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Thursday, October 21

Track Key 

12:00 p.m. – 12:45 p.m. EDT

Healthcare Disruptive Innovation: Are you Ready?
Presented by: Jon Burroughs, MD, MBA, FACHE, FAAPL
Executive Management Track | CEs: 0.75 | Mid-Level

The healthcare industry is going through a once in a century transformational revolution by digitizing, standardizing, commoditizing and globalizing. Understand what this means and why these changes are inevitable, necessary, and important for your to lead.

Tales from the Crypt: A Review of Recent Hair Raising Medical Staff Cases and Lessons Learned
Presented by: Catherine M. Ballard, Esq. & Avery A. Schumacher, Esq., MHA
Credentialing/Privileging Track | CEs: 0.75 | Mid-Level

This presentation will examine a number of high profile and meaningful cases that have impacted the medical staff world over the last couple of years. What went wrong? What went right? What are the implications? Cases examined will include an Ohio ICU physician indicted on 35 counts of murder, a hospital sued by the EEOC for blanket medical testing physicians over 70, a physician awarded a $4.75 million jury verdict in a defamation suit against a hospital, a Pennsylvania appellate court ordering the production of NPDB reports from the credentialing file, and others.

How Credentialing Staff Can Better Prepare for Emergency Situations
Presented by: David Welsh, MD, MBA
Credentialing/Privileging Track | CEs: 0.75  

The onset of COVID-19 introduced significant credentialing challenges that health care organizations had not faced in prior emergency/disaster situations. In addition to hitting a large portion of the United States—physicians included—all at once, the pandemic has also lasted much longer than previous emergencies and disasters. Both factors have made it difficult to expedite recruiting and credentialing of volunteer physicians using traditional emergency plans, and the challenges have been even steeper for health care organizations without an emergency plan. Ultimately, this pandemic has exposed a critical need for change in emergency credentialing practices. In this session, the immediate past chair of the AMA Organized Medical Staff Section Governing Council will present lessons learned and updates on the AMA’s efforts to streamline the general credentialing application process and address emergency situations like a pandemic that are long-lasting and have unique health care consequences to both the public and health care providers.

The Joint Commission Standards Overview and Updates
Presented by: Robert Campbell
Accreditation/Regulatory Track | CEs: 0.75 

In this annual favorite, Robert Campbell of The Joint Comission will provide an overview of standards as well as any recent updates. This is a great opportunity to get your questions answered directly from the Clinical Director of Standards Interpretation for Hospital and Ambulatory Programs at The Joint Commission.

1:30 p.m. – 2:15 p.m. EDT

Skills and Knowledge Needed to Support an Effective Privileging Program
Presented by: Vicki Searcy
Systems Track | CEs: 0.75  

One of the most important functions of a medical staff organization is defining and granting clinical privileges to competent providers. And – medical staff organizations must be supported by knowledgeable and skillful Medical Services Professionals (MSPs) in order to create and maintain an excellent privileging program. As the gatekeepers of patient safety, it is critical that MSPs obtain the knowledge and skills to support the privileging process. How do MSPs obtain the knowledge and skills that are necessary?

Pivotal Conversations: Get Comfortable with the Uncomfortable
Presented by: Brianna Foulkrod, CPCS, CPMSM
Leadership/Professional Development Track | CEs: 0.75  

Do you know what you want to say, but have trouble putting the words together? Do you deal with colleagues, people, and peers that can be… less than easy? Do you find yourself thinking of everything you should have said (or not said) after the conversation has already happened? Mastering the art of improving dialogue, better alignment, and a culture of clarity is much easier said than done. In this session, participants will learn tips and tricks for honing skills to improve the way we communicate!

NCQA CVO Question and Answer Session
Presented by: Gerald Stewart
CVO Track | CEs: 0.75  

Do you have questions about the NCQA CVO Standards? Then this is the session for you. Gerald Stewart, Senior Manager of Accreditation Policy at NCQA, is ready to answer all of your questions. This session will be completely based on your questions, so make sure to come prepared with a list!

