CGH MEDICAL CENTER

GRANTING OF PRIVILEGES FOR GASTROINTESTINAL ENDOSCOPY

I. PRINCIPLES OF CREDENTIALING

PREAMBLE

Credentialing for the performance of esophagogastroduodenoscopy (EGD) ,  colonoscopy  , ERCP  and sigmoidoscopy  should be based on prior demonstration of proficiency in the performance of these techniques. 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 , colonoscopy , ERCP and flexible sigmoidoscopy)   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.

A. PURPOSE

The purpose is to provide the guidelines necessary to perform endoscopic procedures (EGD , colonoscopy , ERCP and flexible sigmoidoscopy) at CGH Medical Center.

B. UNIFORMITY OF STANDARDS

The following uniform standard will apply to all hospital staff requesting privileges to perform endoscopic procedures  (EGD , colonoscopy , ERCP and flexible sigmoidoscopy) at CGH Medical Center . The following criteria  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. SPECIFICITY OF PRIVILEGING FOR (EGD , colonoscopy , ERCP and flexible sigmoidoscopy)  

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 can be granted.

D. RESPONSIBILITY FOR PRIVILEGING

The credentialing structure and process remains always the individual responsibility of each hospital. 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. TRAINING AND DETERMINATION OF COMPETENCE

A. FORMAL RESIDENCY TRAINING IN GASTROENTEROLOGY OR SURGERY

The Accreditation Council for Graduate Medical Education 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)

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 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. 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.

C. DETERMINATION OF COMPETENCE

  1. Completion of a residency program that incorporates structured experience in gastrointestinal endoscopy. Competence should be documented by the instructor(s).
  2. Proficiency in endoscopic procedure(s) and clinical judgement equivalent to that obtained in a residency program. Documentation and demonstration of competence is necessary.
  3. Participation in gastrointestinal endoscopic training until competence in the specific procedure(s) is equivalent to 1.
  4. 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 actually 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. 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.

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.

E. 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. 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.

F. MONITORING OF ENDOSCOPIC 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.

G. CONTINUING 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.

H. THE 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.

 

Guidelines for credentialing and granting privileges for gastrointestinal endoscopy (EGD , colonoscopy , ERCP and flexible sigmoidoscopy)

