Medical Staff Leadership Credentialing and Privileging Workshop

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Start Time:12:00 AM
End Time:12:00 AM
Contact Information
Additional Information

This educational activity is jointly provided by AXIS Medical Education and MHA Health Institute.
image001 Health Institute

Date & Location

Friday, Nov. 17, 2017

Missouri Hospital Association
4712 Country Club Drive
Jefferson City, Mo.

Register on or before Friday, Nov. 10.

MHA-member — $299
Nonmember — $399

The registration fee includes continental breakfast, refreshments, lunch and program materials. This seminar is being offered at a reduced registration fee to MHA-member hospitals because of a contribution from MHA Management Services Corporation.

MHA mailed coupons to MHA-member hospital CEOs on Jan. 13. One coupon may be applied toward your registration fee.

Hotel Reservation

Comfort Suites
4804 Country Club Dr.
Jefferson City

Hampton Inn
4800 Country Club Dr.
Jefferson City


medical staff officers, department chiefs, credentials/medical executive committee members, chief medical officers, medical directors, quality assurance/performance improvement directors, medical staff services managers, COO, VP medical affairs, risk managers


This program will use activities, discussions and case studies to help participants understand effective credentialing and privileging practices. Medical staff leaders will learn how to address issues, such as appropriate documentation of competency, handle requests for temporary privileges, develop privileging criteria for new procedures, manage meetings and understand the concept of negligent credentialing. It also is designed for participants to use the provided resources to develop a leadership training program at their facility.


Upon completion of this program, participants will be able to:

  • recognize a complete medical staff application and identify “red flags” and areas requiring additional documentation
  • develop a strategy for assessing and addressing low- and no-volume practitioners
  • describe processes to document current competency
  • assess mechanisms for developing a criteria-based privileging process
  • develop strategies for handling requests for new procedures
  • discuss the concept of negligence in credentialing
  • identify processes for granting of temporary privileges and expedited credentialing
  • apply critical thinking to avoid confirmation bias


8:30 a.m. — Registration/Continental Breakfast

9 a.m. — Brief Discussion of Definition of Credentialing and Privileging

9:15 a.m. — Understanding Negligence in Credentialing

10:15 a.m. — Brief Overview Centers for Medicare & Medicaid Services’, Missouri State Regulations, and The Joint Commission Requirements for Credentialing and Privileging

11 a.m. — Roles and Responsibilities

11:15 a.m. — Applying Criteria for Appointment Work Session

11:45 a.m. — Overview of Red Flags

Noon — Lunch (provided)

12:30 p.m. — Red Flags Work Session

1 p.m. — Documenting Competency

1:30 p.m. — Applying Critical Thinking Skills to Avoid Confirmation Bias – (includes exercises)

2:15 p.m. — Break

2:30 p.m. — Developing an Effective Privileging Process for Temporary Privileges (includes exercise) and Expedited Credentialing

3:30 p.m. — Strategies for Dealing With Low- and No-Volume Practitioners

4 p.m. — Adjournment


Jane C. Drummond, J.D.
General Counsel and Vice President of Legal Affairs
Missouri Hospital Association
Jefferson City, Mo.

Jane Drummond joined MHA in 2014 as the General Counsel and Vice President of Legal Affairs. Drummond provides a full range of legal support to MHA, its related organizations and boards. Her duties include health care compliance, corporate advice and judicial advocacy. Drummond also serves as liaison to a variety of legal professional groups involved in health care law and policy.

Drummond graduated from the University of Missouri School of Law in 2001. Since then, she has largely worked in the public policy arena, while gaining additional experience in private practice. She began her legal career as a health and employment law associate at Husch and Eppenberger (now Husch Blackwell). Based on her health law experience, she was appointed to the position of General Counsel for the Missouri Department of Health and Senior Services under Governor Matt Blunt. Drummond later served in that same capacity in the governor’s office. In 2007, Governor Blunt appointed her to serve as the director of the DHSS, a cabinet-level position which she held through the end of the Blunt administration.

Drummond re-entered private practice in 2009, joining the Jefferson City firm of Schreimann, Rackers, Francka & Blunt. While there, she focused on employment-related services and litigation, largely for public entities.

Kathy Matzka, CPMSM, CPCS
Lebanon, Ill.

Kathy Matzka has authored several books related to medical staff services. For the past eight years, she has been the contributing editor for the credentialing industry’s premier credentialing publication, The Credentials Verification Desk Reference, and recently, its companion website.

Matzka is a highly-regarded industry speaker. She has developed and presented numerous programs for professional associations, hospitals and hospital associations on a wide range of topics, including provider credentialing and privileging, medical staff meeting management, peer review, negligent credentialing, provider competency and accreditation standards.

Continuing Education

Participants must attend the program in its entirety to receive a certificate of completion and continuing education contact hours.

This course has been approved for 7.5 National Association Medical Staff Services continuing education credits. Accreditation of this educational program in no way implies endorsement or sponsorship by NAMSS.

Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by AXIS Medical Education and the MHA Missouri Health Institute. AXIS Medical Education is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Credit Designation for Physicians
AXIS Medical Education designates this live activity for a maximum of 6.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AXIS Contact Information
For information about the accreditation of this program please contact AXIS at 954/281-7524 or

Disclosure of Conflicts of Interest
AXIS Medical Education requires instructors, planners, managers and other individuals and their spouse/life partner who are in a position to control the content of this activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly vetted by AXIS for fair balance, scientific objectivity of studies mentioned in the materials or used as the basis for content, and appropriateness of patient care recommendations.

The faculty reported the following financial relationships or relationships they or their spouse/life partner have with commercial interests related to the content of this continuing education activity:

Name of Faculty or Presenter Reported Financial Relationship
Jane C. Drummond, J.D. 
Nothing to disclose
Kathy Matzka, CPMSM, CPCS Nothing to disclose

The planners and managers reported the following financial relationships or relationships they or their spouse/life partner have with commercial interests related to the content of this continuing education activity:

Name of Planner/Manager Reported Financial Relationship
Rita F. Kay Nothing to disclose
Dee Morgillo, MEd., CHCP Nothing to disclose
Ronald Viggiani, MD    Nothing to disclose

Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed in this activity should not be used by clinicians without evaluation of patient conditions and possible contraindications on dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.

Americans with Disabilities Act
In compliance with the Americans with Disabilities Act, we will make every reasonable effort to accommodate your request. For any special requests, please contact MHA Health Institute at 573/893-3700 before the meeting dates.

Requirements for Credit:

  • Attend/participate in the educational activity and review all course materials.
  • Complete the CE Declaration form online by 11:59 p.m. ET Monday, Oct. 23, 2017. Instructions will be provided. If you do not enter the online portal by the above date, you will not be able to retrieve your statement of participation.
  • Upon successful completion of the online form, your statement of completion will be presented to you to print.