Canada: FIPPA And Ontario Hospitals: Implementing Change

Last Updated: July 25 2011
Article by Daniel Fabiano and Laurie M. Turner

On January 1, 2012, Ontario hospitals will become subject to the Freedom of Information and Protection of Privacy Act ("FIPPA" or the "Act").

Over recent months, most hospitals have taken steps to understand FIPPA and to prepare to implement its requirements. It is important to note that implementing FIPPA's requirements will involve significant effort by hospital personnel. Hospitals must utilize the time between now and January 1, 2012 to ensure that they can carry out their obligations under the Act. Indeed, hospitals should assume that they will receive freedom of information requests on January 1, and should be prepared to handle those requests in accordance with FIPPA.

Operational and Cultural Change

The obligations conferred by FIPPA will require two types of changes to occur within hospitals: operational changes and cultural changes. The degree of operational and cultural changes will partially depend on the hospital's existing policies, procedures and values.

Cultural changes and operational changes are closely related – in fact, one cannot occur without the other. To effectively implement new policies, procedures, etc., hospital personnel must see access to certain information as a right of the public (and not a privilege). Similarly, in order to facilitate the shift in thinking (i.e. of seeing access to certain information as a right), the hospital will have to establish parameters for that change by way of new policies, procedures, etc.

Initial Implementation Steps

If they have not already done so, hospitals will need to take the following initial implementation steps as soon as possible:

  1. Form an implementation team;
  2. Prepare an implementation plan; and
  3. Issue preliminary communications to internal stakeholders.

Each of these items is discussed below.

1. Form an Implementation Team

FIPPA provides little guidance on how its requirements should be implemented. Hospitals will need to determine how to effect operational as well as cultural change in the context of their unique circumstances. This will require each hospital to form a team to develop and oversee a plan to achieve compliance by January 1, 2012. The implementation team may be composed of internal or external personnel, but should, collectively, possess the following qualities:

Varied expertise – personnel from different departments, units, etc. should be involved in the team to represent relevant points of view (including senior management, along with records management, information technology and human resources personnel);

Credibility – the team should be regarded by hospital personnel as credible so that the implementation plan will be taken seriously by other hospital personnel;

Leadership – the team should include proven leaders who can drive change across the hospital; and

Vision – the team members must have a strong understanding of the rationale for freedom of information and an appreciation of why FIPPA will apply to hospitals (i.e. fairness, accountability, democratic participation, protection of personal privacy).

2. Prepare an Implementation Plan

Operational and cultural change will require a plan. A FIPPA implementation plan may be general – in the sense that it establishes, at a high level, the broad tasks to be accomplished by the hospital for the remainder of 2011. Alternatively, or in addition to a general implementation plan, the hospital may develop a more in-depth implementation plan that describes specific tasks and sets out dates for completion and the responsible hospital personnel. The implementation team should meet frequently to ensure that the hospital (and anyone who has been tasked with responsibilities under the implementation plan) is on track to fulfill its obligations under FIPPA beginning on January 1, 2012.

An implementation plan must, at a minimum, address the following broad topics:

  • Conduct an inventory of records;
  • Establish one or more offices to coordinate FIPPA compliance;
  • Review, establish and/or amend policies and procedures related to FIPPA compliance (e.g., records management, privacy, security, FOI requests);
  • Adopt/finalize templates and tools to assist in FIPPA compliance; and
  • Educate and train key hospital personnel.

Hospitals can find implementation assistance in the forthcoming Ontario Hospital Association FIPPA Toolkit, of which Fasken Martineau was the lead author.

3. Issue Preliminary Communications to Internal Stakeholders

Communicating with stakeholders is an integral part of initiating cultural change. Although communications with both internal and external stakeholders will be necessary, initial communications efforts should focus on internal stakeholders (e.g., personnel, board of directors). These communications should achieve the following:

Establish a sense of urgency. This can be done by drawing attention to the broad range of obligations under the Act, the necessary implementation steps and the effective date of January 1, 2012. By instilling this sense of urgency, internal stakeholders will be more apt to see their role in FIPPA implementation as a real priority.

