0016-5107/92/3806-0765$02.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1992 by the American Society for Gastrointestinal Endoscopy
Methods of granting hospital privileges to perform gastrointestinal endoscopy This statement was prepared by the American Society for Gastrointestinal Endoscopy's Standards of Training and Practice Committee and is based on the committee members' experience with the granting of hospital privileges to perform gastrointestinal endos- . copy. It has been approved by the Governing Boards of the American Society for Gastrointestinal Endoscopy, the American Gastroenterological Association, and the American College of Gastroenterology. I. Principles of Credentialing A. Purpose The purpose of this statement is to outline principles and provide practical suggestions to assist hospital credentialing committees in their task of granting privileges to perform gastrointestinal endoscopy. In conjunction with the standard JCAHO guidelines for granting hospital privileges, implementation of these methods should help hospital staffs ensure that endoscopy is performed only by individuals with appropriate competency, thus assuring high quality patient care and proper procedure utilization. B. Statement of the problem The general principles of defining competency in gastrointestinal endoscopy are provided by the A/S/G/E guidelines on The Standards of Practice of Gastrointestinal Endoscopy and the Statement on Endoscopic Training. Although hospitals have frequently used these guidelines in their independent development of credentialing standards, many have requested more specific or practical suggestions on how these principles might be best implemented. C. Uniformity of standards Uniform standards should be developed which apply equally to all hospital staff requesting privileges to perform endoscopy and to all areas where endoscopy is performed within a given institution. Criteria must be established which are medically sound, not unreasonably stringent, and which are applicable in common to all of those wishing to obtain privileges in each specific endoscopic procedure. The goals must be quality assurance, patient protection, and VOLUME 38, NO.6, 1992
cost containment, not arbitrary restraint of practice. D. Specificity of credentialing Privileges should be granted for each major category of endoscopy separately. The ability to perform one endoscopic procedure does not imply adequate competency to perform another. Associated skills generally considered to be an integral part of an endoscopic category may be required before privileges for that category are granted. For example, competency in polypectomy and electrocoagulation must be documented before colonoscopy privileges can be granted. The application for privileges will require adequate verification of competency for each separate procedure. E. Responsibility for credentialing Determination of who does credentialing and which specific methods are chosen to perform the process remains always the individual responsibility of each hospital. When defining privilege-granting criteria and procedures, it should be kept in mind that hospital trustees and all medical staff share common responsibility and liability for all procedures performed within their institution. It is highly desirable to establish a multidisciplinary endoscopic procedure committee to advise the credentialing body regarding initial granting of privileges, to monitor ongoing procedure performance and outcome, and to assist in the renewal of privileges. Every attempt should be made to cooperate between hospitals with overlapping staff to reduce the time and paperwork in the credential-granting process. F. Competency in the diagnosis and management of gastrointestinal disorders The decision of who should perform gastrointestinal endoscopy in a given hospital should be based on the applicant's knowledge, training, and experience in the overall management of gastrointestinal disease, as well as competency to perform the endoscopic procedure. Flexible sigmoidoscopy is generally considered a separate category. With adequate supervised training it may be performed by physicians 765
Table 1. Number of cases performed No. of cases required
Procedures Standard Diagnostic EGD Total colonoscopy Snare polypectomy Non-variceal hemostasis (upper) and lower; includes 10 active bleeders) Variceal hemostasis (includes 5 active bleeders) Esophageal dilation with guidewire Flexible sigmoidoscopy PEG Advanced ERCP (diagnostic) ERCP (therapeutic) Tumor ablation Pneumatic dilation for achalasia Laparoscopy Esophageal stent placement
100 100 20 20·
15 15 25 10 75
25 b 20 5
25 10
• Included in total number. b Includes 20 sphincterotomies and 5 stent placements and is in addition to the 75 diagnostic ERCP procedures.
