Flexible sigmoidoscopy

Procedure 21 Clinical PRIVILEGE WHITE PAPER Flexible sigmoidoscopy Background Flexible sigmoidoscopy is an exam used to evaluate the lower part of the large intestines. It can be used to locate and examine inflamed tissue, ulcers, and polyps, which can turn into cancer over time. Flexible sigmoidoscopy is also used as a screen for colon cancer. Practitioners use flexible sigmoidoscopy to help them diagnose unexplained changes in bowel habits, abdominal pain, bleeding from the anus, and weight loss. Further, flexible sigmoidoscopy can help a practitioner determine and diagnose the cause of chronic diarrhea, bowel obstruction, diverticulosis, inflammatory bowel disease, anal fissures, and hemorrhoids. It can also be used to detect early signs of cancer. During a flexible sigmoidoscopy exam, a thin, flexible tube called a sigmoidoscope is inserted into the rectum. A tiny video camera at the tip of the tube allows the practitioner to view the inside of the rectum and most of the sigmoid colon about the last 2 ft. of the large intestine (the lower one-third of the colon). Tissue samples can be taken through the scope during a flexible sigmoidoscopy exam. The flexible sigmoidoscopy does not allow the practitioner to see the entire colon and, as a result, cannot be used to detect cancers or polyps beyond this lower third. To do this, physicians perform a colonoscopy, which allows the doctor to examine the entire colon. Colonoscopy is the preferred screening method for colorectal cancer. However, flexible sigmoidoscopy requires less time about 20 minutes to perform on an outpatient basis. According to the American Society of Colon and Rectal Surgeons (ASCRS), a flexible sigmoidoscopy should be conducted every five years beginning at age 50. Involved specialties Positions of societies and academies ASGE, SAGES, ASCRS Gastroenterologists, surgeons, colon and rectal surgeons, internists, family practitioners, RNs, nurse practitioners, and physician assistants The American Society for Gastrointestinal Endoscopy (ASGE) published a statement, Principles of Privileging and Credentialing A supplement to Briefings on Credentialing 781/639-1872 08/10

for Endoscopy and Colonoscopy, and the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and ASCRS. The organizations state that appropriate training in gastrointestinal (GI) endoscopy is critical to providing quality endoscopists: ASGE s training guidelines call for acquisition of endoscopic skills in the context of training programs in gastroenterology or surgery and for an assessment of endoscopic skill after a threshold number of procedures has been performed. There has been considerable variability among professional societies in the numbers of procedures required to assess the competence of trainees. As additional studies have been performed, it is clear that more procedures are needed than were previously recommended to ensure competency. Individuals applying for privileges for endoscopic procedures such as flexible sigmoidoscopy should have demonstrated satisfactory completion of an Accreditation Council for Graduate Medical Education (ACGME) approved training program in adult or pediatric gastroenterology, general surgery, colon and rectal surgery, or pediatric surgery. The program director and, if deemed necessary, the credentialing or privileging committee at the institution at which a physician is seeking flexible sigmoidoscopy privileges or other teaching faculty from the applicant s residency program should provide an attestation to competency in the performance of the procedure. The statement also says that for applicants who already have privileges to perform these procedures and are applying for similar privileges at another facility or for renewal of privileges at the same facility, attestation of competency should be provided by the applicant s chief of service. Uniform standards should be developed that apply to all hospital staff requesting privileges to perform endoscopy and to all areas where endoscopy is performed. Additionally, ASGE, SAGES, and ASCRS state that institutions should grant privileges for each major category of endoscopy separately. The ability to perform one endoscopic procedure does not imply adequate competency to perform another. Associated skills generally considered an integral part of an endoscopic category may be required before privileges for that category can be granted. 2 A supplement to Briefings on Credentialing 781/639-1872 08/10

