Program Topics

HortySpringer specializes in all aspects of physician/hospital/system relationships. A program can be designed to meet your needs around any of those issues, including:

Legal Protections for Credentialing and Peer Review Activities
• Legal protections for hospitals, Medical Staff Leaders, and board members
• Best practices to qualify for immunity
• Additional steps that can be taken in-house to minimize disputes and litigation (including good authorization forms, confidentiality policies, responses to references)

The Respective Responsibilities of Hospital Boards and Medical Staffs for Quality and Safety
• Sources of Board authority and responsibility
• Sources of Medical Staff authority and responsibility
• How Boards and Medical Staff leaders can satisfy the duties of loyalty and care
• How hospitals can set up Medical Staff leaders for success
• Legal protections for those involved in credentialing, peer review, and other quality and patient safety activities
• The Board’s role in credentialing, peer review, and other Medical Staff functions

The Peer Review Continuum
• Changing the perception of peer review from punitive to educational
• Using Performance Improvement Plans and other collegial measures
• Keeping the physician in the loop
• Information-sharing
• Employed physicians and peer review
• FPPE to confirm competence and OPPE

Peer Review of Unprofessional Conduct
• Identifying and defining “unprofessional” conduct
• Conducting effective collegial intervention meetings with a practitioner who is not collegial
• Anticipating and dealing with common deflection tactics, including, but not limited to: blaming others, demanding information about the “accuser,” communicating only through lawyers and/or making legal threats, refusing to attend meetings, ghosting the Medical Staff leadership, claiming “whistleblower” status, and claiming disparate treatment
• Understanding sexual (and other unlawful) harassment and the organization’s unique legal duties to respond in such cases

Peer Review of Practitioner Health Concerns
• Identifying impairment in your Practitioner Health Policy (it’s about more than drugs and alcohol!)
• Which leaders should have primary responsibility for review of health concerns?
• Requesting fitness for practice evaluations
• Requesting treatment records and other health information from applicants and members of the Medical Staff
• Leaves of absence and reinstatement
• Industry trends for managing concerns about late career (aging) practitioners

Tips on Effective Credentialing
• Threshold eligibility criteria
• Practical tips to help align recruitment and credentialing
• Managing incomplete applications
• Addressing misrepresentations and omissions on the application form and as part of the application process
• Asking health-related questions on the Medical Staff application form and at other phases of the credentialing process. Are there “Americans with Disabilities Act” considerations?
• Giving and getting meaningful references
• Credentialing options for low-volume/no-volume practitioners
• Conditional reappointment

ER Call & EMTALA
• EMTALA hot spots
• Dealing with difficult on-call issues
• The role of advanced practice clinicians in serving on the call list and assisting with on-call responsibilities

Medical Staff Bylaws
• Hot topics in Medical Staff Bylaws
• Best practice recommendations for Medical Staff Bylaws and other Medical Staff policies
• Steps for successful revision of Medical Staff Bylaws

Precautionary Suspension & Restriction
• Appropriate (and not appropriate) situations for precautionary suspension
• Options to address immediate concerns – other than precautionary suspension
• NPDB reporting of precautionary suspension

Privileging Challenges
• Managing relinquishment of privileges, to avoid operational disruption
• Privileges for new procedures
• Privileges that cross specialty lines
• Privileging advanced practice clinicians
• Privileging low and no volume providers
• Telemedicine privileging

Conducting Effective Investigations
• When and how to initiate an investigation
• Obtaining external reviews
• Recognizing and managing conflicts of interest
• A checklist important steps in the investigation process
• Managing reappointment during the course of an investigation
• Giving a reference for a practitioner who is under investigation

National Practitioner Data Bank Reporting
• What is – and is not – reportable?
• Best tips for drafting a report
• Employment actions and reports to the NPDB
• When does a relinquishment or resignation constitute a “surrender” of privileges while under investigation?
• When does a peer review activity constitute a “restriction” of privileges?

Collegial Intervention
• Who should do it? How far can you go?
• Tips, tools and implementation
• Documentation

Confidentiality/Documentation/Access to Files
• Fundamentals of confidentiality for credentialing and peer review information and files
• What should be in minutes?
• Confidentiality in the electronic age
• Physician access to information
• Access to information within the hospital
• Sharing of information within the system
• Disclosure of information outside the hospital (references, affiliation verification, and more)

Intersection of Employment and the Medical Staff
• Is credentialing a Management, Medical Staff, or joint responsibility?
• Essential terms in an employment agreement
• When issues arise, which policy should be followed?
• Effect of termination of employment on Medical Staff appointment

Update on Stark Antikickback Statute and the False Claims Act on Physician Agreements