Onsite and Virtual Education

Onsite and Virtual Education

Onsite and Virtual Education

At Horty, Springer & Mattern, we focus our legal practice and educational programming on all aspects of Medical Staff, hospital, and health system relationships. Our onsite and virtual education programs are designed with this focus in mind, based on our clients’ interests. CME credit is available for most HortySpringer educational presentations. Arrangements for CME can be made by the client or by HortySpringer for an additional fee. A current listing of our program topics can be found here. If there are topics that you are interested in that are not listed, we are happy to work with you to customize a program to specifically address your needs. For more information or to request an onsite program, please contact us 412.687.7677 or info@hortyspringer.com.

Program Options

Option 1 Full-Day Program

  • Choose 6-8 of the topics listed on the Program Topics page (or let us customize a program for you).
  • Plan on approximately six hours for the program, excluding meals and breaks.

Faculty —

One or two HortySpringer attorneys.

Option 2 — Half-Day Program

  • Choose 3-4 of the topics listed on the Program Topics page (or let us customize a program for you).
  • Plan on approximately three hours for the program, excluding meals and breaks.

Faculty —

One HortySpringer attorney.

Option 3 Customized Physician Leadership Series

This option is designed to best meet your educational needs over the course of a one-year period. Contact us at 412.687.7677 or info@hortyspringer.com to discuss and design your Leadership Series.

Program Topics

HortySpringer specializes in all aspects of physician/hospital/system relationships. A program can be designed to meet your needs around any of those issues, including:

Legal Protections for Credentialing and Peer Review Activities
• Legal protections for hospitals, Medical Staff Leaders, and board members
• Best practices to qualify for immunity
• Additional steps that can be taken in-house to minimize disputes and litigation (including good authorization forms, confidentiality policies, responses to references)

The Respective Responsibilities of Hospital Boards and Medical Staffs for Quality and Safety
• Sources of Board authority and responsibility
• Sources of Medical Staff authority and responsibility
• How Boards and Medical Staff leaders can satisfy the duties of loyalty and care
• How hospitals can set up Medical Staff leaders for success
• Legal protections for those involved in credentialing, peer review, and other quality and patient safety activities
• The Board’s role in credentialing, peer review, and other Medical Staff functions

The Peer Review Continuum
• Changing the perception of peer review from punitive to educational
• Using Performance Improvement Plans and other collegial measures
• Keeping the physician in the loop
• Information-sharing
• Employed physicians and peer review
• FPPE to confirm competence and OPPE

Peer Review of Unprofessional Conduct
• Identifying and defining “unprofessional” conduct
• Conducting effective collegial intervention meetings with a practitioner who is not collegial
• Anticipating and dealing with common deflection tactics, including, but not limited to: blaming others, demanding information about the “accuser,” communicating only through lawyers and/or making legal threats, refusing to attend meetings, ghosting the Medical Staff leadership, claiming “whistleblower” status, and claiming disparate treatment
• Understanding sexual (and other unlawful) harassment and the organization’s unique legal duties to respond in such cases

Peer Review of Practitioner Health Concerns
• Identifying impairment in your Practitioner Health Policy (it’s about more than drugs and alcohol!)
• Which leaders should have primary responsibility for review of health concerns?
• Requesting fitness for practice evaluations
• Requesting treatment records and other health information from applicants and members of the Medical Staff
• Leaves of absence and reinstatement
• Industry trends for managing concerns about late career (aging) practitioners

Tips on Effective Credentialing
• Threshold eligibility criteria
• Practical tips to help align recruitment and credentialing
• Managing incomplete applications
• Addressing misrepresentations and omissions on the application form and as part of the application process
• Asking health-related questions on the Medical Staff application form and at other phases of the credentialing process. Are there “Americans with Disabilities Act” considerations?
• Giving and getting meaningful references
• Credentialing options for low-volume/no-volume practitioners
• Conditional reappointment

• EMTALA hot spots
• Dealing with difficult on-call issues
• The role of advanced practice clinicians in serving on the call list and assisting with on-call responsibilities

Medical Staff Bylaws
• Hot topics in Medical Staff Bylaws
• Best practice recommendations for Medical Staff Bylaws and other Medical Staff policies
• Steps for successful revision of Medical Staff Bylaws

Precautionary Suspension & Restriction
• Appropriate (and not appropriate) situations for precautionary suspension
• Options to address immediate concerns – other than precautionary suspension
• NPDB reporting of precautionary suspension

Privileging Challenges
• Managing relinquishment of privileges, to avoid operational disruption
• Privileges for new procedures
• Privileges that cross specialty lines
• Privileging advanced practice clinicians
• Privileging low and no volume providers
• Telemedicine privileging

Conducting Effective Investigations
• When and how to initiate an investigation
• Obtaining external reviews
• Recognizing and managing conflicts of interest
• A checklist important steps in the investigation process
• Managing reappointment during the course of an investigation
• Giving a reference for a practitioner who is under investigation

National Practitioner Data Bank Reporting
• What is – and is not – reportable?
• Best tips for drafting a report
• Employment actions and reports to the NPDB
• When does a relinquishment or resignation constitute a “surrender” of privileges while under investigation?
• When does a peer review activity constitute a “restriction” of privileges?

Collegial Intervention
• Who should do it? How far can you go?
• Tips, tools and implementation
• Documentation

Confidentiality/Documentation/Access to Files
• Fundamentals of confidentiality for credentialing and peer review information and files
• What should be in minutes?
• Confidentiality in the electronic age
• Physician access to information
• Access to information within the hospital
• Sharing of information within the system
• Disclosure of information outside the hospital (references, affiliation verification, and more)

Intersection of Employment and the Medical Staff
• Is credentialing a Management, Medical Staff, or joint responsibility?
• Essential terms in an employment agreement
• When issues arise, which policy should be followed?
• Effect of termination of employment on Medical Staff appointment

Update on Stark Antikickback Statute and the False Claims Act on Physician Agreements