VERIFICATION SURGEON The American College of Surgeons Children s Surgery Verification Program R. Lawrence Moss, MD Surgeon-in-Chief Nationwide Children's Hospital E. Thomas Boles Jr., Professor of Surgery The Ohio State University, College of Medicine 1
Disclosures I am on the scientific advisory board of Avexegen, a company with a potential therapy for NEC. I will not discuss their products during this presentation. 2
WHAT WILL BE NEEDED FOR THE APPLICATION? WHAT HAPPENS DURING THE SITE VISIT? 3
The Application Process REQUIREMENTS FOR SURGEONS Board Certification or Equivalent Clinical Involvement Performance Improvement and Patient Safety (PIPS) Education Regional or National Commitment The MDCS must have the responsibility and authority to ensure compliance 4
BOARD CERTIFICATION Board Certification or eligibility by the ABS, relevant board of the ABMS, or equivalent (Bureau of Osteopathic Specialists and Board of Certification, Royal College of Physicians and Surgeons of Canada) Eligible surgeons must be credentialed by the applicant organization 5
BOARD CERTIFICATION Must be certified within 7 years after successful completion of an ACGME approved or Canadian residency Alternate pathway is available on a case by case basis and, in general, requires that at least 30% of the surgeon s case volume is in pediatric specialty surgery and that all other conditions are met 6
CONDITIONS FOR ALTERNATE PATHWAY 1. Evidence of residency completion with the time period consistent with the years of training in the US for that specialty 2. PALS provider completion 3. 48 hours of specialty specific CME in 3 years 4. Membership/attendance at specialty meetings for the immediate 3 years 5. Clinical practice is at least 30% pediatric specialty surgery and includes children <2 years 6. Full and unrestricted license to practice medicine 7. Appropriate QI review/documentation for the provider 7
PRQ 5.1 Levels I, II, III Does the applicant center s credentialing body of the hospital ensure that qualifications of the practicing providers are current, specific, and correlate with specific privileges for the care of children? Y/N Briefly describe how this is done for both initial credentialing and for re-credentialing 8
CLINICAL INVOLVMENT Children s surgeons must have specific children s DOP and provide the bedside care for such children (CD5-2) Participation in the organization of protocols, teams, call rosters, and rounds Maintenance of surgical skills by participation in elective and emergency surgery Periodic re-credentialing (CD 5-3) 9
CLINICAL INVOLVMENT Delineation of Privileges There should be specific DOPs for each specialty that separate: the core privileges for someone who trained in general surgery or a surgical specialty without specific training for children the core privileges for a surgeon who trained in pediatric general surgery or a surgical specialty with specific pediatric training and certificate documentation or board examination and is credentialed to care for children < 2 years old 10
CLINICAL INVOLVMENT Delineation of Privileges There must be specific DOPs for specialties with other expertise and clear delineation of age limits for credentialing, e.g. transplantation, bariatric surgery There must also be clear prerequisites for call coverage/transfer when the pediatric specialist is not available and a pediatric emergency arises 11
PRQ 5.2 Levels I, II, III Do all surgical specialists at the applicant center have institutional credentials for specific privileges for operative procedures to be done in children (Delineation of Privileges)? Y/N Describe the process to credential children s specialty surgeons Describe the process to credential highly specialized procedures in children to ensure appropriate expertise and ongoing experience 12
PRQ 5.3 Levels I, II, III Do all surgeons remain actively involved in clinical surgery? Y/N You will also show this standard has been met by completing the SURGEON TABLE Describe the applicant center s policy and practice with regard to re-credentialing Satisfied by participation in elective and emergency surgery in the applicant organization 13
CLINICAL INVOLVMENT CALL REQUIREMENTS LEVEL I: Pediatric surgeons and anesthesiologists must be dedicated to the center when on call LEVEL II: Pediatric surgeons and anesthesiologists must be available on a consultant basis to care for a patient within 60 minutes of request LEVEL III: These requirements may be met by GS and anesthesiologists with pediatric expertise 14
PRQ 5.4 Level I Are the pediatric surgeons and pediatric anesthesiologists on call at the applicant center exclusively dedicated to the center while on call? Y/N If No, briefly explain 15
PERFORMANCE IMPROVEMENT AND PATIENT SAFETY (PIPS) LEVELS I, II, III: there must be a multidisciplinary peer review process with leadership by the MDCS or designee and representatives from anesthesiology and all relevant surgical and medical specialties for scope of service Goal is improvement of surgical care by review of deaths, complications, sentinel events, identifying issues and developing appropriate responses 16
PEER REVIEW VS PIPS AHRQ, with responsibilities for implementing the Patient Safety Act, issued new guidance that reversed previous positions on when information can be considered Patient Safety Work Product A few states will not have privilege protections for incident reports, quality or peer review, or cause analyses The MDCS should include risk management and the hospital legal team when developing the surgical review process for this program 17
PRQ 10.4 Levels I, II, III At the applicant center, does the medical director of children s surgery, the liaison representatives from each of the surgical subspecialties performing children s surgery, as well as the liaison of medical director of pediatric anesthesiology, emergency medicine, and radiology accrue an average of 16 hours annually or 48 hours in 3 years of related external Category 1 CME? Y/N You will also show this standard has been met by completing the SURGICAL PROGRAM LEADERSHIP AND PIPS COMMITTEE TABLE 18
PRQ 10.5 Levels I, II, III At the applicant center, are all members of children s surgical specialties who take call knowledgeable and current in the care of children with surgical needs, as evidenced by documenting participation in an internal educational process conducted by the children s surgical program and the specialty liaison based on the principles of practice-based learning and the PI and patient safety program or by meeting MOC requirements of the respective specialty board? Y/N You will also show this standard has been met by completing the SURGEON TABLE 19
EDUCATION LEVEL I, II: external CME recommended MDCS - 48 hr in 3 yr of relevant 1 children s surgical Category 1 Programs by guest professors considered Category 1 All other surgeons can be combination of external or internal CME 16 hr/yr average 1. Relevant CME is defined as specialty specific CME for the provider and representative of his/her practice 20
REGIONAL OR NATIONAL COMMITMENT Membership and active participation in regional or national organizations relevant to children s surgery essential for the MDCS and the MDCA in Level I, II desirable in Level III recommended for all surgeons 21
The Site Visit: will you need to be there and what will happen? Chart review process Interviews with chiefs of service and MDCS Site visit dinner Hospital tour Exit interview 22