Joint Statement by the American Society for Gastrointestinal , the Society of American Gastrointestinal Endoscopic , and the American Society of Colorectal Surgeons

Principles of privileging and credentialing for endoscopy and

Granting privileges for GI endoscopy should be substantiated by documentation provided by the applicant from 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 -accredited or and for an assessment of training program in adult or pediatric gastroenterol- endoscopic skill after a threshold number of proce- ogy, , 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 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 endo- scopic procedure for which privileges are requested. UNIFORMITY OF STANDARDS It is no longer acceptable for 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 equiva- lent 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, , 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. Gastrointest Endosc 5 1999;49:823-5. submitted written material. The procedural details 6. ASGE. Methods of privileging for new technology in gastroin- of proctoring should be developed by the credential- testinal endoscopy. Gastrointest Endosc 1999;50:899-900. ing body of the hospital and provided to the appli- cant. Proctors may be chosen from existing endos- ADDITIONAL READING copy staff or solicited from endoscopic societies. The 1. Anderson ML, Heigh RI, McCoy GA, Parent K, Muhm JR, proctor should be responsible to the credentials com- McKee GS, et al. Accuracy of assessment of the extent of mittee, and not to the patient or to the individual examination by experienced colonoscopists. Gastrointest Endosc 1992;38:560-3. being proctored. Documentation of the proctor’s 2. Barthel J, Hinojosa T, Shah N. Colonoscope length and proce- evaluation should be submitted in writing to the dure efficiency. J Clin Gastroenterol 1995;21:30-2. credentials committee. Criteria of competency for 3. Chak AM, Cooper GS, Blades EW, Canto M, Sivak MV Jr. each procedure should be established in advance. It Prospective assessment of colonoscopic skills in trainees. Gastrointest Endosc 1996;44:54-7. is essential that proctoring be provided in an unbi- 4. Church JM. Complete colonoscopy: how often? And if not, why ased, confidential, and objective manner. A satisfac- not? Am J Gastroenterol 1994;89:556-60. tory mechanism for appeal must be established for 5. Cosgrove JM, Cohen JR, Wait RB, Margolis IB. Endoscopy individuals for whom privileges are denied or grant- training during general surgery residency. Surg Laparosc ed in a temporary or provisional manner. Endosc 1995;5:393-5. 6. Galandiuk S. A surgical subspecialist enhances general sur- MONITORING OF ENDOSCOPIC PERFORMANCE gical operative experience. Arch Surg 1995;130:1136-8. 7. Gruber M. Performance of flexible by a clinical To assist the hospital credentialing body in the nurse specialist. Gastroenterol Nurs 1996;19:105-8. ongoing renewal of privileges, a mechanism should 8. Hasseman JH, Lemmel GT, Emad RY, Douglas RK. Failure of colonoscopy to detect : evaluation of 47 cases be in place whereby each endoscopist’s procedural in 20 hospitals. Gastrointest Endosc 1997;45:451-5. performance is monitored.6 This should be done 9. Jentschura D, Raute M, Winter J, Henkel TH, Kraus M, through existing quality assurance mechanisms or, Manegold BC. Complications in endoscopy of the lower gas- alternatively, through a multidisciplinary endoscopy trointestinal tract ( and prognosis). Surg Endosc committee. This should include monitoring endo- 1994;8:672-6. 10. Marshall JB. Technical proficiency of trainees performing scopic utilization, diagnostic and therapeutic bene- colonoscopy: a learning curve. Gastrointest Endosc 1995;42: fits to patients, complications, and tissue review in 287-91. accordance with previously developed criteria. 11. Parry BR, Williams SM. Competency and the colonoscopist: a learning curve. Aust N Z J Surg 1991;61:419-22. CONTINUING EDUCATION 12. Rai S, Moran MR, Rai AM. Are performed by subspecialists more expensive? [abstract]. Dis Colon Rectum Continuing medical education related to endoscopy 1996;39:A2. should be required as part of the periodic renewal of 13. Saad, JA, Pirie P, Sprafka JM. Relationships between flexible endoscopic privileges. Participation in local, national sigmoidoscopy training during residency and subsequent sig- or international meetings and courses is encouraged. moidoscopy performance in practice. Fam Med 1994;26:250-3. 14. Wexner SD, Garbus JE, Singh JJ, the SAGES Colonoscopy Outcomes Study Group. A prospective analysis of 13,580 THE RENEWAL OF PRIVILEGES colonoscopies. Reevaluation of credentialing guidelines. Surg For the renewal of privileges an appropriate level of Endosc 2001;15:251-61. continuing clinical activity should be required, in addi- 15. Wexner SD, Forde KA, Sellers G, Geron N, Lopes A, Weiss EG, et al. How well do surgeons perform colonoscopy? Surg tion to satisfactory performance as assessed by moni- Endosc 1998;12:1410-4. toring of procedural activity through existing quality 16. Wigton RS, Blank LL, Monsour H, Nicolas JA. Procedural assurance mechanisms as well as continuing medical skills of practicing gastroenterologists: a national survey of education relating to gastrointestinal endoscopy. 700 members of the American College of Physicians. Ann Int Med 1990;113:540-6. REFERENCES 17. Parry BR, Williams SM. Competency and the colonoscopist: a learning curve. Aust N Z J Surg 1991;61:419-22. 1. ASGE. Guidelines for credentialing and granting privileges 18. Cass OW, Freeman ML, Cohen J, Zuckerman G, Watkins J, for gastrointestinal endoscopy. Gastrointest Endosc 1998;48: Nord J, et al. Acquisition of competency in endoscopic skills 679-82. (ACES) during training: a multicenter study [abstract]. 2. ASGE. Principles of training in gastrointestinal endoscopy. Gastrointest Endosc 1993;43:308. Gastrointest Endosc 1999;49:845-53. 19. Cass OW, Freeman ML, Peine CJ, Zera R, Onstad GR. 3. ASGE. Statement on role of short courses in endoscopic train- Objective evaluation of endoscopic skills during training. Ann ing. Gastrointest Endosc 1999;50:913-4. Intern Med 1993;118:40-4. 3. ASGE. Alternative pathways to training in gastrointestinal 20. Galandiuk S, Ahmad P. Impact of sedation and resident teach- endoscopy. Gastrointest Endosc 1996;43:658-60. ing on complications of colonoscopy. Dis Surg 1998;15:60-3.

