Attach to Form 990 or Form 990-EZ.
Go to
www.irs.gov/Form990 for the latest information.
| (i) Name of supported organization | (ii) EIN | (iii) Type of organization (described on lines 1- 10 above (see instructions)) | (iv) Is the organization listed in your governing document? | (v) Amount of monetary support (see instructions) | (vi) Amount of other support (see instructions) | |
|---|---|---|---|---|---|---|
| Yes | No | |||||
| (A)
CATHOLIC HEALTH CARE FEDERATION |
999999999 | 1 | Yes | 0 | 0 | |
|
Total 1
|
0 | 0 | ||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grant.") .. | ||||||
| 2 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf.... | ||||||
| 3 | The value of services or facilities furnished by a governmental unit to the organization without charge.. | ||||||
| 4 | Total. Add lines 1 through 3 | ||||||
| 5 | The portion of total contributions by each person (other than a governmental unit or publicly supported organization) included on line 1 that exceeds 2% of the amount shown on line 11, column (f).. | ||||||
| 6 | Public support. Subtract line 5 from line 4. | ||||||
Calendar year
(or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 7 | Amounts from line 4.. | ||||||
| 8 | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources... | ||||||
| 9 | Net income from unrelated business activities, whether or not the business is regularly carried on.. | ||||||
| 10 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.).. | ||||||
| 11 | Total support. Add lines 7 through 10 | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 1 | Gifts, grants, contributions, and membership fees received. (Do not include any "unusual grants.") . | ||||||
| 2 | Gross receipts from admissions, merchandise sold or services performed, or facilities furnished in any activity that is related to the organization's tax-exempt purpose | ||||||
| 3 | Gross receipts from activities that are not an unrelated trade or business under section 513 ..... | ||||||
| 4 | Tax revenues levied for the organization's benefit and either paid to or expended on its behalf... | ||||||
| 5 | The value of services or facilities furnished by a governmental unit to the organization without charge | ||||||
| 6 | Total. Add lines 1 through 5 | ||||||
| 7a | Amounts included on lines 1, 2, and 3 received from disqualified persons | ||||||
| b | Amounts included on lines 2 and 3 received from other than disqualified persons that exceed the greater of $5,000 or 1% of the amount on line 13 for the year. | ||||||
| c | Add lines 7a and 7b.. | ||||||
| 8 | Public support. (Subtract line 7c from line 6.) | ||||||
Calendar year (or fiscal year beginning in) ![]() |
(a) 2014 | (b) 2015 | (c) 2016 | (d) 2017 | (e) 2018 | (f) Total | |
|---|---|---|---|---|---|---|---|
| 9 | Amounts from line 6... | ||||||
| 10a | Gross income from interest, dividends, payments received on securities loans, rents, royalties and income from similar sources.. | ||||||
| b | Unrelated business taxable income (less section 511 taxes) from businesses acquired after June 30, 1975. | ||||||
| c | Add lines 10a and 10b. | ||||||
| 11 | Net income from unrelated business activities not included in line 10b, whether or not the business is regularly carried on. | ||||||
| 12 | Other income. Do not include gain or loss from the sale of capital assets (Explain in Part VI.) .. | ||||||
| 13 | Total support. (Add lines 9, 10c, 11, and 12.).. | ||||||
| Section A - Adjusted Net Income | (A) Prior Year |
(B) Current Year (optional) |
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| 1 | Net short-term capital gain | 1 | ||||
| 2 | Recoveries of prior-year distributions | 2 | ||||
| 3 | Other gross income (see instructions) | 3 | ||||
| 4 | Add lines 1 through 3 | 4 | ||||
| 5 | Depreciation and depletion | 5 | ||||
| 6 | Portion of operating expenses paid or incurred for production or collection of gross income or for management, conservation, or maintenance of property held for production of income (see instructions) | 6 | ||||
| 7 | Other expenses (see instructions) | 7 | ||||
| 8 | Adjusted Net Income (subtract lines 5, 6 and 7 from line 4) | 8 | ||||
| Section B - Minimum Asset Amount | (A) Prior Year |
(B) Current Year (optional) |
||||
| 1 | Aggregate fair market value of all non-exempt-use assets (see instructions for short tax year or assets held for part of year): | 1 | ||||
| a | Average monthly value of securities | 1a | ||||
| b | Average monthly cash balances | 1b | ||||
| c | Fair market value of other non-exempt-use assets | 1c | ||||
| d | Total (add lines 1a, 1b, and 1c) | 1d | ||||
| e |
Discount claimed for blockage or other factors (explain in detail in Part VI): |
|||||
| 2 | Acquisition indebtedness applicable to non-exempt use assets | 2 | ||||
| 3 | Subtract line 2 from line 1d | 3 | ||||
| 4 | Cash deemed held for exempt use. Enter 1-1/2% of line 3 (for greater amount, see instructions). | 4 | ||||
| 5 | Net value of non-exempt-use assets (subtract line 4 from line 3) | 5 | ||||
| 6 | Multiply line 5 by .035 | 6 | ||||
| 7 | Recoveries of prior-year distributions | 7 | ||||
