Name: DEPARTMENT OF CARDIOLOGY CRITERIA FOR RECOMMENDATION AND CATEGORIZATION OF MEDICAL STAFF PRIVILEGES

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1 Name: DEPARTMENT OF CARDIOLOGY CRITERIA FOR RECOMMENDATION AND CATEGORIZATION OF MEDICAL STAFF PRIVILEGES A. Applicants (Full Privileges) 1. Satisfactory completion of an application, including documentation of either: a. Initial applicants who are trained in the United States and have completed an approved fellowship in the field of cardiology will be required to obtain cardiovascular Board certification within five (5) years after completion of the fellowship program, or understand that application and/or privilege assignment will be reconsidered by the medical staff if Board certification is not obtained. (See attached Medical Staff policy concerning Board Certification for new Medical Staff members.) b. The Canadian Cardiovascular Boards or Fellowship in the Royal College of Physicians is deemed equivalent to ABIM certification only for those grandfathered before Satisfactory documentation of appropriate experience and current competence in regard to all privileges requested. 3. Satisfactory documentation of continuing education activities (if applicant is over one (1) year post residency/fellowship training). B. Reappointment Requirements (Full Privileges) 1. Must continue satisfactory documentation of all appropriate items in A, plus: a. Documentation of current clinical competence/skills for procedures which are requested. b. All other Medical Staff Bylaw requirements of a satisfactorily completed reappointment application. C. Initial/Reappointment for Limited Privileges 1. Must possess training, experience, and supervised demonstrated competence in the specific procedures or entity for which privileges are requested as a non-cardiologist. Example of limited privileges may be exercise or pharmacologic stress testing. 2. Must provide continuing documentation of proficiency in the limited privilege requested. D. The following stipulations apply: 1. All members of the Department have full admitting privileges to the hospital s acute care and long term care units, and history and physical privilege. 2. Core cardiology privileges are defined as all privileges/procedures included in an approved cardiovascular three ( 3) year subspecialty training program, unless specifically designated otherwise by the applicant. 3. Full electrophysiology and interventional cardiology privileges require at least one (1) year specialty training in addition to full cardiovascular subspecialty training in order to obtain any privileges in EP or interventional cardiology. 4. Full privileges for peripheral vascular intervention will require the applicant to have fulfilled the ACC/AHA guidelines for training in peripheral vascular intervention. 5. Alternative credentialing for prophylactic AICD placement for non-electrophysiologists will require the applicant to fulfill the Heart Rhythm Society and ACC guidelines for this procedure. 6. Maintenance of Certification is required per ABIM guidelines for all Department members whose board certificates require recertification (after 1989). 7. Maintenance of Certification in Internal Medicine is not required as long as maintenance of certification in Cardiovascular Disease or an appropriate Cardiovascular subspecialty is achieved (Interventional Cardiology, Electrophysiology). Page 1 of 4

2 Name: CARDIOLOGY SPECIAL PRIVILEGE DELINEATION: Please designate the privileges you feel qualified to receive and submit documentation supporting your request which includes board certification or eligibility, procedures, outcomes and information pertaining to instructional courses or supervising mentors. (Appropriate documentation of continuing proficiency may be requested.) 1. Core privileges in Cardiology (competency supported by completion of Cardiology fellowship and board certification or eligibility): Cardiovascular consultative services A) EKG, event recording and Holter interpretation B) Exercise stress testing and Pharmacologic stress testing C) Cardioversion D) Transthoracic echocardiography E) Insertion of arterial and central venous lines Requested Recommended Recommended with the following modifications (s) and reason(s): Special privileges in Cardiology: 2.Cardiac catheterization A) Right heart catheterization/angiography B) Left heart catheterization/angiography C) Temporary transvenous pacemakers D) Insertion and management of IABP (intra-aortic balloon) 3. Swan-Ganz catheter placement and management 4. Pericardiocentesis 5. Nuclear cardiology interpretation 6. Stress echocardiography interpretation 7. Transesophageal echocardiography 8. Use of conscious sedation 9. Management of adults on ventilatory devices Requested Recommended Page 2 of 4

