Sunnybrook's Conflict of Interest Policy

Conflict of Interest

Policy Statement

It is the policy of Sunnybrook Health Sciences Centre ("Sunnybrook" or the "Hospital") to define broad principles and behaviour standards that promote a high level of ethical conduct. This policy is intended to promote the highest standard of public trust and integrity while protecting all of Sunnybrook's Stakeholders by providing the means to avoid or resolve situations that may otherwise place these Stakeholders in ethically questionable situations.

This policy applies to all of Sunnybrook's Stakeholders.

It is recognized that the policy does not replace the roles that professional bodies play in regulating ethical conduct.

Defintion(s)

Conflict of interest

Any situation in which a Stakeholder by virtue of the Stakeholder's position, has or may be perceived to have (by a reasonable and objective person in the circumstances), a conflict between his or her private or personal interest (or the private, personal or other interest of the Stakeholder's Associate) and the Stakeholder's duties to Sunnybrook that results in, or may result in, the following:

the execution of Sunnybrook duties being influenced to the detriment of Sunnybrook or those having dealings with Sunnybrook, and/or
a gain, advantage or showing of preference to a Stakeholder or Stakeholder Associate, to the detriment of Sunnybrook or those having dealings with Sunnybrook.

For examples to assist in understanding conflict of interest, see Appendix I

Immediate Family Members of a Stakeholder
Include a Stakeholder's parent, grandparent, sibling, spouse (including a life partner), child, grandchild, son-in-law, daughter-in-law, brother-in-law, sister-in-law and the parent, grandparent, sibling, child, grandchild, son-in-law, daughter-in-law, brother-in-law, sister-in-law of the Stakeholder's spouse.

Stakeholders
Persons in the following relationship to Sunnybrook:

Members of the Board of Directors
Members of Committees of the Board of Directors
Members of the Medical/Dental/Midwifery Staff
Research Staff
Contract Staff
Employees
Volunteers
Students

Stakeholder Associates

Immediate Family Members or close friends of a Stakeholder
Corporations (other than Sunnybrook) of which a Stakeholder is a director or officer
Other legal entities to whom a Stakeholder owes a fiduciary duty

CONFLICT OF INTEREST CODE OF CONDUCT:

Public trust and Sunnybrook's policy require that all Stakeholders:

Perform their duties and functions impartially, objectively, responsibly, diligently, efficiently, with integrity and in a manner that will bear public scrutiny.
Arrange their private interests in a manner that will prevent a conflict of interest from arising.
Not solicit or accept directly or indirectly for personal benefit or the personal benefit of a Stakeholder Associate, a fee, gift or benefit from a person or an organization that deals with Sunnybrook where the fee, gift or benefit could influence or be perceived to influence the performance of Sunnybrook duties and functions.
Disclose to the appropriate level of authority the solicitation or acceptance of donations, gifts, or other benefits for use by Sunnybrook, from a person or organization that conducts business with Sunnybrook where such solicitation or acceptance could influence or be perceived to influence the performance of Sunnybrook duties and functions.
Not grant preferential treatment in relation to any Sunnybrook matter to a Stakeholder Associate or to organizations in which the Stakeholder or a Stakeholder Associate has an interest, to the detriment of Sunnybrook or those having dealings with Sunnybrook.
Not benefit or permit a Stakeholder Associate to benefit from information that is obtained in the course of performing Sunnybrook duties, to the detriment of Sunnybrook or those having dealings with Sunnybrook.
Not benefit from the use of Sunnybrook property for anything except in the course of Sunnybrook duties or functions, unless such use has been reviewed and approved by the appropriate level of authority.
Maintain confidentiality of all confidential information.

PROCEDURE:

GENERAL PROCEDURE:

Each Stakeholder must declare any conflict of interest as soon as it has been identified. The declaration should be made in writing or orally to the person identified below as the Policy Administrator for that Stakeholder.
As the identification of a conflict of interest is sometimes difficult, each Stakeholder is encouraged to consult with his or her Policy Administrator regarding those matters that the Stakeholder considers could constitute a conflict of interest. It is the responsibility of the Policy Administrator to determine whether a conflict of interest exists. In making that determination, the Policy Administrator may be guided by advice from the Stakeholder and the other people listed below and by the advice of counsel, if sought. The Policy Administrator should resolve any uncertainty as to whether a conflict of interest exists on the side of its existence. Once the Policy Administrator has determined that the Stakeholder is in a conflict of interest position, the Stakeholder should formally declare the conflict of interest in the manner set forth in this policy.
Where a Stakeholder has made a declaration of a conflict of interest and the shareholder is an employee, research staff member, contract staff member, student, volunteer or member of the Medical/Dental/ Midwifery Staff, his or her Policy Administrator will:
a. document the situation in detail for the file of the Stakeholder and forward a copy of the written declaration (if one was delivered) and the Policy Administrator's report to the person indicated below; and
b. resolve the conflict of interest. The resolution should be affected in a manner that is consistent with this policy and in a manner that affords the Stakeholder the protections provided by the documents referred to below.

