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Why You Need Policies and Procedures

Why You Need Policies and Procedures

 

Why You Need Health Information Policies and Procedures

Maybe you’ve heard you need written policies and procedures for your health information, but you’re left asking yourself why it’s so important?

The truth is, without written policies and procedures, you open a healthcare practice up to a whole host of problems, including major legal issues.

In fact, every business needs good practices that apply to your:

  • Information that you collect from patients/clients
  • Website
  • Email
  • Business practices including electronic (or paper) patient records, and computer network
  • Financial information
  • Billing, collection, and payment processing

Within the healthcare industry, there are additional legislation requirements that require specific written health information policies and procedures.

The Health Information Act (HIA) and the Personal Information Privacy Act (PIPA)

As we mentioned, when a custodian collects health information, you must follow the Health Information Act (HIA) in Alberta.

Like most other private businesses in Alberta, private healthcare practices must also comply with the Personal Information Privacy Act (PIPA).

The colleges of regulated health professionals (like the Alberta Dental Association and College (ADAC) and the College of Physicians and Surgeons of Alberta (CPSA), require dentists and physicians to meet the standards of practice which includes compliance to HIA and PIPA legislation.

In addition, the college has other standards of practice that you must meet, including policies and procedures for the collection, use, disclosure, and access of health information.

So, let’s explore further why written policies and procedures are so essential, as well as what can happen without them, and why healthcare practices may not think they need them in the first place.

Benefits of Policies and Procedures

One of the most critical benefits of having policies and procedures in place is that they’re good for business.

Here’s how:

  • They contribute to consistent, efficient workflow.
  • You can figure it out once, write the procedure, tweak it to make it better, and then repeat the same procedure again and again.
  • They help you make better business decisions, like buying supplies, choosing services, and selecting vendors.
  • They help support your accreditation efforts.
  • On-boarding employees the right way with no missed steps is much easier with policies and procedures in place.

If you’re looking for even more proof of the benefits of having written procedures, it can also help you avoid:

  • Internal disputes within your team and external disputes with your patients and clients
  • Re-work and re-training employees
  • Poor customer service
  • Poor reputation
  • Fines and penalties

Fines And Penalties For Not Having Written Policies And Procedures

You might be wondering why you would face fines and penalties for not having written policies and procedures in the first place.

The HIA requires the custodian – which includes the physician, pharmacist, dentist or dental hygienist – to take reasonable safeguards to protect the privacy and confidentiality of patients’ health information.

Having written policies and procedures is a common, expected, and reasonable safeguard.

Let’s say you have a privacy breach in your practice or an error (like sending a fax to the wrong number or you are a victim of a phishing or ransomware attack).

You can learn more about what makes a privacy breach a privacy breach here.

If you can’t demonstrate that you had the appropriate reasonable safeguards, like written policies and procedures in place, you are guilty of an offence under the law.

It’s illegal not to have policies and procedures when you collect health information.

If you are guilty of this offence, you are liable for a fine of a minimum of $2,000 and not more than $500,000. (HIA section 107(7)).

3 Policies and Procedures Myths

One reason some healthcare practices fail to have written policies and procedures is because they believe they don’t need them.

Often, this is because they’ve fallen prey to the common myths about policies and procedures.

There are 3 of the common myths that stop healthcare providers and their clinic managers from creating written policies and procedures:

  1. It’s Too Hard

While it does take some skill to write clear, easy to read, and easy to understand policies and procedures, it doesn’t have to be heard. In fact, you can even purchase templates to make this easier.

  1. It Takes Too Much Time

Writing policies and procedures does take some time.

But investing the time to create policies and procedures pays off by preventing suffering from inconsistent or broken procedures, using or disclosing health information in error, and having to pay fines, penalties, public relations nightmares, or spending the time required to run a privacy or security investigation.

  1. It’s A Waste Of Time

Here are a few good reasons that prove writing policies and procedures is not a waste of time:

  • Practical privacy policies and procedures will create a more efficient practice and help you make better business decisions.
  • The policies and procedures become the foundation of your privacy impact assessment.
  • Policies and procedures are pre-requisites for other initiatives, like access to Netcare or other community integration initiatives, and privacy impact assessment (PIA). Click here to learn more about PIAs.
  • You must have them as part of your legislative compliance.
  • It’s the law. Not having policies and procedures regarding the collection, use, disclosure, and access of health information is illegal.