Credentialing and Privileging During a Disaster: A Collaborative Approach Between a Large Healthcare System and Centralized Credentialing
Presented by: Kaysha Hervey, MHA, CPCS, CPMSM & Kendra Zepeda, CPCS, CPMSM
Credentialing/Privileging Track | CEs: 0.75
This session will share how HCA Healthcare and Parallon responded to the COVID-19 pandemic as related to disaster privileging. The speakers will demonstrate the impact of centralization of credentialing activities to proactively support the hospitals and medical staffs ensuring continued patient care services, in addition discuss the strategies implemented to ensure continued membership and privilege for current practitioners.

2:30 p.m. – 3:30 p.m. EDT

System-Wide Bylaws: It’s Time to Recognize the Benefits
Presented by: Mary Hoppa, MD, MBA
Systems Track | CEs: 1   | Mid-Level

If left to Medical Staffs, health systems might not exist. While it’s hard to argue against the operational efficiencies garnered by becoming a “system,” those benefits are not always transparent to a Medical Staff. In fact, it’s the bureaucracy that oftentimes catches their attention, leading to a negative view of the system structure. But 2020 ushered in a new way of looking at things. Medical Staff experienced the opportunity for and benefits of increased access to staff, equipment, and other resources while battling a global pandemic. And they’ve begun to see the wisdom of consistent “rules” as they’ve worked across institutions. Now is the time to proceed with the creation of system-wide bylaws (and rules and regulations). Under such a structure, most documents are identical while allowing site-specific variation where needed.  And in some systems, it may be the time to proceed with an even greater alignment by creating a unified medical staff.

Building Your Provider Enrollment Toolbox: Tangible Tools for Success
Presented by: Mathieu O. Gaulin & Jenny Jackson, EdD, MBA, CPMSM, CPCS, FMSP
Provider Enrollment Track | CEs: 1 | Mid-Level

Do you have the all provider enrollment tools you need to be effective? Or do you only have a hammer? This session will provide concrete tools to make Provider Enrollment Professionals more effective in addressing a multitude of functions. The goal is to make enrollment less abstract through slides that will double as tangible checklists that can be used when these tasks present themselves.

PAs & APRNs in 2021: Are They Interchangeable? Hot Topics for Tomorrow's MSP
Presented by: Tricia Marriott PA-C,MPAS, MJ Health Law, CHC & Greg P. Thomas, PA-C Emeritus, MPH
          Credentialing/Privileging Track | CEs: 1 | Mid-Level

PAs and APRNs are providing care in many settings and specialties, at times creating challenges for credentialing committees and medical staff professionals. This session will provide detailed information on education, certification, scope of practice, administrative requirements, and emerging trends, with a focus on the similarities and differences between the professions.


Wednesday, October 20

Track Key 


12:00 p.m. – 12:45 p.m. EDT

CMS Enrollment Session
Presented by: Andrew Stouder
Provider Enrollment Track | CEs: 0.75 

Join Andrew Stouder, Team Lead in the Devision of Enrollment Policy and Operations at CMS for a session discussion best practices of CMS enrollment. Hear directly from the source on how to use PECOS, how to avoid delays, and more.

DEI Best Practices and How to Implement Changes That Work
Presented by: DeLibra Wesley, Chief Executive Officer, National Recruiting Consultants
Leadership/Professional Development Track | CEs: 0.75   

Dive into 5 areas to consider when determining best practices for your organization.

  • Commitment: Everyone committed to goals and working together to achieve an inclusive workplace. 
  • Culture: The organization brands itself as an inclusive place to work and all members can see actions that match the branding. 
  • Recruiting and Hiring: Maintaining a proactive approach to sourcing and recruiting diverse talent by continuously improving the hiring practices to remove biased decisions.
  • Retention: The organization works to retain and promote a diverse workforce. 
  • Training and Development: Providing training for leaders and staff that will prepare them to serve each other and diverse communities.

