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The Advanced Roundtable
for Physician Leaders

The AHP Workshop

The Complete Course for
Medical Staff Leaders

The Credentialing Clinic

Governance for the Future

Hospital-Physician Financial Arrangements:
New Rules, New Risks, New Relationships

On-Call & EMTALA

The P.E.E.R. Program

 

   
 
 
 
 
 
       
 
   

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

  • Mock Hearing

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
  • Practical Tips for Compliance with the 2007 Joint Commission Medical Staff Standards

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

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