Focused Professional Performance Evaluation of a Radiologist--a Centers for Medicare and Medicaid Services and Joint Commission Requirement

Curr Probl Diagn Radiol. 2016 Mar-Apr;45(2):87-93. doi: 10.1067/j.cpradiol.2015.08.006. Epub 2015 Aug 14.


The Centers for Medicare and Medicaid Services require that all physicians undergo periodic performance evaluation to maintain hospital privileges. This evaluation is achieved through a screening ongoing professional practice evaluation, typically performed at 8-month intervals. When any concerns are raised through this evaluation, for all newly appointed physicians seeking hospital privileges or for physicians seeking privileges for new procedures, a focused professional practice evaluation must be undertaken. Although not well defined for any group of physicians, the process is especially challenging in the radiology environment, given the lack of a template for performing such an evaluation and ever-growing spectrum of diagnostic and image-guided procedures. The purpose of this review is to describe the requirements and various components of an focused professional practice evaluation process, as well as to provide examples of initiating events and suggestions for managing such events. Challenges inherent in the peer review process are also addressed.

MeSH terms

  • Centers for Medicare and Medicaid Services, U.S.
  • Clinical Competence / standards*
  • Credentialing
  • Humans
  • Joint Commission on Accreditation of Healthcare Organizations
  • Professional Practice / standards*
  • Quality Assurance, Health Care
  • Radiologists / standards*
  • United States