Policing privileges: How to know if your docs can do a new procedure
Policing privileges: How to know if your docs can do a new procedure
Credentialing experts offer tips on monitoring skill levels
When a "hot" new procedure becomes available, are your doctors qualified to perform it? To answer that question and to keep up with the rapid pace of change in the OR, managers need an effective system for monitoring and documenting physician credentials, same-day surgery experts say.
Credentialing dilemmas arise daily. For example, a surgeon uses a YAG laser to remove bladder tumors. The same surgeon performs trans-urethral resections of the prostate with an electrosurgery device. Can he or she step right into a visual laser ablation of the prostate?
A gynecologist performs diagnostic laparoscopies and hysterectomies. Is that surgeon qualified to begin performing laparoscopic-assisted vaginal hysterectomies (LAVH)?
Not so fast, cautions Vangie Paschall, RN, laser/endoscopic coordinator at Promina Gwinnett Hospital System in Lawrenceville, GA.
Complication rates rose nationally as more surgeons began to perform the LAVHs, Paschall notes. That rise didn't reflect on the merits of the procedure itself, but on the need for tighter credentialing policies at hospitals and surgery centers, she contends. A similar rise in complication rates occurred when laparoscopic cholecystectomies became popular.
"The eyes of the scope are on the tip, so you've got a larger room for error," Paschall says. "Just because [surgeons] were qualified to do a hysterectomy, just because they were qualified to do laparoscopic procedures, that doesn't mean they were qualified to do a laparoscopic-assisted hysterectomy."
Is the physician qualified?
Same-day surgery managers need better systems to monitor credentialing in new technologies, while still allowing for innovation by experienced surgeons, says Paschall and other experts.
"There is one primary issue, and that's patient safety," says Kenneth A. Forde, MD, FACS, professor of clinical surgery at Columbia University in New York City. Forde is also chairman of the credentialing committee of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) in Santa Monica, CA, which has developed guidelines for the granting of privileges in endoscopy and laparoscopy. (For more information, see source box, p. 28, and Same-Day Surgery, February 1995, p. 25.)
"We want to know that any physician who's going to do a procedure is qualified to do it," says Forde.
Here are 10 tips offered by same-day surgery experts as you review your credentialing procedures:
1. Designate a committee with responsibility for reviewing new technologies and procedures.
At Promina Gwinnett Hospital System, an advanced technology committee, which includes physicians from various specialties, administrators, and the laser safety officer, handles credentialing for lasers and makes recommendations on endoscopic and laparoscopic issues. When new technologies emerge, the committee reviews research information and outcomes at other facilities, Paschall says.
Having an advanced technology committee allows the hospital to integrate new instruments and procedures in a safe but expeditious way, Paschall says.
With the exception of lasers, credentialing matters are decided by a multispecialty committee at Promina Gwinnett. Before physicians receive privileges for specific procedures, they must receive approvals from their department chief, the credentials committee, the medical executive committee, and the hospital board. That provides four layers of review, says Melanie White, RN, medical staff coordinator.
When procedures cross specialty lines, credentialing issues may become more complex, notes Kay Ball, RN, MSA, CNOR, a perioperative consultant based in Columbus, OH, and a past president of the Denver-based Association of Operating Room Nurses. For example, orthopedic surgeons and podiatrists may perform foot surgery.
Because there may be more competition than collaboration among physicians in different specialties, Ball cautions: "Make sure the [credentialing] committee is balanced and fair in its treatment of others."
2. Classify procedures according to difficulty level.
By designating four levels for endoscopic procedures of differing difficulty, the credentialing committee can set an orderly pattern for physicians to advance, Paschall says. Promina Gwinnett developed a classification system based on one at Mount Sinai Hospital in New York City, with four classes of procedures. Physicians need to complete training and credentialing in Class I procedures before applying for privileges in Class II.
For example, at Promina Gwinnett, diagnostic laparoscopy and tubal ligation are designated as Class I. LAVH or laparoscopic burch are Class IV procedures.
How to handle wavelength changes
3. Credential laser procedures by wavelength.
To be credentialed in laser surgery at Promina Gwinnett, physicians must complete a course of at least eight hours in a specific wavelength with documented hands-on experience. Documentation includes a course syllabus and certificate.
The hospital doesn't necessarily require physicians to take a course if they want to use a new wavelength but the technique remains the same, Paschall says. Instead, she sets up an inservice session in a lab, which allows the physician to use the laser on tissue. Paschall and the chief of the advanced technology committee sign off on the wavelength change.
"The laser is a tool. The laparoscope is a tool," she says. "What we've got to determine is whether the technique is altered."
If the technique is substantially different -- as in the earlier example of the urologist who wants to perform a visual laser ablation of the prostate -- then formal training and proctoring is required, Paschall says.
