guide for establishing a credentialing and privileging program

Guide for Establishing a Credentialing Guide for Establishing a Credentialing and Privileging Program for Users of and Privileging Program for Users of Fluoroscopic Equipment in Fluoroscopic Equipment in Healthcare OrganizationsHealthcare Organizations

AAPM Task Group Report # 124AAPM Task Group Report # 124Melissa Martin, MS, FACMP, FACR, FAAPMMelissa Martin, MS, FACMP, FACR, FAAPMACMP Annual Meeting ACMP Annual Meeting May 3, 2009 Virginia Beach, VAMay 3, 2009 Virginia Beach, VA

Membership of CommitteeMembership of Committee

�� Mary E. Moore, M.S., Chairperson Mary E. Moore, M.S., Chairperson �� Stephen Stephen BalterBalter�� Joel E. GrayJoel E. Gray�� Alan M. Jackson Alan M. Jackson �� PeiPei--Jan Paul LinJan Paul Lin�� Melissa C. MartinMelissa C. Martin�� Keith J. Strauss Keith J. Strauss �� Lynne Fairobent, AAPM StaffLynne Fairobent, AAPM Staff

Need for Credentialing Need for Credentialing and Privileging Programand Privileging Program�� Fluoroscopy usage continues to Fluoroscopy usage continues to

increase in all areas of medicineincrease in all areas of medicine�� Training for the safe use of Training for the safe use of

fluoroscopy has not kept pace with fluoroscopy has not kept pace with increasing clinical applicationsincreasing clinical applications

�� Lack of appropriate training has Lack of appropriate training has resulted in increasing number of resulted in increasing number of injuriesinjuries

Who Needs to be Trained?Who Needs to be Trained?

Physician Specialists such as:Physician Specialists such as:�� RadiologistsRadiologists�� CardiologistsCardiologists�� GastroenterologistsGastroenterologists�� Orthopedic SurgeonsOrthopedic Surgeons�� UrologistsUrologists�� Pain Management SpecialistsPain Management Specialists�� Vascular SurgeonsVascular Surgeons

Who Needs to be Trained?Who Needs to be Trained?

NonNon--Physician Groups such as:Physician Groups such as:�� Radiology AssistantsRadiology Assistants�� Speech PathologistsSpeech Pathologists�� Nurse PractitionersNurse Practitioners�� Physician AssistantsPhysician Assistants�� Radiologic TechnologistsRadiologic Technologists

Who is at Risk?Who is at Risk?

�� The PatientThe Patient�� The OperatorThe Operator�� Support StaffSupport Staff�� FacilityFacility

Program ComponentsProgram Components

�� Didactic ContentDidactic Content–– Radiation BiologyRadiation Biology–– Radiation Protection PrinciplesRadiation Protection Principles–– Radiation Imaging PhysicsRadiation Imaging Physics

�� Formal Support by Facility Formal Support by Facility ManagementManagement

�� Acceptance by the Medical StaffAcceptance by the Medical Staff

Credentialing and Credentialing and Privileging ProgramsPrivileging Programs�� Process for Healthcare Facilities to Process for Healthcare Facilities to

assure the quality and safety of assure the quality and safety of medical care provided by their staffmedical care provided by their staff

�� Essential part of Healthcare Essential part of Healthcare Organizations today to meet Joint Organizations today to meet Joint Commission (JC) requirements for Commission (JC) requirements for accreditationaccreditation

�� Two separate and distinct programsTwo separate and distinct programs

Credentialing ProgramCredentialing Program

�� Collection of relevant for the individual Collection of relevant for the individual applying for privileges to perform applying for privileges to perform specific medical procedures at an specific medical procedures at an institutioninstitution

�� Collection of necessary documentation Collection of necessary documentation such as applicantsuch as applicant’’s education, training, s education, training, experience and continuing educationexperience and continuing education

�� Verification of supplied documentationVerification of supplied documentation

Privileging ProgramPrivileging Program

�� Delineation of Medical Procedures that an Delineation of Medical Procedures that an individual may perform individual may perform -- may be global in may be global in nature (diagnostic imaging procedures) or nature (diagnostic imaging procedures) or specific (CT, MRI, Interventional specific (CT, MRI, Interventional Procedures, etc.)Procedures, etc.)

