Neurological surgery. Background. Practice area 155

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1 Practice area 155 Clinical PRIVILEGE WHITE PAPER Neurological surgery Background Neurological surgery, also called neurosurgery, is a medical discipline and surgical specialty that provides care for adult and pediatric patients in the treatment of pain or pathological processes that may modify the function or activity of the central nervous system (e.g., brain, hypophysis, and spinal cord); the peripheral nervous system (e.g., cranial, spinal, and peripheral nerves); the autonomic nervous system; and the supporting structures of these systems (e.g., meninges, skull and skull base, and vertebral column) and their vascular supply (e.g., intracranial, extracranial, and spinal vasculature), according to the Accreditation Council for Graduate Medical Education (ACGME). Treatment encompasses nonoperative management, including prevention, diagnosis (e.g., image interpretation), and follow-up (e.g., imaging surveillance), as well as treatments such as outpatient counseling, medical interventions, physical therapy referrals, operative interventions, pre- and postoperative critical care, and convalescent care. According to the American College of Surgeons (ACS), conditions that specialists in neurological surgery commonly treat include, but are not limited to, the following: Brain tumors Intracranial aneurysms Head injuries Spinal canal stenosis Herniated discs Spinal tumors Spinal fractures Spinal deformities The ACS website also states that technological advancements (e.g., new treatment methods and surgical techniques) are proliferating within the specialty of neurosurgery, contributing to the creation of numerous subspecialities within the field. In addition, an increasing number of neurosurgeons are electing to enter optional one-year fellowships in neuro-oncology, spinal surgery, epilepsy surgery, functional neurosurgery, cerebrovascular surgery, or pediatric neurosurgery following the completion of training in neurological surgery. As of July 1, 2009, physicians specializing in neurological surgery must complete a training program that is at least 72 months in duration. After residency, physicians may apply for certification in neurological surgery by the American Board of Neurological Surgery (ABNS) or the American Osteopathic Board of Surgery (AOBS). A supplement to Credentialing Resource Center Journal /13

2 Involved specialties Neurological surgeons Positions of specialty boards ABNS The ABNS grants certification in neurological surgery to those who qualify. Starting July 1, 2009, to be eligible for certification, residents must have completed a residency that is a minimum of 72 months in length, including the PGY-1. This must be done as a full-time resident enrolled in a program recognized by the ABNS and accredited by the residency review committee (RRC) for neurological surgery. Requirements also specify that: At least 42 months must be devoted to core clinical neurosurgery with progressive responsibilities culminating in 12 months at the most senior level. The entire 42 months must be done in programs accredited by the RRC. At least 21 months must be obtained in one program. The PGY-1 must include a minimum of three months of fundamental clinical skills training (critical care, trauma, and other rotations as determined by the program director) and may include up to six months of neurosurgery, which will count toward the 42 months required. At least three months (preferably six months, although only three are required) must be devoted to clinical neurology done in an ACGME-accredited neurology program. This requirement must be satisfied during the first three years of training, preferably during the PGY-1. The remaining undesignated 24 months may be devoted to the basic or clinical neurosciences. These should include neuropathology, neuroradiology, and research; the board expects residents to acquire basic knowledge and skills in each of these areas. Elective time may also be dedicated to the neurosurgery subspecialties for instance, enfolded fellowships with special emphasis on complex spine surgery, endovascular surgery, or pediatric neurosurgery. Candidates for certification must submit a list of all inpatients for whom the candidate was the responsible physician or surgeon, plus all outpatient operations, during the preceding 12 consecutive months of practice; a minimum of 100 operative procedures is required. Additionally, each applicant must successfully pass the multiple-choice primary examination before being considered for entry to the oral examination, which is the final step in the certification process. AOBS Candidates for certification in neurological surgery by the American Osteopathic Association (AOA) through the AOBS must: Have graduated from an AOA-accredited college of osteopathic medicine. Be licensed or credentialed to practice in the state or military jurisdiction where practice is conducted. Candidates must provide documentary evidence 2 A supplement to Credentialing Resource Center Journal /13

