The Endeavor Health Conflict of Interest and Commitment Policy outlines our commitment to ethical conduct and transparency in our operations, clinical care, research and decision-making.

Endeavor Health Conflict of Interest and Commitment Policy - English (PDF)

Revised and effective as of October 2025.

Section 1: Applicability

This policy applies to all Covered Persons (as defined below) associated with Endeavor Health and its wholly owned subsidiaries (collectively, the “System”). It covers all System activities, including clinical care, research (e.g., clinical, basic science, and translational research), education, administration, procurement, and partnerships, regardless of funding source. This policy addresses Institutional Conflict of Interest/Commitment (COIC), Individual Conflict of Interest/Commitment (COIC), and Financial Conflict of Interest in Research (FCOI).

Section 2: Purpose

The System is committed to maintaining integrity, objectivity, and public trust in its operations, clinical care, research, and decision-making processes. This policy aims to:

  • Ensure that institutional and individual decisions are free from undue influence from financial interests or Outside Activities and prioritize patient care, research integrity, and the public welfare.
  • Safeguard the System’s mission to provide Safe, Seamless, and Personal care by identifying, managing, or eliminating COICs and FCOIs that could compromise clinical, educational, research, or operational activities.
  • Protect the security and credibility of research by mitigating risks of undue foreign influence, as outlined in National Security Presidential Memorandum-33 (NSPM-33).
  • Comply with federal regulations, including Public Health Service (PHS) requirements (42 CFR Part 50, Subpart F), and other sponsor policies to promote objectivity and accountability.
  • Foster transparency through disclosure and management of potential conflicts to maintain stakeholder confidence.
  • Preserve and support the System’s not-for-profit mission.

This policy supplements, but does not replace, Illinois laws governing charitable, not-for-profit corporations, ensuring the System’s activities align with its tax-exempt purposes.

Section 3: Policy Statements

A. The System ensures that all institutional decisions, including those related to research, clinical care, procurement, and partnerships, are made objectively, free from bias caused by Financial Interests or Outside Activities.

B. Covered Persons must prioritize their Institutional Responsibilities to the System over personal or Immediate Family interests, ensuring that their time and expertise are used to support the System’s mission.

C. System resources, names, and trademarks may not be used for personal benefit or Outside Activities without authorization.

D. All Covered Persons must disclose Financial Interests, including Significant Financial Interests (SFIs) and Outside Activities related to their Institutional Responsibilities to identify potential COICs or FCOIs.

E. The System will review disclosures to determine if a COIC or FCOI exists and implement Management Plans to mitigate or eliminate conflicts, ensuring integrity across all activities.

F. Relationships between Covered Persons and their Immediate Family must avoid favoritism or impropriety (e.g., an Investigator may not supervise or review a family member’s FCOI).

G. Extra scrutiny will be applied to FCOIs in research involving human subjects to protect participant safety and informed consent.

H. The System will comply with all federal and sponsor requirements, including PHS regulations and NSPM-33, to manage and report FCOIs and mitigate foreign influence risks.

I. Transparency is promoted by disclosing COICs or FCOIs to relevant stakeholders (e.g., patients, research participants, appointed independent monitors and PIs and decision-makers)to reduce or eliminate bias.

J. Covered Persons must complete mandatory training on COICs, FCOIs, and research security to ensure compliance and awareness.