A Stakeholder affected by a resolution of a conflict of interest may request that the method of resolution be reviewed by the person indicated below.
Where it has been determined by a Policy Administrator that a Stakeholder has not declared a conflict of interest in the manner set forth in this policy or taken the steps this policy or the Policy Administrator has required to be taken to deal with the conflict of interest situation, the Stakeholder may suffer the consequences set out below.

	Board and Board Committee Members	Employees, Research Staff, Contract Staff, Students and Volunteers	Medical/Dental/ Midwifery Staff
Policy Administrator	Board Chair	Stakeholder's immediate supervisor	Department, Division and/or Program Chief
Who Policy Administrator may consult with	Other members of the Board or the Committee or the President and CEO	Policy Administrator's appropriate level of authority	Policy Administrator's appropriate level of authority
Written reports to be delivered to	NA	Vice-President to whom the Stakeholder, directly or indirectly, reports	Chief Medical Executive
Remedies to be consistent with these additional documents	NA	Applicable collective agreements, contracts of employment and Human Resources policies	Rules, regulations and policies that apply to the Medical Staff Association and the bylaws of the Medical/Dental/Midwifery staff
Right of review	NA	Policy Administrator's next level of authority	President and CEO
Possible consequences of breach	Removal of the Stakeholder as a Board member or committee member	Discipline up to and including the termination of employment, contract, student privileges or volunteer service, as the case may be	Discipline up to and including the loss of hospital privileges and removal from the Medical/Dental/ Midwifery staff

In addition the following procedures will apply to specific groups of Stakeholders:

Members of the Board and its Committees
a. In addition to declaring a conflict of interest to the Board Chair, a member shall also declare the conflict to the members of the Board or the committee, as appropriate.
b. A Board or committee member who has declared a conflict of interest in respect of a matter, may participate in the discussion of the matter or may be instructed to be absent from the meeting at the time that the matter is being discussed and voted on. In either case, the member shall not vote on the matter. A member who has absented himself or herself from the meeting to comply with this policy and who rejoins the meeting following the discussion of the matter shall be included in determining whether a quorum exists at the time that the vote on such matter is taken.
c. The Board Chair shall report to the Governance Committee of the Board not less than one time each calendar year on compliance by members of the Board and its committees with this policy including any unresolved issues.
Employees, Research Staff, Contract Staff, Students and Volunteers
a. For the purposes of this policy, the supervisor of the President and Chief Executive Officer of Sunnybrook (the "President and CEO") shall be the Board.
Medical/Dental/Midwifery Staff
a. The President and CEO shall report to the Governance Committee of the Board not less than one time each calendar year on compliance by the members of the Medical/Dental/Midwifery staff with this policy including any unresolved issues.

Annual Responsibilities:

In addition to complying with the ongoing responsibilities set forth above, the Stakeholders listed below are required to complete an Annual Declaration Form [See Appendix II]. These forms will be distributed by Sunnybrook to:

Members of the Board of Directors
Members of a Committee of the Board of Directors of Sunnybrook
Medical Staff with administrative responsibilities
Executive Vice Presidents, Vice Presidents & Directors

Each recipient will be obliged to complete and return the Annual Declaration to the Hospital. If notified this may be done electronically.

APPENDICES AND REFERENCES:

Appendix I

UNDERSTANDING CONFLICTS OF INTEREST

In most instances, a conflict of interest can be easily resolved through disclosure and implementation of necessary corrective action. This appendix sets out examples of both conflict and non-conflict of interest situations and circumstances. These examples are intended as illustrations to assist with the understanding and application of this policy but are not intended to describe the only circumstances that may arise. An individual in doubt about the existence of a conflict of interest is required to discuss the matter with the appropriate authority within Sunnybrook.