| 8 | Minimum Asset Amount (add line 7 to line 6) | 8 | ||||
| Section C - Distributable Amount | Current Year | |||||
| 1 | Adjusted net income for prior year (from Section A, line 8, Column A) | 1 | ||||
| 2 | Enter 85% of line 1 | 2 | ||||
| 3 | Minimum asset amount for prior year (from Section B, line 8, Column A) | 3 | ||||
| 4 | Enter greater of line 2 or line 3 | 4 | ||||
| 5 | Income tax imposed in prior year | 5 | ||||
| 6 | Distributable Amount. Subtract line 5 from line 4, unless subject to emergency temporary reduction (see instructions) | 6 | ||||
| Section D - Distributions | Current Year | |
|---|---|---|
| 1 Amounts paid to supported organizations to accomplish exempt purposes | ||
|
2
Amounts paid to perform activity that directly furthers exempt purposes of supported organizations, in excess of income from activity |
||
| 3 Administrative expenses paid to accomplish exempt purposes of supported organizations | ||
| 4 Amounts paid to acquire exempt-use assets | ||
| 5 Qualified set-aside amounts (prior IRS approval required) | ||
| 6 Other distributions (describe in Part VI). See instructions | ||
| 7Total annual distributions. Add lines 1 through 6. | ||
|
8
Distributions to attentive supported organizations to which the organization is responsive (provide details in Part VI). See instructions |
||
| 9 Distributable amount for 2018 from Section C, line 6 | ||
| 10 Line 8 amount divided by Line 9 amount | ||
| Section E - Distribution Allocations (see instructions) |
(i) Excess Distributions |
(ii) Underdistributions Pre-2018 |
(iii) Distributable Amount for 2018 |
|
|---|---|---|---|---|
|
1
Distributable amount for 2018 from Section C, line 6 |
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|
2
Underdistributions, if any, for years prior to 2018 (reasonable cause required-- explain in Part VI). See instructions. |
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| 3 Excess distributions carryover, if any, to 2018: | ||||
| a From 2013....... | ||||
| b From 2014....... | ||||
| c From 2015....... | ||||
| d From 2016....... | ||||
| e From 2017....... | ||||
| fTotal of lines 3a through e | ||||
| g Applied to underdistributions of prior years | ||||
| h Applied to 2018 distributable amount | ||||
|
i
Carryover from 2013 not applied (see instructions) |
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| j Remainder. Subtract lines 3g, 3h, and 3i from 3f. | ||||
| 4Distributions for 2018 from Section D, line 7: | ||||
| $ | ||||
| a Applied to underdistributions of prior years | ||||
| b Applied to 2018 distributable amount | ||||
| c Remainder. Subtract lines 4a and 4b from 4. | ||||
|
5
Remaining underdistributions for years prior to 2018, if any. Subtract lines 3g and 4a from line 2. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
6
Remaining underdistributions for 2018. Subtract lines 3h and 4b from line 1. If the amount is greater than zero, explain in Part VI. See instructions. |
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|
7 Excess distributions carryover to 2019. Add lines 3j and 4c. |
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| 8 Breakdown of line 7: | ||||
| a Excess from 2014...... | ||||
| b Excess from 2015..... | ||||
| c Excess from 2016..... | ||||
| d Excess from 2017..... | ||||
| e Excess from 2018..... | ||||
| Facts And Circumstances Test |
|---|
| Return Reference | Explanation |
|---|---|
| Schedule A, Part IV, Section A, Line 1 Supported Orgs Listed By Name | CHI St. Joseph's Children's articles of incorporation specifically designate Catholic Health Care Federation as its publicly supported organization and designate, by purpose, such other charitable organizations, the purposes of which are to embody the mission of the healing ministry of Jesus in the Church through ownership, management, or governance of health ministries, or the offering of or supporting of charitable and religious programs or services consistent with such purposes, in keeping with the gospel imperative. |
| Schedule A, Part IV, Section A, Line 2 Supported Org. Without IRS Status 509(a)1 or (2) | CHI St. Joseph's Children is organized and operated, within the meaning of Section 509(a)(3)(A) of the Internal Revenue Code of 1986, as now in effect or as subsequently amended ("IRC"), exclusively for the benefit of, to perform the functions of, and/or to carry out the religious, charitable, scientific, and educational purposes within the meaning of Section 509(c)(3) of the IRC, of Catholic Health Care Federation ("CHCF"), a public juridic person within the meaning of the Code of Canon Law for the Roman Catholic Church ("Canon Law"), including by supporting such other charitable organizations, the purposes of which are to embody the mission of the healing ministry of Jesus in the Church through ownership, management, or governance of health ministries, or the offering of or supporting of charitable and religious programs or services consistent with such purposes, in keeping with the gospel imperative. Because CHCF is part of the Roman Catholic Church, it