This policy provides guidelines and mechanisms for dealing with potential, actual or perceived conflicts of commitment and interest to ensure that the Ralph Lauren Center for Cancer Care (“RLCCC or The Center”) employees and Board Members conduct their clinical and administrative activities in a fair and unbiased manner. Thus, an integral part of this policy is disclosure by individuals of their commitments, financial interests and activities.
The Center, its Board of Directors and its employees have a shared interest in assuring the integrity of RLCCC as well as the personal and professional integrity of its employees. RLCCC is committed to maintaining the highest standards of excellence in patient care and welfare. Because of the integrated nature of the healthcare industry and the corresponding multitude of relationships that may lead to, or result in conflicts of interest and/or commitment, RLCCC requires all employees and Board Members to complete a Conflict of Interest and Conflict of Commitment Disclosure Form in accordance with this policy.
Employees and Board Members owe their Primary Commitment to Center activities and responsibilities, and hence, RLCCC employees and agents must act in RLCCC’s best interests, and must not permit any Secondary Commitments to an outside organization, entity or project to jeopardize this Primary Commitment. A Conflict of Commitment occurs when RLCCC’s mission or activities are compromised by one or more Secondary Commitments. For example, a Conflict of Commitment would occur if, as a result of participation in an outside organization, entity or project, an individual’s primary professional loyalty were not to RLCCC.
A Conflict of Interest arises whenever the individual’s professional obligations or judgment owed to RLCCC and its constituencies are compromised by, or could be perceived as being compromised by, his or her Secondary Commitments or Financial Interests. A Conflict of Interest depends on the situation and not on the character of the individual. For example, employees who make decisions about purchasing or contracting for goods or services received by RLCCC should not have relationships with, or Financial Interests in, outside Vendors or suppliers that conflict with, or appear to conflict with, their duty to act in the Center’s best interests when purchasing or contracting on behalf of RLCCC.
- Disclosure: All employees and Board Members must complete a Conflict of Interest and Conflict of Commitment Disclosure Form (COI Form) on an annual basis (by January 31 of each year). Newly hired employees and newly appointed Board Members must submit a Conflict of Interest and Conflict of Commitment Disclosure Form within the first month of employment, and must thereafter comply with the annual filing deadline of January 31. The COI Form requires the individual to report any and all, Leadership Roles, Secondary Commitments and Financial Interests. In addition, this form requires the individual to report any and all Leadership Roles, Secondary Commitments and Financial Interests that the individual’s Immediate Family may have that could reasonably be expected to affect, or appear to affect, the professional judgment of an individual. Individuals must submit completed disclosure forms to the Compliance Officer. The Compliance Officer (in consultation with the employee’s direct supervisor where appropriate) will review and forward (i) the completed COI Form, (ii) a report that includes recommendations concerning the management of any disclosed conflicts, and (iii) a list of the names of individuals who fail to provide a disclosure form to the Compliance Committee.
- Updating: If at any time over the course of the year one or more Leadership Roles, Secondary Commitments or Financial Interests of an employee or Board Member (or their Immediate Family) changes in any material way, the individual must promptly provide an updated COI Form in accordance with the procedures described in Paragraph (1).
- Confidentiality: All financial and other confidential information disclosed to the individuals described in Paragraph (1) will be maintained, to the extent practicable, in strict confidence. The Compliance Committee and CEO may disclose such information only to other employees or agents to carry out the purpose of this Policy. No other uses or disclosures of the financial and other confidential information of an individual will be permitted, unless required by law.
- Review by the Compliance Committee: As promptly as practicable after the January 31 filing deadline (or submission by a new employee/Board Member), the Compliance Committee will review the disclosure forms and reports. The Compliance Committee may ask that an employee / Board Member who has a potential conflict provide additional information or discuss the matter with the Compliance Committee in person. The Compliance Committee will examine disclosed conflicts to assess the degree of risk they carry to Primary Commitments and Professional Interests. The Compliance Committee will endeavor to work with the individual to manage, reduce or eliminate any identified conflicts. When necessary, the Compliance Committee will require that the individual comply with a particular strategy for managing a conflict.
- Compelling and Necessary Exceptions: The Compliance Committee may consider “compelling and necessary” exceptions that would allow an individual for whom an actual Conflict of Commitment or Conflict of Interest has been determined to exist to maintain their Leadership Role, Secondary Commitment or Financial Interest with appropriate oversight and controls to safeguard the reputations and integrity of RLCCC and its employees.