As you can see, written policies and procedures help ensure consistent office procedures and good communication between team members in your healthcare practice.

In addition to those good reasons, you must have good written policies and procedures about how you collect, use, disclose, and provide access to health information to avoid legal problems, fees, penalties, and other problems.

 

Not Sure Which Policies and Procedures That You Need?

Show Me Policy And Procedure Checklist
 

Did you enjoy this article? If you’d like to look at similar posts, visit these links:

Do You Know Where Your Policies and Procedures Are? 

Privacy Impact Assessments (PIA)

Policy and Procedure Checklist book image
Leaving a Group Practice? Know Your Responsibilities for Patient Records

Leaving a Group Practice? Know Your Responsibilities for Patient Records

 

Leaving a Group Practice? Know Your Responsibilities for Patient Records

You’ve been part of a group practice for some time.

Now, you’re preparing to open your own clinic, relocate to another area, or step away from practice altogether. Whatever your next move, it’s important to understand your responsibilities when it comes to patient health records.

Here’s what you need to know to leave well—and stay compliant.

Understanding Your Rights and Responsibilities

When you leave a group practice, you still have important obligations tied to patient records. These include:

  • Record access, security, and retention – You’re responsible for the health records you’ve collected while in practice.
  • Right of continuing access – You have the right to access the records of patients you’ve cared for, even after leaving, to respond to inquiries for access, disclosure, complaints, or investigations.
  • Continuity of care – You’re responsible for ensuring appropriate access to patient records to support ongoing care.
  • Duty to inform – Patients should be made aware of your departure and how their records will be managed.
  • Respect existing agreements – This includes any contracts or group practice policies in place, such as Information Management Agreements (IMAs) or Information Sharing Agreements (ISAs).

Resources to Guide You

Before finalizing your departure, review the following documents and standards:

  • Your contract – especially termination clauses
  • Information Management Agreements (IMAs) – with both the group practice and EMR providers
  • Information Sharing Agreements (ISAs)
  • Privacy and security policies – especially those related to closing or relocating a practice
  • Professional college standards – around recordkeeping and patient notification
  • Provincial health privacy legislation – such as Alberta’s Health Information Act or Ontario’s PHIPA

These documents can help clarify who retains custody of the records, what access rights you have, and how to ensure continuity of care for your patients.

What Are Your Plans?

Your responsibilities will vary depending on your next step:
If You’re Relocating (and Patients May Follow)
You may want to request a copy of relevant patient records for continuity of care. To do this:

  • Review your IMA – Is there a cost to receive a copy of your patient records?
  • Talk to your EMR vendor – Is data export or transfer supported? What is the cost?
  • Ensure data quality assurance – Will the records be intact and complete?
  • Prepare a new Privacy Impact Assessment (PIA) for your new location, including data migration

If You’re Leaving Practice or Relocating Far Away
You may choose to leave records with the current group practice. In that case:

  • Make sure you have a written agreement outlining who is responsible for access, storage, and disclosures.
  • Update your IMA to authorize the group to manage patient inquiries on your behalf.
  • Keep in touch with group practice so that they can reach you in case you’re needed to support access to patient records or respond to complaints. You also want to know if the group practice changes significantly.
  • Don’t abandon your records. Even if you’re no longer practicing, you’re still responsible for their safekeeping

The group practice must also agree to manage your patient records on your behalf. Don’t make assumptions—get it in writing!

It Takes Time

It takes time

You didn’t start your practice overnight. It will take time to successfully plan and implement the transition of patient records when you leave the group practice.

Leaving a group practice is a significant professional step—and handling patient records properly is part of doing it right.

With the right planning, communication, and documentation, you can support your patients, protect yourself, and move forward with peace of mind.

Want Extra Support To Navigate Your Transition?

These resources include practical templates, checklists, and expert guidance to help you leave your current practice confidently and in compliance.

