Introduction

HortySpringer Pathways Webinar Session 1: Internal and External Evaluations and Assessments

One of the most difficult aspects of peer review is obtaining the meaningful expertise of a peer. Medical Staff leaders frequently wrestle with the details: How can we convince our physician colleagues to spend the time on reviews? Who is qualified to offer expertise (especially if we only have one subspecialist in the field)? Can the medical director of a group with an exclusive contract review the members of the group? For that matter, can physicians in the same specialty review those outside of their group (economic competitors)? When do we need to start looking at external review?

And if we do choose external review, are there steps we can take to make the process fair and useful? Get written reports that are more helpful to the PPE process? Ensure the reviewer has the expertise we need? What if the reviewer’s report does not confirm our internal peer reviewers’ initial concerns? Should we share the outcome of an internal or external review with the practitioner? When? And what if the practitioner wants to talk to the reviewer? What if we want to talk to the reviewer? How can we accomplish our review needs without undermining the impartiality of the process?

What if retrospective review is not sufficient – and we need the practitioner to be further assessed or monitored? How can we ask for that? And what if the practitioner resists? Is there any way to make the assessment and evaluation process more efficient so that those involved in PPE can get the information they need and get on to the good stuff (working on quality improvements)?

Topics to be Covered:

The peer review continuum

Conducting reviews internally, while managing limited leadership capacity and sorting out the conflicts of interest that exist on every Medical Staff

The value in separating clinical evaluation/expertise from the rest of the review process

The benefits of review forms (and abandoning punitive methods, like scoring)

How to identify and manage conflicts of interest in peer review

When to notify a practitioner that evaluation/review of a case is underway

Managing external review as part of the PPE process (and whether to involve the practitioner in the selection of the reviewer and/or consideration of the reviewer’s report)

How to respond when the practitioner under review submits conflicting input and/or obtains a contradictory external review

Requesting a practitioner’s cooperation with a third-party assessment/evaluation (e.g. a fitness for practice assessment or clinical competency assessment)

Bylaws/policy language that gives you the tools you need to obtain compliance with evaluation/assessment requests, without hassle or delay

About HortySpringer Pathways

Introducing HortySpringer Pathways – a new training program for hospital and physician leaders who are looking to develop and enhance the skills they need to manage and oversee the hospital’s Medical Staff.

FOCUSED

Each Pathways Series is focused on a topic – or “theme” – that health system, hospital, and physician leaders have told us is essential and timely. Avoiding the sound bites and consultant-talk that permeate so many leadership training courses that are on the market, Pathways favors a deeper discussion of the topics at hand and take-home tips that can be implemented right away.

INCLUSIVE

Medical Staff leadership does not occur in a vacuum. While the “self-governance” of the Medical Staff is largely the purview of the organization’s practicing physicians, a multitude of individuals and bodies support and oversee Medical Staff activities: Board members, advanced practice clinicians, health system and hospital administrators, quality professionals, medical staff services professionals, HR professionals, executive recruiters, and more! Pathways’ web-based format allows organizations to finally make Medical Staff leadership training available to all of these individuals, fostering shared understanding and the implementation of aligned and unified policies, procedures, and leadership strategies across the organization.

ACCESSIBLE

Each Pathways webinar has been designed to require a minimal-to-moderate time commitment and to allow training to be completed from the comfort of your own home or workplace. With four 2-hour web-based training sessions spread throughout the year, participation in the Pathways leadership program means not having to forego leadership development when time for training is limited or travel is difficult or impossible.

Who Should Attend?

The 2024 Pathways program can benefit all the following:

Medical Staff members identified for leadership potential, but not yet placed in a leadership role
Medical Staff officers
Chief Medical Officers
Peer review/PPE committee members
Members of a Medical Staff Leadership Council (or similar officers council/committee)
Members of a Medical Staff professionalism committee
Other physician leaders involved in professional practice evaluation
Hospital personnel who support the peer review/PPE processes (for example, Medical Staff Services directors, quality department directors)
In-house counsel who advise the Medical Staff or Board
Governing Board members (particularly, members of a Board subcommittee on quality)

HortySpringer Webinar Disclaimer

The information presented during a webinar and any supplementary materials provided to registrants are intended for educational and informational purposes only. Nothing contained therein is to be considered as the rendering of legal advice for specific cases or circumstances.

No one should act or refrain from acting on the basis of any information presented during a webinar without seeking the appropriate legal or other professional advice on the particular facts and circumstances at issue from a lawyer practicing as permitted by applicable laws, regulations or rules of professional conduct. No attorney-client relationship is formed by registration for a webinar or the use of the supplementary materials.