GUIDELINES FOR INSTITUTIONS GRANTING PRIVILEGES UTILIZING LAPAROSCOPIC AND/OR THORACOSCOPIC TECHNIQUES

I.PRINCIPLES OF PRIVILEGING

PREAMBLE

The society of American Gastrointestinal Endoscopic Surgeons (SAGES) recommends the following guidelines for privileging qualified surgeons in the performance of surgical procedures utilizing laparoscopy and/or thoracoscopy alone, or in a hybrid fashion with hand or robotic assistance. The basic premise is that the surgeon(s) must have the judgment and training to safely complete the procedure as intended, as well as have the capability of immediately proceeding to a traditional open procedure when circumstances so indicate.

A. PURPOSE

The purpose of this statement is to outline principles and provide practical suggestions to assist healthcare institutions when granting privileges to perform procedures utilizing laparoscopy and/or thoracoscopy. In conjunction with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) guidelines for granting hospital privileges, implementation of these methods should help hospital staffs ensure that laparoscopic and/or thoracoscopic surgery is performed in a manner assuring high quality patient care and proper procedure utilization.

B. UNIFORMITY OF STANDARDS

Uniform standards should be developed which apply to all medical staff requesting privileges to perform procedures utilizing laparoscopy and/or thoracoscopy. Criteria must be established which are medically sound, but not unreasonably stringent, and which are universally applicable to all those wishing to obtain privileges. The goal must be the delivery of high quality patient care. Surgical proficiency should be assessed for every surgeon, and privileges should not be granted or denied solely based on the number of procedures performed.

C. RESPONSIBILITY FOR PRIVILEGING

The privileging structure and process remain the responsibility of the institution at which privileges are being sought. It should be the responsibility of the department of surgery, through its chief to recommend privileges for individual surgeons to perform laparoscopic and/or thoracoscopic procedures. These recommendations should then be approved by the appropriate institutional committee, board, or governing body.

D. DEFINITIONS

MUST/SHALL - Mandatory recommendation

SHOULD - Highly desirable recommendation

MAY/COULD - Optional recommendation; alternatives may be appropriate

DOCUMENTED TRAINING AND EXPERIENCE¹ - Case list that must specify the applicant’s role (primary surgeon, co-surgeon, first assistant, chief resident, junior resident or observer). Complications, outcomes, and conversion to traditional techniques should be included if known. The applicant must specify if these details are not known². Summary letter from preceptor and/or program director and/or chief of surgery (should state if applicant can independently and competently perform the procedure in question).

PRIVILEGING - The process whereby a specific scope and content of patient care services (that is, clinical privileges) are authorized for a health care practitioner by a health care organization based on evaluation of the individual’s credentials and performance.

COMPETENCE OR COMPETENCY - A determination of an individual’s capability to perform up to defined expectations.

CREDENTIALS - Documented evidence of licensure, education, training, experience, or other qualifications.

COMPLETE PROCEDURAL CONDUCT - Competency of the applicant and/or institution regarding patient selection, peri-procedural care, conduct of the operation, technical skill and equipment necessary to safely complete procedure using laparoscopic and/or thoracoscopic techniques, and the ability to proceed immediately with the traditional open procedure.

LAPAROSCOPY AND THORACOSCOPY - Specialized areas within the field of surgery, which require unique knowledge and set of skills related to the equipment, physiology, and operative technique, whether the procedure is performed inside or outside of the traditional operating room.

FORMAL COURSE - A formal course alone is not appropriate training to begin performing a procedure independently. This is a limited period of instruction that should offer category I Continuing Medical Education (CME) credits that meet American Medical Association (AMA) standards. The course should be taught by instructors with appropriate clinical experience, and have a curriculum that includes didactic instruction as well as hands on experience utilizing inanimate and/or animate models. The course director and/or instructor should provide a written assessment of the participant’s mastery of course objectives. Documentation for certain courses consisting of only didactic instruction may consist of verification of attendance.

II. MINIMUM REQUIREMENTS FOR GRANTING PRIVILEGES

Part II A is mandatory, and must be accompanied by either part II B, II C, or at least one component of part II D.

A. FORMAL RESIDENCY TRAINING IN GENERAL AND/OR THORACIC SURGERY

Prerequisite training must include satisfactory completion of an accredited surgical residency program, with subsequent certification by the American Board of Surgery as required by the institution. The residency program must be accredited by the Accreditation Council for Graduate Medical Education or the equivalent body if the program is based outside the United States or Canada.

B. FORMAL TRAINING IN LAPAROSCOPYAND/OR THORACOSCOPY

For surgeons who successfully completed a residency and/or fellowship program that incorporated a structured experience in laparoscopic and/or thoracoscopic surgery, the applicant’s program director, and if desired other faculty members, should supply the appropriate documentation of training.

C. NO FORMAL RESIDENCY TRAINING IN LAPAROSCOPY OR THORACOSCOPY

For those surgeons without residency and/or fellowship training, which included structured experience in laparoscopic and/or thoracoscopic surgery, or without documented prior experience in these areas, a structured training curriculum is required. The curriculum should be defined by the institution, and may include a formal course. The curriculum should include an appropriate number of opportunities for the applicant to observe, assist, and serve as primary operator for the procedure for which privileges are being sought. The curriculum should include didactic sessions and hands-on experience with inanimate and/or animate models. Other teaching aids may include video review and interactive computer programs.