�� Medical Director and/or Department Chair Medical Director and/or Department Chair makes recommendations to Medical makes recommendations to Medical Executive Committee for Specific PrivilegesExecutive Committee for Specific Privileges

JC Requirements for JC Requirements for PrivilegingPrivileging�� JC requires each facility to review and JC requires each facility to review and

revise clinical privileges and revise clinical privileges and appointments at least every two yearsappointments at least every two years

�� Each facility must have a Each facility must have a reprivilegingreprivilegingprocess clearly defined in its bylaws process clearly defined in its bylaws and procedures manualand procedures manual

Basic Elements of Basic Elements of ProgramProgram�� Identification of Individuals to be Identification of Individuals to be

trainedtrained�� Individuals trained at other institutions Individuals trained at other institutions

may not need further training ormay not need further training or�� Individuals trained at other institutions Individuals trained at other institutions

may need to have their training may need to have their training further augmentedfurther augmented

Training Program ContentTraining Program Content

�� Level of training should be Level of training should be commensurate with level of risk of commensurate with level of risk of procedure to be performed by the procedure to be performed by the trainee.trainee.

�� Three levels of training are suggested.Three levels of training are suggested.

Low Risk ProceduresLow Risk Procedures

�� Mini CMini C--armarm�� Orthopedic Orthopedic

Reduction or Reduction or Extremity SurgeryExtremity Surgery

�� 1.0 hours didactic 1.0 hours didactic lecture & exam, lecture & exam, followed by 0.5 followed by 0.5 hour hour ‘‘handshands--onon’’demonstration & demonstration & exam exam

Procedure/Equipment Training Suggested

Moderate Risk ProceduresModerate Risk Procedures

�� Mobile CMobile C--armarm�� R/F TableR/F Table�� GI/GUGI/GU�� Pain ManagementPain Management�� UrologyUrology�� BronchoscopyBronchoscopy



High Risk ProceduresHigh Risk Procedures

�� Interventional Interventional FluoroscopeFluoroscope

�� Interventional Interventional Procedures Procedures performed in performed in Radiology, Radiology, Cardiology or Cardiology or OROR



Components of TrainingComponents of Training

�� Basic Radiation Protection ConsiderationsBasic Radiation Protection ConsiderationsRadiation Safety PrinciplesRadiation Safety PrinciplesRadiation Health EffectsRadiation Health EffectsPersonnel MonitoringPersonnel MonitoringPatient Patient DosimetryDosimetryHospital PoliciesHospital PoliciesState RegulationsState RegulationsPractice GuidelinesPractice Guidelines


�� Other Program Contents Other Program Contents Basic XBasic X--Ray PhysicsRay PhysicsFluoroscopic Imaging PhysicsFluoroscopic Imaging PhysicsEquipment DesignEquipment DesignImage Quality ImprovementImage Quality ImprovementRadiation Dose Reduction TechniquesRadiation Dose Reduction TechniquesQuality Control PracticesQuality Control Practices


�� After the fundamental principles are After the fundamental principles are covered, trainees should receive covered, trainees should receive ““HandsHands--OnOn”” training on the equipment training on the equipment they will actually be using to optimize they will actually be using to optimize image quality and doseimage quality and dose

Examinations & AssessmentExaminations & Assessment

�� Student must pass a written exam Student must pass a written exam with a minimum score of 70% prior to with a minimum score of 70% prior to the initial clinical use of fluoroscopythe initial clinical use of fluoroscopy

�� If student fails test three times, If student fails test three times, he/she must repeat didactic course he/she must repeat didactic course and retake the testand retake the test

HandsHands--On Demonstration On Demonstration on Equipmenton Equipment�� All applicants must demonstrate ability All applicants must demonstrate ability

to operate equipment properly while to operate equipment properly while performing the type of procedure they performing the type of procedure they will performwill perform

�� Review of the applicant will be done Review of the applicant will be done by a previously authorized fluoroscopy by a previously authorized fluoroscopy user or QMP or other qualified person.user or QMP or other qualified person.

Techniques to be Techniques to be DemonstratedDemonstrated�� Ability to achieve acceptable image Ability to achieve acceptable image

qualityquality�� Use available methods to reduce Use available methods to reduce

radiation dose to patient and staffradiation dose to patient and staff�� Proper collimation, minimum patientProper collimation, minimum patient--

image intensifier distance, maximum image intensifier distance, maximum patientpatient--source distance, pulsed source distance, pulsed fluoroscopy modefluoroscopy mode

Frequency of Training and Frequency of Training and Duration of PrivilegesDuration of Privileges�� Duration of privileges should not Duration of privileges should not

exceed a period of two yearsexceed a period of two years�� Fluoroscopy privilege renewal should Fluoroscopy privilege renewal should

be synchronized with the physicianbe synchronized with the physician’’s s other privileging process to minimize other privileging process to minimize administrative burdensadministrative burdens

