Program & Schedule

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Join us Sunday, September 22 to kick off the NAMSS 37th Educational Conference & Exhibition by attending the Ribbon-Cutting and Exhibit Hall Opening Reception.

Sunday, September 22
Time: 6:00 p.m. - 8:00 p.m.
Sponsored by PreCheck, Inc.

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Please find a preliminary schedule of events below. As we are finalizing our session offerings, please note that titles, speakers, and times are subject to change.

Conference Sessions & Events

Monday,
September 23
Tuesday,
September 24
Wednesday,
September 25

Opening Keynote Session
Session Code: MN01
Time: 8:00 a.m. – 9:30 a.m.
Total CE Credits: 1.5
Keynote Speaker: Marty Makary, MD

Contracting and Credentialing: The Good, the Bad, and the Oh So Ugly
Session Code: MN02
Time: 10:00 a.m. – 11:30 a.m.
Total CE Credits: 1.5
Presented By: Susan Lapenta, JD and Henry Casale, JD

Employing physicians should make a Medical Staff Professional’s life a dream come true—but then you wake up to the nightmare! In the real world, candidates are often employed and then presented for medical staff appointment as if it is a fait accompli, with little understanding of the appointment criteria and an unreasonable expectation about the time it takes to perform essential primary source verification. This session will explore the challenges of credentialing and privileging an employed physician, and provide clarity to the process.

Medical Services Professional Skills for Clinical Integration
Session Code: MN03
Time: 10:00 a.m. – 11:30 a.m.
Total CE Credits: 1.5
Presented By: Richard Sheff, MD

Clinical integration (the advancement of physician-hospital collaboration to increase quality and decrease costs) is harder than it looks. The impending pay for- value world we are rapidly entering requires effective leadership to achieve clinical integration that actually works. This session will teach participants new skills to understand and implement the needed changes in physician-hospital alignment structures. Attendees will also walk away with new skills to help create a new level of physician accountability.

How to Safely Credential and Privilege Low/No Volume Practitioners
Session Code: MN04
Time: 10:00 a.m. – 11:30 a.m.
Total CE Credits: 1.5
Presented By: Jonathan Burroughs, MD, MBA, FACHE, FACPE

With changing reimbursement incentives, many healthcare practitioners are shifting most of their clinical activity to ambulatory based practices in which there is little hospital quality data. Simultaneously, CMS, The Joint Commission, and other accreditors increasingly require privileging to be based upon objective and meaningful performance data so that privileging decisions may be ‘objective and evidence based’. Learn ‘best practice’ approaches to safely credential and privilege low/no volume practitioners so that the hospital does not inadvertently exclude practitioners who are strategically important to the organization.

High Risk Privileging: How to Treat Temporary Privileges and Locum Tenens with the Respect They Deserve
Session Code: MN05
Time: 10:00 a.m. – 11:30 a.m.
Total CE Credits: 1.5
Presented By: Sally Pelletier, CPMSM, CPCS and Carol Cairns, CPMSM, CPCS

Granting temporary and locum tenens privileges presents high clinical and legal risks. This session will define key terms, identify regulatory and accreditation requirements, and provide solutions to mitigate risk and minimize the extensive use of resources.

Accountable Care Organizations: Overview and Impact on Medical Staff Professionals
Session Code: MN06
Time: 10:00 a.m. – 11:30 a.m.
Total CE Credits: 1.5
Presented By: Michael Callahan, JD

Learn about the changes under the Affordable Care Act and other health care reform initiatives as well as key requirements needed for establishing an Accountable Care Organization and the status of CMS approved ACO s. There will also be further discussion on how these changes and the movement toward paying providers based on meeting quality and outcome measures will affect medical staff professionals. Participants will also learn what steps need to be taken to limit liability, maximize reimbursement, and remain in compliance with legal requirements.

Regional Lunch with State Leaders (optional; ticket required; additional fee applies)
Time: 11:45 a.m. – 12:45 p.m.
Total CE Credit: 1.0

Join us as we host Regional Lunch Meetings with formal presentations from state leaders and NAMSS ’ directors at large. This is your opportunity to meet local members, discuss issues specific to your region, and find out more about your state association. See the registration form for details.

