Conflict of Interest as of August 2002
Steps to be Performed
Prepared By Workpaper
Obtain a list of those personnel with purchasing capabilities in
the system from Information Services. From that list, prepare
a list of personnel with primary purchasing responsibilities
based on job function and position within the organization.
Verify individual positions with various departments as
Compare current lists to prior lists to ensure completeness.
Obtain the list of recipients of the last mailing of conflict of
interest forms, including all administrators, physicians, and
Also obtain a list of the current Board Members from Risk
Management as well as their current places of employment.
A. Compare recipient list to the list compiled in Step 1 for
completeness and accuracy. Determine whether
recipient list is compliant with Conflict of Interest
Policy for adequate coverage.
B. Determine if any Board Members are employed at
businesses that are current vendors with SLEH.
Document the relationship as well as the year-to-date
expenses paid to the vendor.
Review all conflict of interest forms received back from
recipients by Risk Management. Document whether a
disclaimer or disclosure was indicated. Document all gifts,
trips, services, etc. received including
A. what was received
B. when it was received
C. from whom it was received
D. value (estimate if actual value is not available)
E. the relationship between organization and the vendor
F. year-to-date expenses paid to the vendor
A. Determine whether gifts, trips, etc. received were
allowable per policy.
B. Determine whether gifts, trips, etc. received were
approved and documented properly prior to acceptance,
per policy. Obtain written approval backup from
recipient or Risk Management.
St. Luke's Episcopal Health System Internal Audit Department