Stereotactic core-cut breast biopsy

Transcription

1 Procedure 79 Clinical PRIVILEGE WHITE PAPER Background Stereotactic core-cut breast biopsy Stereotactic core-cut breast biopsy (SCCB) is a mammographically guided, core needle biopsy. Physicians use the procedure to evaluate non-palpable suspicious breast lesions. A minimally invasive procedure, SCCB is a good alternative to surgical biopsy because in most cases it results in little, if any, discomfort and little cosmetic disfigurement. SCCB also costs significantly less than conventional surgical biopsy. SCCB combines two technologies: a specialized mammography machine, which can pinpoint a mass within the breast, and a core needle (also called an automatic, springloaded needle) that extracts samples of tissue. After the mammography unit produces digital images of the breast and suspicious lesion, the physician inserts the core needle into the breast, guides it to the mass, and takes additional x-ray images to confirm the needle is within the lesion. Once the needle tip is within the lesion, it is used to obtain a tissue sample. A specially trained radiologist or general surgeon typically performs SCCB. The procedure is typically completed during an outpatient visit, usually within an hour. Patients feel minimal to no pain, and the procedure does not require sutures or leave scarring. According to the Radiological Society of North America, there are several advantages of SCCB over surgical biopsy. SCCB is less invasive and features a brief recovery time. Further, SCCB does not distort breast tissue or make future mammograms more difficult to interpret. Some risks of the procedure include infection or a collapsed lung as a result of a needle being incorrectly passed through the patient s chest wall. However, such complications are rare. When performing this procedure, patient comfort is an important consideration. Therefore, physicians performing SCCB should plan the route of needle placement to optimize the patient s comfort. In doing so, the shortest route for needle insertion within the breast should be followed. Additionally, minimizing damage to the skin is preferred. Because treatment guidelines are continually evolving and the patient s age and severity of illness must be considered, surgerical biopsy is still a popular option. This choice, however, is a matter of education and awareness of the available options.

2 Involved specialties Radiologists, general surgeons, breast surgeons Positions of specialty boards ABR The American Board of Radiology (ABR) certifies physicians in diagnostic radiology, which consists of a range of image-guided diagnostic and therapeutic techniques. According to the ABR Diagnostic Radiology CORE Examination Study Guide, one of the skills required to pass this examination is stereotactic biopsy systems, which includes mammography-guided stereotactic breast biopsy. However, the ABR does not publish further information regarding the credentialing of SCCB ABS The American Board of Surgery (ABS) certifies physicians in general surgery. However, it does not publish specific requirements for SCCB. AOBS The American Osteopathic Board of Surgery (AOBS) certifies physicians in general surgery. However, it does not publish specific requirements for SCCB. AOBR The American Osteopathic Board of Radiology (AOBR) certifies physicians in diagnostic radiology and radiation oncology, but does not publish specific requirements for SCCB. Positions of societies, academies, colleges, and associations ACR The American College of Radiology (ACR) has published a document titled ACR Practice Guidelines for the Performance of Stereotactically Guided Breast Interventional Procedures. In these guidelines, the ACR provides healthcare providers with recommendations for performing SCCB and outlines qualifications for physicians performing this technique. According to the ACR, stereotactically guided breast biopsy procedures should be performed by physicians who meet the requirements outlined in the Physician Qualifications for Stereotactic Breast Biopsy, a joint publication by the ACR and the American College of Surgeons (ACS). 2

