BOARD CHAIR: 3.0 PROCESS: 3.1 Process for Disclosure The Hospital will retain the services of an external Ethics Helpline Provider.

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1 1 of 8 SECTION: TOPICS: Governance APPROVED: Governance: Sept. 29, 2008 APPROVED: Board of Directors: Oct. 6, 2008 MOST RECENT DATE: NEW OR SUPERSEDES: BOARD CHAIR: NEW 1.0 POLICY STATEMENT: It is the policy of St. John s Rehab Hospital that any employee, physician or volunteer shall be free, without fear of retaliation to make known allegations of alleged misconduct existing within the Hospital. 2.0 PURPOSE: The purpose is to set forth the Hospital s policy on employee, physician or volunteer disclosure of misconduct, also referred to as whistleblowing, and to protect employees, physicians or volunteers from retaliation for disclosing what the employee or volunteer in good faith reasonably believes evidences: A violation of law, rule, regulation or policy; A gross mismanagement; A gross waste of funds; An abuse of authority; A substantial and specific danger to public health A substantial and specific danger to public safety; or Discrimination or harassment or workplace violence of any kind Where there are established policies and procedures to follow with respect to any of the above behaviours, individuals are requested to follow the respective policy prior to bringing forth the concern through the Whistleblowing Policy. 3.0 PROCESS: 3.1 Process for Disclosure The Hospital will retain the services of an external Ethics Helpline Provider An employee, physician or volunteer shall disclose in a timely fashion, all relevant information regarding alleged misconduct to the designated Ethics Helpline Provider Service preferably in a signed written document The designated St. John s Ethics Helpline Provider Service shall inform the Chief Executive Officer or designated Senior Officer of the nature of the disclosure (recognizing and respecting jurisdictional procedure of all health disciplines). The Chief Executive Officer or designated Senior Officer will inform the Chief of Staff of any disclosures of alleged misconduct regarding any member of the Medical Staff In the case of disclosure of alleged misconduct involving the Chief Executive Officer, the disclosure shall be directed by the Ethics Helpline Provider Service to the Chair of the Board of Directors. In consultation with the Board of Directors, the Chair shall consider the disclosure and take whatever action he/she determines to be appropriate under the law and circumstances of the disclosure. Policy & Procedure Manual

2 2 of Contact information for the designated Ethics Helpline Provider Service shall be posted on the Hospital s Intranet, and updated as and when changes to the Provider Service occur. 3.2 Responsibilities of the Chief Executive Officer or designate To ensure that employees, physicians and volunteers understand the requirement to use Hospital information responsibly To promote a culture of open communication within the organization where issues and concerns can easily be dealt with in the normal interaction between employees and their managers, physicians and the Chief of Staff or volunteers and their supervisors To establish internal mechanisms to manage the disclosure of alleged wrongdoing, including at a minimum a designated Ethics Hotline Provider Service, which will be responsible for receiving and informing the CEO or designated Senior Officer of such disclosures. This Provider Service will report directly to the CEO or designated Senior Officer, or Board Chair (as appropriate) on matters related to this policy Inform all employees, physicians and volunteers of this policy, including the name, location and contact information of the Ethics Helpline Provider Service which will be responsible for receiving and acting on disclosures To initiate investigations when required, reviewing and reporting the results of the investigations and making recommendations as appropriate Ensure that disclosures are reviewed in a timely fashion and investigated when required, and that prompt, appropriate action is taken to correct the situation Protect from reprisal the employees, physicians or volunteers who disclose alleged wrongdoing in good faith To prepare a semi-annual report to the Executive Committee of the Board indicating the number and type of disclosures received, and actions taken. 3.3 Responsibilities of Employees, Physicians and Volunteers Employees, physicians and volunteers are responsible for: i. Using Hospital information responsibly and in good faith in accordance with their duty of loyalty; ii. Following the internal processes established to raise instances of alleged wrongdoing in the workplace; and iii. Respecting the reputation of individuals by not making trivial or vexatious disclosures of alleged wrongdoing or, by making disclosures in bad faith.

