Protecting Radiology Through Credentialing

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 ImagingBiz.com. Credentialing 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 formal physician assessments, come from patient records and from current and former peers and supervisors. They cover the practitioner’s medical knowledge, technical skills, clinical judgment, interpersonal skills, communication ability, and professionalism. In addition to practicing physicians, nurse practitioners and physician trainees also require evaluation for privileges through the FPPE/OPPE process. Certification and Recertification Board certification and recertification help to reassure patients, referring offices, and payors that high-quality care will be provided, Yousem says. 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. Certification and recertification can also go beyond the credentialing process in assessing competence and current knowledge; in part, this is because many hospitals and health plans are less rigorous in assessment after the initial credentialing. Yousem notes that about 70% of hospitals allow retention of privileges after board certification expires, and more than half of health plans never call for board certification at all. Board certification was once permanent, but it is now renewed every 10 years through a four-step process of online testing, maintaining licensure, completing 500 CME hours and 20 self-assessment modules, and implementing real-world projects for practice quality improvement. Recertification work must be carried out throughout a decade because its requirements forbid delaying the process until the last years of certification. Radiology subspecialists who completed residency before 2000 can be granted permanent board certification in general radiology, but must be recertified in their subspecialties every 10 years; those who completed residency later must also be recertified in general radiology every 10 years. When the Certificate of Added Qualifications (CAQ) program was initiated in 1994–1995 by the American Board of Medical Specialties, Yousem says, it was intended to protect subspecialty turf by calling for a year of fellowship and a year in practice before the CAQ exam could be taken. Payors were expected to demand CAQs before reimbursing for advanced procedures, thus ensuring that general radiologists and nonradiologists would not be reading subspecialty studies. Payors showed no interest, however, so the CAQ system has not served that purpose. Yousem says that this battle was lost long ago, when obstetricians began using ultrasound; instead, credentialing must take over the protective function that CAQs could not. Credentialing/Certification Problems Both physicians who are waiting for hospital privileges to be granted and the credentialing committee can encounter frustrating (and sometimes costly) delays. Some of these are simply built into the credentialing process, so they can only be overcome by planning for delays. Others, however, can be avoided if the committee and candidate know what to expect. Delays in obtaining privileges for new physicians can be difficult not only for the individuals involved, but for staff-model hospitals and clinics, since they may find themselves unexpectedly understaffed. Excess rigidity in the credentialing process can prevent the awarding of privileges to good physicians who may simply need to make changes in their applications (such as removing a request to perform a specific procedure), or who may need to designate alternate references. Some flexibility is needed in dealing with paperwork-related problems that should not reflect badly on the applicant. The number of signatures required and the level of detail needed can make the application process overwhelming, so inadvertent errors and omissions are not unusual. In addition, verification of training and experience relies on letters from individuals at other facilities, who will not always respond quickly. Committees should be aware that even when verification/reference letters are received, they may convey less information than credentialing requires. Since sources are chosen by the applicant, they may be biased, and in some cases, so much time will have passed that the source’s memory of the physician’s performance is no longer clear. Substance-abuse problems and other detriments may be omitted because the reference source is worried about harming the applicant’s career, about legal liability for such harm, or about damaging a friendship. Board recertification constitutes a scheduling problem for the staff-model employer, since the physician will require days off work to complete both the required continuing education and the recertification testing. For the physician, recertification involves a considerable investment in planning, time, and money. Embracing the Process Despite these difficulties, Yousem says, hospitals have excellent reasons to support robust credentialing and certification programs. While the effort involved can be significant, it is small in comparison with the trouble that it can prevent in terms of liability exposure, reputation, and patient safety. Credentialing reassures the public that the institution has a high level of concern about the quality of care, and that it screens and monitors the individuals who provide that care. Yousem also encourages radiologists to become involved in credentialing because this is an essential step in ensuring that high-quality imaging is performed—and that it is, as often as appropriate, conducted by radiologists. Being active in credentialing can give radiologists the opportunity to help set guidelines for approval of the procedures that the applicant intends to perform. By setting reasonable levels of experience and proficiency through those procedural guidelines, radiologists can help their hospitals (and their specialty) reserve each type of imaging procedure for the physicians most qualified to perform it.