Hospital Privileges Research Articles

Hospital Privileges for Psychologists in the Era of Competencies and Increased Accountability

After campaigning to be granted hospital privileges decades ago, new issues are emerging that are affecting psychologists' hospital privileges. Some of the forces shaping hospital privileges emanate from within the field of psychology, where there has been a movement to more closely examine psychologists' competences. Other forces impinging on hospital privileges are external to psychology, most notably the Joint Commission, which has promulgated new standards for hospital-based practitioners across disciplines. This article discusses the effects of these new standards on the practice of psychology and describes the findings of a survey examining how privileges are currently obtained and maintained within hospitals.

Some Med Ed Traditions Showing Their Age

Some Med Ed Traditions Showing Their Age

American Venous Forum membership: Who are We and Where are We Going?

The American Venous Forum (AVF) membership was surveyed regarding their current certification and professional activities. The certification survey was forwarded to all of the members of the AVF with a 28% response rate. Of the respondents, currently one-third have a practice limited to venous disease and two-thirds have a mixed practice. Ninety-one percent have hospital privileges that are active, and 9% do not have hospital privileges. Fifty-two percent of respondents have active privileges in an outpatient surgery center, and 48% do not participate in an outpatient surgery center. Twenty percent have a practice limited to office procedures, and 80% have a mixed practice. Sixty-five percent of the membership is board certified in vascular surgery. Several other boards are represented amongst the membership, for example: general surgery, cardiothoracic, and family practice. Respondents identified issues with hospital emergency department call coverage, endovascular privileges, or described their practice as established before vascular board certification. Emergency department call requirements appear to have regional variations with a variety of requirements for hospital privileges. Several respondents plan to limit their scope of practice to venous disease only. Many respondents identified the circular logic of the need for hospital privileges to maintain certification. Many respondents also identified the requirement for a minimum number of procedures to maintain hospital privileges while their scope of practice is still limited. This was especially problematic for arterial procedures in a practice limited to venous disease. As venous stenting, mechanical thrombectomy and thrombolytic therapies evolve, the scope of venous practice will become more diversified. The need for hospital privileges is a current requirement of the Board of Surgery for maintenance of certification. Many members of the AFV have identified these issues as an impediment to board certification. Several respondents, however, identified vascular certification as a bad idea. Modular maintenance of certification was also thought to be a poor solution by some of the membership. Several members suggested a separate standard be applied to those specializing solely in venous disease. The American Board of Surgery will need to address the current requirements as maintenance of certification moves forward. The results of this survey have been shared with the American Board of Surgery.

Use of Board Certification and Recertification in Hospital Privileging: Policies for General Surgeons, Surgical Specialists, and Nonsurgical Subspecialists

Use of Board Certification and Recertification in Hospital Privileging: Policies for General Surgeons, Surgical Specialists, and Nonsurgical Subspecialists

