Complaints Protocol
1. Purpose. Code of Ethics and Reporting Channel or "Whistleblowing" Channel
The organization HOSPITAL VIRGEN DEL ALCAZAR DE LORCA, S.A. has a code of ethics and an ethical channel, hereinafter referred to as the "whistleblowing channel," made available through the Quality Audit documentation, as provided in articles 5.2.h) and i) and 9 of Law 2/23, of February 20, which regulates the protection of persons who report regulatory violations and the fight against corruption (hereinafter, Law 2/23).
The purpose of the information channel is to allow workers, managers, employees to report any irregularities they detect to the persons responsible for managing the channel, in accordance with current regulations and the aforementioned Code of Ethics. However, the existence of the whistleblowing channel does not prevent the submission of information or reports through other channels that the interested party considers relevant or more appropriate.
This Protocol aims to provide information on the use of the mentioned channel, in a clear and easily accessible manner, including the essential principles of the management procedure.
2. Information or Reports
Information or reports can be submitted with the identification of the informant (whistleblower) or even anonymously through:
In the case of anonymous reporting, the informant will not receive information about its progress; they can only view the status of their report by requesting follow-up with the ID provided at the end of the report submission.
If the informant identifies themselves in the report, they can request an in-person meeting, which will take place within a maximum period of 7 days (Article 7.2 Law 2/23).
However, anyone deciding to make a report should consider that "communicating or publicly disclosing information knowingly false" is considered a very serious offense, and the Law provides for fines ranging from €30,001.00 to €300,000.00 for individuals who commit it [articles 63.1.f) and 65.1.a) of said Law].
3. Receipt of the Report: Generation of the Registration Number and Confidentiality Measures
The whistleblowing management system of HOSPITAL VIRGEN DEL ALCAZAR, S.A. was approved by the Management Committee on October 30, 2023, appointing Ms. Mar Mateo Gallego as the person responsible for the system and establishing the following specifics:
The receipt of the report through our ethical channel will generate a registration number that will serve to identify the facts, any internal investigations, and future resolution, preserving the identity of both the whistleblower and the affected parties.
The reports will be recorded in the register book of the information received by HOSPITAL VIRGEN DEL ALCAZAR DE LORCA, S.A., where any internal investigations they may have led to will also be documented, ensuring, in any case, compliance with legally established confidentiality requirements.
This register book will not be public, and access to the content of said register, in whole or in part, may only be granted upon reasoned request from the competent judicial authority, by court order, and within the framework of a judicial proceeding under its protection.
In addition, HOSPITAL VIRGEN DEL ALCAZAR DE LORCA, S.A. guarantees that both the informant and the persons affected by the report have the right to preserve their identity, as provided in Article 32 of Law 2/23. Furthermore, informants have certain rights when the information they provide meets the requirements of Articles 2 and 35 of that regulation, including the prohibition of retaliation (Article 36).
For HOSPITAL VIRGEN DEL ALCAZAR DE LORCA, S.A., the support and protection measures against retaliation provided for in Articles 37 and 38 of the Law are also of great relevance.
4. Acknowledgment of Receipt
Within 7 days [Article 9.2.c) Law 2/23], the identified informant will receive an acknowledgment of receipt with a report code at the email provided at the time of submission. In the case of an anonymous report, the informant will only receive a report code at the time of submission. This code will allow the whistleblower to request information about the status of their report from the channel's manager, as well as to provide any additional information needed when consulted, always maintaining the required security and anonymity conditions by law.
5. Triage or Initial Analysis of the Report
Once the report is received, an initial assessment will be made as to whether the report is well-founded or there are suspicions that it may be a criminal conduct and/or may cause damages that require immediate action to protect the whistleblower, third parties, or the organization itself.
If necessary, additional information may be requested from the informant.
In any case, HOSPITAL VIRGEN DEL ALCAZAR DE LORCA, S.A. notifies that, if the reported conduct could be a criminal offense, immediate communication will be made to the Public Prosecutor or referral to another Authority or Organization that may be competent to handle the communication. However, if the report is not anonymous, it should be noted that the identity of the whistleblower will be preserved and can only be disclosed to the judicial authority, the Public Prosecutor, or the competent administrative authority within the framework of a criminal, disciplinary, or sanctioning investigation.