Section 4: Definitions

  • Aggregate: The consolidated total of monies received from a single Entity (e.g., remuneration, Sponsored Travel, Equity Interests).
  • Authorship: Contributions to publications or presentations from Outside Activities must disclose the individual’s role (e.g., paid consultant) and clarify that the work was not part of System duties. Covered Persons may not publish “ghost-written” materials authored by external entities.
  • Clinical Trials: Studies where human participants are prospectively assigned interventions per a research protocol to evaluate biomedical or health-related outcomes.
  • Compensation Relationship: Receipt or expectation of remuneration, including consulting fees, honoraria, salary, rent, stock options, intellectual property rights, or royalties.
  • Conflict of Interest/Commitment (COIC): A divergence between a Covered Person’s private interests (or those of the System) and their (or the System’s) professional obligations, such that actions or decisions may be, or appear to be, unduly influenced by personal or institutional gain.
  • Contribution: A donation of property (tangible or intangible) to a System entity, including the System Foundations.
  • Covered Person: All System directors, officers, employees, members of the medical staffs, volunteers, Investigators and researchers, whether employed by the System or engaged as external partners.
  • Consulting: A fee-for-service Outside Activity related to a Covered Person’s field or discipline, where they act as an independent contractor to further a third party’s agenda.
  • Disclosure: The process of reporting potential COICs or FCOIs to the System for review and management.
  • Entity: Any corporation, partnership, firm, association, or other non-governmental legal entity organized for profit, nonprofit, or charitable purposes, which engages with or competes against the System.
  • Equity Interest: Stock, stock options, warrants, or other ownership interests in an Entity.
  • Fair Market Value: The price at which property or services would change hands between a willing buyer and seller, in an arm’s length transaction, both with reasonable knowledge and without compulsion to buy or sell, and without consideration of the volume or value of referrals or other business generated between the parties.
  • Financial Conflict of Interest in Research (FCOI): A Significant Financial Interest (SFI) that could directly and significantly affect the design, conduct, or reporting of PHS-funded research, as determined by the System’s designated officials.
  • Financial Interest: A financial relationship involving anything of monetary value, held by a Covered Person or their Immediate Family, including ownership, investment, or compensation relationships.
  • Foreign Financial Interests: Income from foreign entities (e.g., governments, institutions, or organizations) for seminars, lectures, advisory roles, or Sponsored Travel, which must be disclosed regardless of value for research-related activities.
  • HHS: The U.S. Department of Health and Human Services, overseeing PHS and its funding components.
  • Immediate Family: A Covered Person’s spouse, domestic partner, dependents, children, grandchildren, great-grandchildren, siblings, and their spouses or domestic partners.
  • Inside Information: Non-public, material information concerning a publicly traded security.
  • Institutional Conflict of Interest/Commitment (COIC): A situation where the System’s or its Senior Leadership’s financial or non-financial interests could, or appear to, compromise institutional decisions, policies, or mission.
  • Institutional Responsibilities: A Covered Person’s professional duties, including patient care, research, teaching, administration, publication review, or service on System committees, Institutional Review Boards (IRBs), or Data Safety Monitoring Boards.
  • Intellectual Property Rights: Ideas, inventions, creations, or processes derived from intellectual work, such as patents or copyrights.
  • Investigator: An individual named as a principal investigator, co-investigator, or personnel on a Sponsored Project, responsible for the design, conduct, or reporting of research.
  • Manage: Actions taken to mitigate or eliminate bias or risk created by a COIC or FCOI.
  • Management Plan: A documented plan to reduce or eliminate a COIC or FCOI, detailing the activity, its relation to Institutional Responsibilities, mitigation steps, and annual review requirements.
  • National Security Presidential Memorandum-33 (NSPM-33): A 2021 U.S. directive to protect federally funded research from foreign government interference by standardizing disclosure requirements for COICs and FCOIs.
  • Outside Activities: Compensated or uncompensated activities undertaken apart from a Covered Person’s Institutional Responsibilities, such as consulting or board service.
  • PHS: The Public Health Service, part of HHS, responsible for funding research and requires compliance with FCOI regulations under 42 CFR Part 50, Subpart F.
  • PHS Awarding Component: The specific PHS agency (e.g., NIH) that funds a research project.
  • Product: A medical device, implant, pharmaceutical, or other health-related item used inpatient care.
  • Professional Organization: A nonprofit entity advancing a profession, its practitioners, and public interest.
  • Provider: A physician or advanced practice professional.
  • Research: means a systematic investigation, including research development, testing, and evaluation, designed to develop or contribute to generalizable knowledge.
  • Retrospective Review: A process to determine if research was biased due to an undisclosed or unmanaged SFI or FCOI, required for federally funded research.
  • Senior Leadership: Members of the Board of Directors, Chief Executive Officer, Chief Financial Officer, Chief Medical Officer, and other officials with decision-making authority.
  • Significant Financial Interest (SFI): A Financial Interest held by an Investigator or their Immediate Family that meets the following criteria:
    • A. Aggregate remuneration and/or Equity Interests from or in a U.S. or foreign publicly traded Entity ≥ $5,000:
      • For PHS funded Research in the prior 12 months prior to disclosure and the value on the date of disclosure.
      • For non-PHS funded Research during the time the discloser is carrying out the study and for 1 year following completion of the study.
    • B. Aggregate remuneration ≥ $5,000 from a non-publicly traded Entity or nonprofit in the prior 12 months.
    • C. Any Equity Interest in a non-publicly traded Entity.
    • D. Aggregate remuneration ≥ $5,000 from a foreign governmental organization in the prior 12 months.
    • E. Income from Intellectual Property Rights paid by an Entity other than the System.
    • F. Sponsored Travel from an Entity related to Institutional Responsibilities, including purpose, sponsor, destination, and duration (applies to PHS Investigators).
  • SFI Exclusions:
    • A. Remuneration from the System (e.g., salary, royalties).
    • B. Income from Immediate Family unrelated to Institutional Responsibilities.
    • C. Income from Authorship of academic works.
    • D. Income from seminars, lectures, teaching engagements, or advisory roles for U.S. federal/state/local governments, U.S. institutions of higher education, academic teaching hospitals, medical centers, or affiliated research institutes.
    • E. Income from investment vehicles (e.g., mutual funds) where the Covered Person does not control investment decisions.
  • Sponsored Project: An externally funded instruction, research, or service project.
  • Sponsored Travel: Travel expenses paid to or on behalf of a Investigator or their Immediate Family by an Entity, related to Institutional Responsibilities, in a 12-month period (applies to PHS Investigators).
  • Visiting Scholars: Temporary academic appointees engaged in research or scholarly activities at the System, subject to this policy if involved in Sponsored Projects.