3 of an unrestricted license prior to taking an examination. Conform to the standards set forth in the Code of Ethics of the AOA. Be a member in good standing of the AOA or the Canadian Osteopathic Association throughout the certification process. Have satisfactorily completed an AOA-approved OGME-1. Have completed all the prescribed years of an AOA-approved residency training program in the surgical specialties under the jurisdiction of the board, including one year of training in general surgery followed by four years of training in neurological surgery or five years in neurological surgery. Candidates who began their residency training with the required OGME-1R internship year, effective in academic year 2008, must have six years of training in neurological surgery. At least one year of the surgical specialty training program must encompass all aspects of the particular specialty, including adequate training in the basic medical sciences, with emphasis on pathology, physiology, and osteopathic principles as related to the specialty. Positions of societies, academies, colleges, and associations AANS The American Association of Neurological Surgeons (AANS) is a membership organization dedicated to advancing the specialty of neurological surgery. AANS provides CME activities such as national meetings, educational materials, and online courses. However, it does not publish specific training requirements for medical education in neurological surgery. SNS The Society of Neurological Surgeons (SNS), also referred to as the Senior Society, is composed of leaders in American neurosurgical residency education. According to the SNS, educational programs in neurological surgery should be a minimum of 12 months and must occur in an ACGME-accredited neurosurgical residency training program or its equivalent. Such an educational program must provide the opportunity for residents to acquire advanced knowledge of the following aspects of neurosurgical critical care, particularly as they relate to the management of patients with hemodynamic instability, multiple system organ failure, and complex coexisting medical problems: Cardiorespiratory resuscitation Physiology, pathophysiology, diagnosis, and therapy of disorders of the cardiovascular, respiratory, gastrointestinal, neurological, endocrine, and musculoskeletal systems, as well as of infectious diseases Metabolic, nutritional, and endocrine effects of critical illness Hematologic and coagulation disorders A supplement to Credentialing Resource Center Journal /13 3

4 Trauma as it relates to neurological disease Monitoring and medical instrumentation Critical pediatric neurosurgical conditions Pharmacokinetics and dynamics of drug metabolism and excretion in critical illness Ethical and legal aspects of neurosurgical critical care Additionally, the SNS states that the program must provide supervised training that will enable the resident to gain competence in the performance and application of the following neurosurgical critical care skills: Respiratory: airway management Circulatory: invasive and noninvasive monitoring techniques, including computations of cardiac output and of systemic and pulmonary vascular resistance, electrocardiograms, and electroencephalograms Neurological: the performance of complete neurological examinations, the use of intracranial pressure monitoring techniques and of the electroencephalogram to evaluate cerebral function, and application of hypothermia in the management of cerebral trauma Renal: the evaluation of renal function as it relates to the neurosurgical patient and the treatment paradigm Gastrointestinal: utilization of gastrointestinal intubation in the management of the critically ill patient, application of enteral feedings, and management of percutaneous catheter devices Hematologic: coagulation status and appropriate use of component therapy Infectious disease: classification of infections and application of isolation techniques, pharmacokinetics, drug interactions, and management of antibiotic therapy during treatment of the neurological patient Nutritional: application of parenteral and enteral nutrition, and monitoring and assessment of metabolism and nutrition Miscellaneous: use of special beds for specific injuries, and employment of pneumatic antishock garments, traction, and fixation devices A training program in advanced neurosurgical critical care must enable the trainee to acquire an advanced body of knowledge and level of skill in the management of critically ill neurologic and neurosurgical patients with competency to assume responsibility for care of these patients in the ICU setting. According to SNS, this advanced body of knowledge and level of skill must include the mastery of: The use of advanced technology and instrumentation to monitor the physiologic status of children or adults, including those in neonatal, pediatric, child-bearing, or advanced years Organizational and administrative aspects of a neurosurgical critical care unit Ethical, economic, and legal issues as they pertain to critical care ACGME In its Program Requirements for Graduate Medical Education in Neurological Surgery, the ACGME states that the educational program in neurological surgery 4 A supplement to Credentialing Resource Center Journal /13

