June 2021 Grand Rounds —
How to Craft and Use a Transition Plan to Successfully Navigate Major Medical Staff Policy Changes

June 1, 2021 - 1:00 pm to 2:00 pm (ET)

After a Bylaws Committee, MEC, and Board have spent months (and sometimes years!) drafting, scrutinizing, reworking, and adopting Bylaws, policies, or other procedures and regulations – the real work begins!

That’s right – just as many leaders breathe a sigh of relief – the work of implementing new policies and procedures begins. This phase of any major policy change is often the least considered, though arguably the most important. Often, there are forms to be developed or revised, policies to be reviewed for consistency, new committees to be formed, leaders to be elected, new criteria to be enforced, and more!

If you think this seems daunting, you’re not alone. Many hospital and physician leaders have questions about how to successfully roll out a major policy change to ensure that the transition is efficient and smooth.

Join HortySpringer attorneys, Rachel Remaley and Nicholas Calabrese for the June installment of Grand Rounds, where she will provide tips for developing and using a transition plan to guide the roll out of major medical staff policy changes. The discussion will highlight some of the major implementation issues that organizations need to consider when the Bylaws are rewritten, the peer review process is substantially altered, or a Medical Staff unifies.

Reading Resources

Guidelines for Adopting and Implementing Revisions to the Medical Staff Bylaws, Medical Staff Leader Monthly, Horty Springer Publications, March 2015.

Why Policies and Procedures Matter, Lauren Amadei, Risk Management Magazine, Nov. 1, 2016 (

Learning Objectives

Upon completion of this session, participants should be able to:

  • Prepare a transition plan for any major Bylaw or policy change, to ensure efficient and orderly transition from current practices to new practices;
  • Plan and implement a transition from current Medical Staff categories and credentialing criteria to new categories/criteria, including planning needed updates to forms and letters and planning for application of new criteria to current members and applications already in progress;
  • Plan and implement a transition from the Medical Staff leadership structure to the new structure, including planning for enforcement of new policies/criteria to current leaders,

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.

CEUs Credit

Other health care professionals are awarded 0.1 continuing education units (CEUs), which is equal to 1 contact hour.

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.

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.

About Grand Rounds

The Grand Rounds 2021 Audio Conference Series consists of twelve audio conferences spread over the course of the year, with the goal of providing focused, manageable bites of education for Medical Staff leaders and those who support them.

  • Registration includes an MP3 containing the audio conference at no additional charge following each conference.
  • CME credit issued for live conference participation.
  • Register for the full series of 12 monthly audio conferences. More information on how to register will be provided shortly.

* Registration fee includes up to three phone lines; you may add two additional lines to your order for $50 each line (per audio conference).

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.


PLEASE NOTE: To help your staff and medical professionals adhere to social distancing guidelines, we will waive the extra line fee for up to 3 additional lines so others in your organization are able to safely listen from their home or office.

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 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/audio conference.

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

Register Online