Practice area 127

CLINICAL PRIVILEGE WHITE PAPER

Colon and rectal surgery

Background

Colon and rectal surgery is the medical specialty that is dedicated to the treatment of
patients with diseases and disorders affecting the colon, rectum, and anus. Colon and
rectal surgeons, in addition to proficiency in the field of general surgery, acquire particu-
lar skills and knowledge with regard to the medical and surgical management of diseases
of the intestinal tract, anal canal, and perianal area. They also acquire special skills in the
performance of endoscopic procedures of the rectum and colon.

Colon and rectal surgeons are trained to deal with conditions such as colon and rectal
cancer, polyps, inflammatory bowel disease, diverticulitis, as well as anal conditions such
as hemorrhoids, fissures, abscesses, and fistulas. Training in the specialty also provides
the physicians with in-depth knowledge of intestinal and anorectal physiology required
for the treatment of problems such as constipation and incontinence. In addition, they
deal with other organs and tissues such as the liver, urinary, and female reproductive
system involved with primary intestinal disease.

Surgeons who specialize in colon and rectal surgery must complete a minimum of five
years of an accredited program in general surgery. They then must complete a training
program in colorectal surgery that is accredited by the Accreditation Council for Grad-
uate Medical Education (ACGME). The period of training should be one year, and the
program must comply with the institutional requirements for residency training.

The educational program must also include training in both diagnostic and therapeutic
colonoscopy. The objective is to develop the necessary competence in the use of this
procedure to qualify as an expert in the field. Therefore, adequate numbers of both
diagnostic and therapeutic colonoscopies must be available either in the colon and rec-
tal training program or through an appropriate institutional affiliation that can satisfy
this requirement.

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Colon and rectal surgery Practice area 127

Involved specialties Colorectal surgeons, endoscopic surgeons, general surgeons,

and pediatric surgeons

Positions of societies The Society of American Gastrointestinal Endoscopic Surgeons

and academies (SAGES), the American Society for Gastrointestinal Endoscopy
SAGES, ASGE, ASCRS (ASGE), and the American Society of Colon and Rectal Sur-
geons (ASCRS) jointly prepared and endorsed the consensus
statement Principles of Privileging and Credentialing for Endoscopy
and Colonoscopy.

The statement includes the following sections:

Preamble
Privileging or credentialing for the performance of esopha-
gogastroduodenoscopy (EGD) and colonoscopy should be
based on prior demonstration of proficiency in the perform-
ance of these procedures. Proficiency should be substantiated
by documentation provided by the applicant from residency
program directors, chiefs of service, or other members of the
teaching faculty who have directly observed the applicant per-
forming endoscopy.

Individuals applying for privileges for EGD and colonoscopy

should have demonstrated satisfactory completion of an
ACGME-accredited training program in adult or pediatric gas-
troenterology, general surgery, colorectal surgery, or pediatric
surgery.

Attestation to competency in the performance of these tech-

niques should therefore be provided by the program director
and, if deemed necessary, by the credentialing or privileging
committee at the institution at which these privileges are
being sought or by other teaching faculty from the applicants
residency program. In the case of applicants who already have
privileges to perform these procedures and are applying for
similar privileges at another facility or for renewal of privi-
leges at the same facility, attestation of competency should be
provided by the applicants chief of service.

Uniformity of standards
Uniform standards should be developed that apply to all hos-
pital staff requesting privileges to perform endoscopy and to
all healthcare facilities where endoscopy is performed. Criteria
must be established that are medically sound and that are

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applicable to all those wishing to obtain privileges in each spe-

cific endoscopic procedure. The goal must be the delivery of
high-quality patient care.

Specificity of privileging for EGD and colonoscopy

Privileges should be granted 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.

Formal residency training in surgery or gastroenterology

The ACGME has mandated that programs in surgery and gas-
troenterology must provide experience to each resident in the
performance of EGD and colonoscopy.

Endoscopic training and experience outside a formal residency pro-

gram after satisfactory completion of an ACGME-accredited general
surgery, pediatric surgery, colorectal surgery, gastroenterology, or the
equivalent
Equivalent training and/or experience obtained outside a for-
mal program is recognized, but must be at least equal to that
obtained in surgery and gastroenterology programs. Certifica-
tion 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 with-
out supervision, and the actual observed competency of the
applicant for each endoscopic procedure for which privileges
are requested. It is no longer acceptable for physicians to ac-
quire equivalent endoscopic experience by performing unsu-
pervised procedures when skilled endoscopists are available in
the medical community.

New procedures
Self-training in new techniques in gastrointestinal endoscopy
must take place on a foundation of basic endoscopic skills.
The endoscopist should recognize when additional training is
necessary.