Illinois Passes Endoscopy Legislation

You have accessThe ASHA LeaderPolicy Analysis1 Nov 2009Illinois Passes Endoscopy Legislation Celeste R. KobulnickyMS, CCC-SLP Celeste R. Kobulnicky Google Scholar More articles by this author , MS, CCC-SLP https://doi.org/10.1044/leader.PA2.14142009.3 SectionsAbout ToolsAdd to favorites ShareFacebookTwitterLinked In A three-year advocacy effort by speech-language pathologists in Illinois has achieved success—a new state law enacted in August amends SLPs’ scope of practice to include the independent use of endoscopic procedures. The need for the law, which states specifically that licensed, qualified SLPs in an appropriate setting may use rigid and flexible endoscopes, stems from reimbursement denials for SLPs who provided laryngeal stroboscopy. In addition, some medical facilities did not allow SLPs to perform stroboscopy or flexible fiberoptic endoscopic evaluation of swallowing (FEES) because of legal questions about scope of practice. The Illinois Speech-Language-Hearing Association (ISHA) Board voted to sponsor legislation more than three years ago, but the research and networking required to prepare for the legislative effort took several years. ISHA received guidance from ASHA, including the appropriate knowledge and skills statements, training guidelines, contact information for colleagues who had worked on similar legislation in other states, and language from similar state statutes and regulations. Members of the ISHA Division of Legislative and Regulatory Affairs contacted SLPs and other interested parties from across the state to encourage them to contact their legislators; called and initiated e-mail trees to SLPs in private practice and health care settings across the state; informed physicians about the need for the law and the possibility that SLPs might no longer be able to provide endoscope procedures if the bill was defeated; arranged for letters of support from SLPs and the physicians on their teams; and contacted legislators. ISHA’s long-time lobbyist James Morphew chose sponsors for the bill, educated legislators and their staff members, advised ISHA on protocol, arranged meetings, and, with input from ISHA members, wrote many drafts. Professionally knowledgeable and politically connected SLPs participated in phone conferences and trips to the state capitol. Susan Langmore, creator of FEES, provided compelling, expert testimony during a phone conference. On ISHA’s annual lobbying day members met with legislators to urge the lawmakers to support the bill. A critical part of the advocacy effort involved communication with the Illinois State Medical Society and the American Academy of Otolaryngology to develop language acceptable to all parties. New Requirements The law outlines the provisions necessary for SLPs to become competent to engage in independent practice and specifies the requirements needed for medical backup and supervision. Provisions to allow the use of a rigid or flexible laryngoscope for the purpose of training or research are also included. SLPs working in hospitals or hospital affiliates are exempt from requirements of the new law, but they must meet requirements set by their individual facilities. SLPs working in other settings must take an ASHA-approved course, observe a number of rigid and/or flexible laryngoscope procedures, and perform a number of laryngoscope procedures under the direct supervision of a qualified physician. The supervising physician must have hospital privileges to perform such procedures but need not be an otolaryngologist. The law stipulates three sets of requirements for observation and performance: for SLPs qualifying for rigid laryngoscopy only, for flexible laryngoscopy only, and for both. The supervising physician may delegate supervision of performed procedures to an SLP qualified under the terms of the law. Other requirements include a signed statement from the physician, written referral and direct authorization from the appropriate physician to perform a laryngoscope procedure for each patient, and some restrictions on practice setting. At the end of this complex process we have great satisfaction in knowing that voice and swallowing patients will receive the best care, providers will be reimbursed appropriately, and facilities need not fear litigation. Author Notes Celeste R. Kobulnicky, MS, CCC-SLP, is owner of Fox Valley Speech and Swallowing Center, a private practice in Aurora, Ill. Contact her at [email protected]. Advertising Disclaimer | Advertise With Us Advertising Disclaimer | Advertise With Us Additional Resources FiguresSourcesRelatedDetails Volume 14Issue 14November 2009 Get Permissions Add to your Mendeley library History Published in print: Nov 1, 2009 Metrics Downloaded 117 times Topicsasha-topicsleader_do_tagleader-topicsasha-article-typesCopyright & Permissions© 2009 American Speech-Language-Hearing AssociationLoading ...

AVAS Best Clinical Resident Award (Tied): Fate of non-designated preliminary general surgery residents seeking a categorical residency position

Background As pyramidal programs in general surgery were eliminated in recent decades, nondesignated preliminary surgery (NDPS) positions were introduced to fill vacant positions. Graduating medical students can pursue NDPS positions with the goal of obtaining categorical positions in either general surgery residencies or other fields altogether. The fate of residents who complete 2 years as NDPS residents remains ill defined. Methods From 1997 to 2007, data concerning NDPS residents were prospectively collected from 2 general surgery training programs. Trainees were followed by prospectively gathered data, Internet identification, and internal records of hospital privileging. Results One hundred ten graduating medical students initiated postgraduate training as NDPS residents. Seventy-four (67%) were men, and 98 (89%) were international medical graduates. Among all 110 subjects, 95 (86%) were hired as postgraduate year 1 NDPS residents, and 15 (14%) were hired as postgraduate year 2 NDPS residents. Fifteen (14%) left postgraduate medical education. Fifty-two NDPS residents (47%) pursued nonsurgical specialties after their internships. Forty-three (39%) eventually matriculated as categorical general surgical residents. Of these, 20 (47%) became categorical residents in their initial training programs. Nearly all NDPS residents who proceed to categorical positions obtained board certification. Conclusions More than one third of NDPS residents successfully obtained categorical general surgery positions. Only a small fraction (14%) failed to continue in postgraduate medical education. NDPS positions allow most candidates successful career paths. The persistent rate of attrition among categorical surgical residents allows NDPS residents to join categorical training programs and become eligible for board certification in general surgery.

