EDUCATIONAL PROGRAMS FOR HOSPITALS, MEDICAL STAFFS, MANAGED CARE, AND PROFESSIONAL ORGANIZATIONS

Due to decreasing reimbursement, many employers are forced to cut back or stop paying for continuing education for their employees and medical staff officers. These conferences are typically held at resort locations and can cost $2,000 - $3,000 per individual to attend. Kathy can speak to your entire medical staff and support staff for less than the cost of sending one person to a conference. All presentations are customized to your needs. Scroll down to view a sample of educational presentations offered, or you can download a PDF of all programs currently offered.

Applying Critical Thinking Skills to Avoid Confirmation Bias in Credentialing Decisions

Confirmation bias should be avoided in the credentialing and privileging processes because it can lead poor decisions based on debatable information.  One way to avoid confirmation bias is to apply critical thinking skills in credentialing and privileging decisions.  This may mean taking the “unpopular” stance on an issue, having to admit that a decision was wrong, or confronting a superior about a decision made.  Although these can be uncomfortable actions, failure to admit and correct mistakes can lead to public ridicule and can cause distrust of the organization’s ability to provide safe, effective patient care.  Participants will utilize provided tools and exercises to practice critical thinking skills in making credentialing and privileging decisions.

Temporary Privileges and Expedited Credentialing: Meeting Patient Need without Compromising Patient Safety

This presentation discusses the reasons for credentialing and privileging, Joint Commission requirements for granting temporary and disaster privileges and expedited credentialing. Discussion will include "red flags" to be aware of, sample policies for implementing temporary privileges and expedited credentialing, and barriers to functional credentialing processes.

Credentialing, Recredentialing, and Privileging Basics

This program covers all aspects of credentialing and recredentialing including, bylaws, policies, rules & regulations, qualifications/application, verification/review of information, peer review process, due process, temporary privileges. A great program for those new to credentialing and a good refresher for the experienced. Includes an interactive hands-on session reviewing an application for “red flags”. Credentials and Medical Executive Committee members, hospital administration, and board members will benefit as will anyone on the medical staff who has an interest in credentialing. This program can be presented as a 2-hour overview or a 4-hour in depth presentation.

Advanced Credentialing and Privileging Concepts

This program will delve into complex issues in credentialing and privileging such as developing an effective privileging process, evaluating and documenting practitioner competency, documenting recommendations, handling requests for new privileges, and proctoring.  Great as a stand alone program or can be combined with the Basics program. 

Credentialing Allied Health and Complementary and Alternative Medicine Providers

We often hear that credentialing AHP and CAM should be done the same as for other providers. Unfortunately, it is not always that easy. These providers make for some interesting challenges. This program begins with a history of the use of AHPs and CAM providers and discusses ways to effectively credential and privilege them. Topics include classifying allied health professionals and CAM providers, Joint Commission standards, federal (Medicare, NPDB/HIPDB) and state laws, defining the role of the AHP, establishing community need, acceptance by hospital ancillary staff and medical staff, documenting competency, privileges vs. job descriptions, supervision/proctoring/monitoring, credentialing sources, and recredentialing/reappointment/reappraisal. Credentials and Medical Executive Committee members, hospital administration, medical staff support personnel, and board members will benefit as will anyone on the medical staff who has an interest in credentialing.

Joint Commission Medical Staff Standards

This session covers Joint Commission Standards for the medical staff with emphasis on recent changes in the standards. Also includes a discussion of the survey process including Tracer Methodology and medical staff participation in the survey. Included are examples of forms, policies, and procedures to help comply with standards.

Evaluating Meeting Effectiveness

This presentation goes beyond the basics of agenda preparation and taking minutes. Included are tips on how to increase meeting attendance, how to make meetings more efficient and effective, when not to meet, evaluating effectiveness and cost of meetings, reengineering the medical staff, and building the right team for medical staff committees.

Effective Communication and Networking

All situations are dependent in some way on the conveyance of meaning and information. Everyone communicates, but some people are more skilled at this than others. This program focuses on effective communication including barriers, breakdowns, feedback, verbal and non-verbal communication, listening and ways to make sure that the information we communicate is meaningful to the receiver. We will discuss in detail how the human resources department evaluates requests for salary changes and how to communicate the importance of the role of the MSP in these evaluations. Networking skills will be discussed including, building and maintaining your network.

Medical Staff Meeting Management

This program covers the basics of agenda preparation, communication with key speakers or presenters, the roles of the chairman/MSP/members, use of scheduling software, taking and transcribing minutes compliant with Joint Commission and NCQA standards, record retention, and basics of understanding and evaluating the cost of meetings vs. the benefit.

Can be combined with Evaluating Effectiveness and Restructuring of Committees (see next section).

Hot Topics in Credentialing and Privileging

This program will provide an overview “hot topics” in credentialing and privileging. Recent examples include:

• Hot areas in TJC, AOA-HFAP and NCQA standards for credentialing/recredentialing
• Credentialing and privileging AHPs including APRNs and PAs
• Use of pictures and other documentation to assure provider identity
• Identifying and responding to “red flags”
• Turf Battles – How to draw the line when granting privileges that cross boundaries
• Handling “problem” practitioners
• Preparing for NAMSS’ certification exams
• Obtaining recognition for the MSP
• CMS privileging requirements

Due to hot topics coming up on a routine basis, this list can be modified at any time prior to the or during the conference. If your organization wishes to discuss an issue related to medical services, I am ready!! Let me know what issues are important or relevant to your members and I will customize this presentation to meet your members’ needs. I like to include a lot of interaction and encourage audience discussion and questions during the program.

