Board policy manual & workplace conduct - Kingston General Hospital

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ISSUED BY:AUTHORIZED BY:CATEGORY:COMMITTEE:KGH Board of DirectorsKGH Board of DirectorsQuality and EffectivenessAuditNUMBER: III-12ISSUE DATE: May 2011REVISION DATES: NewREVIEW DATE: AnnuallyPAGE: 1 of 1SUBJECT:WORKPLACE CONDUCTArticle 4.12 (b) of the By-law provides for the “profile of Director” and outlines the genericqualities and person attributes expected of all Directors. Specifically, the By-law states that aDirector must have a “commitment to comply with the Board of Directors’ conflict of interestpolicies and code of business conduct and ethics.”The Board of Directors expects hospital management to have in place an administrative policywith respect to workplace conduct. The administrative policy should document the expectationsof business conduct and business ethics to be followed by persons employed, appointed, andaffiliated with Kingston General Hospital, including Directors.See Administrative Policy attached.
KINGSTON GENERAL HOSPITALADMINISTRATIVE POLICY MANUALSubject: Reporting of Inappropriate Workplace ConductPrepared/Reviewed by: Audit Committee, Board of DirectorsIssued by: President & Chief Executive OfficerNumber: 01-218Page: 1 of 10Original Issue: 2011.09Revised:NEWIntroductionThis policy will assist persons to report concerns regarding inappropriate workplace conduct.The hospital is committed to protecting a person from inference when reporting, or fromretaliation for having reported if deemed protected disclosure. In some cases there areprofessional and legal obligations to report. This policy endorses a proactive environment ofdisclosure and protection to ensure that that Kingston General Hospital meets legislativerequirements and aligns to the guiding principles of transparency and accountability.Policy StatementSection A, Reporting of Inappropriate Workplace Conduct and Protected Disclosures, outlinesprocedures to ensure a timely response to a report received by Kingston General Hospital (the“hospital”) regarding any concern related to accounting/auditing controls and matters, violationof the hospital’s bylaws, practices and policies including, but not limited to, the WorkplaceConduct policy, the commission of a criminal offence or other legislative or regulatory violations(hereinafter collectively referred to as “wrongdoing”). It establishes internal procedures inresponding to a report by person(s) on a confidential basis and in good faith, regarding awrongdoing.Section B, Non-Retaliation, Non-Discrimination, Anti-Harassment Protection and WhistleblowerProtection refers to established procedures for the protection of any person who, in good faith,reports any concern regarding a wrongdoing, presents a complaint or report to the hospital, to agoverning college, or to any governmental authority, or to an agency responsible for accreditingor evaluating the hospital in respect of a wrongdoing that is deemed to be a protecteddisclosure.Policy Definitions• Affiliate: an individual who is not employed by the hospital but performs specific tasks at thehospital, including: learners, volunteers, contractors or employees of contractors who maybe members of a third-party contract or under direct contract to the hospital, and individualsworking on the hospital premises, but funded/employed through an external source (i.e.research and university staff on site).• By-Law: the by-laws of the hospital.• Complainant: Person or persons reporting inappropriate workplace conduct (wrongdoing),including retaliation after submission of the report.• Credentialed Staff: Physicians, dentists, midwives, extended class nurses.• Disclosure: Report of a wrongdoing made in good faith by person(s) in accordance with thispolicy.• Employee: An individual who is employed by the hospital and is on the hospital’s payroll.• Good Faith: Honestly and without deception. Good faith is evident when the report is madewithout malice or consideration of personal benefit, and that there is a reasonable basis tobelieve the report is true; however, a report does not have to be proven to be true to be ingood faith. Good faith is lacking when the report is known to be malicious or false.• Governing Legislation: All legislation governing the hospital, including but not limited to thePublic Hospitals Act and related Regulations, Health Care Consent Act, Quality of CareInformation Protection Act, Local Health System Integration Act, Substitute Decisions Act,
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