October’s Grand Rounds: Does Fair and Just Culture Have a Place in Your Peer Review Process?

October 4, 2022 - 1:00 pm to 2:00 pm (ET)

You won’t want to miss October’s installment of Grand Rounds, where we will discuss what has become a touchy subject in some hospital and medical staff circles – Fair and Just Culture.  If you ask us Fair and Just Culture has gotten a bad rap due to anecdotal reports that it riles up complaints from nurses, technicians, and other hospital personnel.  But, there’s so much more to “Just Culture” than reports.

You may be surprised by how many Just Culture principles align with existing “best practices” for peer review (some of which are likely already part of your processes).  And, in the end, you may find that a fair and just culture works for the members of your Medical Staffs just as well as it works for the organization as a whole.

During this one-hour audio conference, we will discuss the rise of the Just Culture methodology and give physician leaders some tips for incorporating fair and just practices into Medical Staff professional practice evaluation activities.  Specific topics to be covered include:

  • Is there room for anonymous reporting in a reliable and just peer review system?
  • What is retaliation – and how can leaders prevent it?
  • Using transparency and early and open communication, along with appropriate tone, to set the stage for a collaborative effort focused on voluntary improvements.
  • Ensuring leaders have the discretion to tailor the process to match the concerns – and the ability to check reckless and intentional behaviors.
  • Differentiating informal, collegial peer review activities from the formal, disciplinary process – to ensure that performance improvement can be achieved without unnecessary judgment, shame, or punitive measures (while retaining the goals of accountability and patient safety).
  • Shifting the focus away from judgment and scores and towards practical improvements and success! – A fair, just, and Performance Improvement Plan (PIP)-centered approach.
  • When hospital and system-based issues are identified during the peer review process, how can physician leaders ensure they are appropriately addressed?
  • Using peer review “lessons learned” as part of widespread education for the Medical Staff means we can use the process to raise everyone up!

Learning Objectives

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

  • Identify core principles of a “Just and Fair Culture” and describe how they relate to the goal of patient safety.
  • Incorporate Just Culture principles into the Medical Staff peer review process, providing Medical Staff with greater participation through notice, open communication, a chance to participate, and opportunities to learn from the successes and challenges faced by others.
  • Develop policies that promote willingness of hospital personnel to report concerns about practitioner conduct, health, and clinical performance.


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.


PLEASE NOTE: To assist your staff and medical professionals who work remotely, we will waive the extra line fee for up to 3 additional lines so they are able to 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/each (Separate MP3 purchase does not qualify for CME credits. CMEs will only be given for live participation the day of the AC).

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

Register Online