Recognizing the limitations of written reports, proctoring of applicants for privileges in gastrointestinal endoscopy by a qualified, unbiased staff endoscopist may be desirable, specifically when competency for a given procedure cannot be adequately verified by submitted written material. The procedural details of proctoring should be developed by the credentialing body of the hospital and provided to the applicant. Proctors may be chosen from existing endoscopy staff or solicited from endoscopic societies. SAGES In its Granting of Privileges for Gastrointestinal Endoscopy, SAGES states that privileges should be granted based on prior demonstration of proficiency and privileges should be separately granted for each major category of endoscopy, including sigmoidoscopy. Regarding training, SAGES states that the physician must satisfactorily complete an ACGME-accredited surgical or gastroenterologic training program with subsequent eligibility and/ or certification by the appropriate certifying board. Physicians who did not complete an ACGME-accredited program may hold privileges for flexible sigmoidoscopy if their experience obtained outside of a formal training program is equal to that of a formal training program. Physicians must show proficiency in endoscopic procedure(s) and clinical judgment equivalent to that obtained in a residency program. Certification of experience by a skilled endoscopic practitioner must include a detailed description of the nature of informal training, the number of procedures performed with and without supervision, and the actual observed competency of the applicant for each endoscopic procedure for which privileges are requested. The applicant s endoscopic director should confirm in writing the training, experience (including the number of cases for each procedure for which privileges are requested), and observed level of competency. Attendance at short endoscopy courses, which do not provide supervised hands-on training with patients, is not an acceptable substitute in the development of equivalent competency. Regarding proctoring, SAGES states that proctoring of applicants for privileges in gastrointestinal endoscopy by a qualified, unbiased staff endoscopist may be desirable, especially when competency for a given procedure cannot be adequately verified by submitted written material. The procedural details of proctoring should be developed by the credentialing body of A supplement to Briefings on Credentialing 781/639-1872 08/10 3

the hospital and provided to the applicant. Proctors may be chosen from existing endoscopy staff or solicited from endoscopic societies. The proctor should be responsible to the credentials committee and not to the patient or to the individual being proctored. Documentation of the proctor s evaluation should be submitted in writing to the credentials committee. Criteria of competency for each procedure should be established in advance. It is essential that proctoring be provided in an unbiased, confidential, and objective manner. A satisfactory mechanism for appeal must be established for individuals for whom privileges are denied or granted in a temporary or provisional manner. ASGE The ASGE addresses the issue of nonphysician endoscopists in its statement Endoscopy by Nonphysicians. Allowing a nonphysician to perform endoscopies should be based on the practitioner s competency in the procedure, according to the ASGE. When determining whether to use nonphysician endoscopists, ASGE says institutions should consider the availability of physician resources and the volume of procedural demand as dictated by local conditions. Physician endoscopists undergo extensive formal training in the cognitive aspects of GI disease, as well as the technical performance of endoscopic procedures. It is unlikely that nonphysician endoscopists routinely obtain this same level of cognitive training, according to the ASGE. However, nonphysician endoscopists should be expected to receive the same volume and supervision during training of the technical aspects of performing endoscopic procedures as physician endoscopists. Achieving threshold numbers of procedures does not ensure competence. As with physician endoscopists, nonphysician endoscopists require either direct or indirect supervision after the completion of training to assess competence and ongoing evaluation to ensure that competence is maintained. The majority of the literature that involves nonphysician endoscopists pertains to the performance of sigmoidoscopy and specifically for the purposes of colorectal cancer screening. Flexible sigmoidoscopy requires fewer supervised examinations to attain objective measures of technical competency than other endoscopic procedures, does not require sedation, and is associated with an inherently low complication rate. According to the position paper, several studies documented that when 4 A supplement to Briefings on Credentialing 781/639-1872 08/10

nonphysician endoscopists are given thorough training, they can perform flexible sigmoidoscopy at a level comparable with physicians. AOA/ACOI AAFP In thespecific Requirements for Osteopathic Fellowship Training in Gastroenterology, the American Osteopathic Association (AOA) and the American College of Osteopathic Internists (ACOI) state that training in small bowel endoscopy and colonoscopy must be included in an AOA-approved fellowship in gastroenterology. According to a position statement on flexible sigmoidoscopy published by the American Academy of Family Physicians (AAFP), physicians can benefit from a comprehensive course on sigmoidoscopy. Physicians need to be well versed in pathology recognition, according to the AAFP. Physicians can practice the manual skills of scope manipulation on models. Great debate exists over the minimum number of procedures needed for competency. Gastroenterology organizations have suggested procedure numbers of 25 100 before privileges are granted. Many physicians have demonstrated good skills after just 10 procedures. Physicians should strive to have as many supervised procedures as they need to be comfortable with scope insertion and pathology recognition. Most physicians achieve comfort after 10 25 procedures. Unsupervised procedures should not be performed unless the physician has had some precepted experience. SGNA In its Guideline for Performance of Flexible Sigmoidoscopy by Registered Nurses for the Purpose of Colorectal Cancer Screening, the Society of Gastroenterology Nurses and Associates (SGNA) states that RNs educated and experienced in gastroenterology nursing and trained in techniques of flexible sigmoidoscopy may perform the procedure for the purpose of colorectal cancer screening of average-risk individuals. In regard to general RN qualifications, SGNA states that both cognitive and technical skills are required to perform flexible sigmoidoscopy competently. Knowledge of the anatomy, physiology, and pathology of the colon and abdomen and indications/contraindications to the procedure are essential. Experience and good hand-eye coordination are also required to perform a safe and thorough examination. SGNA believes that nurse endoscopists can best document their expertise in the A supplement to Briefings on Credentialing 781/639-1872 08/10 5

