Hôpital Montfort Records Management and Archives Needs Analysis

Christine Newman, Kelly Sirett, Arouce Wasty, and Versna Zaremba

Wednesday, February 26, 2014

ISI 6521 : Gestion des Documents

Table of Contents

Introduction ................................................................................................................................... 1

0.1 Context of Records Management in Hospitals ..................................................................... 1

0.2 Objectives of the Analysis .................................................................................................... 2

0.3 Methodology Used for Analysis ........................................................................................... 2

0.4 Report Plan ............................................................................................................................ 2

1.0 Preliminary Investigation Report .......................................................................................... 3

1.1 Activities Performed by the Organization and Scope of Analysis........................................ 3

1.2 Structure and Size of the Organization ................................................................................. 3

1. 3 Applicable Laws and Regulations........................................................................................ 5

1.4 Business Risks Arising from Applicable Laws and Regulations .......................................... 6

1.5 Current Technological Environment ..................................................................................... 7

1.6 Strengths and Weaknesses of Current Records Management Strategy ................................ 8

1.7 Importance of Information Management and Archives in the Organization ........................ 9

1.8 Motivation for Records Management ................................................................................. 10

2.0 Functional Analysis ............................................................................................................... 11

2.1 List of Documents ............................................................................................................... 11

2.2 High Level Functions and Descriptions .............................................................................. 11

3.0 Strategy for Integrated Records and Archives Management ........................................... 13

3.1 Identification of the Requirements of Records Management and Archives ....................... 13

3. 2 Synthesis of the Organization’s Records Management and Archive Needs ...................... 16

3.3 Tools to be developed for the Organization ........................................................................ 17

3.4 Action Plan .......................................................................................................................... 17

Conclusion ................................................................................................................................... 19

Bibliography ................................................................................................................................ 21

Appendices ................................................................................................................................... 23

Appendix 1: Ontario’s Health Statutory Context .................................................................... 23

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Introduction

0.1 Context of Records Management in Hospitals

Records and the information they contain are valuable assets to any organization and

Hôpital Montfort is no exception. Good medical care relies on well-trained doctors and nurses

and on high-quality facilities and equipment. Good medical care also relies on good record

keeping. This ensures that health care institutions maintain control of their administrative records

and that the primary records of hospital patients are not lost. It also ensures that unneeded

records are transferred or destroyed regularly and that storage areas are clear and accessible.

Important records can then be found quickly, saving time and resources. Records also provide

evidence of the hospital’s accountability for its actions and they form a key source of data for

medical research, statistical reports and health information systems. However, many hospitals

face the challenge of records being in more than one place or in duplicate forms. Unfortunately,

this decentralization of records management often leads to poorly designed filing systems, loss of

information, premature destruction or unnecessary retention of records and ultimately to

inefficiency and wasted resources.

The two major types of hospital records are patient (also known as medical records) and

administrative records. Patient records are usually very well organized because they are normally

under the control of staff that possesses formal training in managing patient information such as

the patient chart. The retention periods for these records are usually legislated, meaning that they

can be disposed of, in whole or in part, on a regular basis. The primary use of these records is to

facilitate the immediate treatment of the patient, but they may also be used in the continuing care

of the patient. The administrative records in a hospital do not usually receive the same care and

attention as patient information. These records contain such items as the minutes of the Board of

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Directors or Trustees, annual reports, financial records and personnel records of hospital

employees. Some of these records may be used in budget preparation and for litigation purposes.

Administrative records are also valuable because they are often the basis for a history of the

hospital’s origins, activities, and culture.

0.2 Objectives of the Analysis

The following report will provide an analysis of the records management system currently

used by Hôpital Montfort to manage their administrative records. It will look at the strengths and

weaknesses of the current records management system. The objective of this analysis is to create

a Records Management Policy which will ensure the following:

Development of a corporate strategy so that corporate records, in whatever medium, are

appropriately managed and available, to support day-to-day business operations;

Analysis of the hospital’s risks regarding administrative records management to ensure

compliance with all regulatory and statutory requirements by the province of Ontario;

Analysis of business processes to facilitate better records management;

Improvement of the quality, relevance, and organization of records required for the

operation of each administrative unit in the health care institution.

