appendix Granting Gynecologic Privileges ^24

Credentialing and granting privileges to members of its medical staff are among the most important responsibilities of any health care facility. Credentialing is a multifaceted process that involves verification of licen­sure, education and training, malpractice experience, malpractice insurance coverage, and board certification as required by the facility.

The more difficult, yet critical, aspect of this process is determining which requested privileges will be granted. Privileging defines what proce­dures a credentialed practitioner is permitted to perform at the facility. The granting of privileges is based on training, experience, and demonstrated current clinical competence. Each staff member must be assessed at the time of initial application as well as every 2 years at the time of reappraisal. In addition to routine requests for privileges, a physician also may request privileges to perform a new technology. The process of assessing current clinical competence and granting privileges is difficult and time-consum­ing, yet it is a critically necessary activity.

Although the terms “credentialing” and “privileging” often are used inter­changeably, they are different processes. Credentialing assures member­ship and comprises the aforementioned components. For privileging, there have been various approaches to setting criteria, such as the following six methods (1):

1. “Laundry list”—An applicant can specifically request procedures and conditions from a checklist.

2. Categorization—Major procedures or treatment areas are identified and classified based on complexity or the level of training.

3. Descriptive—Allows the applicant to describe the requested privileges in narrative form.

4. Delineation by codes—Privileges are requested based on diagnosis codes (from the current edition of the International Classification of Diseases, Clinical Modification system), procedure codes from Current Procedural Terminology, or grouping codes from Diagnosis- Related Group codes.

5. Combination—A hybrid of two or more of the methods described.

6. Core privileging—An alternative to the methods described. This assumes that anyone who has completed an approved residency has sufficient knowledge and technical skills to perform competently within the specialty. This method allows for consistency, flexibility, and objective screening for all applicants.

Privileges often are formatted by levels (eg, Level I, Level II, and Level III obstetric privileges and Level I, Level II, and Level III gynecologic privi­leges). As new technologies evolve, processes for granting privileges for them will need to be formulated. For a sample application for privileges, which outlines such areas as emergency situations, provisional period, and the performance of new procedures, see Appendix C. Hospitals using these materials may adapt them to conform to the specific situations at these facilities. This information is not intended to be all inclusive or exclusive. It is intended primarily for educational purposes.

Granting Privileges

The following list has been developed to aid in granting privileges to those health care providers within the facility to perform gynecologic procedures. The granting of privileges at any level in obstetrics and gynecology is based on satisfaction of criteria for the specified procedures. Criteria for grant­ing privileges must be applied consistently regardless of the applicant’s specialty. As stated, the granting of clinical privileges must be based on training, experience, and demonstrated current clinical competence. The educational requirements assume that applicants have achieved a doctor of medicine or doctor of osteopathy degree. Except as otherwise noted, prerequisites for each category of privileges are listed as follows:

Training

Successful completion of an Accreditation Council for Graduate Medi­cal Education (ACGME)-accredited residency program in obstetrics­gynecology

Certification

• Board certification (or active candidate) by the American Board

of Obstetrics and Gynecology or the American Osteopathic Board of Obstetrics and Gynecology

• Maintenance of Certification, if applicable

Reappraisal (recredentialing and reprivileging) (2-year cycle) should require:

• Review of quality improvement file

— trending

— sentinel events

— other problems with specific procedures

• Review of level of activity

— total number of cases

— total number of complications

— outcomes

If the credentials committee determines that the number of cases per­formed within the cycle is insufficient for adequately assessing compe­tency, it may recommend that the individual be proctored and evaluated for a designated period until competency is demonstrated.

I. Gynecologic Privileges

A. Level I (Basic) Gynecologic Privileges

1. Privileges may include the following:

a. Appropriate screening examination of the female, including breast examination

b. Obtaining vaginal and cervical cytology

c. Colposcopy

d. Cervical biopsy, polypectomy

e. Endometrial biopsy

f. Cryosurgery and cautery for benign disease

g. Microscopic diagnosis of urine and vaginal smears

h. Bartholin cyst drainage or marsupialization

i. Dilation and curettage for incomplete abortion

j. Vulvar biopsy

B. Level II (Specialty) Gynecologic Privileges

1. Privileges may include the following:

a. All Level I gynecologic privileges

b. Dilation and curettage, with or without conization

c. Laparotomy

d. Operations for removal of uterus, cervix, oviducts, ovaries (abdominal or vaginal), and appendix

e. Diagnostic laparoscopy

f. Diagnostic hysteroscopy

g. Tubal sterilization

h. Operations for treatment of urinary stress incontinence, vaginal approach, retropubic urethral suspension, or sling procedure

