HortySpringer Pathways Webinar Session 4: Formal Investigation & The MEC Action that Follows

While the vast majority of concerns about a practitioner’s clinical performance, professional conduct, or health status are resolved with education and other informal and/or collegial measures, virtually every health care organization will periodically come face-to-face with a concern that is far too serious for collegial intervention or a practitioner who is resistant to the leaders’ collegial efforts.  That’s when a formal “investigation” becomes necessary.  And since the stakes are high (appointment and/or privileges can be at stake!), it’s important to be meticulous.

But, how can organizations master investigations when they are only a small, infrequent part of the review process?  A good first step is to ensure that all hospital and physician leaders are trained about the role of investigations in the grander PPE process.  This can help to eliminate one of the biggest hiccups in the investigation process (when no one is sure whether or not the current process is actually an “investigation” or not).  Then, outlining detailed investigation procedures in the Medical Staff Bylaws and/or Credentials Policy can help to guide the leadership (along with their counsel) once a formal investigation is actually underway.  During this final installment of the 2024 Pathways leadership training program, we will discuss essential provisions for your Bylaws and policies, as well as tried and true methods for conducting investigations and considering/taking adverse professional review action.

Topics to be Covered:

  • When does an investigation begin? (Is an applicant for reappointment under “investigation”?  Is failure to renew the same thing as a resignation while under investigation? Do all precautionary suspensions begin an investigation?  Should investigations begin only with written and signed requests for corrective action?)
  • Why is an investigation necessary after one or more rounds of PPE have already been conducted?
  • Who should serve on an investigating committee (should it be a subcommittee of the MEC?)
  • Providing the practitioner with notice of an investigation and an opportunity for input
  • What to tell the MEC and/or Board about ongoing investigations
  • The role of attorneys in investigations
  • Comprehensive fact gathering (interviewing witnesses and exhaustively gathering information that may be relevant)
  • Documenting witness interviews
  • Investigating committee report/findings & recommendations
  • When does the investigation end? (and what are the NPDB reporting implications?)
  • Steps to take before making an adverse professional review recommendation
  • How to record minutes of an MEC meeting at which adverse recommendation is made
  • Giving a reference for someone under investigation or with an adverse recommendation pending
  • Special considerations at reappointment when the practitioner is under investigation or has an adverse recommendation pending

Supplemental Materials:

  • Investigation checklist
  • Sample letter appointing investigating committee member(s)
  • Sample letter documenting voluntary refrain
  • Sample reappointment letter (applicant under investigation)

Learning Objectives:

Upon completion of this audio conference, participants should be able to:

  1. Identify the method(s) for commencing a formal Medical Staff investigation;
  1. Appoint an investigating committee that complies with the requirements of the Health Care Quality Improvement Act (HCQIA) and minimizes the risk of conflicts of interest;
  1. Prepare an investigation report that documents with clarity the good work of the investigating committee, including the information gathered, the issues considered, and the recommendation for next steps; and
  1. Usher the investigating committee’s report through the MEC, for consideration and action, in a manner that is thoughtful and fair to the practitioner under review.

About HortySpringer Pathways

Introducing HortySpringer Pathways – a new training program for hospital and physician leaders who are looking to develop and enhance the skills they need to manage and oversee the hospital’s Medical Staff.


Each Pathways Series is focused on a topic – or “theme” – that health system, hospital, and physician leaders have told us is essential and timely.  Avoiding the sound bites and consultant-talk that permeate so many leadership training courses that are on the market, Pathways favors a deeper discussion of the topics at hand and take-home tips that can be implemented right away.


Medical Staff leadership does not occur in a vacuum.  While the “self-governance” of the Medical Staff is largely the purview of the organization’s practicing physicians, a multitude of individuals and bodies support and oversee Medical Staff activities:  Board members, advanced practice clinicians, health system and hospital administrators, quality professionals, medical staff services professionals, HR professionals, executive recruiters, and more!  Pathways’ web-based format allows organizations to finally make Medical Staff leadership training available to all of these individuals, fostering shared understanding and the implementation of aligned and unified policies, procedures, and leadership strategies across the organization.


Each Pathways webinar has been designed to require a minimal-to-moderate time commitment and to allow training to be completed from the comfort of your own home or workplace.  With four 2-hour web-based training sessions spread throughout the year, participation in the Pathways leadership program means not having to forego leadership development when time for training is limited or travel is difficult or impossible.

Who Should Attend?

The 2024 Pathways program can benefit all the following:

  • Medical Staff members identified for leadership potential, but not yet placed in a leadership role
  • Medical Staff officers
  • Chief Medical Officers
  • Peer review/PPE committee members
  • Members of a Medical Staff Leadership Council (or similar officers council/committee)
  • Members of a Medical Staff professionalism committee
  • Other physician leaders involved in professional practice evaluation
  • Hospital personnel who support the peer review/PPE processes (for example, Medical Staff Services directors, quality department directors)
  • In-house counsel who advise the Medical Staff or Board
  • Governing Board members (particularly, members of a Board subcommittee on quality)

HortySpringer Webinar Disclaimer

The information presented during a webinar and any supplementary materials provided to registrants are intended for educational and informational purposes only. Nothing contained therein is to be considered as the rendering of legal advice for specific cases or circumstances.

No one should act or refrain from acting on the basis of any information presented during a webinar without seeking the appropriate legal or other professional advice on the particular facts and circumstances at issue from a lawyer practicing as permitted by applicable laws, regulations or rules of professional conduct. No attorney-client relationship is formed by registration for a webinar or the use of the supplementary materials.



Individual or organization webinar session purchase: $595

Participants Will Receive:

HortySpringer Pathways Webinar Includes:

  • 2 hours CME/NAMSS credits
  • All supplementary materials
  • 60-day on-demand access

The complete four-part series can be purchased for $1,850. Please click here to download the order form for the series.

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