is not required to apply for recognition of exempt status pursuant to IRC §508(c). By virtue of its decree of canonical erection by the Congregation for Institutes of Consecrated Life and Societies of Apostolic Life, CHCF is a public juridic person of pontifical right, subject to the direct oversight and jurisdiction of the Apostolic See in the Vatican. As a public juridic person in the Church, CHCF is the juridical equivalent of a diocese or parish or religious order in the Catholic Church. As a public juridic person, CHCF is not merely affiliated with the Catholic Church; it is the Catholic Church, an official part of the Church itself, with a munus or duty assigned to it by the Church, and able to act publicly in the name of the Church. The Congregation for Institutes of Consecrated Life and Societies of Apostolic Life by decree dated June 8, 1991, conferred public juridic personality in the Church on CHCF, stating that CHCF was "to be governed in accordance with Canon Law and its own approved Statutes". |
| Schedule A, Part IV, Section B, Line 2 Benefit Of Supp. Org. Other Than The One Operating The Org. | The organization operates exclusively to support or benefit its publicly supported organization by supporting organizations, other than a private foundation, which are described in section 501(c)(3) and are operated, supervised, or controlled directly by or in connection with such publicly supported organizations, or which is described in section 511(a)(2)(B). No part of the organization's activities is in furtherance of a purpose other than supporting or benefiting one or more specified publicly supported organizations. |
| Software ID: | 18007697 |
| Software Version: | 2018v3.1 |
Attach to Form 990 or 990-EZ.
Go to www.irs.gov/Form990 for the latest information.
| Return Reference | Explanation |
|---|---|
| Form 990, Part III, Line 4a Community Benefit Narrative | Introduction CHI St. Joseph's Children (SJC) is a non-profit organization that works to ensure children reach kindergarten with the health and family capacity necessary to support learning. SJC achieves this goal through four primary programs: Home Visiting, Enhanced Referral Services, Research and Advocacy. During fiscal year FY 2019 SJC provided benefits to the economically disadvantaged in the amount of $3,689,177 and to the broader community in the amount of $646,642. Those dollars represented 18,550 contacts with residents of the State of New Mexico. Benefit for those Living In Poverty Community health services - Home Visiting: Number of Persons Served 9,566 Community Benefit $3,302,715 Other benefit provided to the poor - Referral/Philanthropy: Number of Persons Served 6,593 Community Benefit $386,462 Total Benefits for those Living in Poverty: Number of Persons Served 16,159 Community Benefit $3,689,177 Benefits for Broader Community Community Health Services - Advocacy/Research: Number of Persons Served 2,349 Community Benefit $420,680 Donations - Community Support: $128,873 Community benefit operations: $24,001 Other benefit provided to the broader community: Number of Persons Served 42 Community Benefit $73,088 Total Benefits for the Broader Community: Number of Persons Served 2,391 Community Benefit $646,642 Total Benefits for those Living in Poverty and the Broader Community: Number of Persons Served 18,550 Community Benefit $4,335,819 Community Outreach for those Living in Poverty Home Visiting This program is the flagship program of SJC providing home visits by trained professionals to expectant moms and families with first born children. SJC utilizes outcomes-based models (First Born, Partners for a Healthy Baby) that have proven results in improving child and family outcomes. The benefits of early intervention and health promotion in maternal and child health are well-documented and have a lifetime affect. The net benefit provided to the community by this program during fiscal year 2019 was $3,302,715 and included 9,566 contacts. Enhanced Referral This program operates in conjunction with the Home Visiting program (see above). The Enhanced Referral program provides services to address housing, legal aid, transportation, medical care, access to food, child care, employment, dental care, school re-entry and special needs services. Addressing these underlying social-environmental factors has been shown to impact physical health, emotional/social development, family capacity and functioning. In fiscal year 2019 the enhanced referral program provided a net benefit of $367,038 to the community and resulted in 5,763 community contacts. Miscellaneous Programs This category covers events sponsored by SJC throughout the year including the SJC Celebration of Babies Event. The net benefit provided to the community by these programs was $19,424 and yielded 830 community contacts. Community Outreach for the Broader Community Community Support This program consists mostly of donations provided by SJC to various programs around New Mexico serving the broader community. The net benefit provided by SJC to the broader community was $128,873. Advocacy This