At Vanderbilt University Medical Center in Nashville, TN, physicians take wavelength-specific courses, which include work on tissue, but they don't need to repeat instruction on basic laser physics, says James Duncavage, MD, FACS, associate professor and vice chairman of otolaryngology.
"A physician would have to demonstrate that he has some experience with each particular wavelength," says Duncavage, who is also president-elect of the Wausau, WI- based American Society of Lasers in Medicine and Surgery.
4. Create a method to monitor compliance with credentialing guidelines.
Make sure your credentialing policies are clearly communicated to your staff, same-day surgery experts say. Otherwise, you could wind up with risk management or accreditation problems, Ball says.
"The Joint Commission [on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL] doesn't care what your policy says as much as whether you follow your own policies," she says.
You may want to designate a scheduling clerk with the responsibility of checking physician credentials when cases are posted, Ball suggests.
Promina Gwinnett has developed a privileges-request form and monitor list to keep track of the status of the physicians. (See sample form, p. 27 and enclosed in this issue.)
"All we have to do is look at that piece of paper and see whether they're released or not," says Paschall. "Nothing's worse than doing this by the seat of your pants."
Are your files complete?
5. Make sure your files contain complete documentation of credentialing.
In an era of high litigation, having the proper documentation is crucial, Ball says. The files should include certificates of completion for all coursework and signed paperwork indicating that a proctor has monitored the physician and validated his or her competency.
If a lawsuit occurs, attorneys will look for that information in the hospital or surgery center files, Ball says.
"[The physician] may be extremely competent, but if the documentation isn't there, that opens the facility and physician up completely to liability," she says.
6. Coordinate credentialing efforts with other facilities in the community.
Credentialing guidelines tend to be similar within a community, says Ball. In fact, you may want to communicate with colleagues at other hospitals or surgery centers, she suggests. Physicians who meet credentialing requirements at one institution typically are able to obtain privileges at others without difficulty, Ball says.
If a surgery center accepts the credentialing decision of a nearby hospital, same-day surgery managers still are responsible for making sure the paperwork is adequate and available, Ball says. Ask your physicians' staff to provide you with copies of the certificates and documents so you can create your own credentialing files, she advises.
7. Consider bringing in an outside proctor for new procedures.
When a new procedure emerges, who is qualified to do the first one? The answer might be to bring in an outside proctor to monitor cases.
Sometimes, the facility pays for the proctor. But the physicians may be willing to foot the bill in order to expand their training, as was the case at Promina Gwinnett when surgeons began doing laparoscopic hernia repair.
"I found out how much the proctor was going to cost and divided it by the number of physicians who wanted to be proctored," says Paschall. "We blocked one day for nothing but laparoscopic hernias."
8. Require surgeons skilled in the laparoscopic technique to have experience in the open procedure.
Medical residency programs now include laparoscopic training. But with the popularity of some "minimal access" procedures, such as laparoscopic cholecystectomy, Forde and others worry that physicians may not have experience in the open procedure.
SAGES guidelines state that "the surgeon must have the judgment, training, and the capability of immediately proceeding to a traditional open abdominal procedure when circumstances so indicate."1
"If I were on the credentials committee and Dr. X came up to me, before I heard about his laparoscopic training, I'd want to know what training he has in the open surgery first," says Forde. "I would not participate in credentialing somebody [for a laparoscopic cholecystectomy] that I thought didn't have enough experience working in the biliary tract."
9. Be flexible within safe standards.
What if you have an excellent surgeon who wants to try a novel procedure? "You don't penalize the progressive surgeon," says Paschall. "But that doesn't mean they can jump right in and do these laparoscopic procedures."
In those cases, Promina Gwinnett creates an ad hoc review board of physicians to evaluate the proposed procedure. They will analyze the technique, the patient criteria, the skill level of the surgeon, and the surgeon's training and credentialing status. They will also consider outcomes information and research related to that technique.
10. Monitor complication rates through a peer review process.
Same-day surgery managers should monitor the complication rates of new procedures -- particularly of the first cases performed, says Paschall. Credentials are reviewed by the chief of the department and the credentialing committee at least every two years at Promina Gwinnett, and outcomes information, such as blood utilization and infection rates, is analyzed at that time.
"Ongoing monitoring of performance is essential," Forde says.
Reference
1. SAGES: Granting of privileges for laparoscopic general surgery. Am J Surg 1991; 161:324-325. *
For more information on credentialing guidelines, contact:
* The Society of American Gastrointestinal Endoscopic Surgeons, 2716 Ocean Park Blvd., Suite 3000, Santa Monica, CA 90405. Telephone: (310) 314-2404. Fax: (310) 314-2585.
* The American Society for Laser Medicine and Surgery, 2404 Stewart Square, Wausau, WI 54401. Telephone: (715) 845-9283. Fax: (715) 848-2493.
Source: Promina Gwinett Hospital System, Lawrenceville, GA.
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