Code of Conduct
October 2010
What is the Central East LHIN (CE LHIN) Code of Conduct?
The Code of Conduct (the Code) identifies expectations for workplace behaviour that is appropriate, acceptable
and encouraged. It is designed with consideration for the CE LHIN Vision, Mission and Values. It identifies
behaviors in support of day-to-day activity and decision making.
The Code is supported by a number of resources such as detailed policies, procedures and guidelines which are
referenced and hyper-linked in this document – such as The Travel and Expense Policy, Conflict Resolution
Process, Diversity in the Workplace Policy, Harassment and Discrimination Policy, etc.
Why a Code of Conduct:
The Code of Conduct is intended to be a central guide and reference for all employees and the Board in support
of our day-to-day interactions and decision making, and to help us work more effectively together. It is a tool for
everyone to handle a variety of work situations some of which may be difficult such as managing workplace
conflict, or coping with ethical dilemmas such as making decisions that ensure you avoid a conflict-of-interest
situation.
Guiding Principles:
The Code was developed based on the following Guiding Principles:
1.
2.
3.
4.
5.
6.
7.
8.
9.
We support the CE LHIN’s Mission, Vision and Values in our daily activities
We act with honesty and integrity as public servants
We treat others with respect and value differences
We maintain a professional, safe and supportive working environment
We acknowledge conflicts and manage them responsibly and timely
We declare and proactively manage conflicts of interest
We respect and maintain privacy and confidentiality
We are accountable for our actions and decisions
We consistently, fairly, and equitably apply CE LHIN policies and procedures
Who does the Code apply to?
The Code has been developed to support and guide all our work practices at the CE LHIN and as such applies to
all employees and Board members. This includes anyone who works on contract with the CE LHIN organization,
including contractors, students and consultants. The CE LHIN encourages our community partners to adopt and
maintain a similar Code of Conduct and Guiding principles to those outlined in the Code.
“The Code of Conduct provides the standards of business conduct
and ethics that are expected of every one of us, regardless of our
position at the CE LHIN.”
--Deborah Hammons, Chief Executive Officer, CE LHIN
2
When does the Code apply?
In the spirit of the Code and recognizing the opportunity for public scrutiny, the Code applies to day to day
workplace interactions and whenever you are representing the CE LHIN. In some situations this may be outside
your normal place of work or working hours – for example at work functions, after- hours work activities, and
when you represent the CE LHIN in the community.
Who can support me in complying with the Code?
If you need more information on your obligations under the Code, please speak with your manager or supervisor.
Our Corporate Human Resources unit can also provide you with assistance when needed.
How can I be sure I am complying with the Code?
This Code provides minimum expectations and general guidelines regarding your conduct but cannot possibly
cover every conceivable circumstance you may experience. In day to day interactions you are expected to use
good judgment, consider the expectations of the Code and act accordingly. If you are in doubt about whether
your conduct is consistent with the Code – here are some questions to ask yourself:
Does it feel like the right thing to do?
What would a CE LHIN colleague /stakeholder expect me to do in this situation?
What would the reaction be if this was reported in the newspapers?
Would my colleagues or manager consider my behaviour appropriate?
What impact might this have on carrying out the CE LHIN’s Mission?
What will happen if I do not comply with the Code?
Upholding the Code is in the interests of everyone, and at the CE LHIN we will work with all employees to ensure
there is an understanding of and commitment to the CE LHIN Mission, Vision and Values in our everyday work
practices. In a perceived non-compliant situation there is a step-by-step fact-finding process in place to handle
the issue fairly and objectively (see Policy Compliance Process). If it is confirmed as a failure to comply with the
Code, it is considered the same as a breach of policy. Consequences of a breach could range from a verbal
warning through to employment termination for a serious breach.
How will we ensure the Code is effective?
After six months of implementation the Code of Conduct Committee will re-convene to review and address any
implementation issues or staff concerns. In addition, ongoing monitoring of how the Code is working will be done
by Corporate Human Resources in collaboration with all staff.
