Accounting Finance:Document Imaging Management Policy

DIMP - Version Control Table

Document	Version #	Date of Issue	Description (Addition/Revision)	DMS Owner (date/doc ref. etc)
DIMP	1.0	July 3, 2003	Initial draft
DIMP	1.1	July 8, 2003	Amendments to section 2.1.2 and inclusion of reference to Payroll in sections 4.1, 4.2 & 4.3. Added Sections 3.3 (Food & Drugs Act/GMP) and 3.4 (Employment Standards Amdt. Act)	Minutes to UNITY Project Status Meeting July 7, 2003 and email (Nancy Ng) dated July 8, 2003
DIMP	1.2	Jan. 20, 2004	Amendments to section 2.1.2	Minutes to UNITY Project Status Meeting January 19, 2004
DIMP	1.3	Aug. 04, 2004	Amendments to section 2.1.2	Document Status Report August 04, 2004
DIMP	1.4	May 05, 2005	Amendments to section 2.1.2	Document Status Report May 05, 2005
DIMP	1.5	Oct. 10, 2006	Amendments to section 2.1.2	Document Status Report Oct. 10, 2006
DIMP	1.6	Sept. 15, 2008	Amendments to section 2.1.2	Document Status Report Sept. 15, 2008
DIMP	1.7	Jan. 26, 2009	Amendments to section 2.1.2	Document Status Report Jan. 26, 2009
DIMP	1.8	Jan. 29, 2010	Amendments to section 2.1.2	Document Status Report Jan. 31, 2009
DIMP	1.9	May 03, 2012	Amendments to section 2.1.2	Document Status Report May 31, 2012
DIMP	1.10	May 03, 2012	Amendments to section 2.1.2	Document Status Report March 26, 2013
DIMP	1.11	Jan. 22, 2014	Amendments to section 2.1.2	Self-Inspection Report January 22, 2014
DIMP	1.12	Jul. 20, 2015	Amendments to section 2.1.2	Self-Inspection Report January 20, 2016
DIMP	1.13	May 11, 2018	Amendments to section 2.1.2	Self-Inspection Report May 11, 2018

Using the DIMP

• This Document Management Imaging Policy (DIMP) Manual has been designed primarily for online use. Excessive printing of the manual is discouraged in order to aid version control and minimize costs.
• Virtually all content is self-contained within a subject ‘table’ to make amendment and/or extraction as easy as possible.
• The primary means of document navigation is via the Table of Contents. However, navigation is aided by the use of ‘hyperlinks’. These dynamic links allow users to jump from one subject to a related subject (or punch out to the documents located on the Internet) by simply clicking on the link. A link is displayed by underlined blue text. To return to the original location click the back button located on the web browswer. Specific topics of interest (within a sentence of paragraph) have been ‘bookmarked’ and their related subjects hyperlinked to further aid navigation and to link closely related issues.
• All references to actual Federal/Provincial regulations are in bold red text.
• The online version of the DIMP manual is to be maintained as ‘read only’.
• Glossary of Terms has been included clarification purposes.

Introduction

Purpose

The purpose of this document is to detail the management policy and business processes to be applied in respect of documents:

• Scanned and stored in the Gauss Document Management System (DMS)
• Accessed, viewed and retrieved from the DMS
• Destroyed as a result of scanning operations

In addition, this document is intended to demonstrate linkage to the principals required for compliance with Federal/Provincial legislation, including:

• The Personal Information Protection and Electronic Documents Act
• Food and Drugs Act (Good Manufacturing Guideline 2002 Edition)
• Income Tax Act
• Employment Insurance Act
• Employment Standards Amendment Act
• Limitation Act

Background

uniPHARM’s vision is to operate, as far as is practical, in a ‘paperless’ environment. The UNITY Project has provided the means for realising this vision through the installation of the Gauss Document Management System (DMS). This system provides uniPHARM with the capability to capture information from a wide range of paper based or electronic sources, store an electronic image of document, and allow images to be retrieved on an enterprise basis.

The benefits of the DMS are clear in terms of efficiency, space utilization and online access to information. However, in order to ensure that the DMS itself is operated efficiently and to comply with all legal requirements covering document imaging, retention, access and privacy, it is necessary to formalize polices through Standard Operating Procedures (SOPs). This approach is consistent with those already in place in respect of GMP, Project Management and IT Management.

Ownership/Roles/Responsibilities

Background

The Personal Information Protection Act states that an organization is responsible for personal information under its control, including personal information that is not in the custody of the organization. The Act requires an organization to designate one or more individuals to be responsible for ensuring that the organization complies with the regulations.