Demonstrate the support of hospital leadership. Senior management and the board of directors should participate in delivering FIPPA related communications both explicitly (by contributing to internal bulletins, notices and training/education seminars) and implicitly (leading by example and actively engaging in their role in FIPPA implementation). The support of hospital leadership contributes to the sense of urgency and assists in driving change.

Use a variety of available communication tools. The hospital should use its intranet, the Internet, internal and external hospital publications, etc. to inform stakeholders of the operational and cultural change that is/will be occurring at the hospital.

What's Next?

Team-building, planning and initial internal communications are merely the early steps preparing to implement FIPPA's requirements. Executing the implementation plan will take time and resources, and it is important that hospitals commence their implementation activities early to avoid the risk of non-compliance with the Act.

This bulletin is part of a series of bulletins on the topic of FIPPA implementation.

View additional information about how to access the FIPPA Helpline

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

To print this article, all you need is to be registered on

Click to Login as an existing user or Register so you can print this article.

In association with
Related Video
Up-coming Events Search
Font Size:
Mondaq on Twitter
Register for Access and our Free Biweekly Alert for
This service is completely free. Access 250,000 archived articles from 100+ countries and get a personalised email twice a week covering developments (and yes, our lawyers like to think you’ve read our Disclaimer).
Email Address
Company Name
Confirm Password
Mondaq Topics -- Select your Interests
 Law Performance
 Law Practice
 Media & IT
 Real Estate
 Wealth Mgt
Asia Pacific
European Union
Latin America
Middle East
United States
Worldwide Updates
Check to state you have read and
agree to our Terms and Conditions

Terms & Conditions and Privacy Statement (the Website) is owned and managed by Mondaq Ltd and as a user you are granted a non-exclusive, revocable license to access the Website under its terms and conditions of use. Your use of the Website constitutes your agreement to the following terms and conditions of use. Mondaq Ltd may terminate your use of the Website if you are in breach of these terms and conditions or if Mondaq Ltd decides to terminate your license of use for whatever reason.

Use of

You may use the Website but are required to register as a user if you wish to read the full text of the content and articles available (the Content). You may not modify, publish, transmit, transfer or sell, reproduce, create derivative works from, distribute, perform, link, display, or in any way exploit any of the Content, in whole or in part, except as expressly permitted in these terms & conditions or with the prior written consent of Mondaq Ltd. You may not use electronic or other means to extract details or information about’s content, users or contributors in order to offer them any services or products which compete directly or indirectly with Mondaq Ltd’s services and products.


Mondaq Ltd and/or its respective suppliers make no representations about the suitability of the information contained in the documents and related graphics published on this server for any purpose. All such documents and related graphics are provided "as is" without warranty of any kind. Mondaq Ltd and/or its respective suppliers hereby disclaim all warranties and conditions with regard to this information, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. In no event shall Mondaq Ltd and/or its respective suppliers be liable for any special, indirect or consequential damages or any damages whatsoever resulting from loss of use, data or profits, whether in an action of contract, negligence or other tortious action, arising out of or in connection with the use or performance of information available from this server.

The documents and related graphics published on this server could include technical inaccuracies or typographical errors. Changes are periodically added to the information herein. Mondaq Ltd and/or its respective suppliers may make improvements and/or changes in the product(s) and/or the program(s) described herein at any time.


Mondaq Ltd requires you to register and provide information that personally identifies you, including what sort of information you are interested in, for three primary purposes:

  • To allow you to personalize the Mondaq websites you are visiting.
  • To enable features such as password reminder, newsletter alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our information providers who provide information free for your use.

Mondaq (and its affiliate sites) do not sell or provide your details to third parties other than information providers. The reason we provide our information providers with this information is so that they can measure the response their articles are receiving and provide you with information about their products and services.

If you do not want us to provide your name and email address you may opt out by clicking here .

If you do not wish to receive any future announcements of products and services offered by Mondaq by clicking here .

Information Collection and Use

We require site users to register with Mondaq (and its affiliate sites) to view the free information on the site. We also collect information from our users at several different points on the websites: this is so that we can customise the sites according to individual usage, provide 'session-aware' functionality, and ensure that content is acquired and developed appropriately. This gives us an overall picture of our user profiles, which in turn shows to our Editorial Contributors the type of person they are reaching by posting articles on Mondaq (and its affiliate sites) – meaning more free content for registered users.