Upon hiring and annually after that, every CE LHIN employee will complete a Code of Conduct Declaration to
affirm that they understand the principles of the Code, confirm that they have complied with them in the previous
twelve months, and agree to comply with them going forward. This will be done in conjunction with the
Performance Appraisal process.
Any breaches of the Code will be documented in the employee’s personnel file and reported in line with the CE
LHIN’s policies and procedures compliance process. At all times appropriate confidentiality will be maintained.
Upon recruitment, every CE LHIN Board member will complete a Code of Conduct Declaration to affirm that they
understand the principles of the Code and agree to comply with them for their tenure on the Board.
3
We support the CE
LHIN’s Mission,
Vision and Values
in our daily
activities.
We maintain a
professional, safe
and supportive
working
environment.
We respect and
maintain privacy
and confidentiality.
As public servants
we act with
honesty and
integrity.
We treat others
with respect and
value differences.
We acknowledge
conflicts and manage
them responsibly and
timely.
We declare and
proactively
manage conflicts
of interest.
We are
accountable for
our actions and
decisions.
We consistently,
fairly and equitably
apply CE LHIN
policies and
procedures.
4
We support the CE LHIN’s Mission,
Vision and Values in our daily
activities.
Each of us has the capacity to contribute to the
success of the CE LHIN, and as such, we must
ensure our behaviours support the CE LHIN
Mission, Vision and Values in everything we do.
The CE LHIN will work with all stakeholders to
maintain and protect its reputation to be one that is
consistently trusted and respected.
Mission: To lead the creation of an integrated sustainable healthcare system that ensures better
health, better care, better value for money.
Vision: Engaged communities, healthy communities
Values: Accountability, Responsiveness, Respect, Integrity, Innovation, Equity
I will lead by example, considering the impact of my actions and behaviours on others within the CE LHIN
organization and the broader community.
I will recognize the importance of engaging others in the creation of an integrated health care system.
I will support informed and participatory decision-making.
I will be responsive and respectful in my dealings with colleagues and health care stakeholders.
I will consistently and in a positive manner, communicate the essential need to realize our Mission.
I will identify opportunities for improvement, work to remove barriers and celebrate innovation, learning and
success.
I will anticipate and embrace challenges and
manage them effectively in a calm, and
constructive manner.
Resources:
Central East LHIN:
Mission, Vision and Values
5
As public servants we act with
honesty and integrity.
As public servants our success is earned by acting with
honesty and integrity and by considering our communities,
stakeholders and partners in all our dealings and decision
making. We must always be mindful of how we use our
position, and that it is vital to honour the oath of public
office.
I will lead by example, considering the impact of my actions and behaviours on others within the CE LHIN
organization and the broader community.
I will undertake my duties, as a public servant, with care and diligence; I will remember that I am accountable
for the decisions that I make and the actions that I take.
When conducting CE LHIN business, my involvement in community events, activities or functions directly
reflects the CE LHIN, as such I will be aware of and comply with all requirements of the CE LHIN Corporate
Travel and Hospitality policies.
I will be honest and helpful in all of my communications and dealing with colleagues, stakeholders and
community in a transparent and accurate manner.
I will never improperly use my position with the CE LHIN, or use any information that I encounter through my
work at the CE LHIN, to further my own personal interests, or help others to do so.
I will consider the interests and needs of colleagues, stakeholders and the community when providing advice,
information or services to them.
I will not accept any gifts, rewards or entertainment including discounted products or services, free travel or
accommodation, if it could create any obligation or expectation that could conflict with my work at CE LHIN.
Resources:
Central East LHIN: Mission, Vision and Values
Queen’s Oath
Corporate Travel & Hospitality Policy
6
We treat others with respect and
value differences.
At the CE LHIN everyone has a unique role in contributing to
our success. The CE LHIN Values celebrate diversity,
treating each other with dignity and respect, and accepting
opinions, needs, and concerns that are different to our own.
I will respect each individual for his/her unique talents and contributions that they bring to the
CE LHIN.