Core Privileging

Has your hospital have considered trading in its “laundry list” privileging for a core privileging process? Although many believe that core privileges do away with lists, they do not realize that defining the core entails developing a list of procedures to be included in the core. When hospitals decide to use a core privileging system, the biggest challenge is developing this “core”. This program will provide the participant the knowledge needed to develop and implement a core privileging process enhanced by the experience of the speaker in developing and implementing such a process.

During the program, the participants will participate in a workshop where they will utilize resources provided to develop a hospital specific core privilege form for a particular specialty.

Understanding the Peer Review and Performance Improvement Processes

The peer review process is often misunderstood and mistaken for the performance improvement process. While closely intertwined and sometimes overlapping, they are two separate processes. This program will cover the steps in both processes including, Joint Commission and CMS requirements, provisional appointment, proctoring, and legal protections afforded by state and federal regulations

Documenting Provider Competency in Privileging

One of the biggest challenges medical staffs face is evaluating the competency of providers. While it is relatively easy to verify licensure, malpractice history, and hospital affiliations, it is difficult, or sometimes impossible, to come up with useful competency data. The increased focus on quality by accrediting organizations, the government, and the public, emphasizes the need for continual monitoring of the quality of services provided as well as having a strong privileging system.

Keeping Medical Staff Bylaws Current

This program will provide an overview of the requirements of the Joint Commission, American Osteopathic Association Healthcare Facility Accreditation Program (AOA-HFAP), and Medicare Conditions of Participation pertaining to bylaws content.  The process for evaluting bylaws for compliance with accrediation standards and for developing and implementing bylaws changes will be discussed.  In addition, current “hot topics” in credentialing and privileging and their effect on medical staff bylaws will be discussed.

Understanding Negligence in Credentialing (Click here to download a copy of the handout.)

This program will discuss past and recent negligent credentialing lawsuits and their impact on the credentialing practices. At the completion of this program, the participant will:

• Understand the concept of negligence in credentialing
• Be able to discuss the process that is followed after a negligent credentialing claim is filed
• Know the role the medical services professional will play in the discovery process
• Understand the elements of a negligent credentialing claim

Leadership in MSP Succession Planning: Ensuring your Organization has the Talent it Needs for the Future

Succession planning is an integrated, systematic approach to identify, develop, and retain talent for key positions and areas to meet current and projected business objectives. This includes making sure medical services professional are educated and equipped to meet the challenges of credentialing, privileging, and medical staff support in this age of public scrutiny. It is important that organizations include key medical services professionals in succession planning, provide educational opportunities, and enhance leadership skills. Since educational programs for MSPs are limited, many get their training on the job. This emphasizes the importance of making sure that the MSP is educated and equipped with the skills necessary to meet the challenges of medical staff support in this age of public scrutiny and increased negligent credentialing claims. This program will explore the importance of assuring that competent personnel are recruited and trained to fill critical positions in medical staff services.

Credentials File Audits:Tools and Techniques for Credentialing Compliance

 Although time consuming, credentialing audits play an important role in oversight of the credentialing process.  Even the most experienced professionals make mistakes and overlook things – it’s part of human nature.  In some cases, an element, such as primary source verification of licensure, is completed but the documentation does not get placed in the credentials file.  Or perhaps an issue requiring follow-up is identified, but is forgotten when a more urgent issue presents itself.  A slip like this can make for a finding of non-compliance on an accreditation survey.

Understanding Telemedicine Credentialing Options

This program will discuss the options and requirements for credentialing telemedicine practitioners under the CMS regulations, Joint Commission and HFAP standards. It will include a discussion of required policies; procedures; and contract and bylaws language. 

Comparison of Joint Commission and Det Norske Veritas Healthcare’s NIAHO Accreditation Standards for the Medical Staff

This program will provide an overview and comparison between Joint Commission Hospital Accreditation Standards and Det Norske Veritas National Integrated Accreditation for Healthcare Organizations (NIAHO) hospital accreditation standards related to the medical staff. 

Understanding CMS Credentialing and Privileging Requirements for Hospitals and Critical Access

This program will cover all regulations related to the medical staff.  We will discuss what CMS expects to see when surveying a hospital for compliance with credentialing and privileging of physicians and other practitioners.

All topics can be customized to fit YOUR time constraints and educational needs.

Is there a topic for which your medical staff members need additional education? I can customize a lecture to meet your needs!

All programs are enhanced by creative use of graphics, humor, and real-life examples to keep the attention of your audience.

Recent comments received regarding educational presentations by Kathy:

• Mrs. Matzka is a very confident and knowledgeable speaker. Good job!
• Detailed coverage of subject. Knowledgeable speaker.
• Well-researched, enthusiastic presenter.
• Kathy’s interaction with the group is great!
• Information current and expressed well. Kathy’s experience is an asset.
• Kathy is fabulous! All the info was most valuable in helping me in my job.
• Explanations and answers were spontaneous and she definitely knows her job.
• Informative, knowledgeable speaker. Creative slides.
• Excellent speaker, good visuals and handout.
• Bring Kathy back for additional topics.
• It’s nice to have a speaker who’s one of us.
• Kathy’s positive attitude is infective!
• The best speaker we’ve ever had – She was “real”.
• Fantastic speaker!
• I walked away with a wealth of information.
• Informative, very pertinent information in a clear & concise method.
• Promoted good discussion & gave good examples, sharing forms & references which is very helpful. Covered a wide comprehensive range of topics.