PREVENTION & MANAGEMENT OF VIOLENCE IN THE WORKPLACE

Transcription

1 SECTION: IV-i Environment Management NO: 110 Occupational Health & Safety Issued By: Executive V.P & Chief Financial Officer APPROVAL DATES : Approved by: Key Words: Board of Trustees Aggressive, Abusive, Threatening, Assault, Bullying, Violence, Aggression, Threats Abuse Date Initially Issued: 03/12/2009 Date Reviewed: 04/14/2010, 10/02/2011, 10/17/2012, 03/05/2013 Date Revised: 04/14/2010, 10/02/2011, 10/17/2012, 27/05/2013, 16/09/2013 Date Implemented: 10/02/2011, 13/12/2012, 20/06/2013, 26/09/2013 Cross Reference(s) CORP V-i 100 Respectful Workplace, CORP IX-i 110 Code White, CORP VII-iii 100 Incident Management, CORP IV-ii 220 Visitors, CORP IV-ii 160 Employee Incident Reporting 1. PURPOSE: To define behaviour that constitutes workplace violence and to outline the process for reporting and resolving incidents of workplace violence. 2. POLICY STATEMENT: The Royal Ottawa Health Care Group () recognizes the potential for violence in the workplace. The will make every reasonable effort to identify all potential sources of violence in order to eliminate and/or minimize these sources, striving to provide an environment free of violence. Any individual who demonstrates or threatens violence towards staff, patients and/or visitors will be managed in accordance with s policies, procedures and professional practice guidelines. All persons engaged by as employees, physicians, students, volunteers, officers, Trustees of the Board, or contractors will demonstrate professionalism, respect and courtesy in performing their duties and in all of their activities supporting the organizational Mission, Vision and Values which are as follows: Mission: Delivering excellence in specialized mental health care, advocacy, research and education. Vision: Mental health care transformed through partnerships, innovation and discovery Values: We are guided by innovation and a passionate commitment to collaboration, honesty, integrity and respect. 1 of 20

2 3. SCOPE: This policy applies to the and extends to locations outside of the physical environment of the organization that may involve staff and/or patients. 4. GUIDING PRINCIPLES: The is committed to a healthy and respectful environment, which includes both physical and psychological safety and where all staff share the responsibility to create and maintain this status. All staff have the right to refuse to work if they have not received the appropriate training or have the equipment necessary to mitigate identifiable personal risk. (Occupational Health & Safety Act - Section 43(2)) In managing violent behaviour, it is essential to consider whether the behaviour is intentional or not intentional, because of the medical or psychological status of the patient. (London Health Sciences Centre Abuse Policy October 2003). If a patient is demonstrating aggressive or escalating behaviours, using clinical judgment, the appropriate measures must be implemented to stabilize the situation. Ministry mandated training in the identification, assessment and management of escalating behaviour is provided to all levels of staff for effective management of risk in workplace violence. Every reasonable effort will be made to identify all potential sources of violence and to eliminate or minimize the associated risks. Reporting acts of violent behaviour or any process or characteristic of the organization s work system that may potentially affect the safety of the workplace is the responsibility of all staff. No report of workplace violence or risks of violence, (excluding frivolous or malicious complaints), can be the basis of reprisal against the reporting staff member. The, in consultation with the Joint Health and Safety Committee (JHSC), assesses for risks of workplace violence in all positions in the workplace as a whole (including work related off-site activities), and integrates health and safety into day-today operations. Workplace violence can occur both in the workplace and in work-related settings outside of the usual workplace and regular working hours. It can occur during work-related functions at off-site locations such as conferences, social events, or visits to patient s homes. Violence may also manifest itself in the form of threatening telephone calls from co-workers, family members, patients, clients or managers. Workplace violence can be committed by anyone: staff, patients, clients, students, contract staff, visitors, families of patients, families or friends of staff, or unauthorized intruders. Workplace violence can be experienced directly or indirectly such as witnessing a violence act or working in a violent environment over time. This Policy is intended to operate in conjunction with other workplace In particular, CORP IX-I 100 Code White for initiating and responding to a psychiatric emergency and CORP VII-iii 100 Patient Safety Incident Management for managing and reporting patient safety and critical incidents are specifically cross-referenced in this Policy and the processes described in those policies apply in the event of violent 2 of 20