0.3 Methodology Used for Analysis

The methodology used for this analysis was a descriptive qualitative study including

interviews, evaluations and observations of employees and managers at Hôpital Montfort. There

was an interview with an archivist in charge of the administrative archives, a visit and interview

of other upper management at Hôpital Montfort and a review of the organization chart and other

documents pertaining to the organization’s record management processes.

0.4 Report Plan

This report will provide an overall description of Hôpital Montfort and analyze the

current status and procedures of its management of administrative records. Since hospitals in

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Ontario are subject to provincial laws, the report will review the legislation and regulatory

requirements that affect the hospital’s day to day activities regarding records management. A

description of the functions and activities of the organization at the high level will also be

analyzed. And, finally, this report will outline potential future strategies and tools needed for the

hospital to have a better records management system for its administrative records.

1.0 Preliminary Investigation Report

1.1 Activities Performed by the Organization and Scope of Analysis

Hôpital Montfort is a bilingual teaching hospital located in the east end of Ottawa, and is

the only francophone hospital west of Quebec. The hospital’s main functions include:

1) Providing health care services to its patients in both official languages;

2) Providing quality education in French to medical, nursing and health sciences students, as

well as continuous professional development to the hospital’s health professionals

3) Conduct and disseminate research that will improve the well-being of the community,

especially the Francophone community (Institut de Recherche de l’Hôpital Montfort,

2014).

Underlying these major functions are the various administrative, day-to-day activities that

enables the hospital to perform the above-mentioned functions. This analysis will focus on the

records management activities in Hôpital Montfort, with particular attention to the management

of administrative records.

1.2 Structure and Size of the Organization

The hospital consists of over 1600 employees, over 300 physicians and teaches over 1000

medical residents and health sciences students from various education institutions such as the

University of Ottawa and La Cité Collégiale. The mission of the hospital is to provide patient

care in both official languages in order to improve the well-being of its community, and hospital

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staff aim to reflect the values of compassion, excellence, commitment and respect in their

activities.

The hospital comprises of 12 medical departments and over 60 clinical programs and

services for its patients, including Mental Health Services and a Family Birthing Centre. Hôpital

Montfort is governed by the Montfort Board of Trustees and the Hôpital Montfort Association.

Upper management is headed by a CEO, followed by 6 departmental vice-presidents and a Chief

Medical Officer (Figure 1).

The hospital’s administrative activities, such as recruitment, accounting, and day-to-day

administration, are managed by the Human Resources, Finances, Organizational Quality &

Performance, and Planning & Support Services departments. The University Affairs department

is responsible for planning and providing medical teaching to medical residents and health

sciences students, and professional development to physicians and other health professionals

working in the hospital. The department is also responsible for research conducted at Hôpital

Montfort through the Institut de Recherche de l’Hôpital Montfort (IRHM). The IRHM aims to

support researchers throughout the research process, provide aid with acquiring research funding

and grants, and ensure that research activities are conducted in a responsible manner (IRHM

Organization, Hôpital Montfort Website, 2014).

The Chief Medical Officer supervises the specialized medical departments- namely

Anesthesiology, Medical Biology, Surgery, Medicine, Family Medicine, Obstetrics &

Gynecology, Orthopedics, Mental Health & Psychiatry, Radiology, Ophthalmology, Emergency

Medicine, and Pediatrics. Though the workplace language is French, nearly all staff can provide

services in both official languages.

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Funding for the hospital is provided by the Ministry of Health and Long-Term Care of

Ontario, and through donations and events organized by the Foundation of l’Hôpital Montfort.

The Foundation is a non-profit organization headed by an administrative council. Its aim is to

support Hôpital Montfort financially, thereby allowing the hospital to fulfill its mission.

1. 3 Applicable Laws and Regulations

Hôpital Montfort is legislatively bound by a number of federal and provincial laws. Given

the purpose and scope of this report, we have chosen to focus on the laws that relate most

directly to records and information management. For a more exhaustive listing of the legislation

Hôpital Montfort must adhere to, refer to Appendix 1 Ontario’s Health Statutory Context.

