Breast ultrasound. Background. Involved specialties. Positions of specialty boards ABR. Procedure 233

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1 Procedure 233 Clinical PRIVILEGE WHITE PAPER Background Breast ultrasound Breast ultrasound, also called breast sonography, is a noninvasive procedure that uses reflected sound waves to view and produce a picture of the breast s internal structures. A handheld device called a transducer is passed over the breast, converting sound waves into electrical impulses. Depending on the strength of the reflections, live images of various shades of white and gray are displayed on a video monitor. Unlike a mammogram (a 2-D black-and-white breast x-ray), breast ultrasound does not use radiation. A breast ultrasound does not replace the need for a mammogram but is used to further evaluate a problem seen on a mammogram. It is especially helpful in distinguishing between a fluid-filled cyst and a solid-mass tumor and can identify lesions that are too small to be felt. Although breast ultrasounds are noninvasive, they are often used to guide a needle during biopsies or other interventional procedures (e.g., removal of fluid from a cyst). Breast ultrasound guided biopsies are as accurate as surgical excision, less expensive than surgical biopsies, and less traumatic for patients than surgical biopsies. Patients undergo breast ultrasounds in a physician s office or other outpatient facility. The procedure, which takes minutes, is painless and carries few risks, but there are drawbacks. Patients who are significantly overweight or unable to remain still for an extended period of time can make it difficult to obtain good ultrasound studies. Also, the skill of the practitioner performing the procedure greatly affects accuracy. Finally, breast ultrasound does not reliably detect tiny calcium deposits that often are precursors to breast cancer. Advances in the field include the use of 3-D ultrasound and improved ultrasound contrast agents that better distinguish tissue from its surroundings. Involved specialties Radiologists and breast surgeons Positions of specialty boards ABR The American Board of Radiology (ABR) offers certification in diagnostic radiology, which requires five years of approved training, broken down as follows: A supplement to Credentialing Resource Center Journal /12

2 One year of clinical training in a specialty (i.e.,internal medicine, pediatrics, surgery or surgical specialties, OB-GYN, neurology, family practice, emergency medicine, transitional year, or any combination of these). If there is an elective in diagnostic radiology, it must be in a department with an Accreditation Council for Graduate Medical Education (ACGME) approved residency program and cannot be longer than two months. No more than a total of three months may be spent in radiation oncology and/or pathology. All clinical training must be in an ACGME-, American Osteopathic Association (AOA), or Royal College of Physicians and Surgeons of Canada (RCPSC) approved program (or equivalent). Four years in an approved diagnostic radiology program, of which a minimum of four months must be spent in nuclear medicine and a minimum of 12 weeks must be spent in mammography. No more than 16 months may be spent in any one discipline. The ABR does not provide specific requirements for breast ultrasound. AOBR The American Osteopathic Board of Radiology (AOBR) is authorized by the AOA to examine candidates for certification in radiology and its subspecialties. To achieve certification in diagnostic radiology from the AOBR, candidates must pass an oral and written examination. Applicants must graduate from an AOAapproved college of osteopathic medicine, complete a one-year AOA-approved internship, and fulfill the training and experience requirements established by the American Osteopathic College of Radiology and published in Basic Standards for Residency Training in Diagnostic Radiology. The AOBR does not provide specific requirements for breast ultrasound. ABS The required residency experience for initial certification in general surgery by the American Board of Surgery (ABS) is a minimum of five years of progressive residency education satisfactorily following graduation from medical school in a program in general surgery accredited by the ACGME or RCPSC. This means 60 months of residency training at no more than three residency programs, with no fewer than 48 weeks of full-time experience in each residency year. Applicants for examination must have been the operating surgeon for a minimum of 750 operative procedures in five years, including at least 150 operative procedures in the chief resident year. Breast ultrasound is not specifically mentioned. 2 A supplement to Credentialing Resource Center Journal /12