Proctoring
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 verified adequately by submitted written material.

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Colon and rectal surgery Practice area 127

The procedural details of proctoring should be developed by

the credentialing body of the healthcare facility and provided
to the applicant. Proctors may be chosen from existing endo-
scopy staff or solicited from endoscopic societies.

Monitoring of endoscopic performance

To assist the healthcare facility credentialing body in the
ongoing renewal of privileges, a mechanism should be in
place whereby each endoscopists procedural performance is
monitored. This should be done through existing quality as-
surance mechanisms or, alternatively, through a multidiscipli-
nary endoscopy committee. This should include monitoring
endoscopic utilization, diagnostic and therapeutic benefits to
patients, complications, and tissue review in accordance with
previously developed criteria.

Continuing education
Continuing medical education related to endoscopy should be
required as part of the periodic renewal of endoscopic privi-
leges. Participation in local, national, or international meet-
ings and courses is encouraged.

Renewal of privileges
For the renewal of privileges, an appropriate level of continu-
ing clinical activity should be required in addition to satisfac-
tory performance as assessed by monitoring of procedural
activity through existing quality assurance mechanisms as
well as continuing medical education relating to gastrointesti-
nal endoscopy.

The ASGE also publishes the statement Methods of Granting

Hospital Privileges to Perform Gastrointestinal Endoscopy. In the
statement, the ASGE says training in endoscopic techniques
must be adequate for each major category of endoscopy for
which privileges are requested. Performance of an arbitrary
number of procedures does not guarantee competency.
Whenever possible, competence should be determined by
objective criteria and direct observation.

The number of supervised procedures necessary to obtain

competency will vary tremendously between trainees. Re-
quired numbers of procedures are an estimate of the thresh-
old number of procedures that must be performed before
competency can be assessed. The number represents a mini-
mum, and it is understood that most trainees will require

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Colon and rectal surgery Practice area 127

more but never less than the stated number.

The following are the minimum numbers of standard endoscopic pro-

cedures required before competency can be assessed:

 30 flexible sigmoidoscopies
 130 diagnostic EGDs
 140 total colonoscopies
 30 snare polypectomies
 25 nonvariceal hemostases (upper and lower), which
include 10 active bleeders
 20 variceal hemostases, which include five active bleeders
 20 esophageal dilations with guide wire
 15 percutaneous endoscopic gastrostomies

Positions of other The American Board of Colon and Rectal Surgery (ABCRS)
interested parties issues certification in colon and rectal surgery to candidates
ABCRS who meet all its general requirements, professional qualifica-
tions, and successfully complete the examinations.

General requirements
Candidates must meet the following ABCRS general
requirements:

 Appear personally and submit to the required examinations

 Limit the majority of their practice to colon and rectal
surgery
 Deliver, if required, sufficient case reports to demonstrate
proficiency in colon and rectal surgery
 Submit, if requested, a bibliography of published papers
and books
 Satisfy requirements in regard to moral and ethical fitness
and show conformity with the Statements on Principles of the
American College of Surgeons and the Principles of Medical Ethics
of the American Medical Association

Professional qualifications
Candidates must have the following professional
qualifications:

 Completed an ACGME-approved residency program in

colon and rectal surgery following completion of general
surgical training in an ACGME approved residency program.

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Colon and rectal surgery Practice area 127

 Hold a current, valid, registered, full, and unrestricted

license to practice medicine in a state, territory, or posses-
sion of the United States or a Canadian province, and con-
tinue to be licensed throughout the certification process
 Successful completion of the qualifying examination of the
American Board of Surgery (ABS) before being admitted to
the ABCRS written examination
 Achieve certification by the ABS before being admitted to
the ABCRS oral examination

The certificate granted by the ABCRS does not confer privi-

lege or license to practice colon and rectal surgery but is evi-
dence that a physicians qualifications for specialty practice are
recognized by his or her peers. It is not intended to define the
requirements for membership on hospital staffs, gain special
recognition or privilege for its diplomates, define the scope of
specialty practice, or state who may or may not engage in the
practice of the specialty.

JCAHO The Joint Commission on Accreditation of Healthcare Organ-

izations (JCAHO) has no formal position on the delineation of
privileges in colon and rectal surgery. However, in its 2005
Comprehensive Accreditation Manual for Hospitals, the JCAHO
states (MS.4.10), The organized medical staff has a creden-
tialing process that is defined in the medical staff bylaws.

