What are the next steps for a provider who completed a fellowship in spinal surgery and is requesting clinical privileges to perform complex spinal surgeries?

Credentialing Process for Complex Spinal Surgery Privileges

As a credentialing provider, you must conduct a formal competency assessment through proctored observation before granting independent privileges, regardless of fellowship completion. 1, 2

Why Fellowship Completion Alone Is Insufficient

Completion of a fellowship does not automatically guarantee competence to perform complex spinal surgeries independently. 1 The available evidence makes clear that:

• Training completion and credentials alone are insufficient for judging overall competence in complex procedures 1
• Some training programs do not include adequate structured teaching, and experience varies significantly between programs 3
• The responsibility for determining surgical competence rests with the credentialing body at your institution, not with the fellow's previous training program 1

Required Credentialing Steps

1. Documentation Review

Request comprehensive documentation from the applicant including: 2

• Detailed list of cases attended and performed as primary operator
• Documentation of complications encountered during training
• Letter from the program director confirming adequate training and capability for independent practice

2. Mandatory Proctored Period

Grant initial privileges only under observation of a qualified proctor. 2 This is essential because:

• The goal of proctoring is to ensure the provider has overcome the technical learning curve to deliver safe and effective care, which varies by individual 2
• Withhold unrestricted privileges until the proctor's report is evaluated 2
• Assessment should be based on actual cognitive knowledge and technical skills rather than solely on the structure of training 1

3. Competency-Based Assessment

Evaluate the surgeon on: 1, 2

• Demonstrated technical skills during proctored cases
• Review of performance on procedures similar to those for which privileges are requested
• Outcomes and complication rates from proctored cases
• When competence is not clear, monitoring the candidate's performance or administration of a formal test may be appropriate 3

Institutional Responsibilities

Your institution has explicit responsibility to ensure patient safety by: 1

• Ensuring that fully trained neurosurgeons are responsible for patient care
• Ensuring all surgeons have access to help and advice
• Making decisions about whether surgeons can operate independently, with direct supervision, or with assistance based on demonstrated competence

Common Pitfalls to Avoid

Do not impose arbitrary time requirements without assessment of actual competence - this approach is not evidence-based and could unnecessarily delay qualified surgeons from practicing within their competence. 1

Do not grant unrestricted privileges based solely on fellowship completion - research shows that only 14% of spine surgeons performing minimally invasive procedures completed fellowships, with many being self-taught through workshops, highlighting the variability in training quality. 4

Ongoing Quality Assurance

After granting privileges, implement: 2

• Participation in quality assurance programs with outcome tracking
• Regular review of complication rates compared to expected standards
• Periodic review of a random sample of procedures by independent experts to confirm continued competence 3