3 AOBS Candidates for certification by the AOA through the American Osteopathic Board of Surgery (AOBS) must have four years of training in general surgery, and for those who began their residency training with the required OGME-1R internship year effective in the academic year 2008, five years of training in general surgery is required. Specifications for general surgery clinical training requirements include 14 breast procedures, although breast ultrasound or ultrasonography is not specifically mentioned. Positions of societies, academies, colleges, and associations ASBS According to the American Society of Breast Surgeons s (ASBS) document Performance and Practice Guidelines for Breast Ultrasounds, to be qualified as a surgeon sonographer, a surgeon should: Successfully complete an American Board of Medical Specialties approved residency program and attain board certification by the appropriate certifying board upon completion of training, or be admissible for certification Complete at least 15 hours of Category I CME credits in breast ultrasound, including at least one full-day course encompassing diagnostic and interventional components Demonstrate maintenance of skills by performing at least 50 breast ultrasound examinations and at least 12 ultrasound-guided invasive procedures per year, and must earn at least three hours of AMA Category 1 CME credit in breast ultrasound every three years To perform ultrasound-guided interventional procedures, the surgeon should be proctored on at least two ultrasound-guided interventional procedures. The proctor must be a physician who can satisfy at least one of the following requirements: Current certification/accreditation in breast ultrasound by the ASBS, the American Institute of Ultrasound in Medicine (AIUM), or the American College of Radiology (ACR) Documentation of five years clinical experience in breast ultrasound with at least 15 hours of AMA Category 1 CME credit in breast ultrasound earned in the preceding five years The ASBS notes that the guidelines contained in the document are based on the ASBS opinion of basic criteria and may require modification to adapt to specific clinical situations. A supplement to Credentialing Resource Center Journal /12 3

4 ACR The ACR publishes ACR Practice Guideline for the Performance of a Breast Ultrasound Examination, which states that physicians who supervise, perform, and/or interpret breast ultrasound examinations should be licensed medical practitioners who have a thorough understanding of the indications for ultrasound examinations as well as a familiarity with the basic physical principles and limitations of the technology of ultrasound imaging. These physicians should be familiar with alternative and complementary imaging and diagnostic procedures and should be capable of correlating the results of these other procedures with the sonographic findings, and should possess a thorough understanding of ultrasound technology and instrumentation, ultrasound power output, equipment calibration, and safety. Physicians responsible for breast ultrasound examinations should demonstrate familiarity with breast anatomy, physiology, and pathology. These physicians should provide evidence of the training and competence needed to perform breast ultrasound examinations successfully. Physicians performing and/or interpreting breast ultrasound examinations should meet at least one of the following criteria: Certification in radiology or diagnostic radiology by the ABR, the AOBR, the RCPSC, or the Collège des Médecins du Québec, and involvement with the supervision and/or performance, interpretation, and reporting of 300 breast ultrasound examinations within the past 36 months Completion of an ACGME-approved diagnostic radiology residency program and involvement with the supervision and/or performance, interpretation, and reporting of 300 breast ultrasound examinations in the past 36 months Physicians not board certified in radiology or not trained in a diagnostic radiology residency program, and who assume these responsibilities for sonographic imaging of the breast, should complete an ACGME-approved residency program in specialty practice plus 200 hours of Category I CME in breast ultrasound; and supervision and/or performance, interpretation, and reporting of 500 breast ultrasound examinations during the past 36 months in a supervised situation. The ACR guidelines also state that in order to maintain competency in performance of breast ultrasounds, physicians should demonstrate evidence of continuing competence in the interpretation and reporting of those examinations. If competence is ensured primarily based on continuing experience, a minimum of 100 examinations per year is recommended to maintain the physician s skills. Because a physician s practice or location may preclude this method, the ACR notes that continued competency can also be aensured through monitoring and evaluation that indicates acceptable technical success, accuracy of interpretation, and appropriateness of evaluation. 4 A supplement to Credentialing Resource Center Journal /12

5 AIUM According to the AIUM s Practice Guideline for the Performance of a Breast Ultrasound Examination, physicians who evaluate and interpret diagnostic ultrasound examinations should be licensed medical practitioners with a thorough understanding of the indication and guidelines for ultrasound examinations. Physicians should have a familiarity with the basic physical principles and limitations of the technology of ultrasound imaging, as well as with alternative and complementary imaging and diagnostic procedures, and should be capable of correlating the results of these other procedures with the ultrasound examination findings. The AIUM recommends that physicians have an understanding of ultrasound technology and instrumentation, ultrasound power output, equipment calibration, and safety, and should demonstrate familiarity with the anatomy, physiology, and pathophysiology of those organs or anatomic areas that are being examined. Physicians must provide evidence of training and requisite competence needed to successfully perform and interpret diagnostic ultrasound examinations in the area(s) they practice and must be trained on the methods of documentation and reporting of ultrasound studies. The AIUM states that physicians should provide evidence of completion of an approved residency program, fellowship, or postgraduate training that includes the equivalent of at least three months of diagnostic ultrasound training in the area(s) they practice, under the supervision of a qualified physician(s), during which the trainees will have evidence of being involved with the performance, evaluation, and interpretation of at least 300 sonograms. Certification in breast ultrasound by the ASBS is accepted as proof of sufficient training in breast ultrasound, according to AIUM. Practice Guideline for the Performance of a Breast Ultrasound Examination also notes that the number of required cases will be greater for physicians utilizing ultrasound for multiple subspecialty applications or anatomic areas (at least 500 cases). AIUM recognizes, however, that the experience gained in the initial 300 cases provides an important foundation of knowledge and skill, which may reduce the number of additional cases needed to master other diagnostic ultrasound uses. In addition to these guidelines, AIUM also publishes Standards and Guidelines for the Accreditation of Ultrasound Practices, which states that physicians applying for accreditation specifically for diagnostic breast ultrasound must attest that they have participated in 60 nonscreening breast ultrasound cases in the year before the application. If the practice is applying for accreditation in interventional breast ultrasound, each physician must have performed 25 ultrasound-guided interventional procedures. The first five of these cases must have been supervised by another physician experienced in interventional sonography of the breast. At least three A supplement to Credentialing Resource Center Journal /12 5