�� Frequency must comply with state Frequency must comply with state requirementsrequirements

RenewalsRenewals

�� Requirements for renewals may vary Requirements for renewals may vary according to state or local regulationsaccording to state or local regulations

�� Refresher didactic training may be Refresher didactic training may be optional prior to successful repeating optional prior to successful repeating of the written examinationof the written examination

�� If new equipment, demonstration of If new equipment, demonstration of competency must be completed prior competency must be completed prior to usage on patientsto usage on patients

TrainersTrainers

�� Variety of individuals may be involved Variety of individuals may be involved in training such as:in training such as:Radiologist or other physician familiar Radiologist or other physician familiar with use of the equipment for specific with use of the equipment for specific proceduresproceduresQMP may develop curriculum and QMP may develop curriculum and perform didactic lecturesperform didactic lectures

Compliance RequirementsCompliance Requirements

�� Fluoroscopy training program must be Fluoroscopy training program must be compliant with local, state and federal compliant with local, state and federal requirementsrequirements

�� One goal of training program is to One goal of training program is to prevent the occurrence of a sentinel prevent the occurrence of a sentinel event defined by JC as the delivery of event defined by JC as the delivery of 15 15 gygy (1500 (1500 radrad) to a patient) to a patient

Administrative RequirementsAdministrative Requirements

�� Proper administrative elements of a Proper administrative elements of a fluoroscopy training program are fluoroscopy training program are necessary to ensure success of the necessary to ensure success of the programprogram

�� To receive privileging to use To receive privileging to use fluoroscopic equipment, applicant fluoroscopic equipment, applicant must demonstrate knowledge included must demonstrate knowledge included in fluoroscopy training programin fluoroscopy training program

Administrative RequirementsAdministrative Requirements

�� Individual at each institution that Individual at each institution that handles privileging program must be handles privileging program must be identified.identified.

�� Availability of didactic training is key Availability of didactic training is key component of program component of program --Live Lecture or WebLive Lecture or Web--Based ModuleBased Module

Experienced Fluoroscopy Experienced Fluoroscopy UsersUsers�� Reasonable requirements may depend Reasonable requirements may depend

on previous trainingon previous training�� Experienced user may skip didactic Experienced user may skip didactic

training and/or demonstrate training and/or demonstrate knowledge of didactic content by knowledge of didactic content by taking exam and demonstrating taking exam and demonstrating competency of equipment operationscompetency of equipment operations

Components of Components of Privileging ProgramPrivileging Program�� Medical Staff Office provides Medical Staff Office provides

management and oversight of all management and oversight of all medical staff privilegingmedical staff privileging

�� Credentials Committee is responsible Credentials Committee is responsible for reviewing all initial and for reviewing all initial and reappointment applications for reappointment applications for fluoroscopy privilegingfluoroscopy privileging

Components of Components of Privileging ProgramPrivileging Program�� Medical Staff Executive Committee is Medical Staff Executive Committee is

responsible for all clinical operational responsible for all clinical operational standards and policystandards and policy

�� Board of Directors approves physician Board of Directors approves physician privileges based on recommendations privileges based on recommendations of the Medical Staff Executive of the Medical Staff Executive CommitteeCommittee

Model Policy for Fluoroscopy Model Policy for Fluoroscopy Privileging ProgramPrivileging Program

�� AdAd--hoc committee to write policyhoc committee to write policy�� Training required Training required -- based on based on

TG124/State regulationsTG124/State regulations�� Who provides trainingWho provides training�� Frequency and of reFrequency and of re--training per training per

TG124/State regulations specificsTG124/State regulations specifics

Implementation of Fluoroscopy Implementation of Fluoroscopy Privileging ProgramPrivileging Program

�� Procedure jointly developed by Medical Procedure jointly developed by Medical Staff Office and Radiation Safety Staff Office and Radiation Safety Officer and approved by both the Officer and approved by both the Radiation Safety and Medical Radiation Safety and Medical Executive CommitteeExecutive Committee

Implementation of Fluoroscopy Implementation of Fluoroscopy Privileging Program Privileging Program

�� Tracking of Fluoroscopy Use in Tracking of Fluoroscopy Use in InstitutionInstitution

�� Quality Management Program Policy Quality Management Program Policy for Fluoroscopy Usagefor Fluoroscopy Usage

