SHAWNEE HEALTH SERVICE POLICY AND PROCEDURE
Applicable to: Shawnee Organization
Subject: Conflict of Interest Policy Executive Director: Signature on file
Distribute to: Personnel Policy and Procedure Board President: Signature on file
Effective Date: August 1, 1999 Board Approval Dates: 7/19/99; 11/1/07
Policy Revision Date(s): 11/1/07, 01/10 Review Dates: 06/07, 01/10
Replaces: Nepotism (Personnel P & P)
Gifts and Rebates (Personnel P & P)
Outside Employment (Personnel P & P)
Political Activities (Personnel P & P)
The purpose of this policy is to provide guidance in identifying and handling potential and actual conflicts of interest involving Shawnee Health Service. In most instances, conflicts of interest can be avoided simply by continuing to exercise good judgment and, indeed, the corporation relies on the sound judgment of its employees to prevent many such conflict situations.
Shawnee Health Service is committed to the highest levels of integrity. Employees, volunteers and Board of Director members are expected to conduct their relationships with each other, the corporation and outside organizations with objectivity and honesty. The general rule is that: Shawnee Health Service’s employees, volunteers and Board of Director members are obligated to avoid and disclose ethical, legal, financial, or other conflicts of interest involving Shawnee Health Service, and remove themselves from a position of decision-making authority with respect to any conflict situation involving Shawnee Health Service.
Identification and Management of Conflict Situations
Generally, a conflict of interest may occur if an interest or activity influences or appears to influence the ability of an individual to exercise objectivity or impairs the individual’s ability to perform his or her employment responsibilities in the best interests of the corporation.
An individual is considered to have a potential conflict of interest when:
- He or she or any member of his or her family* may receive a financial or other significant benefit as a result of the individual’s position at Shawnee Health Service;
- The individual has the opportunity to influence the corporation’s business, administrative, or other material decisions in a manner that leads to personal gain or advantage; or
- The individual has an existing or potential financial or other significant interest which impairs, or might appear to impair, the individual’s independence in the discharge of his or her responsibilities to the corporation.
* The “family” of an individual includes his or her spouse, domestic partner, parents, siblings, children and any other relative who resides in the same household.
Specific Relationships that May Create Conflicts of Interest
A variety of situations, affiliations and relationships may create potential conflicts of interest. Financial or other relationship (i.e., Board/officer or other management positions) by an employee, volunteer or Board member or their family with a prospective contractor, vendor or supplier could potentially create the appearance of impropriety or interfere with an employee’s action of his or her responsibilities on behalf of and in the best interests of Shawnee Health Service and should be disclosed on the employee’s Conflict of Interest Questionnaire. When deciding what kind of relationships should be disclosed, consider the situation from the perspective of an outsider and whether the relationship is of such a nature that it could raise an allegation of apparent or actual conflict of interest, and then err on the side of transparency, as disclosure helps to alleviate or avoid future misunderstandings. Additionally, certain types of relationships between co-workers may create impermissible conflicts of interest. For example, a romantic relationship in the workplace may raise perceptions of bias and favoritism. For these reasons, personal/romantic or financial/business relationships between co-workers that could create the appearance of impropriety or interfere with an employee’s discharge of the employee’s responsibilities on behalf and in the best interests of the corporation should be promptly disclosed to Human Resources.
Board of Directors members and/or a member of his or her immediate family may not be employed by Shawnee. A member of the Board must resign from the Board before he or she or an immediate family member takes a position with Shawnee. No employee of Shawnee shall be permitted to maintain a position on the Board. Hiring of relatives of current employees is permissible.
No employee shall be employed in a position supervised by an immediate family member. A member of the immediate family of an employee may not be assigned to a position in which the one would have direct or indirect administrative or supervisory responsibility for the other or to a position in the same office. No organization manager may sign off on payroll/personnel forms that affect his or her own salary or approve reimbursement of his or her own expenses or those of a direct supervisor. In consideration of the Executive Director, the Human Resources Director will sign off on payroll/personnel forms and/or approve reimbursement of expenses.
