University of Illinois
College of Medicine at Urbana-Champaign
Internal Medicine Residency Program

Program Policy

PURPOSE: To identify specific clinical procedures that require credentialing, and establish the process by which residents are credentialed to perform procedures.

POLICY:

The general criteria for procedure training and approval are qualitative and quantitative.  Additional information is listed at the Accreditation Council of Graduate Medical Education (ACGME) under Internal Medicine Program Requirements, Procedure and Technical Skills

Quantitative considerations include the types and numbers of procedures performed by health care providers.

1. Program Director:

The Program Director or his/her designee has final authority to grant approval of certification, indicating competency. Site Coordinators at each clinical site delegate responsibility for assured credentialing and documentation to the faculty and/or delegated staff, directly involved in supervising procedure peformance. The resident documents performance of the procedure. The supervising faculty directly involved must approve or reject. 

2. Program Office and Administrative Staff Location:

The central location for data collection and record maintenance for credentialing is the residency program administration office. All documentation is reviewed per the Program Director from all training sites.

3.Training Sites:

Residents may be credentialed in a procedure by a qualified faculty and/or delegated staff at any training site.

4. Over-sight Agencies:

Certification:  Certification is the confirmation of successful procedure performance. For the purpose of credentialing, a certifier is defined as an individual, granted Level 3 Privileges, at his/her institution for a specific procedure. Any staff member privileged by that particular institution in the procedure may certify the resident, e.g. a registered nurse may supervise intravenous line insertion.The qualified, certifying individual attests that he/she has directly supervised the performance of the procedure and the resident has demonstrated the following:

• Knowledge of indications and contraindications
• Knowledge of potential risks and ability to effectively explain risks to patients in understandable terms
• Ability to technically perform procedure, using aseptic technique, with minimal patient discomfort
• Ability to deal with expected complications
• Ability to appropriately document procedure(s)

5. Credentialing: Credentialing is the granting of privileges based on specific evidence of performed procedure. The Program Director, board-certified in Internal Medicine and licensed to practice in the State of Illinois has final authority to grant approval of certification, indicating competency.

6.  Mechanism of Credentialing: The credentialing system is based on three levels of clinical privileges:

Level 1: The individual can perform the procedure only under direct supervision.
Level 2: The individual can perform the procedure under indirect supervision, i.e. under the specific written descriptions of lines of responsibility for the care of patients on each type of teaching service.
Level 3: The individual can perform the procedure under indirect supervision and can supervise and certify others performing this procedure. Because these privileges are being granted under the broad auspices of the residency program, they are not intended to be equivalent to those granted to attending physicians who exercise privileges independently.

Evaluation is competency-based, and includes demonstration of technical ability.

The established documentation process for the UIUC Internal Medicine Residency Program is as follows:

Upon the completion of a procedure, the resident submits the required documentation. The supervising faculty signs off the procedure. The signed procedure is forwarded to the Program office. At a minimum, documentation must include patient name, clinic or admission number, date and time of the procedure, resident name, supervisor's name, and clinical site. On receipt in the Program Director's Office, documentation is entered in the resident's procedure log.

Performance does not guarantee credentialing. When procedure criteria are met and the resident's overall performance and level of training are commesurate, the Program Director will consider credentialing. S/he has final authority and may determine additional training is required.

Residents, entering the Residency Program from other training programs, with training credit l, require written documentation from the previous Program Director of credentialed procedures and privileges. The Program Director has discretion to accept the documentation and award priveleges.

7.  Clinical Procedures Requiring Credentialing: The Residency Program recognizes three clinical procedures categories:

• Entry
• Basic
• Optional

A. Entry Level Procedures: Entry level procedures are learned and perfected during medical school. Procedure compentence must be documented before independent performance. Each resident must be credentialed as soon as possible, preferably within six months.

B. Basic Level Procedures: Basic procedures are more complex, require more expertise and are more difficult to master. For the optimal PGY II performance, credentialing should occur during the PGY I. Completion of the basic level procedures are not required for promotion to PGY II.  Only one procedure, i.e. ACLS must be completed and documented at the start of residency training.

The Accreditation Council for Graduate Medical Education (ACGME) and the American Board of Internal Medicine (ABIM) require the following minimal number of successful completed and documented procedures for board certification.

3. Optional Procedures: Optional procedures are appropriate for an internist to perform with proper credentials. Obtaining those credentials are not a promotion requirement. The Program Director has full authority to add or subtract optional procedures to permit maximal flexibility enabling the credentialing process to meet the needs and standards of the training program, institution, or the individual resident.

8. Reporting System: Procedures are primarily documented electronically. When a procedure is certified, the information is forwarded to the Program office for resident-specific documentation of credentialing and privileging.

9. Disciplinary Protocol: The Program has defined disciplinary procedures for residents, who perform or supervise procedures outside the scope of credentialing and privileging.

10. Emergencies: In the case of an emergency, any resident may attempt to accomplish everything possible to save the life of a patient or to save a patient from serious harm to the extent allowed by his/her license and/or within the scope of his/her level of post-graduate education experience, regardless of staff status or clinical privileges.  An emergency is defined as a condition from which serious or permanent harm would result to a patient or in which the life of a patient is in immediate danger and any delay in administering treatment would add to that danger.

11. Documentation of Supervisor: In all cases in which a resident performs a procedure for which he/she is privileged at a Level 1, the chart entry will include either the signature of the supervising individual or appropriate written documentation as to the supervision. The supervising individual must have Level 3 privileges for the specific procedure.

12. Accountability to Governing Body: As medical staff at each affiliated institution are required to be "accountable to the governing body for the quality of the medical care provided to all patients", and "the medical staff shall, based on written criteria, recommend privileges that are specific to treatments or procedures through each individual in such programs prior to delivery of patient care services", each clinical site must maintain an interface mechanism with its governing board tol provide information and feedback as deemed appropriate by said clinical site governing board.

DISCIPLINARY PROTOCOL - VIOLATION of PROCEDURE PRIVILEGING

1. A formal written description of the violation will be forwarded by the Quality Assurance (QA) Department to the Program Director or his/her designee. The Program Director will investigate the incident. The investigation must be completed within ten days including the incident review.
2. Should it be determined the resident acted appropriately, i.e.within his/her delineation of privileges or in an emergency situation, this will be documented in the resident's file, and the incident will be considered closed.
3. Should it be found the resident acted inappropriately, i.e. outside of his/her specific privilege delineation, the Program Director or his/her designee will institute disciplinary action.

If a resident performs a procedure in violation of the credentialing process, presenting a significant risk to a patient, the disciplinary action will be set aside and the report will be directly forwarded to the Residency Progress and Promotions Committee for immediate action as appropriate.