EM PL OY EE FOR M S
153 January 1, 2014
Once again, it is time for designated employees to complete the annual Conflict of Interest Questionnaire. Indiana University Health’s policy on “Standards of Conduct for Business Practices” specifically addresses conflicts of interest and the need for everyone associated with Indiana University Health to uphold the highest ethical standards in our business practices. Sometimes, what appears innocent to us may raise questions to someone else. The annual identification of potential conflicts of interest helps us maintain Indiana University Health’s good reputation in the community.
All exempt (salaried) employees at a manager level or above must complete a Conflict of Interest Questionnaire on an annual basis. Non-exempt (hourly) employees in areas where there is a high degree of vendor involvement, purchasing, marketing, billing financial activity, etc., may also be asked to complete the form, as necessary. Physicians who provide administrative or management services to Indiana University Health in return for direct or indirect compensation are required to complete and return the questionnaire. In addition, all employees are required to complete the questionnaire if they find themselves in a situation that is described in the Conflict of Interest Policy.
Please read the policy and questionnaire carefully. Of course, you may contact Compliance Services with specific questions. People will often ask whether or not something needs to be disclosed. The best rule of thumb is to disclose a situation if you have any question about it. You will not be disciplined for disclosing a potential conflict. However, if you have a conflict situation and you fail to disclose it on the Conflict of Interest Questionnaire, you may be subject to disciplinary action.
There are a total of five sections on the following questionnaire. If there is nothing to report for a particular section, indicate that fact by checking “None” in the space provided. Read over the Declaration Statement and sign the form after completing it. If issues are being reported, the questionnaire should be reviewed and signed by your immediate supervisor prior to being submitted to Compliance Services (Wile Hall 345).
Additional forms are located on the Pulse page under “Forms” within the Legal/Compliance section, as well as under
“Departments” within the Compliance Services section. The deadline for returning the questionnaire to compliance Services is March 31, 2014. Even if there are no conflicts to report as of March 31, your signed questionnaire must be returned to Compliance Services noting as much. Then, as situations occur as noted in the policy, contact Compliance Services to determine the method of disclosure that would be appropriate for that situation.
If you have questions, please call Rasma Kancs, Director – Compliance Services, at 962-1732 or Pam Hyde, Administrative Assistant – Audit & Compliance Services, at 962-1425.
I appreciate your cooperation in this very important matter.
Sincerely yours, Mary Beth Claus
Conflict of Interest Questionnaire
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One of the most important assets of a health care organization is its reputation in the community. Repu- tation is based not only on the medical care that is provided, but also on the community’s perception of the integrity of the organization and its personnel. Although dualities of interest are unavoidable, through disclosure of personal interests, Indiana University Health is able to appropriately manage Conflicts of Interests. Throughout this Questionnaire, each masculine pronoun or adjective includes the feminine, as well as the masculine. This Questionnaire is issued under Indiana Universi- ty Health’s Conflict of Interest Policy, ADM 1.86 (“Policy”).
Indiana University Health Representatives (defined as Indiana University Health em- ployees and contracted personnel, including employed physicians and paid medical di- rectors) at the level of manager and above, together with every other person designated each year by the Indiana University Health Compliance Services Department must complete, sign, and submit a Questionnaire to Compliance Services by March 31.
Indiana University Health Business Partner: An individual or entity of any nature from which Indiana University Health purchases or to which Indiana University Health sells merchandise, materials, equipment, services, or supplies, including any construction or equipment contractor or subcontractor and any equipment or facility lessor or lessee and any medical group contracting with Indiana University Health to receive or provide services, and any individual or entity that you know (or should know) to be attempting to engage in such a transaction with Indiana University Health. (This definition includes an em- ployee or representative acting on behalf of an Indiana University Health Business Partner).
Indiana University Health Competitor: An individual or entity of any nature that offers or sells any of the products or services of- fered or sold by Indiana University Health (including an employee or representative acting on behalf of an Indiana University Health Competitor).