VOLUME 55, NO. 2, 2002 GASTROINTESTINAL ENDOSCOPY 147 Author Title

Prepared by: Anthony Kalloo, MD SAGES Credentials Committee Bret Peterson, MD Steven D. Wexner, MD, Chair Hareth Raddawi, MD Demitrius Litwin, MD Michael Ryan, MD Jeffrey Cohen, MD John Vargo, MD David Earle, MD Harvey Young, MD George Ferzli, MD ASCRS Standards Committee James Flaherty, MD Clifford Simmang, MD, Chair Scott Graham, MD Neil Hyman, MD Santiago Horgan, MD Theodore Eisenstat, MD Brian L. Katz, MD Thomas Anthony, MD Michael Kavic, MD Peter Cataldo, MD John Kilkenny, MD James Church, MD John Meador, MD Jeff Cohen, MD Raymond Price, MD Frederick Denstman, MD Brian Quebbemann, MD Edward Glennon, MD William Reed, MD John Kilkenny, MD Lelan Sillin, MD John McConnell, MD Gary Vitale, MD Juan Nogueras, MD E. S. Xenos, MD Charles Orsay, MD ASGE Standards of Practice Committee Daniel Otchy, MD Glenn M. Eisen, MD, Chair Ronald Place, MD Jason Dominitz, MD Jan Rakinic, MD Douglas Faigel, MD Paul Savoca, MD Jay Goldstein, MD Joe Tjandra, MD

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