Section 5: Procedures

Prohibited Activities

Covered Persons may not:

A. Accept gifts, favors, or benefits that could influence, or appear to influence, decision-making in clinical care, research, procurement, or other System activities.

B. Solicit compensation, gifts, or benefits from actual or prospective customers (e.g., patients, providers, payers, suppliers) that could affect System operations, except for authorized fundraising by System Foundations.

C. Receive free or discounted medical care at System facilities, except as part of standard health insurance or System policies.

D. Use Inside Information to trade securities or share it unlawfully with others, including Immediate Family, including trading System financial instruments (e.g., tax-exempt bonds).

E. Assign intellectual property developed with System resources or as part of Institutional Responsibilities to third parties unless approved in advance by their Executive leader which may include up to and including the System President and CEO, or use System research or confidential information in Outside Activities for preferential access not in compliance with System policy.

F. Use System resources, names, or trademarks for personal benefit or unauthorized Outside Activities.

Acceptable Activities

Covered Persons may:

A. Accept reasonable food and beverages offered to all participants at off-site educational events.

B. Provide token gifts or modest meals to non-federal third parties, provided they do not influence decision-making.

C. Attend occasional local theater or sporting events with a vendor’s representative, if it does not affect System decisions.

Section 6: Disclosure Requirements

A. Annual Disclosure: Covered Persons including Senior Leadership, Investigators, and designated employees must complete an annual Conflict of Interest Questionnaire to disclose Financial Interests, including SFIs, and Outside Activities related to Institutional Responsibilities.

B. Event-Driven Disclosure:

  • Senior Leadership must disclose interests before participating in decisions involving related Entities.
  • Investigators must confirm or update disclosures within 30 days before submitting a Sponsored Project proposal or joining a Sponsored Project.
  • All Covered Persons must disclose Financial Interests as requested annually with disclosures related to Institutional Responsibilities updated as they occur.