SOME TYPICAL EXAMPLES OF CONFLICT OF INTEREST SITUATIONS:
Self-Dealing-Promoting the interests of Stakeholder Associates:

A manager or chief of service appoints a Stakeholder Associate to a position in his/her department. (The primary goal of any selection process is to obtain the best possible individual for the job at hand by means of a process that is fair to all candidates. Where a conflict of interest could be perceived, as in the case of the selection of a Stakeholder Associate, it should be declared to the appropriate authority who will ensure that a selection process is designed that fairly balances the interest of all participants. Situations that involve direct or indirect supervision of a Stakeholder Associate may be permitted to continue provided safeguards deemed necessary by the appropriate authority, in consultation with the Vice President, Human Resources are in place.)
A Volunteer purchases goods for retail sale in the gift shop from a Stakeholder Associate without any competitive tendering. (If no unfair advantage has been obtained, a reminder of the obligation to comply with the tendering policy may suffice. If the arrangement conferred unfair advantage to the Stakeholder Associate at the expense of the gift shop, removal of the Volunteer may be in order.)
A Board member votes in favour of the selection of a not-for-profit corporation of which she is also a director over other potential community partners in a new joint program to be created by the Hospital. (While the board members does not stand to gain financially from the arrangement to be entered into, the director owes duties of loyalty to both corporations and cannot be expected to consider the selection of Sunnybrook's community partner impartially. The director should have declared the interest and abstained from voting. Depending on the circumstances (including the comfort of other directors in discussing the matter in her presence), the Chair may not have required the director to absent herself from the room while the matter was being discussed.)

Self-Dealing-Other:

A therapist refers patients seen in the Hospital to his/her private practice without the knowledge and consent of the Hospital. (Possible Action - Explanation of the policy and/or letter of reprimand.)
A principal investigator uses third party research funds or grants to secure personal benefits unrelated to the purpose of the funds - e.g. purchases a home computer. (Possible Action - Repayment of funds, suspension from duty without pay and/or letter of reprimand.)
A principal investigator has a significant financial interest in a small independent pharmaceutical company in which he/she is involved in clinical trials at Sunnybrook. (Possible Action - Declaration of the financial interest to Research Review Committee for determination of whether or on what basis the trial should continue.)

Accepting Benefits:

An Employee, Researcher or Member of the Medical/Dental/Midwifery staff in a position to influence the purchase of goods or equipment accepts an offer from a competing supplier for the free use of a condo in Florida. (Possible Action - Removal from purchasing process and/or suspension from duty without pay. Termination of employment is warranted in the case of purchasing staff member involvement.)
A Board Member, Employee, Researcher or Member of the Medical/Dental/Midwifery staff accepts an honorarium or consulting fee from a supplier that regularly conducts business with the Hospital. (Possible Action - Disclosure and removal from any involvement in the awarding of business to the supplier.)

Influence Peddling:

A Board Member, purchasing agent, employee, unit manager, Researcher, etc. uses his/her position, influence or authority to promote the purchase of goods used by the Hospital, where the Stakeholder or a Stakeholder Associate stands to gain financially. (Possible Action - Person is removed from the purchasing process, disciplinary action taken and possible removal of the bidder standing to benefit from influence peddling from the purchasing process.)

Use of Hospital Property for Private Advantage:

An Employee, Researcher, Student, Volunteer or Member of the Medical/Dental/Midwifery staff, without the consent of the Hospital, operates a private business, consulting service, counseling service etc. from Hospital property, e.g. use of telephone for long distance calls. (Possible Action - Repayment of any money due and/or a letter of reprimand and/or termination from duty without pay. Criminal charges may also be laid.)
An Employee, Researcher, Student, Volunteer or Member of the Medical/Dental/Midwifery staff removes supplies and/or equipment from the Hospital for personal use at home. (Possible Action - Repayment of any money due and/or a letter of reprimand and/or suspension from duty without pay.)