6. Internal Investigations
Through internal investigations, HOSPITAL VIRGEN DEL ALCAZAR, S.A. seeks to clarify whether the reported facts are true, so they should lead to some type of consequence or corrective action. For this purpose, there will be investigative personnel who will act with all guarantees of confidentiality, impartiality, and absence of conflicts of interest.
Rejection of the report will be agreed upon in the following cases:
The rejection will be notified to the whistleblower within seven calendar days, unless the report is anonymous or the whistleblower has waived receiving communications. In any case, this will be recorded in the register book of reports of HOSPITAL VIRGEN DEL ALCAZAR DE LORCA, S.A.
On the contrary, if the investigation team decides that the report should be processed, this will also be recorded for relevant purposes. The acceptance of the report will be notified to the whistleblower through the mechanisms mentioned in section 2 of this Protocol.
7. Deadline for Decision Making
The investigative team must issue its decision within a maximum period of three months from the receipt of the report or, if an acknowledgment of receipt was not sent to the informant, three months from the expiration of the seven-day period after the communication, unless special complexity requires an extension of the period, in which case it can be extended for a maximum of an additional three months.
8. Content of the Decision
In case the internal investigations conclude that an infringement is detected, and prior to, if necessary, the communications of intermediate steps that have been required with the whistleblower and affected parties, HOSPITAL VIRGEN DEL ALCAZAR, S.A. will take the necessary, appropriate, and sufficient measures to resolve the potential conflict, as well as to monitor that it does not happen again, in accordance with the Code of Ethics, policies, rules, or internal agreements or procedures of HOSPITAL VIRGEN DEL ALCAZAR, S.A. If applicable, internal sanctions may be imposed in accordance with these reference rules.
Conversely, when the investigations conclude that no infringement is detected, the investigator or investigators will motivate their decision, and HOSPITAL VIRGEN DEL ALCAZAR, S.A. will protect the information and custody of the documents received in any case.
In both cases, the decision must include the following:
When the report has led to the opening of an administrative file or judicial procedure, HOSPITAL VIRGEN DEL ALCAZAR, S.A. also undertakes to monitor the results of administrative, judicial, or police investigations.
9. Archiving and Data Deletion
After 3 months from the receipt of the communication without initiating investigation actions, HOSPITAL VIRGEN DEL ALCAZAR, S.A. will proceed to delete the personal data of the report, unless the purpose of preservation is to provide evidence of the system's operation (Article 32.4 Law 2/23).
In any case, HOSPITAL VIRGEN DEL ALCAZAR, S.A. will archive the file generated by the report in the following cases:
The documentation of the investigations carried out may include, among other things, the following: findings, measures taken, lessons learned, etc.
10. Documentation in the Register Book
HOSPITAL VIRGEN DEL ALCAZAR DE LORCA, S.A. undertakes to document in the register book of reports the information received and the internal investigations they may have led to, ensuring, in any case, compliance with legally established confidentiality requirements (Article 26 Law 2/23).
This documentation will include:
The organization HOSPITAL VIRGEN DEL ALCAZAR DE LORCA, S.A. has a code of ethics and an ethical channel, hereinafter referred to as the "whistleblowing channel," made available through the Quality Audit documentation, as provided in articles 5.2.h) and i) and 9 of Law 2/23, of February 20, which regulates the protection of persons who report regulatory violations and the fight against corruption (hereinafter, Law 2/23).
The purpose of the information channel is to allow workers, managers, employees to report any irregularities they detect to the persons responsible for managing the channel, in accordance with current regulations and the aforementioned Code of Ethics. However, the existence of the whistleblowing channel does not prevent the submission of information or reports through other channels that the interested party considers relevant or more appropriate.
This Protocol aims to provide information on the use of the mentioned channel, in a clear and easily accessible manner, including the essential principles of the management procedure.
2. Information or Reports
Information or reports can be submitted with the identification of the informant (whistleblower) or even anonymously through:
• The section enabled for this purpose on the main website's homepage.
• Orally, to the individual person designated by the Management Committee and responsible for the management and processing of investigation files: Ms. Mar Mateo Gallego.
