Great Boards

Promoting Excellence in Healthcare Governance

Legal Issues

Are there any concerns about using in-house counsel rather than a contracted outside lawyer?

Bryant: Inside general counsel is generally deemed to be a member of the management team, and therefore sometimes has a conflict of interest internally. Let's say the issue is senior management's incentive plan. Even if all the proper procedures have been followed, in-house counsel is still a beneficiary of that incentive plan, so when he or she looks at it, it's not really with an objective eye. Being a member of the management team sometimes skews the way you look at things.

Chresand: Given the relationship between the in-house general counsel and the CEO, there are occasions when it's appropriate for us to retain outside counsel to avoid any appearance of conflict. Board members do view outside counsel as having more independence because they're not employees of the organization. Outside counsel also often represent more than one health system or hospital, so sometimes they have a perspective that we might not have from the inside.

added/updated: 4/15/2004
topic(s): Legal Issues
This information comes from GreatBoards.org, the online resource for effective governance.return to top

Can the internal and external audits be conducted at the same time by the same auditor?

Wilson: The internal and external auditors' roles are quite different. The external auditor focuses on financial statements rather than on the daily inner workings of the various hospital departments. That's the purview of the internal auditor.

LeMoine: Never. In Enron's case, Arthur Andersen served as both internal and external auditor.

added/updated: 1/1/2003
topic(s): Audits, Legal Issues
This information comes from GreatBoards.org, the online resource for effective governance.return to top

How do the jobs of full-time, in-house counsel and contracted outside counsel differ?

Adelman: Inside lawyers get involved with everything, and generally much earlier in the process. Outside counsel don't get involved in an issue until after a lot of discussion has taken place. Sometimes that can be a significant disadvantage for outside counsel.

Chresand: In-house counsel is more apt to be involved with the board and the issues on a regular basis and notice trends or issues that come up. We can be proactive rather than reactive with the board in dealing with issues. We're also a fixed expense, while outside counsel typically charges by the hour.

added/updated: 1/1/2003
topic(s): Legal Issues
This information comes from GreatBoards.org, the online resource for effective governance.return to top

How should a board handle conflicts of interest?

What constitutes a conflict of interest?

A board member of a corporation owes a duty of loyalty to act in good faith in the best interests of the corporation. A conflict of interest exists whenever a board member has a “duality of interest” and could benefit privately, or appear to benefit, from decisions of the corporation or one of its competitors. In such cases, boards should follow the “3 D’s”:

  1. Disclose the conflict.
  2. Disassociate the member from discussion and voting on the issues related to the conflict.
  3. Document what has been done in the event legal questions arise.

Should individuals with a conflict of interest be barred from serving on a board?

Not necessarily. Each board should determine an appropriate policy toward conflicts of interest. Although some boards have a "no conflicts allowed" policy, most not-for-profits do not. Bankers, investment professionals, business owners, attorneys and other individuals who do business with the organization can be valuable trustees because of their familiarity with healthcare issues and a commitment that’s grown out of their business association. Recruiting talented members becomes more difficult if the board bars anyone with economic ties to the organization, especially in smaller communities.

If a duality of interest does exist, how does the board determines if it violates the duty of loyalty?

It is important to examine two things in particular:

  1. Does the board member have a direct and material interest in transactions involving the corporation? For example, a radiologist whose group holds an exclusive contract with the hospital clearly has a direct and material interest in matters pertaining to physician contracting, and should not participate in any board discussions or decisions involving the radiology services contract and other physician service contracts. By contrast, a board member who owns very few shares of a publicly traded corporation (usually defined as less than one percent) that sells supplies to the hospital would not have a direct and material interest.
  2. Has the individual complied fully with the board’s policy requiring disclosure of a conflict and disassociation with any matter involving the conflict? For example, a bank officer serving as a board member is required to disclose any financial business done for the corporation, and should be excused from discussions and voting on the selection or renewal of arrangements with financial institutions. Periodically, the organization’s banking business should undergo a competitive bidding or independent review process.

What are the key elements of an effective board conflict of interest policy?

