The Complete Course for Medical Staff Leaders

Credentialing, privileging, peer review, managing issues of behavior and health… and that’s just the beginning. Yet, none of this is taught in medical school or residency.  So The Complete Course for Medical Staff Leaders is a crash course that will equip you with the essentials to hit the ground running as a new leader!

Together, through interactive real world case studies and role plays, we’ll help you develop your skills and provide practical take-home tips and resources.

Highlights from The Complete Course include:

  • Credentialing:  A new OB-GYN has been recruited to fill a dire need.  He wants to collaborate with midwives, just the right fit to build the program. How great it is that he is moving to the community hospital where his father-in-law has been a long-standing, respected, Medical Staff member! But red flags emerge, revealing some unusual circumstances, and concerns.
  • Peer Review:  You’ve received reports during the initial FPPE about a new staff member employed by an affiliated group. The Department Chief worked with him and his performance improved, then new problems arose. Now what? Can you share any information with the head of the group?  What can be considered in a performance improvement plan? How do you involve the practitioner in the solution?
  • Investigations:  Most Medical Staff members are competent, caring and professional. Yet a few individuals are bound to develop a concerning pattern. How do you know when to pull the plug on collegial efforts?  Investigations are rare — but when you need to do one, how do you conduct a fair investigation?
  • Disruptive Conduct:  Since Dr. Tori Nado joined the staff, there has been a report about her interpersonal interactions at least every few months. She’s one of the busiest surgeons, and clinically excellent, but controversy seems to whirl around her. How long can you allow her to fly under the radar? Offer her choices!
  • Health, Aging, Burnout: Protect patients, help a colleague.
  • Suspensions: You don’t use them often, but when you impose a precautionary suspension, it can be a life-changing event for leaders as well as the individual. How can you do this reasonably?
  • Bylaws and Managing Change: A Medical Staff Bylaws project can be a time-consuming and arduous task — but it can transform your staff and pave the way for a more efficient and collegial culture. Come to an open Medical Staff meeting and see what steps you can take to prevent your project from being thrown off track at the last minute!
  • Social Media: How can physicians and physician leaders utilize social media responsibly? By remembering “First, do no harm!”
  • Emergency Call Issues and Solutions: Is there a tougher issue for leaders? What are the options that comply with the law?
  • Physician Leaders’ Role in Management and Governance:  Physician leaders should be involved in both; what are best practices?

Dates and Locations

March 1 - 3, 2018
JW Marriott Austin
Austin, TX

The JW Marriott Austin hotel brings an unparalleled upscale hotel to downtown Austin. Situated in the heart of the city, our hotel in Austin, TX is just a 15-minute drive from Austin International Airport.

April 12 - 14, 2018
JW Marriott Washington
Washington, DC

The JW Marriott Washington, DC is full of comfort, sophistication and style. Ideally situated in the heart of downtown Washington, moments from the National Mall and the US Capitol, this luxury hotel offers everything you need for a wonderful visit.

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.


Credentialing — Day 1

Challenges of Leadership — Patient Safety Starts with You!

Tips for Effective Credentialing — Initial Credentialing Case Study

  • Align recruitment and credentialing
  • Catch issues up front!
  • Threshold criteria  raising the bar
  • Don’t process incomplete applications!
  • When it comes to references, follow the Golden Rule


  • An educational opportunity!
  • Low/no-volume practitioners
  • Conditional reappointment

Privileging Decisions Matter!

  • Developing criteria for new procedures and procedures that cross specialty lines
  • Privileging Advanced Practice Clinicians (APCs)

Legal and Practical Protections for Leaders

  • Balancing excellence and fairness

Peer Review — Day 2

The Peer Review Challenge

  • Understanding OPPE and FPPE: How to make it work!

Addressing a Quality Concern — Case Study

  • Performance Improvement Plans for physicians and APCs
  • Can information be shared with an affiliated group that employs practitioners?

