Horty Springer Children's National Hospital - Washington DC - Medical Staff Leadership Training 5.4.23

May 4, 2023

Target Audience

Nurse Practitioner
Pharmacy Technician
Physician Assistant

Learning Objectives

Learning Objectives:

  • Identify the process and techniques that promote effective and efficient credentialing practices for initial appointment, reappointment and clinical privileges.
  • Identify those elements that commonly impede the peer review process, as well as practices for an organized, constructive, effective peer review process.
  • Utilize collegial intervention and other progressive steps when attempting to address issues related to a practitioner’s clinical competence and/or professional conduct.
  • Review reporting requirements for the National Practitioner Data Bank around investigations, suspensions, revocation of temporary privileges and more.
Course summary
Available credit: 
  • 7.50 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.
  • 7.50 Attendance
Course opens: 
Course expires: 
Event starts: 
05/04/2023 - 8:00am EDT
Event ends: 
05/04/2023 - 3:30pm EDT


8:00–8:15 a.m. Challenges of Leadership –
Patient Safety Starts with You!

8:15–9:15 a.m. Credentialing for Excellence – The Foundation of
Quality Patient Care
In our world “Just Ok” is Not OK!!
Threshold eligibility criteria – Avoiding “denials”
Don’t process applications with misstatements and omissions
What to do with red flags in applications
Obtaining and giving references
Make reappointment more meaningful

9:15–10:00 a.m. Clinical Privileges Challenges – Temporary Privileges & Locums
Telemedicine privileges
“Turf battles” and new procedures
Advanced Practice Providers

10:00–10:15 a.m. Break

10:15–11:00 a.m. Let’s Take the Peer Review Challenge!
Top reasons why peer review fails
Keeping the physician in the loop
Effective action plans

11:00 a.m.–Noon Peer Review Principles in Action: The Return of Dr. Bourne
The return of Dr. Bourne: Interactive case study in peer review
Progressive steps, including mentoring and collegial intervention
Options for performance improvement plans

Noon–1:00 p.m. Lunch

1:00–1:30 p.m. The Art of Conducting a Collegial Meeting: A Case Study
Planning and implementing an effective collegial meeting
Making sure you don’t get thrown off track
o when the practitioner does not show up
o when the practitioner brings a lawyer to the meeting
o when the practitioner starts recording the meeting on her iPhone

1:30–2:15 p.m. How to Deal with Disruptive Behavior that Undermines a Culture of Safety
Classic characteristics of disruptive conduct
Behaviors that undermine a culture of safety
Best practices in dealing with disruptive behavior

2:15–2:30 p.m. Break

2:30–3:00 p.m. National Practitioner Data Bank: What’s Reportable, What’s
Not, and Why??

3:00–3:30 p.m. Peer Review Protection
Requirements for immunity under the Health Care Quality
Improvement Act
State peer review statute
Other protections (release language in bylaws and application forms)
Director’s and Officer’s Insurance
Indemnification Policy

3:30–3:55 p.m. Attracting and Mentoring Medical Staff Leaders
Defining qualifications for leaders
Revamping the nomination process
Keep your leaders longer
Rewards for leadership

3:55–4:00 p.m. Closing Remarks

Washington, DC, DC
United States

Susan Lapenta, JD

Hala Mouzaffar, 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 Statement:
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 7.5 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.

Available Credit

  • 7.50 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.
  • 7.50 Attendance
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