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 Principles and Protections for Medical Staff Leaders

  • Legal and practical protections
  • Steps to qualify for immunity
  • Protections for patients
  • Creating and protecting the record

Tips on Effective Credentialing

  • Threshold criteria — raising the credentialing bar
  • Incomplete applications
  • Aligning recruitment and credentialing
  • Giving and getting references
  • Low-volume/no-volume practitioners
  • Conditional reappointment

Privileging Challenges

  • Privileges that cross specialty lines
  • Privileges for new procedures
  • Privileging for advanced practice clinicians
  • Privileging for telemedicine

Peer Review Continuum

  • FPPE and OPPE
  • Avoiding traditional and ineffective review elements
  • Core recommendations for an effective process
  • Efficient, effective and constructive best practices
  • Keeping the physician in the loop
  • Information-sharing

Collegial Intervention

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

Conducting Effective Investigations

  • Initiating investigations
  • Use of investigation checklist
  • Use of outside experts
  • Recognizing and managing conflicts of interest

Precautionary Suspension

  • When to use suspension — and when not to
  • Identifying non-suspension options
  • Reporting suspension

Dealing with Behavior That May Undermine a Culture of Safety

  • Steps to take and missteps to avoid
  • Anticipating a self-proclaimed “whistleblower”


  • Understanding the organization’s legal duty
  • What about discrimination, harassment and retaliation?
  • What constitutes sexual harassment and how should it be addressed?

Attracting and Preparing Medical Staff Leaders

  • Culture does matter
  • Leadership orientation program is a priority
  • Grooming through mentoring and succession planning

Practitioner Health and Wellness Issues

  • Is collegial intervention an option?
  • Progressive steps and accommodations
  • Practitioner Health Policy
  • Realities concerning aging practitioners
  • Reinstatement: a delicate balance
  • Burnout

National Practitioner Data Bank

  • What is and is not reportable?
  • Best tips for drafting a report
  • Employment actions and reports to the NPDB
  • Determining and reporting “surrenders”

Managing Conflicts of Interest

  • Competing economic interests
  • Does employment create an absolute conflict?
  • Identifying and managing common conflicts


  • EMTALA hot spots
  • Dealing with difficult on-call issues
  • Role of advanced practice clinicians
  • Selective resignation of limited privileges

Medical Staff Bylaws

  • New staff categories for a new era
  • Strengthening appointment criteria
  • A fresh look at attendance, voting and quorum requirements
  • How many committees are too many?
  • Designing a manageable and fair hearing process

HIPAA & Social Media

  • Should HIPAA breaches be handled differently for hospital employees and members of the medical staff?
  • Education to minimize risk

Confidentiality/Documentation/Access to Files

  • Policies and agreements
  • What should be in minutes?
  • Confidentiality in the electronic age
  • Physician access to information

Employment Issues

  • Acceptable pre-employment communications
  • Is credentialing an HR or medical staff responsibility?
  • Criminal background checks
  • Employment of APCs
  • FPPE, OPPE and collegial intervention
  • Termination vs. revocation of employment

Patient Safety Organizations (“PSO”)

  • What is a PSO?
  • Why participate in a PSO?
  • PSO mandate under the ACA
  • How PSOs can — and cannot — help with peer review protections
  • Managing confidentiality and privilege protections

If there are topics not listed that you would like us to cover, we’re happy to work with you to customize a program to specifically address your needs.