Credentialing and Privileging

Comprised of ten chapters, ASGE’s Policy and Procedure Reference Guide for Ambulatory Surgical Centers (ASCs) is intended to provide an organized list of ASGE guidelines that may be considered appropriate for adoption in an endoscopy facility.

Presented in chart form, the Reference Guide highlights ASGE guidelines that meet standards and conditions in the Centers for Medicare and Medicaid Services (CMS) Condition for Coverage.

For a quick summary of recommendations when reviewing any of the ASGE Guidelines we recommend going to the “Recommendations” section located at the bottom of each ASGE Guideline.

To read the overview or additional chapters, please click here.

Introduction 

Standards for credentialing and privileging for procedures within the endoscopy facility require that privileges be granted, in writing, by the governing body specifying the procedures and granted only to licensed practitioners with demonstrated competence in the procedures. The facility should document the process by which privileges are granted, including the documentation (or credentials) it reviews for each candidate, the criteria used in evaluating the candidate, how it selects the qualified medical personnel who make recommendations on the practitioner’s qualifications, and whether and under what circumstances the governing body may make a privileging decision contrary to the recommendation of the qualified medical staff.

The governing body must have a similar process reappraising the privileges granted to each endoscopist including current credentials, as well as the endoscopist’s facility-specific case record including measures employed in the facility’s quality assurance/performance improvement program. The Centers for Medicare and Medicaid Services (CMS) recommends (but does not require) the process every 24 months. The facility should also develop triggers for reappraisal of privileges outside the periodic reappraisal schedule.

For more in-depth information regarding interpretative guidance and surveyor procedures, access the CMS State Operations Manual, Guidance for Surveyors: Ambulatory Surgical Centers (Appendix L).

CMS Conditions for Coverage and Standards Related to Credentialing and Privileging 
  1. §416.45 Condition for Coverage: Medical Staff


    The medical staff of the ASC must be accountable to the governing body.

  2. §416.45(a) Standard: Membership and Clinical Privileges


    Members of the medical staff must be legally and professionally qualified for the positions to which they are appointed and for the performance of privileges granted. The ASC grants privileges in accordance with recommendations from qualified medical personnel.

  3. §416.45(b) Standard: Reappraisals


    Medical staff privileges must be periodically reappraised by the ASC. The scope of procedures performed in the ASC must be periodically reviewed and amended as appropriate.

  4. §416.45(c) Standard: Other Practitioners

    If the ASC assigns patient care responsibilities to practitioners other than physicians, it must have established policies and procedures, approved by the governing body, for overseeing and evaluating their clinical activities.
ASGE Guidelines and Recommendations Related to §416.45, §416.45(a); §416.45(b) and §416.45(c)

Issue

ASGE Guideline

ASGE Applicable Recommendations

General principles in developing policies for granting privileges.

Recommendations for specific procedures (i.e., upper endoscopy, colonoscopy, flexible sigmoidoscopy, sedation, ablative techniques and EMR, including minimum numbers to assess competency).

Guidance in developing proctoring policies and a list of components to be evaluated during assessment of endoscopy competence.

Recommendations for re-credentialing, de-credentialing and renewing endoscopic privileges. Where the document refers to the hospital setting, recommendations are appropriate for the outpatient endoscopy setting.

Training and performance of endoscopy by non-physicians.












Guidelines for Privileging, Credentialing, and Proctoring to Perform GI Endoscopy

GASTROINTEST ENDOSC 2017; 55(2): 273-2801

 

 

 

 

 

 

 

 

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Tips for Applying Recommendations from ASGE Guidelines

1. A statement should be made citing the ASGE references as recommendations from a nationally recognized specialty society that were used in the development of this reference.

2. If other nationally recognized society guidelines are also being used to develop policies and procedures, it is important to review those policies and reconcile differences so that contradictory policies are not developed.

3. The Association of Operating Room Nurses (AORN) has specific policies requiring surgical attire, staffing, and restricted areas that endoscopy facilities may not wish to adopt. In the interpretive guidelines, AORN’s standards are mentioned  as an example of nationally recognized standards. CMS surveyors, therefore, may hold facilities to those standards unless they have specifically adopted others.

4.  Documentation of the adoption of ASGE guidelines should be referenced in the meeting minutes of the organization’s governing body. The reference should include the guideline, the portion of the guideline to be adopted, and an education plan for staff and providers as needed.

Endnotes

1. CMS State Operations Manual, Guidance for Surveyors: Ambulatory Surgical Centers (Appendix L). Centers for Medicare and Medicaid Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_l_ambulatory.pdf.

2. Guidelines for Privileging, Credentialing, and Proctoring to Perform GI Endoscopy. GASTROINTEST ENDOSC 2017; 55(2): 273-280.