How to Deal with Disruptive Behavior that Undermines a Culture of Safety

  • Collegial intervention role play
  • Progressive steps for professionalism

Investigations — Case Study

  • Who should investigate?
  • Should lawyers be involved?

Policy Issues — Day 3

Precautionary Suspensions: A Life-Defining Event

  • When can a suspension be imposed?
  • How much process is fair?

Practitioner Health and Aging — Considering Fitness to Practice

  • Case Study
  • Know the warning signs
  • Options to address the late-career practitioner
  • Practitioner reentry

Medical Staff Bylaws

  • Role play  managing change
  • Unification of System Medical Staffs?

On-Call and EMTALA

  • What’s fair and equitable and also compliant?

The First Rule of Social Media — Do No Harm

National Practitioner Data Bank

  • Flagging mechanism or scarlet letter?
  • What’s reportable and what’s not?

Creating and Maintaining a Collegial, Fair Medical Staff Culture

Medical Staff Leaders’ Role in Governance and Management

Final Take-Home Tips for Medical Staff Leaders

Who Should Attend?

Bring a team comprised of the following:

  • Medical Staff Officers
  • Department Chiefs
  • Credentials Committee Members
  • MEC Members
  • Bylaws Committee Members
  • VPMAs, CMOs, and Medical Directors
  • Medical Staff Services Professionals
  • Quality/Performance Improvement Directors
  • Hospital Management
  • Hospital Counsel

Participation by all individuals is encouraged. Please notify us at least two weeks in advance of the program as advance notification of any special needs will help us provide better service.


Educational Intent

This program is designed for physicians who serve in Medical staff leadership positions in hospitals.

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

  • identify common credentialing issues and develop best practices relating to initial appointment, reappointment, and clinical privileges;
  • identify and manage the variety of peer review issues that confront them in their roles as physician leaders; and
  • define the legal responsibilities of Medical Staff leaders and the legal protections available to them.

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.


Feedback from past attendees of The Complete Course for Medical Staff Leaders:

  • “Presentations were well done. The subjects were handled in a very interesting way and I enjoyed the humor as well!”  — General Counsel @ Chicago
  • “This was an excellent seminar.  The material was appropriate and the presenters were outstanding! Most professional and interesting presentations that I have ever seen at a conference. My attention was held — and the discussions topics were very relevant. This was an inspiring course which challenged me to step up to a new level as med staff president of a medium sized community hospital.”  — Medical Staff President @ Chicago
  • “All 3 of the presenters were great teachers and very engaging.  I really enjoyed the conference!”  — Physician @ Chicago
  • “This was a very well-produced series of presentations by experts in the field. It was a pleasure to learn from them.”
  • “This was one of the best professional presentations I’ve attended.  Great balance of conceptual and factual material, engagingly presented.”
  • “Any and every physician leader should undergo this course.”
  • “As the new Chief of Surgery, this was an excellent first start.”
  • “This is my second time attending. I’ve never been disappointed, always leave feeling like I’ve learned a lot!”
  • “Excellent Information.  It motivates me to go home and make things happen.  I feel more prepared.”
  • “Super course; super location!”
  • “Wonderful!  Informative, yet entertaining.”
  • “Very good!  AM meeting, PM free…  Great Format!”
  • “I loved the role playing.  Very nice integration of PowerPoint, audio & theater.”
  • “I am very new to physician leadership and I found the information presented to be extremely helpful.  It gave me a broad introduction and a good understanding of the topics presented.”
  • “Wonderful conference; best I have ever been to. The presenters were so engaging.  I just loved it!”


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 slide text, forms, letters, procedures, suggestions for policy elements and more.

Hotel Reservations

All registrants are responsible for making their own hotel reservations. Special group room rates have been established for HortySpringer registrants. The special group rate rooms are available until 30 days from the seminar date, or until the room block sells out, whichever comes first.  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.