SPECIALTY OF PLASTIC & RECONSTRUCTIVE SURGERY Delineation of Clinical Privileges
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1 SPECIALTY OF PLASTIC & RECONSTRUCTIVE SURGERY Delineatin f Clinical Privileges Criteria fr granting privileges: Current certificatin by the American Bard f Plastic Surgery, r the American Ostepathic Bard f Surgery fr Plastic and Recnstructive Surgery. Or Successful cmpletin f an ACGME, r AOA accredited pst-graduate training prgram in Plastic Surgery and bard certificatin within 5 years f prgram cmpletin. Applicants will be requested t prvide dcumentatin f practice and current clinical cmpetence as defined n the attached cmpetency grid. Applicants have the burden f prducing infrmatin deemed adequate by the hspital fr a prper evaluatin f current clinical cmpetence, and ther qualificatins and fr reslving any dubts. Current Clinical Cmpetence - MLH In additin t the required educatin, experience and/r training specified n each DOP (Delineatin f Privilege) frm, dcumentatin f current clinical cmpetence is required. TJC (The Jint Cmmissin) describes current clinical cmpetence as having perfrmed the privilege recently and perfrmed it well. Current clinical cmpetence is assessed prir t granting privileges initially and is reassessed when renewing privileges at reappintment fr maintenance f privileges. Current Clinical Cmpetence (CCC) may be lcatin specific (acute hspital care/surgery center (ASC) and/r age specific (adult, pediatric,nenatal). This shuld nt be cnfused with FPPE (Fcused Prfessinal Practice Evaluatin) FPPE: an evaluatin f clinical cmpetence f all new privileges as perfrmed at the specific licensed MLH facility (MHMH, MHOBH, Fayette, MECH) fr which they have been initially granted. This applies t privileges fr all new applicants as well as t new/additinal privileges fr current members. Bth FPPE and current clinical cmpetence assessments are privilege-specific. FPPE is cnducted during the perid after granting new/additinal privileges. FPPE must ccur at the MLH facility(ies) where privileges/membership are held. Current clinical cmpetence may be evaluated frm case lgs prvided by nn-mlh facilities. Current Clinical Cmpetence: Requirements fr New Applicants If applying directly frm training, r based n the training received in a frmal training prgram, prvider shuld submit case* lgs frm the prgram authenticated by the prgram directr alng with their recmmendatin attesting t the cmparable training, experience and qualificatins relative t the criteria fr the clinical privileges requested. If applying mre than 1 year after training cmpletin, submit the fllwing: Aggregate data frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 diagnsis cdes and the number f patients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. 1
2 Prcedure list frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Case lgs (see specificatins belw) fr any special privileges requested that meet the criteria specific fr the number f prcedures defined fr current clinical cmpetence. Current Clinical Cmpetence: Maintenance f Privileges fr Current Members Fr active staff members: MLH surce data will be aggregated t review cases and prcedures perfrmed. and/r special privileges, the practitiner will be required t submit additinal case lgs frm ther facilities. If this des nt meet the minimum requirement fr cre Fr curtesy staff members with lw activity and fr certain active staff with activity that has diminished and is nw lw: Department chair recmmendatin shuld be btained frm their primary facility; and the practitiner shuld submit the fllwing: Aggregate data frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 diagnsis cdes and the number f patients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Case lgs (see specificatins belw) fr any special privileges requested that meet the specific number f prcedures defined fr current clinical cmpetence. Case Lgs All required case lgs and/r prcedure lists must cntain the fllwing infrmatin at a minimum: Date, patient identifier, CPT/ICD prcedure cde, diagnsis, cmplicatins, and dispsitin, and the facility name, name/title f the persn authenticating the lg, signature, date signed, and cntact infrmatin. If the infrmatin requested is nt available, please prvide an explanatin. *A case is defined as an episde f care either cgnitive r prcedural. Fr interpretive care, case is interpretatin f ne diagnstic study. OPPE (Onging Prfessinal Perfrmance Evaluatin) The Jint Cmmissin (TJC) requires OPPE peridically (mre frequently than annually) in the facility where membership/privileges are held. T assure OPPE requirements are satisfied, the practitiner must peridically exercise the privileges in the MLH facility(ies) where he/she has membership. OPPE must ccur regularly n patient encunters in the MLH facility(ies) where privileges/membership are held. 2
3 Specialty/Prcedure Delineatin f Privilege Frm Educatin/Training Dcumentatin fr Initial Granting Initial Applicatin (Prf f current clinical cmpetence) FPPE Validatin f cmpetence after appintment and/r granting f a new r additinal privilege (T be cmpleted within ne year) Maintenance Requirements Plastic & Recnstructive Surgery Cre Current certificatin by the American Bard f Plastic Surgery, r the American Ostepathic Bard f Surgery fr Plastic Surgery. Or Successful cmpletin f an ACGME r AOA accredited pst-graduate training prgram in general surgery and bard certificatin within 5 years f cmpletin. Aggregate data frm primary practice facility fr the previus 12 mnth time perid indentifying the tp 10 diagnsis cdes and the number f inpatients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm primary practice facility fr the previus 12 mnth time perid identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. First 5 cases MLH Data will be btained fr active members when available, the applicant shuld supply additinal case lgs frm ther facilities HIM departments, if necessary, t meet the minimum requirement(s) t be cnsidered fr the privilege. Curtesy members shuld supply case lgs frm ther facilities HIM departments t meet the minimum requirement(s) t be cnsidered fr the privilege. Aggregate data submitted shuld include the tp 10 diagnsis cdes, with the number f inpatients per cde, and prcedure lists indicating the tp 10 CPT/ICD cdes, with the number f prcedures per cde fr the previus 12 mnths. Dcument 5 cases using laser. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Department chair recmmendatin will be btained frm primary practice facility.