• Orally, to the individual person designated by the Management Committee and responsible for the management and processing of investigation files: Ms. Mar Mateo Gallego.
In the case of anonymous reporting, the informant will not receive information about its progress; they can only view the status of their report by requesting follow-up with the ID provided at the end of the report submission.
If the informant identifies themselves in the report, they can request an in-person meeting, which will take place within a maximum period of 7 days (Article 7.2 Law 2/23).
However, anyone deciding to make a report should consider that "communicating or publicly disclosing information knowingly false" is considered a very serious offense, and the Law provides for fines ranging from €30,001.00 to €300,000.00 for individuals who commit it [articles 63.1.f) and 65.1.a) of said Law].
3. Receipt of the Report: Generation of the Registration Number and Confidentiality Measures
The whistleblowing management system of HOSPITAL VIRGEN DEL ALCAZAR, S.A. was approved by the Management Committee on October 30, 2023, appointing Ms. Mar Mateo Gallego as the person responsible for the system and establishing the following specifics:
• Written submission to:
o Email, etica@virgendelalcazar.com
o Website section.
• Orally, to the person responsible for the system.
o Website section.
The receipt of the report through our ethical channel will generate a registration number that will serve to identify the facts, any internal investigations, and future resolution, preserving the identity of both the whistleblower and the affected parties.
The reports will be recorded in the register book of the information received by HOSPITAL VIRGEN DEL ALCAZAR DE LORCA, S.A., where any internal investigations they may have led to will also be documented, ensuring, in any case, compliance with legally established confidentiality requirements.
This register book will not be public, and access to the content of said register, in whole or in part, may only be granted upon reasoned request from the competent judicial authority, by court order, and within the framework of a judicial proceeding under its protection.
In addition, HOSPITAL VIRGEN DEL ALCAZAR DE LORCA, S.A. guarantees that both the informant and the persons affected by the report have the right to preserve their identity, as provided in Article 32 of Law 2/23. Furthermore, informants have certain rights when the information they provide meets the requirements of Articles 2 and 35 of that regulation, including the prohibition of retaliation (Article 36).
For HOSPITAL VIRGEN DEL ALCAZAR DE LORCA, S.A., the support and protection measures against retaliation provided for in Articles 37 and 38 of the Law are also of great relevance.
4. Acknowledgment of Receipt
Within 7 days [Article 9.2.c) Law 2/23], the identified informant will receive an acknowledgment of receipt with a report code at the email provided at the time of submission. In the case of an anonymous report, the informant will only receive a report code at the time of submission. This code will allow the whistleblower to request information about the status of their report from the channel's manager, as well as to provide any additional information needed when consulted, always maintaining the required security and anonymity conditions by law.
5. Triage or Initial Analysis of the Report
Once the report is received, an initial assessment will be made as to whether the report is well-founded or there are suspicions that it may be a criminal conduct and/or may cause damages that require immediate action to protect the whistleblower, third parties, or the organization itself.
If necessary, additional information may be requested from the informant.
In any case, HOSPITAL VIRGEN DEL ALCAZAR DE LORCA, S.A. notifies that, if the reported conduct could be a criminal offense, immediate communication will be made to the Public Prosecutor or referral to another Authority or Organization that may be competent to handle the communication. However, if the report is not anonymous, it should be noted that the identity of the whistleblower will be preserved and can only be disclosed to the judicial authority, the Public Prosecutor, or the competent administrative authority within the framework of a criminal, disciplinary, or sanctioning investigation.
6. Internal Investigations
Through internal investigations, HOSPITAL VIRGEN DEL ALCAZAR, S.A. seeks to clarify whether the reported facts are true, so they should lead to some type of consequence or corrective action. For this purpose, there will be investigative personnel who will act with all guarantees of confidentiality, impartiality, and absence of conflicts of interest.
