Board Policy CA-250: Protection of Confidential Information (Confidentiality)

Effective date: 2022-06-21

This policy is a complement to the policies of Vitalité Health Network (the “Network”) in the area of privacy protection and confidentiality, to the Code of Conduct and Morals of Members of the Board of Directors (the “Board”), and to the By-Laws of the Network.

Purpose

The Board of Directors (the “Board”) of Vitalité Health Network (the “Network”) is committed to ensuring that systems, structures, and policies and procedures are in place to protect the confidentiality and privacy of patients and staff and thereby maintain confidence in the Network.

This commitment includes the assurance that the framework governing the collection, utilization, communication and the destruction of confidential information takes into account the legislation governing privacy and allows ongoing improvement of the information management practices within the Network.

Definition

  • Confidential information:
    Includes, without being limited to, the following types of information:
    • Personal information (PI);
    • Personal health information (PHI);
    • Information of a sensitive nature and information that is confidential (e.g. administrative information noted in personal notebooks or agendas);
    • Human resources or payroll information;
    • Legal information;
    • Financial information.

Policy

  1. The Board is responsible for ensuring that mechanisms and structures are in place to effectively manage all aspects of access to, and the protection of, confidential information.
    1. The Board reviews the policies governing access to, and the protection of, confidential information and receives periodic monitoring reports from the senior management team.
    2. The Chairperson of the Board must inform the Minister of any breach of confidentiality committed by a Board member.
  2. Board members have a responsibility to adopt practices preventing risks related to the unauthorized accessing of confidential information or the unauthorized use, communication or destruction of such information.
    1. Board members must read this policy and sign the Confidentiality and Non-Disclosure Agreement (Appendix CA-250) at the start of their term and every year thereafter.
    2. Board members must neither disclose nor communicate to another person or entity nor use for their own purposes any confidential information concerning the Network’s affairs that they received in the course of their duties on the Board.
      1. Any topic discussed during an in-camera session of the Board must be treated as confidential information until it is disclosed during a public meeting of the Board.
      2. Any topic submitted to a committee or working group of the Board must be treated as confidential information unless it has been deemed otherwise by the Chairperson of the committee or working group in question or by the Board.
    3. Board members must refrain from making statements to the press or public that have not received prior authorization from the Board.
  3. The Board assigns the President and Chief Executive Officer the responsibility for developing and implementing all strategies, policies, designed to ensure that principles and practices governing access to, and the protection of, confidential information are integrated into all aspects of the Network’s philosophy, culture, and operational planning.
    1. The President and Chief Executive Officer must ensure that any hint of a failure to protect privacy or confidentiality is investigated in accordance with the Network’s policies on the protection of privacy and confidentiality.
    2. The President and Chief Executive Officer must inform the Minister of any serious breach of confidentiality or privacy by a senior manager, employee, or medical staff member or by non-employed or agent staff of the Network.
    3. The President and Chief Executive Officer must inform the Board as soon as possible of any breach of confidentiality with the potential to affect the Network’s reputation or the safety of its patients.
    4. The Chairperson of the Board must inform the Minister of any serious breach of confidentiality or privacy committed by a Board member.

Procedure

  1. The Secretary of the Board records the relevant information from an in-camera session in a set of minutes, indicates the nature of the topic discussed and the reasons that justified holding this discussion in camera, and marks this set of minutes as “Confidential.”
  2. The person responsible for a committee or working group or their delegate records the relevant information in a set of minutes and, unless otherwise indicated, marks this set of minutes as “Confidential.”