Provincial/Federal Regulations: Bill 38, Part: 2, 4 (3)

Role Definition

The primary roles associated with the DMS are defined as follows:

Role	Definition
Owner	Designated individual who is held responsible by the uniPHARM Leadership Group for the efficient management of the DMS and compliance with all relevant legislation
Administrator	Designated individual who is held responsible by the Owner for the definition of Document Classes and publication of Batch Classes
Operator	Designated individual who is held responsible by the Owner for the efficiency of scanning operations and the quality of scanned images
Technical/Security Administrator	Designated individual who is held responsible by the Owner for the efficiency of application support and security administration
Delegate	Designated individual held responsible by the Owner for fulfilling the role (as approved by the Owner) of : Owner Administrator Operator Technical/Security Administrator
User	Any individual who has been approved to: initiate/propose that documents be scanned view scanned documents in accordance with the DMS Security Policy and possesses an authenticated iSeries User Name/Password.

Ownership/Roles/Responsibilities

The following table details the individuals who will be responsible and accountable for the management and delivery of the DMS and the extent of their responsibilities:

Name	Nancy Ng
Role	Owner of the DMS
Responsibilities	Accountable to the uniPHARM Leadership Group for ensuring that all aspects of DMS operations comply with relevant legislation Approves document classes to be scanned Approves access to the DMS Reports the status of the DMS to the Leadership Group on a monthly basis Conducts a ‘self-inspection’ process to verify the operation of the DMS SOPs at least annually Approves DMS training requirements Responds to/resolves/escalates DMS issues Plans and oversees the scanning of historical documents Scans ‘management-in-confidence’ documentation Maintains the currency of the DIMP and DMS Log
Delegate	Christine Tung

Name	Christine Tung
Role	System Administrator for Finance, Buying, Human Resources and Retail Services Delegate to Nancy Ng
Responsibilities'	Accountable to the DMS Owner for efficient definition and publication of approved document classes Responsible for the scanning station located in the Finance area Monitors the scanning usage and reports ‘dongle’ rate to the DMS Owner as per the DMS Reporting SOP Defines and publishes documents classes as trained and in accordance with the Gauss VIP Image Capture Administrator Manual and the DMS Administration SOP Provides advice regarding indexing, validation, verification and publishing of document classes as required Reports issues related to Administration operations to the DMS Owner via the DMS Issue Resolution SOP Fulfills the obligations of the DMS Owner as required
Delegate	Nancy Ng

Name	Gordie Lee
Role	Scanning Operator for Distribution Centre Operations (except documents containing Personal Information and Management-in-Confidence)
Responsibilities	Accountable to the DMS Owner for efficiency of scanning operations Scans documents classes as trained and in accordance with the Gauss VIP Image Capture Administrator Manual and the DMS Scanning SOP Reports issues related to scanning operations to the DMS Owner via the DMS Issue Resolution SOP
Delegates	Gerald Petznek

Name	Customer Service
Role	Scanning Operator for Finance, Buying, Human Resources and Retail Services (except documents containing Personal Information and Management-in-Confidence)
Responsibilities	Accountable to the DMS Owner for the efficiency of Finance, Buying, and Retail Services scanning operations Scans documents classes as trained and in accordance with the Gauss VIP Image Capture Administrator Manual and the DMS Scanning SOP Reports issues related to scanning operations to the DMS Owner via the DMS Issue Resolution SOP
Delegates	Nathalie Rodrigues, Cheryl Corkum, Ravinder Atwal

Name	Angela Chan
Role	Scanning Operator for documents containing Personal Information only
Responsibilities	Accountable to the DMS Owner for the efficiency of ‘personal information’ document scanning operations Scans documents classes as trained and in accordance with the Gauss VIP Image Capture Administrator Manual and the DMS Scanning SOP Reports issues related to scanning operations to the DMS Owner via the DMS Issue Resolution SOP
Delegates	Nancy Ng

Name	Norwin Uy
Role	Technical Support/Security Administrator
Responsibilities	Accountable to the DMS Owner for maintaining DMS hardware and software operability – 99% uptime is required Accountable to the DMS Owner for system security administration. This means maintaining secure access to scanned documents on both the iSeries and VIP Image Capture/VIP Document Manager (and in particular – documents subject to the Personal Information Protection Act) in accordance with the DMS Security Policy. Ensures that standard arrangements are in place for system backup and disaster recovery Ensures that delegate is fully familiar with the role and responsibilities of the Technical Support/Security Administrator Reports issues related to technical support and security administration to the DMS Owner via the DMS Issue Resolution SOP
Delegate	Darren Freedman

Impact of Legislation

Income Tax Act and Employment Insurance Act

Provincial/Federal Regulations: Canada Customs and Revenue Agency, Information Circular No: 78-10R3 dated October 5, 1998

