The hospital addresses conflicts of interest and ethics.

(1)

The governing body, senior managers, and leaders of the organized medical staff work together to define in writing conflicts of interest that could affect safety and quality of care, treatment, and services.

(2)

The governing body, senior managers, and leaders of the organized medical staff work together to develop a written policy that defines how conflicts of interest will be addressed.

(3)

Conflicts of interest are disclosed as defined by the hospital.

(4)

Senior managers and leaders of the organized medical staff work with the governing body to develop and implement an ongoing process for managing conflict among leadership groups that has the potential to adversely affect patient safety or quality of care.

(5)

The hospital develops and implements a process that allows staff, patients, and families to address ethical issues or issues prone to conflict.