April Grand Rounds – Back to the Basics: Documenting Progressive Steps and Other Credentialing and Peer Review Activities

April 4, 2023 - 1:00 pm to 2:00 pm (ET)

Almost all Medical Staff leaders will, at some point, be called on to engage in credentialing and/or peer review of a colleague, whether it’s a collegial, mentoring meeting or, at the more extreme side of things, an MEC meeting where adverse action is on the table.  So, it’s important that all physician leaders understand when and how to document credentialing and peer review activities – and also appreciate the difference in tone and treatment when generating documentation relating to early collegial efforts versus that involving more formal professional review activities.


  • The pros and cons of creating written documentation of Medical Staff activities
  • The importance of tone in all professional review communications
  • Documenting requests for clarification of suspected misrepresentations and/or omissions on applications
  • Notifying a practitioner of an incomplete application
  • Notification of application withdrawal
  • Requests for information from Medical Staff members
  • Invitations to meet
  • Mandatory meeting notifications/invitations
  • Drafting a follow-up letter to an initial mentoring effort or a collegial intervention meeting
  • What goes in a written Performance Improvement Plan?
  • Documentation of a Medical Staff investigation
  • Adequate notice when the MEC is considering denial or revocation
  • Documentation of an adverse recommendation by the MEC
  • What goes in a notice of adverse recommendation/ notice of right to a hearing?

Learning Objectives

Upon completion of this audio conference, participants should be able to:

  1. Give appropriate notice of peer review activities, which not only complies with due process requirements and Medical Staff Bylaws but also promotes transparency and fundamental fairness for practitioners
  2. Generate documentation of progressive steps that reflects a tone congruent with the seriousness of the stage of review
  3. Identify the legal, practical, and patient safety risks of failing to appropriately document credentialing or peer review activities

Education Credit

Instructions on how to obtain your Continuing Education certificate for audio conferences will be e-mailed to the contact person for your organization at the conclusion of this audio conference.

Category 1 CME

Joint Provider Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the University of Pittsburgh School of Medicine and HortySpringer Seminars.  The University of Pittsburgh is an affirmative action, equal opportunity institution.  The University of Pittsburgh School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

The University of Pittsburgh School of Medicine designates this educational activity for a maximum of 1 AMA PRA Category 1 Credit™.  Physicians should only claim credit commensurate with the extent of their participation in the activity.

NAMSS Continuing Education Credit

This course has been approved for National Association of Medical Staff Services (NAMSS) continuing education credit and NAMSS hereby awards 1.0 NAMSS continuing education credits for participation in this activity.  Accreditation of this educational content in no way implies endorsement or sponsorship by NAMSS.

About Grand Rounds

Designed for even the busiest hospital and medical staff leaders, registration for the year-long series is a quick and inexpensive way for Medical Staff Officers, members of the Medical Executive Committee, Department Chairs, Chairs of the Credentials and Peer Review Committees, and the Chairs of other key Medical Staff committees to have access to the most up-to-date health care information at their fingertips while obtaining valuable CME credits as well.

  • The audio conference series consists of twelve audio conferences spread over the course of the year (one AC/month)
  • Each audio conference is offered the first Tuesday of each month from 1:00 – 2:00 p.m. (Eastern Time).
  • Registration includes an MP3 containing the audio conference at no additional charge following each conference.
  • CME credit issued for live conference participation only.

HortySpringer Audio Conference Disclaimer

The information presented during an audio conference 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 an audio conference 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 an audio conference or the use of the supplementary materials.


Audio Conferences/Grand Rounds Registration: $250 and includes:

      • 1 AMA PRA Category 1 Credit*
      • 1.0 NAMSS continuing education credit*
      • One MP3 recording to share with your staff throughout the year.
      • Three additional phones lines. You may purchase additional lines for $50/line, per audio conference.

Can’t make the live audio conference? No problem! We offer single MP3 recordings for $250/each (Separate MP3 purchase does not qualify for CME credits. CMEs will only be given for live participation the day of the AC).

Want the entire 2023 Grand Rounds AC Series?
If you would like to purchase the entire 2023 Grand Rounds audio conference series, we’re happy to offer you a special rate of $1,850 to include all 12 episodes (one per month). Please contact our office for more information.

*Not all audio conferences will be approved for continuing medical education credits.

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