Federal regulations concerning the imaging of tax/employment insurance related documentation require the following:	uniPHARM’s interpretation of and response to these requirements is as follows:
Someone in the organization has confirmed in writing that the (imaging) program will be part of the usual and ordinary activity of the organization’s business.	See Statement of Responsibility and Authority for a statement from the CEO of uniPHARM confirming that the (imaging) program will be part of the usual and ordinary activity of uniPHARM’s business. This statement is available to be published to any regulatory body as required.
Systems and procedures are established and documented.	The systems and procedures governing the use of the document management system are laid down in this policy document.
A logbook kept showing: -The date of imaging	All images retained within the DMS are automatically logged by the system. This audit facility enables uniPHARM or any authorized inspector to track and trace all scanned images and record deletions. In the event of system failure and the loss of the automatic auditing capability, proper safeguards have been established within this policy document to ensure that a backup of the system records is available as part of an overall business continuity strategy and disaster recovery plans.
-The signatures of the persons authorizing and performing the imaging	See the table at Acceptance of Responsibility for the signatures of all persons authorizing and performing the imaging. uniPHARM considers that the SOPs established within this policy document and the fact that all batches are to be initialled (electronically) by the scanning operator should be sufficient to establish the identity of scanning authority and operation.
-A description of the records imaged	A description of all documents approved to be scanned is maintained within the DMS Log as required under this document management policy.
-Whether source documents are destroyed or disposed of after imaging, and the date a source document was destroyed or disposed of	Scanned documents are to be disposed of under standing waste paper disposal arrangements and in accordance with the DMS Document Scanning SOP. All scanned documents are to be deemed ‘disposed of’ within 1 month of the date of scanning.
-The imaging software maintains an index to permit the immediate location of any record, and the software inscribes the imaging date and the name of the person who does the imaging	All documents scanned into the DMS will be indexed as defined in the Batch Class creation process (see VIP Image Capture Manual). The indexing process will enable all scanned documents to be retrieved efficiently. All batches scanned are automatically date/time stamped and are initialled (electronically) by the operator.
-The images are of commercial quality and are legible and readable when displayed on a computer screen or reproduced on paper	The scanning operation has in-built quality control checks to ensure that documents scanned are readable on screens. The quality of images is checked via the DMS Self-Inspection SOP
-A system of inspection and quality control is established to ensure the maintenance of the required logs, indexing, and quality	See DMS Self-Inspection SOP
-After reasonable notification, equipment in good working order is available to view, or where feasible, to reproduce hard copies	Hard copies of scanned images can be produced via the DMS (subject to security access permissions)

Personal Information Protection & Electronic Documents Act

Provincial/Federal Regulations: Privacy Commission, Bill - 38 Part 2

To be compliant with Federal regulations, organizations are required to:	uniPHARM’s interpretation of and response to these requirements is as follows:
Consider what a reasonable person would consider appropriate in the circumstances (re: protection of personal information)	See Statement of Responsibility and Authority for a statement from the CEO of uniPHARM confirming that the document management policy and practices are considered reasonable to protect the privacy of personal information subject to imaging.
Accept responsibility for personal information under its control, including personal information that is not in the custody of the organization	See Statement of Responsibility and Authority for a statement from the CEO of uniPHARM confirming acceptance of responsibility for personal information under uniPHARM’s control. Personal information, not in uniPHARM’s custody is subject to a separate policy.
Designate one or more individuals to be responsible for ensuring that the organization complies with the Act (the individuals may delegate the duties required)	See the table at Ownership/Roles/Responsibilities for details of the designated individual and delegates. The responsibility extends only to personal information processed by the DMS.
Make available to the public, the position, name or title and contact details of each designated (or delegated) individual responsible for compliance	This is not within the scope of this Document Imaging Management Policy (DIMP)
Develop and follow policies and practices that are necessary to meet the obligations of the Act	The systems and procedures governing the use of the document management system are laid down in this DIMP
Develop a process to respond to complaints	This is not within the scope of this DIMP
Make information available upon request about: -The policies and practices followed -The complaint process	This Document Imaging Management Policy is available to all uniPHARM staff via the following link: Document Imaging Management Policy The complaint process is not within the scope of this DIMP
Make a reasonable effort to ensure that personal information collected by or on behalf of the organization is accurate and complete, if the personal information -is likely to be used by the organization to make a decision that affects the individual to whom the personal information relates, or -is likely to be disclosed by the organization to another organization.	The content of personal information scanned into DMS is not within the scope of this DIMP. However, details related to the actual source document such as the scanning date are automatically captured by the system log.
Protect personal information in its custody or under its control by making reasonable security arrangements to prevent unauthorized access, collection, use, disclosure, copying, modification or disposal or similar risks	Personal information scanned into the DMS is subject to security measures specifically designed to prevent unauthorized access e.g. access to all document classes categorized as ‘personal’ is restricted to personal described at Security/Access by means of in-built system security functionality. It is considered that it is extremely difficult to modify a scanned image of a source document. Thus the risk of this occurring is very low indeed. In any event this DIMP expressly forbids the unauthorized modification, use, disclosure, copying, and disposal etc. of scanned images of documents containing personal information. The DMS is responsible for conducting a self-inspection process at least annually to ensure that the DMS remains compliant.
Retain personal that information for at least one year after using it so that the individual has a reasonable opportunity to obtain access to it (if an organization uses an individual's personal information to make a decision that directly affects the individual)	See ‘Personal’ category - Document Image Retention Policy
Destroy its documents containing personal information, or remove the means by which the personal information can be associated with particular individuals, as soon as it is reasonable to assume that -the purpose for which that personal information was collected is no longer being served by retention of the personal information, and -retention is no longer necessary for legal or business purposes	See Personal Information Document Scanning SOP

