FAQs: Safe Disclosure/Whistleblower Policy
Why does AHS have Safe Disclosure/Whistleblower policies and procedures?
The Safe Disclosure/Whistleblower policies and procedures are intended to help detect, disclose, address and deter improper
activity within AHS. These documents are also intended to ensure safe patient care, support and enhance a positive and ethical
working environment, and uphold the integrity of AHS and our workforce in our clinical and business operations.
These policies and procedures provide a confidential way to report improper activity occurring within AHS, and protect against
retaliatory action resulting from any such reporting. Individuals are required to report in good faith, and without malicious intent
or for personal benefit.
Are there other documents related to the Safe Disclosure/Whistleblower policies and procedures?
Yes. The Safe Disclosure/Whistleblower policies and procedures are part of a group of documents that work together. This
group of documents is known as the Ethical Conduct Governance Documents Policy Suite. This group consists of three policies
and two procedures that ensure that the AHS Safe Disclosure/Whistleblower policies, procedures and practices align with
relevant legislation such as the Alberta Public Interest Disclosure (Whistleblower Protection) Act (PIDA), with recommendations
of the Alberta Public Interest Commissioner, as well as with best practices for disclosing improper activities including fraud and
theft, protecting whistleblowers, conducting investigations and addressing allegations of improper activities.
What documents are in the Ethical Conduct Governance Documents Policy Suite (Ethics Suite)?
The Ethics Suite includes the following documents:
1. Safe Disclosure/Whistleblower Policy (revised)
2. Safe Disclosure/Whistleblower: Disclosure Decision Appeals Procedure (new)
3. Investigations Policy (new)
4. Investigations Pertaining to the Public Interest Disclosure (Whistleblower Protection) Act (“PIDA”) Procedure (new)
5. Fraud, Theft, or Misappropriation Policy (new)
How does the Ethics Suite work with other ethics governance documents at AHS?
The Ethics Suite provides foundational governance for the core values at Alberta Health Services (AHS). The AHS Values are
compassion, accountability, respect, excellence, and safety. The Ethics Suite is consistent with and supports the Ethics
Framework and Just Culture. The Ethics Suite works in harmony with the other key ethics governance documents that are
already in place at AHS, such as the Conflict of Interest Bylaw and the Code of Conduct.
Why is the Ethics Suite important to the culture of AHS?
The Safe Disclosure/Whistleblower Policy has been in force at AHS since January of 2009, and is foundational to creating and
supporting an organizational culture of trust, openness and transparency. The additional four documents in the Ethics Suite
support the Safe Disclosure/Whistleblower Policy and provide additional guidance and transparency about how the Safe
Disclosure/Whistleblower Policy is intended to work at AHS.
How long have we had a Safe Disclosure/Whistleblower Policy at AHS?
The Safe Disclosure/Whistleblower Policy was approved in January 2009 at AHS and was previously revised in May 2012. The
current update was approved in June of 2015, in accordance with the regular policy review cycle.
What is the purpose of the Safe Disclosure/Whistleblower Policy?
The Safe Disclosure/Whistleblower Policy is intended to:
• deter and detect improper activity within AHS in order to positively impact the reputation, effectiveness, and finances of
AHS, and enhance the working environment for AHS personnel;
• provide clear guidance for the safe disclosure of any improper activity occurring within AHS;
• protect from retaliatory action any AHS personnel, or other individual, who in good faith discloses improper activity
occurring within AHS. Protection from retaliation is also known as “whistleblower” protection; and
• promote awareness and compliance with PIDA.
Last Updated: April 25, 2017
Disclaimer: Every situation depends on the facts. Information and examples are provided by the Ethics and Compliance Office as illustrations and guidance, and are not meant to be exhaustive,
nor alter or limit any policy, Act or other directive that may govern the specifics of your situation. W hen in doubt, please discuss with your supervisor, your professional practice leader, or if
appropriate, the Chief Ethics and Compliance Officer.
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FAQs: Safe Disclosure/Whistleblower Policy
What has changed in the Safe Disclosure/Whistleblower Policy?