One Healthcare System’s Journey into MS 4.15: How to Rollout an Effective OPPE/FPPE Program That Engages the Medical Staff
Session Code: MN07
Time: 12:345 p.m. – 2:15 p.m.
Total CE Credits: 1.5
Presented By: Thomas Zweng, MD , FACS

At Presbyterian Healthcare, a Medical Staff Task Force was formed to create a process to fulfill requirements for TJC MS 4.15. The Task Force’s plan was approved by the medical staff and implemented. In this session, learn about the successful process that has been in place for over four years and has evolved into a comprehensive program that positively impacts quality of care.

Principles for Physician Employment
Session Code: MN08
Time: 12:45 p.m. – 2:15 p.m.
Total CE Credits: 1.5
Presented By: Jay Gregory, MD, FACS

Physicians are increasingly entering into employment relationships with hospitals, group practices, and other entities. The American Medical Association (AMA ) Principles for Physician Employment, which are grounded in AMA policy and the AMA Code of Medical Ethics, are intended to help physicians, those who employ physicians, and their respective advisors identify and address some of the unique challenges employment can present to professionalism and the practice of medicine. This session will provide an overview of the AMA Principles for Physician Employment and their application to real-world situations in which the interests of the employer may differ from those of the physician and his or her patients.

The Great Debate: A Red vs. Blue Take on Partisan Issues for MSPs
Session Code: MN09
Time: 12:45 p.m. – 2:15 p.m.
Total CE Credits: 1.5
Presented By: Todd Sagin, MD, JD and Hugh Greeley

This session will address a number of controversial issues in the field of medical staff affairs through a powerful debate between dueling experts. Debate subjects include board certification vs. maintenance certification, full employment history, problem employed physicians, the future of the “organized” medical staff, and more.

Ongoing Performance Evaluation for Privileged Non-Physician Practitioners
Session Code: MN10
Time: 12:45 p.m. – 2:15 p.m.
Total CE Credits: 1.5
Presented By: Mark Smith, MD

Organizations find Ongoing Performance Evaluation (OPPE) a challenge to complete for physicians. Many find it an impossible task when it comes to measuring performance for non-physician practitioners. This presentation will discuss practical ways that an organization can begin to identify performance measures and collect substantive data on this practitioner group’s individual performance. In addition, speakers will discuss how such information should be reported and the processes for managing deficient performance.

The Effective Medical Services Department for Today and the Future
Session Code: MN11
Time: 12:45 p.m. – 2:15 p.m.
Total CE Credits: 1.5
Presented By: Christina Giles, MS, CPMSM and Sally Pelletier, CPMSM, CPCS

Participants will learn about the key functions and responsibilities that are required from an Medical Staff Services Department (MSSD ) in today’s world. Session speakers will lead discussion about additional issues such as culture, leadership, and the need to proactively interface with recruitment and human resources, all of which influence the successful establishment of a well-run MSSD.

Can’t We All Just Get Along? Conflict Management for Medical Services Leaders
Session Code: MN12
Time: 2:45 p.m. – 4:15 p.m.
Total CE Credits: 1.5
Presented By: Jane Conrad, JD and Jeanne Franklin, JD

Responding to both The Joint Commission Conflict Management (Leadership) imperatives and the sea changes occurring from healthcare reform, this training session presents an introduction to the what, why, and how of dealing with disputes, conflict, and differences of opinion (DCD s) that arise in medical staff and healthcare settings. The concepts presented can be customized to address the particular goals and needs of different medical services professionals.

A Practical Approach to Policy Management
Session Code: MN13
Time: 2:45 p.m. – 4:15 p.m.
Total CE Credits: 1.5
Presented By: Jodi Eisenberg, MHA , CPHQ, CPMSM, CSHA and Leilani Chan, BS, MT (ASCP)

In any healthcare environment, it is important to create policy and procedural documents that support effective, efficient, and safe patient care. This presentation will provide a detailed overview of the definition and types of policy and procedural documents as well as the lifecycle of a policy. Attendees will also receive tools and templates to help ensure accuracy and consistency in the process.

