2.1 All SHR Users are responsible for the security of SHR systems/applications, resources and information.

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1 POLICY Number: Title: Saskatn Health Regin User Accunt Plicy Authrizatin [ ] President and CEO [X] Vice President, Finance and Crprate Services Surce: Directr, Infrmatin Technlgy Services Crss Index: , , Date Apprved: Dec 6, 2006 Date Revised: May 13, 2013 Date Effective: May 30, 2013 Date Reaffirmed: Scpe: SHR & Affiliates Any PRINTED versin f this dcument is nly accurate up t the date f printing. Saskatn Health Regin (SHR) cannt guarantee the currency r accuracy f any printed plicy. Always refer t the Plicies and Prcedures site fr the mst current versins f dcuments in effect. SHR accepts n respnsibility fr use f this material by any persn r rganizatin nt assciated with SHR. N part f this dcument may be reprduced in any frm fr publicatin withut permissin f SHR. Overview A user accunt is a SHR User s primary methd f uniquely authenticating themselves in rder t access the clinical and administrative technlgy systems and resurces required t fulfill their day-t-day respnsibilities. In additin t verifying a user s identity, a user accunt ften defines a user s rle by limiting the systems that he/she can access, what functins can be perfrmed, and what infrmatin the user will be allwed t view, update, and/r delete. It is therefre imprtant that users utilize SHR cmputing resurces respnsibly and prtect their access frm being cmprmised, as they are slely respnsible fr all actins perfrmed using their user accunt. DEFINITIONS LOA (Leave Of Absence) means is any extended leave, including, but nt limited t illness and maternity leave. Saskatn Health Regin (SHR) User means a persn with an active SHR User Accunt that allws access t the SHR cmputer netwrk. A SHR User may include SHR emplyees, physicians, ther healthcare prfessinals, students, cntractrs, vendrs and any ther persn wh has been apprved fr an SHR User Accunt. Saskatn Health Regin (SHR) User Accunt means a persnal accunt cnsisting f an Active Directry username and a passwrd that is granted user access privileges, as specified n the SHR User Accunt Applicatin Frm. Privileges may include access t shared files, and/r systems/applicatins. 1. PURPOSE The purpse f this plicy is t establish SHR s requirements fr SHR Users and SHR User Accunts. Page 1 f 10

2 2. PRINCIPLES 2.1 All SHR Users are respnsible fr the security f SHR systems/applicatins, resurces and infrmatin. 2.2 By establishing strng user accunt requirements, SHR will better secure its infrmatin and cmputing resurces against unauthrized use. 3. POLICY 3.1 Access All SHR Users shall be assigned a SHR User Accunt t access SHR systems/applicatins The Manager must submit the request using his/her wn SHR User/ Accunt in rder t authenticate the request Emplyees wh were hired prir t April 27, 2009 must sign and submit a SHR Cnfidentiality Agreement (see SHR Plicy Privacy and Cnfidentiality, Appendix A r Privacy InfNet page, (frms)) t Peple and Partnerships befre their SHR User Accunt can be created Emplyees hired after April 27, 2009 will have signed this agreement as part f their emplyee rientatin SHR Users shall nly retain access rights and privileges relevant t their current rles SHR Users shall nt retain prir rights and privileges unless they have a clear business r clinical need and they have been explicitly authrized t d s SHR Users will nt have access t their user accunt while n a LOA. Exceptins t this rule will be evaluated by ITS Security n a case by case basis All SHR User Accunts assigned t an individual wh has been terminated must be disabled. 3.2 Cnduct All SHR Users are respnsible and accuntable fr all activities cnducted thrugh the assigned SHR user accunt SHR Users will strictly adhere t all laws, cpyright laws, cdes f cnduct, SHR privacy and IT plicies, the Lcal Authrity Freedm f Infrmatin and Prtectin f Privacy Act (LA FOIP), the Health Infrmatin Prtectin Act (HIPA), the Persnal Infrmatin Prtectin and Electrnics Dcument Act, (PIPEDA) and any ther applicable federal and/r prvincial legislatin n privacy and cnfidentiality including the cllectin, use, strage and disclsure f persnal health infrmatin SHR Users shall nt utilize a SHR User Accunt r cmputing device t access, distribute, r display bjectinable material, including but nt limited t: Obscene r prngraphic material; Hate prpaganda r discriminatry material; Defamatry and libellus material; and Page 2 f 10

