ARTICLE 9 CONFLICTS OF INTEREST
( a ) All those involved in credentialing , privileging , and professional practice evaluation activities must be sensitive to potential conflicts of interest to be fair to the individual whose request is being considered or whose qualifications are under review , to protect the individual with the potential conflict , and to protect the integrity of the process .
( b ) It is also essential that peers participate in credentialing , privileging , and professional practice evaluation review activities for these activities to be meaningful and effective .
( c ) An assessment of whether a conflict of interest exists will be interpreted reasonably by the persons involved , taking into consideration common sense and objective principles of fairness . Conflict of Interest Guidelines , which are attached as Appendix C to this Manual , may be used as guidance in addressing potential conflict of interest situations , including whether and how an individual may participate .
( d ) When performing a function outlined in this Manual , or any of the other medical staff governance documents , if any member has or reasonably could be perceived as having a conflict of interest or a bias , that member will not participate in the final discussion or voting on the matter and will be excused from any meeting during that time . However , the member may provide relevant information and may answer any questions concerning the matter before leaving .
( e ) Any member with knowledge of the existence of an actual or potential conflict of interest or bias on the part of any other member may call the conflict of interest to the attention of the Chief of Staff ( or Vice Chief of Staff if the Chief of Staff is the person with the conflict ), CMO / VPMA , or applicable department chair / section chief , or committee chair .
( f ) Additionally , members are obligated to notify the Chief of Staff , CMO / VPMA , or applicable department chair / section chief or committee chair of any known or suspected conflicts of interest of those who are involved in reviewing a matter . Any potential conflict of interest that is not timely raised will be deemed to be waived .
( g ) The Chief of Staff , or applicable department chair / section chief or committee chair , will make a final determination as to whether the provisions in this Article should be triggered or may submit the issue of whether there is a conflict of interest to a vote of the entire committee or department .
( h ) The fact that a member is in the same specialty as a member whose request is being considered or performance is being reviewed does not automatically create a conflict .
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