Protecting Radiology Through Credentialing

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According to David M. Yousem, MD, MBA, serving on your hospital’s credentialing committee is far more important than you might think. While it’s not typically a highly prized experience, deciding on physicians’ privileges has direct and lasting impacts on patient care, on the hospital’s reputation, on liability exposure, and on the procedural turf ceded to competing specialties.

Board certification and recertification help to reassure patients, referring offices, and payors that high-quality care will be provided. Busy physicians may also be more likely to maintain up-to-date knowledge and skills through continuing education because recertification requirements include a fixed number of CME hours. Since certification allows physicians to be tested by members of their own specialty, the process is a kind of self-policing within that specialty.

David M. Yousem, MD, MBA

Yousem is professor of radiology and director of neuroradiology at Johns Hopkins Medical Institutions, Baltimore, Maryland. He co-edited Radiology Business Practice: How to Succeed,¹ on which he based his presentation, "Credentialing, Accreditation, and Certification,” at the Economics of Diagnostic Imaging conference in Arlington, Virginia, on October 24, 2008. In addition to stressing the importance of a thorough credentialing process, he emphasizes the role of board certification (and recertification) in ensuring the provision of high-quality care. These steps are often seen as dull and bureaucratic, he says, but they are vital to protecting radiologists from losing imaging procedures to less-qualified physicians in other specialties. The accreditation segment of Yousem’s presentation was summarized in the June 2009 issue of


Patient safety and high-quality care are ensured by a solid credentialing process, Yousem says. Careful attention to credentialing reduces the hospital’s exposure to malpractice suits, since courts hold the facility responsible for allowing poorly qualified physicians to practice there. Physicians, regardless of specialty, are allowed to perform the procedures at which they have demonstrated competence (and no other procedures) if credentialing is thorough.

Credentialing also prevents billing difficulties, since some payors will reject reimbursement claims for procedures for which the physician has no privileges. Through the credentialing process, problems in medical licensure or drug-dispensing authority that might otherwise be overlooked can be found and corrected before they affect clinical practice.

A primary function of credentialing is to prevent the hospital from mistakenly granting privileges to the unqualified, including not only the undertrained, but also charlatans or imposters. Of course, sound credentialing practices are also required by accrediting agencies, including the Joint Commission. In addition, by defining precisely how much training and experience are required before a physician can perform a given procedure, credentialing guidelines help to define specialists’ responsibilities and protect their appropriate turf.

The credentialing committee at Johns Hopkins meets monthly, Yousem reports, and consists of the vice president for medical affairs, five or more active members of the medical staff, the dean for graduate medical education, the vice president for nursing and patient-care services, a representative of the institution’s legal department, and the medical-staff registrar.

The committee is responsible for verifying that applicants for privileges

  • meet standards of practice;
  • are not impaired by substance abuse;
  • are not known to be incompetent;
  • have undergone the education needed to mitigate risk; and
  • have up-to-date licensure, prescribing capability, and board certification.

Additional compliance requirements for credentialing were recently imposed by the Joint Commission, and Yousem notes that these extra steps will require more time from committee members (and may, in some hospitals, call for the creation of a second committee). The new standards for focused and ongoing professional practice evaluation (FPPE/OPPE) rely on information gathering, thus making credentialing information systems what Yousem calls the wave of the future. These systems must handle outcomes, performance targets, industry standards, and case complexity/severity, while also managing physician-performance data.

These performance data, which are used to compile initial and ongoing