Course Description:

This training provides a comprehensive overview of the structures and processes that drive effective medical staff governance. Participants will explore the interconnected roles of the Board, Administration, and Medical Staff in credentialing, privileging, and peer review. The session highlights common challenges in initial appointment, reappointment, and clinical privilege decisions, offering practical tools to strengthen credentialing workflows. Attendees will examine factors that commonly hinder peer review and learn strategies for fostering an organized, constructive, and solutions‑oriented process. The training also covers the appropriate use of collegial intervention and progressive actions to address concerns related to clinical competence or professional conduct. Additional topics include meeting key federal and local reporting obligations and developing bylaws language that mitigates risk in areas such as threshold criteria, waivers, misstatements, omissions, administrative relinquishments, and multi-hospital actions. This session equips leaders with actionable insights to enhance quality, safety, and professional accountability.