Food and Drugs Act/GMP Guidelines (2002)

Provincial/Federal Regulations: GMP Regulation, C.02.022, C.02.024 Part 2.1, 2.1.1, 1a & 1b, 2.1.2, 2.2

Federal regulations require that:	uniPHARM’s interpretation of and response to these requirements is contained within the GMP Manual and summarized as follows:
Every wholesaler of a drug retains records of the sale of each item, which enable a recalls from the market for a period of at least one year after the expiration date of the lot or batch unless otherwise specified in their establishment licence.	See ‘Business’ category - Document Image Retention Policy. Also, under the GMP Records SOP, the IT Manager is to ensure that, at a minimum, data is to be immediately accessible from the live production system (or within 1 [one] day if from a verifiable back up source) that will enable any drug to be recalled from any Customer for a period of at least one year after the expiration date of that drug.
Distribution records of all sales of drugs are maintained including those of professional samples.
Records of all sales are retained or readily accessible in a manner that will permit a complete and rapid recall of any lot or batch of a drug. This does not necessarily imply tracking by lot number.
Every wholesaler to maintain records of the results of the self-inspection program required by section C.02.012 and of any action taken in connection with that program; and retain those records for a period of at least three years.	It is the responsibility of the IT Manager to ensure that the contents of all folders located within the GMP the folders are backed up on a regular basis and retained for a minimum of 3 (three) years.
Records to indicate that all customers that have received a recalled drug have been notified.	See ‘Business’ category - Document Image Retention Policy.
Records of the results of the self-inspection program, evaluation and conclusions, and corrective measures implemented.	See DMS Self-Inspection SOP See DMS Reporting SOP

Employment Standards Amendments Act

Provincial/Federal Regulation: Section 48 Subsection 3

Provincial regulations require that:	uniPHARM’s interpretation of and response to these requirements is as follows:
An employer must retain payroll records for 4 years	The information contained within payroll records has been categorized as ‘personal’ for document imaging purposes. See ‘Personal’ category - Document Image Retention Policy.

Limitation Act

Provincial/Federal Regulation: Section 6

Provincial regulations require that:	uniPHARM’s interpretation of and response to these requirements is as follows:
An employer must retain human resources records for 7 years	The information contained within payroll records has been categorized as ‘personal’ for document imaging purposes. See ‘Personal’ category - Document Image Retention Policy.

Statement of Responsibility and Authority

I confirm that:

• The (imaging) program will be part of the usual and ordinary activity of uniPHARM’s business.

• The document management policy and practices are considered reasonable to protect the privacy of personal information subject to imaging.

• uniPHARM accepts responsibility for personal information to be processed and retained with the Document Management System

I consider that the Document Imaging Management Policy including Standard Operating Procedures are sufficient to ensure uniPHARM is currently and will remain compliant with current legislation related to the processing, retention, quality, security and availability of documents scanned into the Document Management System.

I consider that responsibilities placed on any one individual are not so extensive as to present any risk to quality.

I hereby grant authority to the individuals listed at Acceptance of Responsibility to carry out their assigned responsibilities in accordance with Document Imaging Management Policy regulations. When the primary individual responsible is absent, authority is automatically transferred to the appropriate delegates. In the event that both the primary individual and delegates are absent, authority is automatically transferred to the uniPHARM Leadership Group to recommend and implement a reasonable interim solution.

uniPHARM Wholesale Drugs Ltd.

