Horty Springer April Grand Rounds: Back to the Basics – Documenting Progressive steps and Other Credentialing and Peer Review Activities 4.4.23
Upon completion of this audio conference, participants should be able to:
Give appropriate notice of peer review activities, which not only complies with due process requirements and Medical Staff Bylaws but also promotes transparency and fundamental fairness for practitioners Generate documentation of progressive steps that reflects a tone congruent with the seriousness of the stage of review Identify the legal, practical, and patient safety risks of failing to appropriately document credentialing or peer review activities
April Grand Rounds – Back to the Basics:
Documenting Progressive Steps and Other
Credentialing and Peer Review Activities
April 4, 2023 - 1:00 pm to 2:00 pm (ET)
Almost all Medical Staff leaders will, at some point, be called on to engage in credentialing
and/or peer review of a colleague, whether it’s a collegial, mentoring meeting or, at the more
extreme side of things, an MEC meeting where adverse action is on the table. So, it’s important
that all physician leaders understand when and how to document credentialing and peer review
activities – and also appreciate the difference in tone and treatment when generating
documentation relating to early collegial efforts versus that involving more formal professional
The pros and cons of creating written documentation of Medical Staff activities
The importance of tone in all professional review communications
Documenting requests for clarification of suspected misrepresentations and/or omissions
Notifying a practitioner of an incomplete application
Notification of application withdrawal
Requests for information from Medical Staff members
Invitations to meet
Mandatory meeting notifications/invitations
Drafting a follow-up letter to an initial mentoring effort or a collegial intervention
What goes in a written Performance Improvement Plan?
Documentation of a Medical Staff investigation
Adequate notice when the MEC is considering denial or revocation
Documentation of an adverse recommendation by the MEC
What goes in a notice of adverse recommendation/ notice of right to a hearing?
Phil Zarone, JD
Ian Donaldson, JD
In support of improving patient care, this activity has been planned and implemented by the University of Pittsburgh and Horty Springer Seminars. The University of Pittsburgh is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
The University of Pittsburgh School of Medicine designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Other health care professionals:
Other health care professionals will receive a certificate of attendance confirming the number of contact hours commensurate with the extent of participation in this activity.
- 1.00 AMA PRA Category 1 Credit™The University of Pittsburgh School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
- 1.00 Attendance