Privacy and personal information safeguard policy.

In this foundation,* we operate a medical service, with the goal of providing high-quality service with the patient’s needs in mind on a daily basis. In pursuing these aims and to respond adequately, appropriately and quickly to any changes in patient condition, medical information is essential. Your private medical information is also indispensible in establishing a safe, secure medical system which fosters a relationship of trust with patients, allowing them to receive medical treatment with confidence. At this foundation, we strive for the appropriate handling of your personal information, with the below purposes in mind:

1. Collection of personal information
   In the scope in which it is necessary for this foundation to conduct the operation of this hospital and any subsequent medical care, personal information is gathered, with the reasons for this being made clear to the patient beforehand. Furthermore, any information needed for reasons outside of this will be conveyed to the patient in advance and only undertaken upon the patient’s acknowledgement.
2. The use of personal information and conveyance to third parties
   At this foundation, the supply of information to third parties or the use of information outside its originally designated purpose will not be undertaken, except in the below situations:
   
   - Where patient consent is acquired.
   - Where measures have been taken to protect your anonymity though the removal of any identifiable components of data.
   - Where provision of your information is required due to legal reasons.
   
   

   In the instance where the provision of information to a third party occurs, we are committed to protecting the patient’s privacy as much as possible through a process of careful scrutiny. Furthermore, we insist upon conveyance to the third party supplied, that individual privacy is protected.

3. Appropriate management of personal information
   At this foundation, we endeavour to maintain a safe and secure information management system, to prevent any incidences such as unauthorised access, data loss, vandalisation, falsification or unauthorised disclosure of information.
4. Disclosure, confirmation and revision of information
   At this foundation, upon a request for disclosure of personal information from a patient, the contents will be confirmed and the request responded to in the minimum time possible, according to our Guidelines Concerning the Disclosure of Medical Information. Further, in instances where a revision is requested due to a perceived deviation in fact interpretation; an investigation will be conducted to reach an appropriate response.
5. Inquiries regarding personal information
   Any inquiries relating to privacy and our policy, or requests for disclosure can be either made at the consultation area here or forwarded to the Regional Medical Privacy Information Service on 086-422-0210. (In Japanese only: 地域医療センター/個人情報相談窓口)
6. Continued improvement of legal compliance and information security
   At this foundation, laws concerning privacy protection are observed and regulations set regarding the management and storage of private information adhered to, with this being managed through delegation of responsibility to staff who manage personal data.

Furthermore, the suitability of the aforementioned regulations are revised on an ongoing basis, with the aim of continued improvement.

Policy enacted on the 1^st of April, 2005.

Definition of scope concerning the use and object of the gathering of personal information.

Here, the purpose scope of use of all private patient information gathered is as follows:

1. Contributing to the maintenance of patients' health and recovery.

   The specific scope of use is as follows:

   1. Where medical treatment is administered to patients.
   2. Where outside assistance or opinions from fellow medical facilities are requested concerning a patient’s medical treatment.
   3. Where services are conducted in collaboration with other health, medical, welfare or any other related institutions.
   4. Where inquiries are answered from the institutions stated in item number three (with the patient’s consent.)
   5. Where tests and examinations are conducted externally.
   6. Where a patient’s medical condition is explained to family.
   7. Where information is used to improve medical outcomes:
   1. For the clinical training and education of doctors, nurses, other hospital employees, practicum students and intern doctors.
   2. For data gathering pertaining to clinical research.
   3. For applications pertaining to special doctors and medical accreditation.
   4. Medical conferences and presentations (consideration made to remove all identifiable patient information.)
   8. Where utilisation of information is in the public interest:
   1. For contribution to epidemiological surveys determined to be of a high value to the public.
   2. For investigations and compilation of statistics relating to government medical administration.
   3. For reports by public health institutions concerning community health and hygiene.
   9. Where notification of results concerning health checks are conducted upon a request from employers.
2. Utilisation of information that contributes to the management and operation of the hospital.

The specific scope of use is as follows:

1. Where administration concerning medical insurance is undertaken.
2. Where work concerning billing is undertaken.
3. Where ward/bed management concerning admission and discharge is conducted.
4. Where medical actions are justified in audits from external organisations.
5. Where data is used in basic resources in order to improve operations.
6. Where provision of data is required based on legal reasons:
1. For the purpose of complying with observance, guidance and auditing by administrative institutions.
2. For the provision of information according to a court or other legal order.
3. For compliance with regulations for the prevention of infectious diseases.
7. Where consultation or the submission of information is undertaken with an insurance company or other applicable organisation concerning medical public liability insurance.
8. Other applicable actions which aim to improve patient outcomes.

Upon reading the above objectives of use by the patient, if no clear intent of non-willingness to consent is expressed, then your information will be handled with the assumption that consent has been obtained. If you wish to change your position and withdraw your consent or offer it in the future, upon notification the manner in which your data is handled will be changed accordingly.

Policy enacted on the 1^st of April, 2005.
Policy first amended on the 1^st of July, 2006.
Policy further amended on the 1^st of January, 2009.

About the National Clinical Database and Data Collection

There has been debate concerning the breakdown of hospital medicine and the misdistribution of medical practitioners, with many academic and other organisations offering suggestions for the restructuring of the way medical treatment is delivered; however in a situation where place nor method of medical delivery is not adequately taken hold of, the improvement of medical care as from a patient’s perspective cannot be provided. Regarding this, many Japanese clinical associations have formed together and in an effort to gain an understanding of the current state of our country’s medical system, the National Clinical Database has been established, commencing the start of database operations in this field. Through the operation of this, not only will the proper distribution of specialist practitioners be analysed to provide patients with an appropriate level of treatment, the utmost support being provided to clinical practice on the frontline will become a possibility. Upon you understanding of us, we ask for your co-operation and support in helping us fulfil our mission.

National Clinical Database
Representative Director
Susumu Satomi

1. Participation in operations
   Participation in contributing to this database is voluntary. In an instance where the patient does not wish to participate, it is possible to refuse the submission of one’s data. Patients who do not wish to participate will not be placed at any disadvantage in their medical treatment as a result.
2. Objectives of data submission
   In addition to providing a patient-centred quality medical service, the ability to analyse the current state of the medical system is essential. With NCD, improvements towards medical outcomes can be analysed and discussed on an ongoing basis, based on systematically submitted information. Under the NCD system, an individual facility can be analysed in comparison to facilities throughout Japan, based on a standardised set of measures, meaning that the individual facility’s qualities and points for improvement can be understood and improvement measures can be undertaken. There are many examples of this, both domestically and internationally, where implementation has led to the support of reform measures, resulting in a highly successful outcome in quality improvement.
3. Contents of submitted data
   Data that will be collected includes information such as test results, reasons for seeking treatment, treatment methods, diagnoses, surgical procedures, etc. In the data itself, there will be no information included that will allow simple identification; however data will be managed under the strictest of conditions. Concerning treatment of data and security, both legal and voluntary conventions are strictly followed, including the Privacy and Personal Information Protection Act, Ethical Guidelines for Epidemiological Research, Ethical Guidelines for Clinical Research and Guidelines Concerning the Security of Medical Information Systems. If you wish to view the data being submitted, please let your medical professional know at your next visit.
4. The way in which submitted data will be used
   So as to best be of benefit towards improving both treatment outcomes and the well-being of the patient, the submitted data will result in feedback being given for both participating facilities as well as each respective area of clinical medicine . At this stage, once all data is analysed and compiled, all data will be statistical, meaning that any data published from the NCD will in no way contain any identifiable information. Any information published is also the result of rigorous discussion within NCD management and only data which a consensus has been reached upon will be publicised.