Introduction

Pathways 2026 Session 2: The Medical Staff Credentials Policy – Essentials & Updates

The second Pathways installment of 2026 will cover recommendations and updates for the Medical Staff Credentials Policy. The Credentials Policy serves as a guide to the Medical Staff’s processes related to appointment, reappointment, and the granting of clinical privileges. It also provides tools for addressing performance issues when they arise and covers the details of the Medical Staff’s formal peer review procedures (i.e., Medical Staff investigations, hearings, and appeals).

Topics Covered

Modern threshold eligibility criteria, including trends in board certification requirements (are there any new Boards commonly being accepted by hospitals and/or payors?), requirements related to fulfillment of Medical Staff responsibilities (on-call, participation in training, and more!), and criteria to factor in at the time of reappointment;

Options to build carefully-defined flexibility into the eligibility process, without undermining objectivity or opening the flood gates (including routine exceptions, exceptional waivers, and clinical privileges with skills enhancement processes);

Policy provisions that promote administrative management instead of adverse professional review action where subjective consideration of clinical performance and/or professional conduct are not required;

Bylaw and policy language that distinguishes routine peer review from formal Medical Staff investigations;

Essential hearing and appeal provisions, to ensure transparency and due process and maintain order over the proceedings.

Who Will Benefit?

The 2026 Pathways program can benefit all of the following:

Medical Staff officers
Bylaws Committee members
Credentials Committee members
Medical Executive Committee members
Medical Staff Services Professionals (MSSPs) and other hospital or CVO personnel who support the Medical Staff
Chief Medical Officers
In-house counsel
Governing Board members
Medical Staff members looking to get more involved in Medical Staff leadership

About HortySpringer Pathways

What is Pathways? It’s a training program for hospital and physician leaders who are looking to develop and enhance the skills they need to manage and oversee the hospital’s Medical Staff. Key features:

FOCUSED
Each Pathways Series is focused on a topic – or “theme” – that health system, hospital, and physician leaders have told us is essential and timely. Avoiding the sound bites and consultant-talk that permeate so many leadership training courses that are on the market, Pathways favors a deeper discussion of the topics at hand and take-home tips that can be implemented right away.

INCLUSIVE
Medical Staff leadership does not occur in a vacuum. While the “self-governance” of the Medical Staff is largely the purview of the organization’s practicing physicians, a multitude of individuals and bodies support and oversee Medical Staff activities: Board members, advanced practice clinicians, health system and hospital administrators, quality professionals, medical staff services professionals, HR professionals, executive recruiters, and more! Pathways web-based format allows organizations to finally make Medical Staff leadership training available to all of these individuals, fostering shared understanding and the implementation of aligned and unified policies, procedures, and leadership strategies across the organization.

ACCESSIBLE
Each Pathways webinar has been designed to require a minimal-to-moderate time commitment and to allow training to be completed from the comfort of your own home or workplace. With four 2-hour web-based training sessions spread over the course of several months, participation in the Pathways leadership program means not having to forego leadership development when time for training is limited or travel is difficult or impossible.

Webinar Disclaimer

The information presented during a webinar and any supplementary materials provided to registrants are intended for educational and informational purposes only. Nothing contained therein is to be considered as the rendering of legal advice for specific cases or circumstances.

No one should act or refrain from acting on the basis of any information presented during a webinar without seeking the appropriate legal or other professional advice on the particular facts and circumstances at issue from a lawyer practicing as permitted by applicable laws, regulations or rules of professional conduct. No attorney-client relationship is formed by registration for a webinar or the use of the supplementary materials.