�� Compliance with the Policy by Compliance with the Policy by Fluoroscopy UsersFluoroscopy Users

�� Role of the Radiologic TechnologistRole of the Radiologic Technologist

Low Risk Fluoroscopic Low Risk Fluoroscopic ProceduresProcedures�� Complies with institutionComplies with institution’’s clinical privileging s clinical privileging

requirements for clinical examinations, andrequirements for clinical examinations, and�� Complete didactic training for low risk Complete didactic training for low risk

fluoroscopy, andfluoroscopy, and�� Pass exam on didactic material, andPass exam on didactic material, and�� Demonstrate competency using low risk Demonstrate competency using low risk

unitsunits

Moderate Risk Fluoroscopic Moderate Risk Fluoroscopic ProceduresProcedures

�� Complies with institutionComplies with institution’’s clinical s clinical privileging requirements for clinical privileging requirements for clinical examinations andexaminations and

�� Complete didactic training for moderate risk Complete didactic training for moderate risk fluoroscopy, andfluoroscopy, and

�� Pass exam on didactic material, andPass exam on didactic material, and�� Demonstrate competency for moderate risk Demonstrate competency for moderate risk

unitsunits

High Risk Fluoroscopic ProceduresHigh Risk Fluoroscopic Procedures

�� Complies with institutionComplies with institution’’s clinical privileging s clinical privileging requirements for clinical examination, andrequirements for clinical examination, and

�� Complete didactic training for high risk Complete didactic training for high risk fluoroscopy, andfluoroscopy, and

�� Pass exam on didactic material, andPass exam on didactic material, and�� Demonstrate competency for high risk unitsDemonstrate competency for high risk units

Trainees working under Trainees working under supervision of privileged users supervision of privileged users during trainingduring training

�� Shall successfully complete following Shall successfully complete following during first six months of training:during first six months of training:

�� Complete didactic training at the Complete didactic training at the appropriate level of fluoroscopy risk appropriate level of fluoroscopy risk for their specialty, andfor their specialty, and

�� Pass exam on didactic material, andPass exam on didactic material, and�� Demonstrate competency at the level Demonstrate competency at the level

of fluoroscopy risk for their specialty.of fluoroscopy risk for their specialty.

Credentials CommitteeCredentials Committee

�� Should have written criteria for not Should have written criteria for not renewing privilegesrenewing privileges

�� Reasons for Review Prior to Renewing Reasons for Review Prior to Renewing Fluoroscopy Privileges:Fluoroscopy Privileges:Excessively long procedures times and high Excessively long procedures times and high patient dosespatient dosesUnsafe radiation safety practicesUnsafe radiation safety practicesHigh or missing personnel dosimeter High or missing personnel dosimeter readingsreadings

Credentials CommitteeCredentials Committee

�� Reasons for Review Prior to Renewing Reasons for Review Prior to Renewing Fluoroscopy Privileges:Fluoroscopy Privileges:

�� Failure to successfully complete the didactic Failure to successfully complete the didactic examexam

�� Failure to complete practicum requirementsFailure to complete practicum requirements�� Failure to acquire continuing medical Failure to acquire continuing medical

education (education (CMEsCMEs) requirements.) requirements.�� Any other missing elements of the program Any other missing elements of the program

Delineation of AuthorityDelineation of Authority

�� The Radiation Safety Committee has The Radiation Safety Committee has the authority to revoke or not to the authority to revoke or not to renew all approvals.renew all approvals.

�� The Medical Executive Committee also The Medical Executive Committee also has the authority to revoke or not to has the authority to revoke or not to renew privileges.renew privileges.

Organization PolicyOrganization Policy

�� Since privileges are granted by an Since privileges are granted by an institution, the fluoroscopy privileging institution, the fluoroscopy privileging program needs to be an institutional program needs to be an institutional policy, not a departmental policypolicy, not a departmental policy

�� Each facility must have its own review Each facility must have its own review policy involving Department Chairs, policy involving Department Chairs, the QMP, RSO and Medical Executive the QMP, RSO and Medical Executive Committee/StaffCommittee/Staff

Thank You !!!Thank You !!!

Melissa C. Martin, M.S., FACMPMelissa C. Martin, M.S., FACMPTherapy Physics Inc.Therapy Physics Inc.

879 West 190 St., Ste 419879 West 190 St., Ste 419Gardena, CA 90248Gardena, CA 90248

Office Phone: 310Office Phone: 310--217217--41144114ee--mail: mail:

[email protected]@TherapyPhysics.com

guide for establishing a credentialing and privileging program

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