3 incidents in the circumstances described in those Incidents involving inappropriate workplace behaviour that does not fall within the definition of workplace violence under this policy may fall within the scope of CORP V-i 100 Respectful Workplace that provides for a process to address personal harassment and workplace conflicts. 5. DEFINITIONS: Critical Injury: Means an injury of a serious nature that, (a) places life in jeopardy, (b) produces unconsciousness, (c) results in substantial loss of blood, (d) involves the fracture of a leg or arm but not a finger or toe, (e) involves the amputation of a leg, arm, hand or foot but not a finger or a toe, (f) consists of burns to a major portion of the body, or (g) causes the loss of sight in an eye. (OHS Act R.R.O. 1990, Reg. 834, s.1.) Psychological Safety: the absence of harm and/or threat of harm to mental well-being that a worker might experience. Workplace Violence: any act of force or aggression, including obscene or violent behaviour, use of foul language and other actions, which may threaten, assault or abuse any staff member in the course of their association with the. Workplace Violence is: (a) the exercise of physical force by a person against a worker, in a workplace, that causes or could cause physical injury to the worker, (b) an attempt to exercise physical force against a worker, in a workplace, that could cause physical injury to the worker, (c) a statement or behaviour that it is reasonable for a worker to interpret as a threat to exercise physical force against the worker, in a workplace, that could cause physical injury to the worker. It also includes psychological violence such as bullying, mobbing, teasing, ridicule or any other act or words that could psychologically hurt or isolate a person in the workplace. The act may not necessarily take place in the physical environs of the. The four categories of workplace violence are: Type 1 (Criminal Intent) committed by a perpetrator who has no relationship to the workplace. Type 2 (Client or customer) the perpetrator is a patient or past patient of the workplace. Type 3 (Worker-to-worker) the perpetrator is staff or past staff of the workplace. Type 4 (Personal Relationship) the perpetrator usually has a relationship with a staff member (i.e. domestic violence in the workplace) 6. PROCEDURE: 6.1 Roles and Responsibilities: The is responsible and will be held accountable for: Preparing and posting a policy with respect to workplace violence and reviewing the policy at least annually and, otherwise, as often as may be necessary; Developing and maintaining a program to implement this Policy that will: include measures and procedures to control the risks of workplace violence that are identified in the assessment or reassessment of the risks of workplace violence as are likely to expose individuals covered by the scope of this Policy to physical injury; 3 of 20

4 include measures and procedures for summoning immediate assistance when workplace violence occurs or is likely to occur; include measures and procedures for the reporting of incidents of workplace violence; and set out how the will investigate and deal with incidents or complaints/reports of workplace violence. Ensuring that the measures and procedures contained in this Policy are implemented in order to take every reasonable precaution to protect individuals covered by the scope of this Policy from workplace violence; Assisting and cooperating with the Joint Health and Safety Committee (JHSC) in carrying out the functions of that Committee; Conducting an assessment of the risks of workplace violence that may arise from the nature of the services provided by the, the workplace setting or the conditions of employment, and maintaining a written record of the assessment; Reassessing the risks of workplace violence as often as necessary to ensure that the workplace violence program continues to protect individuals covered by the scope of this Policy from workplace violence; Advising the JHSC of the results of the risk assessment and reassessment and providing the JHSC with a copy of the risk assessment and reassessment reports; Providing training to all individuals covered by the scope of this Policy on the workplace policy and program; Providing such information as is reasonably necessary to protect individuals covered by the scope of this Policy from physical injury related to a risk of workplace violence if an individual covered by the scope of this Policy can be expected to encounter a person with a history of violent behaviour and there is likely exposure to the risk of workplace violence in the course of performance of their duties that likely to cause physical injury; Taking every reasonable precaution to protect individuals covered by the scope of this Policy from domestic violence in the workplace if the becomes aware, or it is reasonably apparent to the, that domestic violence may occur in the workplace; Taking corrective action to report safety concerns associated with workplace violence and taking appropriate responsive measures; Facilitating medical attention and/or support for all parties involved in an incident of workplace violence; Ensuring compliance and meeting all reporting obligations under relevant legislation including the Workplace Safety and Insurance Act, the Occupational Health and Safety Act, the Public Hospitals Act, the Excellent Care for All Act, and the requirements of any professional governing bodies; and Delegating the performance of the tasks to carry out the responsibilities to the appropriate group, position and level within the organization Managers and Supervisors are responsible and accountable for: Promoting and maintaining a positive, safe and respectful work environment and supporting in its commitment to implement measures and processes to control the risks of workplace violence; 4 of 20