C. Disclosure Scope:

  • Compensation (e.g., consulting fees, honoraria, board service).
  • Equity Interests in public or private Entities.
  • Royalties from Intellectual Property Rights.
  • Sponsored Travel (for PHS Investigators).
  • Foreign Financial Interests or affiliations (e.g., lectures, talent programs) for Research-related activities.
  • Other relationships or affiliations material to a potential COIC or FCOI (e.g., board service, familial ties).

D. Exclusions: Disclosures are not required for SFI Exclusions (e.g., System salary, income from U.S. government-sponsored activities).

E. Transparency: Covered Persons unsure about disclosure obligations should err on the side of reporting.

Section 7: Review, Evaluation, and Resolution

A. Review Process: Guidelines are maintained to promote prompt and consistent review and evaluation of disclosures.

  • Institutional COIC: Reviewed by the Corporate Compliance Committee or a subset thereof.
  • Individual COIC: Reviewed by the Corporate Compliance Office, with escalation to the Corporate Compliance Committee if needed.
  • Research FCOI: Reviewed by the Research Conflict of Interest Committee (RCOIC) and Corporate Compliance Office, per PHS regulations.

B. Management Plans: If a COIC and/or FCOI is identified, a Management Plan or multiple Management Plans are developed, which may include, among other mitigations:

  • Public disclosure to stakeholders (e.g., patients, research participants, appointed independent monitors and PIs and decision-makers).
  • Recusal from decision-making or Research activities.
  • Appointment of an independent monitor or Investigator.
  • Modification of activities to minimize bias.
  • Divestiture or reduction of SFIs.

C. Escalation: Disagreements related to disclosure evaluation and Management Plans are escalated to the Corporate Compliance Committee or Board of Directors, as appropriate.

D. Retrospective Review: For undisclosed or unmanaged SFIs in PHS-funded Research, the System conducts a Retrospective Review within 120 days to assess bias, with results reported to the PHS Awarding Component.

E. Subrecipient Compliance: For Sponsored Projects involving subrecipients, the System ensures compliance through written agreements specifying the applicable FCOI policy and reporting requirements.

F. Disclosure Prompting: At meetings involving System resource decisions, the leader prompts attendees to disclose potential COICs, with recusals documented in minutes.

G. Part-Time Investigators: May engage in Outside Activities if separate from Institutional Responsibilities, documented in a Management Plan if needed.

Section 8: Governance and Transparency

A. The Chief Compliance Officer oversees compliance with this policy and federal regulations.

B. Disclosure summaries and Management Plans are reported annually to the Corporate Compliance Committee, System President (for local board members), and President and CEO(for parent company board members). The Chief Legal Officer and Chief Innovation and Transformation Officer receive reports of all disclosures with Management Plans. The Chief Financial Officer and Vice President of Supply Chain Management receive reports of all supplier related disclosures.

C. For PHS-funded research, FCOIs are reported to the PHS Awarding Component:

  • Initial Report: Before expending funds or within 60 days of identifying a new FCOI.
  • Annual Report: With annual progress reports, detailing FCOI status and Management Plan updates.
  • Revised Report: If bias is found during a Retrospective Review.

D. FCOIs are disclosed to study teams and, when required, posted on the System’s website for public access (e.g., part of federal public disclosure requirements).

E. A confidential reporting mechanism (e.g., whistleblower hotline) is available for reporting suspected COICs or FCOIs.

Section 9: Training Requirements

A. Covered Persons must review the conflict-of-interest policy annually, with Investigators also completing FCOI training annually and research security training (including foreign influence awareness) before engaging in Sponsored Projects and every four years thereafter.

B. Additional training is required within 30 days if:

  • The policy is materially revised.
  • A Covered Person is new to the System or a project.
  • Non-compliance with the policy or a Management Plan is identified.

C. The Chief Compliance Officer ensures training implementation and compliance with sponsor requirements.

Section 10: Record Retention

Records of disclosures, Management Plans, and Retrospective Reviews are retained per System policies and sponsor requirements (e.g., at least three years for PHS-funded research per 42 CFR Part 50, Subpart F).

