Horty Springer Fast Forward to the Future Medical Staff Bylaws Update 8.8.23

August 8, 2023

Target Audience


Nurse Practitioner


Pharmacy Technician


Physician Assistant


Learning Objectives

Learning Objectives Upon completion of this audio conference, participants should be able to: 
1. Articulate the differences between moonlighting and training 
2. Identify the situations in which moonlighting is permitted by law 
3. Implement policies to ensure clinical privileges are appropriately delineated and granted to residents and fellows who moonlight outside of their training program 
4. Establish a process for monitoring the performance of moonlighting residents and fellows so that appropriate steps can be taken to manage any concerns that may arise

Course summary
Available credit: 
  • 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
Course opens: 
Course expires: 
Event starts: 
08/08/2023 - 1:00pm EDT
Event ends: 
08/08/2023 - 2:00pm EDT

August Grand Rounds – Fast Forward to the Future: Medical Staff Bylaws Update

August 8, 2023 - 1:00 pm to 2:00 pm (ET)

During this installment of Grand Rounds, we will discuss “hot topics” (including 2022-23 update!) and summarize the best practice recommendations for Medical Staff Bylaws and other Medical Staff policies that were covered throughout the course.  Take home a checklist of “best practices” for Bylaws that use to evaluate your current documents – or make improvements – right away.


  • The Joint Commission is now allowing three-year credentialing cycles! We will discuss the pros and cons of credentialing every three years vs. two years.
  • In many jurisdictions, the peer review privilege is under attack. Bylaw and policy language making it clear that individuals are performing activities at the request of committees, specifying the duties of committees and their members, etc., can make all the difference when arguing that your records of peer review activities should be protected.
  • Transparency is key to information sharing! Most practitioners now agree that it is reasonable and appropriate for health care providers within a system (and sometimes outside a system) to liberally share information concerning practitioners they have in common.  But, not all have established methods or policy language to support liberal sharing.  We will discuss the importance of applicant databases, push notifications, pull notifications, and policy language supporting all of these important tools.  We will also discuss notification and involvement of practitioner employers in the peer review process.
  • Eligibility criteria update
  • Modernize your meetings! In the wake of COVID-19, and with many Medical Staffs combining functions or unifying, the nature of meetings has fundamentally changed.  You can revise your Bylaws to provide leaders with the tools that are necessary to make meetings easier to attend and, in turn, increase participation and engagement.

Upon completion of this audio conference, participants should be able to:

  1. Update the threshold eligibility criteria set forth in the Medical Staff Bylaws or related Medical Staff policies (e.g., Credentials Policy) to incorporate more stringent criteria and/or to clarify ambiguities in existing criteria to allow for easier, fairer enforcement
  2. Update Bylaws language to better maximize privilege protections for credentialing and peer review information and avoid waiver of that privilege wherever possible
  3. Make changes to attendance and meeting requirements to reflect more modern methods by which Medical Staff leaders conduct their activities

Faculty: Rachel Remaley

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.


Pittsburgh, PA
United States

Rachel Remaley

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 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.  


Available Credit

  • 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
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