Regulation of the Guttmann Institute Complaints Channel

PREAMBLE

1. The Institut Guttmann Foundation (hereinafter Institut Guttmann) considers that respect for dignity, trust, integrity, autonomy and non-discrimination are essential values to be sought in all its actions; therefore it will maintain a legal, honored, ethical and responsible behavior that it will promote among all the people with whom it relates and from whom it expects to receive equal behavior. It is for this reason that the Complaints Channel is enabled with the aim of preventing and detecting behaviors contrary to its principles and values or that are illegal.
2. Complaints of good faith, in addition to serving to be aware of possible irregularities, are an essential tool for the Code of Ethics to take full force and enable the continuous improvement of prevention protocols and policies, quality standards and other internal regulations. In this sense, the Institut Guttmann is committed to the strictest respect for the legal rules and those of ethical behavior that must inspire each of its actions and govern all the relationships it establishes.
3. The priority objective of this Regulation is to establish the guarantees of confidentiality and indemnity of the complainant, who acts in good faith when reporting using the Complaints Channel that the Institut Guttmann makes available through an external technological platform. At the same time, this Regulation guarantees the preservation of the honour and presumption of innocence of persons denounced in the face of unfounded or malicious complaints.

Article 1. Object

1. This Regulation aims to regulate the Complaints Channel, establishing an internal communication channel through which the organization receives and manages complaints (or communications) made by workers or people linked to the organization, about possible irregular, illicit or criminal behavior.
2. The Institut Guttmann makes available to the people included in article 2 the Complaint Channel, being an essential tool of the compliance management system (in reference to the set of measures and procedures that aim to ensure compliance with the laws and regulations that apply to us) that will be managed by an external company and in accordance with these Regulations.

Article 2. Personal scope of application

It is applicable to any reporting person who has any type of relationship with the Institut Guttmann and informs or reports an irregular, illegal or criminal event through the Complaints Channel.

Therefore, applicable to people with whom the Institut Guttmann maintains an employment relationship, users, volunteers, interns, providers, collaborators, people in training or any other person who interacts with the organization.

Article 3. Irregular, illicit or criminal behavior

Irregular, illegal or criminal behaviour means any type of legal infringement or violation of the Code of Ethics, the Code of Conduct or those internal procedures or protocols whose function is to prevent and detect behaviors that harm the Institut Guttmann or the realization of criminal acts by workers, volunteers or any other person related to the Institut Guttmann in the exercise of its activity.

Article 4. Denunciation of good faith

1. The complainant is considered to act in good faith when his/her complaint is carried out in accordance with the provisions of this regulation and is based on facts or indications from which irregular, illegal or criminal behaviour may reasonably arise.
2. The complaint is considered to be in good faith when it has been filed without the intention of revenge, morally harassing, causing labor or professional harm or injuring the honor of the person reported or a third person.

Article 4 bis. Complaint of not good faith

It is considered that the complainant does not act in good faith when he is aware of the falsity of the facts or does so with the intention of revenge or to harm the Institut Guttmann, harass the person denounced, injure his or her honour or harm her work, professionally or personally.

Article 5. Guarantee of Indemnity

1. Persons who act in good faith in accordance with the previous article and report irregular, illegal or criminal behaviour, in accordance with the provisions of this Regulation, may not suffer any kind of harm in their relationship with the Institut Guttmann as a result of the lodging of a complaint.
2. The report in good faith of an event or behaviour in accordance with this Regulation does not constitute, where appropriate, an infringement of the principle of good faith in employment relations, nor is the violation of a company or institutional secret, where appropriate.

Article 6. Protection measures for the complainant

When the complainant, and as a result of this action, suffers any type of negative measure and/or threat, discrimination or harassment in the employment context of the Institut Guttmann, this conduct will be investigated and, if applicable, the sanctioning regime established in the collective agreement in force of reference applicable to each worker will be applied.

Article 7. Rights of the person denounced

1. The person denounced has the right to know the existence of the complaint.
2. In the event that the complaint is false, the person denounced has the right to appear in the Complaint Register.

Article 8. Complaints Channel. Confidentiality and other rights

1. The Institut Guttmann offers the organization a confidential Complaint Channel that has been articulated through a technological platform supplied by an external supplier.
2. Complaints will be received by the External Manager. Therefore, the institution offers adequate guarantees of independence, confidentiality, data protection and secrecy of communications and, favors and promotes an ethical and transparent culture within the organization.
3. The Complaints Channel has all the information fully encrypted. In addition, it allows to delete the metadata of any document or image that is sent through the Complaints Channel and, if it is a verbal complaint, offers the possibility of distorting the voice to allow its anonymization, which guarantees the confidentiality of the information.
4. The external technology provider and the External Manager will keep the complaints for the time necessary for their internal management and to respond to future external processes.
5. In addition, the Institut Guttmann has appointed an Internal Responsible for the Complaints Channel, who has the following functions:

• Implement, develop and update the Complaint Channel and all the elements that compose it.
• Ensure the correct dissemination of information on the Complaint Channel as well as the confidentiality regime applicable to communications and, in particular, information on the processing of personal data.
• The receipt and diligent processing of the corresponding reports received by the External Manager.
• Guarantee the confidentiality of the identity of the complainant and any third party mentioned in the communication, as well as the actions carried out in the management and processing of this.
• Guarantee the protection of personal data, preventing access by unauthorized personnel.
• Ensure that the system respects the presumption of innocence, the right of defence, access to the file and the right to honour of the affected persons.
• Establish in the system the measures that guarantee the protection of the complainant against possible reprisals.
• Ensure that the system informs the complainant of the collection and processing of their personal data.
  1. The processing and preservation of the documentation and personal data of the affected persons during the period strictly necessary for the investigation of the facts corresponds to the Investigation Commission described in article 11. Once the Investigation Commission is closed, the person responsible for guarding the documentation will be the Directorate-Management, except in the case of the bodies provided for in the “Protocol for the Prevention and Addressing of Sexual, Psychological Harassment, Based on Sex and Other Discrimination at Work”.

Article 9. Access to the Complaints Channel

1. You can access the Complaints Channel and these Regulations through the website and the Intranet of the Institut Guttmann, specifically from (Link Canal Complaints). At the same time, it can also be accessed through a QR code located on the website, on the Intranet and in preferential locations of the Hospital and Guttmann Barcelona. Therefore, the complainant may read and understand these Regulations before making a complaint.
2. The complaint may be made in writing or verbally, through voice messaging with recording, offering the possibility of distorting the voice to allow its anonymization, as specific in article 8.2.
3. Received accusation will be sent immediately upon receipt of the communication.

1. The Institut Guttmann has a Complaint Register in which all reported cases are registered, in encrypted format, with restricted access to the persons designated by the Directorate. The external company will assign a unique code to each complaint that will be included in the Complaint Register.
2. The External Manager will receive the complaint notice from the Complaint Channel that, in order to ensure the restriction and confidentiality of the data, will need a double authentication in order to access it.
3. The External Manager will carry out a preliminary analysis to verify the entity of the information, its sufficiency and verisimilitude, the credibility of the complainant and the relevance of the facts reported, determining whether these may constitute a violation.
4. Depending on the result offered by the preliminary analysis, the External Manager will adopt any of the following decisions:

• 
  
  • Issuance of a legal report recommending the non-admission of the complaint and its file in the following cases:

1. When the facts reported in the complaint do not constitute a violation.
2. When the complaint is a mere reproduction of another previous previously unadmitted or duly investigated, without new information being provided.
3. When the content of the complaint is manifestly irrelevant or the facts reported are implausible or the complainant totally lacks credibility.
4. When the information is insufficient to proceed with any further action.

1. 
   
   • Issuance of a legal report recommending the file of the complaint and deriving the anonymized communication to the corresponding department of the Institut Guttmann, in the event that the complaint does not refer to possible events or irregular, illegal or criminal behavior (for example, those issues that are strictly related to matters strictly labor or human resources policies or related to professional practice).
   • Issuance of a legal report recommending the admission of the communication and initiation of the corresponding investigation file when there are indications that an irregular, illegal or criminal action or behavior has been committed in the terms defined in article 3 of the Regulation.
   • In this case, a Commission of Inquiry shall be set up for the corresponding investigation in the terms defined in Article 11.
2. In compliance with the applicable regulations on data protection, only the personal data known through the Complaints Channel will be given to those who are strictly necessary, among which can be found:
   • The person in charge of the Complaints Channel.
   • The person responsible for HR, when it is necessary to initiate disciplinary proceedings against the person reported.
   • The persons designated by the Management (ex.: the external manager).
   • The Delegate of Data Protection.

Article 11. Procedure after the complaint. The file and the investigation

1. In the case defined in section 10.4.3 above, the External Manager shall promote a Commission of Inquiry. The External Manager will lead the Commission in which it participates. In the rest of the Research Committees, the Management will appoint the person to lead it. In any case, the person who leads will have a quality vote.
2. The Investigation Commission, with a minimum composition of four people, which will be formed ad hoc for each case, will define the strategy to be followed in the internal investigation and develop it.
3. The Investigation Commission will decide in each case the appropriate moment to report the progress of the investigation to the person in charge of the Internal Responsible of the Complaints Channel of the Institut Guttmann.
4. Upon completion of the investigation, the Investigation Committee will issue a report of findings with a description of the complaint, the actions carried out in the course of the investigation and the conclusions and assessment of the facts and propose the measures to be undertaken to the Directorate.
5. The Investigation Committee shall ensure that the rights of the complainant, the person denounced and the other persons involved in the complaint are respected.
6. A maximum period is established for the Investigation Commission to issue a report with the findings within 10 working days from the date of the accusation received. This period may be extended by reasoned resolution of the Investigation Commission.

Article 12. Content of the complaint

In the complaints the following information will be requested:

1. Identification data of the complainant.
2. Identification of the persons reported.
3. Description of the facts that are reported.
4. Identification of potential witnesses, if any.
5. Contribution of possible documentary, graphic and/or audiovisual evidence, if any.
6. Others.

Badalona, March 2024