  1. Definition. The policy should clearly define what constitutes a conflict of interest.
  2. Orientation and education. Every year or two, the general counsel or another individual should review the conflict of interest policy with the board and engage in an open discussion of any questions members may have.
  3. Disclosure. Board members should disclose any conflicts of interest in writing on an annual basis and when they arise during the year.
  4. Designate an arbiter. The conflict of interest policy should designate an individual or a committee to serve as an arbiter who reviews disclosure statements and determines whether a conflict of interest exists and how it should be handled.
  5. Handling conflict of interest situations. Whenever the board or a board committee considers a transaction for which a member has a conflict of interest:
    1. The member should declare the conflict and leave the room during the discussion and the vote. The chairman should assure this occurs.
    2. The interested director should not have private conversations about the matter with any other member of the board.
    3. The board may want to designate a disinterested third party or expert review panel to conduct a competitive bidding process or in some other way review the arrangement to be sure that the economic terms are favorable.
    4. The board should determine by a formal and documented vote that the transaction that it approves is in the organization’s best interests, and that it cannot conclude a more advantageous transaction with another organization.
  6. Documentation. The minutes of board and board committee meetings should document that the conflict of interest procedures have been followed, and the board has made a good faith effort to make decisions in the best interests of the corporation.
  7. Independent board functions. No board member with a conflict of interest should serve on the audit committee or the executive evaluation and compensation committee.
  8. Reasonable fees and prohibition on loans to directors. If the board provides compensation in the form of director’s fees, compensation should be reasonably based on the services provided. Compensation should not include loans to members of the board.
  9. Consider conflict of interest in the nominations process. When recommending individuals for election or re-election to the board, the nominating or governance committee should explicitly consider whether the knowledge and skills that an individual brings to the board outweigh any conflicts of interest he or she may have. In some instances, a conflict of interest is so material and direct that, even when all of a board’s conflict of interest procedures are followed, the individual’s presence on the board would still lead reasonable people to question whether the duty of loyalty is being fulfilled. Such individuals should not be elected to the board.
added/updated: 4/15/2004
topic(s): Legal Issues
This information comes from GreatBoards.org, the online resource for effective governance.return to top

Is it acceptable for a member of the board to double as general counsel?

Adelman: It's a huge mistake. It totally distorts the attorney/hospital relationship. I'm being asked for my unbiased advice of the pros, cons, risks, benefits and alternatives for a particular transaction. If I give that to the board, and then I turn around and vote on the decision, I've colored my advice. I'm biased. I'm saying you ought to vote how I vote.

Chresand: I would frown on that. I think it creates potential conflicts; it puts them in a less-than-objective position.

Iseman: It's a bad idea for the general counsel to sit as a member of the board. It's a conflict of interest. The general counsel needs to remain independent and to not be a part of the final decision-making process.

added/updated: 4/15/2004
topic(s): Board and committee structure, Legal Issues
This information comes from GreatBoards.org, the online resource for effective governance.return to top

Should board members be compensated?

This practice, common on corporate boards, is rare among not-for-profit organizations but is growing slowly because of the increased responsibilities and time demands placed on directors. According to the 2003 survey of boards by The Governance Institute, 88% of hospital and health system boards do not compensate board members. Compensation is most common among boards of Catholic health systems (27%), other systems (15%), County hospitals (37%) and District hospitals (24%). Among Catholic health systems, another 9% compensate selected board members, such as the Board Chair.

A follow-up survey published in November by The Governance Institute and Clark Consulting found little change.  Of the 439 organizations that responded (22% response rate), just 12% offer boards cash compensation, with an annual retainer of $8,572 and an average per meeting fee of $528.

If your board is thinking about compensation, consider these questions:

An opinion from legal counsel on the implications for directors’ liability is essential. In addition, how will the community and public regulators, such as the State Attorney General, view compensation for directors? Draft guidelines from IRS (Feb. 2007) say boards generally should not be compensated, and if they are, compensation must be approved by a committee of independent directors.

added/updated: 2/19/2007
topic(s): Board Composition, General Governance, Legal Issues
This information comes from GreatBoards.org, the online resource for effective governance.return to top

What are "disabling guidelines"?

Disabling guidelines describe conflicts that are, or could appear to be, so material that an individual should not serve on the board. Each organization should develop its own guidelines; one size does not fit all. Here are examples from one institution: "Under the following circumstances, a director should consider resigning, or may be asked to resign in the best interests of the organization: • Repeated, intentional failure to disclose a conflict of interest • A single but significant, intentional failure to disclose a conflict of interest • Intentional violation of the organization’s confidentiality policy or code of conduct • Engaging in any external conduct that the board construes may adversely impact the organization • Serving as a board member, partner, investor, or senior executive of a direct competitor to the corporation or its subsidiaries (not to be construed as barring physicians whose practices offer routine services, such as in-office laboratories) • Speaking publicly against positions of the board or the best interests of the hospital • Serving as an employee of the organization, or having an immediate family member who is a senior executive officer for the organization • Receiving direct compensation for ongoing services provided to the organization (i.e., serving as a “de-facto employee”) • Serving as an owner, partner, employee, board member, or investor of a vendor (professional services, financial institution, or other business) receiving a substantial amount of revenue from the organization—which we define as the greater of $200,000 or 2 percent of the annual revenues of that vendor in the preceding or current year.
added/updated: 11/15/2006
topic(s): Board Composition, General Governance, Legal Issues, Physician Issues
This information comes from GreatBoards.org, the online resource for effective governance.return to top

What happens when a conflict arises between counsel and the CEO to whom counsel reports?