Use of Board Certification and Recertification in Hospital Privileging

To better understand the relationship between board certification and credentialing policies for surgeons and nonsurgical subspecialists and to examine possible variation in use of board certification among different types of hospitals. Telephone survey conducted from November 14, 2006, through March 16, 2007, of the privileging personnel among a random sample of 235 nonchildren's hospitals stratified by teaching status, bed size, metropolitan statistical area, system affiliation, and tax status. Proportion of hospitals that require specialty board certification to gain privileges and hospital requirements for recertification. Of 235 hospitals, 11 were ineligible and 183 completed the telephone interview, resulting in an overall response rate of 82%. Approximately one-third of hospitals did not require surgeons and nonsurgical subspecialists ever to be board certified to receive hospital privileges. Among the 109 hospitals that required certification at some point, only 5 (5%) required surgeons and 3 (3%) required nonsurgical subspecialists to be board certified at the point of initial privileging. More than three-fourths of hospitals had exceptions to their certification policies for surgeons and 84 (77%) had them for nonsurgical subspecialists. Eighty-two percent of all hospitals and two-thirds of hospitals whose policies required recertification allowed surgeons and nonsurgical subspecialists to retain privileges when their board certification expired. Most hospitals do not consistently use board certification to ensure physician competence at their institutions.

Use of Board Certification and Recertification in Hospital Privileging—Invited Critique

Use of Board Certification and Recertification in Hospital Privileging—Invited Critique

Family Physicians' Personal and Practice Characteristics that Are Associated with Improved Utilization of Bone Mineral Density Testing and Osteoporosis Medication Prescribing

Family physicians' personal and practice characteristics may influence how osteoporosis is managed. Thus, we evaluated the impact of family physicians' personal and practice characteristics on the appropriate use of bone mineral density testing and osteoporosis therapy. The physician questionnaire assessed 13 personal and practice characteristics of the physicians. The patient questionnaire was used to collect data to ascertain how family physicians managed osteoporosis. A total of 225 family physicians from 7 provinces across Canada completed both the physician and patient questionnaires. The family physicians evaluated a total of 5601 patients. The generalized estimating equations technique was utilized to model the associations between family physicians' personal and practice characteristics and appropriate use of bone mineral density testing and osteoporosis therapy. Odds ratios (OR) and corresponding 95% confidence intervals (CI) are reported. Findings indicated that female family physicians have higher odds of administering appropriate bone density testing compared to male family physicians (OR: 1.28; 95% CI: 1.05, 1.55), and that physicians who have hospital privileges (OR: 0.77; 95% CI: 0.62, 0.97) and who graduated more recently from medical school (OR: 0.87; 95% CI: 0.77, 0.99) have lower odds of administering appropriate bone mineral density tests. Physicians who use electronic health records have higher odds of administering appropriate therapy (OR: 1.30; 95% CI: 1.06, 1.59) as compared to physicians who do not use them. Several family physicians' personal and practice characteristics are associated with appropriate utilization of bone mineral density testing and therapy. The education of both clinicians and policy makers regarding these new insights may translate to enhanced individual practices and an improved overall health care system to optimize the environment for managing osteoporosis.

Emergency Department Coverage by Primary Care Physicians in a Rural Practice‐Based Research Network: Incentives, Confidence, and Training

In rural areas of the United States, emergency departments (EDs) are often staffed by primary care physicians, as contrasted to urban and suburban hospitals where ED coverage is usually provided by physicians who are residency-trained in emergency medicine. This study examines the reasons and incentives for rural Oregon primary care physicians to cover the ED and their reported measures of confidence and priorities for additional training. We conducted a cross-sectional survey of primary care physicians in rural Oregon who are members of the Oregon Rural Practice-Based Research Network (ORPRN). The survey was sent to 70 primary care physicians in 27 rural Oregon practices. Fifty-two of 70 (74%) ORPRN physicians representing 24 practices returned the questionnaire. Nineteen of the 52 responding physicians reported covering the ED. The majority (75%) of physicians covering the ED did so as a requirement for practice employment and/or hospital privileges. Physicians covering the ED reported low confidence in pediatric emergencies and expressed the need for additional training in pediatric emergencies as their top priority. Almost two fifths of surveyed primary care physicians in a rural practice-based research network provide ED coverage. Based on these physicians' low levels of confidence and desire for additional training in pediatric emergencies, effective education models are needed for physicians covering the ED at their rural hospitals.

