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ISLHD PROCEDURE

COVER SHEET

COMPLIANCE WITH THIS DOCUMENT IS MANDATORY Feedback about this document can be sent to [email protected]

NAME OF DOCUMENT

Management of ISLHD Conflicts of Interest and Gifts and Benefits

TYPE OF DOCUMENT

Procedure

DOCUMENT NUMBER

ISLHD CORP PROC 118

DATE OF PUBLICATION

March 2018

RISK RATING

Medium

REVIEW DATE

March 2021

FORMER REFERENCE(S)

ISLHD OPS PROC 118

EXECUTIVE SPONSOR or

EXECUTIVE CLINICAL SPONSOR

Executive Director

Strategic Improvement Programs

AUTHOR

Senior Corporate Governance Co-ordinator

KEY TERMS

Conflicts of Interest, Gifts and Benefits, ethics, accountability, reporting, declarations, online reporting, central register

SUMMARY

This Procedure provides the processes to follow for reporting and managing ISLHD Conflicts of Interest and Gifts and Benefits.

mailto:[email protected]

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ISLHD CORP PROC 118

Revision 2 DX19/411 March 2018 Page 1 of 16

THIS DOCUMENT BECOMES UNCONTROLLED WHEN PRINTED OR DOWNLOADED UNLESS REGISTERED BY LOCAL DOCUMENT CONTROL PROCEDURES

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1. POLICY STATEMENT

This document has been written to support the Ministry of Health Policy - PD2015_045 - Conflicts of Interest and Gifts and Benefits. All members of staff at all sites and facilities of the Illawarra Shoalhaven Local Health District (ISLHD) are required to report any actual, perceived, or potential Conflicts of Interest and any accepted, offered, or considered Gifts and Benefits in the ISLHD Conflicts of Interest and Gifts and Benefits online register.

2. RESPONSIBILITIES

2.1 Staff members will:

Report any perceived, apparent or potential conflicts of interest to their Manager or Supervisor.

Declare any offers or actual gifts and benefits as defined in PD2015_045 - Conflicts of Interest and Gifts and Benefits by informing their Manager or Supervisor.

Receive an automated email as confirmation of their declaration made in the ISLHD Conflicts of Interest and Gifts and Benefits online reporting system. (See 3.2 below for online reporting system details). If a staff member does not hold an ISLHD email account, the Manager or Supervisor will use their own email address on behalf of the staff member. (See section E - ISLHD Online Conflicts of Interest and Gifts and Benefits Reporting System User Guide for further details regarding staff members without email accounts).

2.2 Managers and Supervisors will:

Assist any staff member to complete the online reporting forms in the ISLHD Conflicts of Interest and Gifts and Benefits online reporting system.

Ensure the conflict of interest or gifts and benefits declaration is forwarded to the relevant approving officer for review, approval and/or development of a management plan.

2.3 Approving Officers will:

For Conflicts of Interest: Make a determination and, if required, develop a management plan and then nominate the Tier 2 or 3 for final approval.

For Gifts and Benefits: Review the conflict of interest or gifts and benefits declaration and provide approvals, comments, review dates and any management plans which may be necessary for each declaration.

http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2015_045.pdf


http://sesinet/sites/Internal-Audit/SitePages/Home.aspx?FollowSite=1&SiteName=Internal%20Audit%20%2D%20ISLHD









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Ensure a decision is made and communicated to the staff member within seven calendar days of the declaration date (date submitted). Where it is not possible to make a determination within this timeframe, the staff member concerned is to be kept informed of progress on the matter, in writing.

Ensure a review date is entered in the online form. The review date needs to be 12 months or less from the date of declaration (date submitted).

Provide advice to, and assist, staff with appropriate ways to manage any potential or actual conflicts of interest or gifts and benefits issue.

Monitor the work of staff and the risks they are exposed to, in relation to conflicts of interest or gifts and benefits issues, and regularly discuss these issues with staff.

2.4 Authorised Officers will:

The Director of Internal Audit will review and sign off Conflicts of Interest and Gifts and Benefits Registers annually, to ensure all actions have been completed and identify any trends and/or instances of concern that require further action, and report this to the Audit and Risk Committee.