6 of the first five must be core biopsies. A physician documenting that he or she has safely performed 75 interventional cases in the three years before the application can also satisfy the requirement. Practices applying for accreditation in breast ultrasound must also obtain a minimum of 10 AMA PRA Category 1 Credits in breast ultrasound every three years. If the practice is applying for accreditation in other ultrasound modalities as well as breast, the 10 CME credits apply toward the requirement of 30 CME credits over three years. For diagnostic breast ultrasound accreditation, each participating physician must meet a minimum of 60 diagnostic ultrasound procedures annually. For interventional breast ultrasound accreditation, each participating physician must meet a minimum of 12 interventional ultrasound procedures annually. AOA/AOCR According to the Basic Standards for Residency Training in Diagnostic Radiology, published by the AOA and the AOCR, the residency training program in diagnostic radiology must be 48 months in duration and should include three months of diagnostic ultrasound. Also, each resident must have a minimum of 12 weeks of clinical rotations in breast imaging. The Basic Standards for Residency Training in Surgery mentions an exposure to ultrasound but does not give specific requirements. ACGME The Program Requirements for Graduate Medical Education in Diagnostic Radiology includes breast radiology and ultrasonography as two of nine major focus areas of training. Residents should provide patient care through safe, efficient, appropriately utilized, quality-controlled diagnostic and/or interventional radiology techniques. The residency program is four years of graduate medical education in diagnostic radiology. ACGME s Program Requirements for Graduate Medical Education in General Surgery states that the clinical program should be 60 months in length. The program requirements do not provide specific requirements for breast ultrasound. Positions of subject matter experts Peter Littrup, MD Detroit Breast ultrasounds are typically performed by radiologists, and particularly those who specialize in women s imaging, says Peter Littrup, MD, professor of 6 A supplement to Credentialing Resource Center Journal /12

7 radiology, urology, and oncology at Wayne State University School of Medicine and director of imaging core and radiological research at Karmanos Cancer Institute in Detroit. In some instances, general surgeons who specialize in procedures of the breast may perform breast ultrasounds, but only if they have completed basic training in ultrasound techniques. Radiologists undergo a one-year medical internship and four years of radiology residency, which will cover breast ultrasound, Littrup says. The board exams go through 10 different sections, and ultrasound in general is one of the sections. Then on top of that, breast imaging is its own specific section, which also includes some aspect of ultrasound, so those are pretty major components of getting board certified as a radiologist, Littrup says. Some radiologists may choose to undergo additional training in cross-sectional imaging or women s imaging, which would provide additional training and experience, but is not necessarily a privileging requirement. Board certification in radiology should be sufficient to be granted privileges to perform breast ultrasound, Littrup says. In his facility there are no specific required number of breast ultrasound procedures to obtain privileges, nor is there a specific number of annual procedures for reprivileging. I know for mammograms you need to have read 600 over a two-year period, Littrup says. For ultrasound, mainly it s just maintaining your skill set. Ellen Mendelson, MD, FACR Chicago Although breast surgeons have begun performing breast ultrasound procedures recently, radiologists specializing in breast imaging should really be the ones to perform breast ultrasound, says Ellen Mendelson, MD, FACR, professor of radiology and section chief of breast and women s imaging at the Feinberg School of Medicine at Northwestern University and program director at the Lynn Sage Comprehensive Breast Center at Northwestern Memorial Hospital in Chicago. Ultrasound is a difficult imaging modality, Mendelson says. To learn the physics is complicated, and there are so many intertwined parameters to exhaust as you scan that it takes some time to learn. That s what you get during your radiology residency, which a lot of surgeons and non-radiologists don t. Most hospitals require radiologists to be fellowship trained in breast imaging, even though breast imaging fellowships are not accredited by the ACGME. At the very minimum, radiologists performing breast ultrasound should be board certified in radiology. A supplement to Credentialing Resource Center Journal /12 7