In addition, Shawnee Health Service operates programs that receive funding which requires the disclosure of potential conflicts of interest. For example, the Shawnee Alliance for Seniors program requires disclosure to evaluate potential conflicts that include:
- Organizational conflicts, which include, but are not limited to, ownership or investment interest in a long term care facility or of a provider of a long term care service; employment by or participation in the management of a long term care facility; governing board members with ownership, investment or employment interest in long term care facilities; direct involvement in the licensing or certification of a long term care facility or long term care services; or receiving or having the right to receive, directly or indirectly, remuneration (in cash or in kind) under a compensation arrangement with an owner or operator of a long term care facility.
- Individual conflicts, which include, but are not limited to, employment of an individual or a member of his or her immediate family by a long term care facility in the service area or by the owner or operator of any long term care facility in the service area; participation in the management of a long term care facility by an individual or a member of his or her immediate family; ownership or investment interest in an existing or proposed long term care facility or long term care service by an individual or a member of his or her immediate family; involvement in the licensing or certification of a long term care facility or provision of a long term care service by an individual or a member of his or her immediate family; receipt of remuneration under a compensation arrangement with an owner or operator of a long term care facility; if employed as an Ombudsmen, accepts money or other consideration from anyone other than Shawnee Health Service; and if employed as an Ombudsmen, has no conflicting responsibilities while providing services to a resident such as adult protective services, discharge planning, serving as a guardian, agent under power of attorney or other surrogate decision-maker for a long term care resident in the service area, pre-admission screening or case management for long term care residents.
Disclosure and Management of Conflicts of Interest
Should an appearance of impropriety or actual conflict of interest exist, appropriate actions must be taken, which will vary depending upon the particular facts. The employee, volunteer or Board member involved in the conflict situation must work cooperatively with his or her manager to achieve a resolution of the conflict issues in the best interests of the corporation, as requested by the corporation. This may include the employee being removed from a position of decision-making authority with respect to the conflict situation or other more serious actions, depending upon the nature of the conflict. If the conflict involves a financial activity on behalf of the corporation, written documentation of the conflict disclosure and the steps taken to address the conflict must be completed. A copy of this information must be provided to the Corporate Compliance Officer.
Gifts and Rebates
As a general rule, corporation employees may not receive or offer any gift or anything else of significant value from persons or organizations doing or proposing to do business with Shawnee. Gifts (except those of a nominal value of $25 or less) received from vendors, suppliers, consultants or patients/clients as part of normal business practice must be given to the corporation or shared with the corporation generally, and if acknowledgement is appropriate, acknowledged on behalf of the corporation. This guideline is not intended to prohibit normal business practices, such as meetings over meals, corporate items given to participants in meetings and conferences, or token gifts, as long as they are of nominal and reasonable value and promote the corporation’s legitimate business interests. If an employee believes there is an appropriate reason to make an exemption to this policy for an individual situation, he or she should contact the Corporate Compliance Office prior to giving or accepting the gift.
Fees, Honorariums, Expense Reimbursements, and other similar payments
Staff members are encouraged to undertake speaking engagements, serve on boards and write articles, provided the time for such activities does not interfere with the employee’s responsibilities at Shawnee. Director’s fees, author’s royalties, honorariums, and payments for published articles or speaking engagements should only be accepted if the materials prepared and all activities undertaken in connection with these activities are on personal time, the issues addressed are not related to the corporation’s activities or mission, and corporate resources are not utilized. If an employee believes a particular circumstance merits an exception to this policy, the employee should consult the Corporate Compliance Officer for advice and appropriate documentation. Travel costs and expenses incurred in connection with any activities that are not Shawnee related must be borne by the individual or the organization inviting the individual to participate in the activity and should not be paid or reimbursed by Shawnee.