5 Demonstrating behaviours in keeping with a safe and healthy work environment; Maintaining visibility and involvement in safety issues. Understanding the responsibilities associated with the management, control and mitigation of the risks of workplace violence under the Occupational Health and Safety Act; Understanding this Policy and being able to explain the contents to their employees and other persons working within their area of responsibility at the ; Supporting training initiatives on this Policy and the Mission, Values and Vision statements; Responding immediately and appropriately to incidents of workplace violence, or the risk of workplace violence, and seeking advice from Labour Relations on this Policy, where necessary; Dealing promptly and appropriately with any report made under this Policy; Advising the Vice President Communications/Stakeholder Relations of an incident of workplace violence when the incident has the potential to attract media attention. Facilitating access to a Union representative and/or to the Manager-Labour Relations and Conflict Resolution (LR & CR) if an individual falling within the scope of this Policy wishes to make a report under this Policy; Assisting with a report and an investigation and any action required to resolve a report, as may be required; Monitoring the situation closely, once an investigation has been completed and appropriate action has been implemented, to ensure that the parties involved can perform their duties safely and with dignity and respect; Responding immediately and appropriately to a refusal to work in accordance with the terms of this Policy and the provisions of the Occupational Health and Safety Act. Ensuring that there is no reprisal for invoking this Policy in good faith. Responding and investigating any allegations of workplace violence and staff reported safety concerns of potential workplace violence risks. Failure to do so can be a violation of the OHS Act. Taking whatever reasonable measures are necessary to ensure a safe workplace. Posting signage at each entrance to each patient care unit to guide staff to inquire at the care desk regarding any potential hazards on the unit. Ensuring that when staff inquire at the care desk about any potential hazards, information is provided regarding any precautions that should be in place in regards to patients who have been identified as being a risk for injury to others (historical and/or current). Identifying training needs of staff and ensure all staff receive training on this policy and track compliance of staff training. Determining what additional unit specific orientation and training staff, may require, and ensure that the training occurs. Manager s Responsibility - When aware of an incident of violent behaviour: Assessing the safety of self and others in the area of the incident. If the incident involves a patient, contact the treating or on-call physician when a patient exhibits violent behaviour. As soon as reasonably possible, investigate and discuss the 5 of 20

6 situation with relevant staff to determine the extent of the violent behaviour and determine whether additional measures are required. Reviewing the patient care plan to ensure controls identified in the investigation for safety of staff and patients are included. Providing all necessary support for staff as soon as possible and facilitate medical attention as required. Determining if individuals involved in the incident require post incident support or help coping with the event and notify them of the resources available (e.g. Employee Assistance Program (EAP), the Peer Support Team (ROMHC) or Psycho Social Response (BMHC), Occupational Health Safety Services (OHSS), union representative, etc.) Providing support and guidance to staff should they decide to file a report with the local Police. Determining if there is a need for a formal review in conjunction with OHSS and Patient Safety Manager. In the event of conflicting opinion, the Director Patient Care Services will provide the final determination. Conducting a post-incident investigation to gain understanding of actions of involved parties and develop mitigating strategies in collaboration with involved staff/individuals. Setting behavioural limits and expected outcomes where the violent behaviour is by a visitor - should the visitor not comply, contact security and have the visitor removed All employees, physicians, students, volunteers, officers, Trustees of the Board and contractors are responsible and will be held accountable for: Contributing to a positive, safe and respectful workplace and mitigating the risks associated with workplace violence by demonstrating behaviour that complies with the terms of this Policy; Participating in training initiatives concerning this Policy and the Mission, Values and Vision statements and reviewing updates; Following best practices in client-centered care, including all existing safe work practices, as well as following this policy and guidelines outlined in programs that address Workplace Violence Prevention. Seeking advice on and taking action under this Policy if they are aware of, or reasonably believe, there is a risk of workplace violence; Promptly reporting incidents of workplace violence of which they are aware to their supervisor, manager or to the Manager-LR & CR; Cooperating with any efforts to investigate and resolve matters brought forward under this Policy; Acting in a manner that reduces and does not exacerbate an incident of workplace violence, or the threat or risk of violence, when this occurs in the workplace; Strictly maintaining the confidentiality and privacy rights of individuals involved in workplace violence reports to the fullest extent possible in the circumstances. Participate in a review at least annually of this policy and associated programs. Using reasonable precautions at all times when carrying out work-related duties and be vigilant for the potential for violence. Reasonable precautions in the Mental Health 6 of 20

