Horty Springer Reston Hospital Center Medical Staff Leadership Education 9.30.23

September 30, 2023

Target Audience

Nurse Practitioner
Pharmacy Technician
Physician Assistant

Learning Objectives

Upon completion of this program, participants should be able to:

identify legal issues that affect credentialing and should be able to define the benefits of having policies and procedures to address problem practitioners

identify “best practices” for medical staff peer review and recognize potential legal risks or inefficient or ineffective peer review procedures.

Course summary
Available credit: 
  • 6.25 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.
  • 6.75 Attendance
Course opens: 
Course expires: 
Event starts: 
09/30/2023 - 8:00am EDT
Event ends: 
09/30/2023 - 5:00pm EDT

Time Topic 
8:00 – 8:15 a.m. Welcome, Introductions, & Overview
8:15 – 9:00 a.m. Confidence to Become Great Leaders – Despite What You Hear, the Law Is 
on Your Side!
 Medical Staff Law 101 
 Legal and practical protections when serving as a Medical Staff leader 
 Focus on the patients, not on the lawyers 
9:00 – 10:00 a.m. Credentialing for Excellence – Tools, Tips, and Tactics 
 Good policies and procedures – the road map for everything you do 
 Use your threshold eligibility criteria 
 Don’t process incomplete applications 
 Skills enhancement process 
 Avoid unnecessary “denials” 
 Responding to reference requests 
10:00 – 10:15 a.m. Break 
10:15 – 11:00 a.m. Collegial Counseling and Other Progressive Steps
 Using the “progressive steps continuum” 
 How to conduct an effective collegial counseling session 
 Documentation – tone and content, and where is it kept? 
11:00 – 11:30 a.m. What if You Can’t “Fix” Something? 
 Precautionary suspensions (or voluntary refrainment?) 
 What happens if you have to take an “adverse action”? 
11:30 – Noon Tips for Conducting a Medical Staff Investigation 
Noon – 12:30 p.m. Lunch 
4863-1283-8249, v. 1 2 
12:30 – 1:15 p.m. Let’s Take “The Peer Review Challenge” 
 Peer review basics 
 Understanding FPPE and OPPE 
 Tips, traps, and tools 
1:15 – 2:00 p.m. Understanding the Behavior/Patient Safety Connection 
 What do physicians, accrediting entities, and courts say about the 
connection between behavior and patient safety? 
 Tools that should be in your policy 
 Performance Improvement Plans for conduct 
 What about a Medical Staff member’s bad behavior on Social Media? 
2:00 – 2:15 p.m. Break 
2:15 – 3:00 p.m. Practitioner Health 
 How common are health concerns? 
 Best practice tips for reviewing health issues using the Practitioner Health 
 What about “late career practitioners”? 
3:00 – 3:45 p.m. Understanding Your Medical Staff Bylaws – and How They Work for You!
3:45 – 4:00 p.m. Attracting and Preparing 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.

Reston Hospital Center, A & B Pavilion II 
1850 Town Center Drive 
Reston, VA
United States

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 6.75 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

  • 6.25 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.
  • 6.75 Attendance
Please login or register to take this course.