8 If you don t have a lot of personal, hands-on experience with ultrasound, you are handicapped, Mendelson says. Although there are a number of performance guidelines from various organizations, Mendelson points to the ACR for guidance on the number of breast ultrasound procedures that are required initially and upon reprivileging. ACR requires physicians who are performing and interpreting breast ultrasounds to be board certified in diagnostic radiology, with performance of at least 300 breast ultrasound procedures in the past 36 months. Those who aren t board certified in diagnostic radiology should have 200 hours of Category I CME and have performed 500 breast ultrasound procedures in the past 36 months. For reprivileging, ACR recommends that radiologists perform a minimum of 100 breast ultrasound procedures annually. Additionally, maintenance of competence through continuing education is encouraged by hospitals, including requirements for mammography procedures and cutting-edge modalities. The specificity isn t that great for breast ultrasound, but there are all sorts of requirements for continuing medical education and for malpractice insurance, Mendelson says. You absolutely have to show and establish that you have done those CME courses. Positions of accreditation bodies CMS CMS has no formal position concerning the delineation of privileges for breast ultrasound. However, the CMS Conditions of Participation (CoP) define a requirement for a criteria-based privileging process in (c)(6) stating, The bylaws must include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges (a)(6) states, The governing body must assure that the medical staff bylaws describe the privileging pro cess. The process articulated in the bylaws, rules or regula tions must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners that considers: Individual character Individual competence Individual training Individual experience Individual judgment 8 A supplement to Credentialing Resource Center Journal /12

9 The governing body must ensure that the hospital s bylaws governing medical staff membership or the granting of privileges apply equally to all practitioners in each professional category of practitioners. Specific privileges must reflect activi ties that the majority of prac titioners in that category can perform competently and that the hospital can support. Privileges are not granted for tasks, procedures, or activities that are not conducted within the hospital, regardless of the practitioner s ability to perform them. Each practitioner must be individually evaluated for requested privileges. It cannot be assumed that every practitioner can perform every task, activity, or privilege specific to a specialty, nor can it be assumed that the practitioner should be automatically granted the full range of privileges. The individual practitioner s ability to perform each task, activity, or privilege must be individually assessed. CMS also requires that the organization have a process to ensure that practitioners granted privileges are work ing within the scope of those privileges. CMS CoPs include the need for a periodic appraisal of practitioners appointed to the medical staff/granted medical staff privileges ( [a][1]). In the absence of a state law that establishes a time frame for the periodic appraisal, CMS recommends that an appraisal be conducted at least every 24 months. The purpose of the periodic appraisal is to determine whether clinical privileges or membership should be continued, discontinued, revised, or otherwise changed. The Joint Commission The Joint Commission has no formal position concerning the delineation of privileges for breast ultrasound. However, in its Comprehensive Accreditation Manual for Hospitals, The Joint Commission states, The hospital collects information regarding each practitioner s current license status, training, experience, competence, and ability to perform the requested privilege (MS ). In the introduction for MS , The Joint Commission states that there must be a reliable and consistent system in place to process applications and verify credentials. The organized medical staff must then review and evaluate the data collected. The resultant privilege recommendations to the governing body are based on the assessment of the data. The Joint Commission introduces MS by stating, The organized medical staff is respon sible for planning and implementing a privileging process. It goes on to state that this process typically includes: Developing and approving a pro cedures list Processing the application Evaluating applicant-specific information A supplement to Credentialing Resource Center Journal /12 9

