All members of Temiskaming Hospital’s (TH)  workplace community, will be treated with, and will treat each other, with dignity and respect at all times. Through individual efforts and the consistent application of this policy, TH will have a safe, healthy and respectable environment in which to work, visit and heal.

All complaints and reports of abusive, harassing and/or aggressive behaviour will be treated seriously, will be investigated thoroughly and fairly, and will be dealt with accordingly.

As an organization, Temiskaming Hospital (TH) believes in and is committed to ensuring that all members of this workplace community experience a workplace:

  • with a zero tolerance for violence and all inappropriate behaviour;
  • that is civil and respectful;
  • in which interactions, communications and dealings with all individuals are polite, supportive, civil, constructive, respectful and inclusive; and
  • that is free from gossip and harmful speculation.

TH expects that all members shall acknowledge and accept that creating and maintaining a positive and safe environment is the responsibility of all persons sharing the workplace community.

Therefore, the following are the objectives for behaviour in our workplace:

  1. Free from all violent or threatening behaviour. All members shall refrain from violent or threatening behaviour at all times;
  2. Professional communication. All members of the workplace will ensure that all communications and interactions are professional, businesslike, respectful and civil, both in terms of time and content;
  3. Professional ethics of members. All members of the workplace who belong to a professional association are expected to also abide by their association’s ethics and professional standards;
  4. All members of the workplace community are expected to report alleged violations of the Code.
  5. All employees, Board of Directors, professional staff, volunteers, directors and students will sign the Code of Conduct Agreement (Form 2010 / 2008) on an annual basis,
  • Employee agreements are kept in Human Resources personnel file
  • Volunteer agreements are kept in Human Resources files
  • Board of Director’s agreements are kept in Governance files
  • Professional Staff agreements are kept in privileges files.
  • Student agreements are kept in Human Resources file
  • Suppliers/Contractors will sign an agreement before contracts are entered into. This will be managed by the Support Services Manager.
  1. The Code of Conduct constitutes a condition of employment, privileges or contracts for all Board of Directors, employees, Professional Staff, volunteers, directors, students and suppliers/contractors/stakeholders of TH.

Failure to abide by the Code will result in corrective action including discipline, conditions or termination.


  1. Complete Form D1597 Code of Conduct Complaint and submit to your Direct Report (e.g. immediate supervisor or manager);
  2. Direct Report must notify their ‘Director’ that a Code of Conduct complaint has been received and submit a copy to the Human Resources Manager;
  3. An investigation will be conducted for all complaints and findings reported to all parties in as timely a manner as possible.


Direct Report Submit to:

‘Director’ Reported to:

Board of Directors

Chair or Vice-Chair

Chair / CEO / Chief of Staff


Supervisor / Manager / Direct Report

Vice President


President of Auxiliary

Vice President of Corporate Services


Preceptor / Instructor

Human Resources Manager / Vice President

Medical Student / Residents

Chief of Staff

Chief of Staff / CEO

Professional Staff

Chief of Staff

Chief of Staff / CEO

Supplier / Contractor


Vice President of Corporate Services


Procedure for Dealing with Violations of the Code of Conduct

An individual may choose to begin the process at Stage 1, 2 or 3 depending on the circumstances of their situation. Communicating with individuals about inappropriate behaviour should be done face-to-face, not by email.

Stage 1 – Voluntary Resolution

This is not a formal complaint stage and cannot be used to address issues of violence and/or destruction of property. The individual attempts to resolve the issue by communicating directly with the person in a confidential and professional manner. Ideally, this should be done face-to-face but if this is not possible, it could be done by telephone. If the individual is not comfortable communicating directly with the person about the behaviour, or if the issue cannot be resolved, assistance may be needed. The individual may also seek assistance from their Manager or Chief of Staf in the case of Professional Staff. Coaching is provided to assist the individual in developing an approach for speaking with the person about their behaviour. If the person that the individual has an issue with is their own manager, then the individual should seek assistance from the individual who supervises their manager. In order to promote a healthy work environment, if the issue remains unresolved, it is important to proceed to the next stage.