i. Fistula repairs (vesicovaginal or rectovaginal)

j. Tuboplasty

k. Hernia repair (incisional or umbilical)

l. Operations for treatment of noninvasive carcinoma of vulva, vagina, uterus, ovary, and cervix

m. Repair of rectocele, enterocele, cystocele

n. Vaginectomy (total or partial)

o. Colpocleisis

p. Strassman procedure (metroplasty)

q. Myomectomy

r. Node dissection (superficial inguinal, pelvic, or para-aortic)

s. Second-trimester abortion by medical or surgical means

C. Level III-A: Basic Endoscopic Procedures

1. Privileges may include the following:

a. All Level I and Level II gynecologic privileges

b. Endoscopic ovarian or endometrial biopsy

c.

d. Management of ectopic pregnancy (linear salpingostomy, par­tial salpingectomy)

e. Destruction of endometriosis stage I and stage II as graded by American Society for Reproductive Medicine criteria

2. Training should include successful completion of an ACGME- accredited residency program in obstetrics and gynecology

3. Certification should be required:

a. Board certification (or active candidate) by the American Board of Obstetrics and Gynecology

b. Maintenance of Certification, if applicable

4. Experience should be required:

a. The applicant must possess the proficiency and be privileged to perform the requested procedures in an open (laparotomy) manner

b. The applicant should have been granted privileges to perform basic (Level III-A) endoscopic procedures and should have demonstrated competency in these techniques

D. Level III-B: Advanced Endoscopic Procedures

1. Privileges may include the following:

a. All Level I and Level II gynecologic privileges

b. Laparoscopically assisted vaginal hysterectomy

c. Ovarian cystectomy

d. Salpingo-oophorectomy

e. Adhesiolysis

f. Management of endometriosis, stage III and stage IV

g. Division of the Uterosacral ligaments

h. Appendectomy

i. Operative hysteroscopy requiring use of the resectoscope (division or resection of the uterine septum, surgical treatment of Asherman syndrome, resection of uterine myomas)

j. Myomectomy

k. Pelvic lymphadenectomy

l. Pelvic sidewall dissection

m. Ureteral dissection

n. Presacral neurectomy

o. Dissection of obliterated pouch of Douglas

p. Hernia repair

q. Retropubic bladder neck suspension

r. Sling procedure

s. Bowel surgery

t. Total hysterectomy

u. Supracervical hysterectomy

2. Also required is successful completion of advanced training that includes training in listed procedures, or documented course, including didactic and hands-on laboratory experience, unless included in residency program.

3. Experience should include advanced procedures, which require the following additional training and documentation:

a. Completion of a postgraduate course, accredited by the ACGME that includes didactic training (must include educa­tion on equipment operation and safety factors) and hands-on laboratory experience, and

b. If the privileges requested were not included in residency train­ing, the applicant must follow the requirements for a precep­torship as discussed under the section for “Requests for New Privileges.”

c. In the event that credentials in advanced endoscopy are already established at a different hospital, the applicant must present evidence of these established credentials in lieu of (a) and (b) above. In addition, the applicant must provide a list of cases performed over the past 24 months, including preoperative and postoperative diagnoses, procedure, type of endoscope used, outcome, and complications of the procedure.

d. A letter from the director of an approved residency program can substitute for (a) and (b) above. In addition, this new residency graduate must provide a list of advanced endoscopy cases performed over the past 24 months.

E. Level III-C: Gynecologic Oncology

1. Privileges may include the following:

a. All Level I and Level II gynecologic privileges

b. Treatment of malignant disease with chemotherapy

c. Radical hysterectomy for treatment of invasive carcinoma of the cervix and uterus

d. Radical surgery for treatment of gynecologic malignancy to include procedures on bowel, ureter, bladder, pelvic or abdom­inal organs, as indicated

e. Treatment of invasive carcinoma of vulva by radical vulvec­tomy

f. Treatment of invasive carcinoma of the vagina by radical vagi­nectomy and other appropriate surgery

g. Pelvic, periaortic, and inguinal lymphadenectomy and recon­structive surgery of pelvis and external genitalia

2. Training also should include documentation of specialized post­residency training, experience, or subspecialty certification by the American Board of Obstetrics and Gynecology.

F. Level III-D: Assisted Reproductive Techniques

1. Privileges may include:

a. Gynecologic Level I, Level II, Level III-A, and Level III-B

b. In vitro fertilization and gamete intrafallopian transfer

c. Monitoring of ovulation induction and intrauterine insemina­tion

d. Management of ovarian hyperstimulation

2. Training should also include the following:

a. Documentation of training and experience in reproductive endocrinology and pelvic reproductive surgery, including expe­rience in operative laparoscopic procedures, and

b. Documentation of training and experience with in vitro fer­tilization-embryo transfer and gamete intrafallopian transfer procedures.