Section 11: Confidentiality and Disclosure to Third Parties

A. Disclosures are treated as confidential, shared only with the RCOIC, Corporate Compliance Office, IRB, or Office of the General Counsel for review and management.

B. COICs or FCOIs are disclosed to relevant stakeholders (e.g., patients, study teams, independent monitors, relevant decision makers) to ensure transparency.

C. For PHS-funded research, FCOIs are reported to the PHS Awarding Component and made publicly accessible as required.

D. Disclosures are not shared externally unless mandated by law or sponsor conditions.

Section 12: Non-Compliance

A. Failure to disclose Financial Interests related to Institutional Responsibilities, including SFIs, comply with Management Plans, or adhere to this policy may result in disciplinary action, including reprimand, suspension, compensation impact, privilege removal, or termination, per System policies.

B. Non-compliance in PHS-funded research triggers a Retrospective Review to assess bias, with results reported to the PHS Awarding Component.

Approvals: System President and CEO

Exhibit A: Relationship with Industry

This exhibit applies to Providers within the scope of their employment or services under contract with the System.

A. Financial Interest: Providers who have a Financial Interest in an entity involved in the provision of goods or services to Endeavor patients are required to disclose the relationship to the patient when ordering drugs, services or devices provided or manufactured by the Entity with whom they have a Financial Interest.

B. Industry Visits:

  • Industry representatives must comply with System vendor certification programs and access Providers only in non-patient, non-public areas by appointment and with a valid business reason. Meals may not be provided on-site.

C. Consulting Arrangements (including paid speaking arrangements):

  • Must meet a legitimate need, be documented in a signed agreement, and provide Fair Market Value compensation.
  • System resources (e.g., personnel, facilities, confidential information) may not be used.
  • If the Provider with a consulting arrangement has research with the third party, the Provider is required to provide the executed consulting agreement for consideration in the conflict-of-interest evaluation.
  • When Providers are involved in Outside Activities not directly associated to Endeavor:
    1. The Provider is prohibited from using their Endeavor Health title or affiliation, using Endeavor Health facilities, creative, branding or proprietaryor patient information or wearing apparel with Endeavor Health branding.
    2. The Provider is responsible for all content developed and discussed, as well as ensuring proper use of intellectual property.
    3. Where possible, it should also be noted “The views expressed are my own and do not reflect the views of my employer.
    4. See the Marketing and Communications for further guidance.

D. Educational Events:

  • Providers may attend industry-sponsored events meeting ACCME/ACGME standards, paying for costs unless approved by the System.
  • Product-specific training is allowed with System approval.
  • Industry funding for System-sponsored events must be in the form of unrestricted grants.
  • Speaking engagements must meet educational standards and disclose financial relationships and follow the requirements of “2. Consulting Arrangements” above and the requirements in the Marketing and Communications Policy.

E. Patient Education Materials:

  • Non-branded materials are preferred; branded materials are allowed for informed consent or patient education.

F. Samples and Equipment:

  • Drug samples are prohibited for inpatients but allowed for outpatient use with proper control.
  • Discounted equipment for evaluation requires Value Analysis Team approval.

G. Charitable Contributions:

  • Industry donations for medical missions or clinics must be approved and not stored at System sites unless authorized.

H. Decision-Making:

  • Providers with Financial Interests in an Entity that produces or develops pharmaceuticals, medical devices/equipment and/or other healthcare related products or services may provide clinical input but must recuse themselves from voting on procurement, contracting or affiliation-related decisions. If the System elects to use a supplier in a specific contract or category, but a physician has a conflict and a preference for a different supplier and did not vote, they are still obligated to use the System’s selected supplier going forward.

Exhibit B: System Bylaws

Section 1.1 Conflict of Interest:

The Board of Directors adopts this policy, requiring all Covered Persons to complete a Conflict of Interest Disclosure Statement per policy requirements. Such policy may be updated on a periodic basis with review and approval by the Corporate Compliance Committee.