The following Statement on Credentialing and Privileging and Volume Performance Issues was developed by the Credentialing and Privileging and Volume Performance Issues Workgroup of the American College of Surgeons (ACS). The ACS Board of Regents approved the statement at its February 2018 meeting in Chicago, IL.
The safety and quality of surgical procedures depend on the training, experience, and skills of the surgeon; the availability of institutional resources; and the ability to measure surgical outcomes.
Key criteria and elements of the credentialing process
Credentialing is the process of assessing the qualifications of physicians or other health care professionals. Standard objective criteria used in considering surgeons for a medical staff appointment include:
- Graduation from a liaison committee on medical education-accredited allopathic medical school, colleges of osteopathy, or recognized international medical schools
- Completion of an Accreditation Council for Graduate Medical Education or osteopathic-approved residency training program in a surgical discipline
- Licensure to practice medicine in the respective state
- Review of National Practitioner Data Bank reports of adverse events
- License to administer controlled substances at the national and state levels
- Certification by a member board of the American Board of Medical Specialties or an American Osteopathic Association specialty certifying board
- Verification of past performance (including review of adverse professional actions or terminations from all previous practice locations)
- Verification of any previous or ongoing liability claims and their outcomes
- Verification of medical liability insurance coverage
- A suitable practice/clinic environment to see patients
- Willingness to comply with institutional practice policies
- Verification of professional qualities, training, and experience, with confirmation from previous training directors and locations of practice
- Verification that the physician is free of any physical, mental, and cognitive impairment that would preclude the safe practice of surgery (including drug and alcohol dependence, disruptive conduct, and the adverse effects of aging)
Comprehensive review of peer recommendations may be part of the assessment prior to credentialing.
Key criteria and elements of the privileging process
Privileging designates the specific surgical conditions and procedures that a surgeon will be allowed to manage and perform at a health care institution. Considerable variation exists with respect to privileging practices, ranging from very broad criteria for privileges (for example, general surgery) to detailed lists (for example, privileges to operate on specific anatomical sites and perform specific procedures). Although institutional needs guide the privileging process, the institution’s surgical leadership should take the initiative in developing these criteria.
Most surgical specialties encompass a range of surgical procedures. In an era characterized by the growth of surgical subspecialties and post-residency fellowship programs, institutions may seek greater clarity in the scope of surgical privileges by defining “core” and “advanced” privileges because advanced or complex procedures are often associated with a higher risk of adverse events and may require a specific skill set and supportive services, infrastructure, and resources. These definitions may vary across institutions. Therefore, privileging criteria in a rural hospital may differ from those in a tertiary referral system. The available technologies and institutional assets (for example, operating room equipment, intensive care unit, and blood bank capabilities) define the limits of complex care delivery and thereby influence the scope of surgical practice.
Intervals at which surgical privileges are evaluated
Entry to surgical practice
Initial privileging as an independent surgeon depends on the applicant’s scope of training and clinical experience. Surgeons entering practice for the first time generally are required to pursue board certification before final credentials or privileges are recognized.
Operative and patient management experience, especially in “complex” procedures, varies widely among surgical training programs and graduates of those programs. This variability poses a challenge in the initial privileging review process, which therefore must include careful examination of the applicant’s residency/fellowship case logs. Some institutions may require specific fellowship training before awarding privileges for complex procedures.
In recent years, concerns about insufficient opportunities for independent practice in residency and fellowship have emphasized the variability in experience obtained during formal training and the need for scrutiny of the young surgeon transitioning to independent practice. Institutional privileging bodies often acknowledge this vulnerability by granting provisional privileges for a period during which focused professional practice evaluations (FPPEs) are performed, usually at six-month intervals. Initial approval for a surgeon entering independent practice to perform complex as well as core procedures may be subject not only to FPPE, but also to a more experienced co-surgeon verifying the surgeon’s readiness to perform such operations. For problematic events identified in these six-month evaluations, the surgeon should receive constructive feedback, counseling, and mentoring.
Periodic re-credentialing and re-privileging
Periodic re-credentialing and re-privileging is customary in health care environments to ensure that surgeons continue to qualify for the privileges they hold. Although the interval of review varies, many institutions use a two-year cycle. The periodic review addresses both procedural privileging and objective credentialing requirements, including maintenance of licensure, pending or closed liability claims, compliance with institutional medical record requirements, professionalism, and areas of potential concern regarding institutional quality initiatives.