program provides funding for state-wide advocacy efforts to support early childhood development issues/programs. In supporting this program SJC provided a net benefit to the community of $285,722 and made 2,349 community contacts. Research/Community Education This program provides funding for state-wide education efforts centering on research performed on early childhood development issues/programs in order to educate New Mexico voters and State legislators. In supporting these programs SJC provided a net benefit to the community of $134,958. Canonization SJC is currently providing funding for a campaign supporting the canonization of one of SJC's founders, Sister Blandina Segale. The net benefit provided to the community for the fiscal year was approximately $24,001. Study Tour The SJC International Home Visiting Study Tour program teaches seasoned professionals from around the world how to design, implement and deliver an effective home visiting program. It is intended to be an educational and inspirational experience. The net benefit provided to the community for the fiscal year was approximately $73,088 and made 42 contacts. |
| Form 990, Part VI, Line 15a PROCESS FOR DETERMINING COMPENSATION - TOP MANAGEMENT OFFICIAL | The organization's top management official's compensation was paid by Catholic Health Initiatives ("CHI"), a related organization. CHI had a defined compensation philosophy. Both the executive and non-executive compensation structures and ranges were reviewed annually in comparison to market data. Catholic Health Initiatives used Korn Ferry as the independent third party to assess executive compensation programs and to ensure the reasonableness of actual salaries and total compensation packages. Compensation of the senior most executives was reviewed annually. Korn Ferry reviewed both cash and total compensation for overall reasonableness, for adherence to Catholic Health Initiatives' compensation philosophy, and for comparability to the not-for-profit healthcare market. This independent review was delivered by Korn Ferry to the CHI HR committee of the Board of Stewardship Trustees annually at their September meeting and minutes shared with the full board at the December meeting. The last review was September 25, 2018. In addition, Korn Ferry completed a comprehensive review of all positions at the level of vice president and above in the fall of 2014 to determine and validate appropriate compensation levels. These levels were reviewed annually and revised based on market data, where applicable. |
| Form 990, Part VI, Line 14 Document Retention Policy | The document retention and destruction policy is more of an operational policy. These types of policies usually do not go to the board of directors. This has not been adopted by the board of directors. |
| Form 990, Part VI, Line 12c Conflict of Interest Policy (continued) | c) Board evaluation of non-transactional conflicts - I. The board carefully reviews and scrutinizes any non-transactional conflict of interest (e.g., disclosure of nonpublic information, competition with CHI or a CHI entity, failure to disclose a corporate opportunity, excessive gifts or entertainment, etc.). II. In such circumstances, by a majority vote of the disinterested trustees, the board takes whatever action is deemed appropriate with respect to the trustee or corporate officer under the circumstances (including possible disciplinary or corrective action) to best protect the interests of CHI or the CHI entity. The board is encouraged to consult with the general counsel of CHI or his or her designee when considering disciplinary or corrective action. III. The conflicted trustee or corporate officer is not permitted to use his or her personal influence with respect to the conflict matter. However, if requested, such trustee or corporate officer is not prevented from briefly stating his or her position in the matter, nor from answering pertinent questions from trustees, as his or her knowledge may be relevant. The trustee or corporate officer is excused from the meeting during discussion and vote on the conflict of interest. d) Record of proceedings - with respect to board member and officer conflicts of interest, minutes of the board are expected to reflect the identity of the individual making the disclosure, the nature of the disclosure, discussion regarding any proposed transaction, the decision made by the board, and that the interested trustee or corporate officer was excused during the discussion, and that the interested trustee abstained from voting. D. Conflicts reporting: All conflicts of interest are reported by CHI as required by law, regulations, and policy. |