The 4W's of Delegated Credentialing ... Who, What, When, Why 
Presented by: Diana "Di" Hall, CPCS, CPMSM, FMSP & Mark Hirschhorn, CPCS
CVO Track | CEs: 0.75 | Advanced

In this session, attendees will learn ways to identify the 4 W’s of credentialing delegation and their importance. The best practices for collaboration between delegated entities for the contracting and reporting process will be unveiled, and discussion will include a review of current NCQA standards for delegated credentialing. In addition, the session will detail a walk through of elements of a delegated credentialing contract.

Telemedicine Privileging: Something New or Something Old?
Presented by: Todd Sagin, MD, JD
Credentialing/Privileging Track | CEs: 0.75 

The COVID pandemic has fostered a rapid leap forward in the delivery of 'virtual' health care. Over the past decade the processes for credentialing telemedicine providers have become clear as CMS and accrediting bodies have reached agreement on the basic requirements. However, no consensus has been reached over whether the delivery of medicine 'virtually' requires a new skill set for physicians for which they must demonstrate competence. This presentation will discuss why telemedicine is not just an alternative delivery modality for established privileges. The unique skills required to practice virtual medicine will be outlined and there will be discussion of how medical schools, residency programs, and licensing boards are thinking about teaching and vetting these skills. This will be an interactive presentation with facilitated discussion focusing on whether or not medical staffs should create and adopt special privileges for virtual medicine and the pros and cons of taking this route.

2:00 p.m. – 3:00 p.m. EDT

Provider Enrollment, Credentialing and Privileging ... United!
Presented by: Lisa L. Velasco, CPCS, CPMSM, MSM, LPTA
Systems Track | CEs: 1 | Introductory

Credentialing and provider enrollment are complex, time-consuming, and redundant processes that negatively impact provider satisfaction, patient satisfaction, and revenue cycle management. This solutions-oriented presentation will provide MSPs with specific tools and takeaways to streamline processes, gain operational efficiencies, and accelerate turn-around time which will result in cost savings, positive impact to revenue and improve provider and patient satisfaction.

There's an Imposter Among Us?
Presented by: Brianna Foulkrod, CPCS, CPMSM & Maggie Palmer, CPCS, CPMSM
Leadership/Professional Development Track | CEs: 1 | Introductory

Have you ever found your way into a job and felt like you didn't deserve to be there? Have you felt like a fraud at work and like everyone knows that you'll be 'found out' at any moment? Do you have trouble accepting your own successes? You are not alone! Imposter Syndrome is real! In this session, we will learn all about Imposter Syndrome and ways to identify, overcome, and become the hero you always were.

View from the Other Side: Key Learnings from a Summary Suspension Proceeding
Presented by: Robin Locke Nagele & Heather Fields
Executive Management Track | CEs: 1 | Advanced

Every medical staff hearing has its unique issues and challenges. Ms. Fields and Ms. Nagele, both of whom typically represent hospitals/health systems in medical staff proceedings, share insights gained from representing a physician in a successful challenge to a summary suspension.  They will provide practical lessons and takeaways regarding a variety often overlooked issues that can negatively impact a peer review process such as: (i) maintaining employment and medical staff issues as distinct; (ii) the need for clear analysis of the standards for summary suspension before action is taken;  (iii) the importance of knowing the difference between, and segregating, employment mentoring, feedback and documentation from that provided under the context of the medical staff credentialing process; and (iv) the value of training medical staff leaders and executive physician leaders acting in the capacity of the physician employer on how to create objective, contemporaneous records of decision-making and avoid creating post-hoc justification in support of a challenged decision.

Hiding in Plain Sight 2021
Presented by: Erin Muellenberg, JD, CPMSM, CPCS & Kay Brown, CPMSM, CPCS
Credentialing/Privileging Track | CEs: 1 | Mid-Level

Hitting the headlines are the physicians who are the subject of class actions. They have treated multiple patients over the years and been productive members of the medical staff. Now hundreds of patients are banding together to file actions that can bankrupt an organization. The culture of silence needs to be changed and it can be changed through education and transparency join Kay and Erin as they explore new actions against providers and discuss strategies for avoiding this at your organization.