10 Submitting recommendations to the governing body for applicant-specific delineated privileges Notifying the applicant, relevant personnel, and, as required by law, external entities of the privi leging decision Monitoring the use of privileges and quality-of-care issues MS further states, The decision to grant or deny a privilege(s) and/or to renew an existing privilege(s) is an objective, evidence-based process. The EPs for standard MS include several requirements as follows: The need for all licensed independent practitioners who provide care, treatment, and services to have a current license, certification, or registration, as required by law and regulation Established criteria as recommended by the organized medical staff and approved by the governing body with specific evaluation of current licensure and/or certification, specific relevant training, evidence of physical ability, professional practice review data from the applicant s current organization, peer and/or faculty recommendation, and a review of the practitioner s performance within the hospital (for renewal of privileges) Consistent application of criteria A clearly defined (documented) procedure for processing clinical privilege requests that is approved by the organized medical staff Documentation and confirmation of the applicant s statement that no health problems exist that would affect his or her ability to perform privileges requested A query of the NPDB for initial privileges, renewal of privileges, and when a new privilege is requested Written peer recommendations that address the practitioner s current medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism A list of specific challenges or concerns that the organized medical staff must evaluate prior to recommending privileges (MS , EP 9) A process to determine whether there is sufficient clinical performance information to make a decision related to privileges A decision (action) on the completed application for privileges that occurs within the time period specified in the organization s medical staff bylaws Information regarding any changes to practitioners clinical privileges, updated as they occur The Joint Commission further states, The organized medical staff reviews and analyzes information regarding each requesting practitioner s current licensure status, training, experience, current competence, and ability to perform the requested privilege (MS ). In the EPs for standard MS , The Joint Commission states that the 10 A supplement to Credentialing Resource Center Journal /12

11 information review and analysis process is clearly defined and that the decision process must be timely. The organization, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a request for privileges. The criteria must be consistently applied and directly relate to the quality of care, treatment, and services. Ultimately, the governing body or delegated governing body has the final authority for granting, renewing, or denying clinical privileges. Privileges may not be granted for a period beyond two years. Criteria that determine a practitioner s ability to provide patient care, treatment, and services within the scope of the privilege(s) requested are consistently evaluated. The Joint Commission further states, Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privileges, or to revoke an existing privilege prior to or at the time of renewal (MS ). In the EPs for MS , The Joint Commission says there is a clearly defined process facilitating the evaluation of each practitioner s professional practice, in which the type of information collected is determined by individual departments and approved by the organized medical staff. Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege. HFAP The Healthcare Facilities Accreditation Program (HFAP) has no formal position concerning the delineation of privileges for breast ultrasound. The bylaws must include the criteria for determining the privileges to be granted to the individual practitioners and the procedure for applying the criteria to individuals requesting privileges ( ). Privileges are granted based on the medical staff s review of an individual practitioner s qualifications and its recommendation regarding that individual practitioner to the governing body. It is also required that the organization have a process to ensure that practitioners granted privileges are working within the scope of those privileges. Privileges must be granted within the capabilities of the facility. For example, if an organization is not capable of performing open-heart surgery, no physician should be granted that privilege. In the explanation for standard related to membership selection criteria, HFAP states, Basic criteria listed in the bylaws, or the credentials manual, include the items listed in this standard. (Emphasis is placed on training and competence in the requested privileges.) A supplement to Credentialing Resource Center Journal /12 11

12 The bylaws also define the mechanisms by which the clinical departments, if applicable, or the medical staff as a whole establish criteria for specific privilege delineation. Periodic appraisals of the suitability for membership and clinical privileges is required to determine whether the individual practitioner s clinical privileges should be approved, continued, discontinued, revised, or otherwise changed ( ). The appraisals are to be conducted at least every 24 months. The medical staff is accountable to the governing body for the quality of medical care provided, and quality assessment and performance improvement ( ) information must be used in the process of evaluating and acting on re-privileging and reappointment requests from members and other credentialed staff. DNV DNV has no formal position concerning the delineation of privileges for breast ultrasound. MS.12 Standard Requirement (SR) #1 states, The medical staff bylaws shall include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to those individuals that request privileges. The governing body shall ensure that under no circumstances is medical staff membership or professional privileges in the organization dependent solely upon certification, fellowship, or membership in a specialty body or society. Regarding the Medical Staff Standards related to Clinical Privileges (MS.12), DNV requires specific provisions within the medical staff bylaws for: The consideration of automatic suspension of clinical privileges in the following circumstances: revocation/restriction of licensure; revocation, suspension, or probation of a DEA license; failure to maintain professional liability insurance as specified; and noncompliance with written medical record delinquency/deficiency requirements Immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioner s Medicare/Medicaid status Fair hearing and appeal The Interpretive Guidelines also state that core privileges for general surgery and surgical subspecialties are acceptable as long as the core is properly defined. DNV also requires a mechanism (outlined in the bylaws) to ensure that all individuals provide services only within the scope of privileges granted (MS.12, SR.4). 12 A supplement to Credentialing Resource Center Journal /12

