Canada: FIPPA And Ontario Hospitals: Setting-Up A FIPPA Compliance Office

Last Updated: August 2 2011
Article by Daniel Fabiano and Laurie M. Turner

This bulletin follows our previous bulletin, FIPPA and Ontario Hospitals: Implementing Change, in which we discussed the operational and cultural changes that are required if hospitals are to fulfill their obligations under the Freedom of Information and Protection of Privacy Act ("FIPPA" or the "Act"). This second bulletin is intended to provide a general overview of how hospitals can structure a central office that will be responsible for FIPPA compliance.

Establishing a compliance office will be a significant task in implementing and operationalizing FIPPA's requirements. While a central office is not a requirement under FIPPA, designating a coordinating body is a practical necessity. The OHA Primer: A Practical Guide for Hospitals Preparing for FIPPA Implementation, published in April 2011, sets out numerous action items and priorities for hospitals to complete prior to January 1, 2012, one of which is establishing a FIPPA compliance office. Accordingly, many hospitals may have already begun planning for their FIPPA compliance office.

Core Resources / Attributes of a FIPPA Compliance Office

In order to determine the most effective approach to structuring a FIPPA compliance office, it is important to note the core resources and attributes required. These core resources and attributes are, generally speaking:

  • personnel with expertise in FIPPA and who understand the purposes of the Act;
  • direct access to authority (e.g., the head and other delegated decision-makers); and
  • secure premises and equipment (e.g., dedicated computers, scanners and fax machines; locked filing cabinets; password protected computers).

Structuring the FIPPA Compliance Office

Although these core resources and attributes are clearly required in order to effectively comply with the Act, there are a variety of approaches to creating or designating a FIPPA compliance office. How a particular hospital will structure this office will depend on various factors, including:

  • the hospital's approach to governance and existing organizational structure (i.e., how FIPPA functions will fit within that existing structure);
  • whether an existing office has the capacity (or can be allocated resources to extend its capacity) to encompass FIPPA compliance activities – for example, the office tasked with coordinating compliance with the Personal Health Information Protection Act ("PHIPA") or the records management department could be candidates to take on freedom of information and/or privacy compliance under FIPPA; and
  • the potential benefits of participating with another hospital and sharing a common FIPPA compliance office. In order to determine whether this model would be beneficial to the hospital, the hospital should consider (among other factors):
    • the scope of the hospital's services – a hospital with a broad scope of services (e.g., a long-term care home, a research institute, multiple sites) would likely align with an in-house office rather than a shared office, as a hospital's own personnel would be better positioned to navigate any records management complexities; and
    • other complexities in the hospital's record-keeping systems – the more complex a hospital's record-keeping system, the more likely it will be that the hospital's own personnel should be involved.

Also, it is important to keep in mind that FIPPA has two parts: a freedom of information part (which gives the public a right to access records in the custody or control of the hospital) and a protection of privacy part (which generally protects the privacy of individuals). Depending on the circumstances at a particular hospital, it may make sense to assign the obligations stemming from these two parts to two different offices, or to assign all FIPPA-related obligations to the same office.

Once these and other factors1 are taken into account, a hospital will likely take one of the following approaches to coordinating FIPPA compliance:

Single Office: This approach involves making a single office responsible for FIPPA compliance (i.e., both freedom of information and protection of privacy). This will involve either creating that office anew or designating an existing office as also responsible for FIPPA compliance. This approach has the advantage of centralizing knowledge, responsibility and accountability, and minimizing the resources needed if multiple offices were involved.

Two Offices: This approach involves making two offices responsible for FIPPA compliance (i.e., one for freedom of information compliance, the other for privacy compliance). Likely, this will involve designating the office responsible for health privacy / PHIPA compliance as also responsible for privacy compliance under FIPPA, with a new or existing office responsible for freedom of information compliance. This approach has the advantage of leveraging existing resources and knowledge to assist with FIPPA compliance. Even so, dividing knowledge and accountability under FIPPA has potential disadvantages, which would require that the hospital take steps to ensure that the two offices were engaged in regular communication.