4:00 p.m. – 5:00 p.m. EDT

Are Your Leadership Traits Aligned with Those Around You? 
Presented by: Maggie Palmer, MSA, CPMSM, CPCS
Leadership/Professional Development Track | CEs: 1 | Mid-Level

Today's (and Tomorrow's) MSP needs to continue to hone their leadership skills in an era of remote work, pandemics, changes in regulations, etc. Are you ready to take yourself to the next level in building your strength as a leader? Now is the time to implement we are now aware change is the only constant!

What every Medical Staff Professional Needs to Know About Population Health
Presented by: Jon Burroughs, MD, MBA, FACHE, FAAPL
Credentialing/Privileging Track | CEs: 1 | Mid-Level

Population health is sweeping the world with its more focused and cost-effective approach. This program summarizes how population health works and why it is so different from the 20th century healthcare model. It also shows how you as a Medical Staff Services Professional can help lead this transition.

Conquering Credentialing, Privileging and Peer Review in the Ambulatory Environment
Presented by: Mary Hoppa, MD
Credentialing/Privileging Track | CEs: 1 | Mid-Level

The functions of credentialing, privileging, and peer review are three interconnected and well-established processes in the hospital environment. As more and more care migrates to the ambulatory setting, the lines sometimes become a bit blurred as to what is required versus what is a leading practice for these critical functions. This session will set the record straight on the requirements for compliance with regulatory and accreditation requirements for provider-based clinics versus stand-alone ambulatory facilities while providing attendees with tools to conquer today’s credentialing, privileging, and peer review conundrums in the ambulatory environment. Taught by nationally known experienced presenters in the field of credentialing and peer review, this session features case studies, polling, and inspires interactive exchange of ideas. 

Peer Review Investigations & a Culture of Patient Safety
Presented by: Anne Roberts, Esq., CPMSM, CPCS & Brijen Shah, MD
Accreditation/Regulatory Track | CEs: 1 | Advanced

Addressing concerns related to a provider's clinical competence or professional conduct can be challenging and there are a lot of legal pitfalls that organizations need to be aware of. Establishing a culture of safety and having a solid process for investigating and addressing these concerns is essential for all healthcare organizations.

Tuesday, October 19

Track Key 

12:00 p.m. – 1:00 p.m. EDT

Being Happy Together – Standardizing Peer Review within Systems
Presented by: Catherine M. Ballard, Esq.; Kimberly S. Parks, Esq; Stephen R. Kleinman, Esq.
Systems Track | CEs: 1 | Mid-Level

Inconsistent peer review procedures among medical staffs at hospitals within a healthcare system can be a source of ongoing problems with unintended consequences. However, creating a standardized peer review process can be a daunting task. The purpose of this session is to provide guidance on the steps to 
take and a process that can be followed to achieve a standardized peer review program.

How to Engage the Disruptive Physician
Presented by: Raul H. Zambrano, MS, MD, FAAFP, FACHE
Executive Management Track | CEs: 1 | Advanced

Physicians and providers can and must be great partners in the C&P process, however, many times a lack of understanding and pressure to meet acute care needs makes for behavior that is intimidating and disruptive to the MSP,  medical staff leaders, and endangers the integrity of credentialing and privileging. This session will discuss how to directly address such behaviors and how MSP's can help coach their medical staff provider partners to manage disruptive behavior.

We Together
Presented by: Karen Reed-Coffman, MBA, CPMSM, CPCS & Marcy Lechner, BHA, CPMSM, CPCS
Credentialing/Privileging Track | CEs: 1 | Mid-Level

Whether you are a large, multi-system organization or a small rural hospital, recruitment and medical staff teams are looking for ways to save time, on board the best and brightest in a timely manner and cut costs.  We will share our journey from recruitment, medical staff, and provider enrollment working in silos to where we are today – communicating and collaborating, and thoughts for the future on how we can better ensure that the work we do is “We Together”.