I will encourage and participate in healthy debate in order to bring different and new
perspectives to the table.
I will withhold judgment on opinions until others have had a chance to participate in the
decision.
I will do my part to ensure an inclusive and engaged workplace by accepting differing views
to my own.
Resources:
Diversity Information
Bill 168
Harassment and Discrimination Policy
Inclusive Workplace Practices
7
We maintain a professional, safe
and supportive working
environment.
The CE LHIN is committed to a proficient, innovative,
tolerant, secure, and supportive working environment to
develop our people to be the very best at what we do.
I will treat all people through my work at the CE LHIN with dignity and respect – such as
understanding and appreciating opposing or contrary opinions.
I will never discriminate, harass or bully my colleagues, stakeholders or anyone else in the
workplace; this includes being aware that some behaviours may be acceptable to me but not to
others.
I will contribute to a safe working environment by taking responsibility for following all CE LHIN
Health and Safety policies and reporting any issues as soon as possible to ensure a safe working
environment - such as adhering to the Workplace Violence & Harassment Program.
I will seek the support of others (CE LHIN resources) when I feel compromised in my working
environment such as using the “buddy system” for challenging situations, Human Resources for
advice on conflict resolution, or the Employee Assistance Program (as available) for personal and
workplace difficulties.
Resources:
Violence in the Workplace Program
Bill 168
Health & Safety Policies
Employee Assistance Program (EAP)- pending approval
8
We acknowledge conflicts and
manage them responsibly and
timely
At the CE LHIN each of us must take responsibility to
acknowledge and deal with workplace issues and concerns,
and at all times engage in a process that is open,
constructive, results-oriented and free-of-blame.
In my interactions with colleagues and broader stakeholders I will take responsibility to acknowledge conflicts
both stated and perceived.
I will address conflicts in a timely and forthright manner – this includes:
consider and discuss my own interests and values.
ask about, and listen interactively and authentically to the interests and values of the other individual(s)
without criticism or judgment.
share and acknowledge information to assist in resolving the conflict, including actions, situations and
emotions.
identify mutual or shared interests and collaborate with the other individual(s) to clarify the issues
which need to be addressed (e.g. using a “How can we fix it” approach).
work collaboratively with the other individual(s) to define a durable and acceptable option(s) and steps
needed to resolve the conflict.
commit to take action on agreed-to steps to resolve the conflict.
If I need additional support, I will seek assistance from Human Resources or my supervisory manager in
handling the conflict as necessary.
I will develop my Conflict Resolution skills through participating in training, and applying what I learn.
Resources:
Conflict Resolution Process
Employee Assistance Program (EAP)- pending approval
9
We declare and proactively
manage conflicts of interest.
There are many situations in which conflict of interest can
occur. As CE LHIN employees we must be mindful of these
situations and our responsibility to avoid them. We must
ensure our decision-making is objective and free of
inappropriate influence, and we must follow CE LHIN
systems, procedures, and process at all times.
I will behave in a way that takes into account my impact on our stakeholders and the broader community and
the environment in both the short and long term.
I will be alert to actual or potential conflicts of interest and disclose them to my manager, Human Resources
representative or appropriate parties.
I will seek approval of my manager for any outside business interests including directorships, contracts,
partnerships, collaborations, services or financial interests which have the potential to be in conflict with my
employment, the interest of the CE LHIN or CE LHIN partners.
I will declare any situation in my work that may be perceived as indirectly providing gain for immediate family
members or relatives.
I will not engage in outside work that would otherwise constitute full-time employment for another person or
organization.
I will not be involved as an officer and/or board member of any corporation, agency or entity that represents
the interests of persons who are part of the health sector; the College of a health profession or group of
health professionals as defined in the Regulated Health Professions Act 1991; or an entity that receives
funding from the CE LHIN or is directly affected.
I will not solicit or accept favours or economic benefits from
any individuals, organizations or entities known to be seeking
funding, business or contracts with the CE LHIN or that is
engaged in the delivery of services within the CE LHIN’s
mandate in the CE LHIN’s geographic area.