field through board certification and, therefore, recommends that RNs performing endoscopy hold current certification from the American Board of Certification for Gastroenterology Nurses (ABCGN). Medical supervision is determined by institutional policy. SGNA recommends that a minimum of 50 flexible sigmoidoscopies be performed under the supervision of a skilled physician endoscopist before an RN performs this procedure independently. RNs who perform flexible sigmoidoscopy should practice within the limits of state licensure as well as institutional policy. In addition to the general qualifications, the following specific competencies are required of RNs who perform flexible sigmoidoscopy in any practice setting: Cognitive skills, including the ability to: Describe the indications/contraindications for screening flexible sigmoidoscopy, including the definition of average and high risk Distinguish normal versus abnormal anatomy, physiology, and pathophysiology of the abdomen, anus, rectum, sigmoid, and descending colon Identify options for patient bowel preparation Discuss risks, benefits, and alternatives to flexible sigmoidoscopy with the patient in order to obtain informed consent Provide patient education, which includes the purpose of the procedure, positioning and relaxation methods, and sensations the patient will likely experience Identify indications for antibiotic prophylaxis based on current recommendations Demonstrate knowledge of and ensure compliance with SGNA guidelines for cleaning, disinfecting, and storing the flexible sigmoidoscope and accessories Identify and initiate nursing interventions for adverse reactions, such as pain, perforation, bleeding, infection, and vasovagal response/abdominal distention Document per institutional policy, including informed consent, prep quality, findings and outcomes, actions and interventions, patient response, and patient education Communicate outcomes or recommendations for follow-up care to the patient s primary healthcare provider 6 A supplement to Briefings on Credentialing 781/639-1872 08/10

Communicate findings and recommendations to the patient as appropriate Assume responsibilities related to abnormal findings, including: notify supervising physician; document per institutional policy; after consultation with the supervising physician, refer patients requiring further workup to the appropriate provider (primary care provider, gastroenterologist, or surgeon) for diagnostic/therapeutic studies, including follow-up of biopsy findings Technical skills, including the ability to: Demonstrate the proper techniques of flexible sigmoidoscopy, including patient positioning and digital rectal examination Demonstrate correct functioning of equipment and manipulation of the endoscope, including insertion, insufflation, advancement, and withdrawal techniques, and achieve an adequate depth of insertion with minimal patient discomfort Obtain biopsy specimen(s) as indicated according to institutional policy Continued competency and quality monitoring, including the ability to: Maintain competency and quality in performing digital rectal exam and flexible sigmoidoscopy Participate in quarterly monitoring of exam by gastroenterologist three to five times per quarter or as outlined by institutional policy Document continuing education and competency at least annually as outlined by institutional policy In addition to following these guidelines for staff qualifications, SGNA also recommends that each practice setting maintain and implement a quality monitoring plan. Positions of other interested parties ABIM Knowledge of endoscopic procedures are included in the American Board of Internal Medicine s (ABIM) certification examination in gastroenterology. To become certified in gastroenterology, applicants must: At the time of application, be previously certified in internal medicine by ABIM Satisfactorily complete an ACGME- or Royal College of Physicians and Surgeons of Canada (RCPSC) accredited fellowship training program A supplement to Briefings on Credentialing 781/639-1872 08/10 7

