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Hospital Credentialing Guidelines

OBJECTIVE

Develop a strategy to aid practicing oral and maxillofacial surgeons (OMS) in successful application for hospital surgical privileges.

PREAMBLE

Fundamental understanding of the processes involved in gaining hospital surgical privileges for the practicing OMS should follow a specific outline which ensures adequate preparation prior to the actual application processes. These are reflected in various levels in the Addendum attached to this document, and can be highlighted as:

  1. Documentation of literature review, videotape, and observational experiences (preferably within accredited or recognized programs with certificates);
  2. Documentation of accredited CME and recognized didactic and didactic-dissection coursework (preferably dedicated to privileges being sought) ;
  3. Participation in recognized observation training programs in facilities that have recognized residency or fellowship programs that offer certificates or a letter of confirmation from program director;
  4. Documentation of oral and maxillofacial surgeons serving as first assistant or cosurgeon on multiple cases with a surgeon who currently has credentials to perform such procedures within the hospital setting;
  5. Documentation of oral and maxillofacial surgeons serving as primary surgeon on multiple cases, under the supervision of a surgeon who currently has credentials to perform such procedures within the hospital setting . It is recommended that a proctoring form or confirmation letter be obtained from the supervising surgeon, confirming the experience and quality of performance.

(NOTE: Documentation should include surgical log, operative dictation, and standardized photographic documentation of pre- and post-operative cases incorporated into a 3-ring binder and/or in electronic format.)

SEQUENTIAL STRATEGY

  1. Preliminary Considerations
  2. Preparation of Presentation Portfolio
  3. Local Hospital Rules, Regulations, and Bylaws including Due Process
  4. Documentation of Educational and Clinical Experience
  5. Appeals Process and Legal Considerations
  1. PRELIMINARY CONSIDERATIONS
    1. Review states Dental Practice Act and pertinent laws/regulations to ascertain compliance with existing state statutes pertaining to the specific surgical privileges desired.
    2. Usually prudent to initiate discussion with your State Dental Association, State Board of Dentistry, OMS State organization, and local OMS practitioners regarding your intentions. This will preclude many potential misunderstandings that may arise during the application process, and may be pertinent when some of these agencies may be contacted by your hospital or other individuals concerning your efforts or application.
    3. Carefully evaluate your area hospital relative to the most favorable situation and medical staff relationships prior to any application or contacts. It is recommended to approach only one hospital unless economic or logistic circumstances dictate otherwise.
    4. Be certain that the current definition and scope statement of OMS is addressed in the Dental/OMS Department/Committee, and written acceptance placed in the minutes.
  2. PREPARATION OF PRESENTATION PORTFOLIO

    Provide a portfolio to include: comprehensive surgical log (patient identifier in compliance with HIPAA, date, surgeon or assistant, location, list of specific diagnosis, list of specific procedures performed); current CME within curriculum vitae and copies of certificates or agenda of subjects/experiences; standardized photographs pre- and postsurgery of, at least, all cases as primary surgeon; copies of proctor evaluations and/or certification letters provided by credentialed surgeon(s) involved in your clinical experiences.

