CHESAPEAKE REGIONAL HEALTHCARE 
November 3 & 4, 2022 
Medical Staff Leadership Training Agenda 
THURSDAY – NOV. 3, 2022 
Time Topic 
1:00 – 1:45 p.m. Giving Confidence – Legal Protections for Medical Staff Leaders 
 Medical Staff Law 101 
 How the Law Protects You! 
1:45 – 2:45 p.m. Effective Peer Review of Clinical Concerns 
 Obstacles to effective reviews 
 Best practices to create an educational, non-punitive peer 
review process 
 Addressing employed practitioners 
 Obtaining meaningful input from those under review 
2:45 – 3:00 p.m. Break 
3:00 – 3:45 p.m. Stuff Happens on the Best of Medical Staffs! – What Do You Do 
First?
 How to Conduct an Effective “Collegial Intervention”
 The Progressive Steps Continuum - Using “Discipline” Is a 
Last Resort!
3:45 – 4:30 p.m. Performance Improvement Plans for Peer Review of Clinical 
Concerns 
 Best practices for effective plans 
 Case studies 
4:30 – 4:45 p.m. Precautionary Suspensions – When All Else Fails 
 Alternative to precautionary suspensions 
 Implementation tips to protect patients, respect the practitioner, 
and minimize legal risk 
4:45 – 5:00 p.m. Anything Goes Q&A 
 
FRIDAY – NOV. 4, 2022 
Time Topic 
8:00 – 9:00 a.m. Meet Dr. Bourne: Initial Application Case Study 
 Spotting “Red Flags” in an Application 
 But What if You Are “in Dire Need of…”? 
9:00 – 9:45 a.m. Credentialing Tips 
 Importance of eligibility criteria 
 Not processing incomplete applications 
 Avoiding “denials” 
 Responding to reference requests
9:45 – 10:00 a.m. Break 
10:00 – 10:45 a.m. Hot Topics in Privileging 
 What Could Go Wrong?
 “Turf Battles” and New Privileges
 Advanced Practice Providers
10:45 – 11:45 a.m. Medical Staff Leader Potpourri 
 EMTALA 
 National Practitioner Data Bank 
 HIPAA and the Medical Staff 
 Conflicts of interest 
11:45 a.m. – Noon Anything Goes Q&A 
Noon – 1:00 p.m. Lunch 
1:00 – 1:45 p.m. Dealing with Behavior that Undermines a Culture of Safety 
 Connection between behavior and patient safety 
 Best practices for addressing behavioral concerns 
1:45 – 2:30 p.m. Practitioner Health 
 How common are health concerns? 
 Best practice tips for reviewing health issues using the 
Southcoast Practitioner Health Policy 
 What to do about late career practitioners 
2:30 – 2:45 p.m. Break 
2:45 to 3:30 p.m. Conducting an Effective and Legally Sound Investigation 
 How to decide when formal action is necessary
 Conducting an iron-clad investigation
 Preparing for an adverse recommendation 
3:30 to 4:00 p.m. Attracting, Preparing, and Maintaining Medical Staff Leaders 

Disclaimer Statement

The information presented at this CME program represents the views and opinions of the individual presenters, and does not constitute the opinion or endorsement of, or promotion by, the UPMC Center for Continuing Education in the Health Sciences, UPMC / University of Pittsburgh Medical Center or Affiliates and University of Pittsburgh School of Medicine.  Reasonable efforts have been taken intending for educational subject matter to be presented in a balanced, unbiased fashion and in compliance with regulatory requirements. However, each program attendee must always use his/her own personal and professional judgment when considering further application of this information, particularly as it may relate to patient diagnostic or treatment decisions including, without limitation, FDA-approved uses and any off-label uses