Personal Health Information Protection Act (PHIPA), 2004

Ontario’s health specific privacy legislation, PHIPA, came into effect on November 1,

2004. This legislation sets out the rules that health information custodians (eg. hospitals)

and healthcare providers (eg. doctors, nurses, etc.) must follow when collecting, using

CEO

VP Human Resources

VP Finances

VP University Affairs

VP Organizational Quality

& Performance

VP Planning & Support

Services

VP Clinical Programs

Chief Medical Officer

Montfort Hospital

Foundation

Institut de Recherche de l’Hôpital

Montfort (IRHM)

Figure 1: Organizational chart of Hôpital Montfort's upper management and

including the Foundation of l’Hôpital Montfort, and IRHM.

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and disclosing personal health information. This Act has been deemed to be substantially

similar to Canada’s federal privacy legislation, the Personal Information Protection and

Electronic Documents Act (PIPEDA) in regards to health care

(http://www.priv.gc.ca/leg_c/legislation/ss_index_e.asp).

Personal Information Protection and Electronic Documents Act (PIPEDA) (S.C.

2000, c. 5).

PIPEDA concerns legislation for how private sector organizations may collect, use or

disclose personal information in the course of commercial activities.

Freedom of Information and Protection of Privacy Act (FIPPA)

FIPPA is provincial legislation designed to allow the public access to information held by

publicly-funded institutions.

Public Hospitals Act

The provincial Public Hospitals Act and its regulations set out the framework for the

operation of hospitals in Ontario.

Refer to the bibliography for the above-mentioned laws in their entirety.

1.4 Business Risks Arising from Applicable Laws and Regulations

There are a number of business risks that Hôpital Montfort is susceptible to if they do not

adhere to the laws outlined above. Again, given the purpose and scope of this report, we have

chosen to focus on the risks that relate most directly to records and information management.

The table below outlines five business risks for the hospital based on laws and regulations.

Legal action Parties may take legal action against Hôpital Montfort if they do not follow the

legislation under these laws. This will result in high legal costs and potentially

even greater costs if they lose and are required to pay a settlement. Costs may

also be incurred if Hôpital Montfort is required to improve their operations

based on the outcome of trial.

Disputes with

employees and unions

& potential strike

action

If Hôpital Montfort does not adhere to the laws related to labour, disputes with

employees and unions will certainly occur. These risk the operations of

Hôpital Montfort greatly, since these types of disputes not only have financial

effects, but can also harm the organization’s reputation, cause long-term rifts

between employees and the organization, and prevent the hospital’s ability to

deliver its services.

Loss of Accreditation Hôpital Montfort is one of many hospitals and other health care providers in

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from Accreditation

Canada

Ontario who are accredited by Accreditation Canada. In order to remain

accredited, Hôpital Montfort must follow not only the guidelines outlined by

Accreditation Canada, but must also adhere to applicable laws and regulations.

Loss of highly sensitive

information

If Hôpital Montfort does not follow the legislation and regulations related to

the laws outlined above, then the organization puts highly sensitive

information in jeopardy. This information includes not only patient files and

medical records, but also sensitive information related to human resources

(such as employee social insurance numbers) and finance (for example, credit

card numbers).

Threat to Hôpital

Montfort’s reputation

and the loss of public’s

trust

All of the risks outlined above also relate to one final business risk – the loss

of the public’s trust and threat to Hôpital Montfort’s reputation. The trust of

the public is crucial for most organizations, but especially those that provide

healthcare. If Hôpital Montfort were to incur any of the risks outlined above,

the hospital’s reputation would be harmed and the hospital may lose the

public’s trust. This trust includes not only patients, but also the organization’s

employees and partners, future employees, other hospitals and other health

care providers. This negative reputation and loss of trust would certainly affect

the hospital’s ability to perform its mission.

1.5 Current Technological Environment

During our investigation period, an interview with senior management at Hôpital

Montfort highlighted three challenges the hospital faces in the implementation of new IT systems

and tools: first, the resistance to change by staff, second is that there is very little “buy-in” by

senior management, and thereby no champions to ensure compliance among staff, and lastly,

there is not enough time for staff to manage their information while maintaining their

employment duties.

Hôpital Montfort has implemented the use of Microsoft© Office SharePoint© within the

administration at large for the past few years. SharePoint© is designed specifically to manage

documents, share information, and facilitate communication and collaboration (SharePoint 2013

Overview). Hôpital Montfort’s senior management revealed that the tool has been well received;

however, SharePoint© is not being used to its fullest potential. The hospital uses SharePoint© as

an internal collaboration tool but has no standards, guidelines or procedures to ensure that the

information is organized. From an information professional viewpoint, the hospital is lacking an

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information architecture to structure the documents. Additionally, managers use smartphones for

correspondence but all the information is transitory.