Adelman: If there's something going on that is illegal or not in the best interest of the corporation, and the CEO isn't reporting it to the board, then counsel has an obligation to go to the board and report it. That's extremely rare. It's sort of the bottom line, the end point on your relationship that defines everything in front of it.

added/updated: 1/1/2003
topic(s): General Governance, Legal Issues
This information comes from GreatBoards.org, the online resource for effective governance.return to top

What is the role of general cousel?

A general counsel is the Swiss Army knife of lawyers, reviewing and negotiating contracts, verifying compliance with federal and state regulations, advising on business deals, drafting bylaws and resolutions for board consideration, working on employment agreements and physician disciplinary actions and generally weighing in on any discussion that involves legal rights and responsibilities. The general counsel is especially busy before board meetings, reviewing agenda items to determine whether they involve legal issues or require the adoption of formal resolutions. Most important, perhaps, is the general counsel's role in making sure the system is meeting its fiduciary responsibilities.

added/updated: 1/1/2003
topic(s): Legal Issues
This information comes from GreatBoards.org, the online resource for effective governance.return to top

What relationship should the board have with the general counsel?

In August 2002, Great Boards invited four attorneys who specialize in working with health systems to weigh in on the general counsel's place at the boardroom table. The panel included:

S. Allen Adelman, of Adelman, Sheff & Smith in Rockville, Md., who serves as outside counsel to four Maryland hospitals. aadelman@hospitallaw.com

L. Edward Bryant, a partner with Gardner, Carton & Douglas in Chicago. Bryant serves as outside counsel for 25 health systems, and is chairman of the board at the Sisters of Charity of Leavenworth. ebryant@gcd.com

George Chresand, who is employed full-time by Fairview Health Services in Minneapolis, Minn., as legal counsel and chief compliance officer. Gchresa1@fairview.org

Robert Iseman, a partner with Iseman Cunningham Riester & Hyde in Albany, N.Y. riseman@icrh.com

Robert Iseman has held seats on two sides of the boardroom: as a member of Eastern Mercy Health System's Board of Trustees and as outside counsel for a number of other health care systems. He says the role of a lawyer who also is a trustee is much different from that of outside counsel.

"As a board member, I've been very careful not to inject my role as lawyer into my board role because there's already a counsel for the organization," notes Iseman, whose Albany, N.Y., firm serves as general counsel to a number of hospitals and health systems.

Lawyers who serve on boards have a lot of influence with the other trustees, Iseman notes. Trustees might believe they will run afoul of the law if they don't vote the same way as the lawyer-members, he says. "I don't feel they ought to feel that way," he says.

As legal counsel and chief compliance officer for Fairview Health Services, George Chresand works with a number of trustees who are lawyers but are not employed as such by the system.

"Those who have been effective board members have always recognized that their role is as a community member who happens to be a lawyer," says Chresand. "They've realized they're not the corporation's counsel, and they defer to the general counsel to provide the legal advice."

Still, Chresand says he appreciates hearing the opinions of lawyer-trustees because they are intimately familiar with hospital business. "We always include them on task forces, where they can give us their helpful advice," he says. "We've always recognized that the lawyers who are on our board are good lawyers."

Still, he says, there can only be one general counsel. "If they're lawyers but they're not the lawyer for the company, they need to realize they're wearing a different hat while they're serving as a trustee," he says

added/updated: 1/18/2004
topic(s): Legal Issues
This information comes from GreatBoards.org, the online resource for effective governance.return to top

Who is an "independent director?"

All directors must exercise independent judgment. However, in an era of increased accountability and transparency, certain board functions -- e.g., serving on the audit committee and the executive compensation committee -- should be limited to directors with no material economic ties to the organization, i.e., "independent directors." Each board should develop its own definition. Some boards take a hard line, saying independent directors (or their families or business collleagues) may not have any economic relationship with the organization. Others use a "de minimus" standard, e.g., to be independent a director may not be compensated in an amount greater than $60,000 per year, or his firm may not do more $60,000 of business with the organization or 1% of its revcenues, whichever is greater. (dollar amount for illustrative only)
added/updated: 11/15/2006
topic(s): Board Composition, General Governance, Legal Issues
This information comes from GreatBoards.org, the online resource for effective governance.return to top

FAQ Topics