The Quigless Clinic: Its Impact on the Lives of African Americans Living in Tarboro, North Carolina, in the 1950s

Dr Milton Douglas Quigless, a graduate of Meharry Medical College, arrived in Tarboro, North Carolina, in 1936 to practice medicine. For 10 years, he tried to obtain hospital privileges at the Edgecombe General Hospital, but segregation laws prevented him from performing surgery and admitting ill patients to this local facility. After years of frustration, Dr Quigless decided to establish his own hospital so that he could adequately care for his patients. In 1946, the doors of the Quigless Hospital-Clinic opened--the first hospital for blacks in Tarboro. As a noted family physician and distinguished community leader, Dr Quigless had an enormous impact on the lives of multiple generations of North Carolinians.

Confronting the Bureaucracy

After the second hospital received my privileging application, it sent me an urgent letter informing me that I would need to undergo routine drug testing. For hospital privileging, it was required ...

Assessing the Database Needs of Vascular Surgeons

Vascular surgery is an ideal specialty for developing a shared database, because outcomes measures are precise, national standards have been established, and vascular surgeons have traditionally collected data. A questionnaire of database experience and needs was developed, reviewed by a Western Vascular Society advisory committee, and sent to Western Vascular Society and Rocky Mountain Vascular Surgical Society members. Additionally, we obtained software from existing commercial vascular databases. We had a 57% response from 196 surveys: 36% of vascular surgeons have functional vascular databases, which have been used from 1 to 26 years and contain 71 to 15,000 patients. Databases are used for research, quality control, and billing. Time (38%), expense (19%), and expertise (8%) preclude database use. Of physicians without a database, 17% had used 1 previously, and 89% would like 1. Sixty percent of physicians are unwilling to spend more than 5 minutes on data entry, unless forced to do so for reimbursement or to maintain hospital privileges. Seventy-three percent believe it is more important to control data-entry time than number of variables; 98% are willing to share Health Insurance Portability and Accountability Act-compliant data; 82% have interest in a handheld data-entry system. Thirty-nine percent are willing to spend $1,000 for the initial database, and 88% are willing to spend $500 per year on maintenance. Vascular surgeons have interest and experience with databases, although some have discontinued use. If databases have short entry times, limited costs, permit portable data entry, and allow data sharing, most vascular surgeons are enthusiastic about collecting clinical outcomes data.

Adoption of Laparoscopic Colectomy: Results and Implications of ASCRS Hands-On Course Participation

Beginning in 2003, the American Society of Colon and Rectal Surgeons has annually sponsored a laparoscopic colon and rectal surgery instructional course using a cadaver model. This study reports the adoption rate and postcourse practice patterns of participants. All prior participants of hands-on courses from 2003 to 2005 were asked to participate in a 25-question survey. Questions probed practice setting, prior laparoscopic experience, motivation for course participation, time to, indication for, and type of first laparoscopic colectomy, experience prior to cancer resection, factors facilitating skill acquisition, and impact on practice from course completion. A total of 43 of 63 participants completed the survey and 53% had performed at least 1 laparoscopic colon resection prior to the course. A laparoscopic colon resection was performed within 1 week of the course by 52% of participants and within 1 month by 90%. Laparoscopic colectomy was performed frequently postcourse with 42% performing between 1 and 5 laparoscopic colectomies/month and 42% between 5 and 10. Hand-assisted technologies lowered the threshold for performance of first laparoscopic colectomy for 62% of participants. Cancer resection was the first procedure for 31% and 36% performed between 5 and 10 colectomies prior to cancer resection. Most important factor in particular course selection was a cadaver model (77%). A majority of the participants would require course completion prior to granting hospital privileges (73%) and would recommend the course to other surgeons (97%). Cadaver course completion enables rapid integration of laparoscopic colon resection into clinical practice. Experience prior to laparoscopic resection of cancer is modest. Hand-assisted technologies promote technique acquisition.

