Confidentiality and Conflicts of Interest in Accreditation

2. CAPTE: On-site Reviewer Training Module 8 – Confidentiality and conflicts of interest in the Accreditation Process

3. Objectives • Define confidentiality • Identify the importance of confidentiality in the accreditation process and the consequences of breaches of confidentiality • Identify examples of breaches in confidentiality • Identify appropriate strategies to main confidentiality as an on-site reviewers • Define conflict of interest and identify the importance of avoiding/preventing conflicts of interest from occurring in accreditation activities • Identify examples of possible conflicts of interest that might take place in accreditation activities • Identify processes for avoiding/preventing conflicts of interest in accreditation activities

4. Confidentiality Definition Non-disclosure of information specific to an institution or program of which you have knowledge by involvement in the accreditation process As an on-site reviewer, you will have access to detailed information about the program and institution that is often not public knowledge. Information gained during program accreditation reviews is often highly sensitive. It is vitally important to maintain confidentiality at all times.

5. Importance of Confidentiality The program trusts that the privileged information revealed to on-site reviewers will only be shared with others involved in the accreditation process. Confidentiality of accreditation information protects the privacy of the program; the program has a right to this privacy guarantee. It also prevents the misuse of program information that might harm the reputation of the program. Protects privacy of the program Guards against misuse of program information

6. Examples of Breaches in Confidentiality in the Workplace The examples provided here are not meant to be inclusive of all possible breaches but to help you understand the range of activities that are considered a violation of confidentiality. While these examples require an intentional act on your part, others may be unintentional. For example, the Self-study Report is open on your desk when a colleague or student enters your office. Although it may seem harmless to let others know where you are going and why, it increases the possibility of someone volunteering information about the program or asking questions about the program. Only information that is part of the official record can be used to determine which questions to ask on-site or include in the Visit Report. 1 2 3 4 5 • Use of course materials provided in the Self-study Report in a similar course that you teach • Describing the program’s problems to your colleague • Identifying the institution that you are reviewing at your faculty meeting • Responding to questions from a colleague that you are visiting immediately after the visit • Asking a colleague’s opinion about course content in a program’s Self-study Report

7. Breaches in Confidentiality in Public Breaches of confidentiality may unintentionally occur as you review program materials or discuss the program in public locations, including during the on-site visit. You must be aware of the potential for these breaches of confidentiality to occur in public settings and take the necessary steps to prevent them. Some possible examples include: • the airline passenger sitting next to you who reads the program name from the on-site report on your laptop computer; • the waitress at the hotel restaurant who either asks why you are in town or overhears your conversation; or • talking on your cell phone while on the subway about the program’s problems with the commissioner who is reviewing the program. While these examples are by no means exhaustive, it does provide insight about the unintentional ease by which confidentiality can be breached. • While on site: • Hotel • Lobby • Restaurant • Elevator • Cab rides • At school • Hallways • Elevator • Public bathrooms! In public places: Be aware of others who might overhear your conversation or view materials •Airport/plane •Elevators •Restaurants

8. Remember It is important to remember that the physical therapy and higher education communities are very interconnected. A slight comment can be interpreted or misinterpreted. Since you never know who might be listening directly or otherwise, silence is recommended as the best approach to ensure fulfillment of your obligation and commitment as an on-site reviewer. The physical therapy and higher education communities are very interconnected A slight comment can be taken out ofcontext Silence is the bestapproach.

9. Impact of Breaches of Confidentiality on Communities of Interest Breaches of confidentiality can have far-reaching negative effects on the communities of interest. The immediate negative impact is first felt by the program faculty, students, alumni and its institution. Just as importantly, CAPTE’s ability to ensure quality in physical therapy education programs and protect the public is compromised. As a profession, the ability to self-monitor educational programs is questioned if these breaches of confidentiality occur. As consumers of physical therapy, the public’s interests in having high quality physical therapy education programs are not fulfilled if confidentiality is not observed. Program CAPTE Public Profession