D. PRACTICAL EXPERIENCE

1. Applicant’s Experience – Documented experience that includes an appropriate volume of cases equivalent to the procedure in question in terms of complexity. The chief of surgery should determine the appropriateness of this experience. (Two surgeons, already skilled in laparoscopy and/or thoracoscopy working together may be more appropriate in this situation rather than a single surgeon working with an inexperienced assistant.)
2. Complimentary Experience - Two surgeons (applicant and first assistant or co-surgeon) with combined expertise in the complete procedural conduct. (i.e. one surgeon skilled in laparoscopy and/or thoracoscopy, the other surgeon skilled in the traditional open technique).
3. Experience with Preceptor and/or Proctor - The specific role and qualifications of the preceptor and/or proctor, if required, must be determined by the institution. Criteria of competency for each procedure should be established in advance, and should include evaluation of: familiarity with instrumentation and equipment, competence in their use, appropriateness of patient selection, clarity of dissection, safety, and successful completion of the procedure. The criteria should be established by the chief of surgery in conjunction with the specific specialty chief where appropriate. It is essential that proctoring be provided in an unbiased, confidential, and objective manner.

III. INSTITUTIONAL SUPPORT

If the particular procedure in question requires a significant amount of supporting infrastructure vital to the complete procedural conduct of the operation in question, it is incumbent on the institution to have this support in place prior to beginning the procedure (e.g., bariatric, cardiac, and transplant surgery).

IV. MAINTENANCE OF PRIVILEGES

A. PROVISIONAL PRIVILEGES

Once competence has been determined, a period of provisional privileges may be appropriate. The time frame and/or number of cases required during this period should be determined by the chief of surgery and/or the appropriate institutional committee, board, or governing body.

B. MONITORING OF PERFORMANCE

Once privileges have been granted, performance should be monitored through existing quality assurance mechanisms at the institution. These mechanisms may be modified as appropriate, and should evaluate outcomes, as well as competency in the complete procedural conduct.

C. CONTINUING MEDICAL EDUCATION

Continuing medical education related to laparoscopic and/or thoracoscopic surgery should be required as part of the periodic renewal of privileges. Attendance at appropriate local, national or international meetings and courses is encouraged.

D. RENEWAL

An appropriate level of continuing clinical activity should be required. This should include review of quality assurance data, as well as appropriate CME activity, in addition to existing mechanisms at the institution designed for this purpose.

E. DENIAL OF PRIVILEGES

Institutions denying, withdrawing, or restricting privileges should have an appropriate mechanism for appeal in place. The procedural details of this should be developed by the institution, and must satisfy the institution’s bylaws and JCAHO recommendations.

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REFERENCES

1. Dent T.L.: Clinical privileges for laparoscopic general surgery. American Journal of Surgery, 161:399-403 March 1991

2. E.A.E.S. Guidelines: Training and Assessment of Competence- Surgical Endoscopy, 8:721-722, 1994

3.Greene, F.L.: Training Credentialing and Privileging for minimally invasive surgery. Problems in General Surgery 8:502-506, 1991

4. Jakimowicz, J.: The European Association for Endoscopic Surgery, Recommendations for Training in Laparoscopic Surgery- Annals Chirugiae at Gynaecologiae, 83:137-141, 1994

5. Laparoscopic surgery, New York State Department of Health Memorandum- Series 92-20, Albany, New York, June 12, 1992

6. Ooi, L.L.P.J.: Training in Laparoscopic Surgery- Have we got it right yet?- Annals Academy of Medicine, 25:732-736

7.Wexner, S.D. & Weiss, E.G.: A Recommended Training Schema for Laparoscopic Surgery, - The Future of Laparoscopy in Oncology/Surgical Oncology Clinics of North America- Volume 3, No.4, 759-765, October 1994

8. Wexner, S.D. & Weiss, E.G. : Training and Preparation for Laparoscopic Colectomy, - Seminars in Colon & Rectal Surgery, Volume 5, No.4, 224-227, December 1994

9. SAGES: Granting of Privileges for Laparoscopic General Surgery, American Journal of Surgery 161:324-325, 1991

10. Schwaitzberg, S.D.; Connolly, R.J.; Sant, G.R.; Reindollar, R. and Cleveland, R.J.; Planning, Development, and Execution of an International Training Program in Laparoscopy, Volume 6, No.1, 10-15, 1996

11. See, W.A.; Cooper, C.S.; Fisher, R.J.; Predictors of Laparoscopic Complications after Formal Training in Laparoscopic Surgery- JAMA, Volume 270, No.22, December 8, 1993

12. JCAHO 2001 Automated Comprehensive Accreditation manual for hospitals, Update 2-May 2001.

13. Society of American Gastrointestinal Endoscopic Surgeons. Framework for post-residency surgical education and training a SAGES guideline. SAGES Publication #0017, printed January, 1994, Published in SURGICAL ENDOSCOPY 8:9 (SEPT/94) P.1137-1142

This statement was reviewed and approved by the Board of Governors of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) June, 2001. It was prepared by the SAGES Committee on Credentialing.

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Requests for reprints should be sent to:

Society of American Gastrointestinal Endoscopic Surgeons (SAGES)
11300 West Olympic Blvd.
Suite 600
Los Angeles, CA 90064
Phone: (310) 437-0544
Fax: (310) 437-0585
E-mail: sagesweb@sages.org

This is a revision of SAGES publication #0005 printed 05/90 and of SAGES publication #0014 printed 01/92, 10/92 and 10/97 entitled: Guidelines For Granting Of Privileges for Laparoscopic And/Or Thoracoscopic General Surgery.

 

 

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