Credentialing for Excellence

Credentialing is a team effort with medical staff professionals, medical staff leaders, and board members all playing an important role in making sure that only qualified, competent practitioners are granted appointment and clinical privileges.  A thorough, robust credentialing process contributes to a hospital’s primary mission — to provide safe and competent care to the community it serves.  However, the credentialing process involves many challenges and potential pitfalls that, if not handled effectively, could interfere with a hospital’s mission.

Credentialing for Excellence — Advanced Tools and Techniques provides comprehensive training for those involved in all levels of the credentialing process.  The seminar is designed for medical staff professionals, medical staff leaders, and board members.  Attendees will leave the three-day seminar with the skills and knowledge they need to manage the risks involved in credentialing and to use the credentialing process to establish excellence in the provision of care in their institution.  The seminar is designed to be interactive, engaging and thought-provoking so that attendees will get the most out of their experience.

Faculty, Susan Lapenta and Charles Chulack, use a unique approach by combining “credentialing lessons” with active participation by attendees in solving challenging credentialing issues.


Dates and Locations

November 15 - 17, 2018
The Westin St. Francis
San Francisco, CA

Timeless yet modern, The Westin St. Francis Union Square has a vibrant, iconic destination in San Francisco. It is the only San Francisco hotel directly located on Union Square, with cable cars stopping just outside the hotel doors.

All of the city’s best shopping, theatre, nightlife and dining options are just steps away, and the hotel is only a short walk from the Financial District, Chinatown and Moscone Convention Center.

January 24 - 26, 2019
The Ritz-Carlton, Naples
Naples, Florida

Enjoy the beautiful Ritz-Carlton Naples, located on the Platinum Coast along the Gulf of Mexico. Stroll along the miles of white sandy beach, relax in the hotel’s beautiful new spa, play tennis, or enjoy a round of golf at Tiburon, the Ritz-Carlton’s Greg Norman-designed 18-hole course.

March 7 - 9, 2019
Disney's Yacht Club Resort
Orlando, FL

Delight in the formal grace of a grand New England-style yacht club at this lakeside hotel. Relax in the inviting elegance of a plush lobby replete with nautical touches, explore the whimsical Stormalong Bay and rent a variety of watercraft from Bayside Marina. Sharing many amenities with its pastel-toned sister, Disney’s Beach Club Resort, Disney’s Yacht Club Resort is walking distance to Epcot and a convenient boat ride to Disney’s Hollywood Studios.

April 11 - 13, 2019
The Ritz-Carlton, New Orleans
New Orleans, LA

Located right on Canal Street at the edge of the French Quarter, The Ritz-Carlton, New Orleans is an easy walk from countless restaurants and shops. Join us during the New Orleans Jazz and Heritage Festival – the best time of year to visit New Orleans!


Faculty, Susan Lapenta and Charles Chulack, use a unique approach by combining “credentialing lessons” with active participation by attendees in solving challenging credentialing issues.  We will cover the following exercises and topics during the seminar:

Join Our Credentials Committee Meeting

Attendees will participate in a mock meeting of a Credentials Committee.  The meeting agenda is full and includes:

  • spotting red flags in an actual application;
  • determining whether an applicant meets threshold eligibility criteria;
  • identifying circumstances in which a waiver of threshold eligibility criteria may be appropriate;
  • evaluating an application from an advanced practice clinician;
  • reappointing a low/no volume practitioner; and
  • assessing the current competence of a physician returning to practice.

“I Wish I Had Your Bylaws”

Do you think all medical staff bylaws are the same?  Then you’ll want to join us in playing a provocative game about bylaws.  See how the bylaws of two hospitals match up when put to the test of real life scenarios.  There’s a prize for everyone who plays:  excellent bylaws language that you can take home with you.

Credentialing in an Employment World

The push by hospitals and affiliated entities to employ more physicians can cause headaches for those involved in the credentialing process, especially when employment decisions are made before the credentialing process has even begun.  We’ll offer pointers on how to better align your employment and credentialing process.  We will also cover topics that are implicated by credentialing and employment, including sharing information within systems, getting the most from your credentials verification office, and the key components of delegated credentialing.

Clinical Privileges – Who Can Do What in Your Hospital?

Medical staff and allied health appointment does not automatically bestow on a practitioner the right to perform procedures in your hospital.  You must have a separate process for granting clinical privileges.  While many of the key concepts in credentialing apply to privileging, there are different challenges in the privileging arena.  Using interactive case studies, we’ll address difficult to manage clinical privileging issues, including requests to selectively resign privileges to limit call responsibility, privileges for new procedures, locum tenens privileges, assessing competency in an older practitioner, and telemedicine privileges.

