Part of the Workplace Violence Prevention Program. Promoting an Atmosphere of Respect, Cooperation and Professionalism

Part of the Workplace Violence Prevention Program Promoting an Atmosphere of Respect, Cooperation and Professionalism

Code of Conduct Part of the Workplace Violence Prevention Program Table of Contents THE CODE OF CONDUCT... 2 Our Mission... 2 Pledge... 2 A. Principles of Conduct... 2 1. Dignity Principle... 3 2. Reliability Principle... 3 3. Fairness Principle... 3 4. Trust Principle... 4 5. Professionalism Principle... 4 6. Accountability Principle... 5 B. About the Code... 5 1. a) What is workplace violence and how does the Code relate to it?... 5 b) What is the Code?... 5 2. Who does the Code of Conduct apply to?... 6 3. What are my responsibilities?... 6 4. What are Management s responsibilities?... 6 C. Internal Responsibility System (IRS) & The Code... 6 1. Reporting... 6 When to Report... 7 How to Report... 7 2. Managing Reports... 7 3. Hospital Rights & Obligations... 7 D. Process... 8 Step 1 Informal Resolution... 8 Step 2 Reporting... 8 Step 3 Alternate Dispute Resolution (ADR)... 10 Step 4 Investigation Complaint Form... 10 Penalties for Violation... 12 Record Retention... 12 Appeals Process... 12 Related Reference Documentation... 12 NOTE: see related forms June 2009 Page 1 of 12

Workplace Violence Prevention Program THE CODE OF CONDUCT Our Mission Hôpital régional de Sudbury Regional Hospital (HRSRH) is committed to providing a safe, healthy and supportive working environment by treating our employees, medical and credentialed professional staff and clients with respect, fairness and sensitivity. Violence in the workplace can have devastating effects on the quality of life for our employees and on the productivity of the organization. In keeping with the living nature of this mission, the following Pledge has been developed as a further affirmation of our code and behaviours, and as a guide to the mutual relationships that characterize the HRSRH culture. The concept of the Pledge emphasizes that this is a commitment that flows not just one way but among many people. All members of HRSRH will acknowledge and sign the Pledge (Schedule A). PLEDGE We commit to treating patients, medical and credentialed professional staff and employees in a dignified manner that conveys respect for the abilities of each other and a willingness to work as a team of equally valued partners. We promote an atmosphere of respect, cooperation and professionalism. We demonstrate empathy, compassion and respect in our interactions with others and are always polite and courteous. We consistently adhere to all the rules and regulations of our Hospital. We wish to be held accountable for our commitment and we expect the same dedication from all members of our Hospital community. A. Principles of Conduct we derive from the Pledge: 1. Dignity 2. Reliability 3. Fairness 4. Trust 5. Professionalism 6. Accountability June 2009 Page 2 of 12

1. DIGNITY PRINCIPLE Respect the dignity of all people. Protect the health, safety, privacy, and human rights of others; refrain from coercion, harassment, and violence; and adopt practices that enhance human development in the workplace. Key Concepts: Respect for the Individual Respect the dignity and human rights of others; Adopt work practices that respect employees dignity and human rights; Prevent harassment in the workplace. Health and Safety Provide a safe, secure and healthy workplace; Protect employees from avoidable injury and illness in the workplace; Prevent violence in the workplace. Privacy & Confidentiality Respect the patient s privacy and personal information; Respect the privacy of colleagues; Maintain confidentiality. 2. RELIABILITY PRINCIPLE Honour commitments. Be faithful to your word and follow through on promises, agreements and other voluntary undertakings. Exhibit behaviour and conduct that is consistent with the Pledge. Key Concepts: Common Ground Commitment Honour the Pledge and expect the same of your colleagues. Honour your promises, agreements and obligations. 3. FAIRNESS PRINCIPLE Deal with all parties fairly and equitably, and practice nondiscrimination in our interaction with others. Key Concepts: Teamwork Fair Treatment Work as a team of equally valued partners considering the unique abilities of one another; Behave in a manner that is just and equitable to all parties; Practice non-discrimination, and create an environment free from favouritism and bias; Respect the rights of others regardless of their race, ancestry, place of origin, colour, ethnic origin, citizenship, creed, age, record of June 2009 Page 3 of 12