3. Subspecialty certification (or active candidate) by the American Board of Obstetrics and Gynecology in reproductive endocrinology and infertility also may be considered.

4. Experience should require demonstrating knowledge of all aspects of assisted reproductive techniques.

G. Level III-E: Laser Therapy

1. Privileges may include the following:

a. Laser therapy for cervix, vagina, vulva, and perineum (col- poscopically directed)

b. Conization of cervix

c. Lysis of adhesions and photocoagulation (intraabdominal “free hand use”)

d. Lysis of adhesions and photocoagulation (microscopically directed)

e. Oncologic debulking procedures (intraabdominal “free hand use”)

2. Training should also include the following:

a. Documentation of laser training from a residency program director, attesting to the completion of at least 8 hours of observation and hands-on involvement, or

b. Documentation of a laser training course, including laser physics, safety, indications and complications, and hands-on experience

3. Experience should include the following:

a. Level II gynecologic privileges, and

b. Laser privileges as defined on the hospital-wide laser privilege request form

H. Level III-F: Endometrial Ablation

1. Privileges may include the following:

a. Laser ablation

b. Electrosurgical ablation

c. Thermal balloon ablation

d. Other techniques

2. Training should also include additional training for the following procedures:

a. Laser ablation

(1) Documentation from residency program director, attesting to hands-on involvement and competence, or

(2) Documentation of an operative hysteroscopy and laser ablation of the endometrium course, including laser physics, safety, indications and complications, and hands-on experience

b. Electrosurgical ablation

(1) Documentation from residency program director, includ­ing at least 8 hours of observation and hands-on involve­ment, or

(2) Documentation of competency and demonstration of hands-on experience in operative hysteroscopy with endometrial rollerball

c. Thermal balloon ablation

(1) Documentation from residency program director, attesting to the completion of at least 8 hours of observation and hands-on involvement, or

(2) Documentation of competency and demonstration of hands-on experience

3. Experience should include proficiency in diagnostic hysteroscopy if laser or electrosurgical ablation is performed

II. Gynecologic Privileges for Family Physicians

A. Privileges may include the following:

1. Appropriate screening examination of the female, including breast examination

2. Obtaining vaginal and cervical cytology

3. Colposcopy

4. Cervical biopsy, polypectomy

5. Endometrial biopsy

6. Cryosurgery and cautery for benign disease

7. Microscopic diagnosis of urine and vaginal smears

8. Bartholin duct cyst drainage or marsupialization

9. Vulvar biopsy

B. Family physicians requesting these privileges must demonstrate the following:

1. Successful completion of gynecologic training as delineated in the special requirements for residency training in Family Medicine by the ACGME

2. If transferring from another institution, documentation of current competence as supported by ongoing clinical practice and quality review data

3. Maintenance of board certification (or active candidate) by the American Board of Family Medicine

Requests for New Privileges

Physicians also may request new privileges for added skills or qualifica­tions or after a period of inactivity. Privileges for new skills should only be granted when the appropriate training has been completed and docu­mented and the competency level has been achieved with adequate super­vision. Proof of attendance at a postgraduate training course in a new technology or procedure is not sufficient to demonstrate competence in the performance of such procedures. In addition, the National Practitioner Data Bank must be queried whenever physicians request new privileges outside of the normal reappointment credentialing process.

When physicians request re-entry after a period of inactivity, a general guideline for evaluation would be to consider the physician as any other new applicant for privileges. An underlying assumption is that physicians do not necessarily lose competence in all areas of practice with time. A re­entry program should target those areas in which physicians are more likely to have lost relevant skills or knowledge, or in which skills and knowledge need to be updated (2). It is extremely important for physicians consider­ing a leave of absence or major change in practice activities to think in advance about options should they wish to return. At a minimum, licen­sure and continuing medical education activities should be maintained. Working part-time during an absence helps to maintain a minimal amount of competency.

For more information on granting privileges for added skills or qualifi­cations or after a period of inactivity, please see the “Evaluating Credentials and Granting Privileges” section in Part 1. See also Appendix C for a sample application for gynecologic privileges.

References

1. Cairns CS. Core privileges: a practical approach to development and imple­mentation. 3rd ed. Marblehead (MA): HCPro; 2005. ^

2. American Medical Association. Physician reentry. Report 6 of the Council on Medical Education (A-08). Chicago (IL): AMA; 2008. Available at: http://www. ama-assn.org/ama1/pub/upload/mm/377/cmerpt_6a-08.pdf. Retrieved July 10, 2013.