3 The guidelines published by the ACR and ACS state that stereotactic breast biopsies may be performed in either a collaborative or independent setting: A collaborative setting includes both radiologists and surgeons (or other physicians) that conduct stereotactic breast biopsy procedures An independent setting includes either radiologists or other physicians ( typically surgeons) that conduct stereotactic breast biopsies without the other specialty present In a collaborative setting, requirements for radiologists include the following: Initial training and qualifications: Be qualified to interpret mammography findings under the Mammography Quality Standards Act and Program (MQSA) Have performed 12 stereotactic breast biopsies, or assisted in at least three stereotactic breast biopsy procedures under a physician who is qualified to interpret mammography under MQSA and has performed 24 stereotactic breast biopsies Have at least three hours of Category I CME in stereotactic breast biopsy Be competent in interpreting mammograms, and be responsible for recommending biopsies and recognizing lesions Oversee all quality control and quality assurance activities Supervise the radiologic technologist and the medical physicist Maintenance of proficiency and CME requirements: Perform 12 stereotactic breast biopsies per year or requalify as above Obtain at least three hours of Category I CME in stereotactic breast biopsy every three years In a collaborative setting, requirements for surgeons or other physicians include the following: Initial training and qualifications: Have at least three hours of Category I CME in stereotactic breast biopsy, including instruction in imaging triangulation for lesion location Have performed 12 stereotactic breast biopsies, or assisted in at least three stereotactic breast biopsy procedures under a physician who is qualified to interpret mammography under MQSA and has performed 24 stereotactic breast biopsies Be experienced in post-biopsy management of the patient Maintenance of proficiency and CME requirements: Perform 12 stereotactic breast biopsies per year or requalify as above Obtain at least three hours of Category I CME in stereotactic breast biopsy every three years In an independent setting, requirements for radiologists include the following: Initial training and qualifications: Be an MQSA-qualified interpreting physician Have at least three hours of Category I CME in stereotactic breast biopsy 3

4 Have 15 hours of documented breast imaging CME that includes pathophysiology of benign and malignant breast disease and clinical breast examinations Have experience conducting 12 stereotactic breast biopsies or three or more procedures under an MQSA-qualified interpreting physician who has performed 24 stereotactic breast biopsies Interpret mammograms accurately Select appropriate patients with documentation of correlative clinical breast examination Ensure quality in medical audits (record numbers of biopsies conducted, cancers identified, benign lesions, repeat biopsies, and complications) Oversee quality control Supervise the radiologic technologist and medical physicist Manage patients after biopsy and refer to a surgeon for follow-up on certain lesions Maintenance of proficiency and CME requirements: Perform 12 stereotactic breast biopsies per year or requalify as above Have at least three hours of Category I CME in stereotactic breast biopsy every three years that includes managing a patient after biopsy Have 15 hours of Category I CME in breast imaging, including pathophysiology of benign and malignant diseases of the breast, every three years as required for MQSA interpretation of mammography In an independent setting, requirements for surgeons or other physicians include the following: Initial training and qualifications: Have evaluated 480 mammograms every two years in consultation with an MQSA-qualified interpreting physician Have 15 hours of Category I CME in stereotactic breast imaging and biopsy OR three years experience having performed 36 stereotactic breast biopsies Have four hours of Category 1 CME in medical radiation physics Have experience conducting 12 stereotactic breast biopsies OR at least three hands-on stereotactic breast biopsy procedures under an MQSA-qualified interpreting physician who has performed 24 stereotactic breast biopsies Select appropriate patients with documentation of correlative clinical breast examination Ensure quality in medical audits (record numbers of biopsies conducted, cancers identified, benign lesions, repeat biopsies, and complications) Oversee quality control Supervise the radiologic technologist and medical physicist Manage patients after biopsy Maintenance of proficiency and CME requirements: Continue to evaluate 480 mammograms every two years in consultation with an MQSA-qualified interpreting physician 4

5 Perform 12 stereotactic breast biopsies per year or requalify as above Obtain at least three hours of Category I CME in stereotactic breast biopsy every three years ASBS The American Society of Breast Surgeons (ASBS) provides recommendations for performing SCCB in its publication The American Society of Breast Surgeons Performance and Practice Guidelines for Stereotactic Breast Procedures. According to the ASBS, physicians who may perform stereotactic breast biopsy include those who meet the following qualifications: Complete a residency program approved by the American Board of Medical Specialties (ABMS) or AOBS or comparable international equivalent Achieve board certification or admission for certification Meet qualifications for active membership in the ASBS (however, physicians do not necessarily need to be members) Have at least four Category 1 CME credits in medical radiation physics or can attest to the review of Radiation Physics and Safety by Howard Snider, MD, provided with the Certification Application for Stereotactic Breast Procedures Have evaluated 480 mammograms in the last two years that have been interpreted by an MQSA-qualified interpreting radiologist If the surgeon has not performed stereotactic procedures, then the following criteria must be met: Assist with at least three stereotactic breast procedures under a physician who is qualified in stereotactic biopsy procedures by the ASBS or a radiologist who meets the stereotactic breast biopsy requirements of the ACR Complete 15 Category 1 CME hours in mammography and/or stereotactic breast procedures in the preceding five years, with five hours completedwithin the previous year If the surgeon has previously performed stereotactic procedures, the following criteria must be met: Have performed 12 stereotactic procedures within the last year Have at least five hours of Category 1 CME credit in breast imaging and/or image-guided breast procedures earned in the last five years ACS The ACS has published Physician Qualifications for Stereotactic Breast Biopsy: A Revised Statement, which was also reviewed and approved by ACR. ACS outlines two major models of practice: Collaborative practice, in which the radiologist and the surgeon (or other physician) work together and consult with the patient Independent practice, in which a radiologist, surgeon, or other physician has expertise in the diagnosis and management of breast disease 5

