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Introduction and Orientation to Medical Staff Leadership
Learn the basics of what it means to be a Medical Staff leader. This session
focuses on responsibilities and requirements of Medical Staff leaders and
discusses the roles the leaders play vis a vis the Governing Board, Hospital
Administration, and Medical Staff.
Effective Medical Staff Peer Review
This session discusses (1) what peer review is (internal and external), (2) the
different scenarios in which peer review is utilized, (3) the goals of
effective peer review, and (4) how to best utilize peer review in medical staff
matters.
Effective Medical Staff Peer Review and FPPE/OPPE
This session discusses (1) what peer review is (internal and external), (2) the
different scenarios in which peer review is utilized, (3) the goals of
effective peer review, and (4) how to best utilize peer review in medical staff
matters. This session also describes The Joint Commission requirements of
focused professional practice evaluations (FPPE) and ongoing professional
practice evaluations (OPPE) as components of the medical staff competency
evaluation process.
Credentialing and Privileging for Medical Staff Leaders
Understand how both initial and renewal applications are structured, the
credentialing processes and scrutiny applied for Medical Staff appointment
and/or clinical privileges and, specifically, how medical staff leaders and the
credentials committee oversee effective credentialing policy and procedure and
apply discernment in application analysis.
Medical Staff Oversight of Allied Health Professionals
This session discusses how the Hospital's Medical Staff credentialing and
privileging processes apply to allied health professionals, and what roles and
responsibilities Medical Staff leaders and members have in determining
privileges (or position descriptions) and overseeing the practice of privileged
allied health professionals.
Medical Staff Bylaws and Hospital Governance
Learn how Hospital and Medical Staff governance structures work. This session
will focus on best practices for Medical Staff Bylaws format and content as
well as provide tips for Medical Staff leaders as they manage the challenging
issues of creating, building consensus, and implementing these documents.
Medical Staff Standards of The Joint Commission and Medicare Conditions of
Participation
Understand the rules concerning the Medical Staff contained in The Joint
Commission (TJC) standards and the Medicare Conditions of Participation. This
session will explore the mandatory aspects of Medical Staff organization and
functions and will cover how TJC and CMS enforce these requirements.
Medical Staff Standards of Healthcare Facilities Accreditation Program and
Medicare Conditions of Participation
Understand the rules concerning the Medical Staff contained in the Healthcare
Facilities Accreditation Program (HFAP) and the Medicare Conditions of
Participation. This session will explore the mandatory aspects of Medical Staff
organization and functions and will cover how HFAP and CMS enforce these
requirements.
Corrective Action and Fair Hearings
This session provides an overview of the process of making the decision to take
and apply corrective action against a Medical Staff member. Learn when
corrective action is legally defensible, what options are available and
permissible before and during the process, what actions are reportable to the
National Practitioner Data Bank, what actions give rise to hearing rights, and
the role of Medical Staff leadership in planning and preparing for
hearing.
Protections and Immunities: HCQIA and Other Peer Review Protections
Learn about the Health Care Quality Improvement Act (HCQIA) and what
protections and immunities are afforded by these statutes. This session will
discuss how to ensure the immunities apply and what to avoid that would
jeopardize the application of these protections.
EMTALA and On Call Obligations
EMTALA obligations and on call obligations are not synonymous. A violation of
one does not always mean that there has been a violation of the other. This
session will review the basic principles underlying these two responsibilities
and how to remain in compliance with both.
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How to Bring Incident Reports Within the Scope of Ohio's Peer Review
Privilege
A number of recent cases have limited the applicability of Ohio's peer review
privilege to incident reports. Learn how to critique and/or restructure your
current incident reporting process to assure that it comes within the scope of
Ohio's peer review privilege.
Negligent Credentialing
Learn the law on negligent credentialing claims. This session covers tips for
minimizing the risk of exposure to negligent credentialing lawsuits.
Legal Potpourri / Hot Topics
This session provides education on current medical staff and related healthcare
issues to include federal and state laws that impact the Hospital and its
Medical Staff.
Physician / Hospital Alignment
This session looks at current federal law (anti-kickback, referral prohibition,
private inurement) and its impact on physician I hospital relationships. It
also reviews what relationships support alignment.
Credentialing and the Employed Physician
Peer Review of patient care has traditionally been a protected medical staff
process. This session discusses whether and how this information can/should be
shared when a physician is employed by a hospital or a hospital controlled
corporation.
Fundamentals of Healthcare Finance & Business
This session will provide insight into key factors healthcare executives and
boards consider in their decision making process. Assist in understanding how
and why various healthcare decisions are made.
Fundamentals of Working Through Major Transitions
This session will provide insight into key issues for working through
consolidations, mergers, and other transitions. Transitions can be difficult
but there are important ways to effectively manage through such a
process.
Stark Law
An in-depth review of the Stark Law and the most common risk areas for
hospitals and physician relationships.
Engaging Physicians in Quality and Safety Initiatives
It is essential that all Medical Staff become engaged in quality and safety
initiatives, a prerequisite to alignment strategies between Medical Staff and
administration. This session will provide the tools and practical examples to
realize improvement in quality indicator compliance and increased patient
safety.
Prevention and Management of Disruptive Behaviors
Development of a Medical Staff culture that encourages positive supportive
relationships with key constituents is the result of consistent leadership and
strategy. This session provides a pragmatic comprehensive approach for
developing and sustaining a non-punitive, yet just culture.
Orientation for Medical Staff
Orientation of all new Medical Staff to the organization is standard fare. The
highly fictional and successful organization optimizes this process to provide
education to the culture, expectations, prerogatives and opportunities awaiting
the new physician. Orientation is the first step to leadership training and
development for the future of the organization. The second part of the session
focuses on development of the leader by orienting physicians to each new
committee/leadership position to which they are elected/assigned.
Fundamentals of Medical Staff Relationships
This session will provide management individuals with the basics necessary to
realize solid Medical Staff relationships. Often, the fundamentals are
overlooked, but are critical to having a positive relationship with the Medical
Staff.
Fundamentals of Management
An overview of the key aspects of management will be provided in this session.
In the fast paced healthcare industry, it is easy to overlook some of the
important management principles that are critical to success.
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