7 environment includes being aware that all patients have the potential for violence or aggression and all staff should approach their duties with this in mind. Be aware of the potential of a situation to escalate at any time and activate a Code White as necessary. Documenting all violence-related incidents (near miss, hazards or injury) through formal incident reporting process. Contributing to risk assessments for workplace violence Union Representatives are responsible and accountable for: Promoting and maintaining a positive, safe and respectful work environment and supporting in its commitment to implement measures and processes to control the risks of workplace violence; Dealing with reports of workplace violence in a timely and confidential matter in keeping with the provisions of this Policy and collective agreements; and Supporting unionized staff engaged in the processes outlined in this Policy and in accordance with the provisions of collective agreements The Manager-LR & CR is responsible and accountable for: Promoting and maintaining a positive, safe and respectful work environment and supporting in its commitment to implement measures and processes to control the risks of workplace violence; Posting this Policy in the workplace; Communicating the contents of this Policy to all employees, physicians, students, volunteers, officers, Trustees of the Board and contractors falling under the scope of it, in order to ensure that they are aware of their rights and obligations under the Policy; Facilitating access to the EAP and/or OHSS for individuals involved in workplace violence incidents or reports, when requested or where appropriate; Providing advice and support on appropriate conflict resolution measures; Receiving reports under this Policy and assessing each report to determine the appropriate course of action under this Policy; Advising the VP Communications/Stakeholder Relations of an incident of workplace violence when the incident has the potential to attract media attention. Overseeing and directing internal investigations of reports made under this Policy and ensuring that the investigation process is completed without delay and within a reasonable time considering the nature and extent of the report and the availability of the parties and witnesses; Advising parties to an investigation that they may be accompanied by a Union representative, or other support person at their expense, during the investigation; Advising an individual making a report that their report does not preclude them from taking other action which might include: filing a grievance, if any, under a collective agreement, making a police report, making a complaint to the WSIB, to another tribunal or professional governing body or commencing other legal action; Participating in the decision-making process following the completion of an investigation or making the final determination when delegated to do so by the Executive VP and CFO; 7 of 20

8 Providing appropriate information to the parties to an internal investigation of an incident of workplace violence and the Union representative, if required, about the investigation findings and the decision including any remedial or disciplinary action taken subject to confidentiality considerations and respecting the privacy rights of all individuals involved in the process which may dictate limited disclosure of the investigation proceedings and remedial/disciplinary actions; Providing appropriate information to the JHSC concerning the risks of workplace violence following the conclusion of an investigation under this Policy; Maintaining a segregated internal investigation file in accordance with confidentiality considerations, relevant privacy legislation, the terms of collective agreements and this Policy OHSS is responsible and accountable for: Promoting and maintaining a positive, safe and respectful work environment and supporting in its commitment to implement measures and processes to control the risks of workplace violence; Providing first aid or medical attention to individuals covered under the scope of this Policy who have suffered an injury as a result of an incident of workplace violence, and recommending follow-up with the family physician and initiate WSIB claims as appropriate. Ensuring that an investigation of the incident takes place and appropriate preventative measures are initiated. Assist JHSC worker representative or a worker designated by the JHSC representative in the investigation of a violent assault that results in a critical injury to a staff member. Assisting in the investigation of a report of an incident of workplace violence, as requested by the Director- Human Resources and Labour Relations (HR & LR), using investigation tools; Contacting the JHSC and Ministry of Labour (MOL) immediately in the event of all critical incidents (as defined in the Patient Safety Incident Management Policy) or fatality, followed by the submission of a written report within 48 hours of the occurrence and ensure the reporting of all injuries to the MOL and the WSIB and as required by the OHS Act; Arranging for debriefing sessions following an incident of workplace violence, in conjunction with the most appropriate manager and the patient safety manager; Offering support in the form of the Peer Support Team, Psycho Social Response Team and/or EAP; Maintaining and provide statistics regarding incidents of workplace violence to the Senior Management and the JHSC. Enforcing the Post-Injury support guidelines for employees Suggested steps to help injured employees into full employment Updating the JHSC on violence-related statistics on monthly basis using the various categories of violence. HR is required to furnish this information to the OHSS prior to the meeting on monthly basis. Notifying all staff, including Environmental Services, Facilities Services and Supply Chain Management, of any serious employee incident upon receipt of this information, as appropriate. 8 of 20

9 6.1.7 The Director OHSS is responsible and accountable for: Ensuring that all policies, procedures and programs related to workplace violence are communicated and operationalized; Providing training; Conducting an annual review of programs that address workplace violence prevention. Ensuring that the measures and procedures identified in programs that address Workplace Violence Prevention are carried out. Ensuring that management is held accountable for responding to and resolving complaints of violence. Establishing control measures to address identified risks and violence, in consultation with JHSC. Working with Manager-LR & CR and the affected employee's manager, address domestic violence related issues that come to the notice of the Royal. Coordinating issues as identified in sections under and of this policy. Using the "Categorization and Determination of Level of Risks and Violence in the Workplace" template to acquire additional information from managers to initiate incident investigation and to follow-up on a reported aggressive behaviour by a patient towards an staff / visitors /subcontractor. Similarly, this form must be used to determine the level of aggression for reported incidents if investigation or care review had not been completed properly. The information on this form must be used to determine the nature of aggression, the level of risk the patient poses to staff, the consequence of the patient's actions, measures used to control the aggression and action plans developed to avert a repetition of that same incident. Aggression in this context is defined as any verbal, non-verbal or physical behaviour that was threatening (to staff, visitors, sub-contractors and property) or physical behaviour that actually did harm (to staff, sub-contractors and property). Taking corrective action to reported safety concerns associated with workplace violence and provide responsive measures. Facilitating medical attention and support for all those either directly or indirectly involved, as needed. Reviewing all reports of violence, near misses, or threats of violence in a prompt, objective and sensitive manner. This includes a review of all investigations associated with violence-related incidents with JHSC. Ensuring that fatalities, critical injuries, lost time or medical aid injuries are reported to the MOL, WSIB and JHSC as required by relevant legislation. Undertaking an annual review of programs that address Workplace Violence Prevention The JHSC is responsible and will be held accountable for: Making recommendations and assisting in the development and implementation of measures and procedures to control the risks of workplace violence; Making recommendations and assisting in the development and implementation of training programs concerning measures and procedures to control the risks of workplace violence and this Policy; 9 of 20

