Day One - Credentialing
“Survey says ...”
Protections
for Leaders
- Focus on the Patients,
Not on the Lawyers
- Legal & Practical Protections
View from
the Trenches:
Perspective of a Volunteer Leader
Tips for Effective Credentialing
- Case Study
- Threshold Criteria - Raising the Bar
- ACGME General Competencies
- Recognizing Red Flags
- Effectively Getting (and Giving) References
- Dealing with Difficult Applications
- Don’t
Process Incomplete Applications!
- Set Expectations for New Members
Temporary Privileges
- New Applicants, Important Patient Care Need, and Locum Tenens
Reappointment
- An Educational Opportunity
- “Performance-Based” Reappraisal/Quality Profiles
- When There’s Nothing to Evaluate...
- Techniques for Conditional Reappointment
Effective Privilege Delineation
- Core and Supplemental Privileges
- Developing Criteria for New Procedures/
Technology & Procedures That Cross Specialty Lines
Day Two - Peer Review
The
Peer Review Continuum
- “Triage” of Issues that Arise —
Quality/Competence? Behavior? Health?
- Who Conducts the “Triage” and Decides How to Proceed?
- What Are the Options — Peer Review Policy?
Code of Conduct? Practitioner Health Policy? Bylaws?
Addressing a Quality Concern
- Collegial Intervention Regarding
a Quality Concern
- Progressive Steps for Quality
- Essential
Elements of an Effective Peer Review Policy
How to Deal with “Disruptive” Behavior
- Collegial Intervention
- Progressive Steps for Conduct
- Code of Conduct Policy
When Physician Health is an Issue
- Collegial Intervention When Health Is an Issue
- Progressive Steps and Accommodation
- Practitioner Health Policy
What Goes into a Physician’s File?
- How Do You Document Collegial Intervention and Progressive Steps?
- Do Physicians Have a Right to See Their Files?
- Should Physicians Be Able to Respond to Items Placed in Their Files?
- When Should Items Be Removed from a File?
Dealing with Conduct Outside the Hospital
- Medicare/Medicaid Exclusion, Criminal Conduct, Peer Review Actions at Another Hospital,
Conduct in the Physician’s Office,
Malpractice Suits
Anatomy of an Investigation
- Case Study
- How to Document the Process
- Who Should
Investigate?
- Should Lawyers Be Involved?
- Effective Use
of Outside Consultants
- Precautionary Suspensions
Day Three - Policy Issues
Hearing Procedures
How to Handle Conflicts of Interest
- Does Every Member in the Department of
the Physician Under Review Have a Conflict?
- When and How Should You
Recuse Yourself?
Keys to Confidentiality
- Confidentiality Policies and Agreements
- What Should Be in Minutes? What Shouldn’t?
- How to Protect Minutes and Other Documents
- Peer Review in
Cyberspace: What Safeguards Do You Need?
National
Practitioner Data Bank
- What’s Reportable? What’s Not?
OPPE and FPPE
Effective
Medical Staff Documents
- Medical Staff Bylaws
- Credentials Policy
- Organizational Manual — Minimizing
Bureaucracy/Reducing Committees/Giving Yourself the Gift
of Time
- AHP Policy
On-Call Problems and Solutions
- On Call 24/7/365?
- Specialists Who Want Limited Call
- Demands for Payment
- “Exemptions” for Senior Physicians
- Failure to Respond
Attracting Physicians to
Leadership/Rewards
for Medical Staff Leaders
REGISTER
NOW

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