Principles of Initial Credentialing
 

  1. Credentials and privileges should be determined independently for each type of endoscopic procedure (sigmoidoscopy [flexible and rigid], colonoscopy, esophagogastroduodenoscopy [EGD], endoscopic retrograde cholangiopancreatography [ERCP], endoscopic ultrasonography) and any other endoscopic procedures6,7.
  2. Credentialing for all procedures, except sigmoidoscopy, should require the ability to perform common associated therapeutic modalities.
  3. Competence in each endoscopic procedure requires both cognitive and technical components8,9.
  4. Appropriate documentation should be required in the determination of competence in each procedure. This may include the completion of a formal training program (residency or fellowship), or documentation of equivalent training in other settings. Documentation of continued competence should be required for the renewal of endoscopic privileges8,11.
  5. Following the successful completion of a gastrointestinal endoscopy training program (as detailed in “Principles of Training in Gastrointestinal Endoscopy” Gastrointest Endosc 1992; 38: 743-746) the trainee:
    1. Must be able to integrate gastrointestinal endoscopy into the overall clinical evalua-tion of the patient.
    2. Should have sound general medical or surgical training.
    3. Must have a thorough understanding of the indications, contraindications, individual risk factors and benefit-risk considerations for the individual patient.
    4. Must be able to clearly describe an endoscopic procedure and obtain informed consent.
    5. Must have a knowledge of endoscopic anatomy, technical features of endoscopic equipment, accessory endoscopic techniques, including biopsy, cytology, photography, thermal and non-thermal endoscopic therapy.
    6. Must be able to accurately identify and interpret endoscopic findings.
    7. Must have a thorough understanding of the principles, pharmacology and risks of sedation/analgesia.
    8. Must be able to document endoscopic findings and therapy, and communicate with referring physicians.
    9. Must competently perform those procedures that were taught.
      The training in endoscopic techniques must be adequate for each major category of endoscopy for which privileges are requested. Performance of an arbitrary number of procedures does not guarantee competency7,11-14. Whenever possible, competence should be determined by objective criteria and direct observation. The number of supervised procedures necessary to obtain competency will vary tremendously between trainees15. Previously published required numbers of procedures were an estimate of the “…threshold number of procedures that must be performed before competency can be assessed. The number represents a minimum, and it is understood that most trainees will require more (never less) than the stated number.”(Training the Gastroenterologist of the Future: The Gastroenterology Core Curriculum. Gastroenterology 1996; 110:1266-1300.)
      Recent prospective studies using objective measures of endoscopic competence in ERCP and colonoscopy have demonstrated that the previously published threshold numbers (Appendix A) are not adequate for most trainees to achieve competence6,7,9,12. This emphasizes the need to use objective criteria of skill, rather than an arbitrary number of procedures performed when granting privileges to physicians for endoscopic procedures. For example, in ERCP, the ability to cannulate the duct of interest in 80% of cases is used as the minimum measure of compentency15. A prospective evaluation of trainees has demonstrated that at least 180 supervised procedures are required for trainees to reach that threshold, a number much higher than the previously published minimum of 75 procedures9. Evaluation of colonoscopic skills has also demonstrated that the number of supervised procedures necessary to achieve competency is greater than the previously suggested minimum7,12. Specific measures of competency have not yet been developed for all endoscopic procedures. These measures should be rapidly adopted in credentialing processes as they are developed. Even with objective measures of procedural success, the evaluation of endoscopic skills, the ability to interpret endoscopic findings and incorporate these findings into patient care requires repeated direct observation of the candidate by an experienced endoscopist.
      Competence in all procedures, exclusive of sigmoidoscopy, requires the ability to perform appropriate therapeutic maneuvers at the same setting. The performance of diagnostic procedures without the ability to treat all lesions reasonably expected to be encountered during endoscopy cannot be supported.
  6. A clinician can obtain training in formal settings, such as fellowship or residency program, or through less formal training (“Alternative Pathways To Training in Gastrointestinal Endoscopy” Gastrointest Endosc 1996; 43: 658-660).
  7. New endoscopic procedures, or significant advances in existing procedures, may occur. Endoscopists who have not received conventional formal training may wish to acquire privileges to perform these procedures. The degree of training, direct supervision and proctoring will vary with the experience of the endoscopist and the nature of the procedure16. When possible, objective criteria of competence should be developed and met.

Principles of Recredentialing and Renewal of Privileges
 

The goal of recredentialing is to assure continued clinical competence, promote continuous quality improvement and maintain patient safety17-19. The principles of maintenance of competence are detailed in ASGE publication “Maintaining Competency in Endoscopic Skills”. (Gastrointest Endosc 1995; 42: 620-621). These guidelines should be applied in conjunction with those of national accrediting organizations, such as the JCAHO.

Assuring continued competence in the performance of endoscopic procedures includes ongoing:

  1. Documentation of adequate procedure volume to maintain clinical skills. This can include procedure log books or a review of patient records. Such a review should include documentation of objective measures of the number of procedures, procedure success, therapeutic interventions and complications.
  2. Review of above statistics in a continuous quality improvement setting.
  3. Documentation of continued cognitive training through participation in educational activities.

 

The purpose of this review and documentation should be restricted to use in continuous quality improvement and endoscopic credentialing.

Documentation of Guidelines
 
MINIMUM NUMBER OF PROCEDURES BEFORE COMPETENCY CAN BE ASSESSED
STANDARD
PROCEDURE		 NUMBER OF
CASES REQUIRED
Diagnostic EGD 100
Total Colonoscopy 100
Snare polypectomy 20*
Nonvariceal hemostasis (upper and lower; includes 10 active bleeders) 20*
Variceal hemostasis (Includes 5 active bleeders) 15
Esophageal dilation with guide wire 15
Flexible sigmoidoscopy 25
PEG 10
Advanced Procedures
ERCP (Diagnostic) 75
ERCP (Therapeutic) 25#
Tumor ablation 20
Pneumatic dilation for achalasia 5
Laparoscopy 25
Esophageal stent placement 10

*Included in total number
#Includes 20 sphincterotomies and 5 stent placements and is in addition to the 75 diagnostic ERCP procedures
From: Training the Gastroenterologist of the Future: The Gastroenterology Core Curriculum. Gastroenterology 1996;110:1266-1300.
RECREDENTIALING GUIDELINES
Endoscopic Skills
   Number of Procedures
   Success Rate
   Complication Rate
Educational Activity
Participation in Continuous Quality Improvement


 
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Additional  References

 

REFERENCES

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