without other endoscopic skills or specialized training in gastroenterology or surgery (see Aj SjGjE guidelines, Flexible Sigmoidoscopy). II. Definition and Documentation of Competency A. Formal fellowship or residency training in gastroenterology or surgery 1. Duration of training Training should be of adequate duration to provide familiarity with the patients and diseases requiring endoscopic evaluation. There must be an understanding of the indications, complications, and expected advantages of diagnostic and therapeutic endoscopy, as well as cost considerations, and comparisons with alternative approaches. 2. Endoscopic experience The total time spent during training, learning, and performing endoscopic procedures must be adequate for each major category for which privileges are requested. The number of cases which must be observed, performed under supervision, and performed independently necessary to obtain competency varies tremendously. The numbers of cases performed personally by each trainee during training should serve as a guideline for minimal required endosocpic experience (Table 1). 3. Certification The applicant's endoscopic training directors should confirm in writing the training, experience (including the number of cases 766
for each procedure for which privileges are requested), and actually observed level of competency. B. Training and experience outside of a formal fellowship or residency program Equivalent training, obtained outside of a formal program, must be equal to that described above. Certification of experience by a skilled endoscopic practitioner must include a detailed description of the nature of "informal" training, the number of procedures performed with and without supervision, and the actual observed competency of the applicant for each endoscopic procedure for which privileges are requested. It is generally no longer acceptable for physicians to acquire equivalent endoscopic experience by performing unsupervised procedures when skilled endoscopists are available in the medical community. Likewise, attendance at short endoscopy courses which do not provide supervised hands-on training experience with patients is not an acceptable substitute in the development of equivalent competency (see AjSjGjE guidelines, The Statement on Role of Short Courses in Endoscopic Training). C. New procedures As endoscopy evolves, new procedures develop for which privileges may be requested. The process for credentialing depends on the background skills and privileges of the applicant and whether the new procedure is a minor or major variant of established techniques. For GASTROINTESTINAL ENDOSCOPY
minor extensions of demonstrated skills, reading or viewing video tapes may be sufficient training. Some new procedures may require formal training or hands-on equivalent supervised experience with adequate written documentation. Endoscopic sphincterotomy is an example of an extremely complex and high risk procedure requiring extensive training and experience. Therefore, privilege granting for endoscopic sphincterotomy requires documented competency. D. Proctoring Recognizing the limitations of written reports, proctoring of applicants for privileges in gastrointestinal endoscopy by a qualified, unbiased staff endoscopist may be desirable, especially when competency for a given procedure cannot be adequately verified by submitted written material. Proctors are chosen from existing endoscopy staff or are solicited from regional endoscopic societies. Criteria of competency for each procedure should be established in advance. It is essential that proctoring be carried out in an unbiased, confidential, objective manner. The procedural details of proctoring should be provided to the applicant and to the credentialing body of the hospital. A satisfactory mechanism for appeal must be established for individuals for whom privileges are denied or are granted in a temporary or provisional manner.
VOLUME 38, NO.6, 1992
E. Monitoring of endoscopic performance To assist the hospital credentialing body in the ongoing renewal of privileges, a mechanism should be developed to monitor each staff endoscopist's procedural performance. A multidisciplinary endoscopy committee, as described above, could be charged with monitoring endoscopic utilization, diagnostic and therapeutic benefits to patients, complications, and tissue review. A minimum number of cases performed each year for each major endosocopic category may be required to renew privileges. These functions should be accomplished using established peer review methodology and available endoscopic audit criteria. The committee should review in an unbiased random sample the appropriateness of the indications for endoscopy' the impact on management of the patients' problems, the nature and adequacy of safety precautions, and the incidence and cause of all complications. Guidelines for the utilization of endoscopy prepared by the American Society for Gastrointestinal Endoscopy and other societies are available to assist in the periodic reassessment of endoscopic privileges. F. Continuing education Continuing medical education related to endoscopy should be required as part of the periodic renewal of endoscopic privileges. Attendance at appropriate local or national meetings and courses is encouraged.
