Introduction:Hello everyone. We are CAVK Consulting and our goals is to provide archive and document management services to custom fit the needs of our clients. Today we would like to present to Hôpital Montfort the results and recommendations of our report concerning the hospital’s current archive and document management needs.
The following is an outline of what our presentation will cover. First we will look at the pertinent findings of the Needs Analysis of Hôpital Montfort’s administrative archives. Next we will look at the summary of our proposed action plan. Then our team will provide the results of our analysis of two content management systems Microsoft SharePoint® and OpenText Content Server. At the end of our presentation we will provide our final recommendations on how to best meet the administrative records management needs of Hôpital Montfort.
Methodology:The needs analysis was a descriptive qualitative study which included interviews with the archivist in charge of the administrative archives, and upper management of Hôpital Montfort a visit to the hospital’s administrative and clinical archives, and a review of the hospital’s organization chart and documents pertaining to the hospital’s overall records management processes.Furthermore, the needs analysis involvedan examination of the laws and regulations that are applicable to the hospital’s operations, an analysis of the business risks arising from non-compliance to these laws and regulations, a functional analysis, which is a high-level analysis of the business processes performed by the hospital, and an analysis of the risks associated with the mismanagement of administrative records.
The functional analysis we had conducted demonstrated that *click* a records management function exists in Hôpital Montfort. This function has two main activities. *click* The first is managing the health information of patients under the hospital’s care; and the second is managing administrative information produced by the hospital’s administrative departments.
When comparing the management of patient and administrative records, the management of patient records is by far more organized and established, which is appropriate as the organization is after all a hospital.A clear and detailed policy with set procedures is available for the archival, organization and disposal of patient records. The management of patient records is centralized, under sound leadership and with employees dedicated only to this task. Measures for quality control are laid out to ensure that all appropriate documents are present in the file with all the appropriate authentication necessary. Procedures are in place for monitoring, and tracking the use of these records and ensuring that they return to the clinical archives.A physical infrastructure is in place in the hospital for active patient files and at a third-party location for the semi-active and inactive files. Lastly, an electronic document management system for patient information is available and used by the clinical archives in order to complete their records management activities.The management administrative records, however, is not as well-established and standardized as the management of patient records. Although the policy Admin 105 contains a retention schedule covering the retention periods and disposal instructions for administrative records, there is no detailed policy and procedures in place for the management of administrative records as a whole- for instance policies and/or procedures related to monitoring and tracking their use.The management of these records rest in the hands of the administrative assistants of the hospital’s administrative departments, and therefore there is no central body overseeing the administrative records management activities. We are not saying that the administrative assistants do not know how to manage their records however, we realize that administrative assistants are often occupied with many other tasks that have much higher priority than records management.Although a physical infrastructure is available, it is unfortunately not yet suitable for the preservation of these records. Several instances of flooding have already occurred in the locations where the administrative records are being kept. These records require a temperature- and humidity-controlled environment for their ongoing preservation.Finally, compared to the management of patient records, there is no electronic records management system currently being used for the management of administrative records.
The importance of proper organization of patient records is evident as hospitals and health professionals are subject to various laws and regulations governing health care enforced by for instance the Ministry of Health and Long-Term Care of Ontario, as well as professional codes of conduct governed by associations such as the College of Physicians and Surgeons.The management of administrative records is necessary for organizational compliance to laws such as the Personal Information Protection and Electronic Documents Act (PIPEDA) and the Freedom of Information and Protection of Privacy Act (FIPPA). Both of these acts concern personal information including non-health related information. In addition, FIPPA requires that a publicly-funded institution provide information to the members of the public upon request. Compliance to these laws is necessary for the hospital to continue its operations. Proper management of administrative records is also necessary for organizational governance. These records provide a trace of all non-clinical activities performed by Hôpital Montfort, including necessary information such as the who? What? When? Where? Why? And How?. Proper management of these records will therefore aid in providing accountability for Hôpital Montfort’s activities in the face of audits and, at worse, legal actions as the hospital will be able to easily find and render accessible the administrative documents required. Finally, the history of Hôpital Montfort lies in the administrative records. Proper management of administrative records will ensure that documents of historical value are found, well-preserved and accessible for the future.
Action PlanWe recommend the following seven point action plan to develop an effective administrative records management system at Hôpital Montfort. Identify a lead in senior management who will spearhead and be responsible for administrative records management. The development of this position represents support 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. 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.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. 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. 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).Then, evaluation and review of new administrative records management system will be conducted on an ongoing basis by the administrative records management manager and team. Based on the findings of evaluations, improvements will be made to the records management information system on an ongoing basis.Finally, provide ongoing support.
Systems AnalysisNext, we conducted a systems analysis.This evaluation was ranked on a scale of 1 to 3; where 1-Absent Feature; 2- Partial Feature; 3-Full FeatureWe evaluated system functionality within 8 areas:Creation: Does the system support different types of information produced by different applications and permits the addition of metadata at the point of creation?Record Declaration: Does the system identify the information as an archival document that must be managed during its life cycle?Classification: Does the system organize the information using a classification scheme based on Hôpital Montfort’s organization chart?Security: Does the system protect the integrity of record against tampering or unauthorized destruction?Access Management: Canthe system grant or restrict the ability of individuals to access information? Can users see the content and/or title and/or metadata associated?Retrieval: Doesthe system facilitate retrieval of documents using simple or complex queries?Preservation: Doesthe system ensure that the record can be used in the medium and long- term?Disposition: Doesthe system allow to eliminate inactive records or to transfer legal responsibility in accordance with the retention schedule?
Benefits: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 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.
Conclusion:To conclude, we would like to reiterate our full strategy:In response to the hospital’s administrative records management needs, we propose the implementation of SharePoint 2013 as a centralized administrative records management system. Additionally, we propose 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. We thank you for your time.Are there any questions?
Isi 6521 cavk v5
1. Summary of Needs Analysis
2. Summary of Action Plan
3. Systems Analysis between
Microsoft SharePoint® and
OpenText Content Server
4. System Recommendation
On-site visit of Hôpital Montfort
Review of organizational documents
Review of applicable laws and
Management of Patient
Clear, detailed policy and
Quality control measures
Tracking and monitoring of
Physical infrastructure in
Electronic system available
available, but no
standardized policies or
Physical infrastructure not
yet appropriate for archiving
No comparative electronic
records management system
Importance of Administrative Records Management
Compliance with laws and regulations
o Personal Information Protection and Electronic Documents
o Freedom of Information and Protection of Privacy Act (FIPPA)
1. Identify a lead in senior management who will spearhead and be
responsible for administrative records management
2. Develop a team who will be responsible for the records management
3. Develop policies and procedures for administrative records
4. Select and obtain a technological system to support and achieve the
objectives of the policies and procedures
5. Conduct organizational training on the new records management
6. Evaluate and review of new administrative records management
7. Provide ongoing support
Creation 19 23 24
Record Declaration 5.5 4.5 6
Classification 21 18 24
Security 10.5 14 15
Access Management 10.5 11.5 12
Retrieval 19.5 19 21
Preservation 3 6 9
Disposition 19 17 19
TOTAL 108 113 135
• Reduce information redundancies
• Promote communication between departments
• Standardize record keeping practices in accordance with
applicable legislation and standards, and improving
• Provide the foundation that will allow the hospital to
achieve its other strategic goals
• Efficient administrative records management practices
• Support Hôpital Montfort’s mission in providing
excellence in patient care through a centralized
approach to the hospital’s records management.