10 Participating in management s assessment and reassessment of the risks of workplace violence and receiving risk assessment reports from management; Receiving notification of incidents of workplace violence immediately following, or as soon as is practicably possible, after the occurrence; Participating in the investigation of reports made under this Policy as requested by management; Receiving and reviewing information from management concerning the risks of workplace violence following the conclusion of an investigation under this Policy and making recommendations to management concerning measures to mitigate or control of the risks of workplace violence; Receiving and reviewing management reports to the MOL of any critical injury or fatality arising from workplace violence within 48 hours of the occurrence and conducting inquiries and making recommendations to management arising from such reports; Receiving and reviewing written notices of injuries less severe than critical injuries or fatalities arising from workplace violence within four days of the occurrence and conducting inquiries and making recommendations to management arising from such reports; Tracking and analyzing incidents of workplace violence for trends and opportunities to mitigate the risk of workplace violence and making recommendations to management for measures to control such risks or improve precautionary measures to enhance the protection of individuals covered under the scope of this Policy. Ensuring all offices used for interviews are configured to provide a safer and quicker leeway for staff to exit the office via the door to activate code white. Enforcing all interview room requirements. Ensuring that the Yellow Triangle signage is posted at all areas where the potential for violence has been acknowledged by the unit manager or the JHSC. Monitoring and evaluating how the Ekahau and all other distress alarm systems are working on continuous basis. Reviewing, at least annually, all programs that address Workplace Violence Prevention. Investigating all critical injuries related to violence and make recommendations to the employer The General Counsel is responsible and accountable for: Promoting and maintaining a positive, safe and respectful work environment and supporting in its commitment to implement measures and processes to control the risks of workplace violence; Coordinating and overseeing external investigations in accordance with the terms of this Policy; Communicating with external legal counsel in respect of advice concerning reports filed under this policy; Supporting the Manager-LR & CR and the Executive VP and CFO in the decisionmaking process following the completion of an investigation; and 10 of 20

11 Maintaining a segregated external investigation file, in accordance with confidentiality considerations, relevant privacy legislation, the terms of collective agreements and this Policy The Executive VP and CFO is responsible and accountable for: Promoting and maintaining a positive, safe and respectful work environment and supporting in its commitment to implement measures and processes to control the risks of workplace violence; Developing policies and implementation programs to assess and control the risk of workplace violence, to summon immediate assistance in the event of an incident of workplace violence and to identify and implement the reporting, investigation and management response to incidents of workplace violence; Ensuring that all employees and managers receive training and information about this Policy and the Mission, Vision and Values; Ensuring that incidents and reports of workplace violence, or the risk of violence, are addressed effectively and as fairly and expeditiously as possible, in accordance with this Policy and in consultation where appropriate, with managers, supervisors, Code Team Leads (as defined under the Code White policy and process), the Managers and Directors-PCS, the General Counsel, the Director-HR & LR and the JHSC; Making the final determination on any remedial or disciplinary action to be taken after receiving a final investigation report on an incident of workplace violence. The task for carrying out this responsibility may be delegated to the Director-HR & LR. Should the Executive VP and CFO be the subject of an incident report, the investigation report will be referred to the President and CEO for the appropriate decision; Ensuring that the complies with the statutory requirements of the Occupational Health and Safety Act, concerning the provisions relating to workplace violence, and the Workplace Safety and Insurance Act, the Public Hospitals Act and the Excellent Care for All Act; Advising the VP Communications/Stakeholder Relations of an incident of workplace violence when the incident has the potential to attract media attention; Delegating the task to carry out the responsibilities, with respect to particular incidents, to the Director-HR & LR and Director-OHSS, as may be appropriate; The VP Communications/Stakeholder Relations is responsible and accountable for: Promoting and maintaining a positive, safe and respectful work environment and supporting in its commitment to implement measures and processes to control the risks of workplace violence; and Formulating and executing external communications, in conjunction with senior management, concerning incidents of workplace violence when the incident has the potential to attract media attention The Department of Learning and Development is responsible and accountable for: Establishing and delivering training and education for all staff, in consultation with JHSC Providing appropriate training to managers and supervisors concerning this Policy; 11 of 20