3 Sexually harassing material SHR cmputing resurces are prvided fr SHR business and clinical use. Occasinal, limited use f SHR cmputing resurces is acceptable, prvided it ccurs nly n an emplyee s wn time and is therwise in cmpliance with SHR plicy and cdes f cnduct. Hwever, SHR Users shall nt perfrm actins such as dwnlading streaming audi r vide, dwnlading r ing large files, r string persnal files (e.g. music, phts, sftware) n SHR cmputer hard disks r netwrk drives unless there is a clear, defensible SHR business r clinical ratinale. 3.3 Privacy and Cnfidentiality SHR Users shall have n expectatin f privacy. All infrmatin stred n SHR cmputer equipment r accessed via the SHR netwrk is the prperty f SHR LA FOIP (the Lcal Authrity Freedm f Infrmatin and Prtectin f Privacy Act) allws the general public the right t request access t any administrative recrds in the custdy f SHR thrugh a Freedm f Infrmatin Request ITS reserves the right t actively mnitr SHR systems/applicatins t prtect and maintain the integrity f SHR system resurces and t ensure SHR User cmpliance with SHR plicy and prcedures. 3.4 Security SHR Users shall nt share SHR User Accunt infrmatin and/r passwrd(s). Under n circumstance shall a SHR User allw anther individual t use their assigned SHR User Accunt t access a SHR system/applicatin (see SHR s Passwrd Plicy) SHR Users shall reprt any unauthrized use (r suspicins theref) t their Manager. 3.5 Investigatins SHR will investigate unacceptable use r illegal activity that has been reprted r detected. During the curse f these investigatins it may be necessary fr the investigative resurces t access r cnfirm evidence f bjectinable material as defined in clause abve All investigative findings and SHR User activity r audit reprts will be sent t an ITS Manager, wh will fllw up as required with the apprpriate law enfrcement agency and/r the Care Grup/Service Department s Manager. In the event that law enfrcement becmes invlved, SHR s Directr f Risk Management shall be ntified ITS will nt investigate unsubstantiated (spurius fishing expeditin ) requests by a Manager t view SHR User activity In cnfirmed cases f unacceptable use by an SHR User, it is the Manager s respnsibility t take measures in accrdance with SHR human resurces prcedures SHR and SHR Users will cperate fully with external investigatins where the investigatin is related t a SHR User using SHR resurces inapprpriately. Page 3 f 10

4 4. ROLES AND RESPONSIBILITIES 4.1 SHR Users Access SHR systems/applicatins nly via the SHR User Accunt assigned t them and fr the sle purpse f perfrming wrk/business n behalf f SHR Are respnsible and accuntable fr all activities cnducted n SHR systems/applicatins by access gained thrugh their assigned SHR User Accunt Take necessary safeguards t prevent unauthrized access t SHR systems/applicatins thrugh SHR User Accunts Immediately reprt all unauthrized use, r suspicins f unauthrized use, t a Manager Secure wrkstatins when leaving them unattended. In cases where users are the sle user f a wrkstatin, the wrkstatin shuld be lcked. Fr shared wrkstatins, users shuld lg ff (nt shut dwn r lck their wrkstatins) as this will bth secure the wrkstatin and ensure that the next user has easy access Lg ff f their assigned SHR User Accunt at the end f a wrk day/shift. 4.2 Managers Cmplete, apprve, and submit an Infrmatin Technlgy Services SHR User Accunt Applicatin/Terminatin Frm (UAF), which can be fund n the Frms page f the ITS InfNet, fr: An emplyee, physician, ther healthcare prfessinal, student, cntractr, vendr, r ther persn fr whm they are respnsible, in rder t apply fr a SHR User Accunt and becme a SHR User. A SHR User wh has been terminated, in rder t have their SHR User Accunt disabled n the date f terminatin. A SHR User wh has been transferred, in rder t have their assciated SHR User Accunt privileges suitably updated n the date f transfer. (Nte: Fr U f S staff and residents, their designated department/divisin head r administratr must authrize the UAF. Fr physicians, their department head assumes this rle.) Fr new SHR Users, ensure that a SHR Cnfidentiality Agreement signed by the user has been submitted alng with the SHR UAF. EXCEPTION: Fr new emplyees hired at SHR wned and perated facilities n r after April 27, 2009, SHR cnfidentiality agreements are signed at the emplyee s reginal rientatin Ntify an applicant when their new SHR User Accunt has been activated Ntify ITS Security by when an existing SHR User s privileges need t be changed r reduced (e.g. when their jb rle has changed). Once a user s need t access SHR cmputer systems/applicatins, resurces, r infrmatin has Page 4 f 10

