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Code of Ethics

The Code of Ethics applies to all employees, physicians, volunteers, students, officers and directors of the Brant Community Healthcare System (referred to collectively as the BCHS) and we hereby affirm that:

•  We are committed to dealing fairly and ethically with all whom we associate and to conduct ourselves in accordance with our values.

•  We will adhere to a high standard of corporate ethics.

•  We will comply with all applicable BCHS policies and procedures, law, rules and regulations and will avoid any activities that could involve or lead to involvement in any unlawful practice.

Doing the right thing may not always be easy—but it is always right.

Jon C. Maxwell

Mission , Vision and Values Statement

Our Mission

Through creative and innovative use of resources and partnerships, we will focus on primary and secondary acute care, rehab, complex continuing care, palliative care, health promotion and mental health services.

Our Vision

Excellence in healthcare, close to home.

Our Values

Trust - We trust our colleagues as valued members of the healthcare team and pledge to treat one another with dignity.

Respect - We recognize and affirm the unique and intrinsic worth of each individual and treat all those we serve with compassion and kindness.

Integrity - We act with honesty and fairness in the way we conduct our business and the way we live our lives.

Our link to Ethics

In the pursuit of our BCHS mission and vision focusing on the provision of excellent care, partnership and business acumen, our values serve as the beacon that hold us accountable for our behaviours and conduct to each other, to our patients and in all of our business dealings.

Leadership Responsibilities

While all of us are obliged to follow the Code we expect our leaders to set an example and to be in every respect a model. We expect everyone at BCHS with supervisory responsibility to carry out that responsibility in a manner that is kind, sensitive, thoughtful and respectful. We expect every supervisor to create an environment within their services where all team members feel free to raise concerns and propose their ideas.

We also expect that they will ensure those on their teams have access to sufficient information to comply with laws, regulations and policies as they relate to their jobs as well as the resources to resolve ethical dilemmas. They must create culture within BCHS, which promotes the highest standards of ethics and compliance. This culture must encourage everyone in the organization to share concerns when they arise. We must never sacrifice ethical and compliant behaviour in the pursuit of our business objectives.

Putting the Code of Ethics to Work

The purpose of the Code of Ethics is to provide employees with the guidance to make appropriate decisions when encountering ethical issues and policy-based questions and when carrying out daily duties within appropriate ethical and legal standards. These obligations apply to our relationship with patients, physicians, third party payers, volunteers, students, subcontractors, suppliers, consultants and one another. Our Corporate Ethics program is designed to improve how we deal with ethical dilemmas, prejudices, ambivalent situations we experience while in the work place. It sets forth the covenant that we at BCHS make to uphold our values, our commitment to our patients and employees and our standards for doing business at all times. Our Corporate Ethics policy is intended to reflect and preserve the highest ethical standards of patient care and business practices. The key elements of the Code include training in ethical concepts, legal compliance and defined channels of communication.

BCHS adheres to high standards of business ethics and seeks to establish and maintain respect and esteem for government and regulatory authorities, customers, suppliers and community.

The BCHS policies and procedures that guide our practices are noted in this plan. Therefore this policy is meant to complement relevant standards, policies and rules and not to substitute for them. Some of these policies are general in nature and in most instances are covered in more detail by specific policies and guidelines issued by the Board in the BCHS Policy/Procedure Manual or in respective departmental manuals. Staff is expected to review and adhere to hospital policy.

We expect our employees to follow BCHS policies, laws and regulations at all times during the course of their duties when dealing with all business partners.

This document is not intended to be exhaustive. Compliance with applicable government laws, rules and regulations, accepted business and accounting rules and practices is essential and a bare minimum at the BCHS.

We take this responsibility seriously and anyone found violating the policy would be subject to disciplinary action, which may include dismissal.

Compliance Program -Communications and Training

In order to ensure a high level of awareness the Code of Ethics will be communicated to staff and public through a number of methods including the BCHS internet site, the BCHS Policy/Manual and through newsletters and brochures.

A review program has been developed to ensure that staff is aware of the standards that apply to their services. All new staff shall receive this training at general orientation and department specific orientation.

Ultimately, BCHS Management is accountable for the enforcement of and compliance with the Code of Ethics. Employee knowledge and awareness will be assured through distribution of the Code of Ethics to every employee and through appropriate training and consultation. All staff will be required to sign documentation acknowledging their agreement to abide by the Code of Ethics.

Reporting Violations

If you suspect a violation of the Code of Ethics relating to hospital policy, or of law we request that you inform your supervisor, or call the Ethics Line at extension 4212, discussed below.

BCHS, to the extent legally possible, will protect the confidentiality of any disclosed information and the identity of any employee reporting a violation. No employee will be subject to retaliation, discrimination, or any other adverse employment action for reporting suspected violations in good faith pursuant to the terms of this policy or any applicable law. Supervisors are required to refer employees who advise them about possible violations of this policy to one of the officers listed below .

Contact Extension

Director, Community Relations Marketing 4214

Vice President, Corporate Services 5889

Vice President, Resources & Development 5540

Reporting of Concerns

While each of us is individually responsible for putting the Code to work, we need not go it alone. The BCHS has a number of resources, people and processes in place to answer our questions and guide us through difficult decisions. Copies of this Code are available from the Human Resources Department and Community Relations & Marketing Department.

This Code cannot provide definitive answers to all questions. If you have questions regarding any of the policies discussed in this Code or if you are in doubt about the best course of action in a particular situation, you should seek guidance from your supervisor.

If you find yourself in a situation where the "right thing" is unclear or doing the right thing is difficult, you can begin by remembering our values statement.

Ask yourself:

Does my action reflect the principles of Trust, Integrity and Respect? What are the consequences to my patients, to my co-workers, to my hospital and to myself?

Investigations of Suspected Violations

All reported violations shall be promptly investigated and treated confidentially to the greatest extent possible. It is imperative that reporting persons not conduct their own preliminary investigations. Investigations of alleged violations may involve complex legal issues, and acting on your own may compromise the integrity of an investigation and adversely affect both you and the BCHS. All staff is required to cooperate with the investigation process.

Discipline for Violations

This Code will be enforced at all levels, fairly and without prejudice.

The BCHS intends to use every reasonable effort to prevent the occurrence of conduct not in compliance with its Code and to halt any such conduct that may occur as soon as reasonably possible after its discovery. BCHS personnel who violate this Code and other Company policies and procedures may be subject to disciplinary actions, from an oral warning up to and including discharge dependant on the seriousness of the offense

Corporate Ethics Committee & Evaluation

The Corporate Ethics Committee is in place to bring focused ethical attention to the organization's business activities under this Code to continually review the effectiveness of this program, specifically to reflecting the organization's values.

We are committed to assessing the effectiveness of our Ethics and Compliance Program through various efforts. This will include routine review of Policies at all levels of the hospital, and audits of compliance processes, an annual review of the Ethics and Compliance process to assess facility ability to implement Code, policies, procedures and Ethics line, related investigations and monitoring efforts. The Committee will also undertake to identify and share best practices.

Final Notation

This Code of Ethics sets forth fundamental principles of law and ethics governing the way that BCHS does business. However, ultimate responsibility to ensure that we as an organization comply with the many laws, regulations and ethical standards affecting our business rests with each of us. Become familiar with, and conduct yourself strictly in compliance with those laws, regulations and standards, as well as the Hospital's policies and guidelines relating to them.