3 Name: Special privileges in Cardiology: Requested Recommended 10. Electrophysiology A) Diagnostic 1) Invasive electrophysiologic testing 2) Head up tilt testing 3) T wave alternans interpretations B) Interventional 1) Radiofrequency catheter ablation 2) AICD (defibrillator) implantation 3) Prophylactic AICD only 11. Permanent cardiac pacemaker 12. CRT/Biventricular pacemaker (Cardiac Resynchronization Therapy) 13. Chronic pacemaker and AICD lead extraction 14. Percutaneous Coronary Intervention: A) PTCA B) Rotational atherectomy C) Directional atherectomy D) Coronary stent placement E) Intracoronary radiation F) Insertion and Management of Impella G) Laser Atherectomy Page 3 of 4

4 Name: CARDIOLOGY SPECIAL PRIVILEGE DELINEATION: Please designate the privileges you feel qualified to receive and submit documentation supporting your request which includes board certification or eligibility, procedures, outcomes and information pertaining to instructional courses or supervising mentors. (Appropriate documentation of continuing proficiency may be requested.) Special privileges in Cardiology: Requested Recommended 15. Peripheral Vascular Intervention: A) PTA B) Rotational atherectomy C) Directional atherectomy (fox hollow, etc) D) Stent E) Aortic aneurysm stent graft (EVAR) F) Carotid stent G) Coil embolization H) IVC filter placement I) TEVAR J) Angio Vac K) Laser Atherectomy 16. Carotid angiography 17. AIF angiography 18. Endomyocardial biopsy 19. Structural Heart A) PFO/ASD closure B) Ethanol ablation for IHSS C) Mitral Valvuloplasty D) Aortic Valvuloplasty E) TAVR (Transaortic valve replacement F) Watchman procedure G) Place (Lariat) procedure 20. Other (specify) DATE DATE SIGNATURE OF APPLICANT SIGNATURE AND APPROVAL OF CHAIRPERSON, DEPARTMENT OF CARDIOLOGY Approved by the Department of Cardiology 8/98, 4/06, 6/06, 6/12 Approved by Credentials Committee 8/98, 5/06, 08/06, 11/06, 9/12 Approved by Medical Staff Executive Committee 9/98, 6/06, 9/06, 12/06, 10/12 Approved by Board of Directors 10/98, 08/06, 10/06, 1/07, 11/12 Page 4 of 4

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6 MEDICAL STAFF POLICY BOARD CERTIFICATION AND MAINTANENCE OF CERTIFICATION POLICY STATEMENT St. John s Hospital and its Medical Staff are committed to providing quality, safe, and effective care to the community they serve, and to continuously improve upon the care provided. To that end, it is the goal of this policy to ensure this is accomplished. I. POLICY Beginning 12/1/87, all new medical staff members were required to be Board certified in their specialty area or be Board prepared at the time of application with the understanding they must receive Board certification within the parameters established by individual departments or within a maximum period of three (3) years. Since that time, most board certifications have become subject to maintenance of certification by a variety of processes that are specific to each certifying specialty board. It is required for all physicians to maintain certification. Board certification means certification by a certifying board recognized by the American Board of Medical Specialties (ABMS), or certifying Boards that are recognized by the department as equivalent to the Boards of the American Board of Medical Specialties (ABMS). Limited Grandfather Medical Staff Members Appointed Prior to December 1, Those Medical Staff members who were appointed to the Medical Staff prior to December 1, 1987 and who were not board certified as of that date shall be grandfathered and shall not be subject to the requirements of this policy. 2. All such individuals shall be governed by the board certification requirements that were in effect at the time of their initial appointments to the St. John s Medical Staff. 3. This grandfathering is appropriate because all these existing members have been subject to the quality assessment and peer review processes at the Medical Center and the quality and appropriateness of their care has been demonstrated. Board Certification / Recertification Requirements for All Other Medical Staff Members 1. Medical Staff must be certified in their primary area of practice at St. John s by the appropriate specialty/subspecialty board of the American Board of the Medical Specialties (ABMS), the American Osteopathic Association (AOA), the American Association of Oral and Maxillofacial Surgery (AAOMS), the American Dental Association (ADA), or the American Board of Podiatric Surgery (ABPS), as applicable. Applicants possessing Board certification from another country (e.g. Canada, Great Britain) will be evaluated by the Medical Staff leadership and Board on a case-by-case basis, in accordance with the waiver provisions outlined below. 2. New applicants to the Medical Staff who are not board certified at the time of their initial application but who have completed their residency or fellowship training within the last five years shall be eligible for Medical Staff appointment. However, in order to remain eligible, those individuals must achieve board certification in their primary care of practice at St. John s, per Departmental requirements or if not addressed within three (3) years. 3. All Medical Staff members must also maintain board certification and, to the extent required by the applicable specialty/subspecialty board, satisfy recertification requirements, as a condition of ongoing appointment at St. John s. Recertification status shall be assessed at the time an applicant is being processed for reappointment for a determination as to whether the individual is eligible to reapply. II. PROCEDURE

