Medical Staff Investigations


	The Advanced Roundtable for Physician Leaders The Complete Course for Medical Staff Leaders The Credentialing Clinic Governance for the Future Hospital-Physician Financial Arrangements: New Rules, New Risks, New Relationships Medical Staff Investigations and Hearings Seminar Topics Faculty Who Should Attend Registration Certification Seminar Schedule Brochure On-Call & EMTALA The P.E.E.R. Program



	Medical Staff Investigations and Hearings

	Medical Staff Investigations and Hearings is an intensive day-and-a-half program focusing on legal problems related to peer review disputes. Using a combination of case studies and interactive sessions, senior partners from the health law firm of Horty, Springer & Mattern, P.C. will address both strategy and tactics for dealing with problem physicians through the medical staff peer review and corrective action processes, as well as related issues. Seminar Topics Dovetailing peer review/QA/PI process into reappointment and investigations JCAHO’s requirement for benchmarking –be careful not to open the door to discovery Build a good record – start with progressive steps! Use performance improvement plans! Investigations When/how does a formal investigation begin? And why this question matters. Who should conduct an investigation? Full MEC? Credentials Committee? Investigating Committee? Witness interviews and summaries Outside reviews and evaluation programs When should you consider suspension? What pitfalls can be anticipated and avoided? Credentials/MEC recommendations Meeting with affected practitioner – should attorneys be present? Form of recommendation Notice of adverse action Take control of the hearing process Developing a fair hearing plan that anticipates and minimizes the potential for disruptive tactics Limiting the role of attorneys so the physicians on the hearing panel can focus on the clinical or behavioral issues. (Is it OK to say lawyers can be seen but not heard?) Defining the information that will be shared (and not shared) Creating a pre-hearing process that requires the exchange of documents and the resolution of objections in advance of the hearing Limiting the number of hours for a hearing so it cannot be dragged on for months Preparing witnesses Selecting a hearing panel and a hearing officer and preparing them for their responsibilities Preparing the record, including documentation of progressive steps to address problems, investigation report and the hearing Statement of Reasons Board action: format, notice Data Bank reports: when they are required and when they are not Negotiated settlements: key terms, to report or not report? What can you/should you say in response to future inquiries – whether or not there is a settlement agreement? What’s the hospital’s duty? Protect against a new liability risk – implications of the Kadlec case Confidentiality Developing policies and educating physicians Conflict of interest and managing appearances Litigation challenging professional review actions Preparing for injunction actions Forum for dispute: state/federal courts, administrative agencies Alternative dispute resolution: arbitration, mediation Common legal theories: antitrust, interference with business, defamation, violation of civil rights/antidiscrimination laws, breach of contract, “whistleblower” claims Immunities: HCQIA, state peer review protection laws, state action immunity, importance of building a record Preserving the peer review privilege What steps need to be documented during the peer review process? How much detail is needed in meeting minutes and other documentation? How do you avoid waiving the peer review privilege or other applicable privileges? How long must peer review documentation be retained? What are the uses – and limitations – of the attorney-client privilege and attorney work product doctrine in protecting peer review information? Does the federal Patient Safety and Quality Improvement Act of 2005 offer any hope for peer reviewers? Sharing peer review information: the pros and cons of being forthright, releases, memoranda of understanding Exclusive contracts – heading off litigation How to establish a good record to support an exclusive contract RFP process Effect on ability to practice of current staff members – if they aren’t part of the new contract How to prepare for an injunction action Building a good foundation for future protection Make your medical staff documents work for you: key elements of bylaws, credentials policies, rules and regulations, allied health practitioner policy Related policies: Code of Conduct, Practitioner Health Policy, Peer Review Policy Hospital bylaws provisions relating to the medical staff Statements of Expectations for All Staff Members Medical Staff leadership – tips for managing change REGISTER NOW