The Complete Course for Medical Staff Leaders

Hit the ground running!

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.

We’ll teach you what you need to know.

Highlights from The Complete Course include:

  • Credentialing:  A new OB-GYN has been recruited to town, a specialty that’s really needed due to several retirements. He’s experienced in collaborating with midwives, just the right fit to build our program. How great it is that he is moving to our community hospital, where his father-in-law has been a longstanding, respected, Medical Staff member! But red flags emerge revealing some unusual circumstances, and concerns, as we check his background…
  • Peer Review:  You’ve received reports about a new staff member during the initial FPPE. The Department Chair worked with him and his performance improved… and then new problems arose. Now what? Can you share any information with the head of the physician practice? Should you – or can you – involve the group in a performance improvement plan?
  • Investigations:  Most Medical Staff members are competent, caring and professional. Yet a few individuals are bound to develop a pattern of problems. How do you know when to pull the plug on collegial efforts?
  • Disruptive Conduct:  Since Dr. Tori Nado joined the staff, there’s 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?
  • 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!

Dates and Locations

May 4 - 6, 2017
The Ritz-Carlton, New Orleans
New Orleans, LA

Located right on Canal Street at the edge of the French Quarter, the experience of the city comes to life as soon as you cross the threshold of the historic luxury hotel. The Ritz-Carlton, New Orleans highlights traditional Southern ambiance with an elegant interior that reflects the graciousness of antebellum mansions -- and it's an easy walk from countless restaurants and shops.

November 16 - 18, 2017
JW Marriott Phoenix Desert Ridge Resort and Spa
Phoenix, AZ

The JW Marriott Phoenix Desert Ridge Resort & Spa offers everything you'll require for a remarkable experience. Showcasing an array of first-class resources, intuitive service and a picture-perfect location in the heart of Phoenix, this hotel provides an effortless blend of style, comfort and luxury. All of their gorgeously appointed hotel rooms and suites are overflowing with top-quality amenities, as well as awe-inspiring views of immaculate desert vistas and striking mountains.


Credentialing — Day 1

Challenges of Leadership

Patient Safety Starts with You!

  • Legal and practical protections for Leaders
  • Balancing excellence and fairness

Perspective of a Volunteer Leader

  • Rewards for Medical Staff Leaders — compensation and more

Tips for Effective Credentialing — Case Study

  • Align recruitment and credentialing
  • 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 Issues

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

Peer Review — Day 2

The Peer Review Challenge

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

Addressing a Quality Concern — Case Study

  • Collegial intervention regarding a quality concern
  • Performance Improvement Plans for physicians and APCs
  • Can information be shared with affiliated group that employs practitioners?

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

  • Collegial intervention role play
  • Progressive steps for conduct
  • Steps and missteps
  • Sexual harassment

Investigations — Case Study

  • Who should investigate?
  • Should lawyers be involved?
  • How to document the process
  • Take-home tips

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

Medical Staff Bylaws

  • Role play — managing change

On-Call and EMTALA

  • On Call 24/7/365?
  • Specialists who want limited call
  • Payment for call — how to do it right

Succession Planning for Physician Leaders

National Practitioner Data Bank

  • Flagging mechanism or scarlet letter?
  • Is proctoring reportable?
  • How about for cause termination of employment?

Managing Privacy Laws and New Risks

  • PHI is more than just a name
  • The cost of snooping

Physician Leadership

Final 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, Nov. 2016
  • “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, Nov. 2016
  • “All 3 of the presenters were great teachers and very engaging.  I really enjoyed the conference!”  — Physician @ Chicago, Nov. 2016
  • “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.