7 MEDICAL STAFF POLICY BOARD CERTIFICATION AND MAINTANENCE OF CERTIFICATION Failure to certify or maintain certification within the parameters established by the individual departments and to meet the above requirements will result in a one time, one year notice of intent to lose medical staff membership, providing an additional year for the following alternatives: 1. To voluntarily resign in good standing from medical staff membership. 2. To provide a plan to the appropriate Department and Medical Staff to become Board certified within the additional 12 months. If approved by the department chair, the Medical Executive Committee and the Hospital Board, medical staff membership with full privileges would continue for no longer than 12 months. To be eligible for this one (1) year extension the medical staff member must satisfy the following: a. the individual has been on the St. John s Medical Staff for at least two consecutive years; b. there has been no significant peer review issues related to the individual s competence or behavior at St. John s during the individual s tenure (i.e., no Performance Improvement Plans have been developed and no formal investigations have been conducted regarding the individual); c. the individual provides a letter from the appropriate certifying board confirming that the individual remains eligible to take the certification examination within the next two years; and d. the appropriate Department Chair at St. John s provides a favorable report concerning the individual s qualifications. Failure to certify or maintain certification within 1 year of notice will result in termination of medical staff membership and privileges subject to Article XI of the St. Johns Hospital Medical Staff Bylaws. Final medical staff membership termination shall be approved by the Hospital Board subject to appeal under Article XII of the St. Johns Hospital Medical Staff Bylaws. Waiver of Board Certification Requirements: 1. Any individual who does not satisfy the board certification requirements outlined in this Policy may request a complete waiver of the requirement. The individual requesting the waiver bears the burden of demonstrating exceptional and unusual circumstances, and that his or her qualifications are equivalent to, or exceed, the board certification requirement. 2. A request for waiver shall be submitted to the Credentials Committee for consideration. In reviewing the request for a waiver, the Credentials Committee may consider the specific qualifications of the individual in question, input from the relevant department chairman, and the best interests of St. John s and the communities it serves. Additionally, the Credentials Committee may, in its discretion, consider the application form and other information supplied by the applicant. The Credentials Committee s recommendation shall be forwarded to the MEC. Any recommendation to grant a waiver must include the specific basis for such. 3. The MEC shall review the recommendation of the Credentials Committee and make a recommendation to the Board regarding whether to grant or deny the request for waiver. Any recommendation to grant a waiver (parameters for which will be established by the Board) must include the specific basis for the recommendation.