The main changes to this policy involve the ability to make disclosures under PIDA. This policy also includes enhanced provisions
for the collection, access, use, and disclosure of information to ensure AHS’ ongoing compliance with the Health Information Act
(Alberta), the Freedom of Information and Protection of Privacy Act (Alberta), and AHS’ Collection, Access, Use, and Disclosure of
Information policy.
What is the purpose of the Safe Disclosure/Whistleblower: Disclosure Decision Appeals Procedure? The Safe
Disclosure/Whistleblower: Disclosure Decision Appeals Procedure is a new document. It is intended to provide a consistent, fair,
and timely process for submitting and handling appeals of decisions or recommendations made by the AHS Chief Ethics and
Compliance Officer in respect of a disclosure made under the AHS Safe Disclosure/Whistleblower policy.
What is the purpose of the Investigations Policy?
The Investigations Policy is a new policy that is intended to set out AHS’ commitment to investigating allegations of improper
activities and retaliation. Additionally, this policy sets out AHS’ requirements and responsibilities under PIDA for disclosing,
investigating, and addressing allegations of wrongdoing and reprisal. These responsibilities are further defined under the
Investigations Pertaining to the Public Interest Disclosure (Whistleblower Protection) Act (PIDA) procedure.
What is the purpose of the Investigations Pertaining to the Public Interest Disclosure (Whistleblower Protection) Act (PIDA)
Procedure?
The Investigations Pertaining to the Public Interest Disclosure (Whistleblower Protection) Act (PIDA) Procedure is a new
procedure that sets out AHS requirements and responsibilities under PIDA for disclosing, investigating, and addressing
allegations of wrongdoing and reprisal. A separate procedure is required as PIDA establishes certain requirements and timelines
that AHS must follow when a matter is being addressed under PIDA.
This procedure recognizes that the Medical Staff Bylaws will apply to investigations impacting the medical staff. Due to the
requirements to comply with PIDA legislation, under certain circumstances, it is possible that a parallel investigation may be
conducted outside of the Medical Staff Bylaws to meet the requirements of PIDA (for example, investigations under PIDA must
be completed within 110 business days).
What is the purpose of the Fraud, Theft or Misappropriation Policy?
The new Fraud, Theft or Misappropriation Policy has been developed to set out the AHS commitment to preventing, detecting,
disclosing and responding to allegations of fraud, theft, or misappropriation of AHS assets. A fraud policy clearly establishes an
organization’s approach to preventing, detecting, disclosing and addressing such allegations and is seen as a best practices
requirement.
Who can report improper activity under the Ethics Suite?
The Ethics Suite including the Safe Disclosure/Whistleblower Policy allows AHS personnel and the public to safely report anything
they consider to be improper activity within AHS without fear of retaliation as set out in the policy. The public may disclose an
improper activity, but AHS personnel have a duty to disclose an improper activity.
When do AHS personnel have a duty to report an improper activity?
All AHS personnel who have a reasonable basis to believe that improper activity has occurred, or is occurring within AHS, have a
duty to disclose the improper activity.
To whom does the Ethics Suite apply?
This suite applies to AHS personnel. AHS personnel means any person acting for or on behalf of AHS, including senior officers,
employees, members of the AHS Board, members of the medical, dental, podiatry, and midwifery staffs, and other AHS agents,
consultants or representatives including:
Last Updated: April 25, 2017
Disclaimer: Every situation depends on the facts. Information and examples are provided by the Ethics and Compliance Office as illustrations and guidance, and are not meant to be exhaustive,
nor alter or limit any policy, Act or other directive that may govern the specifics of your situation. W hen in doubt, please discuss with your supervisor, your professional practice leader, or if
appropriate, the Chief Ethics and Compliance Officer.
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FAQs: Safe Disclosure/Whistleblower Policy
•
•
•
•
•
•
•
Members of the AHS Board,
Senior Officers,
AHS employees,
Members of the medical, dental, podiatry, and midwifery staffs,
Students,
Volunteers, and
Agents, consultants or persons acting for or on behalf of AHS.
Does the Ethics Suite apply to the general public?
