Guidelines for hospital privileges in vascular surgery☆
Article Outline
- Responsibility for granting hospital privileges
- Definition of vascular surgery
- Evaluation of the new applicant for hospital privileges
- Renewal of hospital privileges in vascular surgery
- Management of the surgeon in noncompliance
- References
- Copyright
One of the important elements of a quality assurance program in vascular surgery is the identification of those surgeons who are both qualified and competent to perform vascular surgery for purposes of granting hospital privileges. The corollary to that statement implies that there may be surgeons who are deficient in qualification or competence or both and should be denied hospital privileges for the performance of vascular operations.
This issue has been addressed in depth by an ad hoc committee of the Joint Council of the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery in a report subsequently published in the JOURNAL OF VASCULAR SURGERY.1 The readers are referred to that article for an in-depth discussion. However, since the issue of hospital privileges represents a key component to this quality assurance symposium, this article will summarize the important points of the original publication and will expand the issue of renewal of hospital privileges and methods for hospital monitoring of performance.
Responsibility for granting hospital privileges
Many surgeons who have spent long years in training, including subspecialty training, and have successfully passed examinations leading to certification in their specialty, are of the opinion that the completion of these hurdles represents sufficient documentation of expertise to be granted hospital and operating room privileges for the performance of their specialty. Such is not the case. Although the quality of training programs in surgery and general vascular surgery is carefully monitored by the Residency Review Committee (RRC) for surgery, and the definition of the body of knowledge combined with an examination process is managed by the American Board of Surgery, completion of a training program and successful passing of an examination only represent testimony to the surgeon's qualifications. They do not guarantee competence. The ultimate test of surgical competence can only be judged by the outcome of treatment rendered to patients by the individual surgeon. For this reason the final responsibility for who practices in a given hospital rests with each individual hospital through its applicant review and credentialing mechanisms.
Definition of vascular surgery
In the publication previously referred to,1 a definition of vascular surgery was prepared. The following definition has been accepted by the American Board of Surgery and deserves repeating:
"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 nonoperative 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 surgery reconstruction.”
It is important to keep this definition in mind when determining the spectrum of services that are to be provided by the surgeon who is applying for hospital privileges. Particular attention is drawn to the importance of both medical and interventional aspects of care.
Evaluation of the new applicant for hospital privileges
Two major categories of applicant for hospital privileges can be identified. These include the surgeon who has just completed training and is entering into vascular surgery practice for the first time and those surgeons who have completed training sometime in the past and are relocating or applying for hospital privileges in a new institution. In the case of the latter category, practicing surgeons can also be further subdivided into two categories; those who completed their training and entered into practice before 1984, and those who completed training and entered practice after 1984. The year 1984 is pivotal in that was the year that the American Board of Surgery first offered examination and certification in the subspecialty of general vascular surgery.
Applicants for privileges who have just completed their surgical training
The Committee recommended hospital privileges be granted to those individuals who have just completed their training provided that they can fulfill one of the following four criteria:
“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 credentialling 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.”
Table I. Residency review committee definition of vascular operation categories
| Reconstructive operations |
 Category I—single |
| Aneurysms |
| Infrarenal aorta, emergent |
| Infrarenal aorta, elective |
| Suprarenal aorta, emergent |
| Suprarenal aorta, elective |
| Iliac, emergent |
| Iliac, elective |
| Femoral emergent |
| Femoral, elective |
| Popliteal, emergent |
| Popliteal, elective |
| Cerebrovascular |
| Carotid |
| Vertebral |
| Arch branches |
| Direct |
| Cervical bypass |
| Peripheral chronic obstructive (direct operations) |
| Aortoiliac-femoral |
| Femoral-popliteal-tibial |
| Intraabdominal aortic branches |
| Celiac/SMA |
| Renal |
| Upper extremity (axillary, brachial) |
| Direct repair or graft |
| Extra cavity bypass operations |
| Axillary-femoral |
| Femoral-femoral |
| Portal decompression operations |
| Childs A and B, emergent |
| Childs A and B, elective |
| Childs C, emergent |
| Childs C, elective |
| Category II—other major or combined operations |
| Category III—selected operations |
| Arterial embolectomy |
| Arterial or graft thrombectomy |
| Venous thrombectomy |
| Caval interruption |
| Saphenous vein ligation, stripping |
| Operations for venous ulcerations (exclude STSG) |
| Hemoaccess operations |
| Operations for lymphedema |
| Thoracic outlet decompression operations |
| Cervical sympathectomy |
| Lumbar sympathectomy (list only if separate operations) |
| Amputations |
| Digit |
| Transmetatarsal |
| Arm |
| BK |
| AK |
| Other |
Applicants for hospital privileges who have completed their training before 1984
Individuals who have completed their surgical training before 1984 may have received additional training in vascular surgery as a part of an informally established fellowship program or have developed vascular surgery skills as a part of their practice and experience. Individuals in this category were afforded the opportunity to sit for examination and certification for “special qualification in vascular surgery” if their practice volume was sufficiently high and if they were making major contributions to the speciality of vascular surgery on either a local or national level. Applicants in this category have also been in practice for a sufficient length of time to have accumulated a case experience and can provide data with respect to performance outcome. Those individuals who have had only limited practice experience with vascular surgery and have not obtained further training probably should not be granted new privileges in general vascular surgery when applying to another hospital. Those who have had extended experience can document their experience by one of the following: (1) American Board of Surgery Certificate of Special Qualification in Vascular Surgery, or (2) letter(s) from the 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.
