PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER DEPARTMENT OF SURGERY General Surgery

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1 DEPARTMENT OF SURGERY STANDARDS FOR PRIVILEGES In order to be eligible to request clinical privileges for both initial appointment and reappointment, a practitioner must the following minimum threshold criteria. EDUCATION: M.D. or D.O. Degree TRAINING: Privileges in are granted in clinical cognitive areas and for specific procedures. Surgeons requesting privileges are to be board certified by the American Board of Surgery or the American Osteopathic Board of Surgery, or have successfully completed a general surgery residency in a program accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA). REQUIRED CLINICAL EXPERIENCE: Recent clinical experience is required of all applicants for appointment and reappointment. Recent clinical experience for initial appointment and reappointment is defined as having performed at least 30 inpatient clinical services, procedures, or clinical consultations in a Joint Commission accredited hospital or hospital-based ambulatory setting in the last two years. The variety and type of clinical activities must be sufficient to cover the scope of practice and privileges requested. Applicants must certify at the time of initial appointment and reappointment, that there are no problems of health or mental status that will interfere with the exercise of clinical privileges requested. Requests for specific procedural privileges not present on this form should be made in writing to the Department Chair. This request must be accompanied by documentation of specific training, experience and current competence for the privilege(s) requested. Write-in privileges on this form are not accepted. SURGERY ADDITIONAL CRITERIA FOR ADVANCED PRIVILEGES Privileges followed by an asterisk are identified in this table. Please submit required documentation at the time of request. The numbers indicated in this table represent minimal criteria for appointment and reappointment. Additional documentation of training, experience and/or current competence may be requested. Additional proctoring may be required at any time by the Department Chair, or the Medical Staff Executive Committee.

2 DEPARTMENT OF SURGERY Additional Criteria for Advanced Privileges PROCEDURE TRAINING NECESSARY NUMBERS OF PROCEDURES FOR INITIAL APPOINTMENT NUMBER OF PROCEDURES PROCTORED INITIALLY CRITICAL CARE MANAGEMENT 4 NA ANESTHESIA Procedural Sedation Conscious Sedation Test Adult and Pediatric CARDIOTHORACIC Install/Implant AICD* 1 1 Pacemaker (temporary) 1 1 Pacemaker (permanent) 1 1 HEAD AND NECK Radical Neck Dissection Documentation of training and current competence ENDOSCOPIC PROCEDURES Transoral Incisionless Fundoplication LAPAROSCOPIC PROCEDURES Appendectomy Cholestectomy Hernia Repair Laparoscopic assisted Colon Resection Laparoscopic Fundoplication Laparoscopic Spleenectomy LASER KTP/YAG, C02 Completion of Hands On Course Min. 2 Documentation of training and current competence 2 3

3 SPECIALTY: NAME: DEPARTMENT OF SURGERY - BOARD CERTIFIED: YES NO GENERAL PRIVILEGES Admitting and Attending Privileges First six (6) cases are to be proctored during the Provisional period (first two years) before a member is qualified for advancement. Assist in Surgery C-Arm with Fluoroscopy (Current Fluoroscopy Certificate Required) Consultation - First 10 cases are to be proctored during the Provisional period (first two years) before a member is qualified for advancement Critical Care Admission and Management* BUNDLED PRIVILEGES These procedures are customarily performed by board certified or fully trained general surgeons, and; Documentation of specific training and current competence in bundled procedural privileges may be required, and; Bundled privileges have no asterisk. ADVANCED PRIVILEGES These procedures may be performed by board certified or fully trained general surgeons, and; Advanced procedural privileges require documentation of training and current competence when requested by any surgeon, and; Advanced procedural privileges are denoted by one asterisk (*). Please review the above criteria sheet for current competence and proctoring requirements. Anesthesia

4 NAME: DEPARTMENT OF SURGERY - Completion of Written Exam Necessary Procedural Sedation Adult Procedural Sedation - Child Anterior Approach for Spinal Procedures Anterior Abdominal Approach Anterior Thoracic Approach Abdominal & Gastroenterological Bundle Abdominoperineal Resection Anoplasty Appendectomy/Meckel s Diverticulectomy Colon Resection Complex anorectal procedure Drainage of major abscess Enterolysis Exploratory laparotomy Internal Sphincterotomy Anoplasty Anal Fissurectomy Anal Fistulectomy Gastric Resection and reconstruction Gastric Ulcer Surgery Gastroenterostomy Gastrorrhaphy Gastrostomy Hemorrhoidectomy Hiatal hernia repair (open), anti-reflux procedures Ileal reservoir or conduit Paracentesis Peritoneal dialysis-catheter placement Pilonidal cyst excision Pyloromyotomy Pyloroplasty with vagotomy Retroperitoneal Exploration Small bowel resection Staging Laparotomy Transanal excision of neoplasm Hernia Repair Bundle Epigastric Femoral Inguinal Umbilical Ventral