8 MEDICAL STAFF POLICY BOARD CERTIFICATION AND MAINTANENCE OF CERTIFICATION 4. No individual is entitled to a waiver or to a hearing if the Board determines not to grant a waiver. A determination that an individual is not entitled to a waiver is not a denial of appointment or clinical privileges that must be reported to the State of Illinois or to the National Practitioner Data Bank. 5. The granting of a waiver in a particular case is not intended to set a precedent for any other individual or group of individuals. 6. An application from an individual who does not satisfy the board certification requirements shall not be processed unless and until the Board has determined that a waiver should be granted. Approved by Credentials Committee 09/28/2012 Approved by Medical Staff Executive Committee 09/08/2012 Approved by Hospital Board of Directors 10/03/2012

9 ST. JOHN S HOSPITAL MEDICAL STAFF EXTENSION OF CLINICAL PRIVILEGES PROFILE Credentialing Criteria for Laser Ablation for Atrial Fibrillation Laser Ablation for Atrial Fibrillation is replacement of the aortic valve utilizing a balloon-expandable valve delivered via a transcatheter retro-flex introducer sheath. I. Indications: 1. Patients with symptomatic, severe aortic stenosis who have been deemed inoperable by two cardio-thoracic surgeons. Patients should not have aortic regurgitation >3+, untreated clinically significant coronary artery disease requiring revascularization, or Iliofemoral vessel characteristics that would preclude safe placement of an introducer sheath such as severe obstructive calcification, severe tortuosity or small vessel size (applicable for transfemoral patients only), unless the patient qualifies for a transapical or other aortic/surgical approaches. II. Qualifications of Initial Application A. Board Status: 1. Board prepared or certified in Interventional Cardiology; OR 2. Board prepared or certified in Cardiothoracic Surgery B. Education/Training: 1. Completion of Edwards LifeSciences Fundamentals training ; OR cases of supervised experience; AND 3. Signoff of experience by director of Structural Heart Disease program and product line III. Initial Granting of Privileges (subject to review after the first 25 cases): 1. The first five (5) cases for any credentialed physician will be done as a team of two physicians credentialed in the procedure with at least one member of the team having TAVR privileges. 2. The next five (5) cases done by any credentialed physician will be reviewed through the FPPE procedure. 3. The first 25 cases at SJH will be reviewed by all initially credentialed physicians plus one other physician credentialed and experienced in left-sided structural (EVAR [endovascular aneurysm repair] or TEVAR [thoracic endovascular aortic repair]. Their findings, including indications, outcomes and complications, will be reported to the Credentials Committee. Approved: Credentials Committee 2/24/12 Medical Executive Committee 3/3/12 Board of Directors 4/4/12

10 ST. JOHN S HOSPITAL MEDICAL STAFF EXTENSION OF CLINICAL PRIVILEGES PROFILE Credentialing Criteria for Percutaneous Left Atrial Appendage Ligation (LAAL) Left atrial appendage ligation is epicardial or transseptal suture closure of the left atrial appendage. I. Indications: Patients with atrial fibrillation with contra-indications for or failure of oral anticoagulation to prevent thrombo-embolic events. II. Qualifications of Initial Application A. Board Status: 1. Board prepared or certified in Interventional Cardiology; OR 2. Board prepared or certified in Electrophysiology B. Education/Training: 1. Completion of SentreHEART Lariat Fundamentals training ; OR 2. 5 cases of supervised experience; AND 3. Signoff of experience by director of Structural Heart Disease program and product line III. Initial Granting of Privileges (subject to review after the first 25 cases): 1. The first five (5) cases for any credentialed physician will be done as a team of two physicians credentialed in the procedure with at least one member of the team having LAAL privileges. 2. The next five (5) cases done by any credentialed physician will be reviewed through the FPPE procedure. 3. The first 25 cases at SJH will be reviewed by all initially credentialed physicians plus one other physician experienced in epicardial or transseptal procedures (closure devices, pericardiocentesis, or electrophysiology). Their findings, including indications, outcomes and complications, will be reported to the Credentials Committee. Approved: Credentials Committee 3/30/12 Medical Executive Committee 4/14/12 Board of Directors 5/2/12