✅ Download the Practice Management Success Tips – Closing or Moving Your Healthcare Practice

✅ Get your copy of The Top 3 Agreements Your Healthcare Practice MUST Have (and Why)

Does AI Take Your Data? AI and Data Privacy

Does AI Take Your Data? AI and Data Privacy

 

Does AI Take Your Data? AI and Data Privacy

Generative AI, including platforms like ChatGPT, DALL-E, Google Gemini, Apple Intelligence, has revolutionized our relationship with technology. Maybe these tools have completely changed how you work and engage with the internet. There seems to be endless ways to use these platforms, many of which are called large language models (LLMs). These chatbots can assist with brainstorming, writing, and even coding—but they also can be significant risks when used carelessly. One of the biggest concerns? Employees inadvertently exposing sensitive company information.

The National Cybersecurity Alliance 2024 Oh Behave report found that 65% of us are concerned about AI-related cybercrime, and most people (55%) haven’t received any training about using AI securely. For AI Fools Week, let’s change that! #AIFools

First and foremost, when you’re using an AI tool, think about what you’re sharing and how it could be used.

Generative AI

 

Think intelligent about AI

AI models process and store data differently than traditional software. Public AI platforms often retain input data for training purposes, meaning that anything you share could be used to refine future responses—or worse, inadvertently exposed to other users.

Here are the major risks of entering sensitive data into public AI platforms:

  • Exposure of private company data – Proprietary company data, such as project details, strategies, software code, and unpublished research, could be retained and influence future AI outputs.
  • Confidential customer information – Personal data or client records should never be entered, as this could lead to privacy violations and legal repercussions.

Many AI platforms allow you to toggle off the use of what you enter for training data, but you shouldn’t trust that as an ultimate failsafe. Think of AI platforms as social media: if you wouldn’t post it, don’t enter it into AI.

Check Before You Use AI At Work

Before integrating AI tools into your workflow, take these critical steps:

  1. Review company AI policies – Many organizations now have policies governing AI use. Check whether your company allows employees to use AI and under what conditions.
  2. See if your company has a private AI platform – Many businesses, especially large corporations, now have internal AI tools that offer greater security and prevent data from being shared with third-party services.
  3. Understand data retention and privacy policies – If you use public AI platforms, review their terms of service to understand how your data is stored and used. Specifically look at their data retention and data use policies.

How To Protect Your Data While Using AI

If you’re going to use AI, use it safely!

  • Stick to secure, company-approved AI tools at work – If your organization provides an internal AI solution, use it instead of public alternatives. If your workplace isn’t there yet, check with your supervisor about what you should do.
  • Think before you click – Treat AI interactions like public forums. Don’t enter information into a chatbot if you wouldn’t share it in a press release or post it on social media.
  • Use vague or generic inputs – Instead of inputting confidential information, use general, nonspecific questions as your prompt.
  • Protect your AI account with strong passwords and MFA – Protect your AI accounts like all your other ones: use a unique, complex, and long password (at least 16 characters). Enable multi-factor authentication (MFA), which will add another solid layer of protection.

Increase your AI IQ

Generative AI is powerful! But you are wise. Use AI intelligently, especially when sensitive data is involved. By being mindful of what you share, following company policies, and prioritizing security, you can benefit from AI without putting your company at risk.

You May Also Be Interested In

Is AI the Right Fit for Your Clinic? Key Considerations Before You Implement

 

 
Medical Secretary Fined for Unauthorized Access And Disclosure to Health Information

Medical Secretary Fined for Unauthorized Access And Disclosure to Health Information

Medical Secretary Fined for Unauthorized Access And Disclosure

Privacy Breach Nugget
Ever wonder how privacy breaches happen—and what you can do to stop them? Privacy Breach Nuggets takes real cases and turns them into practical lessons for privacy officers, clinics, and healthcare practices. Let’s unpack today’s case and explore what went wrong, what worked, and how you can apply these insights to protect patient information.

What Happened

In 2020, a medical secretary working at the University of Alberta Hospital in Edmonton, Alberta, accessed the health information of 17 individuals without any legitimate job-related reason.