Poor Care, Not Poor Protocols, for Alcohol Withdrawal–Reply–I

Poor Care, Not Poor Protocols, for Alcohol Withdrawal–Reply–I

Successfully Managing Attending Physicians

Successfully Managing Attending Physicians

Office Surgery Incidents: What Seven Years of Florida Data Show Us

In the wake of increased media attention focusing on human error in medicine, numerous state medical boards and legislatures have drafted, and are continuing to draft, regulations aimed at protecting patients undergoing procedures in the office setting. These regulations will have a considerable impact on patient access to medically necessary procedures, and any regulations should be based on good data. This report summarizes 7 years of prospective data from the state of Florida, the best data available on office surgery incidents. The objective was to determine the nature and incidence of hospital transfers and deaths resulting from office procedures. This study is a compilation of mandatory reporting by Florida physicians to a central agency of all in-office adverse incidents resulting in death, serious injury, or hospital transfer in the State of Florida from March 2000 to March 2007. Telephone and internet follow-up was conducted to determine reporting physician board certification, hospital privileges, and office accreditation. In 7 years there were 31 deaths and 143 procedure-related complications and hospital transfers. Liposuction and liposuction with abdominoplasty or another cosmetic procedure resulted in 24 complications and 8 deaths. Of the offices reporting adverse incidents, 38.5% were accredited by an independent accrediting agency, 92.5% of the physicians were board-certified, and 96.6% had hospital privileges. A total of 58% (18/31) of the deaths and 61% (87/143) of the complications were associated with nonmedically necessary (cosmetic) procedures. A total of 78% (14/18) of these deaths were in ASA Class 1 patients. Plastic surgeons were responsible for 48% of all deaths (83% of cosmetic surgery deaths) and for 52% of all hospital transfers (83% of cosmetic surgery complications and hospital transfers). Plastic surgeons were responsible for an inordinate number of deaths and hospital transfers. Requiring physician board certification and physician hospital privileges would not seem to increase safety, because most physicians already have these credentials, and physicians without these credentials were not responsible for a disproportionate share of incidents. These data do not show an emergent hazard to patients from medically necessary office surgery. Liposuction under general anesthesia deserves continued scrutiny because deaths due to this procedure continue to occur and this procedure can be performed with dilute local anesthesia, with which no deaths were reported. Mandatory reporting of office incidents should be strongly supported, as well as reporting of incidents that occur after surgery in the hospital outpatient department and ambulatory surgery center. These data should be available for analysis after protecting patient confidentiality. A national debate needs to occur to determine how many deaths and injuries are acceptable from cosmetic procedures performed under general and intravenous anesthesia.

Alzheimer's disease: trade-off for increased survival with atherosclerosis?

tions and to aid the progression of neurologists in this field, we would like to clarify a few issues. First, there were several errors in the neurology-directed training programs box (Neurology-Directed Interventional Neurology Training Programs). Some neurologists of the listed programs are codirectors or faculty only, and program directors are either neurosurgeons or neuroradiologists who encourage the hiring and training of neurologists (http:// www.svineuro.org/pdfs/interventional_news_letter_winter_ 2007.pdf). Second, we acknowledge the Chairmen and Vice-Chairmen of Neurology Departments who are the pioneers in initiating neurointerventional training programs within their departments: Safwan Jaradeh at the Medical College of Wisconsin, Milwaukee; Larry Wechsler at University of Pittsburgh; David Anderson at University of Minnesota; Patrick Pullicino (previous Chair) at University of Medicine and Dentistry of New Jersey and Stephen Kamin (Acting Chair); David Kaufman at Michigan State University; Kerri Remmel at University of Louisville; Walter Koroshetz previously Vice-Chair at Massachusetts General Hospital and currently the National Institute of Neurological Disorders and Stroke Deputy Director; Jeremy Shefner at Upstate Medical University in Syracuse; Ralph Sacco at University of Miami; and Michael Gruenthl at Albany Medical College. In addition, we acknowledge the neurosurgeons and neuroradiologists who have trained neurologists in the past and are continuing this trend. The Society of Vascular and Interventional Neurology at its inaugural meeting last year granted the Honorary Award for providing visionary mentorship to interventional neurologists to Fernando Vinuela, Chief of Interventional Neuroradiology, University of California Los Angeles. Third, this year there will be about 10 to 12 graduating interventional neurologists from various programs run by neurology, neuroradiology, and neurosurgery. (The names can be viewed online at: http://www.aan.com/globals/axon/ assets/2423.pdf.) Fourth, several factors are needed to establish a successful interventional neurology program. Based on our own experience, a supportive chairman and an excellent relationship with neurosurgery and radiology departments are paramount. At a national level, the need for support from different societies cannot be overstated, particularly the American Neurological Association, American Academy of Neurology, American Stroke Association, and National Stroke Association. Published training and qualification guidelines, emphasizing requirements for neurologists, endorsed by these societies are critical in supporting interventional neurologists obtaining local hospital privileges. Finally, our program at the Medical College of Wisconsin (run by two interventional neurologists and currently three fellows) is in Milwaukee and not in Madison.

