Use these cases to test your understanding of the relevant practice standards. Discuss these with colleagues, reflect on your practice, and take action if necessary.

Conflict of Interest Cases

Case of the “Convenient Vendor
Focus: offering choices

Case of the Moonlighting OT
Focus: explaining the potential conflict of interest if follow-up services are provided privately

Case of Accessing “Inside Information”
Focus: establishing boundaries with family members who request favours

Case of the “Best Deal
Focus: purchasing equipment for a client

Case of the Convenient Vendor

© Can Stock Photo / cteconsulting
© Can Stock Photo / cteconsulting

An occupational therapist (OT) works in a BC health authority residential setting. He has recently completed a seating assessment and the findings indicate that a resident requires a customized tilt-in-space wheelchair and specialty cushion.  The residential setting is in an urban area where there are several local medical equipment vendors that sell these types of seating systems.

The OT is relatively new to this practice area and has limited experience working with wheelchair vendors. Recently he had an excellent experience working with one particular vendor representative and would prefer to work with representative again. The process was smooth and efficient for the OT, the vendor was knowledgeable, and the client was very satisfied. How should the occupational therapist proceed? (Select 2)
1.    Ask for consent to work with this preferred vendor because it is in the resident’s best interest to use a knowledgeable vendor who provides good service.
2.    Provide the resident with the alternatives available in the area and then encourage the resident to choose a vendor representative.
3.    Seek out organization policies and procedures related to working with medical equipment vendors and/or fair business practices.
4.    Encourage the resident to choose the vendor after outlining the alternatives and describing previous professional experiences.
5.    Provide the resident with information regarding vendors recommended by colleagues with more experience in the area.

College Preferred Answer:
2 and 3 are correct

Conflict of Interest Practice Standard #2: Preventing Conflict of Interest states that occupational therapists “avoid preferential or discriminatory treatment towards particular … organizations” and will “apply any conflict of interest-related policies and procedures of the occupational therapist’s employer or organization” (pp. 16-17). While the occupational therapist may have had a positive experience with one particular vendor, it remains the occupational therapist’s responsibility to provide the client with information about the range of alternatives available, so that the client themselves can make an informed choice. For example, this may include, but is not limited to, the occupational therapist objectively presenting information regarding differences in vendor costs and types of equipment sold, as well as customer service considerations such as return policies, warranties, availability of trials, and timeliness of equipment repairs and servicing. The occupational therapist must be careful not to inadvertently influence a decision when communicating information about vendors. What’s easiest for the occupational therapist is not necessarily in the client’s best interests.
Checking with your organization’s purchasing or procurement department will help prevent unnecessary violations of policies. If not available, consider developing policies and procedures to ensure you are consistent and fair when dealing with suppliers.

1 is incorrect
This approach does not give the client an opportunity to understand the alternatives available and personally make an informed choice among them.

4 is incorrect
While the occupational therapist has provided the client with an understanding of the alternatives available, by ‘encouraging’ the client to choose the occupational therapist’s preferred vendor, the occupational therapist is introducing his own bias and influencing the informed consent process.
5 is incorrect
While talking with colleagues is one approach the occupational therapist may use to develop his professional knowledge about various vendors, as with previous answers, limiting the alternatives presented impacts the client’s ability to make an informed choice among the options and introduces bias.

Reference

College of Occupational Therapists of British Columbia. (2016). Conflict of interest practice standard #2: Preventing Conflict of Interest, pp. 16-17.

Additional questions for reflection, on your own or with others…

1. What would you do in a similar situation?
2. What other factors might have made it easier or more difficult for the occupational therapist to explain the conflict of interest?
3. What organizational policies are in place – or could be – to help prevent conflicts of interest in your practice?

Case of the Moonlighting OT

© Can Stock Photo Inc. / Bialasiewicz
© Can Stock Photo Inc. / Bialasiewicz

An occupational therapist in a publicly funded, community-based facility is working with a 4-year-old boy diagnosed with autism. The child is getting ready to start kindergarten soon and has some issues with independent toileting, managing transitions, and certain fine-motor activities. The occupational therapist has established a strong therapeutic relationship with the child and his parents, and they have been making positive gains working together. The parents approach the occupational therapist at the next visit and ask that she also work privately with their son as they have access to some extra funding that must be used within the next few months. In this community there are occupational therapists in private practice who already provide this service.  How should the occupational therapist proceed? (Select 2)
1.    Decline working with the family privately and provide the name of a past colleague/friend that now works privately.
2.    Decline working with the family privately and create a home program that she will modify on an as-needed basis.
3.    Decline working with the family privately and provide them with a list of occupational therapists in private practice.
4.    Decline working with the family privately but increase the frequency of visits to maintain their strong relationship.
5.    Agree to work with the family privately once she has appropriate insurance and storage for the client’s information.
6.    Discharge the child from her current caseload at the public facility so that she can work with the family privately.