Authorized Signatory: Ron Gracan

Title: General Manager

Signature: __________________________________

Date: _________

Acceptance of Responsibility

I hereby accept the authority granted to me at Statement of Responsibility and Authority to carry of the responsibilities defined in sections Role Definition and Ownership/Roles/Responsibilities

Signatory	Primary Role	Signature	Date
Nancy Ng	Owner
Christine Tung	Administrator
Customer Service	Operator
Gordie Lee	Operator
Angela Chan	Operator (Personal Information)
Gerald Petznek	Operator Delegate
Norwin Uy	Technical/Security Administrator
Darren Freedman	Technical/Security Administrator delegate

Document Policies

Categorization

The following document categories will apply throughout the DMS:

• Business. This is a non-legal, non-personal document required for business purposes only e.g. query resolution, reference, business intelligence etc. Examples include: waybills, packing slips etc.
• Legal. This is a document the treatment of which is covered by specific legislation (e.g. the Income Tax Act, the Employment Insurance Act) other than the Protection of Personal Information and Electronic Documents Act (see below).
• Management-in-Confidence. This is a document that is for ‘management eyes’ only. Examples include: strategic plans, confidential business notes, correspondence with Directors etc.
• Personal. This is a document that contains personal information covered by the Protection of Personal Information and Electronic Documents Act, the Employment Standards Amendment Act (Payroll Records) and the Limitation Act (Human Resources).

It is recognized that there will be overlap between document categories e.g. a legal document may contain personal information. Where such overlap is identified, the following order of precedence applies:

1. Personal

2. Legal

3. Management-in-Confidence

4. Business

Image Retention

Provincial/Federal Regulations: Canada Customs and Revenue Agency, Information Circular No: 78-10R3 dated October 5, 1998, Para 30, Privacy Commission, Bill - 38 Part 9 - Care of Personal Information, Para 35, Employment Standards Amdt Act Section 48 Subsection 3, Limitation Act 6

The following retention periods apply in respect of the document categories:

• Business. 3 years (unless otherwise specified by the DMS Owner following instruction from the uniPHARM Leadership Group)
• Legal. Under the Income Tax Act, books, records, and their related source documents have to be kept for a minimum of six years from the end of the last tax year to which they relate. The tax year is the fiscal period for corporations. Under the Employment Insurance Act and Canada Pension Plan, the retention period begins at the end of the calendar year to which the records relate.

Based on the above, the retention period for documents categorized as ‘legal’ is 7 years.

• Management-in-Confidence. 3 years or as specified on a case by case basis by Management
• Personal. Under the Personal Information Protection Act, if an organization uses an individual’s information to make a decision that directly affects the individual, the organization must retain that information for at least one year after using it so that the individual has a reasonable opportunity to obtain access to it.

An organization must destroy its documents containing personal information, or remove the means by which the personal information can be associated with particular individuals, as soon as it is reasonable to assume that:

• The purpose for the that personal information was collected is no longer being served by retention
• Retention is no longer necessary for legal or business purposes

Under the Employment Standards Amdt Act (2002) organizations are to retain payroll records for 2 years. Under the Limitation Act organizations are to retain human resources records for 6 years. Based on the above, the policy is to retain personal information for 7 years beyond the duration of an individual’s employment or association (e.g. a Director) with uniPHARM.

It is recognized that there will be overlap between document categories e.g. a legal document may contain personal information. Where such overlap is identified, the following order of precedence applies in respect of retention periods:

1. Personal

2. Legal

3. Management-in-Confidence

4. Business

Security/Access

The following security access will apply to document images stored within the DMS

Business	Accessible by: -All permanent uniPHARM staff -Temporary uniPHARM employees (as required and approved by the DMS Owner) -uniPHARM Shareholders (as required and approved by the DMS Owner) -uniPHARM Customers (as required and approved by the DMS Owner) -Contractors (as required and approved by the DMS Owner) -External auditors (as required) -Government inspectors (as required)
Legal	Access restricted to: -Specified members of uniPHARM Management -Specified members of uniPHARM staff -External auditors (as required) -Government inspectors (as required)
Management-in-Confidence	Access restricted to specified members of uniPHARM Management
Legal	Access restricted to: -Named Human Resources personnel (including Payroll Personnel) -DMS Owner -uniPHARM Management

Standard Operating Procedures

Background

Legislation related to the treatment of information stored electronically requires that organizations have proper systems and processes in place to ensure compliance regulations.