Demonstrate clinical competence in the care of patients Meet the licensure and procedural requirements Pass the Certification Exam in Gastroenterology ABFM The American Board of Family Practitioners (ABFM) has no formal position concerning the delineation of privileges for flexible sigmoidoscopy. However, in the article Technical Competency in Flexible Sigmoidoscopy, which appeared in the Journal of the American Board of Family Medicine, the authors state that procedural competency in flexible sigmoidoscopy consists of knowledge, technical skills, and attitudes. Knowledge and attitudes, which were not addressed in the article, can be assessed with such tools as examinations and direct observation, the authors state. Primary care faculty can use standards of insertion depth and procedure time when determining technical skill proficiency for their residents in flexible sigmoidoscopy, while using other tools to determine knowledge and attitude proficiency. To become certified by the ABFM, candidates must meet the following requirements: Satisfactorily complete three years of training (a full 36 calendar months with 12 months in each of the years) in a family medicine residency program accredited by the ACGME. Candidates who obtained their MD degree from medical schools in the United States or Canada must have attended a school accredited by the Liaison Committee on Medical Education or the Committee for Accreditation of Canadian Medical Schools. Candidates who obtained a DO degree must have graduated from a college of osteopathic medicine accredited by the AOA. Have completed the last two years of residency training in the same accredited program. Transfers after the beginning of the second year are approved only in extraordinary circumstances. July/August candidates must complete all training requirements of the ABFM no later than June 30, and December candidates have until November 30. Hold a current, valid, full, and unrestricted license to practice medicine in the United States or Canada. ABS The American Board of Surgery (ABS) grants board certification to qualified applicants. To be eligible for the general surgery board exam, candidates must: 8 A supplement to Briefings on Credentialing 781/639-1872 08/10

Demonstrate to the satisfaction of the program director of an accredited graduate medical education program in general surgery that they have attained the level of qualifications required by the ABS. All phases of the graduate educational process must be completed in a manner satisfactory to the ABS. Have ethical, professional, and moral status acceptable to the ABS. Be actively engaged in the practice of general surgery as indicated by holding admitting privileges to a surgical service in an accredited healthcare organization or be currently engaged in pursuing additional graduate education in a component of surgery or other recognized surgical specialty. An exception to this requirement is active military duty. Hold a currently registered full and unrestricted license to practice medicine in the United States or Canada within six months after completion of general surgery residency. The full set of qualifying requirements are available in the Booklet of Information Surgery. ABCRS ABCGN The ABCRS grants board certification for qualified physicians. To become board certified, surgeons must: Complete an ACGME-accredited residency program in colon and rectal surgery following completion of an approved ACGME or RCPSC general surgical residency program that ultimately leads to ABS certification Have a currently valid registered full and unrestricted license to practice medicine in a state, territory, or possession of the United States or by a Canadian province, and must continue to be licensed throughout the certification process Successfully complete the Qualifying Examination of the ABS before being admitted to the ABCRS Written Examination (Part I) Achieve certification by the ABS before being admitted to the ABCRS Oral Examination (Part II) The ABCGN offers certification for RNs specializing in gastroenterology. Nurses board-certified by the ABCGN receive the CGRN credential. To qualify to take the certification exam, RNs must meet the following requirements: A supplement to Briefings on Credentialing 781/639-1872 08/10 9

At the time of application, candidates must have been employed in clinical, supervisory, administrative, teaching/education, or research capacities in an institutional or private practice setting for a minimum of two years fulltime, or its part-time equivalent of 4,000 hours, within the past five years in GI/endoscopy Work experience must be at the level the candidate is certifying Full-time industry nurses whose focus is at least 40% clinical practice, education, or research are eligible; those whose focus is sales are not Each candidate is required to obtain the signatures of two responsible practitioners in the specialty who can verify his/her work experience and professional qualifications Submit a photocopy of his/her current RN license University of Chicago Medical Center Ira Hanan, MD, is a gastroenterologist and associate professor of medicine in the Division of Gastroenterology and Nutrition at the University of Chicago Medical Center. He is also a gastroenterologist in the school s Inflammatory Bowel Disease Center. Flexible sigmoidoscopy is almost exclusively performed by gastroenterologists, general surgeons, and colon and rectal surgeons, says Hanan, adding that he is not aware of any nonphysicians performing the procedure. Gastroenterologists will perform approximately 300 colonoscopies or flexible sigmoidoscopies during the course of their gastroenterology fellowship, Hanan says. Surgical residents receive limited training in colonoscopy, performing about 25 30 during the residency, which he says gives them adequate training in flexible sigmoidoscopy. To remain competent, Hanan says physicians who do not perform colonoscopies should do at least 10 flexible sigmoidoscopies per year. If a physician does enough colonoscopies, the physician can stay competent in flexible sigmoidoscopy without actually doing any flexible sigmoidoscopies that year. Hanan says he performs about 15 20 flexible sigmoidoscopies per year but also does roughly 800 colonoscopies each year. Gastroenterologists perform fewer flexible sigmoidoscopies now than in the past because so many gastroenterologists now opt for the more comprehensive colonoscopy when screening for colon cancer. Colonoscopy is used far more often for cancer 10 A supplement to Briefings on Credentialing 781/639-1872 08/10