Conflict of Interest: An Indiana University Health Representative’s personal or other outside interest or affiliation that may unduly influence, or appear to unduly influence, a decision by or on behalf of Indiana University Health or an Indiana University Health patient, or when an Indiana University Health Representative or his Family Member (defined as a person’s spouse, domestic part- ner, child, parent, brother, sister, or other individual residing in a person’s home) might benefit, or appear to benefit directly or indi- rectly through another individual or organization by virtue of an Indiana University Health Representative’s position with Indiana University Health or by using the authority or benefits of that position.
Significant Ownership Interest: An aggregate interest of an Indiana University Health Representative, together with all interests of all of his Family Members, of more than a) one percent (1%) of the outstanding ownership of a corporation or other entity, or b) five percent (5%) of the total assets of an Indiana University Health Representative or his Family Members.
1. Please respond to each of the questions. Include a description of each interest with sufficient detail to allow an evaluation of a possible Conflict of Interest. Include the identity of Family Members when their interests are disclosed.
2. Check NONE if you have no interests to report.
3. If you need more room to complete the form, attach additional pages to the back, including the relevant number for the disclo- sure.
4. If issues are being reported, the questionnaire should be reviewed and signed by your immediate supervisor, prior to being sub- mitted to Compliance Services.
5. Submit the completed Questionnaire to Compliance Services, preferably by e-mail in .pdf format to [email protected]. 6. Refer to the Policy for additional guidance or direct questions to Compliance Services personnel (317.962.1425).
1. Significant Ownership Interests. List and describe all Significant Ownership Interests held by you or any Family Member in an Indiana University Health Business Partner or Indiana University Health Competitor. An interest may be in the form of stocks, bonds, partnership, or other ownership. Do not disclose any interest held by way of an Indiana University Health-sponsored retirement or savings plan. NONE ____
Policy Statement
Persons Required to Disclose
Definitions
Instructions
Conflict of Interest Questionnaire
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Description of Interest(s) (1) Interest (2) Extent of Interest (3) Value of Total Value
Table Instructions:
(1) Include the name of the corporation or entity.
(2) For each corporation or entity listed, identify the type and relevant percentage of interest held (e.g. stocks, bonds, ownership). (3) For each corporation or entity listed, identify the value of the interest held by you and each Family Member.
2. Positions of Influence. List and describe all positions of governance, employment or other influence in an Indiana University Health Business Partner or Indiana University Health Competitor that is held by you or your Family Members. Examples include, but are not limited to, positions of director, officer, consultant, or employee of an Indiana University Health Business Partner or
Competitor. NONE ____
Description of Position(s) (1) Person Holding
the Position (2)
Table Instructions:
(1) Provide a description of the position of influence. It is not necessary to disclose salaries or compensation paid to Family Members by Indiana University Health Business Partners or Competitors.
(2) Include the name of the individual holding the position.
3. Proprietary Information. List and describe all of a) your uses, or planned uses, and b) your disclosures or planned disclosures to an Indiana University Health Business Partner or Indiana University Health Competitor, of confidential Indiana University Health business information that resulted in, or could result in, personal benefit to you or your Family Members. NONE ____ Description of Use(s) or Disclosure(s)
Table Instructions:
Briefly describe the confidential Indiana University Health business information that was a) used or may be used, or b) disclosed or may be disclosed to an Indiana University Health Business Partner or Competitor. Include a description of the personal benefit to you or your Family Members resulting from or expected to result from the use or disclosure. Examples of such uses or disclosures include using or disclosing knowledge about Indiana University Health’s plans to build facilities or to acquire real estate, confiden- tial marketing strategies, plans to purchase services or supplies from an Indiana University Health Business Partner, or other Indiana University Health business secrets.
4. Gifts, Gratuities and Entertainment. For you and your Family Members, list all items of value received directly or indirectly from any Indiana University Health Business Partner or Indiana University Health Competitor that you know (or could reasonably be expected to know) were either a) intended to influence your decision or action on behalf of Indiana University Health or b) irrespec- tive of an intent to influence you, total more than seventy-five dollars ($75) in value in a single calendar year. Items of value include, but are not limited to payments, fees, gifts, services, loans, travel, education, entertainment, or other favors. You need not count items of nominal value (e.g., an occasional cup of coffee, soda, donut, or notepad). NONE ____
Conflict of Interest Questionnaire
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Item of Value (1) Value (2)
Table Instructions:
(1) Include the name of the Indiana University Health Business Partner or Competitor that gave the item of value, a description of the item of value and to whom it was given.