5 must be 84 months in length. Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents must also be able to competently perform medical, diagnostic, and surgical procedures considered essential for the area of practice. Therefore, with regard to patient care, residents must demonstrate competence in: Gathering essential patient information in a timely manner Synthesizing and properly utilizing acquired patient data Generating a differential diagnosis and properly sequencing critical actions for patient care, including managing complications, morbidity, and mortality Generating and implementing an effective management plan Prioritizing and stabilizing multiple patients simultaneously With regard to procedural skills, residents must demonstrate competence in performing neurosurgical operative procedures, including the following adult cranial procedures: Craniotomy for brain tumors, intracranial vascular lesions, and trauma Endovascular/interventional procedures for intracranial cerebrovascular and neuro-oncologic conditions Extracranial vascular procedures (open surgery and endovascular) Functional procedures Radiosurgery Transsphenoidal sellar/parasellar Tumors (endoscopic and microsurgical) Ventriculoperitoneal (VP) shunt Residents must also demonstrate competence in performing adult spinal p rocedures, including: Anterior cervical approaches for decompression/stabilization Posterior cervical approaches for decompression/stabilization Interventional procedures for spinal conditions Lumbar discectomy Peripheral nerve procedures Thoracic/lumbar instrumentation fusion Additionally, residents must demonstrate competence in performing the following pediatric procedures: Craniotomy for brain tumor Spinal procedures, including Chiari decompressions, laminectomy for dysraphism, laminectomy for spinal tumors, laminectomy for syringomyelia, and correction of spinal deformity VP shunt For both adult and pediatric patients, residents must demonstrate competence in performing craniotomy for epilepsy. A supplement to Credentialing Resource Center Journal /13 5

6 In addition to the aforementioned procedures, residents must also demonstrate competence in assessing postoperative recovery, recognizing and treating complications, communicating with referring physicians, and developing the physician/patient relationship; analyzing patient outcomes; and providing healthcare services aimed at preventing health problems and maintaining health. With regard to medical knowledge, residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and socialbehavioral sciences, as well as the application of this knowledge to patient care. Residents must demonstrate competence in their knowledge of: Neurosurgical emergencies Treating neurosurgical conditions, including: Cerebrovascular disorders Functional neurosurgery Neurocritical care Neuro-oncology Pain Pediatric neurological surgery Peripheral nerve disorders Spinal disorders Trauma Different medical practice models and delivery systems and how to best utilize them to care for an individual patient Study design and statistical methods AOA According to the AOA s Basic Standards for Residency Training in Surgery and the Surgical Subspecialties, the neurological surgery residency training program must provide a meaningful education that prepares the resident upon graduation to meet certification requirements of the AOA through the AOBS. The required length of a neurosurgery residency program is 72 months, which includes an AOA-approved common surgical OGME-1R year. The AOA also outlines the following requirements: Programs that extend the residency beyond 72 months must present a clear educational rationale for the extension consonant with the program requirements and the objectives of the residency During the first 36 months of education, residents must have a minimum of three months of structured education in a neurology program The program must provide 36 months of clinical neurological surgery at the sponsoring institution or one of its approved participating sites The remaining time not devoted to clinical neurology and neurosurgery must be spent in the study of the basic sciences, neuroradiology, neuropathology, or other subject matter related to the neurosciences Residents must spend a 12-month period performing the duties as chief resident on the neurological surgery clinical service in the sponsoring institution under supervision, and demonstrating advanced-level responsibilities 6 A supplement to Credentialing Resource Center Journal /13