The individuals whose information was accessed had personal relationships with the secretary. She went a step further by disclosing sensitive health information about two of them—including infectious disease details—to others who had no reason to know this information.

One of the individuals experienced harassment through text messages as a direct result of this disclosure.

Managing the Breach

The management of the privacy breach can be examined using the 4 Step Response Plan.

unauthorized breach

Step 1 – Spot and Stop

When a privacy incident is suspected, the first priority is to stop the unauthorized access. It would be appropriate to immediately suspend the employee’s access to health information systems like ConnectCare and Netcare.

If you suspect a privacy breach, don’t wait—report it to your Privacy Officer and Custodian right away.

Step 2 – Investigate

Alberta Health Services (AHS) completed an internal investigation including auditing the employee’s system activity.

The investigation assessed the “real risk of significant harm” (RROSH). This case is a stark reminder of how improper access and disclosure of health information can lead to serious harm.

Step 3 – Notify

In Alberta, custodians like physicians and healthcare organizations are legally required to notify:

• The Office of the Information and Privacy Commissioner (OIPC). (See Guide to Reporting Privacy Breaches)
• The Alberta Minister of Health.
• The affected patients whose personal health information was improperly accessed or disclosed.

Additional notifications may include law enforcement, insurers, or other stakeholders depending on the situation.

Step 4 –Prevent the Breach from Happening Again

Proactive prevention is key to prevent breaches like this. Here’s how:

• Conduct regular privacy training to keep privacy awareness top of mind.
• Maintain a privacy incident log to spot trends and address recurring issues.
• Implement and enforce privacy-monitoring practices to detect and deter snooping.

Diane McLeod, Alberta’s Privacy Commissioner, highlighted an “alarming rise” in snooping incidents in health information systems. The OIPC’s 2023-2024 Annual Report revealed 14 potential breaches of the Health Information Act investigated by the Commissioner’s office, with hundreds more reported.

Commissioner’s Investigation

The OIPC has implemented a process to focus on high-priority breaches. Following its investigation, the Commissioner recommended charges under the Health Information Act (HIA).

Court’s Decision

In February 2025, the court sentenced the medical secretary, Kayla Satre, to a $2,000 fine for unauthorized access to health information, violating the HIA.

However, the Crown Attorney withdrew charges related to the unauthorized disclosure of health information.

Take-Aways

Snooping is the unauthorized access to health information. This remains a persistent issue in healthcare. Here’s what you can do:

• Educate and remind your team regularly about the importance of patient privacy.
• Monitor system access proactively to detect and stop unauthorized activity.
• Share real-world examples like this one to drive home the importance of privacy compliance.

Protecting patient information isn’t just about compliance—it’s about trust. Share this example with your team and make privacy a daily priority!

Reference and Resources

Office of the Information and Privacy Commissioner of Alberta. Former Alberta Health Services employee fined for unauthorized disclosure of health information, February 6, 2025. https://oipc.ab.ca/former-alberta-health-services-employee-fined-for-unauthorized-disclosure-of-health-information/

You May Also Be Interested In

3rd Largest Fine Ever Under the HIA – Blog post on the unauthorized use of health information that led to costly fines
Practical Privacy Officer Strategies – Training for clinic manages and privacy officers includes how to respond to a privacy breach and prevention strategies.
Tips to Prevent Employee Snooping – A Key Component of Your Privacy Practice Management Program: A Hands-On Guide to Protect Your Healthcare Practice from Privacy Beaches
3 Parts to Every Privacy Awareness Training Plan

3 Parts to Every Privacy Awareness Training Plan

Reasonable Safeguards – the Myth

You may have heard the myth that the Health Information Act (HIA) is a big scary thing that will interrupt your routine, rob you of countless billable hours, impact all of your staff, turn your office inside out, and change the way that you run your entire business!

Myth Buster

The HIA provides structure and framework for reasonable safeguards that apply to any healthcare business.

One of the requirements of reasonable safeguards includes having a privacy awareness training plan.