In regards to patient records, there is an information system call Meditech, which is a

medical software solution that manages the electronic patient records. Meditech serves as the

central information repository, which enables health care providers to track a patient's medical

records and monitor ongoing treatment.

1.6 Strengths and Weaknesses of Current Records Management Strategy

Below is a SWOT analysis outlining the strengths, weaknesses, opportunities and threats

related to Hôpital Montfort’s current strategy for records management and archives.

Strengths Weaknesses

Patient records management systems are well-

established and very well organized within the

medical records management department; this

means that a potential model for administrative

records management currently exists within the

organization.

Expertise is available within the organization

(from patient records management department)

Effective records management policies exist for

patient records; again, these could potentially

be transferred or used as a basis for

administrative records management.

There is no clear lead/person responsible for

administrative records management.

Administrative records management functions

and responsibilities operate in silos; this means

that knowledge, expertise, and strategies are

not shared within the organization.

Administrative records management policies

are not clear, nor are they being applied by all

those performing administrative records

management.

The physical infrastructure for administrative

records management is lacking and therefore

records are vulnerable to environmental threats.

Opportunities Threats

Opportunity to review and improve current

administrative records and information

management practices and policies.

Opportunity to transfer knowledge and

expertise (before employees with this

experience retire/leave)

Opportunity for employees (those who are

newer to Hôpital Montfort and those who are

older) to collaborate.

Mentorship opportunities between employees

across departments.

Hôpital Montfort recently launched

SharePoint© as a collaboration tool for

employees. This project was very successful

and employees felt empowered by this system.

Hôpital Montfort management is not aware,

and therefore not convinced of the risks

associated with current administrative records

management.

Natural disasters, like flooding, are a serious

and existing threat.

With the current situation in administrative

records management, if there was an Access to

Information request or an audit of

administrative records (like the ones performed

within the patient records management

department for the hospital’s accreditation), it

is not clear whether or not the hospital could

complete it or respond to these requests in a

timely way.

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The success of this project may prove to be a

launching pad for a collaborative

administrative records and information

management system.

Hôpital Montfort employees are very busy

performing their duties.

Potential high financial costs of implementing

a records and information management system

Hôpital Montfort is a publicly funded

organization and therefore operates with

committees and other bureaucratic systems,

which tend to slow the implementation of

projects and processes.

1.7 Importance of Information Management and Archives in the Organization

Administrative records management is important to hospital administration as it ensures

that records of administrative, legal, fiscal, and evidential value are retained. Records provide

information for managers to improve the organization of administrative files contributing to

operational efficiency. A comprehensive records management system will ensure that hospital

staff has access both to clinical information and administrative records on a wide range of

issues, including policy, precedents, legal rights and obligations, personnel, finance, buildings,

equipment and resources. In addition to controlling records required for current business, the

system will ensure that the hospital can meet its legal and financial obligations and can defend its

actions when necessary. Records are vital to virtually every aspect of the governance process.

Hôpital Montfort’s strategic plan for 2011-2015 emphasized five goals the organization aims to

achieve:

1) Continuous improvement of quality of care and optimal performance of clinical services

2) Improving organizational performance

3) Promoting a healthy work environment

4) Developing the hospital’s academic identity

5) Reinforcing relationships with partners and communities

(translated liberally from Plan stratégique 2011 – 15 – Hôpital Montfort, 2011)

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Under strategic goal number two, one of the outcomes indicated by the organization is to

have in place “integrated information management systems that respond to our needs” (translated

from Plan stratégique 2011 – 15 – Hôpital Montfort, 2011, p. 2). The organization already has in

place a clinical archive responsible for the retention and management of patient records. The

clinical archives also act as a quality control measure to ensure that patient records contain all the

necessary documentation and authentication as required by legislation. The archives contain over

170 000 patient files with the active files stored within the archives, and semi-active and inactive

files housed in third-party storage. The clinical archives are managed under the Organizational

Quality and Performance department, has approximately 25 employees, and is supervised by the

Privacy Officer.

