May 2022 Board of Health Meeting - Whistle Blowing Policy Correspondence

Meeting Date
May 2022 Board of Health Meeting
Meeting Document Type
Correspondence
Whistle Blowing Policy

TITLE

Whistle Blowing

DEPARTMENT

Corporate Services

APPROVED BY

Board and Chief Executive Officer

DATE OF ISSUE

2017/06/17

ISSUE BY

Board and Chief Executive Officer

REVIEW/REVISE DATE:

2022/05/19

  1. DEFINITIONS
    1. “Wrongdoing” for the purposes of this Policy includes the following:
      1. contravention of any law or regulation applicable to the Health Unit;
      2. act or omission that creates a substantial and specific danger to the life, health or safety of individuals other than a danger inherent in the performance of the duties or functions of an employee, external contract worker, student or volunteer, as the case may be;
      3. an act or omission that creates a substantial and specific danger to the environment;
      4. gross mismanagement of public funds or a public asset;
      5. material violation of Health Unit policies;
      6. contravention of any material contractual commitment of the Health Unit; and
      7. counselling an individual to commit any of the above,
        that has already occurred, is in the process of occurring or is about occur.
    2. “Reprisal” includes any adverse action taken against an employee, external contract worker, student or volunteer, as the case may be, who seeks advice on making a report of Wrongdoing, makes a report of Wrongdoing, or co-operates in an investigation of Wrongdoing, or declines to participate in a Wrongdoing.  Examples of Reprisal include:  a dismissal, layoff, suspension, demotion or transfer, discontinuation or elimination of a job, change of job location, reduction in wages, change in hours of work or reprimand, or any other adverse measure (e.g., bullying), and/or threats to do any of the foregoing.
  2. PURPOSE
    1. Recognizing that whistle blowing is an important element of transparency and that transparency in turn contributes to accountability, the board of the Health Unit has enacted By-laws requiring the establishment of a transparency framework, including a whistle blowing policy.  The purposes of this Policy are to:
      1. Implement the By-law requirements.
      2. Facilitate the reporting of Wrongdoing.
      3. Protect those who report Wrongdoing, investigate Wrongdoing, or take action subsequent to a finding of Wrongdoing, so that such reporting, investigation and action can be undertaken without fear of Reprisal.
      4. Provide for the appropriate management of reports of Wrongdoing.
      5. Promote public confidence in the Health Unit.
  3. APPLICATION
    1. Applies To.  This Policy applies to Health Unit board members, employees, external contract workers, students and volunteers.
  4. GUIDING PRINCIPLES
    1. Implementation of this Policy will be guided by the following principles and policy statements:
      1. The Health Unit complies with all relevant laws and regulations.
      2. All policies support and embody the Health Unit’s core values.
      3. The Health Unit maintains high standards of business and ethical conduct and applies these standards to all matters of business.
      4. All reports of Wrongdoing will be dealt with promptly, be fully reviewed and/or investigated as appropriate in a fair and equitable manner, ensuring a respectful process is followed for all those involved.
      5. There will be no Reprisals against anyone reporting Wrongdoing in good faith under this Policy, investigating Wrongdoing or taking action subsequent to a finding of Wrongdoing.
      6. Confidentiality will be protected to the maximum extent possible.
  5. INTERNAL REPORTING
    1. Reporting Responsibility.
      1. Individuals becoming aware of Wrongdoing must report the same as soon as possible.
      2. Reports of Wrongdoing should include the following:
        1. a description of the Wrongdoing;
        2. the name of the individual or individuals involved in the Wrongdoing;
        3. the date of the Wrongdoing; and
        4. any additional information that may reasonably be required in order to investigate the Wrongdoing.
    2. Acting in Good Faith.
      1. In making a report of Wrongdoing, an individual must act in good faith and on reasonable grounds.
      2. An individual who makes a report of Wrongdoing knowing it to be false or makes it with malicious intent, may be subject to discipline, up to and including termination.
    3. Confidentiality.
      1. Anyone involved in a report process will keep the matter confidential to the maximum extent possible, consistent with the Health Unit’s legal and ethical responsibilities, including the need to conduct an effective investigation and comply with the Municipal Freedom of Information and Protection of Privacy Act.
      2. Confidentiality may not mean anonymity.
      3. The Health Unit will accept reports under this Policy on an anonymous basis.
      4. The Health Unit will not tolerate any attempts to identify an individual who reports in good faith on a confidential or anonymous basis.
    4. Internal Reporting Targets and Investigation Responsibility

      1. “Individual” Being Reported

        Reported To

        Investigated By

        Chair

        Reporter’s manager, Director, Human Resources , AMOH, MOH, CEO or board vice-chair

        Committee of 3 appointed by the rest of the board based on skills/expertise, in consultation with qualified external party selected by the committee

        Board member (other than Chair)

        Reporter’s manager, Director, HR Director, AMOH, MOH, CEO or board chair

        Committee of 3 appointed by the rest of the board based on skills/expertise, in consultation with qualified external party as selected by the committee.

        Board as a whole

        Reporter’s manager, Director HR Director, AMOH, MOH or CEO

        CEO in consultation with qualified external party as selected by the CEO.

        CEO

        Reporter’s manager, HR Director, AMOH, MOH (if different from CEO) or board chair

        Committee of 3 appointed by the board based on skills/expertise, in consultation with qualified external party selected by the committee

        MOH

         

        Reporter’s manager, Director, HR Director, AMOH, CEO (if different from MOH) or board chair

        Committee of 3 appointed by the board based on skills/expertise, in consultation with qualified external party selected by the committee

        Subject to professional obligations of the reporter and the nature of the report, report may also be required to The College of Physicians and Surgeons of Ontario.