The Authorised Officers (see ISLHD Delegations of Authority Manual) will ensure all reported conflicts of interest and gifts and benefits are managed effectively.

Undertake assessments of conflicts of interest and gifts and benefits to ensure all matters are being managed in line with the MoH Policy PD2015_045 - Conflicts of Interest and Gifts and Benefits.

Override a decision made by an Approving Officer if it is not appropriate or does not comply with the MoH Policy PD2015_045 - Conflicts of Interest and Gifts and Benefits.

3. REPORTING PROCEDURE

All declarations for conflicts of interest and gifts and benefits will be reported in the ISLHD Conflicts of Interest and Gifts and Benefits online reporting register.

The procedure for reporting declarations is outlined in section E - ISLHD Online Conflicts of Interest and Gifts and Benefits Reporting System User Guide and in the flow charts – sections B and D.

Refer to the Policy Directives in section E – Documentation (below) to ensure compliance with related Policy Directives and ISLHD Delegations.

4. APPEALING DECISIONS

If a staff member disagrees with a decision, the matter is to be discussed between the staff member, the Approving Officer and the Authorised Officer in an attempt to seek a resolution or implement a management plan.

http://islhnintranet/Governance/Delegation_Manual/default.asp









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If, following this discussion, the matter remains unresolved, local grievance procedures are to be followed.

5. DOCUMENTATION

PD2015_045 - Conflicts of Interest and Gifts and Benefits

PD2015_049 - NSW Code of Conduct Policy

ISLHD Delegations Manual

PD2014_005 - Goods and Services Procurement Policy

6. REVISION AND APPROVAL HISTORY

Date Revision

No. Author and Approval

April 2017 1

Drafted by Senior Corporate Governance Coordinator (Author)

Approved by Senior Manager Enterprise Risk, Corporate Strategy & Governance Director and Executive Director Strategic Improvement Programs

February

2018 2

Drafted by Senior Corporate Governance Coordinator (Author).

Approved by Manager, Enterprise Risk Approved by A/Director Corporate Strategy & Governance

7. ATTACHMENTS:

Managing Conflicts of Interest

Flow Chart – Reporting and Managing Conflicts of Interest

Managing Gifts and Benefits

Flow Chart – Reporting and Managing Gifts and Benefits

Online Reporting System User Guide

A. Managing Conflicts of Interest



http://islhnweb/Delegation_Manual/




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Name Managing Conflicts of Interest

What it is The process for Managing Conflicts of Interest in ISLHD.

Who it applies to To all staff working in any permanent, temporary, casual, termed appointment or honorary capacity within ISLHD.

This includes volunteers, patient advocates, contractors, visiting practitioners, students, consultants and researchers, performing work within ISLHD facilities.

Understanding a Conflict of Interest

A conflict of interest exists when it is likely that a staff member could be influenced, or perceived to be influenced, by a personal interest when carrying out their public duty. Conflicts of interest can be actual, perceived or potential.

Conflicts of interest that result in impaired decision making may constitute corrupt conduct or a breach of the PD2015_049 - NSW Code of Conduct Policy.

Having a conflict of interest is not necessarily a problem, it is how it is dealt with that is important. However it should be noted that reporting a conflict of interest is a mandatory requirement as stated in PD2015_045 - Conflicts of Interest and Gifts and Benefits.

What to do Report any actual, perceived or potential conflicts of interest in the Online Reporting System. The Online Reporting System is accessible to all ISLHD staff with computer access.

All Managers and Supervisors are required to assist their direct reports to make any declarations in the online system. Managers should complete the online entry on behalf of any staff who do not have computer access.

Sections B and E explain the steps in making an online report.

The Authorised Officers will collate and report on the District’s








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Register to the Chief Executive.

A copy of the completed register will be made available for review by Internal Audit as required.

When to use it Any staff member who is in a situation that is or has the potential to be perceived as a conflict of interest, whether pecuniary (potential financial gain or loss) or non-pecuniary (non-financial gain or loss), must declare it in the Online Reporting System. Those without computer access will seek assistance from their manager.