The Danger of Submitting an Early Letter of Resignation

To the Editor:—Change in academic jobs is an important and common pathway for promotion in academic medicine. About 9% of physicians change jobs each year in America.1,2 The frequency is even higher for academic physicians because of limited availability of internal promotions in a pyramidal system. However, the perils of providing early written notice of resignation to a current employer in anticipation of a new job based only on a letter of intent of employment and before securing hospital privileges at a new hospital of employment have not been analyzed or reported. A 53-year-old board-certified academic gastroenterologist received, signed, and returned a letter of intent from a large teaching hospital to start work 3 months later as Chief of Gastroenterology at a guaranteed salary for several years. Employment at the new hospital was contingent on hospital credentialing. The physician anticipated rapid hospital privileging because of a professional history of no malpractice judgements or settlements, no adverse actions reported to the National Practitioner Data Bank, and no adverse actions by any hospital or medical licensing body. The physician thereupon submitted a letter of resignation effective 3 months thereafter to his current employer, an academic hospital, to satisfy professional etiquette and to start fulfilling his contractual obligations regarding notice. The physician promptly submitted a completed application, including all 26 requested supporting documents, for clinical privileges at the new hospital. The new position was placed in jeopardy immediately thereafter. First, the proffered written contract contained a new and unacceptable clause granting the hospital the right to unilaterally reduce the guaranteed salary at any time, which took two revised contracts and 75 days of negotiations for mutually satisfactory resolution. Second, hospital privileging was delayed for 100 days after application submission because of the 24 required further documents from the 6 prior employers or other individuals in the physician’s 22-year long academic career; these documents included 4 character references, 7 hospital evaluations, 6 hospital verifications, 4 credential verifications, and 3 malpractice claims histories from the most recent malpractice carriers. Because of delays, the physician was compelled to postpone his new job for 40 days, experienced considerable psychological stress, felt he signed a less favorable contract because of a weakened bargaining position, and experienced a modest loss of income. Fortuitously, the financial loss was mitigated because the physician requested and was granted a 1-month extension beyond his date of resignation at his old job. This case describes previously unreported and unappreciated perils associated with a physician job change. Although the reported physician was a gastroenterologist, the reported problems pertain to all physicians, including internists or general practitioners. To avoid these perils, a physician should unambiguously secure a new position at satisfactory terms before unambiguously relinquishing an old position; should plan for delays in hospital credentialing because of the voluminous required documentation and arduous process; and should resign with sufficient notice from his current employer to maintain cordial professional relations and satisfy contractual obligations. Legal advice is recommended. Whereas the proffered advice of securing a contract at a new job before resigning from an existing job pertains to any job, physicians are particularly vulnerable to problems in changing jobs because of the complex nature of their job responsibilities; the often complex nature of their financial agreements, which often includes a base salary plus an incentive plan; the professional obligation to provide adequate notice to their existing employers; and the need to secure hospital privileges for employment at a new job. Hospitals should consider means to streamline the credentialing process by (1) requiring all hospitals to respond within 30 days to physician credentialing queries, (2) substituting secure computer-based communications for regular surface mail, and (3) instituting a centralized, secure, computer-based national database for (at least parts of) credentialing, resembling the National Practitioner Data Bank.

Critical Mass: The Potential Role of the Mega-group to Address the Manpower Shortage and Facilitate Office-based Practice in Interventional Radiology

THE American College of Radiology and Society of Interventional Radiology (SIR) have recognized that contemporary interventional procedures are often the primary invasive therapeutic treatment in a patient’s disease and that interventional radiologists must be accountable for patient outcomes over time (1,2). For this to take place, interventional radiologists need to perform evaluation and management services, see patients in ambulatory settings, plan and implement treatment, and then follow patients in an ambulatory setting. Of course, all this requires office-based practice, and it is recognized in interventional radiology (IR) that an office-based practice model with hospital privileges is in the best interests of patients and is the only reasonable way for interventional radiologists to compete for ambulatory, elective patients in the future (3). The traditional alignment of interventional radiologists in hospital radiology departments poses several problems. The first is that the foundation of radiology group practice is usually the hospital franchise model; that is, usu-