Practitioner Competence: Do You Know if All Your Clinicians are Safe to Practice and What You Can Do to Be Sure
Session Code: MN14
Time: 2:45 p.m. – 4:15 p.m.
Total CE Credits: 1.5
Presented By: Todd Sagin, MD, JD

Medical staff professionals and physician leaders need to be aware of the various tools and resources available to evaluate practitioner competence and to remediate deficiencies when found. This presentation will examine the various national programs available to perform clinical skills assessments, the availability of resources for remediating problems with professional conduct or clinical performance, new requirements being imposed by licensing boards, and new concepts of physician competency being explored by educational institutions.

Making FPPE for Initial Applicants Relevant
Session Code: MN15
Time: 2:45 p.m. – 4:15 p.m.
Total CE Credits: 1.5
Presented By: Mark Smith, MD

FPPE for initial applicants is a required competency process under the Joint Commission. By adding the enhanced element of mentorship to the FPPE, an organization can expect to realize much greater benefit for the expended effort. Mentorship allows medical staff leaders a way to help new members more easily navigate the orientation and initial practice process while providing adequate information about practitioner competency to satisfy the regulatory requirements. This presentation will discuss the reasoning behind choosing to adopt mentorship into the FPPE process, practical ways to implement the process, and examination of the overriding benefits for so doing.

The Impact of Pay-for-Value Reimbursement on Credentialing and Privileging
Session Code: MN16
Time: 2:45 p.m. – 4:15 p.m.
Total CE Credits: 1.5
Presented By: Jonathan Burroughs, MD, MBA, FACHE, FACPE

Under new “pay for value” reimbursement methodologies, physicians, mid-level practitioners, and hospitals must modify their approach to patient care to achieve high compliance with quality metrics, HCA HPS scores, patient safety measures, and lower costs. These new metrics must become part of the organization’s ongoing professional practice evaluation (OPPE) and focused professional practice evaluation (FPPE) systems. In this session, learn how the credentialing and privileging process should utilize key metrics that have the greatest impact on quality, service, safety, and cost so that current clinical competence is measured in a way that assures optimum patient care and sufficient reimbursement to support the organization’s mission.

Becoming a Volunteer: An Introduction to Volunteering with NAMSS (optional; ticket required; included in Conference Registration)
Time: 7:00 a.m. – 8:00 a.m.
Total CE Credit: 1.0

Join NAMSS’ committee and board leaders to learn more about volunteering with NAMSS. Committee Chairs and Board members will share their volunteer experience and provide a pathway for serving as a volunteer at the national level. Continental breakfast will be provided.

Roundtable Networking Breakfast (optional; ticket required; included in Conference Registration)
Time: 7:00 a.m. – 8:00 a.m.
Total CE Credit: 1.0

Join in an upbeat networking breakfast complete with roundtable discussions by areas of interest including CVO, hospital, and managed care setting. NEW THIS YEAR! This session is now included in your conference registration fees. Continental breakfast will be provided.

Corporate Negligence and Medical Malpractice: Navigating the Potential Land Mines of Hiring, Credentialing, and Retention
Session Code: TU01
Time: 8:00 a.m. – 9:30 a.m.
Total CE Credits: 1.5
Presented By: Joshua McCaig, JD, MS

Medical malpractice litigation is a known risk to those entering the health care profession. In an effort to address this crisis most states implemented tort reform to deal with excessive jury verdicts. However, plaintiff attorneys are now using corporate negligence claims in order to implicate the hospital or health care entity with potential punitive damages. These attorneys use the leverage of costly litigation, disclosure of sensitive documents, and risk of a large verdict to entice settlement from such entities. This session discusses the nature of corporate negligence theories, how they are being used in medical malpractice litigation, discovery related concerns, risk management issues, and strategies for defending the claims.

National Practitioner Data Bank Developments: Research, Reportability, and Hospital Compliance
Session Code: TU02
Time: 8:00 a.m. – 9:30 a.m.
Total CE Credits: 1.5
Presented By: Ernia Hughes, MBA

Ernia Hughes, Acting Director, Health Resources and Services Administration, Bureau of Health Professions, Division of Practitioner Data Banks (DPDB), will provide an overview of developments and initiatives within the National Practitioner Data Banks (NPDB), including its recent merger with the Health Care Integrity and Protection Data Bank. Ms. Hughes will describe select research activities, provide scenario-based practical guidance on NPDB reporting and querying requirements, and describe DPDB’s hospital compliance initiative.