The options available to deal with a conflict of interest are dependent on the type of conflict (e.g. pecuniary or non-pecuniary). Refer to section 4 – Managing Conflicts of Interest in PD2015_045 - Conflicts of Interest and Gifts and Benefits.

Refer to MoH Policy - PD2014_005 - Goods and Services Procurement Policy for engagement of suppliers.

How to use it Refer to Sections B and E for detailed steps in using the online reporting system.

Why the rule is necessary

It is necessary to protect the integrity of ISLHD and to comply with PD2015_045 - Conflicts of Interest and Gifts and Benefits Policy.

Who is responsible All ISLHD Staff are responsible for declaring any conflicts of interest in the Online Reporting System or to their Manager or Supervisor directly.

All Line Managers/Supervisors are required to assist staff to complete an online declaration (if requested).

A Line Manager/Supervisor is responsible for:

Reviewing the details in the form

Making an approval determination.

Implementing a management plan, which should be noted in the system.

Nominating the appropriate Tier 2 or Tier 3 Executive











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Approver (details in the online reporting system for the final

approval).

The Executive Approver will:

Review the Line Manager’s decision and action plan.

Make an overall approval determination for the matter.

Ensure a printed copy of the report will be saved in the ISLHD TRIM database within the relevant staff members Personnel File (with confidential and secured access)

References

PD2015_045 - Conflicts of Interest and Gifts and Benefits


ISLHD Delegations Manual

PD2014_005 - Goods and Services Procurement Policy

B. Flow Chart – Reporting and Managing Conflicts of Interest in ISLHD



http://islhnweb/Delegation_Manual/




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C. Managing Gifts and Benefits



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Name Managing Gifts and Benefits

What it is The process for managing gifts and benefits in ISLHD.

What it is not A register to record token gifts exchanged between staff members/colleagues at Christmas, birthdays, baby showers and farewell gifts. Also it is not:

A register for donations – refer to ISLHD Fundraising Guideline.

A register for sponsorships - refer to NSW Health PD2005_415 - Sponsorship Policy

Who it applies to To all staff working in any permanent, temporary, casual, termed appointment or honorary capacity within ISLHD.

This includes volunteers, patient advocates and contractors, visiting practitioners, students, consultants and researchers performing work within ISLHD facilities.

What to do Report the receipt or offer of any gifts or benefits in the Online Reporting System. The Online Reporting System is accessible to all ISLHD staff with computer access.

All Managers and Supervisors are required to assist their direct reports to make any declarations in the online system. Managers should complete the online entry on behalf of any staff who do not have computer access.

Sections D and E explain the steps in making an online declaration.

The Authorised Officers will collate and report on the District’s Register to the Chief Executive.

A copy of the completed register will be made available for review by Internal Audit as required.

When to use it All gifts or benefits, given or offered, to any staff member or group of staff members must be declared in the register. Token or inexpensive gifts (to the amount of $75) may only be accepted if offered as a gesture of appreciation, and not to

../AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.Outlook/I2NBYQ9R/ISLHD%20Fundraising%20Guideline

../AppData/Local/Microsoft/Windows/Temporary%20Internet%20Files/Content.Outlook/I2NBYQ9R/ISLHD%20Fundraising%20Guideline






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secure favour. Acceptance of the gift must be declared, managed and documented in line with PD2015_045 - Conflicts of Interest and Gifts and Benefits.

Disclosures are to be treated as confidential wherever possible. It is the responsibility of the staff member and the Manager or Supervisor, who receives the disclosure, to enter the details into the Online Reporting System.

As a general rule, gifts and benefits offered by commercial organisations should not be accepted and all offers should be declared and reported in the Online Reporting System.

To deal with inappropriate offers of gifts, without causing offence, staff members should politely decline the offer, explaining that acceptance would breach NSW Health policy.

Refer to PD2015_045 - Conflicts of Interest and Gifts and Benefits for full details of gifts and benefits.

How to use it The Online Reporting System is available via the ISLHD Intranet and is accessible by all staff with computer access.

Refer to Sections D and E for detailed steps in using the Online Reporting System and PD2015_045 - Conflicts of Interest and Gifts and Benefits.

