Guidelines for Privileging and Credentialing Physicians in Gastrointestinal Endoscopy SAGES Guidelines Committee [Insert Author Address information here] Admin Group Outline: Working draft Update from 2002 and 2007 Guideline Preamble These guidelines for granting privileging in gastrointestinal endoscopy are intended to assist and provide practical guidance to hospital, ambulatory facility or other credentialing committees in their task of granting privileges for flexible gastrointestinal endoscopy. Privileging in flexible gastrointestinal endoscopy should be based on demonstration of competency in these techniques. Privileges should be separately granted for each major category of endoscopy (i.e. upper endoscopy, enteroscopy, biliopancreatic endoscopy, sigmoidoscopy, colonoscopy, etc.) as the ability to perform one endoscopic procedure does not imply competency to perform others. Many operative procedures require intraoperative endoscopy and credentialing for these endoscopic procedures should be included in the credentialing for the surgical procedure. Initial credentialing should be followed by measurement and monitoring of quality metrics by the local credentialing organization and the renewal of privileges should be based on adherence to established quality metrics, practice recommendations, and clinical outcomes. Disclaimer Guidelines are intended to indicate preferable approaches to medical problems as established by experts in the field. These recommendations are based on existing data or a consensus of expert opinions when little or no data are available. These guidelines are applicable to all physicians who perform flexible gastrointestinal endoscopy without regard to medical specialty, training pathway, or practice interests. They are intended to indicate the preferred approach, but not necessarily the only acceptable one, due to the complexity of the healthcare environment. Guidelines are intended to be flexible. Given the wide range of specifics in any health care system, the local credentialing committee must always choose the course best suited to the variables in existence at the time of the credentialing decision. Each guideline below has been systematically researched, reviewed and revised by the guidelines committee. The recommendations are therefore considered valid at the time of production based on the available data. Each guideline is scheduled for periodic review to allow incorporation of pertinent new developments in medical research, knowledge and practice. Literature Review Methodology These guidelines are the product of a systematic review of published literature and recommendations are linked to the supporting evidence. The GRADE system was used to evaluate the strength and weakness of available evidence and expert opinion referred to only where evidence was lacking [1]. A systematic literature search using PubMed, Medline, and Cochrane Databases was done between October 2011 and September 2015. Search strategy was limited to adult human studies in English. The relevance of each study was assessed and those not relevant were dismissed. Keywords Colonoscopy, gastrointestinal endoscopy, upper endoscopy, credentialing, competence, competency, surgeons, quality, training, privileges, privileging, surgical education, endoscopy training, intraoperative endoscopy, simulation. Years 1992 to 2015 included Study Randomized trials, meta-analyses, systematic reviews, types prospective, retrospective, editorials, existing and past guidelines Dates of October 2011 to September 2015 review Reviewers manually searched bibliographies to identify any missed additional articles and then graded the level of evidence. UNIFORMITY OF STANDARDS Uniform standards should be developed that apply to all physicians requesting privileges to perform endoscopy and to all practice environments in which endoscopy is performed. Evidenced-based criteria must be applied to all those requesting endoscopy privileges. The goal must be to grant endoscopy privileges to all physicians with proper training and experience, thereby ensuring the delivery of high- quality and safe patient care. RESPONSIBILITY FOR PRIVILEGING The credentialing structure and process is the responsibility of each health care facility and its credentialing body. It should be the responsibility of an appropriate local leader (e.g. chief of surgery, chief of gastroenterology, or director of endoscopy) to recommend that an individual receive privileges in gastrointestinal endoscopy. These recommendations are then subject to evaluation for approval by the appropriate institutional credentialing body. This document is intended to be used in conjunction with standard state or national criteria for granting hospital privileges and with requirements for delivering safe and high quality patient care. MINIMUM REQUIREMENTS FOR GRANTING PRIVILEGES Guideline: Eligibility for credentialing in endoscopy requires completion of a program that includes formal training in gastrointestinal endoscopy. The fields of surgery and gastroenterology are structured such that successful completion of a formal training program grants permission to enter into independent clinical practice. Therefore, completion of the training program implies basic competence in that field. Current requirements for completion of general surgery residency or gastroenterology fellowship include performance of a minimal number of endoscopic procedures, acquisition of core knowledge of gastrointestinal diseases encountered during endoscopy, and demonstration of competent endoscopy skills as determined by the program director. Governing bodies have recently adjusted the requirements for residency programs. The Accreditation Council for Graduate Medical Education has mandated that programs in general surgery and gastroenterology provide experience to each resident or fellow in the performance of esophagogastroduodenoscopy and colonoscopy [2, 3]. Surgery residents are required to complete at least 50 colonoscopies and 35 upper endoscopy procedures. The American Board of Surgery requires trainees to complete a dedicated flexible endoscopy curriculum and to successfully complete the Fundamentals of Endoscopic Surgery program prior to sitting for their Qualifying Examination. By completing a formal training program, the endoscopist will have acquired sufficient cognitive experience in anatomy, physiology, and disease processes to manage gastrointestinal diseases. Training programs that include endoscopy must ensure progressive development of visual and psychomotor skills necessary for safe and effective performance of procedures. Completion of a training program makes one eligible for credentialing in endoscopy, although individual programs may impose additional requirements to grant unrestricted privileges in endoscopy. Guideline: Efficiency in endoscopy increases with increasing experience, but quality measures and complication rates are not related to specialty, experience, or case volume. Endoscopy procedure completion rates, complication rates, and other quality metrics are comparable between different specialties performing endoscopy (general surgery, gastroenterology, colorectal surgery). Although improved efficiency is noted with increasing experience, there is no difference in safety, complication rates, or completion rates as more procedures are performed. [4-7]. A recent study of over 10,000 colonoscopies indicates that having accreditation and a volume of over 100 colonoscopies per year were the most important factors for achieving quality standards. Surgeons had a slightly higher adenoma detection rate (ADR) and physicians a slightly higher cecal intubation rate (CIR) but these differences were not significant and polyp detection rate and complications were equivalent [8]. One study indicates that colonoscopy performed in a hospital by a non- gastroenterologist is a risk factor for interval development of colon cancer [9]. In this same study however, when the colonoscopy was performed in an outpatient setting, there was no difference in interval cancer rate between specialties of endoscopist. This may reflect the benefits of more extensive training in challenging colonoscopies. A large recent study of almost 60,000 colonoscopies showed no difference in quality outcomes according to specialty (internists, surgery, other) or setting (hospital or office). There were minor insignificant differences with hospital based internists having a higher flat polyp detection rate and lower carcinoma detection rate than office- based internists and surgeons having a lower complication rate than internists. They concluded that having a standard quality monitoring program was the biggest indicator of good outcomes [10]. Training programs in general surgery, gastroenterology and colorectal surgery have differing requirements for minimal endoscopic case numbers. Given the comparable outcomes in endoscopy cases, a variety of different training pathways can be expected to produce competent and safe endoscopists. As such, case volume alone is not a valid predictor of competence in flexible endoscopy. Differences in the minimum procedure requirements of training programs should therefore not be used to support or refute credentialing of an individual endoscopist. Satisfactory completion of a training program’s minimum case requirements does not, in and of itself, ensure competency. Physicians learn at different rates and possess different psychomotor skill sets at baseline. Individual variation in ability and learning pattern