Guideline text:
(Rev. 141, Issued: 07-10-15, Effective: 07-10-15, Implementation: 07-10-15)

§482.26(c) - Standard:  Personnel

(1) A qualified full-time, part-time or consulting radiologist must supervise the ionizing radiology services and must interpret only those radiologic tests that are determined by the medical staff to require a radiologist's specialized knowledge. For purposes of this section, a radiologist is a doctor of medicine or osteopathy who is qualified by education and experience in radiology.

## Interpretive Guidelines §482.26(c)(1)

The regulation defines a radiologist as a doctor of medicine (MD) or doctor of osteopathy (DO) who is qualified by education and experience in radiology.  The medical staff must establish the specific criteria related to education and experience that must be met in order to be privileged as a radiologist in the hospital.

Ionizing radiologic services offered throughout the hospital must be under the supervision of a radiologist, who may be part-time, full-time, or consulting.  This may be accomplished in several ways, including by having one organized radiologic service under the direction of the supervising radiologist, or by the governing body ensuring a uniform approach to ionizing radiologic services that are offered in multiple, separately organized departments of the hospital which collaborate with the supervising radiologist in developing their department-specific protocols for ensuring that these services are free from hazards for patients and personnel.

The supervising radiologist, including, if applicable, a consultant who provides such supervision, must be privileged as a radiologist at the hospital.  The extent of radiologic services provided by the hospital determines whether the supervising radiologist must carry out these responsibilities full or part-time.

For diagnostic radiologic services using ionizing radiation, policies and procedures must, in addition to the requirements addressed in other portions of the radiologic services CoP, identify which types of radiologic tests require interpretation by a radiologist, as opposed to another type of practitioner holding privileges; the hospital's medical staff must approve this policy.

When interpretation of radiologic tests (studies) is provided via telemedicine, the radiologist interpreting the radiological test must be licensed and/or meet the other applicable standards that are required by State or local laws in the state where the hospital (and, therefore, the patient) is located.  The requirements concerning granting of privileges to teleradiologists are addressed in the medical staff (§482.22) and governing body (§482.12) Conditions of Participation.

## Survey Procedures §482.26(c)(1)

- Review the medical staff privileging criteria for a radiologist.  Review the credentialing and privileging file of the supervising radiologist to verify that he or she meets the qualifications established by the medical staff and has been granted privileges as a radiologist.
- If the supervising radiologist is a part-time employee or consultant, ask him/her how much time/week is spent on supervising ionizing radiologic services.
- Is there any evidence of problems within the radiologic services that suggest lack of supervision?
- Determine whether the medical staff has reviewed and approved a policy identifying the types of diagnostic radiologic tests (studies) that require interpretation by a radiologist.  Review records to determine that a radiologist interprets those tests (studies) that have been designated.

Structured rule (JSON):
{"intent_tags": ["safety", "quality", "compliance"], "logic_config": {"required_artifact": "qualified and privileged radiologist supervising ionizing radiology services and interpreting specific radiologic tests"}, "rule_type": "existence", "scope_tags": ["clinical", "facility", "legal"]}