This document was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Apr 2010.
I. PRINCIPLES OF CREDENTIALING
Credentialing for the performance of both diagnostic and therapeutic esophagogastroduodenoscopy (EGD) and colonoscopy should be based on prior demonstration of proficiency in the performance of these techniques. Privileges should be granted for each major category of endoscopy separately; i.e., upper endoscopy, enteroscopy, biliopancreatic endoscopy, sigmoidoscopy, colonoscopy, etc. Proficiency in endoscopy should include both diagnostic and therapeutic procedures as there is no role for “diagnostic only” credentialing. The ability to perform one endoscopic procedure does not imply adequate competency to perform another. Associated skills generally considered being an integral part of an endoscopic category might be required before privileges for that category can be granted. Proficiency should be substantiated by documentation provided by the applicant from prior mentors and/or supervisors. Eligible members and/or supervisors include Residency Program Directors, Chiefs of Services, and other members of the teaching faculty. Individuals applying for privileges for EGD and colonoscopy should have demonstrated satisfactory completion of an Accreditation Council for Graduate Medical Education-accredited training program in gastroenterology, general surgery, colorectal surgery, or pediatric surgery. Attestation to competency in the performance of these techniques should therefore be provided by the Program Director, and, if deemed necessary by the Credentialing and Qualifications Committee at the institution at which these privileges are being sought by other prior teaching faculty from the applicant’s residency program. In the case of applicants who already have credentialing to perform these procedures and are applying for similar privileges at another facility or for renewal of privileges at the same facility, attestation as to competency should be provided by the applicant’s respective Chief of Service. Maintenance of continued competency is the responsibility of the respective Credentialing and Qualifications Committee and should be based on ongoing review of the applicant’s performance by their respective Chief of Service. These credentialing guidelines should apply to any site at which EGD and colonoscopy are practiced.
Clinical practice guidelines are intended to indicate the best available approach to medical conditions as established by a systematic review of available data and expert opinion. The approach suggested may not necessarily be the only acceptable approach given the complexity of the healthcare environment. These guidelines are intended to be flexible, as the surgeon must always choose the approach best suited to the patient and to the variables at the moment of decision. These guidelines are applicable to all physicians who are appropriately credentialed regardless of specialty and address the clinical situation in question.
These guidelines are developed under the auspices of SAGES, the guidelines committee and approved by the Board of Governors. The recommendations of each guideline undergo multidisciplinary review and are considered valid at the time of production based on the data available. New developments in medical research and practice pertinent to each guideline are reviewed, and guidelines will be periodically updated.
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 insure that endoscopy is performed only by individuals with appropriate competency, thus assuring high quality patient care and proper procedure utilization.
B. UNIFORMITY OF STANDARDS
Uniform standards should be developed which apply 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 those wishing to obtain privileges in each specific endoscopic procedure. The goals must be the delivery of high quality patient care.
C. RESPONSIBILITY FOR PRIVILEGING
The credentialing structure and process always remains the individual responsibility of each hospital. Privileging guidelines and documentation of proficiency should be based on published competency data with no minimum numbers of procedures necessary to obtain privileges. Adherence to principles outlined in this document help ensure prerequisites are met prior to a candidates presentation to the hospital for credentialing. It should be the responsibility of the service chief, to recommend individuals for privileges in gastrointestinal endoscopy as for other procedures performed by members of his/her department.
II. MINIMUM REQUIREMENTS FOR GRANTING PRIVILEGES
Part II A or B is mandatory and must be accompanied by part IV B, C, and D.
A. FORMAL RESIDENCY TRAINING IN GASTROENTEROLOGY OR SURGERY
Prerequisite training must include satisfactory completion of an accredited surgical or gastroenterologic training program with subsequent eligibility and/or certification by the appropriate certifying board as required by the institution. The residency program must be accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the equivalent body if the program is based outside the United States or Canada. The ACGME has mandated that: “The program must provide experience to each resident in the performance of a variety of rigid and flexible endoscopic procedures, including laryngoscopy, bronchoscopy, esophagoscopy, gastroscopy, colonoscopy, as well as the study and performance of new and evolving endoscopic techniques” (Directory of Residency Training Programs – Graduate Medical Education Directory 1997-1998). The ACGME, with the direction of the Residency Review Committee (RRC), has established a guideline addressing the number of endoscopic procedures required for surgeons upon completion of their surgical training.