767
Methods of granting hospital privileges to perform gastrointestinal endoscopy This statement was prepared by the American Society for Gastrointestinal Endoscopy's Standards of Training and Practice Committee and is based on the committee members' experience with the granting of hospital privileges to perform gastrointestinal endos- . copy. It has been approved by the Governing Boards of the American Society for Gastrointestinal Endoscopy, the American Gastroenterological Association, and the American College of Gastroenterology. I. Principles of Credentialing A. Purpose The purpose of this statement is to outline principles and provide practical suggestions to assist hospital credentialing committees in their task of granting privileges to perform gastrointestinal endoscopy. In conjunction with the standard JCAHO guidelines for granting hospital privileges, implementation of these methods should help hospital staffs ensure that endoscopy is performed only by individuals with appropriate competency, thus assuring high quality patient care and proper procedure utilization. B. Statement of the problem The general principles of defining competency in gastrointestinal endoscopy are provided by the A/S/G/E guidelines on The Standards of Practice of Gastrointestinal Endoscopy and the Statement on Endoscopic Training. Although hospitals have frequently used these guidelines in their independent development of credentialing standards, many have requested more specific or practical suggestions on how these principles might be best implemented. C. Uniformity of standards Uniform standards should be developed which apply equally to all hospital staff requesting privileges to perform endoscopy and to all areas where endoscopy is performed within a given institution. Criteria must be established which are medically sound, not unreasonably stringent, and which are applicable in common to all of those wishing to obtain privileges in each specific endoscopic procedure. The goals must be quality assurance, patient protection, and VOLUME 38, NO.6, 1992
cost containment, not arbitrary restraint of practice. D. Specificity of credentialing Privileges should be granted for each major category of endoscopy separately. The ability to perform one endoscopic procedure does not imply adequate competency to perform another. Associated skills generally considered to be an integral part of an endoscopic category may be required before privileges for that category are granted. For example, competency in polypectomy and electrocoagulation must be documented before colonoscopy privileges can be granted. The application for privileges will require adequate verification of competency for each separate procedure. E. Responsibility for credentialing Determination of who does credentialing and which specific methods are chosen to perform the process remains always the individual responsibility of each hospital. When defining privilege-granting criteria and procedures, it should be kept in mind that hospital trustees and all medical staff share common responsibility and liability for all procedures performed within their institution. It is highly desirable to establish a multidisciplinary endoscopic procedure committee to advise the credentialing body regarding initial granting of privileges, to monitor ongoing procedure performance and outcome, and to assist in the renewal of privileges. Every attempt should be made to cooperate between hospitals with overlapping staff to reduce the time and paperwork in the credential-granting process. F. Competency in the diagnosis and management of gastrointestinal disorders The decision of who should perform gastrointestinal endoscopy in a given hospital should be based on the applicant's knowledge, training, and experience in the overall management of gastrointestinal disease, as well as competency to perform the endoscopic procedure. Flexible sigmoidoscopy is generally considered a separate category. With adequate supervised training it may be performed by physicians 765
Table 1. Number of cases performed No. of cases required
Procedures Standard Diagnostic EGD Total colonoscopy Snare polypectomy Non-variceal hemostasis (upper) and lower; includes 10 active bleeders) Variceal hemostasis (includes 5 active bleeders) Esophageal dilation with guidewire Flexible sigmoidoscopy PEG Advanced ERCP (diagnostic) ERCP (therapeutic) Tumor ablation Pneumatic dilation for achalasia Laparoscopy Esophageal stent placement
100 100 20 20·
15 15 25 10 75
25 b 20 5
25 10
• Included in total number. b Includes 20 sphincterotomies and 5 stent placements and is in addition to the 75 diagnostic ERCP procedures.