12 Providing training updates and refresher programs on the identification, assessment and management of escalating behavior, as necessary to promote a safe environment for patients and staff The Information Technology Department (in collaboration with JHSC) is responsible and accountable for: Ensuring all Personal Alarm devices are tested to determine whether they are working as recommended by the manufacturer on regular basis. Removing and replacing any device found to be mal-functioning must be. Developing a monthly inspection program for the Personal Alarm devices and ensuring records are kept. Ensuring records of all code white announcements are maintained by Switchboard. Records will indicate the time and date of the call, the location, the purpose of call if it was a real or false code and if and why the code was cancelled. Ensuring that a member of the JHSC participates in the monthly preventative maintenance program. 6.2 Domestic Violence In The Workplace: The will take every reasonable precaution to protect individuals covered by the scope of this Policy from domestic violence in the workplace if the becomes aware, or it is reasonably apparent to the, that domestic violence may occur in the workplace. 6.3 Identification of High-Risk Patients: Yellow Triangle signage is posted at the main entrance of each unit to caution any person entering the unit to report to the care desk. When staff inquire at the care desk about any potential hazards, information will be provided regarding any precautions that should be in place in regards to patients who have been identified as being a risk for injury to others (historical and/or current) As part of the initial intake, a risk assessment, using an approved risk assessment tool is completed for all inpatients. The outcomes of this assessment are documented on the patient s individualized care plan and are to be updated on a routine basis and when clinical change is identified Should a patient be identified as currently being a risk for injury to others (patients, staff and/or visitors) or should the patient exhibit this behaviour (an episode of aggression or violence) a Yellow Dot Sticker will be placed on the spine of the patient s Clinical Record and on the patient assignment board at Nursing Station. The Yellow Dot Sticker is dated at the time of the episode or assessment and will be updated on a weekly basis. Should a new episode occur, an updated sticker is applied to the chart and the assignment board. Any changes are communicated to staff on a timely basis (for example, Safety Knot at shift change). Once a patient has had a Yellow Dot Sticker designation this identification will become a permanent flag on their Clinical Record. 6.4 Risk Assessment: The will conduct a risk assessment of the workplace to identify and assess the risks of workplace violence that may arise from the nature of the workplace, 12 of 20

13 the type of work performed or the conditions of work. When conducting the risk assessment, the will take the following into consideration: circumstances that would be common to similar workplaces; circumstances specific to the workplace; and any other elements prescribed by the OHS Act The will reassess the risk of workplace violence as often as necessary to ensure that established policies and programs continue to protect workers from workplace violence. The will conduct a reassessment of risk annually Systematic Review Process: The risk assessment for workplace violence is a systematic review process to evaluate the risks arising from a hazard in the workplace that may give rise to an incident of workplace violence. The objective of the risk assessment is to prevent and manage the risks of workplace violence through identification and awareness. The process of risk assessment for violence in the workplace will provide management with the required information to implement a systematic prevention plan by: identifying the extent of the problem of violence risk, if any, in each part of the s operations and procedures under standard conditions taking into account circumstances that would be common to similar workplaces and circumstances specific to the work environment; identifying specific hazards and controls; determining whether existing control measures are adequate or require improvement; and prioritizing the risks and control measures according to need Risk Assessment Team: The will designate a risk assessment team to assess and reassess the risk and potential risk of workplace violence and to make recommendations to control and/or eliminate workplace violence risks. The contemplates that the risk assessment team may include representatives from the following groups: senior management, operations managers, members of the JHSC or their representatives, OHSS, Security, Legal and Financial services and representatives of the Human Resources group Written Report: Upon completion of the risk assessment or reassessment, a written report will be prepared and provided to the Executive VP and CFO. The report should include the hazards/risks identified, the priority of the hazards/risks, recommended mitigation and/or changes to operations and/or procedures, cost estimates for implementation, recommendations for the implementation of the mitigation and/or changes and a timeframe for completion of the recommended mitigation and/or changes. The Executive VP and CFO will provide a copy of the written report to the JHSC. 6.5 Incident Response: Summoning Immediate Assistance: When an individual falling under the scope of this Policy is confronted with an incident or threat of workplace violence, or when it is apparent that workplace violence is likely to occur, the following measures and procedures apply: when the incident involves an event in which a patient is behaving in a potentially dangerous manner and indicates a potential for escalation, or is escalating beyond 13 of 20