| Form 990, Part VI, Line 1a Delegate broad authority to a committee | Per Section 8.6 of the organization's bylaws, the Executive Committee shall consist of only directors of the Corporation and shall be composed of the Chairperson of the Board, the Vice Chairperson of the Board, and the President and Chief Executive Officer, each of whom shall serve as an ex officio voting member of the Executive Committee, and two (2) voting members appointed by the Board of Directors. Each individual appointed to the Executive Committee shall serve for a term of one (1) year or until his or her successor is duly appointed by the Board of Directors. Any vacancy of an appointed Executive Committee membership may be filled for the unexpired portion of the term in the manner that the original committee member was appointed. Except as provided by law, the Executive Committee shall have and may exercise such powers as may be delegated to it by the Board of Directors. Additionally, the Executive Committee shall have and may exercise such powers to transact routine business of the Corporation in the interim period between regularly scheduled meetings of the Board of Directors, provided that such actions taken shall be consistent with and not conflict with any actions or policies of the Board of Directors or of the Corporate Member, with the Bylaws, or with applicable law. All actions taken by the Executive Committee shall be promptly reported to the Board of Directors at the next regular or annual meeting of the Board of Directors. The Executive Committee shall meet at such times as shall be determined by the Chairperson. The Executive Committee shall keep regular minutes of its proceedings and report the same to the Board of Directors at each regular meeting of the Board. |
| Form 990, Part VI, Line 6 Classes of members or stockholders | According to the bylaws of CHI St. Joseph's Children, the entity's sole member is CommonSpirit Health, a Colorado nonprofit organization. |
| Form 990, Part VI, Line 7a Members or stockholders electing members of governing body | According to the organization's bylaws, directors shall be appointed or refused by the corporate member. The corporate member may appoint one or more individuals to the board of directors, and may at any time remove, with or without cause, any member of the board of directors. According to the organization's bylaws, directors of the corporation shall be appointed by the corporate member no later than June 30 of each year. The names and qualifications of each individual accepted by the board of directors shall be submitted to the corporate member, who shall appoint or refuse each nominee in accordance with the corporate member's bylaws and with endorsement of the senior vice president of operations. The corporate member may unilaterally appoint one or more individuals to the board of directors should the board fail to furnish the corporate member with a list of individuals qualified to serve on the board of directors of the corporation. (CHCF Reserved Rights) Except as otherwise provided in the Corporation's Articles of Incorporation or the laws of the State of organization, Catholic Health Care Federation ("CHCF") shall have such rights as are reserved to the Corporate Member, acting in its capacity as the membership body of CHCF, under the Governance Matrix. |
| Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders | The organization's corporate member is CommonSpirit Health. Pursuant to Section 5.4.2 of the organization's bylaws, the Corporate Member shall have the specific rights set forth in the governance matrix. Pursuant to the governance matrix the following rights are reserved to the CommonSpirit Health Board directly or through powers delegated to the CommonSpirit Health Chief Executive Officer: * Substantial change in the mission or philosophy of the CHI St. Joseph's Children * Amendment of the corporate documents of the CHI St. Joseph's Children * Approve members of the CHI St. Joseph's Children board * Removal of a member of the governing body of the CHI St. Joseph's Children * Approval of issuance of debt by CHI St. Joseph's Children * Approval of participation of CHI St. Joseph's Children in a joint venture * Approval of formation of a new corporation by CHI St. Joseph's Children * Approval of a merger involving the CHI St. Joseph's Children * Approval of the sale of all or substantially all of the assets of the CHI St. Joseph's Children * To require the transfer of assets by the CHI St. Joseph's Children to CommonSpirit Health to accomplish CommonSpirit Health's goals and objectives, and to satisfy CommonSpirit Health debts. * Adoption of long range and strategic plans for CHI St. Joseph's Children Pursuant to Section 5.5.2 of the organization's bylaws, CommonSpirit Health may, in exercise of its approval powers, grant or withhold approval in whole or in part, or may, in its complete discretion, after consultation with the Board and the President and Chief Executive Officer of the organization, recommend such other or different actions as it deems appropriate." (CHCF Reserved Rights) Except as otherwise provided in the Corporation's Articles of Incorporation or the laws of the State of organization, Catholic Health Care Federation ("CHCF") shall have such rights as are reserved to the Corporate Member, acting in its capacity as the membership body of CHCF, under the Governance Matrix. |