Review of operative logs of surgeons reported to the American Board of Surgery and other surgical boards during the Maintenance of Certification process shows that a typical surgeon’s scope of practice often changes over time, potentially evolving to reflect local institutional needs, referral patterns, and the surgeon’s particular interest or expertise. Therefore, renewal of surgical privileges may require tailoring to a surgeon’s practice patterns and may even require FPPE or mentoring for procedures no longer frequently performed by that surgeon.
For some complex procedures, published evidence suggests that a high case volume is associated with improved surgical outcomes. However, these outcomes may reflect not only the knowledge, experience, and skill of the individual surgeon, but also the aggregate ability of the institution and hospital staff to provide high-quality care for specific groups of patients. Thus, while high case volume for a particular complex procedure is usually associated with better surgical outcomes, the two are not synonymous. It is well documented that some surgeons performing a relatively low volume of these procedures also achieve excellent outcomes. Numeric criterion for privileges in specific procedures, a value that also accounts for the circumstances in which the surgeon is practicing, likely cannot be determined.
Quality measurement systems at the surgeon-specific level remain underdeveloped, especially for uncommon complex procedures. In addition, a minimal case number threshold for the required experience of rarely performed operations or those performed for rare diseases is likely impossible to define or be meaningful. Case selection criteria, experience with procedures of similar scope and technical requirements, and examination of risk-adjusted surgical outcomes, both short- and long-term, rather than simple numbers should be considered in the process of surgical privileging. The ACS Surgeon Specific Registry (SSR) and some surgical specialty society databases (such as The Society of Thoracic Surgeons (STS) National Database) address this issue by collecting surgeon-specific, clinically relevant data along with relevant outcomes. Hospital peer-review data also can be helpful in identifying patterns of marginal performance. The institutional surgical quality and safety committee should review all available data to gauge individual surgeon performance and address areas of concern.
Because surgeons often practice at multiple locations, querying all practice locations may offer a more accurate perspective on quality of care and execution of professional responsibilities. Surgeons should share data across institutions, and unexplained discrepancies should prompt a direct request for clarification.
Privileges in new procedures and technologies
Rapidly evolving medical knowledge and technologies require that surgeons continuously acquire expertise in procedures and technologies developed subsequent to their formal training. Patient safety can be maintained only if new procedures and technologies are incorporated into clinical care in a standardized, iterative manner with thoughtful assessment of outcomes.
The ACS Division of Education has defined the principles for learning new surgical procedures and technologies and incorporating these into clinical practice as follows: mastering didactic content, technical training in an inanimate model, precepted incorporation of the new technique or technology into practice, and demonstration of satisfactory patient outcomes. Based on these principles, institutions can develop privileging criteria for new procedures and technologies for local use. A multidisciplinary committee of medical staff surgeons should review new technologies and procedures and consider the addition of a special privilege if the following criteria are met:
- The patient population needs access to the procedure
- The institution has the resources and staff expertise to offer the procedure safely and effectively
- Addition of the procedure offers needed capabilities otherwise unavailable to patients
- The procedure or technology differs enough from existing procedures to warrant a specific designation of a privilege
- Training is required before awarding a provisional privilege
Outcomes of the new procedure should be monitored and evaluated through a FPPE during a provisional trial period before granting fully independent privileges.
At present, no absolute answer for these decisions is available other than to include a procedural laboratory training requirement and a period of first supervised, then proctored practice. Generally, a training experience that includes didactic and hands-on training should be required for all new procedures. Certainly for complex procedures, proctored observation should be required. The number of cases that must be performed to maintain existing privileges also is an area of active discussion, but no absolute numbers exist. Proctors should observe surgeons in the operating room and offer unbiased opinions regarding whether a surgeon is technically competent, recognizing that this is only one component of the privileging process. For some situations, a surgical proctor may need to be brought in from another specialty already conversant in the new technique or technology or from another geographic area in person or through tele-proctoring technology.
Leading the credentialing and privileging processes
The surgical credentials committee should have a document that outlines its governance, role, and responsibilities, including an organizational chart and composition. The authority, membership, and leadership of this committee should both meet the specific needs of the institution and have adequate surgical expertise to make appropriate judgments and decisions based on deep and current knowledge of the operative environment. Essential core functions include oversight of credentialing, privileging, and FPPEs, as well as ongoing professional practice evaluations. Each of these activities should be associated with explicit criteria and based on validated, risk-adjusted data, such as the ACS SSR or the STS National Database.