In addition to the policies laid down in this document, the following Standard Operating Procedures have been developed:

• Document Scanning Definition SOP
• Document Scanning Approval SOP
• Document Administration SOP
• Document Scanning SOP

-Standard Scanning SOP

-Personal Information Scanning SOP

-Management-in-Confidence Scanning SOP

• DMS Reporting SOP
• DMS Issue Resolution SOP
• DMS Self-Inspection SOP

Document Scanning Definition SOP

Purpose:

• To define document classes
• To capitalize on users first-hand knowledge of workflow.
• To define/document the scanning workflow/process specific to a document class
• To assist Users to understand when scanning will occur within a business process

Responsibility:

• DMS Users are responsible for defining the scanning workflow
• DMS Owner is responsible for the currency and completeness of the DMS Log and the overall conformance to the SOP

Standard Operation Procedure:

• Any employee, Director, Shareholder, contractor may initiate (i.e. suggest or propose) that a specific document class be scanned. If the initiator is not a uniPHARM employee or does not have access internal systems, the matter should be referred to the DMS Owner who will appoint a ‘User’ to represent the initiator.
• User identifies a document for which scanning has potential benefits
• User maps the current workflow associated with the document and identifies the precise point for scanning of the document to take place
• User completes the following fields in the DMS Log, located at: Document Management Log (note: completion instructions are available by clicking on column headers)

- Document Title

- Document Description

- Primary Purpose

- Secondary Purpose (if applicable)

- Benefits

- Category (select from; Business, Legal, Management-in-Confidence, Personal)

- Information Access (select from: Finance, Customer Service, DC Operations, Human Resources, Purchasing, Retail Operations, Customers, Shareholders, Directors, Contractors, Vendor, Government, Auditors, Other (specify).

- Retention Period

- Index Field (choose and define up to 7 index fields)

- Quantity on hand

- Annual quantity

- Current storage location

- Suggested scanning point

- Completed by

- Date completed

• Upon completion (and save) of the DMS Log, the User is to alert the DMS Owner (by email) of the availability of the document scanning definition , in accordance with the Document Scanning Approval SOP

Document Scanning Approval SOP

Purpose:

• To control what document classes are scanned
• To ensure compliance with all relevant legislation
• To avoid unnecessary scanning
• To promote enterprise communication and collective decision-making

Responsibility: The DMS Owner is responsible for conformance to the Document Scanning Approval SOP

Standard Operating Procedure (see workflow diagram ref: DSA dated June 30, 2003)

• Each document class to be scanned into the DMS is to be approved by the DMS Owner prior to any documents being scanned
• A document class need be approved ONLY ONCE, unless there is significant changes in the information contained within the documents to be scanned e.g. the redesign of a document previously categorized as a ‘business’ document, now includes ‘personal’ information.
• Upon receipt of an email alert (see Document Scanning Definition SOP), the DMS Owner is to review the proposal, accept/reject the submission, update the DMS Log accordingly (columns AX, AY, AZ & BA) and advise the User of the decision (by email).
• For accepted submissions, the DMS Owner is to convene a meeting to be attended by representatives of the relevant user community and update the DMS Log (column BB).
• The User who submitted the proposal is to be supply the meeting with all appropriate material associated with the document class(es) under review e.g. samples, workflow
• The objective of the User Meeting is to reach a collective decision regarding the requirement to scan and identify any special considerations (if applicable). The DMS Owner will be the final arbiter in the event that a consensus cannot be reached.
• For rejected submissions, the DMS is to update the DMS Log (column BC) and advise the user/initiator officially of the outcome (an email or a link to the minutes of the meeting will be sufficient)
• For accepted submissions that DO NOT include ‘personal information’, the DMS Owner is to update the DMS Log (columns BC & BF) and issue a Scanning Approval (an email is sufficient) to the appropriate DMS Administrator (see Document Administration SOP)
• For accepted submissions that DO include ‘personal information’, the DMS Owner is to update the DMS Log (column BD) and initiate the ‘Consent Process’. This process is not part of the Document Imaging Management Policy. Once proper consent has been obtained, the DMS Owner is to update the DMS Log (columns BE & BF) and issue a Scanning Approval (an email is sufficient) to the appropriate DMS Administrator (see Document Administration SOP)
• For accepted submissions, the DMS Owner is to arrange for the workflow diagram (indicating the precise scanning point) to be incorporated in the DIMP.

Document Administration SOP

Purpose:

• To ensure document classes are approved prior to the commencement of document administration
• To ensure compliance with all relevant legislation
• To ensure that security measures are in place prior to the availability of a document class
• To ensure that users are aware of when scanning operations will commence

Responsibility: The DMS Owner is responsible for conformance to the Document Administration SOP. The DMS Administrator is responsible for creating document classes and for initiating the security aspects The Technical/Security Administrator is responsible for setting the correct access permissions and document retention periods.

