Conflicts of Interest

Ray Barishansky is a featured speaker at EMS World Expo 2015, September 15–19 in Las Vegas, NV. Register today at EMSWorldExpo.com.

Ed's Note: Since the story referred to below appeared, Los Angeles Mayor Eric Garcetti, responding to a barrage of criticism about a Fire Department hiring system that eliminated thousands of qualified applicants, announced that he is scrapping the process.

Recently, while looking at the EMS World website, an article caught my eye. Titled L.A. Fire Commanders Reassigned in Wake of Recruitment Scandal, it spoke of the competitive process to become an L.A. firefighter/paramedic and how the latest fire academy recruit class contained family members of two of the top officials who have the responsibility of choosing who gets into the academy. 

Here was one of the largest EMS agencies in the country being accused of nepotism, and one of the first thoughts I had was to wonder, how does this happen in this day and age of policies and procedures about conflicts of interest in the EMS world? It should be stated that, like all of us, the personnel mentioned in this piece are to be considered innocent until proven guilty.   

Although this particular article on EMS World dealt with the potential issue of nepotism and the conflict of interest that may have arisen, there are various types of conflicts of interest. They can include, but are certainly not limited to, those related to financial concerns, those related to personnel actions and those related to board members voting on issues in which they have an interest.

Definition

One definition of a conflict of interest is as follows: “A term used to describe the situation in which a public official or fiduciary who, contrary to the obligation and absolute duty to act for the benefit of the public or a designated individual, exploits the relationship for personal benefit, typically pecuniary.”¹

The American College of Emergency Physicians (ACEP) has an expansive conflict of interest policy which states, “Conflicts of interest arise when participants in positions of responsibility have personal, financial, business, or professional interests or responsibilities that may interfere with their duties on behalf of ACEP. The immediacy and seriousness of various conflicts of interest situations differ. Of basic importance is the degree to which the interest would tend one toward bias or pre-disposition on an issue or otherwise compromise the interests of the College.” ACEP's policy goes on to state that, “All individuals who serve in positions of responsibility within the College need not only to avoid conflicts of interest, but also to avoid the appearance of a conflict of interest,” and goes further in asking key leaders to fill out a disclosure statement with information on positions of leadership with other entities, positions of employment, various financial interests and other areas that could potential cause, or be seen as causing, a conflict.

Policies and more

EMS-specific conflicts of interest can arise from a multitude of areas including, but not limited to:

• A director or purchasing agent purchasing supplies or equipment from an organization that is providing him/her with some benefit
• A supervisor or manager supervising a relative or someone with whom they are in a relationship
• EMS employees who have employment with other EMS agencies or other EMS-related entities 
• A regional or state council board member who works for one EMS agency voting on issues that can impact a competitor

As mentioned, perhaps one of the most common areas of conflict of interest involves personnel—this means volunteers as well as career providers. These conflicts can include supervisors or managers not representing an EMS agency’s interest due to their own interests; a medical director making equipment determinations for an agency while having a professional relationship with the equipment manufacturer; or a supervisor or manager making personnel determinations in regard to a relative or someone with whom they are in a relationship. This last example is one that seems to come up often; EMS is very often a family affair, both lateral and generational. Good managers should try to predict things and prepare their employees who may be looking to promote at some point in the future that it may affect their candidacy, and they should discuss that with their spouses, future spouses or family members.

Although there is no tried and true recipe for avoiding a conflict of interest, one of the critical factors in ensuring that a potential conflict of interest situation is understood is the establishment of policies and procedures that clearly outline which areas are to be considered a conflict, how the conflict should be handled, and in the case that the policy isn’t followed, how that will be dealt with. As with all policies, these should be disseminated to all agency personnel and these specific policies should be as expansive as possible with specific elements including examples of real or potential conflicts and a direction for employees to follow in case of a real or potential conflict.

A good example of the aforementioned is the Solano County EMS Agency conflict of interest policy. This policy includes relevant definitions and references to California State Administrative code on conflict of interest. It additionally outlines areas to be aware of when contemplating potential conflicts of interest.² The Dakota County (MN) EMS Advisory Council’s policy on conflict of interest speaks specifically to situations where the member, or the member’s immediate family member, has a financial interest in the outcome or decision of the EMS Advisory Council.³

Another element of assuring you don’t fall into the “conflict of interest” pitfall is the establishment of a well-thought out EMS agency code of ethics, developed in consultation with your EMS agency legal counsel. This code could include areas such as issues of confidentiality, patient autonomy and consent. This type of code can potentially spell out the extent to which such conflicts should be avoided, and what the parties should do where such conflicts are permitted by a code of ethics (disclosure of relationship, recusal from a particular vote, etc.)

Additional points to consider

One of the areas that is more nebulous than an actual conflict of interest is the air of impropriety that can occur; this is analogous to the “where there is smoke, there is fire” scenario. In regard to ensuring that an air of impropriety does not occur, you may want to implement some of the following tips:

• Make sure all employees (line, supervisory, managerial and executive) understand the agency’s conflict of interest policy and know who to go to if they feel they have questions. 
• When voting on issues, ensure that meeting minutes reflect when a board member discloses that s/he has a conflict of interest and how the conflict was managed—for example, that there was a discussion on the matter without the board member in the room, and that a vote was taken but that the “interested” board member abstained. (Board members with a conflict are “interested,” while board members without a conflict are “disinterested.”)    
• Many entities circulate a questionnaire each year to find out whether any board members or staffers have a conflict of interest. Typically, the questionnaire asks board and staff members to disclose existing conflicts, reminds them of any policies that may exist and reminds them to disclose any that may crop up in the future.

Conclusion

Clearly, conflicts of interest should be mitigated against and avoided as much as possible. However, we all know that there will be specific circumstances that even the most exhaustive policy may not cover.

It’s critical to not only be aware of actual, definitive conflicts of interest, but to also avoid any air of impropriety that may paint you and your EMS agency in a bad light. To this point, a follow-up news article regarding this article's opening scenario outlined how there may not have been an actual conflict of interest but the fire chief moved the personnel involved while investigating. He is quoted as saying, “Nepotism may not have played a role in the recruitment of firefighters, but having the appearance of favoritism may have been just as bad.”⁴

References

1. The Free Dictionary. Conflict of interest, legal-dictionary.thefreedictionary.com

2. Solano County Health & Social Services Dept. Conflict of interest policy,www.solanocounty.com

3. Dakota County. Bylaws of the EMS Advisory Council, www.co.dakota.mn.us

4. Walton, A. LA fire chief reviews nepotism accusations for department under scrutiny. Southern Calif. Public Radio, www.scpr.org

Raphael M. Barishansky, MPH, MS, CPM, is director of EMS for the Connecticut Department of Public Health. A frequent contributor to and editorial advisory board member for EMS World, he can be reached at rbarishansky@gmail.com.