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Title: Whistleblower Policy Manual: Management Document Number: Date Issued: April 2009

Section: General Issuing Authority: Board of Directors Date Revised: September 2009

PURPOSE:
The Brant Community Healthcare System (BCHS) is committed to protecting individuals who disclose information, made in good faith, regarding an ethical, clinical, safety or administrative Wrongdoing. POLICY STATEMENT: The BCHS is committed to building and preserving a safe working environment for all BCHS members (staff, physicians, volunteers, students, Board members, and affiliates), including the protection of individuals who make a disclosure, in good faith, of an ethical, clinical, safety or administrative Wrongdoing. Reprisal will not be tolerated against any BCHS member, patient or visitor. Guiding principles of a workplace where people feel safe to report a Wrongdoing include: A Safe Workplace The BCHS strives to create a work environment safe from all forms of abuse and violence. All BCHS members are responsible for ensuring that the workplace is free of any reprisal. A Non-discriminatory Workplace The BCHS is committed to a non-discriminatory and harassment-free workplace. The BCHS will not discipline, terminate, or retaliate against any BCHS members who report, in good faith, allegations of disruptive behaviour. An Informed and Productive Workplace The BCHS will inform BCHS members of their right to report disruptive behaviour and freedom from retaliation. A Respect for Confidentiality The BCHS will inform other BCHS members about Wrongdoings on a need to know basis only, and to the extent necessary to conduct investigations, protect safety, and comply with legislation/law. Roles and Responsibilities of BCHS Members

Accept personal responsibility for performing duties according to policy and ethical standards of behaviour. Work with other BCHS members in a professional manner and resolve issues in a non-violent, non-disruptive manner. Participate in mandatory education. Disclose Wrongdoings experienced or witnessed, especially if it may pose a risk to self or others in the workplace (e.g., colleague, patient, visitor), through completing a Risk Pro report (Incident Reporting software). Note: if the disruptive behaviour is by a direct supervisor, do not file a Risk Pro report; contact the

DISCLAIMER: This is a CONTROLLED document. The most current version is in electronic format on the BCHS intranet site. Any documents appearing in paper form are NOT controlled.

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Manager of Human Resources directly. If the incident is regarding a member of senior leaders, do not report the incident in Risk Pro; include the details of the Wrongdoing in a letter addressed to the Audit Committee ( Board of Directors). Refrain from making false, misleading, fraudulent or vexatious allegations of Wrongdoing. Participate in investigations as required. Ensure documents or items likely to be relevant to an investigation under this policy are not destroyed, altered, falsified, or concealed.

Roles and Responsibilities of BCHS Leaders

Follow the expectations of all BCHS members as stated above. Model the substance and intent of this policy and demonstrate through words and actions the BCHSs commitment to intolerance of disruptive or unethical behaviour of any kind in the organization. Follow due diligence to mitigate risk of Wrongdoings. Ensure staff are able to access and participate in mandatory training. Listen to reported concerns of Wrongdoing, and ensure incidents are formally reported in Risk Pro. Investigate allegations of disruptive behaviour received via Risk Pro according to protocol learned in Investigation Training; document finding and follow through to resolution. Work collaboratively with union and College representation (as applicable) and others involved who share joint responsibility to resolve issues of the Wrongdoing. Take corrective action as appropriate.

Roles and Responsibilities of Audit Committee

Investigate allegations of Wrongdoing according to the steps in this policy; document finding and follow through to resolution. Review possible and identified areas of Wrongdoing proactively and retrospectively as standard Board process.

DEFINITION(S):

BCHS member employed staff, privileged staff (physicians, midwives, dentists, extended-class nurses), volunteers, students, Board members, and affiliates (e.g., contractor) of the BCHS. Complainant the person who alleges a complaint against another BCHS member. Disruptive Behaviour - inappropriate words, actions or inactions by a person that interferes with an individuals ability to function well with others to the extent that the behaviour interferes with, or is likely to interfere with, quality health care

DISCLAIMER: This is a CONTROLLED document. The most current version is in electronic format on the BCHS intranet site. Any documents appearing in paper form are NOT controlled.

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delivery, patient or workplace safety, recruitment or retention of staff, or the cost of providing health care. Disruptive behaviour includes abuse, bullying, discrimination, harassment, sexual harassment, and workplace violence.

Respondent the person about whom the complainant is alleging a complaint. Reviewer the investigator of a complaint. Witness a person who was present, observed and/or heard disruptive behaviour occurring. Workplace All on-site locations, including adjacent parking areas, extended Hospital property, and remote locations (including through phone, email or other remote communications) where staff engage in Hospital business and/or social functions. Wrongdoing a departure from acceptable ethical, clinical, safety or administrative expectations, behaviours and procedures.

PROCEDURE:

Enter a Risk Pro report as soon as reasonably possible. If the wrongdoing involves personal information or confidential information, the Complainant must take reasonable precautions to ensure that no more information is disclosed than is necessary to make the Disclosure. If a leader receives a report in written form, she or he must enter the wrongdoing into Risk Pro. Note: if the wrongdoing is by a direct supervisor, do not enter a Risk Pro report call the Manager of Human Resources directly. If the incident is regarding senior leadership, do not enter a Risk Pro report - send a letter addressed to the Audit Committee of the Board of Directors. When the Reviewer (i.e., the direct supervisor or delegate such as the Manager of Human Resources, or for serious incidents, Vice President of Resources & Development or Chair of the Audit Committee as appropriate) receives a Risk Pro or verbal report of Wrongdoing, the following steps take place (note: see Appendix B regarding circumstances that would cease an investigation). The Reviewer will: 1. Ensure the BCHS member and others in the work environment are not at immediate risk, and if so, take immediate action to ensure safety, such as calling a Code White or Police. Incidents that constitute criminal acts will be referred to the appropriate policing agency immediately. 2. Review Risk Pro report in detail within 3 business days. Determine if there will be a challenge in being unbiased, impartial, maintaining confidentiality or providing a timely response; if so, an appropriate Delegate is secured (e.g., Manager of Human Resources).