Standard Operating Procedure (see workflow diagram ref: DSA dated June 30, 2003)

• Only documents classes that been approved by the DMS Owner are to be created by the DMS Administrator
• On receipt of a Scanning Approval email from the DMS Owner, the DMS System Administrator is to create a Batch Class Definition in accordance with:

- Specific instructions from the DMS Owner

- The definition/requirements recorded in the DMS Log

- The outcome of the User Meeting

- Further discussions with the User Community

- The conventions agreed in initial training

- The VIP ImageCapture Administrator Manual Version 8.1

- VIP ImageCapture Version 8.1 online help

• The Batch Class definition is to follow the standard process:

- Create field types

- Create document class

- Create form type

- Create batch class

- Publish batch class

• Upon publication of a batch class, the DMS Administrator is to request (by email) the DMS Technical/Security Administrator to set the security access permissions and retention period and update the DMS Log (columns BH, BI & BJ)
• On receipt of a request the DMS Technical/Security Administrator to set the security access permissions and retention period, update the DMS Log (column BK) and inform the DMS Owner and DMS Administrator accordingly (by email).
• Once satisfied that all quality, DMS process, scanning workflow, security and retention aspects are complete, the DMS Owner is to inform the User Community that scanning operations may commence (User attention should be drawn to the precise scanning point previously defined) and complete column BL of the DMS Log.

Document Scanning SOP

Purpose:

• To ensure compliance with all relevant legislation
• To define how documents are to be prepared for scanning
• To define when source documents are to be disposed of

Responsibility: The DMS Owner is responsible for conformance to the Document Scanning SOP. Users are responsible for the proper preparation of documents to be scanned The DMS Operator is responsible for the efficiency and currency of the scanning workload, the quality of the scanned images and disposal of source documents

Standard Operating Procedure - see workflow diagrams ref:

- SDS (Standard Document Scanning) dated June 30, 2003

- PIDS (Personal Information Document Scanning) dated June 30, 2003

- MICDS (Management-in-Confidence Document Scanning) dated June 30, 2003

• Standard Document Scanning:

- Standard Document Scanning refers to documents that are not classified as ‘Personal’ or ‘Management-in-Confidence’

- The timing of scanning operations throughout the working day will be as specified in the workflow diagram incorporated in the DIMP by the DMS Owner. The schedule for scanning of historical documents will be published by the DMS Owner

- Users are to remove staples, paper clips etc. from all documents prior to placing the prepared documents in the appropriate scanning tray

- The DMS Operator is to:

• identify the document class, select the appropriate batch class and scan documents into the DMS in accordance with training and instructions
• initial (electronically) each batch class scanned
• check the quality of the scanned image(s) produced and adjust accordingly
• release qualified images to the iSeries for viewing on an enterprise basis
• follow standard practice for the disposal of source documents

- All source documents are to be rendered for disposal within 1 month of scanning

• Personal Information Document Scanning (as for 'Standard' except as noted below):

- Documents categorized as ‘personal’ will be handled, scanned and disposed of by the personnel named at Section 2.1.2

- The DMS Operator is to schedule scanning time at a scanning station, log out of the system immediately scanning operations are complete and remove source documentation from the scanning station area.

• Management-in-Confidence Document Scanning (as for 'Standard' except as noted below):

- Documents categorized as ‘Management-in-Confidence’ will be handled, scanned and disposed of by the personnel named at Section 2.1.2

- The DMS Operator is to schedule scanning time at a scanning station, log out of the system immediately scanning operations are complete and remove source documentation from the scanning station area.

DMS Reporting SOP

Purpose:

• To provide a standard process to report the status of the DMS and track ‘dongle’ usage

Responsibility:

• The DMS Owner is responsible for:

- conformance to the DMS Reporting SOP

- reporting DMS status to the Leadership Group

- maintenance of the DMS Usage Log

• The DMS Administrator is responsible for tracking and recording dongle usage per scanning station

Standard Operating Procedure

• At noon on the last working day of each month, the DMS Administrator is to record the dongle usage for their scanning station in the DMS Usage Log. The DMS Usage Log is part of the DMS Log located at: Document Management Log
• By noon on the first working day of each month, the DMS Owner is to complete a status report and submit this (by email or link) to the Leadership Group for review.

Status Reports are to be saved in the DMS Status Report Folder located at: DMS Status Report folder

• The Status report is to include (but is not limited to) the information detailed at the DMS Status Report Template at the Document Management Status Report Template
• The DMS Owner is to report the results of the DMS Self-Inspection SOP (via the Self-Inspection Log) to the Leadership Group on an annual basis, and within 2 weeks of the audit occurring.
• DMS records (status reports, DMS Log, DMS Usage Log, DMS Self-Inspection Logs etc.) are to be categorized as ‘business’ documents and retained for a minimum of 3 years in accordance with the retention policy at Image Retention.