7 During the training period, each resident must document a minimum of 400 major neurosurgical procedures, 200 of which must be cranial and must represent a well-balanced spectrum of neurological surgery in both adults and children. This spectrum should include craniotomies for trauma, neoplasms, aneurysms, and vascular malformations; extracranial carotid artery surgery; transsphenoidal and stereotaxic surgery (including radiosurgery); pain management; and spinal procedures of a sufficient number and variety using modern techniques. Additionally, the training program must include a distribution of the following procedures: Cranial Extracranial Peripheral nerve Spinal Positions of accreditation bodies CMS CMS has no formal position concerning the delineation of privileges for neurological surgery. However, the CMS Conditions of Participation (CoP) define a requirement for a criteria-based privileging process in (c)(6) stating, The bylaws must include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges (a)(6) states, The governing body must assure that the medical staff bylaws describe the privileging pro cess. The process articulated in the bylaws, rules or regula tions must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners that considers: Individual character Individual competence Individual training Individual experience Individual judgment The governing body must ensure that the hospital s bylaws governing medical staff membership or the granting of privileges apply equally to all practitioners in each professional category of practitioners. Specific privileges must reflect activi ties that the majority of prac titioners in that category can perform competently and that the hospital can support. Privileges are not granted for tasks, procedures, or activities that are not conducted within the hospital, regardless of the practitioner s ability to perform them. A supplement to Credentialing Resource Center Journal /13 7

8 Each practitioner must be individually evaluated for requested privileges. It can not be assumed that every practitioner can perform every task, activity, or privilege specific to a specialty, nor can it be assumed that the practitioner should be automatically granted the full range of privileges. The individual practitioner s ability to perform each task, activity, or privilege must be individually assessed. CMS also requires that the organization have a process to ensure that practitioners granted privileges are work ing within the scope of those privileges. CMS CoPs include the need for a periodic appraisal of practitioners appointed to the medical staff/granted medical staff privileges ( [a][1]). In the absence of a state law that establishes a time frame for the periodic appraisal, CMS recommends that an appraisal be conducted at least every 24 months. The purpose of the periodic appraisal is to determine whether clinical privileges or membership should be continued, discontinued, revised, or otherwise changed. The Joint Commission The Joint Commission has no formal position concerning the delineation of privileges for neurological surgery. However, in its Comprehensive Accreditation Manual for Hospitals, The Joint Commission states, The hospital collects information regarding each practitioner s current license status, training, experience, competence, and ability to perform the requested privilege (MS ). In the introduction for MS , The Joint Commission states that there must be a reliable and consistent system in place to process applications and verify credentials. The organized medical staff must then review and evaluate the data collected. The resultant privilege recommendations to the governing body are based on the assessment of the data. The Joint Commission introduces MS by stating, The organized medical staff is respon sible for planning and implementing a privileging process. It goes on to state that this process typically includes: Developing and approving a pro cedures list Processing the application Evaluating applicant-specific information Submitting recommendations to the governing body for applicant-specific delineated privileges Notifying the applicant, relevant personnel, and, as required by law, external entities of the privi leging decision Monitoring the use of privileges and quality-of-care issues MS further states, The decision to grant or deny a privilege(s) and/or to renew an existing privilege(s) is an objective, evidence-based process. 8 A supplement to Credentialing Resource Center Journal /13

9 The EPs for standard MS include several requirements as follows: The need for all licensed independent practitioners who provide care, treatment, and services to have a current license, certification, or registration, as required by law and regulation Established criteria as recommended by the organized medical staff and approved by the governing body with specific evaluation of current licensure and/or certification, specific relevant training, evidence of physical ability, professional practice review data from the applicant s current organization, peer and/or faculty recommendation, and a review of the practitioner s performance within the hospital (for renewal of privileges) Consistent application of criteria A clearly defined (documented) procedure for processing clinical privilege requests that is approved by the organized medical staff Documentation and confirmation of the applicant s statement that no health problems exist that would affect his or her ability to perform privileges requested A query of the NPDB for initial privileges, renewal of privileges, and when a new privilege is requested Written peer recommendations that address the practitioner s current medical/clinical knowledge, technical and clinical skills, clinical judgment, interpersonal skills, communication skills, and professionalism A list of specific challenges or concerns that the organized medical staff must evaluate prior to recommending privileges (MS , EP 9) A process to determine whether there is sufficient clinical performance information to make a decision related to privileges A decision (action) on the completed application for privileges that occurs within the time period specified in the organization s medical staff bylaws Information regarding any changes to practitioners clinical privileges, updated as they occur The Joint Commission further states, The organized medical staff reviews and analyzes information regarding each requesting practitioner s current licensure status, training, experience, current competence, and ability to perform the requested privilege (MS ). In the EPs for standard MS , The Joint Commission states that the information review and analysis process is clearly defined and that the decision process must be timely. The organization, based on recommendations by the organized medical staff and approval by the governing body, develops criteria that will be considered in the decision to grant, limit, or deny a request for privileges. The criteria must be consistently applied and directly relate to the quality of care, treatment, and services. Ultimately, the governing body or delegated governing body has the final authority for granting, renewing, or denying clinical privileges. Privileges may not be granted for a period beyond two years. A supplement to Credentialing Resource Center Journal /13 9

