Horty Springer Chesapeake Regional Healthcare Medical Staff Leadership Program November 3-4, 2022

November 3, 2022 to November 4, 2022

Target Audience


Learning Objectives

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.

Course summary
Available credit: 
  • 9.25 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.
  • 9.25 Attendance
Course opens: 
Course expires: 
Event starts: 
11/03/2022 - 1:00pm EDT
Event ends: 
11/04/2022 - 5:00pm EDT

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 
 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 
 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 
 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

Chesapeake Virginia
United States

Phil Zarone, JD
LeeAnne Mitchell, JD

Faculty Disclosure

No members of the planning committee, speakers, presenters, authors, content reviewers and/or anyone else in a position to control the content of this education activity have relevant financial relationships with any proprietary entity producing, marketing, re-selling, or distributing health care goods or services, used on, or consumed by, patients to disclose.

Accreditation and credit designation

In support of improving patient care, 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.

Physician (CME)

The University of Pittsburgh School designates this live activity for a maximum of 9.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Other Healthcare 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.

Available Credit

  • 9.25 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.
  • 9.25 Attendance
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