Stage 2 – Formal Complaint and Investigation Process

When a formal complaint under the Code of Conduct policy is received from a complainant, or is initiated by the employer, it shall be investigated as follows:

  1. The complaint shall be processed and investigated by the Human Resources Manager or by an external Investigator appointed by the Vice President of Corporate Services in situations that warrant a third party (e.g. perceived conflict, complex, legally sensitive cases).
  2. At the earliest opportunity, the Investigator shall meet with the worker who lodged the complaint (the “Complainant”) to obtain the details of the allegations. This process may entail one or more meetings. If the Complainant has not already done so, they may be asked to provide such information in writing, in addition to meeting with the Investigator.
  • The Investigator shall meet with the person who is alleged to have been the source of the harassment (the “Respondent”) to advise them of the particular complaint and to provide a fair opportunity to respond. This process may entail one or more meetings. The Respondent may be requested to respond in writing, in addition to meeting with the Investigator.
  1. In consultation with the Complainant and Respondent, the Investigator shall determine whether an informal resolution of the complaint is possible (i.e., by way of a face-to-face meeting to clear the air, an apology or some other informal resolution). If so, Human Resources shall retain a copy of the written complaint and a memo outlining the resolution in a separate file and no reference to the complaint unless otherwise provided in the informal resolution.
  2. If an informal resolution is not possible, the Investigator shall conduct a formal investigation of the complaint. Both the Complainant and the Respondent may provide names of witnesses who may assist in the investigation. The Investigator may interview these witnesses as well as any other individual who reasonably appears to have information relevant to the matters in dispute.
  3. The Investigator shall conduct the investigation fairly, objectively and reasonably promptly. The Investigator shall make, maintain and preserve interview notes and the investigation file. Where the Investigator is external to TH, the Investigator shall submit the original investigation file to the Human Resources Manager or delegate.

Within a reasonable time period following the conclusion of the investigation, the Investigator shall prepare an Investigation Report that makes Findings of Fact and an assessment of whether or not the Respondent violated the policy.

  • The Investigation Report shall be reviewed by the Vice President of Corporate Services or delegate.
  • If it is concluded that harassment has occurred, the Human Resources Manager or delegate shall determine what action is appropriate in the circumstances in accordance with this policy. If the Human Resources Manager or delegate concludes that no inappropriate behaviour occurred, or cannot be established based on the evidence available, a record of the complaint together with the results of the investigation shall be retained by Human Resources in a separate file. No reference to the complaint shall be placed in the Respondent’s employee file.
  1. If the Human Resources Manager or delegate concludes that the complaint was made frivolously, vexatiously or in bad faith, they shall determine what corrective and disciplinary action is appropriate in respect to the Complainant.
  2. Human Resources shall meet separately with the Complainant and Respondent and advise each of the results of the investigation. The Complainant and Respondent shall have an opportunity to comment at that time.
  3. Human Resources shall consider whether the Complainant or Respondent raised any legitimate basis for changing the conclusion of the investigation. The final decision regarding corrective and disciplinary action shall be made by Human Resources.
  • Human Resources shall inform the Complainant and Respondent separately, of the final results of the investigation.

Stage 3 – Corrective Action

Before taking any steps towards corrective action, it is the responsibility of the manager to consult with Human Resources regarding staff, or the Chief of Staff regarding Professional Staff.

Accountability – Roles & Responsibilities

  1. CEO, Senior Leadership Team & Chief of Staff

The CEO, together with the Senior Leadership Team and the Chief of Staff has the responsibility for the present and future direction of strategy and planning for TH, and the responsibility for the health, safety and well-being of staff.