College preferred answer:
2 and 3 are correct

Conflict of Interest Practice Standard #1: Recognizing Conflict of Interest (2016) states that occupational therapists will “recognize if a situation involves any direct or indirect benefit (i.e. personal, professional, political, academic, financial, or material) to the occupational therapist that could affect his or her judgement” (p. 13). It also states that occupational therapists “consider whether others could potential perceive a conflict of interest that could compromise the occupational therapists credibility or quality of client care” (p. 14). By declining the provision of private services and recommending suitable alternatives, the occupational therapist manages any perceived or actual conflict of interest associated with referring to her own private practice.

1 is incorrect
The occupational therapist does not have to gain directly for there to be a conflict of interest. Others may still perceive a conflict of interest if the occupational therapist refers only to a past colleague/friend, when there are other suitable alternatives available.

4 is incorrect
Conflict of Interest Practice Standard #2: Preventing Conflict of Interest states that occupational therapists “avoid preferential … treatment towards particular clients or organizations” (p. 16). Increasing the frequency of visits beyond service levels typically offered by the centre could be perceived as preferential treatment.

5 is incorrect
Despite completing some of the necessary preparations to work privately, the occupational therapist is not addressing the conflict of interest that arises given the benefits she stands to gain.

6 is incorrect
The occupational therapist is not acting in the client’s best interest to discharge him from her current caseload and personally benefit by offering her services privately.

References

College of Occupational Therapists of British Columbia. (2016). Conflict of interest practice standard #1: Recognizing Conflict of Interest, pp. 13-14.

College of Occupational Therapists of British Columbia. (2016). Conflict of interest practice standard #2: Preventing Conflict of Interest, pp. 16-17.

Additional questions for reflection, on your own or with others…

1. What would you do in a similar situation?
2. What other factors might have made it easier or more difficult for the occupational therapist to explain the conflict of interest?
3. What organizational policies are in place – or could be – to help prevent conflicts of interest in your practice?

Case of Accessing “Inside Information”

© Can Stock Photo Inc / BernardaSv
© Can Stock Photo Inc / BernardaSv

An occupational therapist practising on an acute care psychiatric unit receives a phone message from her cousin who is a health care professional working in community mental health. The cousin had just visited his close friend who is a client on the unit and working with the occupational therapist. The cousin is seeking information about his friend’s care and would like to support him post discharge. The occupational therapist has just completed an assessment during which time the client expressed he had limited supports in the community. How should the occupational therapist respond? (Select 2)

  1. Inform the cousin that the information is accessible to him via the client’s e-record.
  2. Offer to send the cousin a copy of the client’s assessment, in confidence, provided he does not share it.
  3. Inform the cousin that this information is confidential and cannot be shared without the client’s permission.
  4. Do not respond to the call and avoid the cousin until the client has been discharged.
  5. Invite the cousin to attend the unit’s rounds to discuss discharge plans for the client.
  6. Suggest the cousin contact the client directly to offer his support post-discharge.

College preferred answers:
3 and 6 are correct

This case is related to both the Conflict of Interest (COI) and the Managing Client Information (MCI) practice standards and illustrates how a conflict of interest can be interconnected with other practice issues such as patient/client privacy.

COI Practice Standard #2: Preventing Conflict of Interest (2016) states that “occupational therapists must maintain a relationship of trust and confidence by not taking advantage of his or her position, including access to privileged information or knowledge received in dealings with clients or organizations” (p. 17). As an occupational therapist on the unit, the occupational therapist has access to privileged confidential information. The occupational therapist must not use this information for her benefit or for the benefit of her family, in this case, her cousin.