Why the rule is necessary

It is necessary to protect the integrity of ISLHD and to comply with PD2015_045 - Conflicts of Interest and Gifts and Benefits Policy.

Who is responsible All ISLHD Staff are responsible for declaring any conflicts of interest in the Online Reporting System or to their Manager or Supervisor directly.

All Line Managers/Supervisors are required to assist staff or to complete an online report (if requested).

A Line Manager/Supervisor is responsible for:

Reviewing the details.

Making an approval determination.
















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Management of the use of the gift or benefit.

Reference

NSW Health Conflicts of Interest and Gifts and Benefits PD2015_045


ISLHD Fundraising Guideline






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D. Flow Chart – Reporting Gifts and Benefits in ISLHD



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E. Online Reporting System User Guide

1. Where can I find the relevant information? This information is located on the ISLHD Corporate Governance Services intranet sites, specifically on the following pages:

Conflicts of Interest

Gifts and Benefits To ensure you are fully informed around these issues, it is recommended that you read the fact sheets, guidelines, policies and procedures on these sites before making a declaration.

Note: If a staff member does not have an ISLHD computer account, their Manager or Supervisor is responsible for entering the declaration in the register.

2. The Forms

2.1 Conflicts of Interest Declaration Form (online form)

The online form used to declare a conflict of interest, has mostly mandatory fields as well as drop-down boxes with a selection options. Your relevant Line Manager (as per the ISLHD Delegations Manual) will be required to review this declaration and will provide a decision in line with ISLHD and NSW Health Policy and Procedure. For more information go to the ISLHD Conflicts of Interest intranet pages. If you have difficulties submitting, approving or entering details in any of the forms whilst using Internet Explorer, you can copy the address of the form into Google Chrome.

http://islhnweb/Governance/Conflicts_of_Interest.asp

http://islhnweb/Governance/Gifts_Benefits.asp


http://islhnweb/Governance/Conflicts_of_Interest.asp



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The table below is a guide which clarifies the information that is required in the online form.

Date of Declaration Enter the current date.

Email Address Email address of person making the declaration. If your name is not found automatically, you can search for your name by entering ‘sesahs\XXXXXXXX’ (change XXXXXXXX to your user name).

Surname Surname of person making the declaration.

First Name First name of person making the declaration.

Position/Job Title Current job title of person making the declaration.

Employment Location Employment site, physical work location, Directorate, Unit of person making the declaration.

Conflict of Interest Relates To Use the drop-down options.

Conflict of Interest Details Enter correct company name or full name of individual, address and phone number. Expected roles or duties to be performed (if applicable). Explain the actual or perceived conflict (in detail) and risks associated to ISLHD.

Conflict of Interest Type Use the drop-down options.

Conflict of Interest Type Use the drop-down options.

Line Manager Email Email address of your Line Manager. Line Manager Name The Line Managers name

Line Manager Position The Line Managers Position Title or Description

Once all the details are complete then the "Submit" button should be pressed. An automatic email will be sent to yourself and the Line Manager you nominated in the form. Line Manager’s Approval Section: There are a number of fields which need to be completed by the Line Manager as follows: Decision The decision to approve, not to approve or to

resubmit.

Other Information Any other information relating to the decision.

A Management Plan Every Conflict of Interest declaration should have a management plan. It is the your responsibility as the Line Manager to propose a suitable management plan that will resolve or manage the reported conflict of interest. Examples of management plans are as follows:

For a reported relationship with a supplier, a management plan could be implementing a plan to ensure the reporting staff member has



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no involvement in ordering supplies; in procurement processes or in supplier selection or tendering processes.

Where a staff member is continually asked to recommend private treatment providers and therefore submits a declaration for a 'Perceived Conflict of Interest, a suitable management plan could be introducing a list of local treatment providers to hand out and signage in the relevant areas advising staff are unable to make individual recommendations.

Further examples can be found in Appendix 1

of NSW Health Policy - PD2015_045 ‐ Gifts & Benefits & Conflicts of Interest.

A Date of Review The date of review should be within 12 months of the date of the declaration. An automated email will be sent to the Line Manager on that date to remind the manager to revisit reassess the situation. Any updated circumstances will need to be entered onto a new online form.