Document Management Status Report Template

Document Management Status Report

as at: DD/MM/YYYY

Status Period:	xxxxx to xxxxxx, 200x
DMS Owner:	Nancy Ng
Complete by:	Xxxxx xxxxxxxxx
Date completed:	DD/MM/YYYY

Key Performance Indicators
DMS Team Satisfaction	G
User Satisfaction	G
Quality	Y
Dongle Usage	R

Status

Dongle Usage

Scanning Station	Monthly Dongle Usage	Cumulative Dongle Usage (Annual)
Administration	Xxxx	Xxxx
Distribution Centre	Xxxx	Xxxx

Status of Compliance

Legislation	Complaint	Non-complaint
Protection of Personal Information Act	Y/N	Y/N
Income Tax/Employment Insurance Act	Y/N	Y/N

Issues

Risks

DMS Issue Resolution SOP

Purpose:

• To provide a standard process to record, escalate and resolve issues

Responsibility:

• Issue Initiators (typically Users) are responsible for instigating issues via the DMS Issue Log
• The DMS Owner is responsible for:

- conformance to the DMS Issue Resolution SOP

- reviewing and resolving issues

- maintenance of the DMS Issue Log

- escalating issues to the Leadership Group as necessary

Standard Operating Procedure -see workflow diagram ref: IR dated July 1, 2003

• Any DMS User can initiate an issue
• DMS Users are to complete the following columns of the DMS Issue Log:

- Issue Description

- Date Issue Submitted

- Submitted by

• The DMS Issue Log is part of the DMS Log located at: Document Management Log
• Upon completion of the DMS Issue Log, the DMS Owner is to be alerted by email.
• On receipt of an email alert, the DMS Owner is to review and resolve the issue.
• The DMS Owner is to complete the following columns of the DMS Issue Log:

- Date Issue Reviewed

- Issue Status, record/update status as follows:

• Open
• Escalated
• Closed

- Outcome

- Date referred to Leadership Group (if applicable)

- Date User informed of outcome

• The DMS Owner is to inform the User (Initiator) of the outcome of the issue review/escalation (if applicable) by email or reference to meeting minutes etc.
• The DMS Owner is to maintain the currency and accuracy of the DMS Issue Log

DMS Self-Inspection SOP

Purpose:

• To ensure that the entire DMS is audited on an annual basis in order to promote:

- Continued compliance with current and anticipated legislation

- Process improvements

- Technological upgrades (as necessary)

- An assessment of training needs

Responsibility:

• The DMS Owner is responsible for conducting the DMS Self-Inspection SOP on an annual basis and reporting the results to the Leadership Group

Standard Operating Procedure

• The DMS Owner is to audit the DMS on an annual basis via a process of ‘self-inspection’. This means that all aspects of the DMS are to be reviewed and assessed for quality and compliance.
• At a minimum, the DMS Owner is to complete the DMS Self-Inspection Log (below). The DMS Self-Inspection Log is to be saved in the DMS Self-Inspection Folder located at: DMS Self-Inspection Report folder
• The DMS Owner is to report the results of the DMS Self-Inspection SOP to the Leadership Group (via the Self-Inspection Log) on an annual basis, and within 2 weeks of the audit occurring, in accordance with the DMS Reporting SOP.

Document Management System - Self-Inspection Log

This form can be found and printed in the Document Imaging Management Policy under section '5.8.1 Document Management System - Self-inspection Log' on Page 40.

Glossary of Terms

Term	Definition
Backup	Refers to the copying of electronic files for recovery purposes.
Batch Class	Describes how documents are to be processed with the DMS.
Bookmark	Electronic marker linked by a 'hyperlink' (see below).
DIMP	Document Imaging Management Policy.
DMS	Document Management System.
DMS Log	A record of document types submitted for approval and subsequent approval status.
Document Class	A definition of a particular type of document.
Dongle	Automatic counter that tracks the number of images scanned.
Field Type	A definition of a piece of information extracted from a document.
Form Type	A definition of a unique form within a document class.
GMP	Good Manufacturing Practice (Regulations).
Hyperlink	Electronic link between words, paragraphs, tables, pages, etc.
iSeries	Refers to the IBM iSeries server.
Index	Used to define how images are retrieved.
Read only	Refers to an electronic document that is protected against modification by unauthorized users.
Self-Inspection	The process of evaluating the effectiveness of a SOP.
Self-Inspection Log	Log for recording the results of the Self-Inspection SOP.
SOP	Standard Operating Procedure.
Status Report	Monthly report completed by the DMS Owner and submitted to the Leadership Group.
Table of Contents	List of contents, subject headings, etc.
Version Control	In relation to DIMP, relates to the process to ensure only the most current version of the DIMP Manual and other DIMP documents are available.
VIP DocManager	Gauss application software - a document archiving and retrieval system.
VIP ImageCapture	Gauss application software - a document image processing system.