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?

Competency Assessment and Credentialing for Complex Spinal Surgery Privileges

As a certificant provider, you must conduct a formal competency assessment of the fellowship-trained surgeon before granting clinical privileges for complex spinal surgery, rather than automatically approving privileges based solely on fellowship completion. 1

Why Fellowship Completion Alone Is Insufficient

The available guidelines make clear that training completion does not automatically equal competence to practice independently 2, 1:

• Completion of a fellowship or residency does not guarantee competence, as some training programs may not provide adequate structured teaching or sufficient case volume in specific procedures 2
• The Joint Commission on Accreditation of Healthcare Organizations mandates that granting clinical staff privileges must be based on assessment against professional criteria specified in medical staff bylaws, not simply credential verification 2, 1
• Physicians are charged with identifying the criteria that constitute professional competence and evaluating their peers accordingly 2, 1

Required Assessment Process

Applicants for privileges must be evaluated on the basis of their actual cognitive knowledge and demonstrated technical skills rather than solely on the structure of their training 2, 1:

• When the competence of a physician requesting privileges is not clear, monitoring the candidate's interpretations or administration of a test may be appropriate 2
• Assessment should include review of the surgeon's performance on procedures similar to those for which privileges are requested 1
• The neurosurgical trainers at your hospital have explicit responsibility to ensure patient safety by determining whether surgeons can operate independently, with direct supervision, or with assistance based on demonstrated competence 1

Specific Steps for Credentialing

The responsibility for determining surgical competence rests with the trainers and credentialing bodies at the hospital where privileges are being requested, not with the fellow's previous training program 1:

1. Review the fellow's case logs and outcomes data from fellowship training, focusing specifically on complex spinal procedures 1
2. Conduct direct observation of the surgeon performing procedures or review surgical videos if available 2
3. Evaluate cognitive knowledge through discussion of complex cases, management algorithms, and complication management 2
4. Consider proctoring for initial cases if competence assessment reveals any gaps 1

Critical Context About Complex Spinal Surgery

The complexity and risk profile of spinal surgery has increased substantially over the past decade 2:

• Complex fusion procedures increased 15-fold among Medicare beneficiaries between 2002 and 2007 2
• With increased complexity came a 70% increase in complication rates following lumbar fusion in patients over 65 years of age 2
• Research shows that only 14% of spine surgeons performing minimally invasive and endoscopic procedures had completed formal fellowship training, with many being self-taught through workshops 3

Common Pitfalls to Avoid

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

• Avoid granting privileges based solely on fellowship completion certificates without competency verification 2, 1
• Do not assume that all fellowship programs provide equivalent training in complex spinal procedures 4, 5
• Recognize that the assessment of competence is complex and multidimensional; isolated recommendations or credentials alone may not be sufficient for judging overall competence 2, 1

Ongoing Quality Assurance

As part of quality assurance programs, a random sample of procedures should be reviewed periodically by independent experts to confirm continued competence 2, 1:

• Regular reading and performing of procedures alone may not ensure continued competence 2
• The trainers must answer truthfully if patients ask about the experience of those who will perform their surgery 1
• All surgeons must have access to help and advice, regardless of their training background 1