Rejection of the report will be agreed upon in the following cases:
a) When the facts on which the information is based are absolutely implausible.
b) When these facts do not constitute any infringement of the legal system, nor do they contravene the Code of Ethics or any internal policies, rules, or agreements of HOSPITAL VIRGEN DEL ALCAZAR, S.A.; or even if they do, they do not represent a real impact on the general interest or its proper functioning.
c) When there are reasonable indications that the data on which the report is based have been obtained unlawfully.
d) When the report is a mere reproduction of another previously rejected or properly investigated report.
b) When these facts do not constitute any infringement of the legal system, nor do they contravene the Code of Ethics or any internal policies, rules, or agreements of HOSPITAL VIRGEN DEL ALCAZAR, S.A.; or even if they do, they do not represent a real impact on the general interest or its proper functioning.
c) When there are reasonable indications that the data on which the report is based have been obtained unlawfully.
d) When the report is a mere reproduction of another previously rejected or properly investigated report.
The rejection will be notified to the whistleblower within seven calendar days, unless the report is anonymous or the whistleblower has waived receiving communications. In any case, this will be recorded in the register book of reports of HOSPITAL VIRGEN DEL ALCAZAR DE LORCA, S.A.
On the contrary, if the investigation team decides that the report should be processed, this will also be recorded for relevant purposes. The acceptance of the report will be notified to the whistleblower through the mechanisms mentioned in section 2 of this Protocol.
7. Deadline for Decision Making
The investigative team must issue its decision within a maximum period of three months from the receipt of the report or, if an acknowledgment of receipt was not sent to the informant, three months from the expiration of the seven-day period after the communication, unless special complexity requires an extension of the period, in which case it can be extended for a maximum of an additional three months.
8. Content of the Decision
In case the internal investigations conclude that an infringement is detected, and prior to, if necessary, the communications of intermediate steps that have been required with the whistleblower and affected parties, HOSPITAL VIRGEN DEL ALCAZAR, S.A. will take the necessary, appropriate, and sufficient measures to resolve the potential conflict, as well as to monitor that it does not happen again, in accordance with the Code of Ethics, policies, rules, or internal agreements or procedures of HOSPITAL VIRGEN DEL ALCAZAR, S.A. If applicable, internal sanctions may be imposed in accordance with these reference rules.
Conversely, when the investigations conclude that no infringement is detected, the investigator or investigators will motivate their decision, and HOSPITAL VIRGEN DEL ALCAZAR, S.A. will protect the information and custody of the documents received in any case.
In both cases, the decision must include the following:
a) Identification code of the report and date of its receipt.
b) Exposition of the reported facts.
c) Investigation actions carried out to clarify the facts, the assessment of the evidence obtained, and the indications.
d) Investigation conclusions.
e) If applicable, measures to be taken.
b) Exposition of the reported facts.
c) Investigation actions carried out to clarify the facts, the assessment of the evidence obtained, and the indications.
d) Investigation conclusions.
e) If applicable, measures to be taken.
When the report has led to the opening of an administrative file or judicial procedure, HOSPITAL VIRGEN DEL ALCAZAR, S.A. also undertakes to monitor the results of administrative, judicial, or police investigations.
9. Archiving and Data Deletion
After 3 months from the receipt of the communication without initiating investigation actions, HOSPITAL VIRGEN DEL ALCAZAR, S.A. will proceed to delete the personal data of the report, unless the purpose of preservation is to provide evidence of the system's operation (Article 32.4 Law 2/23).
In any case, HOSPITAL VIRGEN DEL ALCAZAR, S.A. will archive the file generated by the report in the following cases:
a) No measures needed to be taken.
b) The facts do not indicate that an investigation is needed.
c) Another procedure (judicial, police...) must be followed.
d) The investigation has ended (with detected or undetected infringement).
b) The facts do not indicate that an investigation is needed.
c) Another procedure (judicial, police...) must be followed.
d) The investigation has ended (with detected or undetected infringement).
The documentation of the investigations carried out may include, among other things, the following: findings, measures taken, lessons learned, etc.
10. Documentation in the Register Book
HOSPITAL VIRGEN DEL ALCAZAR DE LORCA, S.A. undertakes to document in the register book of reports the information received and the internal investigations they may have led to, ensuring, in any case, compliance with legally established confidentiality requirements (Article 26 Law 2/23).
This documentation will include:
a) Date of conclusion of the file.
b) Who approves the conclusion.
c) What measures were taken.
d) Relevant evidence.
b) Who approves the conclusion.
c) What measures were taken.
d) Relevant evidence.