Fair Competition Fair Process offenses, marital status, family status or disability. Engage in free and fair competition with suppliers. Do not retaliate against others who report violations of the law, the Code, or Hospital Policy. 4. TRUST PRINCIPLE Act in good faith with care, honesty, and loyalty in fulfilling your obligations. Key Concepts: Loyalty Patient and Employee/ Medical Credentialed Professional staff Promote the Hospital s interests in a diligent and professional manner; Use position and Hospital resources only for Hospital purposes (not for personal gain); Safeguard the Hospital s resources and ensure their prudent and effective use; Disclose potential conflicts between personal and Hospital interests. Advocate for the safety and well-being of our patients; Do not place yourself or others at risk. 5. PROFESSIONALISM PRINCIPLE We will govern ourselves with respect, cooperation and professionalism, and comply with applicable laws, regulations and policies. Key Concepts: Competence Learning & Development Conduct Ensure valid registration, re-certification and credentialing to continue professional practice; Assist each other in developing skills and knowledge; Create employment opportunities that enhance human development; Duty to seek out education and information when required. Uphold a character of high-esteem and mutual respect in our interactions with others; Act in a professional manner that promotes teamwork and communication. June 2009 Page 4 of 12

6. ACCOUNTABILITY PRINCIPLE Make moral and rational decisions and be accountable for our behaviour and conduct. We will not condone inappropriate behaviour or conduct. Key Concepts: Responsibility Reporting Dedication to the Code is a collective and ongoing responsibility for which we are accountable; Recognize that every employee has the ability to improve his/her work environment through addressing inappropriate conduct; Participate as a member of the team, seeking input from others when necessary; Know and apply the Code, legislation, and policies where applicable. Report violations of the Code or illegal acts to the appropriate authority. B. ABOUT THE CODE 1. a) What is workplace violence and how does the Code relate to it? Workplace violence is any abusive or aggressive behaviour that can include physical assault on a person or on property, behaviour considered to be threatening, or abuse in a verbal manner that occurs in a work-related setting. The Code of Conduct complaint process directly links to Type II & III classifications of violence in the workplace Type II involves inappropriate client to worker relationships Type III involves inappropriate worker to worker relationships as defined in the Workplace Violence Prevention Policy. b) What is the Code? The HRSRH Code of Conduct (Code) sets out the pledge, six (6) principles, and the key concepts that govern behaviour within the Hospital environment, in addition to applicable laws and regulations, and Hospital policies related to workplace violence. The Code describes the minimum standards of behaviour and conduct expected from anyone who is on our premises at all times. Compliance with the Code is mandatory (see Part C, Internal Responsibility System). It is a living document which will grow and change with our organization. The Code reinforces HRSRH s commitment to a safe, secure and healthy work environment in which people are respected and valued as equal team members. June 2009 Page 5 of 12

2. Who does the Code of Conduct apply to? The principles of the Code of Conduct apply to all members of the HRSRH organization and to anyone who enters our facilities. 3. What are my responsibilities? Understand and apply the Code in daily work interaction; Rely on our internal sense of what is right and consider the impact of our decisions on others; Assume responsibility for our own actions; Report illegal acts or violations of the Code to management immediately; Document the date and details of the event so that you may refer to it, if necessary; Seek assistance (i.e. peers, supervisors/coordinators, managers, unions, Human Resources (HR). Refer to the document, HRSRH Code of Conduct - Quick Reference Guide for more options. 4. What are Management s responsibilities? In addition to complying with the Principles of Conduct, individuals in management positions have a duty to assist others in making difficult decisions and in providing direction in reporting violations of the Code or a disregard of the law. They must: Ensure all individuals in their department have access to either the online Code documentation and or a paper copy, if required; Ensure the Report of Occupational Hazard/Incident/Accident forms and the Complaint Form are readily available; Set an example by complying with the Code at all times; Participate in the bi-annual review process for the Code; Create and maintain a work environment that encourages respect, cooperation, and professionalism; Promote open communication so that issues may be raised for discussion without fear of retaliation or without fear of reprisal based on any perceived power differential; Management will normally investigate incidents which took place in their department. C. Internal Responsibility System (IRS) & THE CODE 1. Reporting In an effort to promote a culture of safety, wherever possible, the same reporting process and forms are being utilized. The goal is to reinforce existing processes making it easier for individuals to remember what to do when to do it, and how to follow-up. Based on this, issues relating to the Code of Conduct follow the general steps and requirements set out in the Hospital s Employee Hazard/Incident/Accident Reporting Policy. For the purpose of this Code of Conduct document, all matters relating to the Code (i.e. a concern, direct violation, etcetera) will be referred to as an incident. June 2009 Page 6 of 12