Verify and Comply: CMS, JC, NCQA, HFAP, and DNV Credentialing Standards Compared and Contrasted 
Presented by: Sally J. Pelletier, CPMSM, CPCS & Frances Ponsioen, CPMSM, CPCS
 Accreditation/Regulatory Track | CEs: 1 | Mid-Level

Compliance with multiple regulatory and accreditation standards is mandatory for healthcare organizations. However, it is becoming increasingly challenging to understand the similarities and differences in requirements. This session compares and contrasts the specific standards for the five agencies in a manner that is unlike any other. Join us to receive an informative and concise understanding of accreditation requirements related to credentialing.

1:30 p.m. – 2:30 p.m. EDT

Impact of “Systemizing” Credentialing and Privileging on MSPs  
Presented by: Susan DuBois, CPCS, CPMSM; Diane Meldi, MBA, CPCS, CPMSM, FMSP; Heidi Thompson, MBA, CPMSM, CPCS, FMSP; Alena Hope, CPCS
Systems Track | CEs: 1 | Mid-Level

Health systems and hospitals are looking for ways to become more efficient and effective by centralizing and systemizing processes and programs that were traditionally managed as independent services. During this session, we will discuss the impact on and opportunities for medical service professionals (MSPs) working in hospitals, health systems, CVOs, insurance plans and enrollment services, associated with health systems and hospitals centralizing and systemizing credentialing, privileging, enrollment and other related services.

How Bright is YOUR Halo? A Look at Servant Leadership
Presented by: Melissa Walters, MHA, FMSP, CPMSM, CPCS
Leadership/Professional Development Track | CEs: 1 | Mid-Level

Tap into your inner servant leader while learning to empower your people, lead change and design creative solutions in the ever-changing world of healthcare and medical services administration. Learn how to focus on the strength of “team” while developing trust and ultimately serving as the gatekeepers of patient safety.

Employed Physicians: Navigating HR and Peer Review for Employed Physicians
Presented by: John Synowicki, JD
Credentialing/Privileging Track | CEs: 1 | Mid-Level

This session will examine the differences between employed physicians and those that are only credentialed, and will discuss the similarities and differences in how to address peer review issues for each category of physicians.

Physician’s Reentering Practice: Know When to Hold ‘Em  Know When to Fold ‘Em  Know When to Walk Away  Know When to Run!
Presented by: Elizabeth Korinek, MPH & Sally J. Pelletier, CPMSM, CPCS
          Credentialing/Privileging Track | CEs: 1 | Mid-Level

Returning to practice or reengaging in specific practice areas can be a complex process, both for the practitioner and for the hospital where they seek to practice. Is it up to you to alert your medical staff leaders that approving privileges for these practitioners after an extended leave shouldn’t be a slam dunk? How do you know when to “hold em” and when to “walk (or run) away”? Do you know what resources are available to help your institution make these decisions? Do you know how to mitigate concerns about negligent credentialing? Do the waivers allowed during COVID intensify your level of risk? Do you have consistent policies to guide decision-making when addressing requests from practitioners to expand/change their scope of practice and/or refresh skillsets they have not used in several years? MSPs struggle with how to objectively and consistently navigate the requirements of privileging and credentialing processes, while at the same time ensuring that patients are safe and well cared for as these practitioners regain their clinical skills. This session will identify the unique challenges presented by practitioners who have a gap in patient care or in experience in specific procedures or services. The session will include an overview of national reentry trends, guidance on reentry policies to ensure you have appropriate processes in place, considerations related to waivers during COVID, review of approaches to facilitate an effective and safe transition to exercising clinical privileges, methods for monitoring to meet focused practice evaluation expectations, and presentation of case studies.