screenings than flexible sigmoidoscopy, Hanan says. Gastroenterologists often perform flexible sigmoidoscopies for other things, such as to examine a patient for ulcerative colitis. At the same time, surgeons are doing more flexible sigmoidoscopies than previously, often to examine a patient after rectal surgery. Hanan says that at his hospital, physicians who obtain privileges to perform flexible sigmoidoscopy are typically required to perform their first procedures at that hospital under supervision if they cannot demonstrate a history of competency. University of Maryland School of Medicine, Baltimore Raymond Cross, MD, MS, is a gastroenterologist and assistant professor of medicine in the University of Maryland School of Medicine s Division of Gastroenterology and Hepatology. He is also director of the school s inflammatory bowel disease program and chief of the GI section of the VA Medical Health Care System Home in Baltimore. Practitioners who perform flexible sigmoidoscopy have typically learned to do so through one of three ways, according to Cross. The most common way applies to gastroenterologists who have completed a residency in internal medicine, then learn how to perform the procedure during a gastroenterology fellowship. The vast majority of those who are doing flexible sigmoidoscopies have taken this path, Cross says. The second pathway applies to surgeons who learn how to perform flexible sigmoidoscopy during their residency program. Although they are trained in the procedure, they typically perform far fewer flexible sigmoidoscopies during their residency because their focus is not on gastroenterological procedures alone, Cross says. The third way applies to physicians who are neither surgeons nor gastroenterologists. It could also apply to nonphysicians in some cases. This route entails performing the procedure under close supervision of a proctor until the proctor declares the person to be competent, which typically requires performing the procedure around 100 150 times. Cross says that there is a physician assistant (PA) at his facility who has been performing flexible sigmoidoscopies for roughly 10 years. That PA earned his privileges after having been supervised on roughly 150 procedures. Cross says that due to the relatively simple nature of flexible sigmoidoscopy, it is possible A supplement to Briefings on Credentialing 781/639-1872 08/10 11

for nonphysicians such as PAs, nurses, and nurse practitioners (NP) to earn privileges specifically for flexible sigmoidoscopy. There is some precedence, he says, noting that facilities that grant privileges to practitioners other than surgeons or gastroenterologists would likely do so because they are in a rural or underserved area. In terms of numbers required to attain competency, Cross says the University of Maryland requires physicians to have performed at least 30 flexible sigmoidoscopy procedures during the course of training, but that is somewhat misleading. Gastroenterologists, he says, will perform many more sigmoidoscopies during the course of their fellowship. Moreover, that 30 also assumes that the physician has done a significant number of other related gastroenterological procedures, such as colonoscopies. Cross says a practitioner needs to do roughly 25 flexible sigmoidoscopy procedures per year to maintain competence, in conjunction with around 25 50 colonoscopies per year. Cross stresses that most gastroenterologists do many more than this each year. However, he adds, maintaining those kinds of numbers is more pertinent to those recently out of training and in the beginning of their medical career. Those numbers will be less relevant for those who have been practicing for a longer period of time. Cross says that flexible sigmoidoscopy is being used less often as a way to screen for cancer as opposed to colonoscopy. That s in part because many patients do not want to undergo such a procedure without sedation, and colonoscopy, which is performed under sedation, is also more thorough as a screening procedure for colon cancer. The Joint Commission The Joint Commission (formerly JCAHO) has no formal position concerning the delineation of privileges for flexible sigmoidoscopy. 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.06.01.03). In the rationale for MS.06.01.03, 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 12 A supplement to Briefings on Credentialing 781/639-1872 08/10