2013 Medical Staff Standards Update Panel featuring TJC, NCQA, DNV, URAC, and HFAP: Part 1 of 2
Session Code: TU03
Time: 8:00 a.m. – 9:30 a.m.
Total CE Credits: 1.5
Presented By: Susan DeMarino, RN, MSHS, CPHQ, RN-BC; Laurel McCourt, MD; Frank Stelling, MEd, MPH; and Merrill N. Werblun, MD

This session will provide a comparison of applicable credentialing and medical staff standards from The Joint Commission (TJC), the National Committee for Quality Assurance (NC QA), Det Norske Veritas (DNV ), Utilization Review Accreditation Commission (URAC ) and Healthcare Facilities Accreditation Program (HFA P). This two-part presentation will provide an overview of each organization, with an emphasis on credentialing and medical staff standards, followed by a discussion on the comparison of various standards based on the NAMSS Comparison of Accreditation Standards Grid.

The Credentialing, Privileging, and Reappointment of Employed Practitioners: Panacea or Pain for the Medical Staff Professional?
Session Code: TU04
Time: 8:00 a.m. – 9:30 a.m.
Total CE Credits: 1.5
Presented By: William Cors, MD

Increasingly organizations are employing physicians and other practitioners who need to go through the credentialing and privileging process overseen by the Medical Staff Services Department (MSSD ). This introduces a new layer of complexity for many Medical Staff Professionals as they have to interact with divergent organization stakeholders including physician recruiting, human resources, and practitioner billing. This session outlines best practices for interaction and information-sharing between these stakeholder groups; how to educate others about the credentialing and privileging process; and the new perils and pitfalls of how physician performance is handled and where information is stored.

Mastering Clinical Excellence: The Synergy Between Risk, Quality, and Medical Staff Services
Session Code: TU05
Time: 8:00 a.m. – 9:30 a.m.
Total CE Credits: 1.5
Presented By: Kate Conklin, BS, CPMSM, CPCS, CPHQ; Susan T. Goodwin, RN, MSN, CPHQ, FNAHQ, FACHE; and Michelle Hoppes, RN, MS, DFASHRM

Join the Past Presidents of NAMSS, NA HQ, and AS HRM to discuss the importance of creating a unified front in managing the rapid changes in the healthcare arena. The roles and responsibilities of quality, patient safety, and risk management professionals often blend and even compete within organizations. In this session, presenters will demonstrate the value of a joint agenda that forces collaboration and unifies the team to promote positive outcomes in all areas of patient safety and healthcare improvement.

VBP Metrics: A Catalyst for Systems-Based Hospital Peer Review?
Session Code: TU06
Time: 10:00 a.m. – 11:30 a.m.
Total CE Credits: 1.5
Presented By: Robin Nagele, JD

The ACA ’s Value-Based Purchasing (VBP) program uses financial rewards and penalties to promote improved hospital quality based on metrics established annually by CMS . Hospitals that fail to incorporate the VBP metrics into their quality oversight and peer review processes risk losing valuable Medicare dollars at a time when every penny counts. This session suggests how physician peer review can be more successfully integrated into a hospital’s broader systems-based quality improvement processes.

Managing the Disruptive Physician: How Joint Commission Standards, the ACGME Milestones, and Your Medical Staff Bylaws Can Help Create an Effective System for Addressing Unprofessional Behavior in the Hospital Setting
Session Code: TU07
Time: 10:00 a.m. – 11:30 a.m.
Total CE Credits: 1.5
Presented By: Nili Yolin, JD and Colleen McMahon, JD

Intimidating and disruptive behavior can foster medical errors, contribute to poor patient satisfaction, and compromise staff morale. Safety and quality of patient care is dependent on communication and a collaborative work environment. To assure quality and to promote a culture of safety, a hospital must address the problem of behavior that threatens the performance of the health care team. In this session, presenters will discuss best practices for ensuring a culture of safety in the hospital.