without other endoscopic skills or specialized training in gastroenterology or surgery (see Aj SjGjE guidelines, Flexible Sigmoidoscopy). II. Definition and Documentation of Competency A. Formal fellowship or residency training in gastroenterology or surgery 1. Duration of training Training should be of adequate duration to provide familiarity with the patients and diseases requiring endoscopic evaluation. There must be an understanding of the indications, complications, and expected advantages of diagnostic and therapeutic endoscopy, as well as cost considerations, and comparisons with alternative approaches. 2. Endoscopic experience The total time spent during training, learning, and performing endoscopic procedures must be adequate for each major category for which privileges are requested. The number of cases which must be observed, performed under supervision, and performed independently necessary to obtain competency varies tremendously. The numbers of cases performed personally by each trainee during training should serve as a guideline for minimal required endosocpic experience (Table 1). 3. Certification The applicant's endoscopic training directors should confirm in writing the training, experience (including the number of cases 766
for each procedure for which privileges are requested), and actually observed level of competency. B. Training and experience outside of a formal fellowship or residency program Equivalent training, obtained outside of a formal program, must be equal to that described above. Certification of experience by a skilled endoscopic practitioner must include a detailed description of the nature of "informal" training, the number of procedures performed with and without supervision, and the actual observed competency of the applicant for each endoscopic procedure for which privileges are requested. It is generally no longer acceptable for physicians to acquire equivalent endoscopic experience by performing unsupervised procedures when skilled endoscopists are available in the medical community. Likewise, attendance at short endoscopy courses which do not provide supervised hands-on training experience with patients is not an acceptable substitute in the development of equivalent competency (see AjSjGjE guidelines, The Statement on Role of Short Courses in Endoscopic Training). C. New procedures As endoscopy evolves, new procedures develop for which privileges may be requested. The process for credentialing depends on the background skills and privileges of the applicant and whether the new procedure is a minor or major variant of established techniques. For GASTROINTESTINAL ENDOSCOPY
minor extensions of demonstrated skills, reading or viewing video tapes may be sufficient training. Some new procedures may require formal training or hands-on equivalent supervised experience with adequate written documentation. Endoscopic sphincterotomy is an example of an extremely complex and high risk procedure requiring extensive training and experience. Therefore, privilege granting for endoscopic sphincterotomy requires documented competency. D. Proctoring Recognizing the limitations of written reports, proctoring of applicants for privileges in gastrointestinal endoscopy by a qualified, unbiased staff endoscopist may be desirable, especially when competency for a given procedure cannot be adequately verified by submitted written material. Proctors are chosen from existing endoscopy staff or are solicited from regional endoscopic societies. Criteria of competency for each procedure should be established in advance. It is essential that proctoring be carried out in an unbiased, confidential, objective manner. The procedural details of proctoring should be provided to the applicant and to the credentialing body of the hospital. A satisfactory mechanism for appeal must be established for individuals for whom privileges are denied or are granted in a temporary or provisional manner.
VOLUME 38, NO.6, 1992
E. Monitoring of endoscopic performance To assist the hospital credentialing body in the ongoing renewal of privileges, a mechanism should be developed to monitor each staff endoscopist's procedural performance. A multidisciplinary endoscopy committee, as described above, could be charged with monitoring endoscopic utilization, diagnostic and therapeutic benefits to patients, complications, and tissue review. A minimum number of cases performed each year for each major endosocopic category may be required to renew privileges. These functions should be accomplished using established peer review methodology and available endoscopic audit criteria. The committee should review in an unbiased random sample the appropriateness of the indications for endoscopy' the impact on management of the patients' problems, the nature and adequacy of safety precautions, and the incidence and cause of all complications. Guidelines for the utilization of endoscopy prepared by the American Society for Gastrointestinal Endoscopy and other societies are available to assist in the periodic reassessment of endoscopic privileges. F. Continuing education Continuing medical education related to endoscopy should be required as part of the periodic renewal of endoscopic privileges. Attendance at appropriate local or national meetings and courses is encouraged.
767