Shared Office: This approach involves entering into an arrangement with one or more other hospitals to create a shared office that is responsible for FIPPA compliance. This approach could assign the shared office responsibility for full compliance with FIPPA (i.e. both freedom of information and privacy protection), or for only freedom of information compliance (with privacy compliance assigned to an office within each participating hospital). A shared office has the advantage of minimizing costs to participating hospitals, and leveraging their resources and/or expertise. However, a shared office may also have some disadvantages. The FIPPA compliance office would likely be located at one site, without a physical presence at all participating hospitals – this may require additional efforts to ensure that the necessary level of cultural change occurs at all participating hospitals. Another challenge that may arise in using a shared office is ensuring that the FIPPA compliance office understands the operations and structure of all participating hospitals, and is in regular communication with on-site FIPPA personnel at each participating hospital. It is therefore important that the participating hospitals address these issues in a written agreement, as well as the issues of governance and oversight, financial contributions and expectations regarding personnel and equipment.

Hospitals can find further direction on these matters, as well as FIPPA implementation more generally, in the forthcoming Ontario Hospital Association Hospital Freedom of Information Toolkit: A Guide to Implementing the Freedom of Information and Protection of Privacy, of which Fasken Martineau was the lead author.

What's Next?

Determining how to structure the office responsible for FIPPA compliance is one of several early-to-mid stage steps in preparing to implement FIPPA's requirements at the hospital. Assembling the personnel and resources for the FIPPA compliance office will take some time. It is therefore 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. The next bulletin will address the issue of delegation by the head of his or her powers and duties under the Act – a step which is necessary if the FIPPA compliance office (and its staff) are to be able to exercise those powers and duties after January 1, 2012.


1 Hospitals should consult the forthcoming Ontario Hospital Association Hospital Freedom of Information Toolkit: A Guide to Implementing the Freedom of Information and Protection of Privacy for additional factors to be considered in this process.

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 Topics
Related Articles
Related Video
Up-coming Events Search
Font Size:
Mondaq on Twitter
Mondaq Free Registration
Gain access to Mondaq global archive of over 375,000 articles covering 200 countries with a personalised News Alert and automatic login on this device.
Mondaq News Alert (some suggested topics and region)
Select Topics
Registration (please scroll down to set your data preferences)

Mondaq Ltd requires you to register and provide information that personally identifies you, including your content preferences, for three primary purposes (full details of Mondaq’s use of your personal data can be found in our Privacy and Cookies Notice):

  • To allow you to personalize the Mondaq websites you are visiting to show content ("Content") relevant to your interests.
  • To enable features such as password reminder, news alerts, email a colleague, and linking from Mondaq (and its affiliate sites) to your website.
  • To produce demographic feedback for our content providers ("Contributors") who contribute Content for free for your use.

Mondaq hopes that our registered users will support us in maintaining our free to view business model by consenting to our use of your personal data as described below.

Mondaq has a "free to view" business model. Our services are paid for by Contributors in exchange for Mondaq providing them with access to information about who accesses their content. Once personal data is transferred to our Contributors they become a data controller of this personal data. They use it to measure the response that their articles are receiving, as a form of market research. They may also use it to provide Mondaq users with information about their products and services.

Details of each Contributor to which your personal data will be transferred is clearly stated within the Content that you access. For full details of how this Contributor will use your personal data, you should review the Contributor’s own Privacy Notice.

Please indicate your preference below:

Yes, I am happy to support Mondaq in maintaining its free to view business model by agreeing to allow Mondaq to share my personal data with Contributors whose Content I access
No, I do not want Mondaq to share my personal data with Contributors

Also please let us know whether you are happy to receive communications promoting products and services offered by Mondaq:

Yes, I am happy to received promotional communications from Mondaq
No, please do not send me promotional communications from Mondaq
Terms & Conditions (the Website) is owned and managed by Mondaq Ltd (Mondaq). Mondaq grants you a non-exclusive, revocable licence to access the Website and associated services, such as the Mondaq News Alerts (Services), subject to and in consideration of your compliance with the following terms and conditions of use (Terms). Your use of the Website and/or Services constitutes your agreement to the Terms. Mondaq may terminate your use of the Website and Services if you are in breach of these Terms or if Mondaq decides to terminate the licence granted hereunder for any reason whatsoever.

Use of

To Use you must be: eighteen (18) years old or over; legally capable of entering into binding contracts; and not in any way prohibited by the applicable law to enter into these Terms in the jurisdiction which you are currently located.

You may use the Website as an unregistered user, however, you are required to register as a user if you wish to read the full text of the Content or to receive the Services.

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 or with the prior written consent of Mondaq. You may not use electronic or other means to extract details or information from the Content. Nor shall you extract information about users or Contributors in order to offer them any services or products.