4:00 p.m. – 5:00 p.m. EDT

The Plethora of Provider Profiles
Presented by: Yesenia Servin, CPMSM, PESC & Jenny Jackson, EdD, MBA, CPMSM, CPCS, FMSP
Provider Enrollment Track | CEs: 1 | Mid-Level

Do you feel like you are constantly juggling provider enrollment portals? In Provider Enrollment we are tasked with maintaining multiple provider profiles, including CAQH, I&A, NPPES, payer portals, PECOS and on and on. An MSP who is part of enrollment is constantly fearful of dropping the ball. Whether on-boarding a provider, opening a new practice, updating or revalidating information, or off-boarding a provider each of these must be managed continuously. This session will review several of the most common provider enrollment web portals.

Centralized Credentialing: Improving Patient Safety and Quality of Care While Increasing Efficiency and Effectiveness 
Presented by: Kendra Zepeda, CPCS, CPMSM & Kaysha Hervey, MHA, CPCS, CPMSM
            CVO Track | CEs: 1 | Mid-Level

During this session you will learn the why behind HCA Healthcare’s decision to partner with Parallon to develop a Credentials Verification Organization. Leaders from both Parallon and HCA Healthcare will discuss operational development of their CVO model, the implementation strategy used to transition more than 300 facilities to the standardized model and how they assimilate acquisitions into their Credentialing Process Centers (CPCs). This partnership, along with the goals set forth as part of their credentialing strategy, have directly impacted the care received by patients across the HCA Healthcare enterprise.

Multi-Level Critical Analysis of Appointments and Reappointments: Avoiding the One Who Slipped Through
Presented by: Erin Muellenberg, JD, CPMSM, CPCS
           Credentialing/Privileging Track | CEs: 1 | Mid-Level

This course will reinforce the uniform obligation for multi-level critical analysis of the initial application, the reapplication and privilege request. In addition to first level review we can train others at different levels when to question and stop a file. Orientation of the Credentials Committee and the departments to the files are a must. Is there a template for each level of review? Have you clearly defined a “clean file”? Does your CVO have clear instructions when to bring a file to your attention? Have you reviewed your attestation questions? Are they clear and concise? If automated, is there a continuous warning regarding the consequences of misrepresentations? The multi-level review process is designed to catch problems before they occur but it only works if each level of review conducts a critical analysis of the files and responds accordingly.

Sharing Peer Review Information
Presented by: Jeremy R. Morris, Esq. & Catherine Ballard, Esq.
Accreditation/Regulatory Track | CEs: 1 | Mid-Level

Although every state statute is different, they are in agreement that information loses peer review protection if it is used for a non-peer review purpose.  Most statutes provide that the information is now available from the non-protected source. Some provide that the information is now available from the peer review file. Either way, it can destroy your peer review program. The purpose of this session is to provide guidance on how maintain protection and how to respond to the numerous requests that are constantly being made to share information in your peer review files.

Monday, October 18

Track Key 

2:00 p.m. – 2:45 p.m. EDT

Building Efficient Medical Staffs in Multi-Hospital Systems 
Presented by: Todd Sagin, MD, JD
Systems Track | CEs: 0.75 | Mid-Level

Consolidation in the healthcare industry continues to be robust and more and more hospitals have become part of multi-campus health systems. This provides important opportunities to make medical staffs more efficient and effective. Such opportunities range from cross-campus collaborations (e.g. creating an health system external peer review capability) and common health system medical staff committees (e.g. a system credentials committee) to full merger of two or more medical staffs in a system. This presentation will discuss the following: pros and cons of full versus partial unification of medical staffs; how to overcome physician resistance to medical staff redesign within a health system; the salient design options available when making structural changes to health system medical staffs; the role of medical staff professionals in facilitating medical staff and medical staff office redesign in multi-hospital systems; and an outline of the critical steps for unifying disparate medical staffs within a health system.