10 Criteria that determine a practitioner s ability to provide patient care, treatment, and services within the scope of the privilege(s) requested are consistently evaluated. The Joint Commission further states, Ongoing professional practice evaluation information is factored into the decision to maintain existing privilege(s), to revise existing privileges, or to revoke an existing privilege prior to or at the time of renewal (MS ). In the EPs for MS , The Joint Commission says there is a clearly defined process facilitating the evaluation of each practitioner s professional practice, in which the type of information collected is determined by individual departments and approved by the organized medical staff. Information resulting from the ongoing professional practice evaluation is used to determine whether to continue, limit, or revoke any existing privilege. HFAP The Healthcare Facilities Accreditation Program (HFAP) has no formal position concerning the delineation of privileges for neurological surgery. The bylaws must include the criteria for determining the privileges to be granted to the individual practitioners and the procedure for applying the criteria to individuals requesting privileges ( ). Privileges are granted based on the medical staff s review of an individual practitioner s qualifications and its recommendation regarding that individual practitioner to the governing body. It is also required that the organization have a process to ensure that practitioners granted privileges are working within the scope of those privileges. Privileges must be granted within the capabilities of the facility. For example, if an organization is not capable of performing open-heart surgery, no physician should be granted that privilege. In the explanation for standard related to membership selection criteria, HFAP states, Basic criteria listed in the bylaws, or the credentials manual, include the items listed in this standard. (Emphasis is placed on training and competence in the requested privileges.) The bylaws also define the mechanisms by which the clinical departments, if applicable, or the medical staff as a whole establish criteria for specific privilege delineation. Periodic appraisals of the suitability for membership and clinical privileges is required to determine whether the individual practitioner s clinical privileges should be approved, continued, discontinued, revised, or otherwise changed ( ). The appraisals are to be conducted at least every 24 months. 10 A supplement to Credentialing Resource Center Journal /13

11 The medical staff is accountable to the governing body for the quality of medical care provided, and quality assessment and performance improvement ( ) information must be used in the process of evaluating and acting on re-privileging and reappointment requests from members and other credentialed staff. DNV DNV has no formal position concerning the delineation of privileges for neurological surgery. MS.12 Standard Requirement (SR) #1 states, The medical staff bylaws shall include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to those individuals that request privileges. The governing body shall ensure that under no circumstances is medical staff membership or professional privileges in the organization dependent solely upon certification, fellowship, or membership in a specialty body or society. Regarding the Medical Staff Standards related to Clinical Privileges (MS.12), DNV requires specific provisions within the medical staff bylaws for: The consideration of automatic suspension of clinical privileges in the following circumstances: revocation/restriction of licensure; revocation, suspension, or probation of a DEA license; failure to maintain professional liability insurance as specified; and noncompliance with written medical record delinquency/deficiency requirements Immediate and automatic suspension of clinical privileges due to the termination or revocation of the practitioner s Medicare/Medicaid status Fair hearing and appeal The Interpretive Guidelines also state that core privileges for general surgery and surgical subspecialties are acceptable as long as the core is properly defined. DNV also requires a mechanism (outlined in the bylaws) to ensure that all individuals provide services only within the scope of privileges granted (MS.12, SR.4). Clinical privileges (and appointments or reappointments) are for a period as defined by state law or, if permitted by state law, not to exceed three years (MS.12, SR.2). Individual practitioner performance data must be measured, utilized, and evaluated as a part of the decision-making for appointment and reappointment. Although not specifically stated, this would apply to the individual practitioner s respective delineation of privilege requests. A supplement to Credentialing Resource Center Journal /13 11

