Principles of Privileging and Credentialing for Endoscopy and Colonoscopy

Joint Statement by the American Society for Gastrointestinal Endoscopy, the Society of American Gastrointestinal Endoscopic Surgeons, and the American Society of Colorectal Surgeons Principles of privileging and credentialing for endoscopy and colonoscopy Granting privileges for GI endoscopy should be substantiated by documentation provided by the applicant from Residency Program Directors, Ensuring that high-quality endoscopy is provided to Chiefs of Service, or other members of the teaching the public has been one of the main principles of the faculty who have directly observed the applicant per- ASGE for many years. Appropriate training in GI forming endoscopy. Individuals applying for privi- endoscopy is critical to providing quality endoscopists. leges for EGD and colonoscopy should have demon- ASGE’s training guidelines call for acquisition of strated satisfactory completion of an Accreditation endoscopic skills in the context of training programs in Council for Graduate Medical Education-accredited gastroenterology or surgery and for an assessment of training program in adult or pediatric gastroenterol- endoscopic skill after a threshold number of proce- ogy, general surgery, colorectal surgery, or pediatric dures has been performed. There has been considerable surgery. Attestation to competency in the perfor- variability among professional societies in the num- mance of these techniques should therefore be pro- bers of procedures required to assess the competence of vided by the Program Director and, if deemed neces- trainees. As additional studies have been performed, it sary, by the Credentialing or Privileging Committee is clear that more procedures are needed than were at the institution at which these privileges are being previously recommended to ensure competency. sought or by other teaching faculty from the appli- I am very pleased that with the cooperation and cant’s residency program. In the case of applicants understanding of my fellow Society Presidents, who already have privileges to perform these proce- William Traverso of the Society of American dures and are applying for similar privileges at Gastrointestinal Endoscopic Surgeons and John another facility or for renewal of privileges at the MacKeigan of the American Society of Colorectal same facility, attestation of competency should Surgeons, our three societies were able to agree on a be provided by the applicant’s Chief of Service. joint guideline on granting privileges for gastroin- Maintenance of continued competency is the respon- testinal endoscopy. This guideline clearly states that sibility of the respective Credentialing or Privileging all three of our societies are aligned on the impor- Committee and should be based on ongoing review of tance of training before granting privileges for upper the applicant’s performance by their Chief of Service. endoscopy and colonoscopy. The other important These credentialing guidelines are intended to apply principle highlighted in this guideline is that these to any site at which EGD and colonoscopy are prac- principles of training for endoscopy apply to endos- ticed. These guidelines should supplement previously copy performed in any setting. As more endoscopy is published guidelines by ASGE, ASCRS, and SAGES.1- done in the unregulated office setting, payers will 7 More comprehensive discussions of issues sur- ultimately determine who performs endoscopy. rounding the granting of privileges for gastrointesti- Having uniform guidelines for endoscopic privileges nal endoscopy are available on the societies’ websites, across specialties should help convince payers of the i.e., the ASGE at www.asge.org, the Society of importance of training in ensuring the delivery of American Gastrointestinal Endoscopic Surgeons at high-quality endoscopic services. www.sages.org, and the American Society of Michael B. Kimmey, MD Colorectal Surgeons at www.fascrs.org. Immediate Past President, ASGE PURPOSE PREAMBLE The purpose of this statement is to outline princi- Privileging or credentialing for the performance of ples and provide practical suggestions to assist hos- esophagogastroduodenoscopy (EGD) and colonoscopy pital privileging or credentialing committees in should be based on prior demonstration of proficiency their task of granting privileges to perform gas- in the performance of these procedures. Proficiency trointestinal endoscopy. In conjunction with the Also published in Diseases of the Colon and Rectum and Surgical standard Joint Commission on Accreditation of Endoscopy. Healthcare Organizations (JCAHO) guidelines for VOLUME 55, NO. 2, 2002 GASTROINTESTINAL ENDOSCOPY 145 Author Title granting hospital privileges, implementation of experience by a skilled endoscopic practitioner must these