14 the abilities of the present staff to control the situation, CORP IX-i 110 Code White procedures apply. The Code White procedure to summon immediate assistance is to use the red phones that are located throughout the facilities or by deploying the Personal Alarm devices in areas where these are in use. All individuals falling under the scope of this Policy must be familiar with the principles and processes outlined in CORP IX-i 110 Code White; when an incident of workplace violence or a threat of violence, involves any person that is not a patient, (for example a visitor, supplier or other service-provider) who is present on the premises or who is present at an off-site location in connection with an activity, immediate assistance can be summoned by doing any of the following depending on the location of the incident: contacting Security Services by dialing extension 5752 on a local telephone, or by dialing extension 5752 if using an internal telephone line or by using one of the red phones that are located throughout the facilities or by contacting switchboard either directly or with the assistance of a co-worker or supervisor if practical and safe to do so under the circumstances; or contacting emergency services Refusal to Work: Subject to the exceptions in this policy an individual covered by the scope of this Policy may refuse to work or to do particular work where they have reason to believe that workplace violence is likely to endanger himself or herself Work Refusal Process: Upon refusing to work or to do particular work, the individual shall promptly report the circumstances of the refusal to their supervisor or manager who shall, without delay, investigate the report in the presence of the individual and a representative of the JHSC or Union Representative if the individual is a member of a union. The individual refusing the work shall remain in a safe place near his or her work station and be available for the purposes of the investigation. Where, following the investigation or any steps taken to deal with the circumstances that caused the work refusal, the individual refusing the work has reasonable grounds to believe that workplace violence continues to be likely to endanger himself or herself, the work refusal may continue and an inspector will be appointed under the OHS Act to investigate the refusal to work and will render a decision in accordance with the process described under that Act; Limited Work Refusal Rights for Specific Employees: The right to refuse work does not apply to employees, and to individuals covered by the scope of this Policy who perform work or supply services for monetary compensation by the, when: the likelihood of the danger of workplace violence (or the use of any equipment, machine or device or the physical condition of the workplace) is a normal condition of the employment or engagement for the employee or individual; or the refusal to work by the employee or individual would directly endanger the life, health or safety of another person. 6.6 Reporting and Investigation of Workplace Violence: An incident of workplace violence, or the threat of violence, will be addressed by the following procedure: 14 of 20

15 the incident will be reported to the individual s manager or supervisor who will promptly make sufficient inquiries to determine whether the matter can be managed effectively by addressing the conduct directly with the perpetrator to the satisfaction of the and all parties concerned assuring that there is no safety risk or whether the actions or statements warrant the completion of a written report of workplace violence, whether no further action is required to address the matter, or whether the incident engages another policy (for example the Respectful Workplace Policy); if the circumstances engage this Policy, the individual will complete the Workplace Violence Incident Report in the form attached to this Policy. If a Code White was initiated, the Code White debriefing form and documentary procedures must also be followed. If the incident engages the Patient Safety Incident Management Policy, the reporting and documentary protocol outlined in that policy must also be followed. Managers, supervisors and HR are available to assist in providing direction regarding the applicable workplace policies; The Workplace Violence Incident Report shall be provided to the Manager- LR & CR who will initiate and oversee an internal investigation of the incident. The Manager- LR & CR may delegate the task of performing an internal investigation to qualified individuals within who may include managers, supervisors and members or representatives of the JHSC or any combination of them. The also has the discretion to engage the services of an external investigator; An internal or external investigation process will normally include interviewing the parties and witnesses, and collecting and reviewing relevant communications, documents, records, surveillance and other information concerning the incident, to the extent available for and relevant to the investigation. The will endeavour to complete the investigation to the fullest extent possible, but may modify, suspend or discontinue its process in order to avoid interfering with a police investigation, if any; Following completion of the investigation, an investigation report will be prepared outlining the factual findings, analysis and conclusions and any recommendations for mitigation strategies or changes to the workplace violence program or policy. The investigation notes and records form part of the investigation file that will be maintained confidentially by the investigator; The final investigation report will be provided to the Manager- LR & HR in respect of an internal investigation or to the General Counsel and/or Executive VP and CFO in respect of an external investigation. In the case of an internal investigation where the Executive VP and CFO has retained decision-making authority for the matter the Manager-LR & CR will also provide a copy of the internal investigation report to the Executive VP and CFO; Based on the findings of fact and conclusions in the investigation report the Executive VP and CFO will make a determination about the appropriate remedial or disciplinary action, if any, to be taken in respect of the perpetrator of the violence or threat. In this respect, the Executive VP and CFO may: make his decision in consultation with the Director-HR &LR, General Counsel, responsible manager(s) or supervisor(s), if appropriate; delegate his decision-making authority to the Director-HR & LR, if appropriate; 15 of 20