12 CRC draft criteria The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding this practice area. The core privileges and accompanying procedure list are not meant to be allencompassing. They define the types of activities, procedures, and privileges that the majority of practitioners in this specialty perform. Additionally, it cannot be expected or required that practitioners perform every procedure listed. Instruct practitioners that they may strikethrough or delete any procedures they do not wish to request. Minimum threshold criteria for requesting privileges in neurological surgery Basic education: MD or DO Minimal formal training: Successful completion of an ACGME- or AOAaccredited residency in neurological surgery and/or current certification or active participation in the examination process (with achievement of certification within [n] years) leading to certification in neurological surgery by the ABNS or the AOBS in neurological surgery. Required current experience: At least 50 neurological surgical procedures, reflective of the scope of privileges requested, in the past 12 months or successful completion of an ACGME- or AOA-accredited residency or clinical fellowship within the past 12 months. References If the applicant is recently trained, a letter of reference should come from the director of the applicant s training program. Alternatively, a letter of reference may come from the applicable department chair and/or clinical service chief at the facility where the applicant most recently practiced. Core privileges in neurological surgery Core privileges for neurological surgery include the ability to admit, evaluate, diagnose, and provide consultative, nonoperative, and pre-, intra-, and postoperative care to patients of all ages presenting with injuries or disorders of the central, peripheral, and autonomic nervous systems, including their supporting structures and vascular supply. Practitioners may provide evaluation and treatment of pathological processes that modify function or activity of the nervous system, including the hypophysis, and provide operative and nonoperative management of pain. These privileges include but are not limited to care of patients with disorders of the nervous system (i.e., the brain, meninges, skull, skull base, and their blood supplies), including the surgical and endovascular treatment of disorders of the intracranial and extracranial vasculature supplying the brain and spinal cord; the pituitary gland; the spinal cord, meninges, and vertebral column; and the cranial and spinal nerves throughout their distribution. Privileges also include the ability to provide care to patients 12 A supplement to Credentialing Resource Center Journal /13

13 in the intensive care setting in conformance with unit policies, and to assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the following procedures and such other procedures that are extensions of the same techniques and skills: Performance of history and physical exam Ablative surgery for epilepsy All types of craniotomies, craniectomies, and reconstructive procedures (including microscopic) on the skull, including surgery on the brain, meninges, pituitary gland, and cranial nerves and including surgery for cranial trauma and intracranial vascular lesions Angiography Discography and intradiscal/percutaneous disc treatments Endoscopic laser foraminoplasty Endoscopic minimally invasive surgery Epidural steroid injections for pain Insertion of subarachnoid or epidural catheter with reservoir or pump for drug infusion or cerebrospinal fluid withdrawal Laminectomies, laminotomies, and fixation and reconstructive procedures of the spine and its contents, including instrumentation Lumbar puncture, cisternal puncture, ventricular tap, and subdural tap Management of congenital anomalies, such as encephalocele, meningocele, and myelomeningocele Muscle biopsy Myelography Nerve biopsy Nucleoplasty Ordering of diagnostic studies and procedures related to neurological problems or disorders Percutaneous and subcutaneous implantation of neurostimulator electrodes Peripheral nerve procedures, including decompressive procedures and reconstructive procedures on the peripheral nerves Posterior fossa-microvascular decompression procedures Radiofrequency ablation Selective blocks for pain, stellate ganglion blocks, and nerve blocks Shunts (VP, ventriculoatrial, ventriculopleural, subdural peritoneal, and lumbar subarachnoid/peritoneal [or other cavity]) Spinal cord surgery for decompression of spinal cord or spinal canal, for intramedullary lesion, intradural extramedullary lesion, rhizotomy, cordotomy, dorsal root entry zone lesion, tethered spinal cord, or other congenital anomalies (e.g., diastematomyelia) Stereotactic surgery Surgery for intervertebral disc disease Surgery on the sympathetic nervous system A supplement to Credentialing Resource Center Journal /13 13