  3. LOCAL HOSPITAL RULES, REGULATIONS, BYLAWS
    1. Review and become thoroughly knowledgeable about the hospital’s Medical/Dental Staff structure, rules, regulations, and bylaws, particularly regarding items of credentialing, denial of privileges, the appeal process, and expectations of membership.
    2. Become familiar with medical staff standards of the hospital’s accrediting organization. (The Joint Commission, the Health Facilities Accreditation Program, and DNV Healthcare are currently recognized as national accreditation programs that meet the Medicare Conditions of Participation for Hospitals.)
    3. Become knowledgeable about specific regulations or rules relative to extension of additional privileges and by which committee and process your application will be reviewed. Some hospitals have no such protocol or precedents, but are managed on case-by-case basis.
    4. Become familiar with the staff political structure and activity level of pertinent staff members.
    5. Develop a working relationship with the Chief of the OMS Dental Department, or equivalent, before beginning the application process. Dialog at this level may be essential to your ultimate success.
    6. Know the exact make-up of the pertinent committees such as Surgery, Credentials, Medical Executive, Board of Directors, and the Hospital Administration. You should try to determine as much as possible the names, specialty, and training.
    7. Make an effort to establish relationships with as many of the individuals mentioned above as is practical, including conversations relative to how staff members go about obtaining additional privileges with continuing education (e.g., liposuction, laser treatment, etc.)
    8. Determine the annual financial contributions of in-hospital surgery performed by you and/or your associates. This is a potentially important issue relative to the Administration’s support and willingness to help facilitate the application process. i. Perform procedures in the hospital(s) to ensure there are performance data for the reprivileging process.
  4. DOCUMENTATION OF EDUCATIONAL AND CLINICAL EXPERIENCE FOR NON-CORE PRIVILEGES
    1. Maintain concise and complete documentation of any and all pertinent education, dissection experience, and clinical activities to justify request.
    2. Determine current recommendations by equipment vendors if applicable.
    3. Determine any current recommendations by the American College of Surgeons or other appropriate bodies.
    4. Determine if the privilege is offered at other nearby hospitals and what their criteria is if any
    5. Determine specific numerical or other criteria, which would be desired by the committee(s) concerned with privileging in OMS or any other surgical specialties requesting addition of specific procedure privileges that cross specialty lines. If no guidelines exist, it is important to see that the same criteria that will apply to your application be applied uniformly for future requests for privileges by staff members of any specialty.
    6. When the application process begins, consider requesting attendance at the Credentials, Medical Executive , or other committee(s) meeting(s) where your request for additional privileges is presented. A slide presentation and personal answers to any questions may be advisable.
  5. APPEALS PROCESS AND LEGAL CONSIDERATIONS WITH PARTICULAR ATTENTION TO DENIAL OF NON-CORE (ADDTIONAL) PRIVILEGES
    1. It may be advantageous to seek legal advice with experienced counsel (specific expertise in hospital and privileging matters) from the beginning of your application process for additional privileges. This advice may provide you with specific items to be considered, statutes which affect your application rights, and the components and format of ideal documentation methods which may vary by state.
    2. If the original request for additional privileges is denied, you should request, in writing, the specific reasons for their denial and the type of denial (i.e. administrative, etc.) Transmit all communications to your hospital in a timely fashion by registered or certified mail.
    3. All communications (phone, verbal, or otherwise) should be carefully documented soon after their occurrence. It is advised you maintain a very detailed, written diary, which identifies the parties, date, time, and details.
    4. All conversations should be followed by a written reiteration of the content to the appropriate source so that any objections to your interpretation will be identified.
    5. Review the Medical Staff Bylaws for appeals process regarding denial or limitation of privileges, and the National Practitioner Data Bank (NPDB) reporting requirements as they apply.
    6. Initiate your appeal, in accordance with your hospital’s bylaws, in a timely manner in consultation with your legal counsel.
    7. The ADA Council on Access, Prevention and Interprofessional Relations (CAPIR) has been informed by the AMA that administrative denials of privileges are not reportable. A letter from HCFA and NPDB criteria explain and support this position.
    8. If there is to be an administrative appeal, your legal counsel is essential to ensure your rights. This appeal pathway mechanism is mandatory before any actual filing of legal action is appropriate.
    9. AAOMS should be kept informed of your circumstances and be provided copies of all materials pertaining to your experiences. This will facilitate assistance from AAOMS to you and your legal counsel in your efforts to obtain additional privileges.
    10. In any appeals process, it is strongly recommended that you request to record or otherwise transcribe the events associated with the process, and to bring legal counsel with you to any meetings.
    11. Consider legal intervention on the basis of restraint of trade issues, and discriminatory credentialing in a non-uniform manner without due process.
CREDENTIALING IN MAXILLOFACIAL COSMETIC SURGERY
Example

In recent years the specialty of OMS has evolved into multiple areas of surgical interest and expertise in response to the needs and requirements of the patients served. Esthetic and cosmetic surgical procedures have been performed by oral and maxillofacial surgeons as a primary procedure for over two decades. These procedures include, but are not limited to, forehead/browlifting, blepharoplasty, facelifting, rhinoplasty, skeletal alloplastic augmentation, otoplasty, scalp reduction and hair transplants, scar and skin flap procedures. In addition, other adjunctive procedures such as liposculpture, mechanical and chemical abrasion, collagen injections, etc., are recognized procedures by OMS.