External Peer Review Strategically Tackles Cardiology Abuse and Fraud
Session Code: TU08
Time: 10:00 a.m. – 11:30 a.m.
Total CE Credits: 1.5
Presented By: Andrew Rowe

High-profile cases of overutilization, abuse, and fraud in cardiology departments continue to expose the widespread extent of questionable physician/hospital practices. Poorly managed peer review breaks down a hospital’s physician performance improvement program and quality management system, jeopardizing patient safety, and increasing risk. Unfortunately, many organizations face ongoing challenges to establishing an effective peer review (PR) process. This session will help attendees understand how effective PR depends upon best practices in risk management that can help hospitals overcome barriers in cardiology departments.

2013 Medical Staff Standards Update Panel featuring TJC, NCQA, DNV, URAC, and HFAP: Part 2 of 2
Session Code: TU09
Time: 10:00 a.m. – 11:30 a.m.
Total CE Credits: 1.5
Presented By: Susan DeMarino, RN, MSHS, CPHQ, RN-BC; Laurel McCourt, MD; Frank Stelling, MEd, MPH; and Merrill N. Werblun, MD

Learn about the comparisons of applicable credentialing and medical staff standards from The Joint Commission (TJC), the National Committee for Quality Assurance (NC QA), Det Norske Veritas (DNV ), Utilization Review Accreditation Commission (URAC ) and Healthcare Facilities Accreditation Program (HFA P). This two-part presentation will provide an overview of each organization, with an emphasis on credentialing and medical staff standards, followed by a discussion on the comparison of various standards based on the NAMSS Comparison of Accreditation Standards Grid.

Successful Managed Care Audits
Session Code: TU10
Time: 10:00 a.m. – 11:30 a.m.
Total CE Credits: 1.5
Presented By: Angela Ross, MA and Sallye Marcus

Managed Care Auditing is rapidly evolving with a variety of on-site and electronic audit options. As a result it is oftentimes difficult to keep up with the documentation and requirements necessary, but success is attainable. Learn how to manage current day-to-day work responsibilities while maintaining a comprehensive program geared towards managed care or other oversight audits.

Business Luncheon and Keynote Address
Session Code: TU11
Time: 11:45 a.m. – 2:00 p.m.
Total CE Credit: 1.5
Keynote Speaker: David Glickman

Anatomy of a Medical Staff Investigation: The Case of Dr. Travis T. Scully
Session Code: TU12
Time: 2:30 p.m. – 4:00 p.m.
Total CE Credits: 1.5
Presented By: Paul Verardi, JD

Over the last several years, Medical Staff peer review processes have become more effective in addressing questions and concerns with physicians than ever before. While this improvement has lessened the need to conduct formal investigations, it has not eliminated it. When an investigation must be conducted, the process still seems daunting and risk-prone to all who are involved. This session will use video-enhanced case studies with neurosurgeon Dr. Scully to explore the essential “do’s and don’ts” of a Medical Staff investigation.

A Kinder and Gentler Medical Staff Dispute Resolution Process
Session Code: TU13
Time: 2:30 p.m. – 4:00 p.m.
Total CE Credits: 1.5
Presented By: Elise Brennan, JD, MSW

The Joint Commission, HCQIA, and the U.S. Supreme Court all provide support for the use of alternative dispute resolution (ADR ) techniques to resolve physician peer review issues and conflicts between the MEC and the Medical Staff and the Medical Staff and the Hospital’s Governing Board. This session will discuss the different ways to use mediation and arbitration, the benefits from their use, the legal authority for using them, and required Medical Staff Bylaw revisions or Hospital policy changes necessary to insert mediation and arbitration in the dispute resolution process.

A Risk Management Guide to Health Care Reform Credentialing
Session Code: TU14
Time: 2:30 p.m. – 4:00 p.m.
Total CE Credits: 1.5
Presented By: Fay Rozovsky, JD, MPH and Patricia Hughes, RN, MSN, CPHRM, FASHRM

The Affordable Care Act, the Medicare ACO Shared Savings Program, and state law changes in jurisdictions (such as in Massachusetts) raise new risk management issues for the credentialing process. Using a case example, this presentation will examine emerging legal, regulatory and compliance credentialing risk exposures, and offer practical solutions to manage these concerns. Sample tools will be included for participants.

