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Greeley Reflections

Accreditation Connection, June 15, 2009

Each week, a senior consultant from The Greeley Company’s Center for Healthcare Accreditation will discuss a hot-button topic or challenging issue facing hospitals in the areas of accreditation, survey preparation, and more. To learn more visit The Center for Healthcare Accreditation.

Brenda Gail Summers
MBA/MHA, MSN, RN, NEA-BC, CSHA, senior consultant

The board’s role in conflict of interest situations

Part 3 of 3:

As closed last week with, if a potential conflict of interest exists, the defined process should be followed.

But what do you need to do?

• Develop policies to address actual or potential conflicts of interest involving anyone in the organization. Include in the policy the organization’s definition of a conflict of interest.

• Define the steps an individual is expected to take should an actual or a potential conflict of interest present, noting that the steps may be different in the situation of actual vs. potential conflict of interest.

• Include the conflict of interest in orientation for all new leaders, and at initial orientation for all staff and LIPs. Consider providing examples, perhaps as case studies, of potential or actual conflicts of interest involving senior leaders and examples involving others in the organization.

• Inform patients of any potential conflict of interest on the part of staff or LIPs, so patients might make informed decisions about their care, treatment, or service.

• Document all actions taken in response to potential or actual conflicts of interest.

Helpful hint: Review your current board bylaws, medical staff bylaws, and any existing policies already developed on the subject. It’s possible you already have the foundation for a complete conflict of interest policy. Some may need little, if any revision.

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