Therefore, it is the responsibility of this group to implement the following:

  • Model the substance and intent of TH’s policy and procedure for Code of Conduct while performing their respective roles and demonstrating through words and actions a commitment to maintaining a workplace that is free of abuse or aggression of any kind and ensures that all individuals are treated with dignity and respect at all times;
  • Lead the way in developing a comprehensive communication plan regarding the implementation of the Code of Conduct Policy and Procedure;
  • Implement programs that provide comprehensive support for those who experience abuse, aggression or bullying at work;
  • Provide resources to educate and inform all TH staff regarding abuse, aggression or bullying at work;
  • Ensure that safe behaviours are integrated into day-to-day operations;
  • Ensure corrective actions are taken and response measures are in place;
  • Ensure that the potential for reprisal due to the power differential which exists in the formal hierarchy or due to the designation or professional qualifications of any individual is recognized and will not be tolerated;
  • Sign a Code of Conduct Agreement (Form 2008 / 2010).
  1. Leadership Staff & Physician Leaders

Individuals who are in positions of responsibility for the health, safety and wellbeing of staff of TH must demonstrate in their attitudes and behaviour the highest regard for the respect and dignity of all members of their Team.

Therefore, all TH Leaders shall:

  • Model the substance and intent of the TH Code of Conduct Policy and Procedures, and demonstrate in their words and actions as leaders, commitment to intolerance of abuse, harassment and/or aggression of any kind within the organization;
  • Work collaboratively with union representatives and others involved who share joint responsibility to resolve issues with regard to abusive, aggressive or violent behaviour at TH;
  • Take all reports of threats of abusive and/or aggressive behaviour seriously;
  • Learn to identify the early warning signs of the potentially problematic situation or individual and use preventative measures to avoid escalation of abuse and/or aggressive behaviour through training provided;
  • Upon receipt of a Code of Conduct complaint send the completed form to Human Resources;
  • Upon receiving a Code of Conduct complaint, consult with Human Resources to determine the course of action to appropriately address the complaint;
  • Educate and train all direct staff in safe working practices regarding the creation of respectful work environments, free from violence or harassment;
  • Introduce, manage and maintain written reporting procedures, documentation processes, tracking mechanisms as required by this policy so that TH tracks and measures the impact to the organization of both the policy and the breaches of the policy;
  • Sign a Code of Conduct Agreement (Form 2008 / 2010).
  1. Staff and Professional Staff with TH Privileges

Every individual employee and professional staff member with TH privileges contributes to the creation of a safe and healthy work environment by demonstrating respectful and appropriate conduct at work. All staff and professionals with TH privileges must accept as a personal responsibility, their own role in eliminating the use of abuse, harassment and/or aggression in the day-to-day activities of their own work unit. Therefore, staff and professional staff withTH privileges shall:

  • Understand and follow this policy and procedure;
  • Attend or participate in appropriate training regarding Code of Conduct;
  • Uphold the Code of Conduct and its principles;
  • Sign a Code of Conduct Agreement (Form 2008 / 2010); and
  • Promote respectful interactions at work.
  1. Patients, Family Members, Volunteers, Students, Contractors and other Visitors

Patients, family members, volunteers, students, contractors, visitors and all others carrying on business at TH can expect to be treated with dignity and respect at all times. They should not be expected to find an abusive and/or aggressive environment when they come to use the services of TH, or are visiting the organization for any reason.                                                                                                

It is also the expectation that patients, family members, volunteers, students, contractors and all other visitors will treat TH staff with the same respect and dignity, and that they do not exercise abusive and/or aggressive behaviour towards staff.


In developing the code of conduct, input was sought from those affected by the code, to create buy-in and support for the code.

Georgian Bay General Hospital Policy, August 2016
Accreditation Leadership Standard 2.4, 2.5, 12.7

Cross References
Form D2010 Employee Code of Conduct Agreement
Form D2008 Professional Staff Code of Conduct
Form D1598 Contract Worker Code of Conduct
Form D1597 Code of Conduct Complaint
ADM-G-66 Respectful Workplace Violence Harassement Free Environment
GOV-10 Code of Conduct


Updated February 10, 2023, posted June 7, 2023