We are only able to provide the material on the Mondaq (and its affiliate sites) site free to site visitors because we can pass on information about the pages that users are viewing and the personal information users provide to us (e.g. email addresses) to reputable contributing firms such as law firms who author those pages. We do not sell or rent information to anyone else other than the authors of those pages, who may change from time to time. Should you wish us not to disclose your details to any of these parties, please tick the box above or tick the box marked "Opt out of Registration Information Disclosure" on the Your Profile page. We and our author organisations may only contact you via email or other means if you allow us to do so. Users can opt out of contact when they register on the site, or send an email to with “no disclosure” in the subject heading

Mondaq News Alerts

In order to receive Mondaq News Alerts, users have to complete a separate registration form. This is a personalised service where users choose regions and topics of interest and we send it only to those users who have requested it. Users can stop receiving these Alerts by going to the Mondaq News Alerts page and deselecting all interest areas. In the same way users can amend their personal preferences to add or remove subject areas.


A cookie is a small text file written to a user’s hard drive that contains an identifying user number. The cookies do not contain any personal information about users. We use the cookie so users do not have to log in every time they use the service and the cookie will automatically expire if you do not visit the Mondaq website (or its affiliate sites) for 12 months. We also use the cookie to personalise a user's experience of the site (for example to show information specific to a user's region). As the Mondaq sites are fully personalised and cookies are essential to its core technology the site will function unpredictably with browsers that do not support cookies - or where cookies are disabled (in these circumstances we advise you to attempt to locate the information you require elsewhere on the web). However if you are concerned about the presence of a Mondaq cookie on your machine you can also choose to expire the cookie immediately (remove it) by selecting the 'Log Off' menu option as the last thing you do when you use the site.

Some of our business partners may use cookies on our site (for example, advertisers). However, we have no access to or control over these cookies and we are not aware of any at present that do so.

Log Files

We use IP addresses to analyse trends, administer the site, track movement, and gather broad demographic information for aggregate use. IP addresses are not linked to personally identifiable information.


This web site contains links to other sites. Please be aware that Mondaq (or its affiliate sites) are not responsible for the privacy practices of such other sites. We encourage our users to be aware when they leave our site and to read the privacy statements of these third party sites. This privacy statement applies solely to information collected by this Web site.

Surveys & Contests

From time-to-time our site requests information from users via surveys or contests. Participation in these surveys or contests is completely voluntary and the user therefore has a choice whether or not to disclose any information requested. Information requested may include contact information (such as name and delivery address), and demographic information (such as postcode, age level). Contact information will be used to notify the winners and award prizes. Survey information will be used for purposes of monitoring or improving the functionality of the site.


If a user elects to use our referral service for informing a friend about our site, we ask them for the friend’s name and email address. Mondaq stores this information and may contact the friend to invite them to register with Mondaq, but they will not be contacted more than once. The friend may contact Mondaq to request the removal of this information from our database.


This website takes every reasonable precaution to protect our users’ information. When users submit sensitive information via the website, your information is protected using firewalls and other security technology. If you have any questions about the security at our website, you can send an email to

Correcting/Updating Personal Information

If a user’s personally identifiable information changes (such as postcode), or if a user no longer desires our service, we will endeavour to provide a way to correct, update or remove that user’s personal data provided to us. This can usually be done at the “Your Profile” page or by sending an email to

Notification of Changes

If we decide to change our Terms & Conditions or Privacy Policy, we will post those changes on our site so our users are always aware of what information we collect, how we use it, and under what circumstances, if any, we disclose it. If at any point we decide to use personally identifiable information in a manner different from that stated at the time it was collected, we will notify users by way of an email. Users will have a choice as to whether or not we use their information in this different manner. We will use information in accordance with the privacy policy under which the information was collected.

How to contact Mondaq

You can contact us with comments or queries at

If for some reason you believe Mondaq Ltd. has not adhered to these principles, please notify us by e-mail at and we will use commercially reasonable efforts to determine and correct the problem promptly.