When to Report: 1.1 All individuals, in accordance with the IRS, have a responsibility to identify hazards or risks in the workplace. 1.2 All individuals have the right to bring violations of the Code or the Workplace Violence Prevention policy forward without fear of adverse consequences. 1.3 All individuals are expected to bring issues forward in a sincere and responsible fashion. How to Report: 1.4 Complete an Employee Report of Occupational Hazard/Incident/Accident (BLUE form Schedule B) for all incidents relating to the Code of Conduct. 1.5 Submit the Employee Report of Occupational Hazard/Incident/Accident form to the supervisor/manager of the department or unit where the incident occurred. The supervisor/manager will complete the YELLOW Supervisor/Manager s Report of Occupational Hazard/Incident/Accident form (Schedule C). 1.6 If the incident involves the supervisor/coordinator, submit the Employee Report of Occupational Hazard/Incident/Accident form to the next level of management or fax it directly to the Occupational Health & Safety Service (OHSS) at 675-4702. 2. Managing Reports The following applies to all types of reporting (i.e. verbal or written) at any step (i.e. from the initial informal step to a full investigation step). 2.1 A false or malicious report with no merit may result in disciplinary action, following investigation. 2.2 All reports will be handled in the strictest of confidence. 2.3 No one will be penalized for initiating inquiries in good faith regarding unethical behaviour, or for seeking advice on how to handle alleged violations of health care legislation or the Code. 2.4 Retaliation will not be tolerated in any form. 2.5 All incidents will be investigated in a timely manner. 2.6 Individuals filing a complaint have a duty to participate in investigations regarding the Code. Failure or refusal to participate or to provide full and truthful disclosure may result in disciplinary action. 3. Hospital Rights & Obligations In accordance with its legislative obligations, the Hospital reserves the right in all circumstances to elevate the reported incident to Step 4 (Formal Complaint Investigation), even if the parties involved elect otherwise. It is understood that all matters will be held in confidence and the Hospital will only involve those who are necessary. June 2009 Page 7 of 12

D. Process The following sequence presupposes that all immediate actions and interventions required to ensure individual and group safety have being taken. Refer to Schedule E - Process Flow Chart for an overview of the steps. Step 1 Informal Resolution Employee/Medical and Credentialed Professional Staff has a troubling issue. The individuals will discuss the issue and come to a mutual resolution. This will not be recorded and tracked. 1.1 If the individual with the troubling issue is uncomfortable with approaching the other(s), he/she may seek support from a supervisor/manager, HR representative or union representative. 1.2 If the issue is satisfactorily addressed no further action is required. 1.3 If the issue is not satisfactorily addressed, the individual with the troubling issue is encouraged to proceed to Step 2. 1.4 When an individual has a concern with a client i.e. a patient or visitor, he/she should immediately move to Step 2. i.e. complete the Employee Report of Occupational Hazard/Incident/Accident (blue form). Step 2 Reporting Employee Report of Occupational Hazard/Incident/Accident Report (BLUE Form Schedule B) and Supervisor/Manager s Report of Occupational Hazard/Incident/Accident Report (YELLOW Form Schedule C) 2.1 Employee or credentialed healthcare professional fills out the Employee Report of Occupational Hazard/Incident/Accident form and faxes it to the OHSS at 675-4702 and submits it to the Supervisor/Manager for follow-up. 2.1.1 Employees that are identifying an incident arising from conduct will fax the form to the OHSS and submit the completed form to Supervisor/Manager or Director for the area where the incident occurred or was identified. 2.1.2 In circumstances involving a Medical and Credentialed Professional Staff, the report will be faxed to the OHSS and submitted to the Administrative Director and the Chief of Service and/or Chief of Staff. 2.1.3 In circumstances involving the Supervisor/Manager or Director, the report form shall be faxed to the OHSS and submitted to the next level of management follow-up. June 2009 Page 8 of 12