(2) Provide a measure of the value of the gift, gratuity, favor, etc. Entertainment tickets are valued at face value.
5. Other Interests. List and describe such direct and indirect personal interest, in addition to those described above, that you or your Family Member have that may constitute, or reasonably appear to constitute, an inappropriate or questionable Conflict of Interest. NONE ____ Description of Interest(s)
Table Instructions:
Describe any personal interest of yours or your Family Member that an objective observer might reasonably perceive as unduly affecting your action or judgment on behalf of Indiana University Health or Indiana University Health’s patients. Examples in- clude, but are not limited to, the receipt of royalties or commissions from an Indiana University Health Business Partner or Com- petitor. Do not include Conflicts of Interest that are unavoidable or cannot reasonably be perceived as inappropriate (e.g., a physi- cian’s receipt of professional fees from patients).
I hereby acknowledge that I have access to Indiana University Health ADM 1.86 policy on Conflict of Interest. I represent that I have completed this Questionnaire truthfully and to the best of my ability in accordance with my current knowledge and under- standing. I understand that I must supplement this Questionnaire in writing if after its submission to Compliance Services a situ- ation arises, or may reasonably be expected to arise, that would change my answers or information if the situation had existed or been anticipated at the time I completed the original Questionnaire.
Indiana University Health
Representative Signature Name (please print legibly) Date Indiana University Health
Representative’s Position Department/Organization
Supervisor Signature Name (please print legibly) Date
The supervisor’s signature indicates that the supervisor is aware of the Indiana University Health Representative’s disclosed inter- ests and that the supervisor does not regard the interest(s) as creating a Conflict of Interest that unduly affects the Indiana Univer- sity Health Representative’s actions or judgments on behalf of Indiana University Health or Indiana University Health’s patients. The supervisor’s signature indicates that he is prepared to work with Compliance Services to manage any Conflicts of Interest as may be appropriate.
If the supervisor does not feel comfortable signing the Questionnaire as indicated, then he should notify Compliance Services about his reservations.
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Responsibility Statement and Data Stewardship Agreement
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INFORMATION SECURITY AND CONFIDENTIALITY
Indiana University Health (“IUH”) is committed to protecting the privacy and security of its confidential information. As an IUH physician, employee, workforce member or other system user you play a crucial role in ensuring the privacy and security of this con- fidential information. IUH owns, controls and stores paper, digital and electronic data about services, programs, systems, finances, patients, families, employees, physicians, payers, and other personally identifiable information (“Data”) – most of which is CONFIDENTIAL information. Access to such Data is available through different formats and media and this Statement and Agreement applies to ALL of the data regardless of how it is accessed.
You have requested access as a user of _____________ [application / software system]. As a user and steward of IUH’s Data, includ- ing in some instances protected health information about its patients (“PHI”) – as that term is defined in the HIPAA Privacy Rules – you must agree to the following terms and obligations before being granted access – please read your responsibilities carefully before agreeing to them by signing below:
1) I understand that in order to perform my clinical and administrative duties at IUH I may be granted access to proprietary, patient or protected health information (“Data”). I agree that privacy and security of Data is my personal duty and responsibility.
2) I agree to take reasonable precautions to protect Data from unintentional or unauthorized inquiry, update, alteration, access, use, disclosure, destruction or removal; I understand that such precautions apply both while I am on and off duty.
3) I agree that I will only use, access or disclose Data as minimally necessary for my IUH-related business operations or treatment obligations.
4) I agree that I will protect my identity and passwords to maintain my individual authentication to Data (“credentials”) and will not disclose my credentials to anyone else.
5) I agree that I am personally responsible for completing IU Health’s privacy and security training at least annually [contact IUH’s Human Resources Department if you need access to annual training] and for complying with IUH’s privacy and security policies and procedures.