resultant privilege recommendations to the governing body are based on the assessment of the data. 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.06.01.07). In the EPs for standard MS.06.01.07, The Joint Commission says the information review and analysis process is clearly defined. 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 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.08.01.03). In the EPs for MS.08.01.03, 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. CRC draft criteria Minimum threshold criteria for requesting core privileges in flexible sigmoidoscopy The following draft criteria are intended to serve solely as a starting point for the development of an institution s policy regarding this procedure. Basic education: MD, DO, RN, NP, or PA Minimum formal training: Successful completion of an ACGMEor AOA-accredited program in gastroenterology, general surgery, or colon and rectal surgery. If flexible sigmoidoscopy was not included in the residency or fellowship program, the physician must have completed training with an experienced endoscopic physician that included proctored procedures. AND Current certification or active participation in the examination process (with achievement of certification within [n] years) A supplement to Briefings on Credentialing 781/639-1872 08/10 13

leading to certification by the appropriate board is required. OR Successful completion of an accredited PA or nursing program that included training in flexible sigmoidoscopy. Required previous experience: Applicants for initial appointment must demonstrate current competence and evidence of the performance of at least 30 flexible sigmoidoscopy procedures in the previous 12 months. RNs, NPs must demonstrate current competency and evidence of the performance of at least 50 flexible sigmoidoscopy procedures under the supervision of a skilled physician endoscopist. References: A letter of reference should come from the director of the applicant s residency or fellowship training program or from the director of the applicant s PA or NP program. Alternatively, a letter of reference regarding competence should come from the physician who supervised the flexible sigmoidoscopy procedures. Reappointment Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanisms. Applicants must demonstrate that they have maintained competence by showing evidence that they have successfully completed at least 30 flexible sigmoidoscopy procedures, reflective of the scope of privileges requested, annually over the reappointment cycle based on the results of ongoing professional practice evaluation and outcomes. In addition, continuing education related to flexible sigmoidoscopy should be required. For more information For more information regarding this procedure, contact: Accreditation Council for Graduate Medical Education 515 North State Street, Suite 2000 Chicago, IL 60654 Telephone: 312/755-5000 Fax: 312/755-7498 Website: www.acgme.org 14 A supplement to Briefings on Credentialing 781/639-1872 08/10

The American Board of Colon and Rectal Surgery 20600 Eureka Road, Suite 600 Taylor, MI 48180 Telephone: 734/282-9400 Fax: 734/282-9402 Website: www.abcrs.org American Academy of Family Physicians 11400 Tomahawk Creek Parkway Leawood, KS 66211-2672 Telephone: 800/274-2237 Fax: 913/906-6075 Website: www.aafp.org American Board of Certification for Gastroenterology Nurses 401 North Michigan Avenue Chicago, IL 60611 Telephone: 800/245-7462 Fax: 312/673-6723 Website: www.abcgn.org American Board of Family Medicine 2228 Young Drive Lexington, KY 40505-4294 Telephone: 859/269-5626 or 888/995-5700 Fax: 859/335-7501 or 859/335-7509 Website: www.theabfm.org American Board of Internal Medicine 510 Walnut Street, Suite 1700 Philadelphia, PA 19106-3699 Telephone: 215/446-3500 Website: www.abim.org American Board of Surgery, Inc. 1617 John F. Kennedy Boulevard, Suite 860 Philadelphia, PA 19103-1847 Telephone: 215/568-4000 Fax: 215/563-5718 Website: www.absurgery.org A supplement to Briefings on Credentialing 781/639-1872 08/10 15