2.1.4 In circumstances involving a client i.e. a patient or visitor, the form will be faxed to the OHSS and submitted to the Supervisor/Manager or Director of the area of service for follow up. 2.1.4.1 Appropriate next steps will be determined based on the circumstances, recognizing that timing may present challenges. 2.1.5 In all cases of a work-related injury or illness, the HRSRH employee(s) involved must comply with the investigation and reporting requirements of the Employee Hazard/Incident/Accident Reporting Policy and the Hazard/Incident/Accident Investigations Policy and procedures. 2.2 In all other cases, the Supervisor/Manager or Director will review the content submitted on the Employee Report of Occupational Hazard/Incident/Accident form, discuss it with the individuals involved; attempt to resolve the concern; complete a YELLOW Supervisor/Manager s Report of Occupational Hazard/Incident/Accident form and fax it to the OHSS at 675-4702. 2.2.1 The Supervisor/Manager or Director and/or Chief of Service (when a medical and credentialed professional staff is involved) will meet with the respective individuals, within five (5) business days or other timeframe that is reasonable given the circumstances. 2.2.2 If resolution is attained, the Supervisor/Manager or Director and/or Chief of Service (when a credentialed healthcare professional is involved) records the resolution on the YELLOW Supervisor/ Manager s Report of Occupational Hazard/Incident/Accident form and provides those involved with a copy. Follow-up/outcome notes can be appended to the form if required. 2.2.3 If resolution is not attained, the Supervisor/Manager or Director and/or Chief of Service (when a credentialed healthcare professional is involved) records the status on the YELLOW Supervisor/Manager s Report of Occupational Hazard/Incident/Accident form and provides those involved with a copy. 2.2.3.1 The parties will be asked if they will consider an Alternate Dispute Resolution (ADR) process. 2.2.3.2 If the individuals express interest in ADR, the Supervisor/ Manager or Chief of Service will contact HR to discuss next steps. 2.2.3.3 The individuals involved are invited to contact HR for information on ADR options. 2.2.4 The OHSS will provide HR with copies with the reports and outcomes. June 2009 Page 9 of 12

Step 3 Alternate Dispute Resolution (ADR) 3.1 Both individuals must agree to participate in ADR and the concept of an interest based outcome ; otherwise, the complaint will be forwarded to Step 4. 3.1.1 A facilitated discussion will typically not be considered when the individuals involved have previously participated in an ADR process with each other. The merits of a second ADR will need to be clearly demonstrated. 3.2 The Supervisor/Manager or Director will contact HR when the parties agree to participate in an ADR process. 3.3 When a Medical and Credentialed Professional Staff is involved, the Supervisor/Manager or Director, and the Chief of Service will contact the Chief of Staff to determine the appropriate resolution step. The Vice President of Human Resources will be notified that this has transpired. 3.4. ADR options will be reviewed and selected based on the circumstances. 3.4.1 It is important to note that using a dispute resolution process, whereby the parties are brought together in the same room, may not be appropriate in all situations. 3.4.2 The ADR meeting will be scheduled within ten (10) business days or other timeframe that is reasonable given the circumstances. 3.5 If ADR is successful (i.e. the parties come to a consensus on next steps etcetera), outcomes and voluntary resolutions will be recorded in writing. A copy will be provided to the participants and other individuals involved in the process. 3.5.1 HR will close the file upon notification of an agreed outcome being achieved. 3.6 If ADR is unsuccessful (i.e. no consensus on next steps etcetera are achieved), HR will acknowledge the outcome no later than five (5) business days of notification. 3.6.1 When a Medical and Credentialed Professional Staff is involved, the Chief of Staff will be copied in on the notification. 3.7 If no outcome is achieved, either individual involved may pursue a formal complaint. A detailed Complaint Form Schedule D must be completed and submitted within a reasonable period of time. 3.8 The ADR process is not contemplated for cases involving a client i.e. a patient or visitor; however, if an ADR approach is considered appropriate given the circumstances, the option will be reviewed. Step 4 Investigation Complaint Form (Schedule D) 4.1 A completed detailed Complaint Form (Schedule D) will trigger the investigation process. June 2009 Page 10 of 12

