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Conflict of interest disclosures

Credentialing Resource Center Connection, August 6, 2009

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Anne Roberts, CPMSM, CPCS, is the director of medical affairs at Children's Medical Center of Dallas, where she oversees the medical administration, graduate medical education, and medical staff services departments.

Dear credentialing colleague:

The Joint Commission revised its Leadership Standards to include requirements that leaders define and address existing or potential conflicts-of-interest related to licensed independent practitioners (LIP). Because of this, MSPs need to partner with their organization’s compliance department to determine how this will be implemented.

Many organizations are implementing it by including conflict-of-interest disclosures in their credentialing packets for LIP’s at initial and reappointment. Additionally, the hospital’s conflict-of-interest policy (or a Web address to access it online) can be included in the credentialing packet. General conflict-of-interest disclosures for all staff and LIPs should require that information related to existing or potential conflicts be disclosed, such as relationships with other care providers, educational institutions, manufacturers, and payers. If a physician discloses a potential conflict-of-interest during the credentialing process, MSPs should consult with their compliance or legal department to determine if additional information is needed.

Physician leaders or other LIPs who are in decision-making roles, or are in a position to influence decisions that impact the hospital, should complete more comprehensive conflict-of-interest disclosures annually. In addition to completing the conflict-of-interest disclosures, the leaders should be educated on how to identify potential conflicts-of-interest. When physicians are appointed to leadership roles, such as medical staff officers, committee chairs, or department chiefs, this information should be included in their orientation and education materials. 

Remember, clear, effective communication is the key to success!

That's all for this week.

All the best,

Anne Roberts, CPMSM, CPCS

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