If a practicing OMS elects to obtain additional education and clinical experience in the area of esthetic (purely cosmetic) surgery, it is suggested that the review of the AAOMS recommendations for hospital credentialing be followed. The process should include appropriate documentation of experience and may, at the minimum, include the following:

  1. Proof of education and training in each of the specific procedures requested. This can either be in a letter from the OMS Residency or Fellowship Director, or from appropriate documented experiences with qualified surgeons. It is recommended that such documents contain language relative to the fact that the OMS has completed certain guidelines suitable to allow the director or faculty to use the terms “experienced in the following” or, preferably, to state “in his/her experience, that said OMS is currently TRAINED TO COMPETENCE in specific procedures.”
  2. Documentation and certificates from all CME, Observational Teaching Programs, etc., should be meticulously maintained. It is suggested that a minimum of 50 hours of CME be documented in the form of didactic-dissection courses dedicated to the subject of esthetic surgery.
  3. A detailed surgical log of all experiences should be maintained for any and all cases having esthetic components.
  4. It has been suggested that OMS should accumulate a minimum of five (5) experiences as primary surgeon, assisted or supervised by a credentialed surgeon as first assistant for each procedure in which the OMS is requesting privileges. The credentialed first assistant or supervisory surgeon should be expected to provide written confirmation of this fact, and a proctoring-type review of performance in each instance to cover diagnosis, treatment planning, surgical management, and clinical outcome.

 

ADDENDUM

LEVEL ONE: Documentation of literature review, videotape review, and appropriate textbook acquisition.

LEVEL TWO: Documentation of completion of CME credits in accredited didactic coursework, to include pure “dedicated” (i.e. subject specific) courses offered within and out of specialty.

LEVEL THREE: Documentation of completion of accredited didactic-dissection (e.g. surgical skills workshop with hands-on experiences) courses, provided by clinicians who are appropriately credentialed (i.e. hospital privileges for all procedures presented and in a Q/A-PRO setting) and recognized experts in the particular areas of clinical interest.

LEVEL FOUR: Documentation of completion of observational training programs which are formally recognized (by AACS, AAFRS, AAOMS, or ASPRS) or their equivalent, and provided by clinicians who are appropriately credentialed (as above) and recognized experts in the particular areas of clinical interest.

LEVEL FIVE: Documentation of completion of actual surgical experiences on patients, acting in the capacity of assistant surgeon (first assist) or co-surgeon, where the primary surgeon is appropriately credentialed (as above) and preferably in a Q/A-PRO setting.

LEVEL SIX: Documentation of multiple surgical experiences as the primary surgeon, actually first assisted or closely supervised by a surgeon who is appropriately credentialed (as above) and who is recognized to be surgically competent in that area of clinical interest. The “consultant” surgeon(s) would be expected to provide written substantiation of such experiences within levels five and six. It is recommended that procedure specific accreditation be provided such that the “consultant” will verify that the surgeon-in-training has substantial experience, or, preferably that, in the opinion of the consultant, the surgeon has been “trained to competence” in particular area(s).

LEVEL SEVEN: Documentation of actual surgical experience as primary surgeon in an outpatient setting (i.e. surgicenters, clincial surgical suites, or ambulatory “day” surgery facility). It is at this point that the surgical experience and training becomes commensurate with submission of application for hospital privileges.

LEVEL EIGHT: The surgeon has hospital privileges to perform such surgery within a hospital which is accredited by a CMS-approved accrediting organization, and thereby operating in a documented Q/A-PRO setting.

Guidelines (levels seven and eight) exclude residents completing oral and maxillofacial surgery training who can fulfill only levels 1-6 of the guidelines as they cannot legally function as a primary surgeon during residency.