How Provider Organizations can Overcome Payer Rejection at Enrollment
Presented by: Jennifer Cloud, CPCS, CPMSM & Christine Andrea Bergeron
Provider Enrollment Track | CEs: 0.75 | Advanced

When enrolling providers in CMS and private insurance companies (i.e., payers/health plans), much is out of your control. In fact, at times you might feel like an opponent rather than a team member in the game of helping health plans to provide adequate and competent care for their member population. Aside from enduring lengthy application processing times and striving to walk a fine line between application status checks and stalking payers, frustration can also stem from receiving a denial from payers when applying for network participation on behalf of providers. However, there are steps you can take to turn that denial around.

Pushed to the Limit: The Impact of a Pandemic on the Prevalence and Management of Disruptive Communication
Presented by: Bill O'Neill, MBA & Alexis Angell, JD 
            Leadership/Professional Development Track | CEs: 0.75 | Mid-Level

Disruptive, intimidating, and unprofessional communication is unfortunately a relatively common phenomenon in the healthcare world. These behaviors can lead to preventable adverse outcomes, excessive staff turnover, and poor patient satisfaction.  These types of behavior may be exacerbated during periods of high stress and exhaustion – and the COVID-19 pandemic has certainly provided an abundance of both conditions. Medical Staff Professionals (MSPs) can play a vital role in helping to manage these challenging situations and assisting institutional leadership in creating a positive clinical workplace even in a world wracked by a deadly epidemic. This session will emphasize practical steps MSPs can take to work with human resource professionals and clinical leadership to establish a policy framework on communication standards that is applied consistently – even in the midst of a crisis. In addition, the session will include approaches to behavioral intervention in acute and/or chronic situations where standards have been violated. Speakers will share “best practice” wisdom gained from interviews with MSP leaders as well as recent research and published guidelines. This session will use a variety of teaching methods including didactic lecture and case discussions.

How Background & Sanction Screening Builds a Better Healthcare Screening Solution  
Presented by: Lorinda Walters & Mary Lundregan
Credentialing/Privileging Track | CEs: 0.75 | Advanced

This session will highlight the importance of coupling healthcare sanction screening with regular background screening, helping Credentialing Verification Organizations and Consumer Reporting Agencies better identify risks in the healthcare industry. The session will detail what an organization can learn from a background screening report and a sanction screening report in turn – each one identifying critical information in an individual’s background that may not be found in the other.

3:00 p.m. – 4:00 p.m. EDT

A Tale of Two Peer Reviews
Presented by: Sara Cameron, CPCS, CPMSM & Sharon Beckwith
Executive Management Track | CEs: 1 | Advanced

This session is aimed to take learners through the experience of navigating the process of peer review by guiding them interactively through the process of two unique and interesting peer review case studies. Through interactive questions the learners will make decisions regarding two different peer review cases from the identification of the need for review, to the need to send the cases for external review, review of the peer review findings, presentation at peer review committees, medical executive committees, formulation of professional improvement plan and in one case, the restriction of privileges. The second case will walk learners through the identification of an impaired “late career” physician and how to effectively use peer review and the medical staff process to ultimately revoke privileges.

Focus in a Fog: Addressing Clinical Performance Concerns in a Distracted World
Presented by: Elizabeth Korinek, MPH
Credentialing/Privileging Track | CEs: 1 | Advanced

Medical Services Professionals faced unprecedented challenges in 2020 that will have ramifications for years to come – some positive and some not. Pressing demands related to the pandemic may have distracted physician leaders from their ability to devote the necessary time to monitoring clinician performance. As we emerge from the fog, it is important to regain focus on patient safety and the quality of care patients receive in your facility. Performance concerns, such as patterns of poor surgical outcomes, staff or patient complaints about communication issues, or colleague reports about skill deterioration, must be addressed and resolved. New challenges have also arisen, such as how to monitor the performance of a clinician who was asked to provide care outside their typical practice setting during the crisis. Delayed intervention could put patients at risk and lead to legal ramifications for the hospital and physician. During this session, attendees will learn how to recognize, respond and resolve concerns regarding clinician performance. Bylaws and policy implications and the MSPs role in influencing appropriate design decisions in these key documents will be explored. A wide array of resources for intervention will be reviewed. Attendees will learn how remedial resources have “pivoted” in response to COVID, decreasing barriers and increasing access to needed intervention options. Relevant case studies will be presented. Even in a distracted world, it is important that the medical services professional understand and fulfill their role in creating a truly accountable medical staff and an effective, consistent approach to addressing clinical performance concerns.