10. Consequences of Breaches of Confidentiality A candid program review can only occur if there is a guarantee that privileged information will not be disclosed and will not be used by third parties for their personal benefit. By definition, when program information is disclosed or used by an unauthorized source, it is a breach of confidentiality. The ultimate result of this breach of confidentiality is damage to the trust and integrity that is embodied in the accreditation process. All stakeholders suffer when lapses in judgment occur by any involved in the process. CAPTE’s rules state that unauthorized disclosure of program information can be the basis for disciplinary and legal action and dismissal from participation in the accreditation process. As an on-site reviewer, you sign a Confidentiality Statement acknowledging that a breach of your promise of confidentiality could result in irreparable damage to CAPTE and its mission, as well as to the public. toCAPTE Breach made public Knowledge of Source Breach of Confidentiality Info Back to Program Spread

11. Strategies to Maintaining Confidentiality As an on-site reviewer, a simple way to remember what needs to be kept confidential is to not reveal anything that you hear and see about a program, and to not speak about the program to others. This applies to positive comments about the program as much as it does to negative comments. Speak only to other team members, Accreditation staff, or Commissioners who might contact you directly for clarification about information contained in the Visit Report. Such communications need to occur in an environment that maintains confidentiality. • Hear no evil (orgood) • Speak no evil (orgood) • See no evil (orgood)

12. Strategies to Maintaining Confidentiality Confidentiality about the program starts as soon as the accreditation staff contacts you to serve as an on-site reviewer for a specific program. The program name and materials are all confidential information. If there are individuals that need to know how to contact you during the on-site visit in case of an emergency, they should be informed that the information is confidential. You should treat materials and information with the same confidentiality that you would like to have others handle your program’s or facility’s documents. Materials should be stored or reviewed in areas where others cannot see identifiable information. MaintainingConfidentiality Conduct phone conversations in private area Do not reveal program name to others Store program materials in secure area Before the visit

13. Strategies to Maintaining Confidentiality Confidentiality continues during the on-site visit as you review additional materials, conduct interviews and discuss findings with the other team members or program representatives. Keep in mind that while on campus, conversations held in hallways, elevators or even bathrooms could be overheard by others. The same principles apply while at the hotel, a restaurant or in a taxi. MaintainingConfidentiality Share interview information only with team, CAPTE, or staff During the visit Keep materials in secure location Conduct conversations in private area

14. Strategies to Maintaining Confidentiality Confidentiality continues after the on-site visit, as you finalize the Visit Report and discuss findings with the Commissioner assigned to the program. Materials that are both electronic and hard copy need to be kept secured. If others have access to your computer, related computer files should be password protected. Team members are asked to comment on the first progress report, if there is one. Once that is done, all program materials must be destroyed. Accreditation staff will send a reminder about destroying materials at the appropriate time. Please remember to delete any computer files or related emails when the process is completed. MaintainingConfidentiality After the visit Keep materials secure Do not share information Conduct conversations in private

15. Conflict of Interest Definition A situation in which a reviewer has a pecuniary or personal interest or with respect to which, because of present institutional or program association, he or she has divided loyalties or conflicts on the outcome of an accrediting decision. Conflict of Interest is when a reviewer has a financial or personal interest in the institution or program such that the ability to remain unbiased is real or might reasonably be perceived by others.

16. Conflict of Interest Guidelines It is important that the accreditation process be impartial, objective, and uninfluenced by the private interests of those involved. Conflicts of interest can be actual or perceived by others and must be avoided in both instances. The Accreditation Handbook identifies five broad areas which guide determining possible conflicts in duty. You may not participate in any component of a program review if you, or an immediate family member, fall within one of these 5 categories. If you have not already done so, you should review this area of the Accreditation Handbook 1 2 3 4 5 Graduate or former employee of the institution Institution located in the same state Your institution has substantial cooperative or contractual agreements with the institution Institution where you interviewed for a job in past three years Institution where you have been a consultant