6 In a situation where a radiologist and surgeon practice collaboratively, either of the qualified physicians may perform the actual procedure, but patient selection and quality assurance are a joint responsibility, according to ACS. Radiologists in a collaborative setting must initially fulfill the following requirements: Qualification under MQSA to be an interpreting physician Performance of at least 12 stereotactic breast biopsies or at least three hands-on stereotactic breast biopsy procedures under a physician who is qualified to interpret under MQSA and has performed at least 24 stereotactic breast biopsies A minimum of three hours of Category I CME in stereotactic breast biopsy Responsibility for mammographic interpretation and experience in recommendations for biopsy and lesion identification at time of biopsy Responsibility for oversight of all quality control and quality assurance activities Responsibility for supervision of the radiologic technologist and the medical physicist Radiologists in collaborative settings must also maintain proficiency and CME requirements by performing at least 12 stereotactic breast biopsies per year and obtaining at least three hours of Category I CME in stereotactic breast biopsy every three years. Surgeons in a collaborative setting must initially meet the following requirements: Three hours of Category I CME in stereotactic breast biopsy, which should include instruction in imaging triangulation for lesion location Performance of at least 12 stereotactic breast biopsies or at least three hands-on stereotactic breast biopsy procedures under a physician who is qualified to interpret under MQSA and has performed at least 24 stereotactic breast biopsies Experience in post-biopsy management of the patient Surgeons in collaborative settings must also maintain proficiency and CME requirements by performing at least 12 stereotactic breast biopsies per year and obtaining at least three hours of Category I CME in stereotactic breast biopsy every three years. According to ACS, radiologists practicing independently must meet the following requirements for initial training and qualifications: Qualification as an interpreting physician under MQSA Three hours of Category I CME in stereotactic breast biopsy At least 15 hours of documented CME in breast imaging, including pathophysiology of benign and malignant breast disease as well as clinical breast examinations Performance of at least 12 stereotactic breast biopsies or at least three handson stereotactic breast biopsy procedures under a physician who is qualified 6

7 to interpret mammography under MQSA and has performed at least 24 stereotactic breast biopsies Responsibility for mammographic interpretation Responsibility for patient selection, including documentation of correlative clinical breast examination Responsibility for quality assurance activities, including medical audit Responsibility for oversight of all quality control Responsibility for the supervision of the radiologic technologist and medical physicist Responsibility for post-biopsy management of the patient, which may include referral to a surgeon for follow-up on certain lesions Additionally, radiologists in independent practices should maintain proficiency and CME requirements by performing at least 12 stereotactic breast biopsies per year; obtaining at least three hours of Category I CME in stereotactic breast biopsy, including post-biopsy patient management, every three years; and obtaining at least 15 hours of Category I CME in breast imagining, including pathophysiology of benign and malignant diseases of the breast, every three years as required for interpretation of mammography by MQSA. Surgeons or other physicians who practice stereotactic breast biopsy independently should meet the following requirements for initial training and qualifications: Evaluation of at least 480 mammograms every two years in consultation with a physician who is qualified to interpret mammograms under MQSA At least 15 hours of Category I CME in stereotactic breast imaging and biopsy or three years experience having performed at least 36 stereotactic breast biopsies Four hours of Category I CME in medical radiation physics Performance of at least 12 stereotactic breast biopsies or at least three handson stereotactic breast biopsy procedures under a physician who is qualified to interpret mammography under MQSA and has performed at least 24 stereotactic breast biopsies Responsibility for patient selection Responsibility for quality assurance activities, including medical audit Responsibility for oversight of all quality control Responsibility for the supervision of the radiologic technologist and the medical physicist Responsibility for post-biopsy management of the patient Surgeons are also required to maintain proficiency and meet CME requirements by continuing to evaluate at least 480 mammograms every two years in consultation with a physician who is qualified to interpret mammograms under MQSA, and by performing at least 12 stereotactic breast biopsies per year. Additionally, surgeons practicing independently should obtain three hours or more of Category I CME in stereotactic breast biopsy every three years, according to ACS. 7

