Board policy manual & workplace conduct - Kingston General Hospital

KINGSTON GENERAL HOSPITALADMINISTRATIVE POLICY MANUALSubject: Reporting of Inappropriate Workplace ConductPrepared/Reviewed by: Audit Committee, Board of DirectorsIssued by: President & Chief Executive OfficerNumber: 01-218Page: 5 of 10Original Issue: 2011.09Revised:NEW2.3.3 The seriousness of the allegation will, out of necessity, be determined basedsolely on the general merit and specific detail outlined in the disclosure.Follow-up for clarification and expansion of facts will not be possible, whichmay have the unintended consequence of limiting the effectiveness of anyinvestigation or finding derived thereof.2.3.4 In view of the investigation limitations outlined in 2.2.3, person(s) consideringan anonymous report under this section are encouraged to review Section B,4&5 of this policy. The hospital clearly prohibits retaliation, discrimination andharassment against any person(s) who reports, in good faith, what isreasonably believed to be a wrongdoing, and is fully committed to thesafeguards outlined in Section II of this policy. Notwithstanding the foregoing,this in no way interferes or limits the right of person(s) who neverthelesschoose to submit an anonymous report.2.3.5 Any person submitting an anonymous report implicitly waives the protectionafforded in Section B, 4&5.2.4 Investigation of a Complaint2.4.1 Following the receipt of a disclosure, including anonymous reports, submittedhereunder, the disclosure shall be assessed promptly by the receiver todetermine if an investigation shall commence. This will include an assessmentof the risks to the complainant(s), employees, credentialed staff, affiliatesand/or patients and the hospital and immediately take appropriate preventativemeasures if required.2.4.2 If the investigation is warranted, determine if the receiver should conduct theinvestigation with applicable in-house support from an individual listed onAppendix A or assign another appropriate investigator dependent on the natureof the report. The determination of an investigation and who will conduct theinvestigation shall be communicated to the known complainant by the receiver.2.4.3 Where there are more specific policies which govern such investigations (forexample the Hospital By-laws for Medical Staff or the KGH Code of Behaviour– Be Real), the receiver will ensure that the more specific policy shall befollowed.2.5 Investigation Procedures, Reporting and Records2.5.1 The receiver responding to the disclosure and overseeing the investigation mayconsult with internal resources, his/her supervisor, including individuals listed inAppendix A and determine resources required to complete the investigation.The investigation is to be conducted as expeditiously as possible. Once thedecision is made to conduct an investigation, the receiver informs therespondent about the nature of the report and that the matter is beinginvestigated. In conducting any investigation, the investigator shall usereasonable efforts to ensure that person(s) are treated fairly including theperson(s) making the disclosure, witnesses, and the person(s) alleged to beresponsible for the wrongdoing(s).