4.2 Individuals pursuing a complaint will submit the completed form to HR. 4.2.1 Complaints involving a Medical and Credentialed Professional Staff as the complainant or respondent will be copied to the Chief of Staff s office. The Chief of Staff will have the option of providing input and direction. 4.3 The steps that follow will be the same for employees and for Medical and Credentialed Professional Staff as complainants or respondents: 4.3.1 The completed Complaint Form will be acknowledged by the respective offices, in writing, no later than five (5) business days following receipt. 4.3.2 A copy of the detailed Complaint Form will be provided to the respondent(s) no later than five (5) business days of it being received in HR. 4.3.3 The respondent will then have five (5) business days, or other period of time agreed to by HR based on the circumstances, to provide written response to the allegation(s). 4.4 When a Medical and Credentialed Professional Staff is the respondent, HR will provide a copy of the Complaint Form to the Chief of Staff s office. The Chief of Staff will have the option of providing input and direction. 4.5 Once the respondent s written documentation is received, a formal investigation will be conducted. The organization reserves the right to determine if the investigator will be internal or external to the organization. 4.6 The outcome of the investigation will be reported to the Vice President of HR, CHRO or designate for final decision-making regarding the appropriate next step. Outcomes involving a Medical and Credentialed Professional Staff as the complainant or respondent will be copied to the Chief of Staff s office. The Chief of Staff will have the option of providing input and direction. 4.7 The results of the decision will be communicated to the parties and followed up in writing by HR. 4.7.1 HR will close the complaint file upon sending out the written followup. 4.7.2 Outcomes will vary. Should an outcome result in further learning/ training, the complainant or respondent will be assigned a contact person (typically his/her immediate supervisor). Should the outcome result in disciplinary action, the immediate supervisor, the respective union representative, if appropriate, and a HR contact will be involved. Note: Timelines for the above process will vary. A complainant or respondent may communicate at any time during the process with management or the HR office for individual up-to-date timing information. June 2009 Page 11 of 12

Penalties for Violation Violations of the Code may warrant progressive discipline up to and including dismissal/revocation of privileges. Staff, Medical and Credentialed Professional Staff, volunteers, students and/or contract workers who cannot practice and uphold the Principles of Conduct risk no longer being a part of the HRSRH team. Record Retention Employee Report of Occupational Hazard/Incident/Accident form will be retained in accordance with the requirements of health and safety record retention. ADR outcomes will be retained by HR for a period of twenty four (24) months from the date of agreement. Records of investigations will be retained in the strictest of confidence, by HR for a period of sixty (60) months from the date of the outcome. Disciplinary action will be filed on the employee record and disposed of in accordance with the requirements of hospital policy, credentialed healthcare professional privilege requirements or collective agreement language, if applicable. Appeals Process There will be occasions where the formal process did not result in agreement with either the disposition of the complaint or the remedial steps to be taken. For unionized employees, the grievance process should be used. In all other instances, the individuals may choose further action in accordance with the related legislation. Please reference the following related documentation: Workplace Violence Prevention Policy (OHSS) Domestic Violence Policy (Sexual Assault Program) Email Etiquette Policy (Finance/IT) Complaint and Compliment Management Policy (Administrative) Consent to Disclose Personal Health Information Policy (Administrative) Protection of Personal Information and Confidentiality Policy (Administrative) Privacy Breach and Complaint Policy (Administrative) Confidentiality Policy (HR) Conflict of Interest Policy (HR) Criminal Reference Check Policy (HR) Critical Incident-Investigation and Reporting Policy (OHSS) Employee Hazard/Incident/Accident Reporting Policy Hazard/Incident/Accident Investigations Policy Nepotism Policy (HR) Pledge to Confidentiality; Pledge to Code of Conduct (HR) Protection of Personal Information and Confidentiality Policy (Administrative) Process for Dealing with Staff Complaints Against Credentialed Medical Staff (Medical Affairs Office) Accountability for Reasonableness (A4R) Framework (Ethics) Interacting with Law Enforcement Agencies: Policy & Procedures (Administrative) Emergency Codes White, Black (Emergency Planning) June 2009 Page 12 of 12