A Date of Resolution / Finalisation

of the Conflict of Interest

The date the issue is resolved.

The Executive Approvers Email

(Tier 2 or Tier 3)

Email address of the Executive Director (Tier 2 or Tier 3) who will make the overall decision. For more information on selecting the appropriate manager for approval, refer to ISLHD Delegations Manual.

Executive Approver's Name The Executive Approvers name

Executive Approver's Position The Executive Approvers position title

Once all the details are complete then the "Submit" button should be pressed. An automatic email will be sent to yourself and the Executive Approver (Tier 2 or Tier 3) you nominated in the form. Executive Director Approvers Section (Tier 2 or Tier 3) There are a number of fields which need to be completed by the Executive Approver as follows:

Approval Decision If the decision is ‘resubmit’ the person submitting the form will need to provide more details on a new form and will go through the online approval process again.

Any other information relating to

the decision

Any other information relating to the decision made to approve or not approve

Any comments or details Any comments or details in regarding the Line






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regarding the Line Manager’s

decision

Manager’s decision and/or management plan.

Declaration By submitting the form you agree and understand that the details you supplied will be an official record of your declaration, of a conflict of interest, and that you have complied with the PD2015_049 - NSW Code of Conduct Policy and the PD2015_045 ‐ Gifts & Benefits & Conflicts of Interest.

Print and Sign The Executive Director should ensure a copy of the form is printed and subsequently entered into TRIM with the relevant staff members Personnel file (with secured access). The signature section on the printed form is to be used at the discretion of the Executive Director.

Once all the details are complete then the "Submit" button should be pressed. An automatic email will be sent to yourself, the Line Manger and the person who submitted the form. For any technical issues with the form a Helpdesk request will need to be made. 2.2 Gifts and Benefits Declaration Form (online form)

The online form, to declare gifts and benefits, has mostly mandatory fields as well as drop-down boxes to provide selection options. It is recommended that you refer to the NSW Health - PD2015_045 - Conflicts of Interest and Gifts and Benefits prior to completing this form. Your relevant Line Manager (as per the ISLHD Delegations Manual) will be required to review this declaration and will provide a decision in line with ISLHD and NSW Health Policy and Procedure. For more information go to the ISLHD Gifts and Benefits intranet pages. If you have difficulties submitting, approving or entering details in any of the forms whilst using Internet Explorer, you can copy the address of the form into Google Chrome. Set out in the table below is a guide to clarify the information requested on the declaration form.










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Date of Declaration Enter the current date.

Surname Surname of person making the declaration.

First Name First name of person making the declaration.

Position/Job Title Current job title of person making the declaration.

Employment Location Employment site, physical work location, Directorate, Unit of person making the declaration.

Email Address Email address of person making the declaration. If your name is not found automatically, you can search for your name by entering ‘sesahs\XXXXXXXX’ (change XXXXXXXX to your user name).

Contact Phone Number Phone number of person making the declaration

Organisation or person who offered the gift or benefit

Enter correct company name or full name of individual, address and phone number.

Description of Gift or Benefit Enter a clear and concise description of what was given or offered to you.

Reason for the offer Explain the reason for gift or benefit.

Has the gift or benefit been accepted?

Use the drop-down options.

Is the gift or benefit over or under $75?

Use the drop down options.

Provide a $ amount Enter a known dollar value or estimate.

Comments This field is optional.

The next section of the form is where you enter your Line Manager’s details – for more information on the appropriate manager for approval, refer to ISLHD Delegations

Manual PD2015_045 ‐ Gifts & Benefits & Conflicts of Interest. By submitting the form you agree and understand that the details you supplied will be an official record of your declaration, and that you have complied with the PD2015_049

- NSW Code of Conduct Policy and the PD2015_045 ‐ Gifts & Benefits & Conflicts of Interest. After submitting the declaration an automated email will be sent to you and your Line Manager for review and authorisation. Once your Line Manager has actioned the declaration you will again receive an automated email advising you of the decision/action. For any technical issues with the form, a Helpdesk request will need to be made.