8 AOCR The American Osteopathic College of Radiology (AOCR) does not publish privileging information about SCCB. Positions of subject matter experts Carl D Orsi Atlanta Carl D Orsi, MD, FACR, the director of breast imaging research at the Emory University School of Medicine in Atlanta, helped develop the ACR guidelines on SCCB in According to D Orsi, the ACR has published the most stringent guidelines available on this procedure, and the ASBS recommendations are not as rigorous. Although he states that not everyone agrees with the ACR guidelines, he fully supports them. D Orsi believes that radiologists who perform SCCB should be qualified to interpret mammography findings under the MQSA, should have experience performing 12 or more stereotactic breast biopsies, and should have sufficient CME credits, as per the ACR guidelines. Positions of accreditation bodies CMS CMS has no formal position concerning the delineation of privileges for SCCB. 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 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. 8

9 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 SCCB. 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 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 privileging decision Monitoring the use of privileges and quality-of-care issues 9

10 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 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 10

11 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 SCCB. 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.) 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 11

12 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 SCCB. 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). 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. 12

13 CRC draft criteria Minimum threshold criteria for requesting SCCB Basic education: MD or DO Minimum formal training: For radiologists, successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited postgraduate training program in radiology that included training in the stereotactic and ultrasound-guided technique of breast biopsy during residency. For general surgeons, successful completion of an ACGME- or AOA-accredited postgraduate program in general surgery and successful completion of training in the stereotactic- and ultrasound-guided technique of breast biopsy during residency or in an accredited course or institution and possession of privileges for breast imaging interpretation. Required current experience: For radiologists, demonstrated current competence and evidence of the performance of at least 12 stereotactic breast biopsies in the past 12 months or completion of training in the past 12 months. For general surgeons, demonstrated current competence and successful completion of at least 15 hours of category 1 CME in stereotactic breast biopsy or performance of at least 36 stereotactic breast biopsies in the past three years; successful evaluation of at least 480 mammograms per year in the past two years in consultation with a physician who is qualified to interpret mammography under the MQSA; successful completion of at least four hours of category 1 CME in medical radiation physics; or performance of either at least 12 stereotactic breast biopsies or at least three hands-on procedures with a physician who is qualified to interpret mammography under the MQSA and has performed at least 24 procedures. 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. To be eligible to renew privileges in SCCB, the applicant must demonstrate current competence and evidence of the performance of at least 24 stereotactic breast biopsies in the past 24 months based on results of ongoing professional practice evaluation and outcomes. Also, applicants must demonstrate continued evaluation of at least 480 mammograms every two years in consultation with a physician who is qualified to interpret mammograms under MQSA. In addition, at least three hours of category I CME in SCCB every three years, or requalification 13

14 according to the specifications under the criteria and required current experience for new applicants, is required. For more information: Accreditation Council for Graduate Medical Education 515 North State Street, Suite 2000 Chicago, IL Telephone: Fax: Website: American Board of Radiology 5441 E. Williams Boulevard Tucson, AZ Telephone: Website: American College of Radiology 1891 Preston White Drive Reston, VA Telephone: Website: American College of Surgeons 633 N. Saint Clair Street Chicago, IL Telephone: or Fax: Website: American Osteopathic Board of Radiology 119 East Second Street Milan, MO Telephone: Fax: Website: American Osteopathic Board of Surgery 4764 Fishburg Road, Suite F Huber Heights, OH Telephone: or Fax: Website: 14

15 American Society of Breast Surgeons 5950 Symphony Woods Road, Suite 212 Columbia, MD Telephone: Fax: Website: Centers for Medicare and Medicaid Services 7500 Security Boulevard Baltimore, MD Telephone: Website: DNV Healthcare, Inc. 400 Techne Center Drive, Suite 350 Milford, OH Website: Healthcare Facilities Accreditation Program 142 East Ontario Street Chicago, IL Telephone: Website: The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL Telephone: Fax: Website: 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