11 ST. JOHN S HOSPITAL MEDICAL STAFF EXTENSION OF CLINICAL PRIVILEGES PROFILE Credentialing Criteria for Transcatheter Aortic Valve Replacement Transcatheter Aortic Valve Replacement (TAVR) is replacement of the aortic valve utilizing a balloonexpandable valve delivered via a transcatheter retro-flex introducer sheath. I. Indications: 1. Patients with symptomatic, severe aortic stenosis who have been deemed inoperable by two cardio-thoracic surgeons. Patients should not have aortic regurgitation >3+, untreated clinically significant coronary artery disease requiring revascularization, or Iliofemoral vessel characteristics that would preclude safe placement of an introducer sheath such as severe obstructive calcification, severe tortuosity or small vessel size (applicable for transfemoral patients only), unless the patient qualifies for a transapical or other aortic/surgical approaches. II. Qualifications of Initial Application A. Board Status: 1. Board prepared or certified in Interventional Cardiology; OR 2. Board prepared or certified in Cardiothoracic Surgery B. Education/Training: 1. Completion of Edwards LifeSciences Fundamentals training ; OR cases of supervised experience; AND 3. Signoff of experience by director of Structural Heart Disease program and product line III. Initial Granting of Privileges (subject to review after the first 25 cases): 1. The first five (5) cases for any credentialed physician will be done as a team of two physicians credentialed in the procedure with at least one member of the team having TAVR privileges. 2. The next five (5) cases done by any credentialed physician will be reviewed through the FPPE procedure. 3. The first 25 cases at SJH will be reviewed by all initially credentialed physicians plus one other physician credentialed and experienced in left-sided structural (EVAR [endovascular aneurysm repair] or TEVAR [thoracic endovascular aortic repair]. Their findings, including indications, outcomes and complications, will be reported to the Credentials Committee. Approved: Credentials Committee 2/24/12 Medical Executive Committee 3/3/12 Board of Directors 4/4/12

12 ST. JOHN S HOSPITAL MEDICAL STAFF EXTENSION OF CLINICAL PRIVILEGES PROFILE Credentialing Criteria for Transcatheter Aortic Valve Replacement-Transapical Approach Transcatheter Aortic Valve Replacement (TAVR) is replacement of the aortic valve utilizing a balloon-expandable valve delivered via a transcatheter introducer sheath. Antegrade access to the aortic valve is conducted through the left ventricular apex. A small anterolateral thoracotomy allows for placement of delivery sheaths and the catheter-based prosthesis. Deployment of the valve is performed under rapid ventricular pacing. I. Indications: 1. Patients with symptomatic, severe aortic stenosis who have been evaluated by two cardio-thoracic surgeons. Patients should not have aortic regurgitation >3+ or untreated clinically significant coronary artery disease requiring revascularization. II. Qualifications of Initial Application A. Board Status: 1. Board prepared or certified in Interventional Cardiology; OR 2. Board prepared or certified in Cardiothoracic Surgery B. Education/Training: 1. Completion of Edwards LifeSciences Fundamentals training ; OR cases of supervised experience; AND 3. Signoff of experience by director of Structural Heart Disease program and product line III. Initial Granting of Privileges (subject to review after the first 25 cases): 1. The first five (5) cases for any credentialed physician will be done as a team of two physicians credentialed in the procedure with at least one member of the team having TAVR privileges. 2. The next five (5) cases done by any credentialed physician will be reviewed through the FPPE procedure. 3. The first 25 cases at SJH will be reviewed by all initially credentialed physicians plus one other physician credentialed and experienced in left-sided structural (EVAR [endovascular aneurysm repair] or TEVAR [thoracic endovascular aortic repair]. Their findings, including indications, outcomes and complications, will be reported to the Credentials Committee. Approved by Credentials: 9/12 Approved by MEC: 10/12 Approved by Board of Directors: 11/12

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