Resources:
Employee Agreement
Conflict of Interest Policy
Recruitment Policy
Procurement Policies
10
We respect and maintain privacy
and confidentiality.
At the CE LHIN we have a privileged role as stewards of
public information. As such we must do everything in our
power to maintain the integrity of not just this information but
of all CE LHIN information assets by ensuring their security,
privacy and appropriate accessibility and approvals at all
times.
I will do everything I can to keep information secure; I will seek clarity when I am unsure on when
information can be distributed internally.
I will rigorously follow the CE LHIN Privacy policy when allowing access to confidential information.
I will follow procedures and requirements to protect information when providing detail over phone,
fax or email and in public presentations.
I will collect, use, store, handle, update and destroy data and information, in line with applicable
policies and procedures; I will ensure or support the appropriate use of electronic signatures and
approvals at all times.
I will not disclose information about the CE LHIN that is not already in the public domain without the
proper authority to do so.
I will uphold the integrity of all CE LHIN’s records and information assets by ensuring there are no
false or misleading entries, no tampering with or forging signatures and that Record Management
procedures are followed at all times.
During the course of my work for the CE LHIN I waive any rights, title or interest in the work I
produce which is the intellectual property of the CE LHIN.
Resources:
Records Management Process & Employee Agreement
Conflict of Interest & Employee Files Policies
FIPPA
11
We are accountable for our actions
and decisions.
Each of us, the government, the public and our communities
have expectations that the CE LHIN mandate will be carried
out in an ethical, responsible and accountable manner. We
must strive to be conscientious in knowing and performing
our roles and responsibilities. We must honour all legal and
ethical requirements in our everyday practices, and we must
strike a reasonable balance between using public resources
and meeting our needs as employees, stakeholders and
communities.
I will strive to make positive and productive decisions in my daily work and with the appropriate
people.
I will make decisions that are aligned with mandated policies and procedures, and strategic priorities
of the CE LHIN.
I will collect the necessary information, evaluate it based on sound criteria, and use a transparent
process to make decisions.
I will answer emails, phone calls, faxes as required, and in a timely manner and be responsive to the
needs of my colleagues, stakeholders and that of our health service providers.
I will fully engage in discussion and listen to obtain information, so that I am accountable for my
actions and decisions.
I will undertake my duties with care and diligence; I will remember that I am accountable for the
decisions that I make and the actions that I take.
I will use CE LHIN assets and funds (both operations and health service providers) for proper
purposes and keep accurate and transparent records for all payments or receipts for transactions
using CE LHIN funds.
Resources:
http://www.mindtools.com/
Communication Directive
12
We consistently, fairly and
equitably apply CE LHIN policies
and procedures.
As a business entity the CE LHIN is responsible for ensuring
it maintains a supportive, effective, efficient and successful
operation. Our policies and procedures must be clear, userfriendly, representative of all employees, and must
communicate the consequences of non-compliance. All
employees have an important role in ensuring our policies
are implemented consistently and completely.
I will adhere to the policies and procedures of the CE LHIN and understand that if I breach policy, procedures
or this Code there may be consequences for my action(s).
If I am unsure whether a policy or procedure applies to my work at the CE LHIN I will seek guidance from
Human Resources or my supervisory manager.
When I believe the behaviour of another interferes with the spirit of the Code, which creates a conflict
situation, I will first consider my option of addressing it directly with the individual, as I feel comfortable, in a
constructive, timely and forthright manner.
I will use appropriate process at all times to handle a suspected breach.
I will seek more information or clarification if I feel a policy is inequitable or unfair.
I will participate in training, education and maintain my awareness of revised and new policies and
procedures of the CE LHIN.
Documents:
Resources:
Process of reviewing and developing
Policies & Procedures
Conflict Resolution Process
Business Operations Manual
Management Letter from annual audit review
Requirements from Auditor General review
Freedom of Information
Community engagement – public input, issues
and correspondence
Procurement Policies
IT Policy
Compliance Policy
13