DISCLAIMER: This is a CONTROLLED document. The most current version is in electronic format on the BCHS intranet site. Any documents appearing in paper form are NOT controlled.

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3. Acknowledge the receipt of the complaint within 3 business days via correspondence to the Complainant through hospital email, face-to-face correspondence or written correspondence. 4. Schedule a meeting with the Complainant within 5 business days from the time of initial follow-up of the complaint, or on a date agreeable to the Complainant. 5. Meet with the Complainant. Obtain a detailed account of the incident(s), information regarding Witnesses of the incident(s), and expectations of resolution. Provide the Respectful Workplaces booklet and information regarding support (e.g., EAP). 6. Inform the Respondent of the complaint within 3 business days of the date of the meeting with the Complainant to review the complaint via hospital email, face-to-face correspondence or written correspondence; secure an interview time and date. 7. Book meetings with Witnesses as deemed necessary to establish the facts of the complaint within 3 business days of the date of the meeting with the Complainant. 8. Interview all Witnesses within 21 days of the initial meeting with the Complainant. 9. Collect and review any relevant data related to the allegation of Wrongdoing. 10. Meet with the Respondent. Provide a summary of the complaint. Interview Respondent regarding his or her recollection of event(s) related to the complaint. 11. Review all facts gathered to determine if there is sufficient or insufficient evidence that a Wrongdoing occurred and/or this or related policies were contravened. 12. Contact the Manager of Human Resources to determine necessary next steps (e.g., discipline) and the appropriate closure of the incident. Document investigation (and resolution in Risk Pro as appropriate). Close file. 13. Inform Complainant and Respondent file is closed with any further action necessary.

Any formal remedial action will be documented and a Notice of Discipline will be placed in the Respondents personnel file and if necessary, and notification to the College to comply with College regulations.

DISCLAIMER: This is a CONTROLLED document. The most current version is in electronic format on the BCHS intranet site. Any documents appearing in paper form are NOT controlled.

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If a BCHS member is disabled from performing his or her usual work or requires medical attention because of an incident of workplace violence, but no person dies or is critically injured because of that occurrence, the BCHS will give written notice and details of the occurrence within 4 business days to the JOHSC and a Director from the Ministry of Labour if an inspector from the Ministry requires notification. If, after an investigation, it is determined that an allegation of Disruptive Behaviour is malicious in nature, corrective action up to and including progressive forms of discipline or dismissal may be taken against the Complainant.

RELATED PRACTICES AND / OR LEGISLATIONS: Criminal Code of Canada Occupational Health and Safety Act Amendments to the Occupational Health and Safety Act Ontario Human Rights Code Human Rights Act Public Hospitals Act

Regulated Health Professionals Act Medicine Act Nursing Act Dentistry Act
Midwifery Act Workplace Safety & Insurance Act Code of Conduct Policy Respectful Workplace - Privileged Staff Respectful Workplace - Customers and Visitors Policy Code White Violent Behaviour Work Refusal Policy

REFERENCES: 1. Ontario Coroner. (2007). Dupont Inquest. Verdict of Coroners Jury. 2. BCHS Respectful Workplaces Booklet. (2009). 3. Ontario Safety Association for Communities and Healthcare. (2009). OSACH Bullying in the Workplace: A Handbook for the Workplace. 4. Dykeman, Dewhirst & OBrien Health Law. (2010). Workplace Violence and Harassment Toolkit. APPENDICES: See pages attached.

DISCLAIMER: This is a CONTROLLED document. The most current version is in electronic format on the BCHS intranet site. Any documents appearing in paper form are NOT controlled.

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Appendix A: Flowchart of Whistleblowing Process

Witness incident of Wrongdoing

File Risk Pro Incident or appropriate delegate if about management

Investigation Interview Complainant Interview Witnesses Interview Respondent Review all data Complete report

Implement any recommendations

Close Wrongdoing file

DISCLAIMER: This is a CONTROLLED document. The most current version is in electronic format on the BCHS intranet site. Any documents appearing in paper form are NOT controlled.

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Appendix B: When an Investigation is Not Required or Should Cease Before or during an investigation, it may be determined by the Reviewer that an investigation is not or no longer warranted. The Reviewer, in consultation with another member of Senior Leadership Team, may cease an investigation if he or she is of the opinion that: The subject matter of the Disclosure could more appropriately be dealt with, initially or completely, according to a procedure in governing legislation, a collective agreement, an employment agreement, the Hospitals By-Laws or a more appropriate and specific BCHS policy The Disclosure is frivolous or vexatious or has not been made in good faith The Disclosure does not deal with a sufficiently serious subject matter The length of time between the date of the Wrongdoing and the date of the Disclosure is sufficiently long that an investigation does not serve a useful purpose The Disclosure relates to a matter that results from a balanced and informed decision-making process The Disclosure does not provide adequate particulars about the Wrongdoing There is another valid reason for not investigating the Disclosure

DISCLAIMER: This is a CONTROLLED document. The most current version is in electronic format on the BCHS intranet site. Any documents appearing in paper form are NOT controlled.