        AMOH

        Reporter’s manager, Director, HR Director, MOH, CEO or board chair

        Committee of 3 appointed by the board based on skills/expertise, in consultation with qualified external party selected by the committee

        Subject to professional obligations of the reporter and the nature of the report, report may also be required to The College of Physicians and Surgeons of Ontario.

         Directors

        Reporter’s manager, HR Director (unless reporting HR Director), AMOH, MOH, CEO or board chair

        Committee of 3 appointed by the board based on skills/expertise, in consultation with qualified external party selected by the committee

        Managers, other employees or external contract workers who are regulated health professionals and students studying to become regulated health professionals

        Reporter’s manager, director, HR Director, AMOH, MOH or CEO

        CEO in conjunction and consultation with such persons as the CEO determines appropriate.

        Subject to professional obligations of the reporter, the status of the individual being reported as a regulated health professional and the nature of the report, report may also be required to the professional college of the individual being reported.

        Other employees, external contract workers, students and volunteers

        Reporter’s manager, HR manager, AMOH, MOH or CEO

        CEO in conjunction and consultation with such persons as the CEO determines appropriate.
      2. Any individual who receives a report of Wrongdoing shall notify:
        1. the chair, if the CEO is the subject of the report;
        2. the vice-chair, if the chair is the subject of the report;
        3. otherwise, the CEO.
    5. INVESTIGATION OF WRONGDOING
      1. Accountability.  Those who have an investigation responsibility as detailed above are accountable for ensuring a report of Wrongdoing is investigated in accordance with this Policy.
      2. Principles.  Investigations of Wrongdoing will be conducted based on the following principles:
        1. The investigation will be carried out fairly and without bias.
        2. Those involved in the investigation will be independent of both the person who made the report and any persons under investigation.  This means they should not either be reporting to, or supervising, any such persons.
        3. Appropriate action shall be undertaken to preserve evidence.
        4. Disclosure of information will be limited to those who need to be involved in order to carry out the investigation.
        5. The person who is the subject of the report is entitled to know the substance of the allegation(s) and have an opportunity to respond.  Knowing the identity of the person who made the report is not a part of this and should not be disclosed.
        6. Investigations will be conducted in a timely manner.
        7. Investigations will be conducted in a manner which is as sensitive as possible to any fears of Reprisal.
        8. Individuals are required to cooperate during any investigation.
      3. Report. Those who are responsible to investigate Wrongdoing shall conclude their investigation with a written report, including recommendations.  The report shall be submitted to:
        1. the CEO, unless the subject of the report is the CEO; and
        2. the Chair, if the subject of the report is the CEO, MOH, AMOH, Director or any member of the board.
    6. ACTION SUBSEQUENT TO INVESTIGATION
      1. Accountability.  Subsequent to any investigation pursuant to this Policy, the CEO is accountable for ensuring that appropriate action is undertaken in connection with any finding of Wrongdoing by any employee, external contract worker, student or volunteer.  The board is accountable for ensuring that appropriate action is undertaken in connection with any finding of Wrongdoing by any board member.
      2. Types of Action.  The actions that may be taken to address a Wrongdoing will depend on the particular circumstances, and consequences may include, but are not limited to, discipline up to and including termination.
      3. Communication with Reporter.  The individual who made the report of Wrongdoing should be notified that the investigation is complete, and what (if any) recommendations are made based on the findings of the investigation.
    7. PROTECTION FROM REPRISAL
      1. No Reprisal.  Individuals reporting Wrongdoing in good faith under this Policy will not suffer Reprisal, even if after the investigation has been completed the Wrongdoing has not been substantiated.
      2. Report Reprisal.  Individuals who experience any form of Reprisal before or after submitting a report of Wrongdoing should report the same as a further Wrongdoing.
      3. Consequences for Reprisal.  An individual who commits any form of Reprisal against another individual involved in reporting, investigating or taking subsequent action in connection with a Wrongdoing will be subject to discipline, which may include termination.
      4. Statutory Protection.  It is noted that:
        1. Criminal Code.  Section 425.1 of the Criminal Code makes it a criminal offence for employers, anyone acting on behalf of an employer, or a person in a position of authority over an employee, to adversely affect or threaten to adversely affect the employee’s employment, or threaten to, in order to force the employee to refrain from providing information to law enforcement officials about the commission of an offence by his or her employer or by an officer, employee or board member of the employer.  However, employees are only protected if they approach a person whose duties include law enforcement.  They are not given protection if they contact a media source or an outside agency or advocacy group.
        2. Other.  It is further noted that there are other statutory protections against Reprisal embedded in certain provincial legislation, including human rights, occupational health and safety and environmental protection legislation.
    8. RECORDS
      1. Separate and Secure.  Records of reports of Wrongdoing and related investigations must be clearly marked and kept separate from other records and stored in a secure location with access limited to those who have a need to know.
      2. Not in Personnel Files.  No records of Wrongdoing will be kept in any personnel files unless there has been a finding of Wrongdoing that results in disciplinary action.  In that case, the outcome of the investigation will be reflected in the personnel file.
    9. SUPPORT FOR INDIVIDUALS
      1. Anyone involved with reporting a Wrongdoing, investigating a Wrongdoing, taking subsequent action to a finding of Wrongdoing or is the subject of a report of Wrongdoing, is encouraged to use the confidential counseling service that is available to all individuals through the Health Unit’s employee assistance program.
    10. REPORTING
      1. The CEO shall report any finding of Wrongdoing to the board that is within the scope of the CEO’s reporting obligations pursuant to the By-laws.
    11. RELATED POLICIES
      1. Code of Conduct.