3 3 of Responsibilities of Managers or Supervisors To inform their employees, physicians or volunteers of this policy To ensure their employees, physicians or volunteers understand the requirement to use Hospital information responsibly To ensure their employees, physicians or volunteers are aware of the processes available to them if they wish to disclose information concerning alleged wrongdoing under this policy To promote an environment and culture of openness in their interactions with employees, physicians or volunteers To act promptly when information concerning alleged wrongdoing is brought to their attention To protect from reprisal the employees, physicians or volunteers who disclose alleged wrongdoing in good faith. 3.5 Responsibilities of the Ethics Helpline Provider Service The mandate of the Ethics Helpline Provider Service is to act as a neutral party for confidentially receiving disclosures of alleged wrongdoing, and summarizing such disclosures to the Board Chair, CEO or designated Senior Officer, as appropriate To receive, record, and summarize disclosures of information concerning alleged wrongdoing To ensure procedures are in place to communicate disclosures that require immediate or urgent action to the Board Chair, CEO or designated Senior Officer as appropriate To ensure the privacy rights of both parties, the employees, physicians or volunteers making the disclosure and the employees, physicians or volunteers implicated or alleged to be responsible for the wrongdoing, are respected To establish adequate procedures to ensure the protection of the information and the treatment of the files are in accordance with privacy laws and the hospital s privacy policies To maintain information for a period of at least 3 years on the number and type of disclosures received, rejected, accepted, completed without investigation, disclosures investigated, disclosures under consideration or investigation To prepare a semi-annual report to the Chief Executive Officer. The report will cover the number of disclosures defined in

4 4 of Administrative and Disciplinary Measures Employees, physicians or managers may be subject to administrative and disciplinary measures up to and including termination of employment or termination of privileges, when they: i. retaliate against another employee, physician who has made a disclosure in accordance with this policy or against an employee or physician who was called as a witness; or ii. choose to disclose in a manner that does not conform to this policy and its procedural requirements Any administrative or disciplinary measures are to be taken in consultation with the department of Human Resources and/or the Chief of Staff. 3.7 Protection from reprisal Except in circumstances of 3.6, no employee, physicians or volunteers shall be subject to any reprisal for having made in good faith disclosure in accordance with this policy Employees, physicians or volunteers who believe they are subject to reprisal as a direct consequence of having made a disclosure in accordance with this policy may complain to the Chief Human Resources Officer or CEO as appropriate. The Chief Human Resources Officer or CEO as appropriate will review the matter following the same process as a disclosure. 3.8 Confidentiality and Monitoring Confidentiality, within the intent of this policy, is subject to the provisions of privacy laws and the hospital s privacy policies. The designated Ethics Helpline Provider Service will explain the parameters of confidentiality the employees, physicians or volunteers can expect when they make a disclosure. The designated Ethics Helpline Provider Service will also make available information on the policy and give informal advice to assist employees, physicians or volunteers considering making a disclosure. Employees, physicians or volunteers should feel free to consult the designated Ethics Helpline Provider Service in confidence Disclosure of any information concerning alleged criminal activity or action should be referred to the proper authorities for investigation.

5 5 of PROCEDURE: 4.1 Departmental internal disclosure and resolution process Employees, physicians or volunteers who become aware of a wrongdoing should first attempt to raise the matter using the usual reporting relationship. If that is not successful or if that is not possible, employees, physicians or volunteers may communicate directly to the designated Ethics Helpline Provider Service The designated Ethics Helpline Provider Service is available to provide information on this policy and to provide informal advice to employees, physicians or volunteers who are considering making a disclosure. The designated Ethics Helpline Provider Service will also explain the parameters of confidentiality the employees, physicians or volunteers can expect when they make a disclosure Another person such as a union representative, a friend or a peer can accompany an employee, physician or volunteer (at his/her own expense) who comes to seek advice or to make a disclosure. 4.2 Steps taken with disclosure of wrongdoing The following steps will be taken when the designated Ethics Helpline Provider Service receives a disclosure of alleged wrongdoing. Each step will be completed promptly, normally all steps are complete within six months or less. The nature of disclosure may require more immediate action: Step 1 Disclosure of wrongdoing The employee, physician or volunteer should disclose the information to the designated Ethics Helpline Provider Service, preferably in writing. The disclosure must include the nature of the alleged wrongdoing, the name of the person alleged to have committed the wrongdoing, the date and description of the alleged wrongdoing and other pertinent information. The information should be as precise and concise as possible Step 2 Screening and review of disclosure The designated Ethics Helpline Provider Service will provide a confidential summary of the disclosure to the Board Chair, CEO or designated Senior Officer as appropriate. That person will review the information and determine if there are sufficient grounds for further action. The disclosure may be rejected if it is determined that it is trivial and/or vexatious, fails to allege or give adequate particulars of a wrongful act, or if it is determined that it was not given in good faith or on the basis of reasonable belief. The designated Ethics Helpline Provider Service will inform the employee, physician or volunteer in writing of whether further action will be taken.