5 disappeared, this access shuld be remved r dwngraded accrdingly Ntify ITS Security f a LOA prir t the start f an LOA, s that the assciated SHR User Accunt can be suspended the same day the LOA cmmences. 4.3 Peple and Partnerships Ntify ITS Security prir t a terminatin fr cause s that the assciated SHR User Accunt(s) can be suspended. 4.4 ITS Security Create a SHR User Accunt upn receipt f a duly authrized UAF and cnfirmatin that a signed SHR Cnfidentiality Agreement is n file fr the assciated applicant Ntify the authrizing Manager when a new SHR User Accunt has been activated, supplying the accunt s username and temprary passwrd Mdify existing SHR User Accunts upn receipt f an authrized request with all relevant infrmatin frm the SHR User s Manager Investigate unacceptable use r illegal activity that has been reprted r detected Disable/suspend a SHR User Accunt: Upn cmmencement f a SHR User s LOA. Upn cnfirmatin f unacceptable use r illegal activity, r if they deem urgent actin is required due t SHR infrmatin r systems being at risk. Prir t a terminatin when requested by a SHR Managerr Peple and Partnerships Upn receipt f a prperly authrized terminatin request. After six mnths f inactivity Back up and delete disabled user accunts after a ttal f 18 mnths f inactivity. Page 5 f 10

6 5. POLICY MANAGEMENT The management f this plicy including plicy educatin, mnitring, implementatin and amendment is the respnsibility f the Directr, Infrmatin Technlgy Services. 6. NON-COMPLIANCE/BREACH Nn-cmpliance with this plicy will result in a review f the incident. A review fr nncmpliance may result in disciplinary actin, up t and including terminatin f emplyment and/r privileges with SHR. 7. REFERENCES Passwrd Plicy Internet Acceptable Use Acceptable Use ing Persnal Health Infrmatin Page 6 f 10

7 PROCEDURE Number: Title: Saskatn Health Regin User Accunt Plicy Authrizatin [ ] President and CEO [X] Vice President, Finance and Crprate Services Surce: Directr, Infrmatin Technlgy Services Crss Index: , , Date Apprved: Dec 6, 2006 Date Revised: May 13, 2013 Date Effective: May 30, 2013 Date Reaffirmed: Scpe: SHR & Affiliates 1. PURPOSE The purpse f this prcedure t establish prcesses assciated with applying fr, activating, using, changing, disabling, and terminating SHR User Accunts. 2. PROCEDURE 2.1 Applying fr a New User Accunt The Manager cmpletes and submits nline a SHR User Accunt Applicatin/Terminatin Frm (UAF) befre the emplyee s first day f emplyment, t initiate the prcess. (Nte: Fr U f S staff and residents, their designated department/divisin head r administratr must authrize the UAF. Fr physicians, their department head assumes this rle.) The Manager ensures that a SHR Cnfidentiality Agreement (see SHR Plicy Privacy and Cnfidentiality, Appendix A r Privacy InfNet page, (frms)) signed by the user has been submitted alng with the SHR UAF. EXCEPTION: Fr new emplyees hired at SHR wned and perated facilities n r after April 27, 2009, SHR cnfidentiality agreements are signed at the emplyee s reginal rientatin. 2.2 Creating and Activating a New User Accunt ITS Security: Cnfirms that a signed SHR Cnfidentiality Agreement is n file fr the assciated applicant. Fr new emplyees hired at SHR wned and perated facilities, ITS Security will check with Peple and Partnerships. Medical Affairs will keep a cpy f all physician signed cnfidentiality agreements. N verificatin necessary. Fr all ther types f users (unpaid students, vlunteers, cntractrs, emplyees f SHR affiliates), a signed cnfidentiality agreement must be Page 7 f 10