The Competency Committee: Pulling It All Together
Session Code: TU15
Time: 2:30 p.m. – 4:00 p.m.
Total CE Credits: 1.5
Presented By: William Cors, MD

Medical Staff Professionals have to interact with a number of new and divergent organization stakeholders including physician recruiting, human resources, and practitioner billing. This session outlines best practices for interaction and information sharing between these divergent stakeholder groups; how to educate others about the credentialing and privileging process; and the new perils and pitfalls of how physician performance is handled and where information about that performance is stored.

Minute Taking Made Easy for the Medical Services Professional
Session Code: TU16
Time: 2:30 p.m. – 4:00 p.m.
Total CE Credits: 1.5
Presented By: Sara Paronish, CPMSM, MHMS and Amy Opsitnick, CPMSM

Do you find the same topics being discussed at your medical staff meetings month after month without resolution? Are you able to use your minutes as a quick reference tool? Do your minutes read like a transcript? Poorly written, unorganized, or unclear minutes can slow down the work of your medical staff committees and raise unintended concerns with regulatory bodies. This session will provide tips and tools for efficient and comprehensive minute taking and help to build confidence in your skills.

Zumba® Workout (optional; ticket required; additional fee applies)
Time: 6:30 a.m. – 7:30 a.m.

Back by popular demand! Join us for an exhilarating, effective easy-to-follow, Latin-inspired, calorie burning dance fitness party that’s moving millions of people toward joy and health. The cost is $25 per person. All proceeds will go to the Susan G. Komen Breast Cancer Foundation.

Certificants' Celebration
Time: 7:00 a.m. – 8:00 a.m.

For all individuals holding the CPCS or CPMSM certification, join your fellow certificants for breakfast to honor you! The Certification Commission of NAMSS (CCN) will be in attendance to interact, answer questions, and discuss future volunteer opportunities for those interested in getting involved in the exam development process!

Legal Considerations Affecting Credentialing Decisions: The Physician’s Perspective
Session Code: WE01
Time: 8:30 a.m. – 10:00 a.m.
Total CE Credits: 1.5
Presented By: David Zarett, JD

Credentialing decisions by hospitals, managed care companies, and large medical practices have a dramatic effect upon a physician’s career and earning capacity. There are interesting and unsettled legal considerations bearing on both the substantive and procedural aspects of any credentialing decision. This presentation will describe some of those legal considerations, and will be presented from the perspective of an experienced attorney who handles these matters on behalf of private practice physicians.

Independent Peer Review Panels: An Escape from the Hearing Panel Nightmare
Session Code: WE02
Time: 8:30 a.m. – 10:00 a.m.
Total CE Credits: 1.5
Presented By: Erin Muellenberg, JD and Lowell Brown, JD

This session will discuss the use of independent peer review panels to act as the hearing committee in disciplinary actions. Too many medical staffs refrain from disciplinary action because they do not want to be tied to months of hearing sessions that never seem to end. With the use of independent hearing panels these issues can be avoided and the process can be streamlined to where a hearing can be held on consecutive days during business hours at less cost and time. This session will discuss these panels and the necessary bylaws modifications for their use.

The Aging Physician: Practical Solutions for a Sensitive Issue
Session Code: WE03
Time: 8:30 a.m. – 10:00 a.m.
Total CE Credits: 1.5
Presented By: Steven Miller, MD, MPH

This session will examine natural aging, the increased prevalence of pathologic changes with age, and the impact of age-related changes on clinical performance. Ageism is reprehensible; however, given the important responsibilities of the medical profession, it is equally irresponsible to ignore the decrements in physical and cognitive function that are attendant upon the passage of time for most of us. Steven Miller will review the current findings on physician aging and competence and provide a forum for discussion around this important issue. Pilot data utilizing new assessment tools will be presented with an initial interpretation of the findings.

Disaster Strikes: Will You Be Prepared if the Lights Go Out?
Session Code: WE04
Time: 8:30 a.m. – 10:00 a.m.
Total CE Credits: 1.5
Presented By: Marianne Ambookan, MBA , RN and Jordan Gilels, CPCS

Healthcare leaders recognize the significant impact a disaster can have on hospital operations and patient safety. In the midst of a disaster, the credentialing office is called to task to provide disaster privileging. Find out how one hospital was prepared and credentialed approximately 400 practitioners in fewer than 3 weeks This program will provide Credentialing Managers with planning strategies to ensure their organization’s disaster policy and disaster privileging processes are comprehensive and well designed.

