Ethical Disclosure Policy

PURPOSE  

St Luke Hospital (SLH) is committed to lawful and ethical behaviour in all its activities, and requires that its directors, management, staff, volunteers and consultants to conduct themselves in a manner that complies with all applicable laws and internal policies. In keeping with this commitment and SLH’s interest in promoting open communication, this policy aims to provide a means through which concerned employees could raise ethics and governance related issues with the assurance that they will be protected from reprisals or victimisation for acting in good faith. 

We choose the term “Ethical Disclosure Policy”, instead of “whistle blowing”, for its simple meaning of allowing employees to raise ethics and governance related issues to the relevant authority and putting good governance practice in action.

Ethics and governance related issues include but not limited to the following: 

• mismanagement or misuse of resources; 
• inappropriate conduct and behavior which are contrary to the code of professional conduct of SLH; 
• dishonest or illegal activities; 
• violation of law, rule, regulation; 
• actions which relates to fraud, 
• health/safety violations; 
• corruption, bribery 
• undisclosed conflict of interest 

PROTECTION FOR EMPLOYEES 

Harassment or Victimization

No employee who in good faith reports an ethics and governance related issue in accordance to this policy shall suffer harassment, retaliation or adverse employment consequence.

Confidentiality

Reports of violations or suspected violations of ethics and/or governance related issues will be kept confidential to the extent possible, consistent with the need to conduct an adequate investigation. Exceptions to the confidentiality rule will include but not limited to situations where SLH is under a legal obligation to disclose the information, where legal advice is sought by SLH, or where police or other authorities require the information for criminal investigation. 

Anonymous Feedback

The policy encourages employees to identify themselves in order that the feedback can be appropriately followed-up and investigated. Anonymous feedback is not consistent with the spirit of this policy. Before a decision is made to investigate an anonymous feedback, consideration will be given to the following matters: 

1. The seriousness of the ethics and governance issue raised; 
2. The credibility and accuracy of the ethics and governance concern; and 
3. The likelihood of confirming the allegation from attributable sources.  

Malicious Feedback

Malicious allegations may result in disciplinary action. 

PROCEDURE 

Reporting

Concerns and feedback should be raised to the Chairman, Audit Committee (Chairman, AC) via email to “audit_committee@stluke.org.sg”. Access to this email is restricted to the Chairman, AC. 

Any concerns and feedback raised to the Board Chairman or other parties within the Board will be directed to the Chairman, AC for independent review and investigation.

Timing 

The earlier an ethics and/or governance feedback is provided to the relevant authority, the easier it is to take action to address the feedback raised. To ensure the factual accuracy of the feedback and to take measures to mitigate or remedy the feedback, all feedback should be made as soon as practicable.

Evidence 

Although the employee is not expected to prove the truth of the feedback, the employee needs to demonstrate that he or she has a reasonable basis for the concern. 

HANDLING OF FEEDBACK 

The action taken will depend on the nature of the ethics and/or governance feedback. The Chairman, AC having received the feedback shall oversee any investigation to be undertaken, unless the Chairman, AC, decides that another committee or party be tasked to oversee the investigation. 

The Board should be kept informed of any investigation where appropriate without violation of the confidentiality principle. 

The investigation officer should observe the following: 

Initial Inquiries  

Initial inquiries will be made to determine whether an investigation is appropriate, and the form that it should take. Some feedbacks may be resolved by agreed action without the need for investigation. The Chairman, AC shall jointly or separately decide if an investigation is warranted and may consult other directors in making this decision.

Anonymous Complainant  

Once the Chairman, AC decides that investigation is warranted, efforts should be made to encourage the anonymous complainant to come forward and identify himself/herself. This is to facilitate the investigation. Chairman, AC will have final discretion whether to maintain the anonymity of a complainant who comes forward, depending on the path the investigations takes. If the complainant refuses to reveal his/her identity and thus the investigation could not proceed, the complainant will be informed accordingly. If upon notification, the complainant still does not want to identify himself or herself and there is inadequate information to perform any investigation, the feedback will be deemed closed. 

Updating the Complainant

If the complainant has identified himself or herself, he or she will be given an update on his or her complaint within four weeks after the feedback was initially made. The update shall include: 

1. an acknowledgement of the receipt of the feedback; 
2. information to complainant on how the matter will be dealt with, whether: 
   • initial inquiries have been made; and 
   • further investigations will follow; if not, the reasons for that decision. 

Further Information

The amount of contact between the complainant and the body investigating the concern will depend on the nature of the feedback and the clarity of the information initially provided. Further information may be sought from the complainant in order to facilitate investigation and to ensure that all pertinent factors are considered in remedying the situation.

Resolution

Subject to legal constraints, the complainant will receive information about the outcome of any investigations.