5 NAME: Breast Bundle DEPARTMENT OF SURGERY - Sentinel lymph node biopsy Axillary node dissection Breast Biopsy Mastectomy Reconstructive breast procedures Cardiac Bundle Arterial Lines--Peripheral Central Venous Lines (Porta-Cath) Swan-Ganz catheterization To document recent clinical experience, enter # and location performed in the last two years where indicated Number Location Cardiothoracic Nonbypass(Advanced) Install/implant Temporary Pacemaker* Install/implant Permanent Pacemaker* (Epicardial, Transvenous) Install/Implant AICD* Central Venous Bundle Temporary & Permanent Esophagus Bundle Esophageal anastomosis Esophageal dilation Esophageal-tracheal fistula repair Esophageal varices ligation, sclerosis Esophagomyotomy (Heller Procedure) Esophagotomy Repair Bundle Rectovagina fistula Surgical rent, bowel, or bladder Salpingectomy Head & Neck Bundle

6 NAME: DEPARTMENT OF SURGERY - Branchial Cleft Cyst, Sinus Excision Excision submaxillary gland Eyelid Trauma Repair Parathyroidectomy Parotidectomy, superficial or deep with or without nerve dissection Thyroidectomy Thyroglossal duct cyst excision Tracheal repair ( trauma related, emergency) Tracheostomy To document recent clinical experience, enter # and location performed in the last two years where indicated Number Location Head and Neck (Advanced) Radical neck dissection* Liver, Billiary Tract, Pancreas Bundle Cholecystectomy, Operative Cholangiogram and CBD Exploration Choledocoenterostomy Cholecystostomy Hepatectomy (trauma related-emergency) Hepatic lobectomy Hepatic wedge resection Liver biopsy Pancreatectomy (partial or complete with reconstruction) Transduodenal sphincteroplasty Lymphatic and Spleen Bundle Excision Lymphadenectomy Splenectomy Splenic Repair Musculoskeletal- Extremity Bundle Excision Repair Amputations, minor and major (ray or distal, upper or lower body) Skin and Subcutaneous Tissue Bundle

7 NAME: DEPARTMENT OF SURGERY - Biopsy Burn Treatment (<20% total body surface) Excision of cyst or other lesion Skin grafts Incision and drainage Secondary wound closure Suture repair Fasciotomy Urologic Bundle Bladder Repair Repair of Ureter Nephrectomy for Trauma Endoscopic Bundle Choledochoscopy Colonoscopy Mediastinoscopy Percutaneous Endoscopic Gastrostomy Tube Sigmoidoscopy Upper GI Endoscopy ERCP Transoral Incisionless Fundoplication* (TIF) Laparoscopic Bundle Diagnostic, Operative and/or Pelviscopy Abdominal: Diagnostic and Biopsy Lysis of Adhesions To document recent clinical experience, enter # and location performed in the last two years where indicated Number Location Laparoscopic Procedures (Advanced) Appendectomy* Cholecystectomy* Hernia Repair* Laparoscopic assisted colon resection* (includes Lap. Colostomy) Laparoscopic Fundoplication Laparoscopic CAPD Insertion Laparoscopic Spleenectomy

8 NAME: To document recent clinical experience, enter # and location performed in the last two years where indicated Number Location Laser Procedures (Advanced) KTP/YAG* CO2* Holmium DEPARTMENT OF SURGERY - PRIVILEGING AGREEMENT I hereby request one or several of the above privileges and/or special procedures, and I attest to the fact that I meet the privileging requirement as set forth by the Medical Staff of Parkview Community Hospital, and that I am competent to perform the privileges that I have requested. Furthermore, I attest that I will not practice any such privilege that has not been granted to me. I understand that I may be asked to submit documentation to support my clinical competency, including, but not limited to, training and experience. I understand that periodic peer review will be performed relating to the privileges that are extended to me. I understand that if I wish to request additional privileges, I must do so in writing and provide supporting documentation of my current clinical competence. Furthermore, I understand that I will voluntarily relinquish those privileges that I am unable to demonstrate current clinical competence. Date Signature of Applicant

9 NAME: DEPARTMENT OF SURGERY - CLINICAL DEPARTMENT CHAIR RECOMMENDATION All privilege delineations have been individually considered and have been recommended based upon the Applicant s specialty, licensure, specific training, experience, health status, current competence and peer recommendations. APPLICANT MAY PERFORM PRIVILEGES AND PROCEDURES AS INDICATED. EXCEPTIONS/LIMITATIONS (Specify): Department Chair Date Revised 12/2009; 09/2010; 10/2011