S. K. Frencher^2,6, A. Sharma⁷, S. Seresinghe⁵, S. M. O’Neill^{1,3  1}University Of California – Los Angeles,Department Of Surgery,Los Angeles, CA, USA ²University Of California – Los Angeles,Department Of Urology,Los Angeles, CA, USA ³VA Greater Los Angeles Healthcare System,Los Angeles, CA, USA ⁴University Of California – San Diego,San Diego, CA, USA ⁵University Of California – Santa Barbara,Santa Barbara, CA, USA ⁶Martin Luther King, Jr. Community Hospital,Los Angeles, CA, USA ⁷University Of California – Los Angeles,Los Angeles, CA, USA

Introduction:
Setting the scope of surgical practice at a new hospital must address the competing objectives of patient safety, quality and reliability, and access to care. New hospitals, by definition, lack institutional knowledge and experience, and different hospitals will have differing internal capabilities, differing financial considerations, and differing community responsibilities. In particular, safety net community hospitals face a unique set of constraints, and fulfilling all of these objectives simultaneously is a challenge. Even in the most well-established hospital systems, surgical privileging, the mechanism by which scope of practice is effectively defined, remains an ongoing challenge. Initial adoption of our staff surgeons’ privileges from other hospitals caused mismatches in terms of support staff capability, equipment, and system readiness. This resulted in several instances with concerning implications for patient safety. Therefore, we present a case study in how we developed an approach to setting the scope of surgical practice at a newly-opened, non-trauma-designated safety net community hospital.

Methods:
At the outset, patient safety and quality of care were explicitly prioritized above having a broad scope of practice. Through interviews with staff, data was collected in regard to the appropriateness, surgeon expertise, and system readiness for all procedures listed on original privileging cards across 12 surgical specialties. We then began a process to review privileges for each specialty in person—first with affiliated surgeons, then with a larger group of all key clinical and administrative stakeholders in the spectrum of surgical care—Nursing and Allied Health Services, Anesthesia, Emergency Medicine, Hospital Medicine, and Operating Room management. For each procedure, four questions needed to be answered affirmatively and unanimously: Could a surgeon do this procedure here? Would a surgeon do this procedure here? Do we have, or could we reasonably acquire, the equipment needed for the procedure? Are all the perioperative services ready for this type of patient, and prepared to handle any likely complications? These meetings, often after robust discussions, yielded clear and unanimous decisions, and privileging forms were revised accordingly.

Results:
This process resulted in a significant (>40%) reduction in the number and complexity of procedures, from an initial list of more than 800. There was a focus on acute surgery, reflecting community needs. For some specialties more procedures were removed than remain, in particular Ophthalmology (>90% reduction) and Neurosurgery. The incidence of patient safety events due to inappropriate levels of care has been reduced; fewer than 50 different types of procedures are performed with regularity.

Conclusion:
Establishing the scope of surgical practice at a new safety net hospital is challenging and must strive for multiple objectives, but can be accomplished through collaborative, surgeon-led processes.