Centralized Credentialing in the Era of Value-Based Healthcare
Session Code: WE05
Time: 8:30 a.m. – 10:00 a.m.
Total CE Credits: 1.5
Presented By: Brian Betner, JD

The concept of centralized or system-wide credentialing is becoming more of a focus throughout the country as hospitals and health systems seek efficient solutions for achieving uniform standards of quality. Also, as health care reform continues to create reimbursement and cost pressures that drive integration, hospitals and health systems will be forced do more with less. This presentation will outline the various regulatory and risk-management considerations associated with centralized or system-wide credentialing and quality/peer review activities and will include number of practical solutions for implementing centralized credentialing and quality/peer review activities.

Avoiding and Winning Credentialing Litigation
Session Code: WE06
Time: 10:30 a.m. – 12:00 p.m.
Total CE Credits: 1.5
Presented By: Tim Adelman, JD

The medical staff bylaws can be the critical foundation to help avoid and win litigation arising from credentialing and corrective actions. It is important to have provisions in medical staff bylaws that provide protections for participants in credentialing and corrective actions, including the appointment and hearing process. This presentation will address the best recommendations for: avoiding unnecessary processing for unqualified applicants; dealing with incomplete applications; avoiding unnecessary hearings and NPDB reporting; and much more!

Redesigning the Medical Staff and its Processes to Advance Quality Initiatives Across the Care Continuum
Session Code: WE07
Time: 10:30 a.m. – 12:00 p.m.
Total CE Credits: 1.5
Presented By: Christopher Anderson, JD and Fatema Zanzi, JD

The changing quality imperatives brought on by healthcare reform are emphasizing the need for increased focus and coordination between health systems, hospitals, and their medical staff(s). This session will explore strategies related to establishing a uniform approach to advancing clinical quality throughout the care continuum. Additionally, this session will provide attendees with mechanisms on how to implement such strategies by not only engaging the relevant parties but also by providing and discussing sample provisions for committee charters, bylaws, medical staff policies and procedures, and employment agreements.

Medical Staff Credentialing: Responding to Credentialing Inquiries Safely and Ethically in the Post-Kadlec Medical Center World
Session Code: WE08
Time: 10:30 a.m. – 12:00 p.m.
Total CE Credits: 1.5
Presented By: Steven Schnier, JD

The medical staff services professional is asked to respond to scores of credentialing inquiries. While most inquiries present few difficulties, some whose practices and personalities defy an enthusiastically positive response concern medical staff members. Just a few years ago, the judicial decision in Kadlec Medical Center v. Lakeview Regional Medical Center reminded us that a misleadingly positive response to a credentialing inquiry not only crosses the line into questionable morality but also may expose the responding hospital to potential liability. In this session, you will learn the ins and outs of a successful response to credentialing inquiries in a post-Kadlec Medical Center world.

One-Stop-Shop Credentialing Office
Session Code: WE09
Time: 10:30 a.m. – 12:00 p.m.
Total CE Credits: 1.5
Presented By: Anne Smith, MBA and Michelle Stultz, RN, CPMSM, CPCS

Representatives from two academic medical centers will describe how they are meeting the needs of the medical staff for assisting with licensing, credentialing, privileging, and enrollment into managed care plans and government plans.

Summary Corrective Actions: Avoiding Them and Imposing Them
Session Code: WE10
Time: 10:30 a.m. – 12:00 p.m.
Total CE Credits: 1.5
Presented By: Joanne Hopkins, JD, MSN

Summary corrective actions are the subject of increasing litigation in the medical staff area due to the severity of the sanction and the fact that the sanction is imposed before affording procedural due process. This session will address the appropriate grounds for summary corrective actions, the immunity available under the Health Care Quality Improvement Act and how to use it, options to avoid summary corrective actions, and the process to follow when it must be used. The session will also cover significant case law on summary corrective action in a manner that provides attendees with practical takeaways for their medical staff bylaws and medical staff education. Case studies will be used in an interactive manner to implement the recommendations presented.

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