6 6 of Step 3 Attempt at resolution It is expected that most situations will be addressed by discussing the matter with the employee, physician or volunteer concerned, identifying avenues of resolution and taking appropriate action Step 4 Investigation If the matter cannot be resolved, the Board Chair, CEO or designated Senior Officer (as appropriate) may initiate an investigation Step 5 Decision The Board Chair, CEO or designated Senior Officer (as appropriate) will prepare a report, including recommendations. As a result of the CEO s or Board Chair s decision, the parties will be informed in writing of the outcome of the investigation. When required, corrective measures will be taken. 4.3 Request for review after employees, physicians or volunteers have disclosed Employees, physicians or volunteers, who disclosed alleged wrongdoing by means of departmental mechanisms and designated Ethics Helpline Provider Service and believe that their disclosure was not adequately reviewed and/or investigated, may make a request to the Chief Executive Officer for a review of the departmental decision. In cases in which the Chief Executive Officer is implicated, the request may be made to the Chair of the Board of Directors for a review of the decision. In these cases, employees, physicians or volunteers should submit in writing their request, specifying: i. The details of the alleged wrongdoing, for example, the nature of the alleged wrongdoing, the name of the person(s) alleged to have committed the alleged wrongdoing; ii. The date and description of the wrongdoing and any other pertinent information, if applicable; iii. A description of the process followed by their department; the reason(s) why the employee or physician or volunteer believes it was not adequately reviewed and/or investigated by the department; and iv. His/her name, address and phone number so the CEO or Board Chair can contact him/her for more information. The CEO or Board Chair (regarding disclosures in which the CEO is implicated) will review the information and inform the employee, physician or volunteer in writing of whether they will proceed further in accordance with the procedures outlined in Section 4.2 above.

7 7 of Process to be followed by an employee, physician or volunteer who becomes aware of a wrongdoing An employee, physician or volunteer who becomes aware of a wrongdoing should follow the recommendations of this policy Employee, physician or volunteer disclosures: First, disclose through normal reporting relationship; Second, disclose, preferably in writing, to the designated Ethics Helpline Provider Service; and Third, if the issue is still unresolved at this stage disclose in writing to the CEO, or the Board Chair (regarding disclosure in which the CEO is implicated) An employee, physician or volunteer may also disclose at their own discretion and expense to: Trusted friend; Union; HR Coordinator; Ombudsman; If the issue is left unresolved after following the above disclosure procedures then the employee, physician or volunteer should seek external third party advice, respecting the requirement to use hospital information responsibly and ensuring the disclosure is made in good faith. 5.0 DEFINITIONS: 5.1 Disclosure: Information raised within the organization in good faith, based on reasonable belief, by one or more employees, physicians or volunteers concerning an alleged wrongdoing that someone has committed or intends to commit. 5.2 Whistleblower: An individual who discloses information he or she in good faith reasonably believes evidences a violation of any law, rule, regulation or policy; a gross mismanagement; a gross waste of funds; an abuse of authority; a substantial and specific danger or risk to the health and safety of patients, staff, employees, volunteers and/or visitors; or discrimination or harassment of any kind. 5.3 Vexatious: Lacking sufficient grounds and serving only to annoy or harass when viewed objectively. END OF DOCUMENT

8 8 of 8 For internal use only at St. John s Rehab Hospital. Persons reviewing a hard copy of this document should refer to the electronic version posted on the Intranet to ensure that this copy is current.