13 Clinical privileges (and appointments or reappointments) are for a period as defined by state law or, if permitted by state law, not to exceed three years (MS.12, SR.2). Individual practitioner performance data must be measured, utilized, and evaluated as a part of the decision-making for appointment and reappointment. Although not specifically stated, this would apply to the individual practitioner s respective delineation of privilege requests. CRC draft criteria The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding breast ultrasound. The core privileges and accompanying procedure list are not meant to be allencompassing. They define the types of activities, procedures, and privileges that the majority of practitioners in this specialty perform. Additionally, it cannot be expected or required that practitioners perform every procedure listed. Instruct practitioners that they may strikethrough or delete any procedures they do not wish to request. Minimum threshold criteria for requesting privileges in breast ultrasound Basic education: MD or DO Minimum formal training: Applicants must have completed an ACGME-/AOAaccredited residency training program in radiology or an approved training program in breast surgery that included the performance and interpretation of breast ultrasounds. If not taught in residency/fellowship, applicants must have completed an approved hands-on training program that involved performing and interpreting breast ultrasounds under the supervision of a qualified physician instructor. Required previous experience: Applicants must be able to demonstrate that they have successfully performed and interpreted at least 100 breast ultrasounds during the past 12 months. References If the applicant is recently trained, a letter of reference should come from the director of the applicant s training program. Alternatively, a letter of reference may come from the applicable department chair and/or clinical service chief at the facility where the applicant most recently practiced. Reappointment Reappointment should be based on unbiased, objective results of care according to a hospital s quality assurance mechanism. A supplement to Credentialing Resource Center Journal /12 13

14 Applicants for reappointment should demonstrate current competence and evidence of the performance of at least 200 breast ultrasounds in the past 24 months based on results of ongoing professional practice evaluation and outcomes. In addition, continuing education related to breast ultrasounds should be required. For more information Accreditation Council for Graduate Medical Education 515 North State Street, Suite 2000 Chicago, IL Telephone: Website: American Board of Radiology 5441 East Williams Circle Tucson, AZ Telephone: Website: American Board of Surgery 1617 John F. Kennedy Boulevard, Suite 860 Philadelphia, PA Telephone: Website: American College of Radiology 1891 Preston White Drive Reston, VA Telephone: Website: American Institute of Ultrasound Medicine Sweitzer Lane, Suite 100 Laurel, MD Telephone: Website: American Osteopathic Association 142 East Ontario Street Chicago, IL Telephone: Fax: Website: 14 A supplement to Credentialing Resource Center Journal /12

15 American Osteopathic Board of Surgery 4764 Fishburg Road, Suite F Huber Heights, OH Telephone: Website: American Osteopathic College of Radiology/ American Osteopathic Board of Radiology 119 East Second Street Milan, MO Telephone: Fax: Website: American Society of Breast Surgeons 5950 Symphony Woods Road, Suite 212 Columbia, MD Telephone: Website: Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD Telephone: Website: DNV Healthcare, Inc Ravello Drive Katy, TX Telephone: Website: Healthcare Facilities Accreditation Program 142 East Ontario Street Chicago, IL Telephone: Website: The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL Telephone: Website: A supplement to Credentialing Resource Center Journal /12 15

16 Editorial Advisory Board Clinical Privilege White Papers Associate Editorial Director: Erin Callahan, Managing Editor: Julie McCoy, William J. Carbone Chief Executive Officer American Board of Physician Specialties Atlanta, Ga. Darrell L. Cass, MD, FACS, FAAP Codirector, Center for Fetal Surgery Texas Children s Hospital Houston, Texas Jack Cox, MD Senior Vice President/Chief Quality Officer Hoag Memorial Hospital Presbyterian Newport Beach, Calif. Stephen H. Hochschuler, MD Cofounder and Chair Texas Back Institute Phoenix, Ariz. Bruce Lindsay, MD Professor of Medicine Director, Cardiac Electrophysiology Washington University School of Medicine St. Louis, Mo. Sally J. Pelletier, CPCS, CPMSM Director of Credentialing Services The Greeley Company, a division of HCPro, Inc. Danvers, Mass. Beverly Pybus Senior Consultant The Greeley Company, a division of HCPro, Inc. Danvers, Mass. Richard A. Sheff, MD Chair and Executive Director The Greeley Company, a division of HCPro, Inc. Danvers, Mass. The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient s institution is forbidden without prior written permission. Copyright 2012 HCPro, Inc., Danvers, MA A supplement to Credentialing Resource Center Journal /12