The Ethics Suite applies to members of the public, as the public is protected from retaliation by AHS under the policy. However,
members of the public are not bound by the ‘duty to disclose’ provisions. For example, if a member of the public is a witness to
improper activities, they are not duty bound to report it. However, if they do report, they cannot be retaliated against by AHS.
For example, a member of the public cannot be denied services by AHS because they reported an improper activity occurring at
AHS.
What is considered to be improper activity?
Improper activity means any alleged unethical, illegal and other improper activity, including but not limited to, fraud, preferential
treatment, violations of laws, violations of the AHS Code of Conduct, principles, policies or bylaws (including the Conflict of
Interest Bylaw), and negligence of duty.
What is not considered to be improper activity?
The Ethics Suite and the PIDA reporting mechanisms are not intended to deal with routine AHS operational or HR matters. AHS
has existing procedures in place to assist in raising such concerns through your supervisor, HR Client Services or union
representative. For more information about reporting workplace HR or operational concerns go the Health and Wellness on
Insite.
If I report an instance of improper activity, should I be afraid of retaliation?
As long as you are acting in good faith, and without malice or desire for personal benefit, you are protected against retaliation
within AHS. For example, your supervisor cannot change all your shifts around to “unwanted” shifts just because you reported an
improper activity.
What protection do I have if there is an allegation of improper activity made against me, but there is no reasonable evidence to
support the claim?
The policy offers the same protection against retaliation for you as for those reporting improper activity. The allegation will be
reviewed by the Chief Ethics and Compliance Officer or delegate, and may be dismissed at the outset if there is no reasonable
evidence to support the claim.
What kinds of retaliation does the Safe Disclosure/Whistleblower Policy protect against?
This policy protects those reporting improper activities against retaliatory actions made as a result of the reporting, such as retaliation in
the form of demotion, suspension, termination, workplace harassment, or denial of service or benefits.
How do I report situations of improper activity?
Whenever possible you should first report improper activity to your supervisor. If the report involves your immediate supervisor,
or you feel unable to discuss with your supervisor, you may choose to report to your HR contact, union representative, or to your
supervisor’s manager, etc. If the above ways to report are not appropriate in your situation, you may contact the Chief Ethics and
Compliance Officer by email at [email protected] , or by Fax: 780-735-1450.
What if I am concerned about disclosing my Identity?
If you are concerned about disclosure of your identity, and it is not appropriate to discuss with your supervisor, etc., or with
the Chief Ethics and Compliance Officer, then you may also call the Confidential Safe Disclosure Line (1-800-661-9675), a 24/7
external confidential reporting and disclosure service engaged by AHS to receive reports of improper activity.
Last Updated: April 25, 2017
Disclaimer: Every situation depends on the facts. Information and examples are provided by the Ethics and Compliance Office as illustrations and guidance, and are not meant to be exhaustive,
nor alter or limit any policy, Act or other directive that may govern the specifics of your situation. W hen in doubt, please discuss with your supervisor, your professional practice leader, or if
appropriate, the Chief Ethics and Compliance Officer.
Page 3
FAQs: Safe Disclosure/Whistleblower Policy
What is the Confidential Safe Disclosure Line (1-800-661-9675)?
The Confidential Safe Disclosure Line (1-800-661-9675) is an external 24/7 service that AHS has engaged to receive confidential
disclosures and reports of improper activity within AHS. Anonymous reports are accepted by the Confidential Safe Disclosure Line,
although there are often limitations in the extent of the follow up that can be done for an anonymous disclosure.
What happens with the information I disclose to the Confidential Safe Disclosure Line?
The information collected will be compiled into a report that is prepared by the external service, which is submitted to the Chief
Ethics and Compliance Officer for follow-up, review, and/or investigation. When anonymity is requested, your name is not
included in the report.
When should I report improper activities to my supervisor?
Improper activities should be reported to your supervisor as soon as you first become aware of the improper activity, as it is
your duty to report. As above, if you are unable to report this to your supervisor, for whatever reason, then you may report to
your HR contact, union representative, or to your supervisor’s manager.
What will my supervisor do with the information I disclose?