14 Transsphenoidal procedures for lesions of the sellar or parasellar region, fluid leak, or fracture Ultrasonic surgery procedures Ventricular shunt operation for hydrocephalus, revision of shunt operation, and ventriculocisternostomy Ventriculography Video-assisted thoracic surgery Special noncore privileges in neurological surgery If desired, noncore privileges are requested individually in addition to requesting the core. Each individual requesting noncore privileges must meet the specific threshold criteria governing the exercise of the privilege requested, including training, required previous experience, and maintenance of clinical competence. Noncore privileges include: Use of laser Percutaneous vertebroplasty Balloon kyphoplasty Deep brain stimulation Mechanical retriever (e.g., Merci) Transcranial Doppler ultrasonography Coil occlusion of aneurysms Lumbar disc arthroplasty Cervical disc arthroplasty Stereotactic radiosurgery Carotid endarterectomy Carotid stenting Administration of sedation and analgesia Reappointment Reappointment should be based on unbiased, objective results of care according to a hospital s quality assurance mechanism. To be eligible to renew privileges in neurological surgery, the applicant must have current demonstrated competence and an adequate volume of experience ([n] 1 neurological surgical procedures) with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges. In addition, continuing education related to neurological surgery should be required. 1. Healthcare organizations should define the minimum case/patient volume (the [n] ) required to maintain clinical competence as recommended by the applicable department chair and the medical executive committee and subject to approval by the governing body. 14 A supplement to Credentialing Resource Center Journal /13

15 For more information Accreditation Council for Graduate Medical Education 515 North State Street, Suite 2000 Chicago, IL Telephone: Fax: Website: American Association of Neurological Surgeons 5550 Meadowbrook Drive Rolling Meadows, IL Telephone: Fax: Website: American Board of Neurological Surgery 245 Amity Road #208 Woodbridge, CT Telephone: Fax: Website: American College of Surgeons 633 North Saint Clair Street Chicago, IL Telephone: Fax: Website: American Osteopathic Association 142 East Ontario Street Chicago, IL Telephone: Fax: Website: American Osteopathic Board of Surgery 4764 Fishburg Road, Suite F Huber Heights, OH Telephone: or Fax: Website: A supplement to Credentialing Resource Center Journal /13 15

16 Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, MD Telephone: Website: DNV Healthcare, Inc. 400 Techne Center Drive, Suite 350 Milford, OH Website: Healthcare Facilities Accreditation Program 142 E. Ontario Street Chicago, IL Telephone: Website: The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL Telephone: Fax: Website: Editorial Advisory Board Clinical Privilege White Papers Associate Editorial Director Todd Hutlock Managing Editor Katrina Gravel William J. Carbone Chief Executive Officer American Board of Physician Specialties Atlanta, Ga. Darrell L. Cass, MD, FACS, FAAP Codirector, Center for Fetal Surgery Texas Children s Hospital Houston, Texas Jack Cox, MD Senior Vice President/Chief Quality Officer Hoag Memorial Hospital Presbyterian Newport Beach, Calif. Stephen H. Hochschuler, MD Cofounder and Chair Texas Back Institute Phoenix, Ariz. Bruce Lindsay, MD Professor of Medicine Director, Cardiac Electrophysiology Washington University School of Medicine St. Louis, Mo. Sally J. Pelletier, CPCS, CPMSM Director of Credentialing Services The Greeley Company, a division of HCPro, Inc. Danvers, Mass. Beverly Pybus Senior Consultant The Greeley Company, a division of HCPro, Inc. Danvers, Mass. Richard A. Sheff, MD Chair and Executive Director The Greeley Company, a division of HCPro, Inc. Danvers, Mass. The information contained in this document is general. It has been designed and is intended for use by hospitals and their credentials committees in developing their own local approaches and policies for various credentialing issues. This information, including the materials, opinions, and draft criteria set forth herein, should not be adopted for use without careful consideration, discussion, additional research by physicians and counsel in local settings, and adaptation to local needs. The Credentialing Resource Center does not provide legal or clinical advice; for such advice, the counsel of competent individuals in these fields must be obtained. Reproduction in any form outside the recipient s institution is forbidden without prior written permission. Copyright 2013 HCPro, Inc., Danvers, MA A supplement to Credentialing Resource Center Journal /13