17. CAPTE considers the following to be a conflict of interest: A program or institution is one in which the CAPTE Representative graduated or with which the CAPTE Representative or an Immediate Family Member is or recently has been connected as a student, faculty member, administrative officer, staff member, or agent; or has interviewed for a job within the past three years. A program or institution is in the member's system or located in the same jurisdiction as the program/institution of the CAPTE Representative. A program or institution has substantial cooperative or contractual arrangements with the program or institution of the CAPTE Representative or an Immediate Family Member. A program or institution has engaged the CAPTE Representative or an Immediate Family Member to act as a consultant on behalf of the program or institution within the past three years. A program or institution in which the CAPTE Representative or an Immediate Family Member has any financial, political, professional or other interest that may conflict with the interests of CAPTE. Conflict of Interest Guidelines

18. Declaring Conflicts of Interest • Anyone from the same state is automatically declared in conflict • On-site reviewers declare conflicts of interests • Programs are given the opportunity to indicate on-site reviewers & Commissioners who they believe have a conflict of interest • Commissioners declare conflicts of interest • Staff declare conflicts of interest Programs, on-site reviewers, Commissioners and staff declare conflicts of interest before reviewer assignments are made. Explanations for the conflict are not expected or required. As an on-site reviewer, you will not be assigned to any program that you or the program indicated was a conflict of interest. It is often best to declare a conflict if there could be a perception of one. However, the higher education and physical therapy communities are relatively small. Having met or sat on a committee with someone from the institution does not automatically indicate a conflict. If you are in doubt about a potential conflict, feel free to contact the Accreditation staff.

19. Conflict of Interest Guidelines for Commissioners • Commissioners shall not participate in a site visit, in discussions during CAPTE meetings, or in a vote regarding a particular program if certain conditions are present. These rules apply to Commissioners whether they be personal or professional in nature. A Commissioner cannot participate in any discussion of his or her program with other Commissioners while the program is under review by CAPTE. In addition, a Commissioner must not be present during formal deliberation of his or her own program. Commissioners are not to act as an external consultant on any topic to any program during the term of appointment. In addition, Commissioners may not act as an external consultant on any topic to a program that they have visited or reviewed until that program has been determined to be in compliance with all criteria.

20. Avoiding Conflicts of Interest Once Assigned as a Reviewer • Do not recruit faculty, administrators, or students from the program to your institution • Do not serve as a consultant or advisor for the program or institution • Do not request a job application to work at the program or institution • Avoid conflicts of interests until program is reviewed and determined to be in compliance with all accreditation criteria • Do not accept gifts from the institution You must continue to avoid conflicts of interest with the program before, during and after the on-site visit until the program is reviewed by CAPTE and found to be in compliance with all criteria. Some suggestions for avoiding conflicts are include here. Always feel free to contact the Accreditation staff if you are unsure if an action would be considered a conflict of interest.

21. Accreditation Handbook Conflict of Interest & Confidentiality Guidelines As a CAPTE representative you will be asked to sign statements regarding maintaining confidentiality and following conflict of interest guidelines. In addition, the signature page of the Visit Report reaffirms each team members commitment to maintain the confidentiality of all information relating to the accreditation of the program. This statement includes a promise not to make copies of, disclose, discuss, describe, distribute or disseminate, in any manner whatsoever, either orally or in written form, any confidential information received or generated during the review of the program. In addition, the statement indicates a promise not to use any confidential information for personal or professional benefit or for any other reason, except directly in connection with service to CAPTE. Sign a statement that they understand and will abide by conflict of interest prohibitions Sign a statement promising complete confidentiality about CAPTE decisions AllCAPTE representatives

22. Summary • Confidentiality • Definition • Process for maintaining confidentiality • Breaches of confidentiality • Mechanisms for maintaining confidentiality • Importance and consequences of breaching • Conflict of Interest • Definition • Examples • During your workshop, you will be asked to sign CAPTE’s Conflict of Interest Guidelines and Statement and the Confidentiality Statement This module has described the important issues of confidentiality and conflict of interest and provided suggestions regarding maintaining confidentiality and avoiding conflict of interest. Your commitment to the integrity of the process is critically important.