Journal of Vascular Surgery
Volume 10, Issue 6 , Pages 678-682, December 1989

Guidelines for hospital privileges in vascular surgery☆☆☆

ad hoc committee to the Joint Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery

Article Outline

Abstract 

This is a report by an ad hoc committee to the Joint Council of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery (North American Chapter) concerning guidelines that hospitals may use or modify when judging individual applicants for hospital and operating room privileges in vascular surgery. The committee recognizes that the completion of training and obtaining a board certificate is testimony to the qualification but not necessarily the competence of an individual to practice vascular surgery. This report identifies three categories of applicant for privileges in vascular surgery; the surgeon who just completed training, the surgeon who completed training after 1984, and the surgeon who completed training before 1984. In addition, the committee recognizes the importance of periodic vascular surgery privileges renewal for established surgeons. Several pathways are defined for use by hospital privilege committees to evaluate the competence of an individual to be granted privileges in general vascular surgery. The ad hoc committee also has outlined a program for evaluation of established surgeons for renewing privileges in vascular surgery using a mechanism of case outcome audit. Finally, a review mechanism, potential corrective actions, and an appeals mechanism are also suggested. This report represents optimal criteria that may require modification by individual hospitals to meet local community needs and standards. It is the hope of the ad hoc committee that this report will help hospitals and practicing physicians improve the quality of care and treatment outcome in patients with vascular disease. (J Vasc Surg 1989;10:678–82.)

 

The responsibility for approving training programs in general vascular surgery rests with the Residency Review Committee (RRC) for surgery. This organization accredits training programs based on the applicant program's ability to meet certain defined standards, confirmed by inspection of the program by on site peer review. The American Board of Surgery (ABS) defines a body of knowledge that is expected among graduates of training programs in vascular surgery. It provides a certifying mechanism to determine whether an individual can meet the standards set by the ABS concerning cognitive knowledge and hypothetical case management.

Although proper training and certification are testimony to surgeons' qualifications, they do not assure competence. The ultimate determination of who should and should not practice vascular surgery in a given hospital rests with the hospital through its applicant reviewing and credentialing mechanisms. In response to numerous requests from individual hospitals to provide guidelines for vascular surgery privileges, the Joint Council of the Society for Vascular Surgery and the International Society for Cardiovascular Surgery (North American Chapter) appointed an ad hoc committee to prepare a report, which may be used as guidelines for hospitals' drafting their own criteria when granting privileges in general vascular surgery. This is the report of that committee. It is important to emphasize that this report represents optimal criteria and may require modification by individual hospitals to meet local community needs and standards. Our ultimate goal in preparing this statement is to help hospitals and practicing physicians improve the quality of care and treatment outcome in patients with vascular disease.

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Definition of vascular surgery 

Vascular surgery is a specialty that encompasses the diagnosis and treatment of diseases of the arterial, venous, and lymphatic systems exclusive of those components intrinsic to the heart and intracranial vessels.

Diagnosis includes all elements of clinical evaluation, noninvasive testing, and under certain circumstances, angiography.

Management includes both operative and non-operative treatment of disorders involving these systems. Operative treatment includes the entire spectrum of surgical procedures used to treat diseases of the circulatory system. Techniques of angioscopy, balloon angioplasty, mechanical atherectomy, and laser angioplasty are also included, as they attain a level of proven clinical applicability making them valuable as an adjunct to vascular surgical reconstruction.

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New applicants for vascular surgery privileges 

Because 1984 was the year that the American Board of Surgery first offered examination and certification in vascular surgery, applicants for vascular surgery privileges may be divided into three groups. These include surgeons who have just completed their training and are applying for surgical staff privileges for the first time; those who have been established in the practice of vascular surgery in another community or hospital and who completed their training after 1984; and those who have been established in another hospital or community and who are now relocating and are requesting privileges in vascular surgery, having completed their training before 1984.

A. Applicants for privileges who have just completed their surgical training 

To qualify for privileges in vascular surgery, the applicant should fulfill one of the following four criteria:

1.Be a graduate of a residency in vascular surgery approved by the RRC for surgery, and provide a letter from the program director attesting to satisfactory completion of the training program. It is recommended that the applicant take and pass the ABS Examination for Special or Added Qualifications in General Vascular Surgery within 3 years of graduation.

2.A second or alternate pathway for training in vascular surgery is the completion of a 1-year senior experience in vascular surgery. This can be as part of a nonapproved vascular surgery fellowship or, in some instances, a part of the general surgery residency training program in which a 1-year time block is provided to the general surgery resident at a senior level. The applicant must provide evidence of having received sufficient training and experience, equivalent to that received in a training program in vascular surgery approved by the RRC. This must include a case list documenting performance of approximately 70 category I and II arterial reconstructions representing a balanced case mix and certified by the program director.