American College of Osteopathic Internists 3 Bethesda Metro Center, Suite 508 Bethesda, MD 20814 Telephone: 301/656-8877 Fax: 301/656-7133 Website: www.acoi.org American Osteopathic Association 142 East Ontario Street Chicago, IL 60611 Telephone: 800/621-1773 Fax: 312/202-8200 Website: www.osteopathic.org American Society of Colon and Rectal Surgeons 85 West Algonquin Road, Suite 550 Arlington Heights, IL 60005 Telephone: 847/290-9184 Fax: 847/290-9203 Website: www.fascrs.org American Society for Gastrointestinal Endoscopy 1520 Kensington Road, Suite 202 Oak Brook, IL 60523 Telephone: 630/573-0600; 866/353-2743 Fax: 630/573-0691 Website: www.asge.org Society of American Gastrointestinal Endoscopic Surgeons 11300 West Olympic Boulevard, Suite 600 Los Angeles, CA 90064 Telephone: 310/437-0544 Fax: 310/437-0585 Website: www.sages.org Society of Gastroenterology Nurses and Associates/American Board of Certification for Gastroenterology Nurses 401 North Michigan Avenue Chicago, IL 60611-4267 Telephone: 800/245-7462; 312/321-5165 Fax: 312/673-6694 Website: www.sgna.org 16 A supplement to Briefings on Credentialing 781/639-1872 08/10

The Joint Commission One Renaissance Boulevard Oakbrook Terrace, IL 60181 Telephone: 630/792-5000 Fax: 630/792-5005 Website: www.jointcommission.org The University of Chicago Medical Center 5841 South Maryland Avenue Chicago, IL 60637 Telephone: 773/702-3230 Fax: 773/702-2182 Website: www.uchospitals.edu The University of Maryland Medical Center 22 South Greene Street Baltimore, MD 21201-1595 Telephone: 410/492-5538 Website: www.umm.edu A supplement to Briefings on Credentialing 781/639-1872 08/10 17

Privilege request form Flexible sigmoidoscopy To be eligible to request clinical privileges in flexible sigmoidoscopy, an applicant must meet the following minimum threshold criteria: Basic education: MD, DO, RN, NP, or PA Minimum formal training: Successful completion of an ACGME- or AOA-accredited program in gastroenterology, general surgery, or colon and rectal surgery. If flexible sigmoidoscopy was not included in the residency or fellowship program, the physician must have completed training with an experienced endoscopic physician that included proctored procedures. AND Current certification or active participation in the examination process (with achievement of certification within [n] years) leading to certification by the appropriate board is required. OR Successful completion of an accredited PA or nursing program that included training in flexible sigmoidoscopy. Required previous experience: Applicants for initial appointment must demonstrate current competence and evidence of the performance of at least 30 flexible sigmoidoscopy procedures in the previous 12 months. RNs and NPs must demonstrate current competency and evidence of the performance of at least 50 flexible sigmoidoscopy procedures under the supervision of a skilled physician endoscopist. References: A letter of reference should come from the director of the applicant s residency or fellowship training program or from the director of the applicant s PA or NP program. Alternatively, a letter of reference regarding competence should come from the physician who supervised the flexible sigmoidoscopy procedures. Reappointment: Reappointment should be based on unbiased, objective results of care according to the organization s existing quality assurance mechanisms. Applicants must demonstrate that they have maintained competence by showing evidence that they have successfully completed at least 30 flexible sigmoidoscopy procedures, reflective of the scope of privileges requested, annually over the reappointment cycle based on the results of ongoing professional practice evaluation and outcomes. In addition, continuing education related to flexible sigmoidoscopy should be required. 18 A supplement to Briefings on Credentialing 781/639-1872 08/10

I understand that by making this request, I am bound by the applicable bylaws or policies of the hospital, and hereby stipulate that I meet the minimum threshold criteria for this request. Practitioner s signature: Typed or printed name: Date: A supplement to Briefings on Credentialing 781/639-1872 08/10 19

Editorial Advisory Board Clinical Privilege White Papers Associate Group Publisher: Erin Callahan, ecallahan@hcpro.com Associate Editor: Julie McCoy, jmccoy@hcpro.com 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, TX Jack Cox, MD Senior Vice President/Chief Quality Officer Hoag Memorial Hospital Presbyterian Newport Beach, CA Stephen H. Hochschuler, MD Cofounder and Chair Texas Back Institute Phoenix, AZ Bruce Lindsay, MD Professor of Medicine Director, Cardiac Electrophysiology Washington University School of Medicine St. Louis, MO Beverly Pybus Senior Consultant The Greeley Company, a division of HCPro, Inc. Marblehead, MA Richard A. Sheff, MD Chair and Executive Director The Greeley Company, a division of HCPro, Inc. Marblehead, MA 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 2010 HCPro, Inc., Marblehead, MA 01945. 20 A supplement to Briefings on Credentialing 781/639-1872 08/10