Build a Strong Privacy Management Program for Your Clinic With These 5 Critical Modules

Many privacy officers in small healthcare practices have other roles—as a clinic manager, healthcare provider, computer network technician, or business owner. It is little wonder that new privacy officers can feel overwhelmed when trying to balance these responsibilities every day.

But that’s not the end of the problem. It actually gets worse!

You could continue to –

Panic when a patient asks for their information for access or correction.

Scramble when new employees and healthcare providers join your clinic . . .and suddenly realize that you never got around to providing privacy and cybersecurity awareness training.

Hope that your practice will not be tapped on the shoulder for a practice review by your college or the OIPC.

Ignore privacy breach and hope no one else notices.

Avoid difficult decisions with your owners / staff who insist on doing things their way – even when it is not privacy compliant.

Never get ‘review privacy impact assessment’ and ‘review privacy policies and procedures’ off of your to-do list.

Avoid discussing privacy and security with your EMR and computer networks managed service providers because you are unsure of what questions to ask and what types of answers you should receive.

If you don’t have a written privacy management program and action plan, you are missing the systems to monitor routine tasks that will protect privacy and alert you to potential problems before they become privacy and security incidents.

Carrying out the duties of a Privacy Officer correctly is vital to ensure your organization is safe from the consequences of a big privacy breach.

But did you know that those organizations who have a privacy officer and a privacy management program are:

• Less likely to have a privacy or security incident
• Increased staff satisfaction
• Increased patient satisfaction and outcomes

We Know That Privacy Is Good For Business

​We know that having policies, procedures, and systems in place will improve your privacy compliance in your organization and help you make good business decision.

When we have consistent practices in place, it improves communication and prevents a multitude of problems.

I’d like to share with you what I believe are the 5 critical modules of a privacy management program

The 5 Modules of a Strong Privacy Management Program for Your Clinic includes

1. Know Your Obligations
2. Train
3. Privacy Breach Management
4. Document
5. Access and Disclosure

We expect organizations which collect, use, or disclose health information to have key components of a privacy accountability program. These include:

Every healthcare and private organization that is subject to privacy laws must comply with them. A comprehensive privacy management program provides an effective way for organizations to create a culture of privacy in their practice, practice accountability for the collection, use, disclosure, and access of personal information, and show compliance with regulations.

Module 1—Know your Obligations

​Key accountability for your privacy management program starts with your healthcare provider(s). These are also known as “custodians”. They are ultimately responsible for the privacy, confidentiality and security of personal health information (PHI).

The key healthcare provider—physician, dentist, chiropractor, nurse—can assign or delegate a key person who is accountable to the custodian to implement and monitor a privacy management program. This is often known as a privacy officer. In many smaller healthcare practices, the clinic manager or practice manager is also the privacy officer.

The business owner (who might also be the healthcare provider) also has obligations to follow the privacy laws as it relates to the privacy of personal information of employee, customers, and general business information.

The healthcare provider, business owner, and privacy officer form a ‘trifecta’ of authority and responsibility in your practice to ensure that you comply with privacy legislation, professional standards of practice, and contractual commitments.

Knowing your obligations includes clear authority and accountability in your practice, inventory of identifying information that you have in your practice, and understanding how privacy legislation guides your business. Your privacy officer and custodians may require training in these areas to better understand their obligations.

Module 2—Training for Privacy Awareness

​Training is an important component of your privacy management program. The privacy officer in your organization ensures that privacy awareness, cybersecurity, and privacy breach management are provided in your healthcare practice.

There should be both a formal and an informal training plan. A pre-planned privacy awareness training must be available for everyone in your organization, including new and seasoned professionals. It is critical that you can provide and document that everyone in your organization completed consistent common training.

We can provide informal training throughout the year. For example, have a standing agenda item during your staff meeting to do something consistently for everyone in the organization throughout the year. Leverage activities like Data Privacy Day, Change Your Password Month, Cybersecurity Awareness Week to provide a variety of content.

A frequently missed trigger for additional training happens when an employee is promoted to a new position. This is a great opportunity for the privacy officer to meet with the employee and discuss their new role and how their responsibility, for example, of authorizing new users or supervising employees contributes to the confidentiality and security of PHI.

Remember to document who attended the training opportunities and keep copies of the training content to show your actions to protect privacy.

Listen to the podcast How To Keep Privacy Awareness Top Of Mind | Episode #093 for more tips and resources to help you plan training throughout the year.

Module 3 – Effective Privacy Breach Management

​Ensure that a written privacy breach management procedure is part of your overall privacy management program. The privacy officer will document your privacy breach management policies and procedures, sanctions policies and procedures, and train all employees to identify a privacy breach and report it to their supervisor. The privacy officer will manage a (suspected) privacy breach and ensure notification to their custodians, individuals affected by the breach, and others as needed.

The privacy officer will manage mandatory privacy breach notification requirements under the health privacy legislation like the Alberta Health Information Act (HIA), Ontario Personal Health and Information Protection Act (PHIPA) and the Personal Information Protection of Electronic Documents Act (PIPEDA) and other province’s legislation.

See Understanding a Privacy Breach for more tips.

Module 4—Documentation: The Backbone of Privacy Compliance

​I think most people in healthcare are familiar with the adage, “If it is not documented, it didn’t happen.” This applies to your privacy management program, too. Your program should include written:

• Health Information Privacy and Security Policies, Procedures
• Risk Assessment – Safeguards
• Practical Privacy Review
• Privacy Impact Assessment
• Information Management Agreement
• Information Sharing Agreement
• Successor Custodian
• Training plan

These actions will help you protect the PHI of your patients and your business. They help to demonstrate your compliance with your privacy and security obligations. Review and update these key documents annually.

See Privacy Impact Assessment for more tips.

Module 5 – Access and Disclosure: Ensuring Patient Rights

​When you collect PHI from patients and PI from employees and customers, you must ensure that they can access, correct, and authorize disclosure of their information.

Release of information (ROI) policies and procedures is a critical module of your privacy management program. Your privacy officer is tasked with ensuring that your ROI plan is written, understood, includes specific training to your employees, and follows legislated standards and professional college standards of practice. When you meet your ROI obligations, you avoid complaints and breaches, work efficiently, and improve the trust of your patients.

Struggling to Learn Your Role As A Privacy Officer On Your Own?

If you are a privacy officer in a healthcare practice who needs practical privacy management strategies to protect your patients and your healthcare business but aren’t sure how to get started, register for the Practical Privacy Officer Strategies training here.

The training starts on Feb 27, 2025.

Not sure if this is for you?

Send me an email and ask me! I’m happy to mentor you and help you assess your practice management and privacy compliance priorities.