3.Graduates from general surgery residencies without a 1-year period of vascular training who wish to practice vascular surgery should be evaluated on a case-by-case basis. Although vascular surgery is considered a primary component of general surgery, vascular surgery experience varies from program to program. Thus satisfactory completion of a general surgery residency does not guarantee proper qualifications in vascular surgery. The importance of extended training in vascular surgery is attested to by the fact that the RRC for surgery has approved programs that provide an additional year of training in vascular surgery beyond the general surgery residency, and graduates of these extended programs are provided the opportunity to be certified by the ABS. On the other hand, some general surgical programs provide a rich experience in vascular surgery. If an applicant considers himself/herself so qualified, we recommend that individual review of the applicant be carried out by the hospital credentialing committee. Such a review should include evaluation of a case list, supported by operative notes and, if possible, discharge summaries. If the applicant can document an acceptable balanced experience (a case list in excess of approximately 70 major arterial reconstructions with a broad mix) and, if the applicant receives written verification by the program director attesting to their qualifications to practice vascular surgery, then the individual may be considered as having completed the training required to obtain privileges in vascular surgery at the entry level.

4.Be a graduate of a cardiothoracic program.

It is recognized that some, although not all, programs in cardiothoracic surgery provide adequate training in general vascular surgery. For an applicant with training in cardiothoracic surgery to qualify for privileges in general vascular surgery, the applicant must provide one of the following:

1.Documentation from the program director that the program is approved by the RRC for training in general vascular surgery and that the applicant completed that portion of the program in good standing. It is recommended that the applicant take and pass the ABS Examination in General Vascular Surgery within 3 years of completing training.

2.For graduates of cardiothoracic programs that are not approved for general vascular surgery, applicants should be evaluated on a case-by-case basis. The applicant may qualify on the basis of their training in general surgery according to the criteria defined in section A2 or A3. If the individual's general surgical residency program did not meet the vascular surgery training requirements, yet the applicant considers himself/herself qualified on the basis of vascular experience obtained in a cardiothoracic program, we recommend that individual review of the applicant be carried out by the hospital credentialing committee. Such a review should include a case list, supported by operative notes and, if possible discharge summaries. If the applicant can document a rich experience (a case list of approximately 70 major arterial reconstructions with a broad mix); and if the applicant receives written verification by the program director attesting to the individual's qualification to practice vascular surgery, then the individual may be considered as having completed the training required to obtain privileges in vascular surgery at the entry level.

B. Applicants in practice who completed training after 1984 

Applicants who have completed training after 1984 may hold an ABS Certificate of Special Qualifications in General Vascular Surgery or should have, as minimal requirements, those described under paragraph A (sections 2 and 3). In addition, since these applicants will have been in practice in another hospital or community, they will have established a practice experience from which to judge skill and competence. Therefore each applicant shall submit to the credentials/privileges committee discharge summaries and operative notes from their last consecutive 50 category I vascular surgery cases or their last 2 years' consecutive case experience in managing vascular surgery problems, whichever is greater. Credential/privileges committees shall have established acceptable limits of operative morbidity and mortality for various vascular procedures, described under “Renewal of Vascular Surgery Privileges” below, and apply these criteria to each applicant. Finally, the applicant will present a letter from the chief of surgery of each hospital in which he/she currently practices or from the former hospital(s) in which they practiced, attesting that the applicant is in good standing and currently has privileges in vascular surgery.

C. Applicants completing training before 1984 

Many applicants may have completed training before 1984 when opportunities for specialized training in general vascular surgery were limited. Such individuals will have obtained experience in the management of the spectrum of vascular surgical diseases during the course of a general or cardiothoracic surgery residency but will have gained the majority of their experience during practice of general vascular surgery. Individuals who have had limited experience probably should be excluded from obtaining new privileges in general vascular surgery unless they have received additional training. Those who have had an extended experience must document their experience by the following:

1.ABS Certificate of Special Qualification in Vascular surgery, or letter(s) from chief of surgery at the hospital(s) in which they are currently practicing stating that the applicant has privileges in vascular surgery and is in good standing.

2.The applicant will submit their last 50 consecutive category I vascular surgery cases or 2 years' experience, whichever is greater, with documentation of operative notes and discharge summaries to the hospital credentials/privileges committee.

3.The credentials/privileges committee will review the case material submitted and apply audit criteria described in “Renewal of Vascular Surgery Privileges” below.

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Renewal of vascular surgery privileges 

Renewal of vascular surgery privileges by reaffirmation of competence is of equal importance to the initial granting of vascular surgery privileges. Surgeons who may have qualified, under criteria described above, may not necessarily maintain proficiency, and therefore continual review is required. Renewal of privileges should be based on experience with case outcome as the ultimate test of surgical judgment and competence. However, it should be recognized that practice and referral patterns can have both a positive and a negative impact upon outcome. For example, it is not uncommon for the most difficult and high risk cases to be referred to surgeons with the best reputation and highest levels of skill. These cases, by virtue of their complexity, will carry a higher risk of morbidity and mortality. Therefore to assure equitable comparison, categories of cases, case mix, and disease severity indexes must be comparable.