8 received by ITS Security befre a new SHR User Accunt can be activated. NOTE: It is the authrizing Manager that is respnsible fr ensuring that a signed Cnfidentiality Agreement is acquired and submitted. Creates the SHR user accunt upn receipt f a duly authrized UAF. NOTE: A minimum f five wrking days ntice is required t create an accunt. Althugh ITS Security strives t prcess requests as quickly as pssible, turnarund times may vary based f the number f requests in the queue. Fr this reasn, It is imperative that Managers submit their request as far in advance as pssible s new accunts can be created and/r activated prir t an emplyee's first day f wrk. Assigns a username and temprary passwrd t create a user accunt. The username and passwrd cmbinatin will be used t grant access rights t infrmatin resurces as requested n the UAF. Ntifies the authrizing Manager after the user accunt is activated, with the user s username and temprary passwrd Manager: Ntifies the applicant f the accunt activatin SHR User: Lgs in fr the first time using the temprary passwrd, and then changes their passwrd when prmpted t d s. The new passwrd must cnfrm t the SHR Passwrd Plicy. 2.3 Using SHR User Accunts Wrkstatin Security Users wh leave their wrkstatins unattended must secure them as fllws: Windws XP: Press the Ctrl, Alt and Delete keys simultaneusly Click the Lck Wrkstatin buttn T unlck the wrkstatin press the Ctrl, Alt and Delete keys again, then lg in t the system t resume wrk Windws Vista & Windws 7: Press the Ctrl, Alt and Delete keys simultaneusly Click the Lck this cmputer buttn T unlck the wrkstatin press the Ctrl, Alt and Delete keys again, then lg back int the system t resume wrk Lgging Off f a SHR User Accunt At the end f a wrk day/shift, SHR Users must lg ff their SHR User Accunt as fllws: Page 8 f 10

9 Windws XP, Windws Vista & Windws 7: Click the Start buttn and select Shutdwn Select Lg ff r Shutdwn frm the selectin list and click the OK buttn 2.4 Changing SHR User Accunt Privileges NOTE: A minimum f five wrking days is required t make changes t a user accunt. Althugh ITS Security strives t prcess requests as quickly as pssible, turnarund times may vary based f the number f requests in the queue. Fr this reasn, It is imperative that Managers submit their request as far in advance as pssible When the User s Authrizing Manager Remains the Same The Manager s the request with all relevant infrmatin regarding the change t (Nte: A UAF is nt required.) When the User Transfers t a New Psitin If a SHR User transfers t a new jb, rle, r psitin, their Manager shall cmplete the Transfer sectin f the UAF and submit it t ITS Security prir t the transfer date. This will allw the accunt access rights t be suitably updated the day f the SHR User s transfer. 2.5 Changing SHR User Accunt Prperties When a SHR User s infrmatin changes (e.g. last name, site, phne number, etc.), the user s Manager(Department Head fr physicians) s the request with all relevant infrmatin regarding the required change t (Nte: A UAF is nt required.) 2.6 Terminatin f SHR Users The SHR User s Manager cmpletes the Terminatin Sectin f the UAF and submits it t ITS Security prir t the terminatin date. This will ensure the accunt is disabled the day f the terminatin. In cases f terminatin fr cause, Peple & Partnerships may assume respnsibility fr infrming ITS Security f a pending terminatin. 2.7 Lcking/Disabling f User Accunts SHR User Accunts are lcked/disabled in the fllwing circumstances: Accunt Misuse Fr urgent situatins that may pse a security risk and require immediate accunt suspensin, the Manager shall call the ITS Service Desk at Otherwise, unauthrized r imprper use (r suspicin theref) may be reprted by ing the ITS Security Investigatins accunt, Leave f Absence (LOA) The Manager must ntify ITS Security f a LOA prir t its start date s that the Page 9 f 10

10 assciated SHR User Accunt can be suspended the same day the LOA cmmences. The Manager s all relevant LOA infrmatin t (Nte: A UAF is nt required.) If three attempts t access a user accunt are unsuccessful The accunt is suspended fr15 minutes. After 15 minutes, the user may try again If they are nt accessed fr six mnths 2.8 Reactivating User Accunts The Manager s all relevant infrmatin t t have a user accunt reactivated. (Nte: A UAF is nt required.) 2.9 Archival/Remval f User Accunts After a ttal f 18 mnths f inactivity, disabled/terminated user accunts will be backed up and deleted. 3. PROCEDURE MANAGEMENT The management f this prcedure including plicy educatin, mnitring, implementatin and amendment is the respnsibility f the Directr, Infrmatin Technlgy Services. 4. NON-COMPLIANCE/BREACH Nn-cmpliance with this prcedure will result in a review f the incident. A review fr nncmpliance may result in disciplinary actin, up t and including terminatin f emplyment and/r privileges with SHR. Page 10 f 10

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