Additionally, MCI Practice Standard #4: Disclosing the Occupational Therapy Record (2014), states “the occupational therapist will transfer, share, or disclose personal information only with the express consent of the client unless otherwise permitted to do so by law” (p. 2).
By suggesting that the cousin talk with the client and offer his support, the client is directly informed of the support available and is able to control if and/or how he accepts it. If interested, the client may choose to invite his friend to become more actively involved in discharge planning.

1 is incorrect
The cousin is not seeking information from the occupational therapist in the capacity of a health care professional. By recommending the cousin access the e-record, the occupational therapist is encouraging a breach of the client’s privacy in an attempt to meet the interests of a family member.

2 is incorrect
The client has not provided consent to disclose this information, even ‘in confidence’.

4 is incorrect
Occupational therapists have the responsibility to manage professional boundaries and communicate honestly and transparently. By ignoring the cousin’s message, the occupational therapist is not meeting these expectations. Additionally, the COTBC Code of Ethics states that occupational therapists “assist their colleagues to recognize and address potential boundary violations” (p. 9). Given the cousin is also a health care professional, by ignoring this request the occupational therapist is not fulfilling this responsibility. An additional consideration is that if the occupational therapist ignores the message, the client may not be able to benefit from a potentially valuable support upon discharge. This is not acting in the client’s best interest.

5 is incorrect
Consistent with answers 1 and 2, the client has not provided consent to disclose his personal information. Additionally, the occupational therapist’s cousin is not the client’s health care professional.

References
College of Occupational Therapists of British Columbia. (2014). Code of ethics, pp. 8-9.
College of Occupational Therapists of British Columbia. (2014). Managing client information practice standard #4: Disclosing the occupational therapy record, p. 2.
College of Occupational Therapists of British Columbia. (2016). Conflict of interest practice standard #2: Preventing Conflict of Interest, p. 17.

Additional questions for reflection, on your own or with others…

1. What would you do in a similar situation?
2. What other factors might have made it easier or more difficult for the occupational therapist to maintain professional boundaries?
3. What organizational policies are in place – or could be – to help prevent conflicts of interest in your practice?


Case of the “Best Deal”

© Can Stock Photo Inc. / McIninch

An occupational therapist works in two different settings: an acute care orthopedic unit and a community-based private clinic. A client from the unit has tried different dressing aids and finds that a few really help increase his independence and comfort. The client would like to purchase these for use at home but has a limited income. The private clinic where the occupational therapist works orders these dressing aids in bulk so can offer competitive pricing.
How should the occupational therapist proceed? (Select 1)

1.    Arrange for the client to buy the dressing aids from the clinic at their regular price.
2.    Arrange for the client to buy the dressing aids from the clinic at a discounted price.
3.    Provide the client with a list of various retailers who sell the dressing aids.
4.    Give the client dressing aids from the clinic with the recommendation to follow up there.

College preferred answer:
3 is correct
A conflict of interest occurs when the occupational therapist’s interests interfere with the client’s best interests or the occupational therapist’s own responsibilities. Practice Standard #2: Preventing Conflict of Interest states that occupational therapists must “provide clients with alternative options for receiving occupational therapy services in circumstances where a perceived or actual conflict of interest exists or a potential conflict of interest may arise” (p. 17). In this case, if the list includes the private clinic where the occupational therapist works, it will be important that she manage the conflict of interest in accordance with Practice Standard #3: Managing Conflict of Interest. This involves disclosing the conflict, providing information about options, informing the client of his right to decline the service, and documenting any steps taken.

1 and 2 are incorrect
Practice Standard #1: Recognizing Conflict of Interest indicates that occupational therapists must “recognize if a situation involves any direct or indirect benefit (i.e., personal, professional, political, academic, financial, or material) to the occupational therapist that could affect his or her professional judgement” (p. 13). If the occupational therapist specifically arranges for the client to buy the dressing aids from the private clinic, the occupational therapist may directly or indirectly benefit, creating a conflict of interest.

4 is incorrect
The occupational therapist stands to gain by soliciting the client to contract her privately as a way of obtaining the dressing aids for free. Additionally, it is unclear from the information provided in the scenario that the client actually requires follow up.

Reference
College of Occupational Therapists of British Columbia. (2016). Conflict of interest practice standards.

Additional questions for reflection, on your own or with others…

1. What would you do in a similar situation?
2. What other factors might have made it easier or more difficult for the occupational therapist to maintain professional boundaries?
3. What organizational policies are in place – or could be – to help prevent conflicts of interest in your practice?