The following recommendations are made concerning renewal of vascular surgery privileges:

A. Record keeping 

The medical records department of each hospital, or equivalent as designated by hospital administration, shall maintain a continuous registry of vascular surgery cases for each surgeon credentialed in vascular surgery. Registry data should include, but not be limited to, patient age, associated diseases, indication for operation, operative procedure, duration of operation, duration of hospitalization, and outcome parameters.

B. Mechanism of audit 

Although hospital privileges are renewed on an annual basis, there should be an audit of index cases every 3 years. It is recommended that the index cases include carotid endarterectomy, elective abdominal aortic aneurysm resection, aortofemoral bypass surgery, and femoropopliteal bypass surgery.

Each index category should be based on a minimum of 75 operations. If, during a 3-year interval, there are not 75 operations in a given category, then the audit team will review the prior years' experience until the total is 75. When a surgeon has been in practice less than 3 years, the technique will be to use a running total of 75 cases by providing initially 75 complication-free cases and subtracting actual cases, as added, to maintain a moving 75-case base. For example, for carotid endarterectomy, a new surgeon will be given 75 hypothetical operations without death or stroke. As he develops his practice, each actual carotid endarterectomy he performs is added to the 75, while at the same time a hypothetical case is dropped. In this way, at any time, the stroke morbidity and mortality can be calculated on the basis of a 75-case experience.

C. Suggested method for establishing acceptable morbidity-mortality rates for index cases 

Each hospital credentials committee should assemble all of the staff surgeons who perform vascular surgery at that institution as a vascular surgery subcommittee for semiannual meetings. The current literature reporting morbidity and mortality for carotid endarterectomy, elective resection of an abdominal aortic aneurysm, aortofemoral bypass grafting, and femoropopliteal bypass grafting should be reviewed as a subcommittee assignment. An appropriate range of operative morbidity and mortality for each procedure as a function of indications should be documented. The subcommittee should then agree on an upper limit of morbidity and mortality for each procedure, beyond which results would be considered below institutional standards. These criteria would then be applied during periodic audit. Surgeons whose results fail to meet the defined acceptable standard for the institution would then be subject to review and possible corrective action.

It is suggested that for carotid endarterectomy, operative stroke morbidity and 30-day mortality be defined for subsets of operations for asymptomatic carotid stenosis, transient ischemic attacks, prior stable stroke with recover, urgent carotid endarterectomy, and recurrent carotid stenosis. For elective resection of abdominal aortic aneurysm, the audit should focus on the 30-day mortality and amputation rates. For aortofemoral bypass surgery the audit should focus on the 30-day mortality, graft limb thrombosis, and amputation rates. For femoropopliteal bypass grafting the subsets of first operation for intermittent claudication or limb-threatening ischemia must be recognized. The audit should focus on the 30-day mortality, graft thrombosis, and limb loss for each subset.

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Corrective action 

If a surgeon fails to meet acceptable institutional standards in any of the four indexed cases, his experience should be peer reviewed. The surgeon in question should have the opportunity to discuss any extenuating circumstances regarding deaths or complications. After this preliminary review, if it is the opinion of the reviewer that the surgeon has failed to meet the standard, then corrective actions may be considered. Possible committee actions might include one of the following:

A. 1-year probation with monitoring 

One or more credentialed vascular surgeons will monitor the surgeon on probation. Each of his cases will be reviewed and a second opinion rendered concerning operative indications. A credentialed vascular surgeon will observe each surgical procedure. After 1 year, results will be reviewed and opinions from the monitoring vascular surgeons will be presented to the credentials committee evaluating reinstatement.

B. Additional training alternative 

As an alternative to the period of probation, a surgeon may take a sabbatical of 6 weeks or more in a teaching unit of an academic medical center with a large vascular surgery volume. He will be expected to actively participate to upgrade judgement and skills. On return from the sabbatical, annual audits will be carried out to determine whether there has been improvement in outcome based on the prior 3-year interval audit mechanism noted above in section B.

C. Reconciliation with hospital bylaws 

Each individual hospital will need to correlate this document with its own bylaws and provisions of the Health Care Quality and Improvement Act of 1986 to obtain the substantial immunities for peer review activity provided by that act. Whereas two potential corrective actions are described above, individual hospitals may wish to add additional alternatives. For example, in particularly egregious cases, more severe corrective actions, such as termination or suspension of privileges may be warranted.

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Appeals 

Any surgeon, subject to review and corrective measures, may request a hearing with a review council consisting of three vascular surgery consultants recruited from a different community. The surgeon may request re-review of the indexed cases and may present data from the prior 3 years for comparison. The surgeon will have the opportunity to discuss specific cases with respect to extenuating or unusual circumstances affecting outcome. The review council will then vote to either uphold or rescind recommendation for corrective action.

☆ J Vasc Surg 1989;10:678–82.

☆☆ Reprint requests: Wesley S. Moore, MD, Department of Surgery, UCLA Center for the Health Sciences, Los Angeles, CA 90024-1749

PII: 0741-5214(89)90012-8

Journal of Vascular Surgery
Volume 10, Issue 6 , Pages 678-682, December 1989

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