4 Plastic & Recnstructive Surgery Cre Privilege: Admit, evaluate, diagnse, prvide cnsultatin t patients f all ages, except as specifically excluded frm practice, presenting with cngenital and/r acquired defects f the bdy s musculskeletal system, cranimaxillfacial structures, hand, extremities, breast and trunk and external genitalia and sft tissue including the aesthetic management. Access, stabilize and determine dispsitin f patients with emergency cnditins cnsistent with the Medical Staff plicy regarding emergency r cnsultative services. Specific prcedures cmmnly perfrmed by plastic surgens include, but are nt limited t: Recnstructive Treatment f skin and sft tissue neplasms, diseases and trauma, including: Recnstructin f all frms f cngenital and acquired skin and sft tissue anmalies Benign and malignant lesins f the skin and sft tissue Grafts and flaps Scar revisins Laser therapy Recnstructive Surgery f the male and female breast, including: Plastic prcedures f the breast (including augmentatin, reductin and recnstructin and bipsy) Treatment f Cngenital anmalies (such as Gynecmastia r Pland s) Mastectmy (subcutaneus and simple) Recnstructive Surgery f the Chest and Abdmen, including: Chest recnstructin Abdminal wall and Trunk recnstructin Bdy Recnstructin fllwing Massive Weight Lss (MWL) Recnstructive Surgery f facial and maxillfacial cngenital disrders, diseases and injuries, including: Facial fractures, including the mandible Nse defrmity Ear defrmity Jaw defrmity Eyelid defrmity Cleft lip and palate defrmities Crrectin f facial paralysis Cranifacial surgery Skull base surgery Facial defrmity and wund treatment Tumrs f the head and neck including ral cavity
5 Resectin f intra ral tumrs, ral cavity, palate Surgery f the hand and extremities, including: Hand wunds Tendn injuries Fractures f the hand and wrist Carpal tunnel syndrme (endscpic and pen) Dupuytren s cntracture Surgery fr rheumatid arthritis Cngenital anmalies Tumrs f the bnes and sft tissues Recnstructive Micrsurgery Free tissue transfers Replantatin and revascularizatin f the upper and lwer extremities Recnstructin f peripheral nerve injury Recnstructin f cngenital and acquired defects f the trunk and genitalia Plastic prcedures f external and internal male and female genitalia (including Vaginal recnstructin, Repair f penis defrmities and Gender reassignment) Chest and abdminal wall recnstructin (e.g. hernia repair) Bdy Recnstructin fllwing Massive Weight Lss (MWL) Treatment f Burns and f Cmplex wunds Burn management and Recnstructin Evaluatin and treatment f cmplex wunds Csmetic Plastic Surgery Bdy cnturing Facial cnturing Breast augmentatin Breast lift (mastpexy) Rhytidectmy Rhinplasty Injectins f Btx and / r f sft-tissue filler material Skin Resurfacing (Chemical peels and Dermabrasin) Vein injectin (Sclertherapy) Lipsuctin (including fat grafting)
6 Endscpic csmetic surgery Laser therapy fr vascular and cutaneus lesins Skin Surgery Skin Resurfacing (Chemical, Mechanical r Phtelectric (ie Laser, IPL etc) Hair transplantatin, punch r strip Special: The physician requesting special privileges must meet the minimum criteria fr the specialty cre and demnstrate the apprpriate pst graduate training and/r demnstrate successful cmpletin f an apprved, recgnized curse when such exists, r ther acceptable experience. Administratin f mderate sedatin: See Credentialing Plicy fr Sedatin and Analgesia by Nn-Anesthesilgists. Requires: Separate DOP, ACLS, NRP r PALS certificatin
7 Plastic & Recnstructive Surgery Clinical Privileges Check belw the particular privileges desired in Plastic & Recnstructive Surgery fr each facility: Privilege Descriptin Age Limitatins Plastic & Recnstructive Surgery Cre Limitatins Please check ( ) applicable age categries fr each privilege requested. Methdist Healthcare Memphis Hspitals (MHMH) Methdist Germantwn, Le Bnheur Medical Center, Extended Care Nrth, Suth & University, Outpatient Clinics & Diagnstic Facilities Hspital (MECH) Nenates (0-28 days) Infants (29 days 2 Years) Children & Adlescents (2-18 years) Adults & Adlescents (13-& Abve) Adults (18 & Abve) Methdist Healthcare Fayette Hspital (MHFH) Adults & Adlescents (13-& Abve) Clinical privileges are granted nly t the extent privileges are available at each facility. Darkly shaded areas represent privileges nt available t any practitiner due t the privilege nt being ffered by the facility. Methdist Healthcare Olive Branch Hspital (MHOBH) Adults & Adlescents (13-& Abve) Acknwledgement f practitiner I have requested nly thse privileges fr which by educatin, training, current experience and demnstrated perfrmance I am qualified t perfrm and fr which I wish t exercise at the facilities indicated abve, t the extent services are available at each facility, and I understand that: (a) in exercising any clinical privileges granted, I am cnstrained by facility and medical staff plicies and rules applicable generally and any applicable t the particular situatin (b) any restrictin n the clinical privileges granted t me is waived in an emergency situatin and in such situatin my actins are gverned by the applicable sectin f the medical staff bylaws r related dcuments Physician's Signature Date Printed Name
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