ADMINISTRATIVE MANUAL

Issued by

PRIVACY OFFICER DIRECTOR, PROFESSIONAL PRACTICE CHIEF OF STAFF PERFORMANCE IMPROVEMENT COMMITTEE MEDICAL ADVISORY COMMITTEE

Number

Approved by Category

: :

Date
For Review

: : :

September 2006

Subject Background

OBSERVER STATUS

Toronto East General Hospital (TEGH) is committed to protecting the privacy, confidentiality and security of patients personal health information. Under the Personal Health Information Protection Act (PHIPA) a health information custodian must obtain the express consent of the patient to collect, use or disclosure their personal health information to anyone who is not directly involved in the care of the patient anyone outside the patients circle of care, except in certain circumstances (i.e. permitted or required by law). Policy Observer status applies to physicians or allied health professionals wishing to accompany a member of the active medical or professional staff at Toronto East General Hospital (TEGH), purely to observe that clinicians practice and with the clear understanding that the observer is not involved with direct patient interaction. Vendors may accompany a member of the active medical or professional staff at TEGH, purely to observe that clinicians practice or to provide technical support. Individuals requesting observer status that are not vendors, regulated health care providers or currently enrolled in a clinical program or under graduate program leading to a clinical program will not be accommodated. The express consent of the patient is required prior to the observer being present with the patient and the consent must be documented in the patients personal health record. Scope This policy applied to all agents of TEGH including staff, physicians and persons who have contracts with the hospital. Definitions Health Information Custodian: As part of their role, any person or organization that has custody or control of other peoples personal health information. Express Consent: Express consent is obtained when patients explicitly agree to the collection, use and disclosure of their personal health information. Express consent can be given in writing, orally, by telephone or electronically. 1

ADMINISTRATIVE MANUAL

Issued by

PRIVACY OFFICER DIRECTOR, PROFESSIONAL PRACTICE CHIEF OF STAFF PERFORMANCE IMPROVEMENT COMMITTEE MEDICAL ADVISORY COMMITTEE

Number

Approved by Category

: :

Date
For Review

: : :

September 2006

Subject

OBSERVER STATUS

Personal Health Information: Information related to the physical and mental health of the individual and their family; includes provision of care, plans of service, payments, eligibility for health care, health care number, donation of body part/substance and the name of the persons health care provider or substitute Decision Maker. Circle of Care: Refers to those in the health care team who are actually involved in the care or treatment of a particular patient. Procedure The observer shall have a clearly designated member of the active medical or professional staff acting as their sponsor and with whom they will be constantly accompanied. The sponsor must request written approval (see Request for Observer Status form) from the Chief of the department or the manager of professional practice, allowing the observers presence on site and will stipulate the areas of the hospital in which the observation will occur. Consultation with the affect unit manager(s) must occur as part of the signing process. The observer will require a photo I.D. badge. A copy of the form will be sent to all affected units. For vendors, the sponsor is required to inform the affected manager or delegate that vendor observation is required and provide the vendors contact information. The manager or delegate will ensure that the Request for Observer Status form is completed. Only the observer and the manager/delegate are required to sign the authorization section (Part C) of the request form. The sponsor is responsible in ascertaining that the observer has appropriate credentials and is fully responsible for the conduct of the observer while at the hospital. The sponsor will inform patients of the observers status and patients have the right to refuse examination or treatment with the observer present. The sponsor will introduce the observer to all hospital personnel with whom they will have contact and ensure that the role of observer is clearly stipulated. The sponsor is responsible for ensuring that the observer has reviewed the hospitals privacy policy Privacy and Confidentiality of Patients Personal Health Information and signed the TEGH confidentiality agreement, prior to beginning their observation. The signed confidentiality agreement along with the copy of the request form will be kept in a designated area on the affect units(s). The agreements will be kept on file for the duration of the request. 2