Click the >> arrow to play the video

Privacy Awareness Training

Your Privacy Awareness Training Plan should include learning objectives throughout the year, including

  • Orientation – Standardized training curriculum provided to everyone in you healthcare practice at the time of employment. This is often included during a new employee’s orientation period.
  • Specific – Privacy training that is more detailed and specific to the roles and responsibilities of that individual’s job in your healthcare practice. There may also be specific training when new software, technology, or procedures are introduced anytime throughout the employment.
  • Reward – Keep privacy awareness top of mind all year long. Recognize and reward when individuals follow privacy principles that also add value to your client satisfaction or business efficiency.

It is reasonable to expect regular privacy awareness training, especially at orientation, and a formal review annually.

What a Privacy Awareness Training Plan Can Do For You

When you implement regular privacy awareness training, you will see:

  • Privacy and security expectations clearly communicated among your team.
  • Team members demonstrate their commitment to privacy, confidentiality, security of personal health information.
  • Efficient practices that protect the privacy and save you time and money
  • Team members confidently and correctly handle personal health information using reasonable safeguards

Are You a Myth-Buster?

You can be a myth-buster, too, and implement privacy awareness training in your healthcare practice.

You can easily implement reasonable safeguards and meet HIA requirements to ensure privacy, confidentiality, and security of health information that saves you time, frustration and money.

If you need a little help, I have written a practical privacy awareness training course designed for the community health care practice. This is ideal for orientation of new employees and a refresher for the rest of us.

Privacy Awareness in Healthcare: Essentials

Understand basic health care privacy principles and how to handle personal information, use safeguards, and recognize and report a privacy breach.

Ideal for community-based health care professionals and staff, direct care providers, or anyone working with a health care, dental, or social services organization.

An effective privacy compliance program promotes organizational adherence to the Health Information Act (HIA), Personal Information Protection Act (PIPA) Alberta, Personal Health Information Protection Act (PHIPA) Ontario and the Personal Information Protection of Electronic Documents Act (PIPEDA) requirements. A compliance program is your first line of defense to promote the prevention of criminal conduct, and enforce government rules and regulations, while providing quality care to patients. All three training products help protect practices against privacy and security breaches, improper payments, fraud and abuse, and other potential liability areas through education.

Canadian Health Care Privacy Training Solutions

Corridor’s online training makes it easy for health care organizations to comply with provincial and federal legislation that mandates regular privacy training for all health care providers, staff, and vendors.

Select the training that best fits your needs:

NEW! Privacy Awareness in Healthcare Training: Dental Practices – Alberta

Dentists and dental practices in Alberta are required to have an ongoing privacy program to ensure the protection of private records and patient information. The appropriate collection, use, and disclosure of personal information is critical to maintaining privacy for patients that choose to trust in your practice. Accomplishing this important goal demands an up-to-date training strategy.

Privacy Awareness in Health Care Training – Canada

Includes detailed resources for each province and territory with key terminology and links to applicable privacy legislation. Resources are provided for our ten provinces: Alberta, British Columbia, Manitoba, New Brunswick, Newfoundland & Labrador, Nova Scotia, Ontario, Prince Edward Island, Quebec, Saskatchewan, and three territories: Northwest Territories, Nunavut and Yukon. This new product is ideal for both organizations and vendors who provide health care services or have health care clients in more than one province.

Privacy Awareness in Health Care Training – Alberta 

Includes the mandatory privacy breach notification amendments to the Health Information Act (HIA).

Privacy Awareness in Health Care Training – Ontario

Specifically covers all legislation and rules specific to the province of Ontario including the Personal Health Information Protection Act (PHIPA).

Refresher: Privacy Awareness in Health Care – Alberta

A quiz-based review of Corridor’s full Privacy Awareness course. The Refresher starts with an initial quiz to assess knowledge on the topics and information covered in the full course. Based on the quiz results, one or more of eight Refresher topic quizzes must be completed, each focusing on a specific subject area. The Refresher also includes access to the original course content.

 

Privacy Awareness in Healthcare: Essentials

Grab your on-line course from Information Managers and Corridor Interactive

for just $30 per individual 3 month subscription now!

Click Here to Grab Your On-Line Privacy Awareness Course Now!