In the rationale for MS.4.10, the JCAHO says credentials

review is the process of obtaining, verifying, and assessing the
qualifications of an applicant to provide patient care, treat-
ment, and services for a healthcare organization. The creden-
tials review process is the basis for making appointments to
membership of the medical staff; it also provides information
for granting clinical privileges to licensed independent practi-
tioners (LIPs) and other practitioners credentialed and privi-
leged through the hospitals medical staff process.

The JCAHO further states (MS.4.20), There is a process for

granting, renewing, or revising setting-specific privileges.

In the rationale for standard MS.4.20, the JCAHO says essen-

tial information needs to be gathered in the process of granti-
ng, renewing, or revising clinical privileges. The information
will dictate the type(s) of care, treatments, and services or
procedures that a practitioner will be authorized to perform.
Privileges are setting-specific because they require considera-

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Colon and rectal surgery
CRC draft criteria
Minimum threshold criteria
for requesting core privileges
in colon and rectal surgery
Practice area 127
tion of setting characteristics, such as adequate facilities,
equipment, number, and type of qualified support personnel
and resources.
Setting-specific decisions mean that privileges granted to an
applicant are based not only on the applicants qualifications,
but also on consideration of the procedures and types of care,
treatment, and services that can be performed within the pro-
posed setting. All LIPs are privileged through the medical staff
process.
The JCAHO further states (MS.4.40), At the time of renewal
of privileges, the organized staff evaluates individuals for their
continued ability to provide quality care, treatment, and serv-
ices for the privileges requested as defined in the medical staff
bylaws.
In the rationale for MS.4.40, the JCAHO says the process for
renewal of privileges involves the same steps as those outlined
under standard MS.4.20 for granting initial privileges, and it
additionally requires the medical staff to evaluate practition-
ers ability to perform the privileges requested based on their
performance during the period of time they have been prac-
ticing at the organization. A hospital reviews the performance
of each practitioner for every setting under the control of the
hospital where the individual practices. Current competence is
determined by the results of performance improvement activi-
ties and peer recommendations.
Evidence of current ability to perform privileges requested is
required of all applicants for renewal of clinical privileges.
The following draft criteria are intended to serve solely as a
starting point for the development of an institutions policy
regarding this practice area.
Basic education: MD or DO
Minimum formal training: Applicants must be able to demonstrate
completion of an ACGME/AOA-accredited training program
in general surgery followed by completion of an accredited
program in colon and rectal surgery.
Required previous experience: Applicants must be able to
demonstrate that they have performed 50 colon and rectal
surgical procedures in the past 12 months. For endoscopic
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Colon and rectal surgery
References
Core privileges in colon and
rectal surgery
Special requests for colon and
rectal surgery
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Practice area 127
procedures, the applicant must demonstrate that he or she has
had the following minimal endoscopic experience:
 130 diagnostic EGDs
 140 total colonoscopies
A letter of reference must come from the director of the appli-
cants colon and rectal surgery training program. Alternatively,
a letter of reference regarding competence should come from
the chief of surgery at the institution where the applicant
most recently practiced.
Core privileges in colon and rectal surgery include the ability
to admit, evaluate, diagnose, treat, and provide consultation
to patients of all ages presenting with diseases, injuries, and
disorders of the intestinal tract, colon, rectum, anal canal, and
perianal areas by medical and surgical means. It can include
intestinal disease involvement of the liver, urinary, and female
reproductive systems.
Core privileges can also include but are not limited to per-
forming the following procedures and treating the following
diseases:
 Anal cancer
 Anal fissure
 Anal warts
 Bowel incontinence
 Colonoscopy
 Colorectal cancer
 Constipation
 Crohns disease
 Diverticular disease
 EGD
 Hemorrhoids
 Irritable bowel syndrome
 Pilonidal disease
 Polyps of the colon and rectum
 Rectal prolapse
For each special request, threshold criteria must be estab-
lished. Special requests for colon and rectal surgery include
any of the following procedures that were not a part of the
applicants residency training program:
Colon and rectal surgery Practice area 127

 Laparoscopic colon resection

 Laparoscopic rectopexy
 Laser procedures

Reappointment Reappointment should be based on unbiased, objective results

of care according to the organizations existing quality assur-
ance mechanisms.

Applicants must be able to demonstrate that they have

maintained competence by showing evidence that they have
performed at least 50 colon and rectal surgical procedures
annually over the reappointment cycle. In addition, appli-
cants must be able to demonstrate that they have performed
50 EGDs and 50 total colonoscopies annually over the reap-
pointment cycle.

In addition, continuing education related to colon and rectal

surgery as well as gastrointestinal endoscopy should be
required.

