the same levels of privacy as the SGBCHC. Staff, volunteers, students and associates with access to client and employee information are expected to comply with the Privacy and Confidentiality Policies. As part of their orientation to the Centre, they are asked to sign a Confidentiality Agreement indicating they understand and agree to abide by the policy. A copy of the signed statement will be kept in the personnel/HR record. The obligation of confidentiality remains in effect even after termination of employment. It is the responsibility of the Executive Director or designate, to ensure that any person having access to client and employee information is made aware of the policies and procedures concerning confidentiality and that each individual sign SGBCHC’s Confidentiality agreement.

The Privacy Lead

The Executive Director may appoint a designated privacy lead. The name and title of this individual will be made available both internally and externally to ensure their accessibility. The Privacy Lead is responsible for facilitating the organizations compliance with all privacy related legislation. They will respond to client’s requests for access to or correction of a record of personal health information. Additionally, they will respond to inquiries from staff and the public about the Centre’s privacy policies and procedures. Finally, the privacy lead may be involved in receiving complaints from staff, clients or the public about privacy and confidentiality-related matters.

Confidentiality of Staff and Centre Information

Employee, Volunteer and Student Information

Each employee, volunteer and student shall maintain the confidentiality of personnel files or employment records of employees, volunteers and students at the Centre

Business Affairs

An employee or volunteer shall not disclose any information about business affairs or operations of theCentre for their purpose or the purposes of any other organization or individual.

External or Third Party

Signed Confidentiality Agreements will be signed by non SGBCHC employees that are in attendance/working in areas where confidential information would exist within the SGBCHC.

Purposes of Information Collection

Information will be gathered from the client, community participant, employee or third party for specific purposes. This individual must be informed in a meaningful way of the purpose for the collection of personal information at or before the time of collection. SGBCHC/NSMSMP shall only collect the information it needs to fulfill the identified purpose. 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. Example Purposes for Data Collection:

  • To contact client’s/volunteers regarding upcoming events
  • To submit information required by funding agencies (i.e.. Ministry of Health)
  • To plan programs and services for community participants
  • To employ individuals
  • Quality Improvement (i.e. Evaluation forms)
  • Any other reason needed to provide services

Obtaining Consent

Valid and informed consent of the individual is required for the collection, use or disclosure of personal information, except when required by legislation. The individual’s consent will be obtained before or at the time of collection, as well as when a new use is identified. For community participants registering for a program or workshop refer to Appendix J Group Consent Form

Information disclosure will not be made a condition for providing service, unless the information requested is required to provide the specific service. Consent may be withdrawn and/or withheld at any time.

Record Keeping

Staff and administration shall use consent forms provided by SGBCHC or NSMSMP. Consents obtained from volunteers and community participants will be kept with the program coordinator.

Valid and Informed Consent

Informed consent means that the client, employee, volunteer or Substitute Decision Maker (SDM) has received information that is clear and understanding of the facts, implications and consequences of an action that a person would require in order to decide about the benefits and risks of providing their information and the alternative courses of action and the consequences of not providing their information. To ensure informed consent, the service provider must disclose to the client the nature of the information gathering, its purpose, any risks, and the consequences of not providing consent. The practitioner must answer any specific questions posed by the client. The client must always be given the opportunity to withdraw their consent. In order for consent to be “valid”, the following criteria must be met:

  • Consent must be voluntary
  • The client must have the physical and mental capacity to consent
  • The client must have been properly informed
  • Verbal consent may be obtained for release of medical information to family members or friends if agreed upon by client. Information regarding who the release of medical information should be disclosed to will be documented in the client’s chart as a “Special Note” with date and who consented the client, as well as who has access to this information.

Competence to Consent

An incapable person cannot provide valid consent. If a practitioner determines a client is unable to consent, a SDM must then act on their behalf. All rights of an individual apply to his/her SDM. People who are judged to be incompetent in one instance are not necessarily incompetent in all instances and may be capable of consenting in a later situation. Also, people have the right to make unreasonable decisions, as long as they are competent and can demonstrate that they fully appreciate the consequences of their decisions.

Limit Collection

Staff members will:

  • limit the amount and type of information gathered to what is necessary for the identified purpose
  • ensure that there is a justifiable purpose for obtaining and recording information about a client
  • Not collect personal health information by misleading or deceiving individuals about the purpose for which the information is collected.

Staff Access and Disclosure

SGBCHC and NSMSMP strives to offer a range of programs and service that are holistic and recognize that a multitude of factors can affect a client’s health and well-being. For this reason, it is important that there are open lines of communication between service providers and SGBCHC programs to ensure the most effective and efficient utilization of services possible. There are both formal and informal means of sharing information ranging from verbal consultation to referral forms and shared care. SGBCHC and NSMSMP will use or disclose personal information only for the purpose for which it was collected, unlessthe individual consents otherwise, or the use or disclosure is authorized by law.

Openness

The following information will be readily available to staff, Board of Directors, volunteers, students and clients:

  • Information about our policies and practices relating to the management of personal information
  • Name and contact information for the Privacy Lead (in order to access information, inquire about our privacy policies or make a complaint)
  • How to comment, report or inquire about privacy issues and
  • How to find information that explains SGBCHC`s policies, standards or codes for confidentiality SGBCHC will ensure the policies and procedures are understandable and easily accessible.

Breach of Privacy

Refer to Appendix E-Privacy Breach Notification – Copy regarding a notification letter; Appendix G- Privacy Investigation of a Privacy Incident; as well as creating an Incident Report

Follow Appendix N-PRIVACY BREACH PROCEDURE

 

Contact Us

If you have any questions regarding our privacy policies, access to your record, correction of information, or if you have a privacy issue, you may contact our Privacy Officer at:

Heather Klein-Gebbinck
Executive Director
South Georgian Bay Community Health Centre
14 Ramblewood Dr., Unit 202
Wasaga Beach, ON, L9Z 0C4

Phone Number: 1-833-474-2242

Email: heather.kleingebbinck@sgbchc.ca