Whenever improper activity occurs and your supervisor is made aware, they are required to address the issue in consultation
with the appropriate expertise including HR Client Services, and/or submit the matter (in writing), for follow-up, review, and/or
investigation by the Chief Ethics and Compliance Officer.
When should I report improper activity to the Chief Ethics and Compliance Officer?
If an allegation of improper activity cannot be resolved with your supervisor or your supervisor’s manager, HR or through your union
representative, you may report the matter to the Chief Ethics and Compliance Officer. This includes concerns about retaliation or
inaction.
How can I contact the Chief Ethics and Compliance Officer?
The Chief Ethics and Compliance Officer can be contacted by:
• E-mail at [email protected], or by
• Fax: 780-735-1450.
What if the improper activity involves the Chief Ethics and Compliance Officer?
The disclosure should be reported to the Confidential Safe Disclosure Line (1-800-661-9675), which will be forwarded directly to the AHS
Governing Body. The Confidential Safe Disclosure Line is a 24/7 external confidential reporting and disclosure service engaged by
AHS to receive reports of improper activity within AHS.
If I chose to disclose anonymously, why would my contact information be requested?
While you may report anonymously, this leaves little room for follow up or resolution. To address, review or investigate
concerns, it is usually necessary to obtain further information from the person reporting. The reporter’s name, identifying
information and contact information (e.g., telephone or email) will remain confidential to the extent possible, whenever addressing an
allegation of improper activity.
What if I choose to remain anonymous?
Your identity will be protected to the extent possible while following up on the disclosure; however, the follow up requires a
balancing of interests and due process. As a general rule, your identity will not be revealed without your permission. If you choose
to remain anonymous, for specific cases that require disclosure of your information or identity by policy, law or for follow up, it
may not be possible to conduct a comprehensive review and/or investigation, or to achieve resolution. Where AHS is required to
disclose the report of improper activity by policy or law, the report may be disclosed as required, but information will only be
disclosed to the extent necessary.
Last Updated: April 25, 2017
Disclaimer: Every situation depends on the facts. Information and examples are provided by the Ethics and Compliance Office as illustrations and guidance, and are not meant to be exhaustive,
nor alter or limit any policy, Act or other directive that may govern the specifics of your situation. W hen in doubt, please discuss with your supervisor, your professional practice leader, or if
appropriate, the Chief Ethics and Compliance Officer.
Page 4
FAQs: Safe Disclosure/Whistleblower Policy
How can members of the public disclose improper activity?
Members of the public can report directly to the AHS Chief Ethics and Compliance Officer or through the external confidential
reporting and disclosure service. The information reported will be provided to the Chief Ethics and Compliance Officer for followup and/or investigation.
What kind of information should disclosures contain?
Disclosures should contain factual rather than speculative information, and have as much specific information as possible. For
example, disclosures should stick to the facts and what has been personally observed, rather than be based on opinion or hearsay.
The improper activity occurred some time ago, can I still report it?
If the alleged improper activity occurred in isolation more than two years prior to the date of the disclosure, it will generally not
be open for review. However, exceptions may be made when the matter represents a continued or future risk to employees,
independent health professionals, students, volunteers, the public, patient safety, the integrity and reputation of AHS, and/or to
the clinical or business operations of AHS.
If the matter happened over two years ago, should I still make the disclosure?
Yes, you should still make the disclosure so that the Chief Ethics and Compliance Officer can review the specific concerns and
determine whether the matter will be reviewed.
What if I am not satisfied with a decision or arecommendation of the Chief Ethics and Compliance Officer?
A decision or recommendation of the Chief Ethics and Compliance Officer may be appealed using the process set out in the Safe
Disclosure/Whistleblower: Disclosure Decision Appeals procedure.
How am I protected from retaliation or retribution related to making a disclosure of improper activity?
AHS strictly prohibits AHS personnel from seeking retribution against anyone who discloses improper activity or who participates
in an investigation related to a disclosure.
What is considered retaliation?
Retaliation includes workplace harassment, prejudicial treatment or dismissal and/or punitive actions unrelated to documented
performance issues, or misconduct, which occurs as a result of reporting an improper activity.
