Horty Springer Baycare Medical Staff Leadership Bootcamp November 4-5, 2022
- Identify legal issues that affect credentialing
- Define the benefits of having policies and procedures to address problem practitioners Identify
- Manage the variety of peer review issues that confront them in their roles as physician leaders
- Define the legal responsibilities of Medical Staff leaders and the legal protections available to them.
DAY 1 – NOVEMBER 4
8:00 A.M. – 9:30 A.M. PREPARING MEDICAL STAFF LEADERS FOR EXCELLENCE
• Legal Protections for Leaders – the Law is on Your Side!
Good leaders need confidence when tackling tough issues. They shouldn’t have to worry about whether their actions will land them in court – or cause them to face a big judgment. The Health Care Quality Improvement Act (HCQIA), Florida’s Peer Review statute, and your own policies and documents protect you from liability when performing credentialing and peer review activities – but there are steps you should take to maximize your protection. Act fairly, honor confidentiality, be transparent, and address conflicts of interest. Learn about these – and other ways – to make sure you’re protected as a leader!
• “A Year in the Life” of a Medical Staff Leader
• Coordination, Combination, and Unification of Medical Staff Activities – the Pros, the Cons, and the Questions to Ask
9:30 A.M. – 10:30 A.M. ADDRESSING QUALITY CONCERNS THROUGH MEANINGFUL PEER REVIEW
• The top reasons traditional peer review does not work
• A more collegial, functional, efficient peer review process
• Who does what?
• How to identify cases for review
• The value of a central repository
• Prep work & support
• Built-in triage
• Transparency – a key to success!
• Clinical review forms
• How multidisciplinary peer review committees work
• Progressive Steps of Collegial Intervention
• Performance Improvement Plans: An improvement-centered approach!
10:30 A.M. – 10:45 A.M. BREAK
10:45 A.M. – 12:00 P.M. HOW TO MANAGE PROFESSIONALISM CONCERNS – AND LIVE TO TELL THE STORY
• MEET DR. DOSRUPTIVE
• Professional conduct issues differ from other concerns about practitioners in a few important ways. In this segment, we will talk about what sets professional conduct apart – and provide tips for being prepared, no matter what outrageousness may come your way!
• The value of a Medical Staff Professionalism Policy to guide management of these most difficult professional conduct issues
• Top tips for management of professionalism issues
12:00 P.M. – 1:00 P.M. LUNCH
1:00 P.M. – 2:45 P.M. PEER REVIEW PRACTICES IN ACTION
CASE STUDY – MEET DR. DEWY
Dr. Dewy is new to town and comes with some history. But, she is joining an established practice and shows lots of potential. When a few of her cases are identified for review, careful management of the review process could be the difference between helping a young practitioner succeed or driving her out. Concepts to be covered include:
• When and how to notify a practitioner that clinical concerns have been raised through the peer review process
• Deciding if precautionary suspension is appropriate – and acting on that decision
• Planning a collegial meeting to discuss clinical concerns
• Formulating performance improvement plans for clinical performance issues
• Whether – and what – to report to the National Practitioner Data Bank (NPDB) when a practitioner under review voluntarily resigns privileges, agrees to proctoring, or simply “goes away”
2:45 P.M. – 3:00 P.M. BREAK
3:00 P.M. – 3:30 P.M. NPDB – WHAT’S REPORTABLE? WHAT’S NOT? WHAT DOES THE MEDICAL STAFF LEADERSHIP NEED TO KNOW ABOUT IT?
3:30 P.M. – 4:00 P.M. MANAGING CONFLICTS OF INTEREST IN CREDENTIALING, & PEER REVIEW – A METHODICAL & PRACTICAL APPROACH
4:00 P.M. DAY 1 CONCLUDES
DAY 2 – NOVEMBER 5
8:00 A.M. – 8:20 A.M. WHY DO WE CREDENTIAL?
8:20 A.M. – 9:00 A.M. CREDENTIAL AS IF YOUR LIFE DEPENDS ON IT
• Establishing detailed threshold criteria
• Appropriately considering waivers
• Spotting red flags
• Managing incomplete applications
• Addressing misrepresentations administratively
• Aligning recruitment and credentialing
9:00 A.M. – 10:00 A.M. PRIVILEGING MATTERS
• Delineation and Relinquishment of privileges
• Requests for privileges to perform new treatments/procedures
• Requests for privileges that cross specialty lines
• Privileges for Advanced Practice Professionals (APPs)
• Low and no volume practitioners
10:00 – 10:15 BREAK
10:15 A.M. – 12:00 P.M. CREDENTIALING PRACTICES IN ACTION
CASE STUDY – MEET DR. ANGLE!
When it comes to unprofessional conduct, seasoned hospital and medical staff leaders know that it is far better to identify disruptive physicians when they are on your doorstep – rather than after they have moved in and taken up residence. Physician leaders hardly have time to willingly take on an established troublemaker! But, how do you know if an applicant is disruptive? And how do you find out whether the behavior is a big problem – or– something you can live with? It’s not as easy as you’d think.
At the conclusion of this case study, leaders should understand the important gatekeeping role that credentialers play and the strategies that credentialers can use to ensure that they never grant membership or privileges to someone about whom they feel unsure. Concepts to be covered include:
• The importance of threshold eligibility criteria
• Why waivers should be used sparingly
• The value of following-up on red flags
• Making the most of the concept of the “incomplete” application
• Managing misrepresentations and omissions administratively
12:00 P.M. DAY 2 CONCLUDES
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 10.25 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.
- 10.25 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.
- 10.25 Attendance