As a part of the applicant submission, details of their last 50 consecutive category I vascular surgery cases or the prior 2 years' experience, whichever is greater, should be submitted to the hospital credentials committee. This should be accompanied by operative notes and discharge summaries for the committee to suitably judge indications for operation, operative management, and outcome.
Hospital privileges for applicants who have been in practice with training completed after 1984
After 1984 approved residencies in general vascular surgery existed. If an applicant has completed an approved residency in general vascular surgery and, in particular, if he holds one of the certificates of either special or added qualifications in general vascular surgery, that applicant should be considered as having completed the qualifications for consideration of hospital privileges. If the applicant has not completed a formal training program, the opportunity to sit for examination for the Certificate of Special Qualification in General Vascular Surgery also existed with the limitations described in the previous section.
If the applicant is in the active practice of vascular surgery in another community or another hospital, the applicant should submit to the credentials/privileges committee discharge summaries and operative notes from the last 50 consecutive category I vascular surgery cases or their prior 2 years' experience in managing vascular surgery problems, whichever is greater. Review of this material by the credentials committee will be judged against established outcome criteria for the various categories of cases in determining whether or not an applicant is competent to practice in that given hospital.
Renewal of hospital privileges in vascular surgery
Periodic renewal of vascular surgery privileges is a reaffirmation of competence and is considered to be of paramount importance in a quality assurance program.
Monitoring of performance in vascular surgery is of particular importance in that it has been determined that small errors in judgment or technique can lead to major morbidity and mortality rates in patients with vascular disease. Reviews of the community based experience has documented that there is considerable variability in results among surgeons.
In addition to the moral and ethical implications incumbent in a quality assurance program, it is apparent that government, private insurers, and managed care contractors are preparing to tie physician reimbursement with performance outcome.
Renewal of hospital privileges should be based on a periodic audit of the individual surgeon's performance. This should take place in individual hospitals based on data that have been gathered objectively by disinterested individuals. This usually means that a medical records department or their designee must maintain a registry of vascular surgery cases for each surgeon practicing in that institution. Personal or group registries based on surgeons' reports are unacceptable because they lack objectivity and cannot be audited.
Auditing of results of individual surgeons' performance is a sensitive issue and must be done in a careful and confidential manner. The following series of steps represent a suggested method of implementation:
Management of the surgeon in noncompliance
Encumbent in any quality assurance program and audit of surgical outcome is the implication that some surgeons may fall below the standard and may ultimately be denied hospital privileges for the performance of specific vascular cases.
This clearly represents a delicate issue that has legal ramifications. This is discussed in more detail in the previous publication.1 Suffice to say that methods of corrective action, reconciliation with hospital bylaws, and an appeals mechanism must be included as a part of due process in dealing with surgeons who are not in compliance. Nonetheless, once these criteria are met, the quality assurance program, to be effective, must have the ability to ultimately restrict practice for those individuals who are noncompliant.
References
☆ Reprint requests: Wesley S. Moore, MD, Department of Surgery, University of California/Los Angeles School of Medicine, 10833 Le Conte Ave., Los Angeles CA 90024-6094.
PII: 0741-5214(91)90314-K
doi:10.1067/mva.1991.27214
© 1991 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter. Published by Elsevier Inc. All rights reserved.