| Form 990, Part VI, Line 11b Review of form 990 by governing body | Once the return is prepared, the return is reviewed by the Director of Finance. Board members receive an electronic version of the Form 990 and are encouraged to ask questions of Management. Subsequent to distribution to the board, the tax department files the return with the appropriate federal and state agencies, making any non-substantive changes necessary to effect e-filing. Any such changes are not re-submitted to the board. |
| Form 990, Part VI, Line 12c Conflict of interest policy | The organization has a conflicts of interest ("COI") policy (the "policy") in place to maintain the integrity of its activities. Through February 7, 2019, conflicts were administered solely through Catholic Health Initiatives' ("CHI") Governance Policy No. 1 (described below). On February 8, 2019, in connection with the alignment of the Catholic Health Ministries of CHI and Dignity Health, the CommonSpirit Health Board of Stewardship Trustees approved CommonSpirit Health Corporate Responsibility Policy No. G-001, a CommonSpirit Health conflicts of interest policy. This policy stipulates that, at minimum, the pre-closing CHI COI policies and pre-closing Dignity Health COI policies identify the individuals that are covered under the new policy. In addition, subject to certain exceptions, pre-closing CHI COI policies shall continue to apply to the CHI entities and the individuals who were subject to the Pre-Closing CHI COI policies; and the Pre-Closing Dignity Health COI policies shall continue to apply to the Dignity Health entities and the individuals who were subject to the Pre-Closing Dignity Health COI policies. Until CommonSpirit Health adopts a single process for identifying and managing conflicts of interest for all system entities, the following individuals shall be subject to the Pre-Closing CHI COI policies from and after the effective date of Corporate Responsibility Policy No. G-001: 1. Members of the CommonSpirit Health Board of Stewardship Trustees and members of the committees of the Board of Stewardship Trustees; 2. Corporate officers of CommonSpirit Health; 3. Members of the Board of Directors of Dignity Health and members of the committees of the Board of Directors of Dignity Health. CHI Governance Policy No. 1: The policy applies to the following persons: members of the CHI board of stewardship trustees and its committees; members of any CHI direct affiliate or subsidiary (each a CHI entity) board and their committees; employees of CHI entities, and all CHI researchers (as defined in the policy). Disclosure, review and management of perceived, potential or actual conflicts of interest are accomplished through a defined COI disclosure review process. A. Disclosure obligations: 1. Ongoing: Each person is required to promptly and fully disclose to his/her direct manager, supervisor, medical staff office, board or board committee chair any situation or circumstance that may create a conflict of interest. The person must disclose the actual or potential conflict as soon as she/he becomes aware of it. In any situation in which the person is in doubt it is expected that full disclosure be made to permit an impartial and objective determination as to the existence of a conflict. 2. Periodic written: In addition to the ongoing disclosure obligation, periodic written conflict of interest disclosure forms must be completed as follows: a) Initially: 1) Upon hiring (employees), 2) Appointment (board / committee members), 3) Upon consideration of affiliation with research sponsor (researchers). b) Annually: 1) Board / committee members, 2) Employees at the level vice president or above, 3) Researchers, 4) Supply chain employees at the level of vice president and above and those employees involved in contracting regardless of employment level, 5) Other employees as determined by CommonSpirit Health leadership. 3. Failure to disclose - an individual who fails to disclose a perceived, potential, or actual conflict of interest, or all material facts surrounding an actual or potential conflict or fails to abide by the final decision regarding the conflict may be subject to disciplinary or corrective actions such as termination of employment, removal from a board or committee, loss or restriction of clinical privileges, or restrictions on research activities in accordance with applicable laws, regulations, rules, contracts, and bylaws. B. Conflicts review: 1. No disclosed conflicts: In the absence of perceived, potential or actual conflicts of interest, no follow-up conflicts review is required or performed. 