Use of Confidential Information:

An Employee, Researcher, Student, Volunteer or Member of the Medical/Dental/Midwifery staff upon learning of the Hospital's plans to purchase neighboring residential properties for a parking garage secretly purchases all or some of the property and holds it in a Stakeholder Associate's name. (Possible Action - Discipline up to and including termination of employment/privileges.)
An Employee, Researcher, Student, Volunteer or Member of the Medical/Dental/Midwifery staff provides the names and addresses of parents of all newborns to a Stakeholder Associate. (Possible Action - This involves a breach of confidentiality as well as conflict of interest and disciplinary action to and including termination of employment may be imposed.)
A Board member upon becoming aware that the Hospital may face challenges in the future in meeting clinical demands in a specialized program, advises another Hospital of which he is a director, to pursue the development of that program. (Possible Action - Removal from the board)

Moonlighting:

An Employee in a department that relies on privately generated revenue sets up a competing business in which he/she participates on a part-time basis. (Possible Action - In consultation with the Vice President of Human Resources, the Employee may be instructed to choose between working for the department in Sunnybrook or the private interest.)
An Employee engages in outside employment to the extent that it interferes with his/her ability to devote sufficient time and energy to Hospital responsibilities. (Possible Action - In consultation with the Vice President of Human Resources, the performance problems are noted and Employee advised that moonlighting as it relates to his/her ability to perform as a Hospital Employee might result in discipline up to and including termination.)

EXAMPLES OF NON-CONFLICT OF INTEREST SITUATIONS AND RESOLVED CONFLICTS:

The Stakeholder Associate of a manager is employed in another department and is removed from any reporting relationship involving the manager. (Conflict resolved.)
A Hospital therapist operates a private employee assistance program service for a local company. (No conflict, unless job performance suffers as a consequence.)
A purchasing agent solicits gifts for a Hospital golf tournament from suppliers who conduct business with the Hospital and discloses all pertinent information to his/her immediate supervisor and advises the suppliers that the gift will play no role in the award of business. (Conflict declared and resolved.)
An Employee, Researcher, or Member of the Medical/Dental/Midwifery staff engages in a working lunch paid for by a supplier where the purpose of the lunch was to conduct Hospital business. (No conflict where such hospitality is within the bounds of propriety, a normal expression of courtesy, or within the normal standards of hospitality and as such is not likely to cast suspicion on the Employee's objectivity and impartiality.)
A specialist participates in a site visit paid for by a potential supplier in the context of a Hospital sanctioned purchasing process. (No conflict.)
An Employee has a business or part-time job that does not compete or interfere with Hospital responsibilities. (No conflict.)
A Board Member who operates a local business and bids on a Hospital tender, declares the conflict of interest, absents him/herself from any and all discussion related to the award of the tender and refrains from any vote on the matter. (Conflict resolved.)
A Board Member submits the name of a Stakeholder Associate that he/she perceives as a good prospective Employee to the CEO. (Members of the Board of Directors, as well as other Stakeholders are a valuable source of referrals in recruitment. In the case of the Board Member, making the CEO or his/her designate as the pivot for such recommendations from Members of the Board of Directors eliminates the appearance of conflict.)

Appendix II

SUNNYBROOK HEALTH SCIENCES CENTRE
CONFLICT OF INTEREST POLICY
ANNUAL DECLARATION FORM

Introduction:

Reference is made to the attached Conflict of Interest policy (Policy No. II-C-1000). Terms with initial capital letters in this Annual Declaration Form have the same meanings as set out in the Conflict of Interest policy. Members of the Board of Directors are required to complete, sign and deliver this Annual Declaration Form to the Chair of the Board, and all other Stakeholders indicated are required to complete, sign, and deliver this Annual Declaration Form to the President and Chief Executive Officer. If you have any questions concerning this Form or the Conflict of Interest policy, please contact the appropriate level of authority as set out in the Policy.

I am: [Check the appropriate box(es)]

__ a member of the Board of Directors of Sunnybrook

__ a member of a Committee of the Board of Directors of Sunnybrook

__ a member of the Medical Staff with administrative responsibilities

__ an Executive Vice President of Sunnybrook

__ a Vice President of Sunnybrook

__ a Director of Sunnybrook

I declare that:

a. I have read the attached Conflict of Interest policy.
b. I acknowledge that I am bound by the Conflict of Interest policy, including the disclosure requirements that apply to me.
c. At the present time, [Check the appropriate box]

__ Neither I nor any of my Stakeholder Associates are in a conflict of interest situation nor am I aware of any fact situation which could give rise to a conflict of interest.

__ I or one of my Stakeholder Associates is in a conflict of interest situation or a potential conflict of interest situation and I have notified the appropriate level of authority as set out in the Conflict of Interest policy.

d. I understand and acknowledge that my failure to comply with the Conflict of Interest policy will be considered a breach of my obligations to Sunnybrook and may result in my removal or termination.

__________________________________________________________________________
Signature

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PRINT NAME

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Date yy/mm/dd