What do I do if I believe I have been subjected to retaliation as a result of disclosing improper activity or participating in an
investigation of an allegation of improper activity?
AHS personnel may report the matter to their supervisor, HR contact, union representative, or the Chief Ethics and Compliance
Officer. Any individual may also report the matter to the Confidential Safe Disclosure Line (1-800-661-9675), a 24/7 external
confidential reporting and disclosure service engaged by AHS to receive reports of improper activity.
What legislation protects my rights if I make a disclosure of improper activity?
Individuals are protected by the Criminal Code of Canada, PIDA and the Freedom of Information and Protection of Privacy Act and
the Health Information Act. The Criminal Code of Canada protects individuals from adverse employment action if they disclose
any type of criminal activity undertaken by their employer, and PIDA, the Freedom of Information and Protection of Privacy Act
(Alberta) and the Health Information Act (Alberta) protect individuals from adverse employment action if they disclose
information in accordance with these Acts.
Does the Ethics Suite limit my rights legislated by the government?
No. The Ethics Suite is intended to enhance and complement other protections, is in alignment with existing legislation, and
does not interfere with AHS personnel or member of the public reporting a matter outside of AHS, to provincial, federal
governments or other agencies including to the Alberta Public Interest Commissioner.
Last Updated: April 25, 2017
Disclaimer: Every situation depends on the facts. Information and examples are provided by the Ethics and Compliance Office as illustrations and guidance, and are not meant to be exhaustive,
nor alter or limit any policy, Act or other directive that may govern the specifics of your situation. W hen in doubt, please discuss with your supervisor, your professional practice leader, or if
appropriate, the Chief Ethics and Compliance Officer.
Page 5
FAQs: Safe Disclosure/Whistleblower Policy
Are there any limits to the protection afforded by this policy?
The provisions in this policy are focused on improper activity as defined in the policy, and are not intended to deal with routine
operational or HR matters. For example, the policy does not interfere with AHS taking normal employment action as a result of poor
job performance or misconduct.
How am I protected from false or malicious allegations being brought against me?
Any AHS personnel that knowingly make a malicious, misleading or false disclosure of alleged improper activity are subject to
appropriate disciplinary action.
Will I receive any follow-up on any disclosures I make?
Yes. You will be informed, in a general way, of the outcome, if possible (e.g., this is not possible where there is no contact
information). The Chief Ethics and Compliance Officer or delegate will consider the specific circumstances, including a request for
confidentiality or anonymity of the individual making the disclosure, and/or information that would unduly compromise the privacy
of any other individual.
Where are the records related to these disclosures kept?
The Chief Ethics and Compliance Officer (or designate) retains the records relating to the disclosure of improper activity and
subsequent actions taken.
Who does the Chief Ethics and Compliance Officer report to?
Functionally, for matters pertaining to the Safe Disclosure/Whistleblower Policy, the Chief Ethics and Compliance Officer reports to the AHS
Governing Body, and administratively, to the President and Chief Executive Officer. Reports are provided to the AHS Governing
Body including the Human Resources Advisory Committee and the Audit and Finance Committee, as well as to the President and Chief
Executive Officer, and to senior leadership and management, as appropriate.
How can I contact the Chief Ethics and Compliance Officer?
You may contact the AHS Chief Ethics & Compliance Officer, by:
• E-mail: [email protected], or by
• Fax: 780-735-1450.
How can I contact the Confidential Safe Disclosure Line (1-800-661-9675)?
You may contact the Confidential Safe Disclosure Line at 1-800-661-9675. The Confidential Safe Disclosure line is an external
confidential reporting and disclosure service engaged by AHS to receive reports of improper activity within AHS on a 24/7 basis.
Last Updated: April 25, 2017
Disclaimer: Every situation depends on the facts. Information and examples are provided by the Ethics and Compliance Office as illustrations and guidance, and are not meant to be exhaustive,
nor alter or limit any policy, Act or other directive that may govern the specifics of your situation. W hen in doubt, please discuss with your supervisor, your professional practice leader, or if
appropriate, the Chief Ethics and Compliance Officer.
Page 6