2. Disclosure of perceived, potential or actual conflicts: a) Are initially reviewed by national or regional legal or corporate responsibility team members (depending upon the role of the individual disclosing the actual or potential conflict) to determine whether an actual or potential for a conflict may exist. b) If it is determined that a potential or actual conflict may exist, I. In the case of board or committee members or officers, issues are elevated to the executive committee of the board or board chair. II. In the case of other persons, conflicts issues are elevated to the conflicts of interest review committee ("C-CIRC"). C. Conflicts determination and management: 1. Matters elevated to C-CIRC: a) The C-CIRC determines whether a disclosed or otherwise identified interest is a conflict of interest. If the C-CIRC determines that a COI exists, and adequate controls are not in place to mitigate the conflict, the C-CIRC facilitates development of a COI management plan designed to mitigate the conflict. Designated entity staff are responsible for monitoring the COI management plan and for documenting monitoring activities. Notwithstanding the foregoing, at its sole discretion, an entity may reject a person's request to enter into the relationship in question, or require the relationship be sufficiently altered to avoid a potential conflict of interest. b) Appeal - if a person does not agree with a determination made by the C-CIRC, its interpretation of the COI policy, still seeks an exemption or exception, or seeks further clarification of the C-CIRC 's decision, the individual may appeal the decision through his or her manager for reconsideration by the C-CIRC, and the C-CIRC will review and issue a final determination based upon any new or additional information presented. 2. Matters elevated to the executive committee or board chair: a) Determination of existence of conflict - the board chair or his or her designee performs any further investigation of any conflict of interest disclosures as he or she may deem appropriate. If the conflict involves the board chair, the vice chair assumes the chair's role outlined in the COI policy. Based on review and evaluation of the relevant facts and circumstances, the board chair makes an initial determination as to whether a conflict of interest exists and whether, pursuant to the COI policy, review and approval or other action by the board is required. A written record of the board chair's determination, including relevant facts and circumstances, is made. The board chair then makes an appropriate report to the executive committee of the board concerning the COI review, evaluation and determination. If a difference of opinion exists between the board chair and another trustee as to whether the facts and circumstances of a given situation constitute a conflict of interest or whether board review and approval or other action is required under the COI policy, the matter is submitted to the board's executive committee, which makes a final determination as to the matter presented. That determination, including relevant facts and circumstances, is reflected in the executive committee minutes and is reported to the board. b) Board evaluation of transactions involving an officer / board member conflict of interest - I. The board carefully scrutinizes and must in good faith approve or disapprove any transaction in which CHI or a CHI entity is a party and in which the trustee or a corporate officer either: 1. Has a material financial interest; or 2. Is a trustee or corporate officer of the other party (other than a CHI affiliated organization). II. The board must approve the transaction by a majority of the trustees on the board (not counting any interested trustee). In reviewing such transactions between CHI or CHI entities and vendors or other contractors who are, or are affiliated with, trustees or corporate officers, the board acts no more or less favorably than it would in reviewing transactions with unrelated third parties. The transaction is not approved unless the board determines that the transaction is fair to CHI or the CHI entity. III. A conflicted trustee or corporate officer is not permitted to use his or her personal influence with respect to the approval or disapproval of the conflicted transaction. However, if requested, such trustee or corporate officer is not prevented from briefly stating his or her position in the matter, nor from answering pertinent questions from trustees, as his or her knowledge may be relevant. The trustee or corporate officer is excused from the meeting during discussion and vote on the conflict of interest. (Continued below) |
| Form 990, Part VI, Line 15b Process to establish compensation of other employees | FOR ALL OF THE ORGANIZATION'S TOP MANAGEMENT EXECUTIVES, OUTSIDE CONSULTANTS ANNUALLY REVIEW COMPENSATION USING MULTIPLE NATIONAL COMPARABILITY SURVEYS. ADDITIONALLY, THE EXECUTIVE COMMITTEE REVIEWS AND APPROVES COMPENSATION AND ALL DISCLOSURES AND DECISIONS ARE CONTEMPORANEOUSLY DOCUMENTED. |
| Form 990, Part VI, Line 19 Required documents available to the public | The organization's financial statements are included in CommonSpirit Health's consolidated audited financial statements that are available at www.commonspirit.org or www.catholichealthinitiatives.org. The Organization's governing documents and conflict of interest policy are not made available to the public. |
| Form 990, Part XI, Line 9 Other changes in net assets or fund balances | Capital Resource Pool Contributions - -70004; Grant write-off - -156193; |
| Software ID: | 18007697 |
| Software Version: | 2018v3.1 |