Continuum Health Partners
Affiliated Ambulatory Endoscopy Centers
Credentialing Policy
The policy for granting privileges at CHP’s affiliated Ambulatory Endoscopy Centers (AEC)
cover the granting of privileges to/for:
1.
2.
3.
4.
initial physicians,
new physicians,
newly introduced procedures,
periodic re-credentialing.
Privileges at the AEC will be granted separately from, and in addition to credentialing at the
affiliated hospital, where the process is under the direct purview of the Chief of
Gastroenterology. The specific privileges being granted may be different at the AEC and at
the affiliated hospital.
Initial Partners
The credentialing process for the initial group of endoscopists is as follows:
privileges can be granted immediately for procedures already being performed at
the affiliated hospital or facility, upon receipt of a procedure log. Proctoring is
not necessary for such privileges and physicians.
New Partners
The process for new physicians is as follows:
prospective physicians who completed internal medicine and fellowship training
at a CHP hospital are exempt from proctoring for cognitive and technical
competencies in internal medicine and gastroenterology, respectively subject to
the submission of appropriate documentation of prior training and case volume
for procedures completed during CHP hospital fellowship or IM rotation.. All
others will require proctoring at the discretion of the Ambulatory Endoscopy
Center’s Medical Director and relevant Division Chief, as will physicians returning
from a prolonged absence. A physician’s refusal to be proctored will result in
their not being credentialed and loss of privileges at the AEC.
Newly Introduced Procedures
The precise determination of what constitutes a ‘new procedure’ will be determined on an
individual basis by the Ambulatory Endoscopy Center’s Medical Director and relevant
Division Chief. Outside proctors will be sought if no partner has expertise with the
procedure being proctored, such as the introduction of a new technique.
Periodic Re-Credentialing
The process of re-credentialing should involve an evaluation of all competencies, not only
technical proficiency. In fact, technical proficiency is a simple estimation, as productivity is
available from the endoscopic database and endoscopic quality indicators as well as actual
complications also should be readily available. Routine proctoring is not required in the
absence of specific problems, such as when a potential practice problem is identified by the
hospital’s quality improvement or risk management programs. Continuing Medical
Education credits specifically in the fields of gastroenterology and GI endoscopy are
required or the equivalent. Documentation of a minimum of 50 Category 1 CME credits
over 2 years will be required for re-credentialing.
The re-credentialing process also will include review of 3600 evaluations. This is necessary
in part because such evaluations will no longer be available through the Hospital Centers’
evaluation process for endoscopists whose focus of activity is exclusively in the
Ambulatory Endoscopy Centers. It also should be understood that the DOP at the ASC and
at the Hospital Centers might differ, especially in providing privileges for the management
of bleeding and other GI emergencies and special procedures.
Proctoring
In terms of medical practice, a proctor is an independent and unbiased observer who is in a
position to evaluate and monitor the skills and ability of another physician. The proctor is
not a member of the treating team and may not become involved in the care of a patient.
Any partner in the Ambulatory Endoscopy Center may act as a proctor for an appropriate
procedure. The patient should be made aware that a proctor is present before entering the
endoscopy room and must consent verbally. There should be a standard form with semiquantitative measures and some form of training.
APPENDIX A
Number of Proctored Exams Required For
Credentialing an Endoscopist who Trained Elsewhere
PROCEDURE
NUMBER
REQUIRED
EGD with and without biopsy or other intervention
EGD with intervention (dilation –non achalasia)
3
2
EGD with mucosal resection
2
EGD therapeutic (non-variceal hemorrhage control)
EGD with control variceal hemorrhage banding/sclero
2
1
Esophageal dilation (bougienage with or w/o wire)
1
Percutaneous endo. gastrostomy
1
Esophageal Dilation Pneumatic for Achalasia
1
Endoluminal Stent placement
1
Colonoscopy with or w/o biopsy (total)
3
Snare polypectomy
1
Colonoscopy therapeutic (hemorrhage control,
dilation)
Small bowel Enteroscopy
2
Percutaneous liver biopsy
1
1
Blakemore/Minnesota Tube
ERCP (total)
5
ERCP sphincterotomy
ERCP Stent
3
2
EUS radial or miniprobe (total)
5
EUS linear with or w/o FNA
5
APC/Laser EGD and CF
2
Nasogastric/duod. Tube
0
Components for evaluation of endoscopy competence
• Review patients records/x-rays
• Identifies potential risk factors
• Understands indications/contraindications
• Believes findings will influence management
• Obtains proper informed consent
• Uses appropriate sedation
• Intubates gastrointestinal tract with good technique
• Correctly identifies landmarks
• Conducts thorough examination
• Detects and identifies all pathology
• Complete examination within a reasonable period
• Obtains tissue properly
• Performs therapeutic maneuvers successfully/effectively
• Recognizes and manages procedural related complications
• Prepares accurate report
• Plans correct management and disposition
• Discusses findings with patient/family and other physicians
• Arranges proper follow-up, review of pathologic finding, case outcome