16 decline to take any further action; or impose a performance or disciplinary measure including, but not limited to, monitoring, training, suspension from the workplace, withdrawal of privileges or termination of employment, a volunteer engagement or contract. The Manager-LR & CR or the Executive VP and CFO will: inform the parties involved in the incident in writing about the findings and conclusions resulting from the investigation; if some form of remedial or disciplinary action will be taken, inform the perpetrator of the workplace violence in writing of that decision. The individual making the report will be provided with appropriate information subject to confidentiality considerations and the requirements of collective agreements and privacy and occupational health and safety legislation; remind the parties that the written notifications must be maintained by them in a strictly confidential manner; oversee the implementation of reasonable measures to restore a harmonious work environment and constructively reintegrate the parties into the workplace to the extent applicable; and provide relevant information to the JHSC from the report pertaining to risks associated with workplace violence for the purpose of facilitating recommendations from, and the work,of the JHSC in order to fulfill its mandate. 6.7 Violent Behaviour-Patients/Family Members/Visitors: The supports an attitude of mutual respect between health care workers and recipients of health services and visitors to the hospital. After taking into reasonable consideration the circumstances of individuals suffering from cognitive impairments and severe mental illness, physical violence and threats of violence in the workplace will not be tolerated by the. The Board of Trustees and the Senior Management Team are committed to providing a safe environment, free from the threat of sexual, physical, verbal and psychological abuse, as is reasonably possible. The following steps will be taken in case of threatened and/or actual violent behaviour by a patient, family member or visitor: Patients. If the violent behaviour, or threat, is perpetrated by a patient, they will be informed that his or her behaviour is perceived as threatening and they will be asked to modify their behaviour. If they do not adequately modify their behaviour, they will be managed in accordance with s clinical policies and procedures and professional practice guidelines; Family Members and Visitors. If the violent behaviour, or threat, is perpetrated by a family member or visitor, they will be informed that his or her behaviour is perceived as threatening and they will be asked to modify their behaviour. If they do not comply, they will be informed by a manager, supervisor or other individual designated by the, that their behaviour is unacceptable and they will be asked to leave the facility. If they refuse to cooperate, they will be escorted off the premises by Security Services. A Code White may also be called or police may be summoned and the will comply with all of its reporting obligations in respect of the incident. The family member or visitor may be prohibited from returning to the facility and 16 of 20

17 their attempts to re-attend, if any, will be monitored and managed by Security Services Violent Behaviour: Individuals Covered by this Policy. If the violent behaviour, or threat, is perpetrated by an individual covered by the scope of this Policy, the reporting and investigation procedures will be engaged. A positive finding against the perpetrator of the violence or threat will be subject to discipline, up to and including termination of employment or the engagement, and the matter may be reported to the police, a professional governing body, and any other agency as may be appropriate in the circumstances or required by legislation. 6.8 Accommodation: When a report of workplace violence is brought forward, the Manager- LR & CR and/or the Executive VP and CFO, in consultation with the responsible manager(s) or supervisor(s), if appropriate, may separate the parties involved in the incident or impose a different reporting relationship or a change in the assignment of duties pending resolution of the matter if it is deemed necessary by management under the circumstances. 6.9 No Reprisal: This Policy prohibits reprisals against individuals, acting in good faith, who report incidents of workplace violence under this Policy or who participate in the investigation process. Reprisal is defined as any act of direct or indirect retaliation arising from an incident report made in good faith and/or participation in an investigation. will take all reasonable and practical measures to prevent reprisals and threats of reprisal following reports made under this Policy Investigation Records And Outcome Notification The final internal investigation report will be maintained in a segregated investigation file in the office of the Manager- LR & CR The final external investigation report will be maintained in a segregated investigation file in the office of the General Counsel If the allegations in the report are unsubstantiated and the report was made in good faith, a copy of any written notification of the outcome provided to the parties will be maintained in the segregated investigation file in the office of the Manager- LR & CR (internal investigation) or the General Counsel (external investigation) If the allegations in a report are substantiated, a copy of the notification to the perpetrator of the violent incident will be placed in their personnel file and also in the segregated investigation file in the office of the Manager- LR & CR and (internal investigation) or the General Counsel (external investigation). Letters of notification in the personnel files of unionized individual will be maintained for a period of time in accordance with the provisions of governing collective agreements and notification in the personnel files of non-unionized personnel will be maintained for a period of three (3) years The documents in the segregated investigation files will be retained for a period of 5 years, subject to extension at the discretion of senior management in the event of further incidents of workplace violence involving a party against whom a substantiated report has previously been made. 17 of 20