In your use of the Website and/or Services you shall: comply with all applicable laws, regulations, directives and legislations which apply to your Use of the Website and/or Services in whatever country you are physically located including without limitation any and all consumer law, export control laws and regulations; provide to us true, correct and accurate information and promptly inform us in the event that any information that you have provided to us changes or becomes inaccurate; notify Mondaq immediately of any circumstances where you have reason to believe that any Intellectual Property Rights or any other rights of any third party may have been infringed; co-operate with reasonable security or other checks or requests for information made by Mondaq from time to time; and at all times be fully liable for the breach of any of these Terms by a third party using your login details to access the Website and/or Services

however, you shall not: do anything likely to impair, interfere with or damage or cause harm or distress to any persons, or the network; do anything that will infringe any Intellectual Property Rights or other rights of Mondaq or any third party; or use the Website, Services and/or Content otherwise than in accordance with these Terms; use any trade marks or service marks of Mondaq or the Contributors, or do anything which may be seen to take unfair advantage of the reputation and goodwill of Mondaq or the Contributors, or the Website, Services and/or Content.

Mondaq reserves the right, in its sole discretion, to take any action that it deems necessary and appropriate in the event it considers that there is a breach or threatened breach of the Terms.

Mondaq’s Rights and Obligations

Unless otherwise expressly set out to the contrary, nothing in these Terms shall serve to transfer from Mondaq to you, any Intellectual Property Rights owned by and/or licensed to Mondaq and all rights, title and interest in and to such Intellectual Property Rights will remain exclusively with Mondaq and/or its licensors.

Mondaq shall use its reasonable endeavours to make the Website and Services available to you at all times, but we cannot guarantee an uninterrupted and fault free service.

Mondaq reserves the right to make changes to the services and/or the Website or part thereof, from time to time, and we may add, remove, modify and/or vary any elements of features and functionalities of the Website or the services.

Mondaq also reserves the right from time to time to monitor your Use of the Website and/or services.


The Content is general information only. It is not intended to constitute legal advice or seek to be the complete and comprehensive statement of the law, nor is it intended to address your specific requirements or provide advice on which reliance should be placed. Mondaq and/or its Contributors and other suppliers make no representations about the suitability of the information contained in the Content for any purpose. All Content provided "as is" without warranty of any kind. Mondaq and/or its Contributors and other suppliers hereby exclude and disclaim all representations, warranties or guarantees with regard to the Content, including all implied warranties and conditions of merchantability, fitness for a particular purpose, title and non-infringement. To the maximum extent permitted by law, Mondaq expressly excludes all representations, warranties, obligations, and liabilities arising out of or in connection with all Content. In no event shall Mondaq 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 of the Content or performance of Mondaq’s Services.


Mondaq may alter or amend these Terms by amending them on the Website. By continuing to Use the Services and/or the Website after such amendment, you will be deemed to have accepted any amendment to these Terms.

These Terms shall be governed by and construed in accordance with the laws of England and Wales and you irrevocably submit to the exclusive jurisdiction of the courts of England and Wales to settle any dispute which may arise out of or in connection with these Terms. If you live outside the United Kingdom, English law shall apply only to the extent that English law shall not deprive you of any legal protection accorded in accordance with the law of the place where you are habitually resident ("Local Law"). In the event English law deprives you of any legal protection which is accorded to you under Local Law, then these terms shall be governed by Local Law and any dispute or claim arising out of or in connection with these Terms shall be subject to the non-exclusive jurisdiction of the courts where you are habitually resident.

You may print and keep a copy of these Terms, which form the entire agreement between you and Mondaq and supersede any other communications or advertising in respect of the Service and/or the Website.

No delay in exercising or non-exercise by you and/or Mondaq of any of its rights under or in connection with these Terms shall operate as a waiver or release of each of your or Mondaq’s right. Rather, any such waiver or release must be specifically granted in writing signed by the party granting it.

If any part of these Terms is held unenforceable, that part shall be enforced to the maximum extent permissible so as to give effect to the intent of the parties, and the Terms shall continue in full force and effect.

Mondaq shall not incur any liability to you on account of any loss or damage resulting from any delay or failure to perform all or any part of these Terms if such delay or failure is caused, in whole or in part, by events, occurrences, or causes beyond the control of Mondaq. Such events, occurrences or causes will include, without limitation, acts of God, strikes, lockouts, server and network failure, riots, acts of war, earthquakes, fire and explosions.

By clicking Register you state you have read and agree to our Terms and Conditions