Protect yourself with good documentation
Protect yourself with good documentation
Documentation is critical when the issue is granting privileges to surgeons, but what happens when the surgeon is literally the first or one of a very few in the country to perform a procedure?
Documenting the decision to allow a new procedure is a challenge because the review committee may have to rely on scientific literature and anecdotal results from other facilities, says Jack Zusman, MD, a professor at the University of South Florida in Tampa.
The first step in documenting the process your facility has undertaken is reviewing the procedure or the technology to show that a committee of medical staff, such as a credentialing committee or a management committee, has properly evaluated the surgeon’s request. "This proof can take the form of minutes of the meeting," says Zusman. The minutes must show that the committee considered scientific reports, medical journal literature, manufacturer’s information, and existing surgery program policies to arrive at the decision. Another good idea is to attach the literature that was considered, he adds.
In addition to the minutes of the meetings needed to make a decision, an attachment that clearly defines the policy governing the privilege should be developed. This policy should define training and proctoring requirements if necessary, says Zusman.
If it is a new procedure, be sure to ask if it is research, he warns. "If it is research, patients need to be told that it is research for full, informed consent."
If your policy requires a proctor in addition to training for a new procedure, it may be difficult to find a proctor for this requirement. Some facilities bring an expert to their facility to proctor surgeons learning a new procedure while other facilities will send their physicians to another facility to be proctored at the expert’s facility, says Zusman.
While telemedicine promises the lower cost option of video proctoring, there are problems with this method, warns Zusman. "Not only do you have to investigate the different regulations within each state because some states do not allow telemedicine broadcasts outside of the state, but you also have to consider that something can go wrong during the surgery. How does a proctor who is not in the room step in to help when the unexpected happens?" he asks.
The best thing to do during any type of credentialing or privileging process is to document every detail, advises Zusman. "Make sure that anyone looking at your documentation can see that the issue was fully evaluated and the decision-making process was logical and based on fact."
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