Board policy manual & workplace conduct - Kingston General Hospital

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KINGSTON GENERAL HOSPITALADMINISTRATIVE POLICY MANUALSubject: Reporting of Inappropriate Workplace ConductPrepared/Reviewed by: Audit Committee, Board of DirectorsIssued by: President & Chief Executive OfficerNumber: 01-218Page: 6 of 10Original Issue: 2011.09Revised:NEW2.5.2 During the investigation, the receiver and the investigator shall maintainneutrality and confidentiality. The receiver will ensure that the investigation isdocumented and that a written record of each step in the process includingspecifics like date, time, and place is completed. The receiver or theinvestigator will interview witnesses and obtain application documentation andrecords as appropriate to review and analyze against disclosure.2.5.3 Upon completion of an investigation, a summary findings, (see attached) isprovided containing findings and any recommendations about the disclosureand wrongdoing.2.5.3.1 If the review concludes that the disclosure cannot be substantiated, nofurther action will be taken. The receiver will discuss with the complainantand respondent to recognize that he/she acted in good faith and that theprocess was followed.2.5.3.2 If an assessment concludes that the disclosure was made in bad faith, thereceiver will follow-up with applicable parties for discipline and/or removalof access and privileges as applicable.2.5.3.3 If the disclosure is substantiated, the receiver will ensure that correctiveaction is taken immediately. The receiver will consult with the HR Advisoror other appropriate management as applicable to determine if disciplineor removal of access and/or privileges are warranted. If the disclosure isunsubstantiated, the decision will be conveyed to the respondent.2.5.3.4 The receiver will ensure that the summary findings is forwarded in aconfidential envelope to be opened by the Chief Operating Officer only, fordocumentation into a log book for quarterly notification to the AuditCommittee.2.5.3.5 Findings will be communicated to the known complainant and respondent.2.5.4 For disclosures that are submitted directly to the Audit Committee forinvestigation, the Chair of the Audit Committee shall make reports on aquarterly basis to the Board of Directors, identifying any investigationsundertaken, any findings arising from such investigations, and any disciplinaryaction taken as a result of such investigations.2.5.5 The Audit Committee shall retain as a part of the records of the AuditCommittee any information and documentation pertaining to such reports for aperiod of no less than seven (7) years.2.6 When Investigation not Required. A receiver may cease or decline to pursue aninvestigation upon review of all available relevant details and determines that:2.6.1 the disclosure is frivolous or vexatious, or has not been made in good faith, ordoes not deal with a sufficiently serious subject matter;2.6.2 so much time has elapsed between the date when the subject matter of thedisclosure occurred and the date when the disclosure was made thatinvestigating it would not serve a useful purpose;2.6.3 the disclosure does not provide adequate facts about the wrongdoing to permita proper investigation;
KINGSTON GENERAL HOSPITALADMINISTRATIVE POLICY MANUALSubject: Reporting of Inappropriate Workplace ConductPrepared/Reviewed by: Audit Committee, Board of DirectorsIssued by: President & Chief Executive OfficerNumber: 01-218Page: 7 of 10Original Issue: 2011.09Revised:NEW2.6.4 the disclosure relates to a matter that could more appropriately be dealt withaccording to the procedures under a collective agreement, employmentagreement, the hospital’s by-laws or a more appropriate and specific hospitalpolicy, practice, procedure; or2.6.5 there is another valid reason for not investigating the disclosure.2.6.6 The decision not to investigate will be communicated to the knowncomplainant.2.7 Appeals to Decision Not to Investigate. A decision made by the receiver not toinvestigate may be appealed in writing to an officer of the hospital. Decisions made byan officer of the hospital, including the Chief Executive Officer, may be appealed to theChair of the Audit Committee. A written response will be provided to the complainantmaking the appeal at each level of the appeal process.3. General Offences3.1 False or misleading statements. No person shall, in seeking advice about making adisclosure, in making a disclosure, or during an investigation, knowingly, make a falseor misleading statement, orally or in writing.3.2 Obstruction in performance of duties. No person shall wilfully obstruct any personinvestigating and fulfilling the requirements under this policy. Such conduct will bedeemed to be a reprisal, as per Section B, 4 of this policy.3.3 Destruction, falsification or concealment of documents or things. No person shall,knowing that a document or material thing is likely to be relevant to an investigationunder this policy:3.3.1 Destroy, mutilate or alter the document or material thing3.3.2 Falsify the document or make a false document3.3.3 Conceal the document or material thing; or3.3.4 Direct, counsel or cause, in any manner, a person to do anything mentioned inabove clauses 3.3.1, 3.3.2, 3.3.3SECTION B4. Whistleblower Policy/Non-Retaliation, Non-discrimination, Anti-harassment Protection4.1 Prohibition Against Retaliation, Discrimination and Harassment. The hospital prohibitsdiscrimination, harassment and/or retaliation against any person who reports, in goodfaith, what they reasonably believe to be a wrongdoing and any protected disclosures.4.2 Protection. The hospital is committed to not discharging, demoting, suspending,threatening, harassing, prejudicially modifying the relationship of, or otherwisediscriminating or retaliating against a person in the terms or conditions of his/heremployment or relationship with the hospital as a result of a disclosure that wassubmitted in good faith in accordance with this policy and without malice of forethought.
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Appendix ANamed Recognition - KGH A
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Board policy manual & workplace conduct - Kingston General Hospital

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