Administrative records are currently managed by the administrative assistants within the

various administrative departments, each in their own fashion. For instance, the Department of

University Affairs has prepared a nomenclature for labeling their records. The administrative

records consist of semi-active and inactive records, and are presently packed into boxes and

deposited into the hospital basement. Recently, a historical archivist has been hired to manage

the hospital’s administrative records which contain historical value. These records permit the

historian to explore the origins, operation, and legacy of the health care institution.

1.8 Motivation for Records Management

In addition to the legislative requirements outlined in part 1.4 of this report and the

business risks described in part 1.5, establishing a strong administrative records management

system is fundamental for the hospital’s productivity. Measures of productivity include:

providing quality patient care; ensuring satisfaction of employees, efficiency of business

operations, fiscal accountability; and innovation. All of these measures provide motivation for

hospital management to implement an effective administrative records management system.

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2.0 Functional Analysis

2.1 List of Documents

The documents below were used to highlight the high level functions and business processes

of Hôpital Montfort illustrated in section 2.2:

Organizational chart

Interview with upper management of Hôpital Montfort

Hôpital Montfort’s website - www.hopitalmontfort.com

o Directory of records and personal information bank

o About Hôpital Montfort

o About the foundation

o Research section

o Education section

2.2 High Level Functions and Descriptions

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3.0 Strategy for Integrated Records and Archives Management

3.1 Identification of the Requirements of Records Management and Archives

An integrated records and archives management system improves the quality, availability

and effective use of records. It provides a strategic framework for all records management

activities that enables better coordination between departments and ensures that these activities

are in alignment with the hospital’s mandate and goals. However, before a records management

system can be put in place the requirements of the system must be identified. Below is a table

detailing the requirements and standards related to records management as well as the risks

associated with if the organization is non-compliant.

Table 1: Requirements for records management as outlined by applicable laws and standards, and

potential risks resulting from lack of compliance to these requirements.

1 Requirement: Classification scheme based on business activities, including the development of

controlled vocabulary and/or thesauri reflecting the terminology used in each business function.

According to: ISO 15489

Risk(s) if non-compliant:

Unable to retrieve information documenting business processes, upon request. This can lead

to loss of accountability of the organization’s actions, potential loss of information, and

negatively impact audits and accreditation of the organization.

Affect compliance to the Freedom of Information and Protection of Privacy Act.

2 Requirement: Records disposition authority defining what records to keep and their retention

periods according to laws and regulations

According to: ISO 15489

Risk(s) if non-compliant:

Lack of conformity to laws and regulations applicable to the department that created the

document (e.g. Human Resources, Finance, etc.).

Overload of information reducing the ability to find and retrieve documents upon request,

for auditing, accreditation, etc.

Non-compliance with Archives and Recordkeeping Act, 2006

3 Requirement: The patients’ personal health information must be retained, stored, transferred and

disposed of in a reasonably secure manner.

According to: Ontario Health Association Toolkit

Risk(s) if non-compliant:

Incompliance with Public Hospitals Act.

Breach of privacy laws

Legal action against the organization.

4 Requirement: Security and access classification scheme which categorizes records according to the

level of access restriction and identifies the level of employee access privileges for each category of

records.

According to: ISO 15489

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Risk(s) if non-compliant:

Possibility of unauthorized access to restricted records that can be used in a negative

manner, i.e. defamation of organization or an employee of the organization, etc.

Loss of records due to unauthorized access and/or inability to trace the handling and

circulation of record.

Breach of privacy laws such as the Personal Information Protection and Electronic

Documents Act.

5 Requirement: Development of a security policy that commits the organization to appropriate

security measures and provides high-level direction on the implementation of these measures.

According to: Ontario Hospital Association Toolkit

Risk(s) if not compliant:

Upper management is responsible for the security policy. Without a clear policy, lower level

management and employees are not trained to manage information properly and in a secure

manner.

6 Requirement: Develop an appropriate set of security standards and procedures based on the

hospital’s security policy. These standards should take into account hospital’s physical (filing

cabinets, restricted office, access, alarm systems); technological (passwords, encryption, firewalls)

and administrative controls (security clearances, access restrictions, staff training, confidentiality

agreements).

According to: Ontario Hospital Association Toolkit

Risk(s) if non-compliant:

Inappropriate physical or technological security infrastructure can increase the likelihood of

unauthorized access to private records, in person, or by electronic means (i.e. hacking, etc.).

