Law, standards and responsibilities in healthcare

Lesson 1 showed how often healthcare workers are hurt. This lesson is about who is responsible for preventing it and what the law requires. HSE-101 covered the general rights and duties that apply in every workplace, so this lesson concentrates on what is different in healthcare: the healthcare-specific rules, the limits on refusing unsafe work when patients depend on you, the accreditation standards that hospitals must meet, and the way the duties of a hospital, a unit manager and a frontline worker fit together.

The law that applies in Ontario

Healthcare workplaces in Ontario are covered by the Occupational Health and Safety Act (OHSA) like any other workplace. Northbridge Community Hospital, Maple Court and Northbridge Home Care are all covered, and so is every worker in them, from the chief executive to a student on placement who is paid. The Act sets out the general duties of employers, supervisors and workers, the internal responsibility system, the joint health and safety committee, the right to refuse unsafe work and the powers of inspectors.

Under the Act sit regulations. The one written specifically for healthcare is Ontario Regulation 67/93, Health Care and Residential Facilities. It applies to hospitals, long-term care homes, psychiatric facilities, laboratories, ambulance services and other health care and residential facilities. Other regulations apply as well, including the WHMIS regulation, the occupational exposure limits in Regulation 833, the designated substances regulation, the X-ray safety regulation, and the Needle Safety regulation (Regulation 474/07), which requires safety-engineered needles in hospitals and many other healthcare settings.

What Regulation 67/93 requires

The heart of Regulation 67/93 is a simple idea. The employer must develop, establish and put into effect written measures and procedures for the health and safety of workers, in consultation with the joint health and safety committee or health and safety representative. The measures and procedures must deal with the hazards of the particular workplace, including safe work practices, safe working conditions, hygiene, the control of infections, immunization, the use of disinfectants and the handling of soiled linen, sharp objects and waste. They must be reviewed and revised at least once a year, and the employer must train workers in the measures and procedures that are relevant to their work, again in consultation with the committee.

The regulation then adds specific requirements, such as the duty to provide and train workers in personal protective equipment (section 10), rules for confined spaces, and requirements for antineoplastic (anti-cancer) drugs (section 97). In practice, an inspector visiting Northbridge will ask to see the written measures and procedures for each hazard, evidence that the joint health and safety committee was consulted, the date of the last annual review and training records.

Ontario's the Occupational Health and Safety Act (OHSA) also has a part on workplace violence and harassment, added in 2010, that matters greatly in healthcare. Every employer must have a workplace violence policy and program, assess the risk of violence and reassess it as often as necessary, and provide workers with information, including personal information, about a person with a history of violent behaviour if the worker can be expected to meet that person in their work and the history creates a risk of physical injury. That last rule is the legal basis for the flagging of patients with a history of violence, covered in HSE-393.

The internal responsibility system

Ontario's law is built on the internal responsibility system: everyone in the workplace has a duty for safety in proportion to their authority and ability, and problems are solved first inside the workplace rather than by an inspector. In a hospital, the parts fit together like this:

A joint health and safety committee is required in Ontario at any workplace that regularly employs 20 or more workers, and at least two of its members, one representing workers and one representing management, must be certified. At Northbridge the committee has 14 members. A worker member inspects part of the workplace every month so that the whole hospital is inspected at least once a year. When the committee makes a written recommendation, the employer must respond in writing within 21 days, either with a plan and timetable or with reasons for not accepting it.

Refusing unsafe work when patients depend on you

The right to refuse unsafe work applies to healthcare workers, but with an important limit. For people employed in hospitals, long-term care homes, psychiatric institutions, rehabilitation facilities, laboratories and ambulance services, among others, the right does not apply when the danger is inherent in the work or a normal condition of employment, or when the refusal would directly endanger the life, health or safety of another person. A nurse cannot walk away from a patient in the middle of a resuscitation because the patient might have an infection, and a personal support worker cannot refuse to help a resident who has fallen.

This limit is narrower than it sounds. It does not mean that anything goes in healthcare. A danger is not inherent in the work just because it is common: a broken lift, a missing sharps container, an untested N95 respirator or a patient known to be violent with no plan in place are hazards that should not be there. Workers in these situations can still raise the concern, ask for help, refuse once the patient is safe, and call the Ministry of Labour. And the employer's duty to take every precaution reasonable in the circumstances is not reduced at all.

For supervisors: when a worker says no

When a nurse or a personal support worker tells you a task is unsafe, the useful question is not whether they have the legal right to refuse. It is what has made them unsafe and how quickly you can fix it. Get the patient safe first, together. Then look at the hazard with the worker and, if the concern is not resolved, bring in a worker member of the JHSC and Joanne. Write down what happened. A manager who argues about the law in the moment teaches the whole unit not to raise concerns, and the next one may not be raised until somebody is hurt.

Accreditation and guidance

Most Canadian hospitals and many long-term care homes are accredited by Accreditation Canada, whose standards include worker safety, workplace violence prevention, infection prevention and control and medical device reprocessing. Accreditation is not law, but surveyors look closely at whether a hospital's safety program actually works. Much of the practical guidance used in Ontario comes from the Public Services Health and Safety Association (PSHSA), the province's health and safety association for the sector, from Public Health Ontario on infection control, and from CSA Group standards on topics such as ventilation in healthcare facilities and psychological health and safety. Long-term care homes are also covered by the Fixing Long-Term Care Act, 2021, which deals mainly with residents' care but affects staffing, training and the handling of residents' responsive behaviours.

None of these sources replace each other. The law sets the minimum. Accreditation checks whether the hospital is managing safety well. Guidance shows how. And the hospital's own program is where all of it turns into what happens on 4 West at three in the morning.

Workers' compensation

Almost all healthcare employers in Ontario are covered by the Workplace Safety and Insurance Board (WSIB). A worker hurt at work is entitled to health care benefits and, if they lose time, wage replacement, whether or not anyone was at fault. In return, the worker cannot sue the employer. The employer must report the injury to the WSIB, and Lesson 11 covers how and when.

What the law looks like on a unit

Most frontline staff will never read the Act or the regulations, and they do not need to. What they need is to recognize the places where the law shows up in their day, so they know what to expect and what to ask for when it is missing. On 4 West, those places are easy to list:

• The written procedures for lifts, sharps, isolation, spills and violence, in a binder at the nursing station and on the intranet, each with a review date less than a year old.
• The joint health and safety committee board by the staff room, with the names and photos of the members, the minutes of the last meeting and the date of the last inspection.
• The workplace violence policy, and the flag on the chart and the door of any patient with a history of violent behaviour, with the care plan that goes with it.
• Training records: lift training, N95 fit testing, WHMIS, violence prevention and the unit orientation, each with a date.
• The safety-engineered needles in every supply cart, which the Needle Safety regulation requires.
• The injury and incident reporting form, and a manager who signs off reports within a day or two.

If any of these is missing or out of date, that is worth raising with the unit manager or a committee member. None of it needs a lawyer to understand. A procedure that is five years old, a committee board with last year's minutes or a lift training record that ends in 2022 are all signs that the system is not working as the law intends.