For more information For more information regarding this practice area, contact:

American Board of Colon and Rectal Surgery

20600 Eureka Road, Suite 600
Taylor, MI 48180
Telephone: 734/282-9400
Fax: 734/282-9402
Web site: www.abcrs.org

American Society for Gastrointestinal Endoscopy

1520 Kensington Road, Suite 202
Oak Brook, IL 60523
Telephone: 630/573-0600
Fax: 630/573-0691
Web site: www.asge.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
Web site: www.fascrs.org

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Colon and rectal surgery Practice area 127

Joint Commission on Accreditation of Healthcare Organizations

One Renaissance Boulevard
Oakbrook Terrace, IL 60181
Telephone: 630/792-5000
Fax: 630/792-5005
Web site: www.jcaho.org

Society of American Gastrointestinal and Endoscopic Surgeons

11300 West Olympic Boulevard, Suite 600
Los Angeles, CA 90064
Telephone: 310/437-0544
Fax: 310/437-0585
Web site: www.sages.org

Publisher/Vice President: Suzanne Perney Senior Managing Editor: Edwin B.

Clinical Privilege White Papers sperney@hcpro.com Niemeyer
Advisory Board Group Publisher: Kathryn Levesque
klevesque@hcpro.com
eniemeyer@comcast.net

James F. Callahan, DPA John E. Krettek Jr., MD, PhD Beverly Pybus
Executive vice president and CEO Neurological surgeon Senior consultant
American Society of Addiction Medicine Vice president for medical affairs The Greeley Company
Chevy Chase, MD Missouri Baptist Medical Center Marblehead, MA
St. Louis, MO
Sharon Fujikawa, PhD Richard Sheff, MD
Clinical professor, Dept. of Neurology Michael R. Milner, MMS, PA-C Chair and Executive Director
University of California, Irvine Medical Center Senior physician assistant consultant The Greeley Company,
Orange, CA Phoenix Indian Medical Center a division of HCPro, Inc.
Phoenix, AZ Marblehead, MA
John N. Kabalin, MD, FACS
Urologist/Laser surgeon
Scottsbluff Urology Associates
Scottsbluff, NE

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 recipients institution is forbidden without prior written permission. Copyright 2005 HCPro, Inc.,
Marblehead, MA 01945.

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Colon and rectal surgery Practice area 127

Privilege request form

Colon and rectal surgery
To be eligible to request clinical privileges in colon and rectal surgery, an applicant must meet the fol-
lowing minimum threshold criteria:

 Basic education: MD or DO

 Minimum formal training: Applicants must be able to demonstrate completion of an ACGME/AOA-accredited

training program in general surgery followed by completion of an accredited program in colon and rectal surgery.

 Required previous experience: Applicants must be able to demonstrate that they have performed 50 colon and
rectal surgical procedures in the past 12 months. For endoscopic procedures, the applicant must demonstrate that
he or she has had the following minimal endoscopic experience:
- 130 diagnostic EGDs
- 140 total colonoscopies
 References: A letter of reference must come from the director of the applicants colon and rectal surgery training
program. Alternatively, a letter of reference regarding competence should come from the chief of surgery at the
institution where the applicant most recently practiced.

 Core privileges: Core privileges in colon and rectal surgery include the ability to admit, evaluate, diagnose, treat,
and provide consultation to patients of all ages presenting with diseases, injuries, and disorders of the intestinal
tract, colon, rectum, anal canal, and perianal areas by medical and surgical means. It can include intestinal dis-
ease involvement of the liver, urinary, and female reproductive systems.

Core privileges also include but are not limited to performing the following procedures and treating anal cancer,
anal fissure, anal warts, bowel incontinence, colonoscopy, colorectal cancer, constipation, Crohns disease, diverticu-
lar disease, EGD, hemorrhoids, irritable bowel syndrome, pilonidal disease, polyps of the colon and rectum, and
rectal prolapse

 Reappointment: Reappointment should be based on unbiased, objective results of care according to the organiza-
tions existing quality assurance mechanisms.

Applicants must be able to demonstrate that they have maintained competence by showing evidence that they have
performed at least 50 colon and rectal surgical procedures annually over the reappointment cycle. In addition,
applicants must be able to demonstrate that they have performed 50 EGDs and 50 total colonoscopies annually
over the reappointment cycle.

In addition, continuing education related to colon and rectal surgery as well as gastrointestinal endoscopy should
be required.

I understand that by making this request I am bound by the applicable bylaws or policies of the hospi-
tal, and hereby stipulate that I meet the minimum threshold criteria for this request.

Physicians signature: _____________________________________________

Typed or printed name: ___________________________________________

Date: ____________________________________________________________

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