Theft and possible misuse of records.

Lack of compliance to ISO 15489 – Requirement of Security and Access Classification

Scheme.

7 Requirement: Records management policy adopted and endorsed at the highest decision-making

level and promoted throughout the organization.

According to: ISO 15489

Risk(s) if non-compliant:

No standardization in records management practices in the organization.

Lack of awareness of records management best practices in the organization, and its

association with laws and regulations affecting the organization.

8 Requirement: Appropriate storage conditions for records

According to: ISO 15489

Risk(s) if non-compliant:

Loss of records or integrity of records due to environmental damage.

Impact on health of employee working in storage environment (i.e. presence of mold,

inadequate ventilation, etc.)

Loss of accessibility to electronic records due to obsolescence of technology or unreadable

file formats.

9 Requirement: Assign a records management lead.

According to: ISO 15489

Risk(s) if non-compliant:

No point of contact for employees within the organization or for third-parties including

accreditation organizations, partners, stakeholder etc.

No one accountable for records management practices.

10 Requirement: Develop and implement a reliable records management system.

According to: ISO 15489

Risk(s) if non-compliant:

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Loss of integrity of records.

Inability to carry out records management processes outlined in policies and procedures.

Inability to preserve records for the length of their retention period.

11 Requirement: Monitoring and evaluation of records management processes.

According to: ISO 15489

Risk(s) if non-compliant:

Mistakes committed in any part of the process will not be identified and can lead to future

problems such as inability to provide appropriate evidence in legal matters, inability to

account for business activities and transactions, etc.

Loss of records or integrity of records.

Inability to account for new business activities if current processes are not evaluated.

12 Requirement: Retention of documentation fulfilling quality management system requirements.

According to: ISO 9000

Risk(s) if non-compliant:

Unable to retrieve records necessary for a quality management system audit.

13 Requirement: Establish a risk management framework, including management policy, objectives,

mandate, and commitment as well as accountabilities, resources, processes, and activities, that

supports and sustains risk management throughout the hospital.

According to: ISO 31000

Risk(s) if non-compliant:

The risk assessment framework needs to operate at the management level otherwise, if there

is no buy-in at the upper management level, the rest of the organization’s staff will consider

risk management unimportant.

Risks affecting organizations can have consequences in terms of economic performance,

professional reputation, and legal implications.

14 Requirement: Carry out a risk assessment process of the organization that identifies, analyzes,

evaluates and treats the risk. The risk assessment process should also be monitored and reviewed.

According to: ISO 31000

Risk(s) if non-compliant:

Organization will be unable to identify the specific risks that are associated with the

mismanagement of administrative records.

Vulnerability to litigation and inability to meet accreditation requirements.

15 Requirement: A record of risk management activities should be maintained.

According to: ISO 31000

Risk(s) if non-compliant:

Inability to produce evidence proving that organization is making efforts to manage their

risks.

Lack of support for risk management process leading to poor decision-making regarding

risks.

16 Requirement: Develop mechanisms to manage risk; enhance risk response decisions; reduce

operational surprises and losses; Identify and managing internal and external operational risks.

According to: Enterprise Risk Management

Risk(s) if non-compliant:

Loss of time and money due to inadequate identification and/or management of risks.

Inability to respond to risks in a coherent and timely manner.

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Proper management of administrative records ensures that the hospital’s business

functions runs smoothly and enables the hospital to meet its’ accreditation requirements. Good

administrative records management do more than support good patient care; they are essential to

it. Without a proper administrative records management system the patient’s medical history

may not be stored properly nor be easily accessible, thereby undermining patient care.

3. 2 Synthesis of the Organization’s Records Management and Archive Needs

The strengths of the hospital’s current records and information management system lie

within in the well-established practices, policies and systems of the patient records management

department. Because patient records are used by a larger number of individuals at Hôpital

Montfort on a more regular basis, are governed by strict legislation, and are also linked more

directly to the hospitals ability to provide care, the records and information management of this

department has been prioritized and centralized. The mission and value of this department is

understood by its employees and by hospital management, and, as a result, the department is

financially supported.

