El Paso Children'S Hospital Corporation

“El paso children's hospital engages an independent accounting firm experienced in the preparation of the form 990 to prepare its form 990. The organization's finance and legal departments review the 990. The final 990 with all required schedules is provided to all voting members of the board of directors, the chief executive officer, the chief financial officer, the controller, and the accounting manager for review, changes, and approval prior to filing form 990.”

“Epch leaders and members of the medical staff sign a conflict of interest certification and acknowledgement of conflict of interest policy (attachment 1) annually, certifying that they received, read, and understood this conflict of interest policy and agree to comply with it. Epch leaders obtain the certification form from the compliance office. Annually, the compliance officer provides notification to epch leaders to complete the form. It is the epch leaders' responsibility to return the signed form to the compliance office no later than the seventh (7th) business day upon notification from the compliance officer as stated above. Failure to return the form to the compliance office shall cause the epch leader to be in violation of this policy. Members of the medical staff obtain the certification form from medical staff services at the time of initial credentialing and recredentialing. It is the medical staff members responsibility to return the signed form to medical staff services in a timely manner. Medical staff members will not be (re)credentialed in the absence of a signed conflict of interest certification and acknowledgement of conflict of interest policy. Each time a procurement process is initiated and a committee is involved in making a decision or recommendation on a business relationship, a conflict of interest certification statement must be completed by those committee members who have not previously completed the annual certification. The compliance office maintains the file of the annual certification forms. In connection with any actual or possible conflicts of interest, an interested person must disclose the existence of, and all material facts concerning his or her financial/personal interest to the compliance officer within seven (7) business days of identifying the actual or potential conflict. Such disclosure will be made in writing by submitting a hospital conflict of interest certification and acknowledgement of conflict of interest policy form. Outside interests shall be disclosed as a potential conflict of interest when epch leaders receive monies for duties performed at entities with the same or similar service offered and in a geographic location serving the same community. The compliance officer reviews with the ceo and general counsel any conflict of interest certification forms that identify potential conflicts. The compliance officer may ask the interested person to discuss the proposed transaction in order to obtain further details. The compliance officer may, if appropriate, appoint a disinterested person or committee to investigate alternatives to any proposed transaction or arrangement and determines whether the hospital can obtain a more advantageous transaction or arrangement with reasonable efforts from a person or entity that would not give rise to a conflict of interest. The compliance officer provides quarterly reports to the board of directors detailing conflicts of interest and how they were addressed. With respect to research conflicts of interest, epch requires that a research investigator disclose to epch outside financial interests above specified thresholds when research would likely be affected by those interests. Epch then reviews the disclosures, determines whether there is a conflict and, if so, manages, reduces, or eliminates it, before allowing participation in the proposed research project. Upon discovery of a potential conflict of interest that has not been disclosed, the epch leader/medical staff member is notified by the compliance officer and afforded the opportunity to explain the alleged failure to disclose. If, after reviewing the response and making such further investigation as appropriate, the compliance officer shall inform the ceo of the determination whether the epch leader/medical staff member failed to disclose an actual or potential conflict of interest. Any violations of this policy may be grounds for disciplinary action including termination of employm”

“El paso children's hospital determines compensation for its ceo and other officers and key employees by considering salary ranges, salary surveys, and market analyses for each position. Specifically, the board of directors' compensation committee reviews and recommends salaries for the ceo, other officers, and key employees. The board of directors approves salaries for the ceo and other officers. The ceo approves salaries for key employees (director level and below).”

“Part vi, section c, line 19: the organization furnishes copies of its governing documents, conflicts of interest policy, form 990, and/or financial statements to the public upon request. Additionally, forms 990 will be published on the organization's website.”

“Professonal fees: program service expenses 16,169,762. Management and general expenses 0. Fundraising expenses 0. Total expenses 16,169,762.”