Credentialing by Proxy (CBP): Embracing Flexibility in a Telehealth World
Presented by: Frances Ponsioen, CPMSM, CPCS
Credentialing/Privileging Track | CEs: 1 | Mid-Level

The delivery of healthcare is ever changing, and even more evident over the last year as organizations across the country were forced to use telemedicine as option in the delivery of healthcare during the COVID pandemic. Will organizations view telemedicine as a permanent solution post pandemic and work towards finalizing agreements with sub-specialists to meet the patient need? How does an increase in telemedicine affect the credentialing and privileging process? How is it possible to assure the competency of practitioners who never grace your hallways? What is credentialing by proxy (CBP) and is it the right option for your organization? During this session, we will review the credentialing and privileging options for telemedicine and explore how to develop a telemedicine process that effectively addresses the four steps of credentialing by embracing the flexibility of CBP provided by the regulators and accreditors.

Year in Review: Legal Impact on MSPs 
Presented by: Michael Callahan, JD
Accreditation/Regulatory Track | CEs: 1 | Mid-Level

The purpose of this presentation is to summarize the major case law, accreditation, Data Bank and other legal developments which will impact the daily responsibilities of MSPs. These developments will be categorized along with Lessons Learned so that the members will obtain practical guidance and recommendations that they can take back to the hospital and medical staff leaders in the areas of peer review, privileging and credentialing, Data Bank reporting obligations and other areas of legal compliance.

4:15 p.m. – 5:00 p.m. EDT

Success in the Digital Age of Credentialing: A Case Study on Surviving and Thriving a Credentialing Software Change
Mallorie Merboth, CPCS, CPMSM, CPHQ; Cheri Lipps-Brindle; and Brian Winslow
            Executive Management Track | CEs: 0.75 | Advanced

Is it time for a technology change in your medical staff services department? Join us to hear about the lessons learned from a multi-hospital health system who made a credentialing software change in the midst of the pandemic to align their credentialing, privileging, payer enrollment, and peer review needs. This case study will share tips and tricks for a successful go-live.  Implementation involved total revisions to 80% of the work flow, completely electronic communication with applicants, references, verifications and medical staff leaders, and valuable reductions in turn-around times.

The Criteria Conundrum: Developing Privilege Criteria for Competency & Patient Safety
Presented by: Diane M. Meldi, MBA, CPCS, CPMSM, FMSP & Dustin Jackson, MHA, CPCS, CPMSM
Credentialing/Privileging Track | CEs: 0.75 | Introductory

This session will review how to develop core privileges by determining competence, basic qualifications, and proctoring requirements.  Discuss what is "Core" and what is "Non-Core" and how an MSP develops privileges for new technology.

2021 DNV Standards Updates and Overview
Presented by: Troy McCann
Accreditation/Regulatory Track | CEs: 0.75 | Mid-Level

In this session, hear directly from the Standards Application and Interpretation Team at DNV. The team will provide an overview of applicable medical staff standards as well as highlighting recent updates. Come prepared with questions and get them answered directly from the source!

Back to the Future – Transformative Performance Metrics
Presented by: Melissa Walters, MHA, FMSP, CPMSM, CPCS and Joseph Travagline, MS RHIA 
CVO Track | CEs: 0.75 | Mid-Level

Digital Transformation is not just a perception anymore it’s a realty. Real-time data for today’s remote workforce is a key asset for MSPs. In this session we will looking at how to utilize technology to measure performance by looking at how you can build “real-time” dashboards to measure department/facility performance as well as individual performance. Join us as we take you on a performance metrics Back to the Future journey!