Unfortunately, the management of the hospital’s administrative records and information

has not been privileged to the same approach. A number of factors have now drawn attention to

the poor management conditions for the hospital’s administrative records and information; some

of these factors include: the increase of information being produced (due to technological

changes of past thirty years), changes in legislation that assure access to these records by the

public, and the hospital’s upcoming 60th

anniversary celebration, which resulted in increased

attempts to access this information and revealed the severity of its poor condition.

All of this has resulted in the need to develop a strong administration records and

information management system. This system will include: outlining a clear management

structure for this department; assigning responsibilities of managing administrative records and

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information to individuals; sharing, developing, and transferring expertise; creating policies and

other documentation to guide practices; selecting, obtaining and teaching users how to use

technological systems; building a stronger physical infrastructure, which is not as susceptible to

risk; and conducting ongoing evaluation. Implementing this system successfully will require an

understanding of its importance by hospital management, as well as their support.

3.3 Tools to be developed for the Organization

A number of tools are required to help the hospital improve its administrative records

management. Some of these tools already exist within certain hospital departments and teams.

However, they currently exist under the lens of patient records management and would require

modification for administrative records management. The tools that should be developed by the

organization are as follows:

1. Administrative Records Management Policy

2. Administrative Records Management Procedures

3. Metadata principles

4. Classification scheme based on business activities

5. Vocabulary controls (thesauri, glossary of terms, etc.)

6. Retention and disposition schedules

7. Security standards (passwords, encryption, access restrictions, etc.)

8. Organizational training

9. Evaluation (monitoring and auditing)

3.4 Action Plan

We recommend the following six point action plan to develop an effective administrative records

management system at Hôpital Montfort.

1. Identify a lead in senior management who will spearhead and be responsible for

administrative records management. The development of this position represents support

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from hospital management. This lead, in conjunction with the management under

administrative responsibilities, will conduct a functional business analysis to determine

administrative records management needs.

2. This lead will then develop a team. These team members will be responsible for the

records management of the following business functions: administration and governance,

information technology, public relations, information management, HR, Finance,

physical resources, academic and research, and education.

3. Working with existing documentation and expertise of patient records management, this

team will develop policies and procedures for administrative records management. These

will include: an appropriate set of security standards and procedures based on the

hospital’s security policy; establishing a risk management framework that supports the

hospital’s objectives and mandates; retention, storage, transfer and disposal of

administrative records; and other records management requirements outlined in part 3 of

this report.

4. Under the direction of the administrative records manager, the administrative records

management team will select and obtain a technological system to support and achieve

the objectives of the policies and procedures regarding administrative records

management.

5. With the support of hospital management, the administrative records management

manager and team will then conduct organizational training on the new records

management system (technology policies and procedures).

6. Finally, evaluation and review of new administrative records management system will be

conducted on an ongoing basis by the administrative records management manager and

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team. Based on the findings of evaluations, improvements will be made to the records

management information system on an ongoing basis.

Conclusion

The purpose of this report was to conduct a needs analysis of the hospital’s administrative

records management practices. This involved conducting interviews, analyzing documents and a

field visit of the hospital facilities. Through this analysis we determined that although the

hospital has very good patient records management practices in their clinical archives, those

practices have not been extended to the hospital’s administrative records.

In the response to the hospital’s administrative records management needs, we propose

the implementation of a centralized administrative records management system; this includes:

the creation of an administrative records management team that would develop and implement

policies and procedures, training and awareness or records management principles and

technologies, and continuous evaluation and review of records management practices. This team

will be guided by the strong leadership of the administrative records manager and supported by

the hospital’s senior management.

The benefits of this strategy for the organization include reducing information

redundancies, promoting communication between departments, standardizing record keeping

practices in accordance with applicable legislation and standards, and improving business

processes. As outlined in Hôpital Montfort’s strategic plan for 2011-2015, under strategic goal

number two, one of the outcomes indicated by the organization is to have in place an “integrated

information management systems that respond to our needs ” (translated from Plan stratégique

2011 – 15 – Hôpital Montfort, 2011, p. 2). The strategy that we have proposed would not only

help the hospital achieve this goal, but will also provide the foundation that will allow the

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hospital to achieve its other strategic goals. Efficient administrative records management

practices and a centralized approach to the hospital’s records management will ultimately

support Hôpital Montfort’s mission in providing excellence in patient care.

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Appendices

Appendix 1: Ontario’s Health Statutory Context