B. ENDOSCOPIC TRAINING AND EXPERIENCE OUTSIDE A FORMAL RESIDENCY PROGRAM, AFTER SATISFACTORY COMPLETION OF AN ACGME ACCREDITED GENERAL SURGERY, PEDIATRIC SURGERY, COLORECTAL SURGERY, OR GASTROENTEROLOGY TRAINING PROGRAM OR THE EQUIVALENT
Equivalent training and/or experience obtained outside a formal program is recognized, but must be at least equal to that described above. A candidate must show proficiency in endoscopic procedure(s) and clinical judgment equivalent to that obtained in a residency program. 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. The applicant’s endoscopic director should confirm in writing the training, experience (including the number of cases for each procedure for which privileges are requested) and observed level of competency. It is recognized that by virtue of completing a residency program, the endoscopist will have acquired sufficient cognitive experience in anatomy, physiology, disease process, combined with the progressive development of visual and psychomotor skills and experience necessary for the performance of diagnostic and therapeutic procedures in the gastrointestinal tract. Such experience includes indications, complications and their management, and alternative approaches. The training director’s opinion and recommendation should be considered prima facie evidence for the trainee’s acceptance as an individual qualified in gastrointestinal endoscopy. 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 with patients, is not an acceptable substitute in the development of equivalent competency.
C. INTRAOPERATIVE AND SURGICAL ENDOSCOPY
It is recognized that some operative procedures require intraoperative endoscopy as an adjunct and/or inherent part of an operative procedure. These endoscopic procedures should be included as part of the operative procedure when granting privileges to surgeons to perform specific operations. Surgeons are uniquely qualified to perform intraoperative endoscopic procedures as an integral part of an operation (Heller myotomy, gastric bypass, etc.). Similarly, surgeons may be required to perform endoscopy as preoperative evaluation or as follow-up for specific operative procedures and this should be considered in the granting of endoscopic privileges for surgeons.
D. NEW PROCEDURES
Self-Training in new techniques in gastrointestinal endoscopy must take place on a background of basic endoscopic skills. The endoscopist should recognize when additional training is necessary and learn new procedures in a formal educational program when available.
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. The procedural details of proctoring should be developed by the credentialing body of the hospital and provided to the applicant. Proctors may be chosen from existing endoscopy staff or solicited from endoscopic societies. The proctor should be responsible to the credentials committee, and not to the patient or to the individual being proctored. Documentation of the proctor’s evaluation should be submitted in writing to the credentials committee. Criteria of competency for each procedure should be established in advance. It is essential that proctoring be provided in an unbiased, confidential and objective manner. A satisfactory mechanism for appeal must be established for individuals for whom privileges are denied or granted in a temporary or provisional manner.
III. INSTITUTIONAL SUPPORT
If the particular procedure in question requires a significant amount of supporting infrastructure vital to the complete procedural conduct of the endoscopic procedure in question, it is incumbent on the institution to have this support in place prior to beginning the procedure.
IV. MAINTENANCE OF PRIVILEGES
A. PROVISIONAL PRIVILEGES
Once competence has been determined, a period of provisional privileges may be appropriate. The time frame and/or number of cases required during this period should be determined by the chief of service and/or the appropriate institutional committee, board or governing body.
B. MONITORING OF PERFORMANCE
To assist the hospital credentialing body in the ongoing renewal of privileges, there should be a mechanism for monitoring each endoscopist’s procedural performance. This should be done through existing quality assurance mechanisms or, alternatively, through a multi-disciplinary endoscopy committee. This should include monitoring endoscopic utilization, diagnostic and therapeutic benefits to patients, complications, and tissue review in accordance with previously developed criteria.
C. CONTINUING MEDICAL EDUCATION
Continuing medical education related to endoscopy should be required as part of the periodic renewal of endoscopic privileges. Attendance at appropriate local, national or international meetings and courses is encouraged.
D. RENEWAL OF PRIVILEGES
For the renewal of privileges an appropriate level of continuing clinical activity should be required, in addition to satisfactory performance as assessed by monitoring of procedural activity through existing quality assurance mechanisms as well as continuing medical education relating to gastrointestinal endoscopy.
E. DENIAL OF PRIVILEGES
Institutions denying, withdrawing or restricting privileges should have an appropriate mechanism for appeal in place. The procedural details of this should be developed by the institution and must satisfy the institution’s bylaws and JCAHO recommendations.
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This document was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) in Apr 2010.
This is a revision of SAGES publication #11 printed Sep 2001, revised Apr 2010.
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Guidelines for clinical practice are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations will be based on existing data or a consensus of expert opinion when little or no data are available. Guidelines are applicable to all physicians who address the clinical problem(s) without regard to specialty training or interests, and are intended to indicate the preferable, but not necessarily the only acceptable approaches due to the complexity of the healthcare environment. Guidelines are intended to be flexible. Given the wide range of specifics in any health care problem, the surgeon must always choose the course best suited to the individual patient and the variables in existence at the moment of decision.
Guidelines are developed under the auspices of the Society of American Gastrointestinal and Endoscopic Surgeons and its various committees, and approved by the Board of Governors. Each clinical practice guideline has been systematically researched, reviewed and revised by the guidelines committee, and reviewed by an appropriate multidisciplinary team. The recommendations are therefore considered valid at the time of its production based on the data available. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research knowledge, and practice.