Minimize risk with lap credentialing
Minimize risk with lap credentialing
8 tips help you be proactive
A general surgeon completes a continuing medical education (CME) course in laparoscopic cholecystectomy and applies for an extension of privileges to use the laparoscope for gallbladder removals. The doctor also requests authorization to use the laparoscope for appendectomies, hernia repairs, esophageal procedures, and other applications. One of the procedures is completely new.
How do you respond?
One of the most critical risk management issues currently facing outpatient surgical programs is credentialing for the range of laparoscopic procedures. What credentialing strategies should a same-day surgery program employ to protect patient safety and minimize the risk of potential lawsuits? How does a facility ensure that its physicians are qualified to perform the newest procedures that arise from advances in technology? How should a surgical center handle the introduction of new laparoscopic techniques?
"Be able to document training and experience for each specific laparoscopic procedure," advises Anne Irving, MHA, CHE, a senior risk management consultant at The Reciprocal Group in Richmond, VA, a corporation that underwrites health care entities and professionals for professional liability. Consider these guidelines:
• Start with the basics.
Irving advises ambulatory surgery centers (ASCs) and hospital-based same-day surgery programs to establish a credentialing method acceptable to groups such as the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Health Care Organizations.
Key elements include verification of a physician’s license, relevant training, and experience, she says. "A facility should be able to document that a physician has the current clinical competence to perform procedures and use devices within its scope of services."
• Define the minimum necessary training.
Unless a physician is trained during residency, many facilities consider a formal CME class with both didactic instruction and hands-on experience using animals as an indication of sufficient training, Irving says.
Beth McGeever, BSN, the administrator of Chestnut Hill Outpatient Surgical Center in Philadelphia, concurs.
"We require a certified CME course with practice as assistant, camera operator, and primary surgeon," McGeever says. "The physician must perform at least one procedure on a live animal and receive a recommendation from the course instructor."
The use of preceptors is a relatively new practice in the field, Irving notes.
"Preceptorships are often a good idea because the incidence of complications may be higher at the beginning of a physician’s learning curve for a procedure," she says.
McGeever agrees that initial procedures carry a higher risk. "After certification, physicians must perform their first 30 cases in the hospital," according to Chestnut Hill’s policies, she says.
• Delineate the minimum credentialing criteria for laparoscopic procedures.
"Health care facilities need to understand that the laparoscope should not be viewed merely as a surgical instrument. Laparoscopic procedures are highly technical," Irving cautions. "To protect against a negligent credentialing claim, same-day surgery centers should establish a credentialing process that specifically delineates each applied use of the laparoscope."
Competence not necessarily transferable
Laparoscopic procedures differ significantly from traditional surgical techniques, she points out. "A physician’s competence in one laparoscopic procedure for example, laparoscopic cholecystectomy does not necessarily reflect an ability to perform other laparoscopic procedures," Irving says.
Irving recommends reading journals and researching professional association literature to identify the credentialing trends for individual laparoscopic procedures.
• Research quality-of-care issues.
A surgical center should carefully research the new procedures it introduces, McGeever warns.
"Determine whether the new approach is superior to the current method by comparing rates of success, complications, morbidity, and mortality," she suggests. "Learn about the new technique and available training."
Research helps identify the risks involved in introducing a new procedure and thus encourages the development of reasonable credentialing criteria.
• Delineate privileges according to specific laparoscopic applications.
"A facility should consider delineating the specific types of basic and advanced laparoscopic applications in its credentialing process," Irving advises.
For example, a CME class may teach five basic gynecological laparoscopic procedures, including "lysis of adhesions," and four advanced procedures, such as the "laparoscopic assisted vaginal hysterectomy." The delineation-of-privileges form should list each of the nine procedures rather than a blanket "laparoscopy GYN" category.
• Establish credentialing criteria for lasers.
"The use of a laser represents a special technique," says Irving. Since each laser has its own unique properties, Irving suggests same-day surgery managers should:
establish additional credentialing requirements for a laser used with a laparoscope;
delineate credentialing by the type of energy source (such as CO2 or nd:YAG) and the type of procedure.
• Review operative consent form.
Irving suggests that in addition to the regular components of informed consent, an operative consent form should note:
the possible presence of an assisting or preceptoring surgeon, students, or others;
the conceivable necessity to convert from laparoscopy to open surgery.
• Equip your facility to handle a proposed procedure.
"A facility should exclude a new procedure from its scope of services until it is fully equipped and prepared to handle the procedure," McGeever suggests. Consider the risks involved with the procedure and the facility’s proximity to a hospital.
Can an operation easily switch from laparoscopy to an open procedure if necessary?
Are enough qualified personnel on staff?
Is emergency equipment in place?
A facility that is attached to a hospital might accept more complicated cases than a surgical program that is 20 miles from the nearest hospital, Irving says.
"With appropriate risk management techniques, surgical centers can stay progressive and introduce new procedures to increase effectiveness," says McGeever.
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