- Management or Elimination of Conflicts of Commitment and Conflicts of Interest: The Compliance Committee’s management strategy will be based upon an assessment of the nature, scope and severity of the Conflict of Commitment or Conflict of Interest. The primary methods of controlling or managing identified Conflicts may include:
- Modifying the responsibilities of the conflicted individual
- Reducing the conflict by reducing or altering the Leadership Role, Secondary Commitment or Financial Interest (i.e., partial divestiture or sequestration of one or more Financial Interests, reduction of time spent in furtherance of one or more Leadership Roles or Secondary Commitment)
- Eliminating the conflict by eliminating the Leadership Role, Secondary Commitment or Financial Interest (i.e., total divestiture or sequestration of one or more Financial Interests, resignation from one or more Leadership Roles or Secondary Commitment)
- Appeal of Compliance Committee’s Decision: An individual who disagrees with the Compliance Committee’s findings or required management strategies may appeal in writing to the CEO. A copy of the appeal must be sent to the Compliance Officer and Compliance Committee. The CEO may agree with the Compliance Committee’s findings and/or management strategy, or may amend such findings and/or strategy. The CEO shall promptly notify the individual and the Compliance Committee in writing of the conclusions of their review, including the actions that must be taken by the individual to comply with this policy. Upon receipt of the CEO’s written report, the individual must promptly comply with the actions specified in that report.
- Disclosure Audit: At the request of the Compliance Committee, an individual may be audited for the purpose of verifying whether the individual truthfully and accurately disclosed his or her Leadership Roles, Secondary Commitments and Financial Interests in the annual Conflict of Interest and Conflict of Commitment Disclosure Form (and in any updates thereto), and for the purpose of verifying whether the individual is complying with the actions, if any, that were specified in the written report of the Compliance Committee (or the CEO where there has been an appeal).
- Sanctions for Non-Compliance: An employee who fails to file a completed Conflict of Interest and Conflict of Commitment Disclosure Form by the deadline, who intentionally fails to disclose or mischaracterizes a potential conflict or who fails to comply with any other action specified by the Compliance Committee or CEO, will be subject to potential sanctions in accordance with applicable RLCCC policy and procedures. These sanctions may include written warning, suspension and/or termination.
- Financial Interest: Aggregate investments (whether in the form of debt, stock or other equity ownership, options or warrants to purchase stock or other
securities or similar instruments) with a value exceeding $10,000 or representing a five percent (5%) or greater interest in any entity, enterprise or trust; royalties on any patent or other intellectual property interests with a value exceeding $10,000, unless paid by RLCCC; or income, salary or remuneration in cash or in kind, emoluments, benefits, gifts, honoraria, travel expenses, goods or services with a value exceeding $10,000. Financial Interest does not include holdings in mutual funds or other equity funds in which the day-to-day control of investments is held by a person not subject to RLCCC’s Conflict of Interest policy.
- Immediate Family: Spouse or domestic partner, children and other dependents, natural or adoptive parents, siblings, stepparent, stepchild, stepbrother or sister, father-in-law, mother-in-law, daughter-in-law, son-in-law, brother-in-law, sister-in-law, grandparent, grandchild and spouse of grandparent or grandchild.
- Leadership Role: Employment, consulting in any administrative or executive capacity, or serving as (i) a member of a Board of Trustees, Directors or Compliance Committees, (ii) an Officer or (iii) a member of a CEO, advisory board or subcommittee of a Board of Trustees, Directors or Compliance Committees, whether compensated or non-compensated.
- Professional Interests: Academic, personal, professional and/or institutional integrity, patient safety and welfare, or any other interest that may be added to this policy from time to time.
- Primary Commitment: The time, energy and loyalty that Staff and Board Members are required to dedicate to RLCCC.
- Secondary Commitment: Activities that are not part of the Primary Commitment, which include but are not limited to employment, consulting or participation in outside businesses or organizations. The time, energy and loyalty that Staff and Board Members dedicate to outside Leadership Roles and other compensated or non- compensated extramural activities. Secondary Commitments do not include personal activities conducted on holidays, vacations and weekends.
- Vendor: Any individual, business, partnership, corporation or other entity that sells or conveys goods or services to RLCCC.