The Credentialing Clinic

Work through the credentialing problems you face every day.

Together with your team, you’ll tackle the toughest and most common issues related to initial appointment, reappointment, and clinical privileges in a proactive manner. We’ll give you tools to empower your medical staff leadership and make your team successful and effective.

This seminar, by utilizing a case study format and registrant participation, examines the impact of ever-changing legal and accreditation requirements and combines credentialing lessons with case studies based on the most common – and most difficult – issues faced by credentialers.


The Credentialing Clinic is an interactive problem-solving workshop that is designed to give registrants an opportunity to work through the credentialing problems they face every day.

Guided by Ian DonaldsonLeeAnne Mitchell (Las Vegas and Naples), and Charles Chulack (Orlando), attorneys at Horty, Springer & Mattern, whose practice is devoted to helping hospitals, medical staff leaders and Board members, The Credentialing Clinic combines “credentialing lessons” with active participation in solving many challenging issues, including:

Legal Protections for Medical Staff Leaders

  • What protections are afforded to your medical staff leaders to protect them from legal liability? (federal and state protections)
  • Bolstering the legal protections in the medical staff bylaws and application forms

Processing Initial Applications

  • How to successfully utilize the concept of “eligibility”
  • Raising the bar on eligibility criteria
  • How does employment affect credentialing decisions?
  • Identifying and addressing “red flags” on applications
  • Asking the right questions — getting meaningful references
  • How much weight should you give to malpractice claims?
  • Incorporating an evaluation of ACGME competencies into your process to comply with Joint Commission requirements


  • How to ensure that your reappointment process is meaningful rather than a rubber stamp
  • How does the Joint Commission’s requirements for ongoing professional practice evaluation impact your reappointment/reappraisal process?
  • Conditional reappointment — a useful tool
  • Creative solutions to address low volume practitioners
  • What to do when health issues — including aging — are identified at reappointment
  • Dealing with the disruptive practitioner

Allied Health Professionals

  • Know what Medicare and accreditation agencies require for these practitioners
  • Who is doing what in your hospital?
  • Are they qualified? How do you know?
  • Should all AHPs be granted privileges?
  • What do you consider when renewing privileges and scope of practice?
  • Due process rights for AHPs: Necessary? Mandatory?

Managing Clinical Privileges Challenges

  • Privileges that cross specialty lines (“turf” battles)
  • Privileges for new procedures — who decides what is new?
  • Establishing focused professional practice evaluation (FPPE) requirements along with threshold criteria
  • Attempts to selectively resign privileges (and limit call responsibility)
  • Is it safe to grant temporary privileges on a routine basis?

Performance Improvement and Peer Review Best Practice

  • Incorporating the Joint Commission’s Elements of Performance for FPPE for new privileges
  • FPPE for new privileges — it’s not just for the medical staff!

Medical Staff Documentation — Managing the Risks

  • What to document and when to document
  • Who “owns” the credentials file? The quality file?
  • How to provide appropriate access to even the most sensitive information

Sharing Information within Systems

  • When corporate structure necessitates information sharing
  • What to share
  • How to share information safely and preserve the peer review privilege

Who Should Attend

  • Credentials Committee Members
  • Medical Staff Officers
  • VPMAs, CMOs
  • Department Chiefs
  • Management Involved in Credentialing
  • Board Members Who Serve on the Credentials 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.



Feedback from past attendees of The Credentialing Clinic:

  • “Speakers did a great job covering our hot-button issues: low volume providers, aging physicians, etc.”
  • “Very educational for new member of Credentials Committee.”
  • “Speakers were very knowledgeable and very informative.”
  • “Speakers were wonderful; Case studies were great. They relate to situations we see and gave more direction for future ‘issue’ applications.”


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 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.

Register Online

Registrations for this seminar can only be made over the phone. Please call us at (800) 245-1205 for more details.