6) I agree that it is my responsibility to obtain appropriate direction when I am unsure of the confidentiality or security precautions that apply to certain Data.
7) I agree to immediately report known or suspected confidentiality breaches to my manager, the IU Health Trust Line or the IU Health Privacy Officer.
8) I agree not use or disclose IUH’s PHI except as minimally necessary to provide health care to patients, process payments or for authorized health care operations (this does NOT include the use of PHI for research – PHI may be obtained for research through a separate process).
9) I agree to use or access PHI using only IUH owned or approved equipment.
10) I agree not to download or transmit PHI using equipment that is not owned or approved by IUH.
11) Except as otherwise authorized in writing by IUH, I hereby represent that I do not have any IUH PHI in my possession, elec- tronic or otherwise, for any purpose other than direct patient care. (Should I have any IUH PHI in my possession for which I do not have written authorization, I will immediately notify IUH’s Data Management Board.)
12) In order to maintain the integrity of IUH’s Data, I agree that I will not access, disclose, or copy my own PHI, except through a system that is read-only (i.e. for which I do not have update capability).
13) I agree that I will not access PHI of friends or family members except as otherwise permitted (e.g. to provide care as part of my IUH responsibilities or in accordance with a duly executed Authorization to Release form).
14) I will not use or disclose PHI for marketing or fundraising purposes except as specifically approved by IUH.
15) If I must store or transmit electronic PHI for patient care or other IUH authorized purpose, then I shall ensure that it is encrypted at all times (e.g. PHI on any mobile device: thumb drive, smart phone, or laptop computer).
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16) I agree to access PHI using only the credentials I have been given by IUH and that I will keep those credentials confidential. 17) I agree that when my employment, affiliation, privileges, or assignment with IUH ends, I will not take any PHI with me. I
agree to immediately report to IUH any suspected unauthorized use or disclosure of PHI, such as the theft of a mobile device containing PHI or inappropriate use or access.
18) I understand that if I do not maintain the privacy and security of IUH Data and PHI that I may be subject to immediate disci- plinary or corrective action, up to and including suspension or termination of employment or clinical privileges and termination of my access to IU Health systems.
19) I understand that unauthorized use or disclosure of PHI may violate federal or state law and could result in criminal or civil penalties.
I have had the opportunity to read and understand this Responsibility Statement and Data Stewardship Agreement and agree to its terms and conditions as indicated by signing my name below:
____________________________ ____________________________ ____________
Printed Name – User Signature Date
____________________________ ____________________________ IU Health Employee Number (if any) IU/ IUSOM ID Number
____________________________ ____________________________
159
Team Member Handbook Acknowledgement Form
The Team Member Handbook summarizes our policies, procedures, practices and benefits at Indiana University Health. It is not intended to cover everything, nor is it a contract of employment. From time to time changes may be needed, and IU Health reserves the right to make such changes.
I acknowledge and am aware that I can view the Team Member Handbook on Pulse. I agree that as an employee, it is my re- sponsibility to read this handbook. I am to ask questions of my supervisor if I need additional information regarding items covered in the handbook and to abide by and observe any and all of the information, policies, procedures, etc. explained in the handbook. I understand that I am subject to all IU Health policies and procedures, even those which are not outlined in this handbook. I understand that this handbook provides only a summary of the policies, and I have access to the Human Resources (HR) Policy manual through my manager or HR. I also understand that IU Health may periodically change or terminate poli- cies, benefits and procedures, and that I will be responsible to abide by and observe such changes. I understand that this hand- book provides me with both notification and summary plan descriptions of benefit plans and programs.
As a member of the IU Health team, I am committed to meeting and exceeding the Standards of Service. I will also provide feedback and support to our team members as we serve one another and our patients.
I acknowledge that in order to read the 2014 Team Member Handbook for IU Health, I must do so by accessing the Team Member Handbook on Pulse.
Team Member Signature ____________________________________
Date Signed ___________________________________________
Team Member ID Number ___________________________________
Department ___________________________________________
Accounting Unit _______________________________________