methods should help assure that endoscopy is include a detailed description of the nature of “infor- performed only by individuals with appropriate mal” training, the number of procedures performed competency, thus assuring high quality patient care with and without supervision, and the actual and proper procedure utilization. observed competency of the applicant for each endoscopic procedure for which privileges are requested. UNIFORMITY OF STANDARDS It is no longer acceptable for physicians to acquire Uniform standards should be developed that apply equivalent endoscopic experience by performing to all hospital staff requesting privileges to perform unsupervised procedures when skilled endoscopists endoscopy, and to all areas where endoscopy is per- are available in the medical community. formed. Criteria must be established that are med- ically sound and that are applicable to all those Determination of competence wishing to obtain privileges in each specific endo- 1. The applicant has completed a residency program scopic procedure. The goals must be the delivery of that incorporates structured experience in gas- high-quality patient care. trointestinal endoscopy.2 Competence should be documented by the instructor(s). SPECIFICITY OF PRIVILEGING FOR ESOPHAGOGASTRODUODENOSCOPY AND 2. The applicant can demonstrate proficiency in endo- COLONOSCOPY scopic procedure(s) and clinical judgement equivalent to that obtained in a residency program.4 This Privileges should be granted for each major catego- generally requires participation in gastrointestinal ry of endoscopy separately.1 The ability to perform endoscopic training until competence in the specif- one endoscopic procedure does not imply adequate ic procedure(s) is equivalent to that which would competency to perform another. Associated skills have been obtained upon completion of a residency generally considered an integral part of an endo- program that incorporates structured experience in scopic category may be required before privileges for gastrointestinal endoscopy. that category can be granted. 3. The applicant’s endoscopic director should confirm RESPONSIBILITY FOR PRIVILEGING in writing the training, experience (including the The credentialing structure and process is the number of cases for each procedure for which priv- responsibility of each hospital. It should be the ileges are requested) and actual observed level of responsibility of the service chief to recommend competency. It is recognized that by virtue of com- individuals for privileges in gastrointestinal endos- pleting a residency program, the endoscopist will copy as for other procedures performed by members have acquired sufficient cognitive experience in of his/her department. anatomy, physiology, and disease processes, com- bined with the progressive development of visual TRAINING AND DETERMINATION OF and psychomotor skills and experience necessary COMPETENCE for the performance of diagnostic and therapeutic Formal residency training in gastroenterology or procedures in the gastrointestinal tract. Such surgery experience includes indications, complications and The Accreditation Council for Graduate Medical their management, and alternative approaches. Education has mandated that programs in surgery The training director’s opinion and recommenda- and gastroenterology must provide experience to tion should be considered prima facie evidence for each resident in the performance of esophagogastro- the trainee’s acceptance as an individual qualified duodenoscopy and colonoscopy. (Directory of in gastrointestinal endoscopy. Documentation and Residency Training Programs—Graduate Medical demonstration of competence is necessary. Education Directory 2000-2001.) NEW PROCEDURES Endoscopic training and experience outside a Self-training in new techniques in gastrointestinal formal residency program after satisfactory endoscopy must take place on a foundation of basic completion of an ACGME accredited general endoscopic skills. The endoscopist should recognize surgery, pediatric surgery, colorectal surgery, when additional training is necessary. gastroenterology, or the equivalent Equivalent training and/or experience obtained out- PROCTORING side a formal program is recognized, but must be at Recognizing the limitations of written reports, proc- least equal to that described above.4 Certification of toring of applicants for privileges in gastrointestinal 146 GASTROINTESTINAL ENDOSCOPY VOLUME 55, NO. 2, 2002 Title Author endoscopy by a qualified, unbiased staff endoscopist 4. ASGE. Proctoring for hospital endoscopy privileges. Gastro- may be desirable, specifically when competency for a intest Endosc 1999;50:901-5. given procedure cannot be adequately verified by 5. ASGE. Renewal of endoscopic privileges.

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