The Ever-Expanding Role of Advanced Practice Clinicians

Advanced practice clinicians (“APCs”), including physician assistants and nurse practitioners, play a critical role in the care delivered in hospitals.  Many states have expanded the scope of practice for APCs to include more complicated procedures and more expansive responsibilities.  Medical staff and hospital leaders are left with lots of questions:

  • “How much responsibility should APCs be given?”
  • “How much training is required first?” and
  • “How much supervision is appropriate?”

We’ll address these issues and provide practical guidance on common questions, such as using APCs to respond to calls from the ED and round on patients and the role of APCs on the medical staff.

Managing Behavior and Health Concerns

With patient safety being paramount in the delivery of care, hospitals often wrestle with how to address disruptive behavior that undermines the culture of safety in their organization.  Drawing on decades of experience, we’ll offer our favorite pearls of wisdom and provide advice on how to avoid the perilous pitfalls that lurk behind both the routine and the more exceptional behavioral challenges you may face.

Anywhere from 10% to 15% of the practitioners in your organization will suffer from a significant impairment during their practice.  As required by some accreditation entities such as The Joint Commission, is imperative that health concerns are handled separately from the disciplinary process.   We’ll help you develop strategies for navigating practitioner health issues, from best practices for leaves of absence to the ins and outs of incorporating drug testing and medical examinations into the credentialing process.

Making the Most of Interviews and References

Many hospitals continue to rely on an applicant’s file without scheduling an interview or making follow-up phone calls to references.  Conducting interviews and speaking with references can uncover invaluable information.  Often, references will communicate over the phone details about an applicant that they may be reluctant to put in writing.  We will present best practices for conducting interviews with applicants and reaching out to peers who provide references.  We will also focus on tools for giving references and managing difficult issues like responding to a reference request when the subject of the request has had a checkered past at your hospital.

Documenting the Credentialing Process

Keeping good minutes for committees involved in credentialing is essential to establishing a record and providing justification for the decisions that are made.  This is especially true when a decision involves an issue with inherent risk like waiver of threshold eligibility criteria or management of conflicts of interest.  In these situations, you want your minutes to reflect the policies followed and the reasons for the decision.  We’ll discuss the “dos and don’ts for meeting minutes.” And, you’ll get a chance to review and revise minutes and then explore the consequences of poorly drafted minutes.

Protecting Your Leaders and Your Organization

When faced with a difficult applicant or a controversial credentialing decision, medical staff leaders and board members often ask about legal liability and protections.  The good news is that the law recognizes the importance of credentialing and provides significant legal protections.  We’ll review recommended best practices in credentialing to help ensure that the legal protections are available to your organization, and you’ll come away with important language to include in your policies and application forms.

Who Should Attend

  • Credentials Committee and MEC members
  • Medical Staff Officers
  • CMOs, VPMAs, CEOs
  • Department Chiefs
  • Medical Staff Professionals
  • Management involved in credentialing
  • Board members
  • Medical Staff members who serve on Performance Improvement or Quality Committees


Educational Intent

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

  • identify legal issues that affect credentialing and should be able to define the benefits of having policies and procedures to address problem practitioners;
  • gain insight into the process and procedure for the credentialing and recredentialing of physicians and allied health professionals.

Continuing Education Credit

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 School of Medicine is accredited by the ACCME to provide continuing medical education for physicians.

Category 1 CME Credit

The University of Pittsburgh School of Medicine designates this live activity for a maximum of 11.25 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

CEU Credit

Other healthcare professionals are awarded 1.125 continuing education units (CEU’s) which are equal to 11.25 contact hours.

NAMSS Accreditation

This course has been approved for National Association of Medical Staff Services (NAMSS) for up to 11 hours of continuing education credit(s). Accreditation of this educational content in no way implies endorsement or sponsorship by NAMSS.

Presenter Disclosure Statement

In accordance with the Accreditation Council for Continuing Medical Education requirements on disclosure, information about relationships of presenters with commercial interests (if any) will be included in materials distributed at the time of the conference.

Presenter Disclosure Statement

All individuals in a position to control the content of this education activity are required to disclose all relevant financial relationships with any proprietary entity producing, marketing, re-selling, or distributing health care goods or services, used on, or consumed by, patients.


Registration fee:

$1,595 Individual


$4,950 for a team of four
$   950 for each additional registrant (after a team of four registration)

We design our programs with a team fee because we found that it usually requires at least three or four Board members or physician leaders to implement changes or to move forward on any particular matter.

You can send a team of four to one seminar in one location, or you can register at multiple locations and for multiple programs.

Included With Registration Fee

  • Online Access to forms, policies, procedures, sample bylaws language and more

Hotel Reservations

All registrants are responsible for making their own hotel reservations. Special group room rates have been established for Horty Springer registrants. The block of rooms being held for registrants will be released 30 days prior to the seminar. Within 30 days of the program, you may not be able to get rooms or receive the special rate.

Refund Policy

Seminar cancellations/refunds are subject to a $100 processing fee.