On some occasions, a staff member may receive an honorarium or gift in recognition of services that are a part of their employment with Shawnee Health Service. If any staff member receives any honorarium or gift, it must be given to Shawnee Health Service.
Accepting Compensated Work Outside Shawnee by Employees
In an effort to prevent potential conflicts, understand the scope and nature of the outside business commitments of Shawnee, and to ensure that outside commitments do not infringe on work responsibilities required on behalf of Shawnee, Shawnee employees who hold the position of a provider (physician, mid-level, dentist, dietitian, LCSW or psychologist), or an employee in an administrative position of clinic manager or program director or above, may not conduct outside business or other activities for which they receive remuneration, if it is related to his or her expertise as a Shawnee employee, or the business of Shawnee, without prior approval from the Executive Director, or in the case of the Executive Director, from the Board of Directors. In requesting permission, the employee should disclose the organization for which the work will be done, the nature of the work, the expected time commitment, and remuneration to be received, as well as an evaluation of any potential conflicts of interest that could arise with Shawnee as a result of the employee’s engagement in such activity.
Political Activities and Lobbying
Shawnee Health Service cannot engage in political campaigns, contribute to political campaigns, or allow for requests for campaign contribution of individuals during work. Board members and employees may not do any kind of fundraising or soliciting for a political party or candidate using Shawnee’s name, facilities, equipment, supplies, or any other corporate resources. Shawnee employees and Board Members are free to engage in these types of political activities on a personal basis and on their own time provided that reasonable steps are taken to avoid the perception that such activities are on behalf of Shawnee. Shawnee employees actively involved in a political campaign or activity may discuss with the Corporate Compliance officer appropriate steps to minimize the risk of the employee’s personal actions being attributed to Shawnee and also review any other unintended potential impacts such activity could have on Shawnee.
Expenses associated with lobbying activities must be authorized by the Executive Director and are allowed so long as the activity is insubstantial in relation to the Corporation’s budget, in accordance with federal regulations. No federal grant money may be used to support such lobbying activities.
Conflict of Interest Questionnaire
Upon commencement of employment and annually thereafter, all upper management and employees in finance positions must complete a “Conflict of Interest Questionnaire”. Upper management employees include: Executive Director, Chief Operating Officer, Finance Director, Program Directors, Assistant Director and Operating Officer. Finance employees include: Accountants and Procurement Agents. Employees are also required to update the Conflict of Interest Questionnaire whenever there has been a change in the employee’s position within the corporation Employees must disclose all of his or her affiliations, as requested on the form, even if there is no current conflict of interest. Upon appointment and annually thereafter all members of the Shawnee Board of Directors must complete a “Conflict of Interest Questionnaire.”
This policy cannot describe all conflicts of interest situations that may arise involving the corporation. Therefore, Shawnee Board members and employees must use good judgment to avoid any appearance of impropriety. Appropriate circumstances may also justify exceptions to the application of the policy. If questions arise about this policy or its application, err on the side of caution and transparence and seek advice from the Corporate Compliance Officer prior to entering into such transaction.
Conflicts of Interest Questionnaire
The undersigned employee, volunteer or Board Member of Shawnee Health Service do hereby certify the following:
- That I have received a copy of the Conflict of Interest Policy of Shawnee Health Service and I have read, understand and to the best of my knowledge have complied with the policy;
- That I wish to disclose for review a transaction, business interest or other situation which may represent a potential or actual conflict of interest with Shawnee Health Service. I understand that I will take no further action relating to the potential or actual conflict of interest until I am advised by Shawnee’s Corporate Compliance Officer. This includes:
- That an action pending before Shawnee Health Service may place me in a position of potential or actual conflict of interest. The pending action includes:
By: _________________________________ Date: _____________________
Print Name: ______________________________
Relationship: ____ Board of Directors Member ____ Employee (indicate title) _______________
Upon completion, forward to:
Corporate Compliance Officer
Shawnee Health Service
109 California Street
PO Box 577
Carterville, IL 62918-0577