RENOWN INTEGRATED HEALTH NETWORK INTERNAL MEDICINE DELINEATION OF PRIVILEGES

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1 Revised 5/21/2013 RENOWN INTEGRATED HEALTH NETWORK INTERNAL MEDICINE DELINEATION OF PRIVILEGES BASIC EDUCATION: M.D. or D.O. MINIMAL FORMAL TRAINING: Successful completion of an ACGME approved residency-training program in Internal Medicine. Other physicians will be considered for membership in the Department on a case-by-case basis. Board Certification: Those applicants who are not board certified at the time of 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 applicants must achieve board certification in their primary area of practice within five (5) years from the date of completion of their residency or fellowship training. Core Privileges Core privileges in IM includes the ability to admit, evaluate, diagnose, perform history and physical exam, consult, and provide non-surgical treatment to patients presenting with general medical problems. CLINICAL EDUCATION: Identify primary and subspecialty. Privileges include general medical management of patients (i.e., assessment and admission, inpatient care, obtaining consultations if needed, and discharge). Physicians with these privileges are expected to have training and/or experience and competence on a level commensurate with that provided by board certification or eligibility. Such physicians may act as consultants to others and may, in turn, be expected to request consultation when needed. Allergy Dermatology Endocrinology & Metabolic Diseases Hematology Pulmonary Disease Rheumatology Internal Medicine Neurology Nuclear Medicine Oncology Hospital Medicine Immunology Infectious Diseases Please select which facility you are requesting privileges at: LEGEND: 1 Renown Regional Medical Center 2 Renown South Meadows Medical Center 3 Renown Rehabilitation Hospital To request privileges at those facilities please place an X in the appropriate column below: CLASS I PRIVILEGES Procedures consistent with Internal Medicine board certification or equivalent training in Internal Medicine Arterial puncture Arthrocentesis/joint injection Applicant must provide documentation of 5 procedures within the last two years Bone Marrow & biopsy EKG interpretation Skin biopsy Page 1 of 5

2 03.31 Lumbar Puncture If the applicant has completed a residency within the last five years, the applicant may obtain letter from Residency Director stating that physician applicant is adequately trained and capable of performing said procedure. If not - the applicant must provide documentation of 5 procedures within the last two years Spirometry, basic Paracentesis: If the applicant has completed a residency within the last five years, the applicant may obtain letter from Residency Director stating that physician applicant is adequately trained and capable of performing said procedure. If not applicant must provide documentation of 2 procedures within the last two years Thoracentesis If the applicant has completed a residency within the last five years, the applicant may obtain letter from Residency Director stating that physician applicant is adequately trained and capable of performing said procedure. If not - the applicant must provide documentation 2 procedures within the last two years may utilize thoracostomy or pericardiocentesis procedures for documentation toward thoracentesis CLASS II PRIVILEGES Invasive procedures consistent with high level of expertise. Specific documentation of training in each technique required, individual case reports as required by appropriate subspecialty section. Current clinical competence reviewed by appropriate subspecialty section. Ventilator Management: To be eligible to apply for core privileges in ventilator management, the initial applicant must meet at least one of the following criteria: 1) Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited postgraduate training program in the relevant medical specialty, and successful completion of an accredited ACGME or AOA fellowship in critical care medicine or pulmonary medicine. AND Current subspecialty certification or active participation in the examination process leading to subspecialty certification in critical care medicine or pulmonary medicine by the relevant American Board of Medical Specialties, or the American Osteopathic Board. 2) Successful completion of an ACGME or AOA accredited postgraduate residency training in general surgery or anesthesiology or emergency medicine. 3) Successful completion and documentation of training comparable to the above that is satisfactory to the Medical Staff Credentials and Privileges Committee. Reappointment Requirements: To be eligible to renew core privileges in ventilator management, the applicant must meet the following maintenance of privilege criteria: Current demonstrated competence and an adequate volume of experience, including 12 patient contacts with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current ability to perform privileges requested is required of all applicants for renewal of privileges. If the applicant cannot provide evidence of 12 patient contacts at local hospitals, the physician will be asked to submit in writing, his or her reasons for wanting to retain the privilege. These reasons will be considered by the Credentials and Privileges Committee, and if sufficient, the applicant will be recommended for reappointment. SWAN GANZ: If the applicant has completed a residency within the last five years, the applicant may obtain letter from Residency Director stating that physician applicant is adequately trained and capable of Swan Ganz performing said procedure. If not - applicant must provide documentation of 5 procedures within the last two years (minimum of 3 for insertion; maximum 2 for monitoring); right heat catheterization counts toward numerical documentation Page 2 of 5

3 CENTRAL VENOUS CANNULATION (CVC) If the applicant has completed a residency within the last five years, the applicant may obtain letter from Residency Director stating that physician applicant is adequately trained and capable of performing said procedure. If a physician has completed postgraduate education in the field of, Anesthesia, Internal Medicine, Emergency Medicine, Family Practice or Surgery, it will not be necessary to supply documentation for CVC If not ~ Applicant must provide documentation of 10 procedures within the last two years Swan Ganz will count toward CVC ARTHROCENTESIS/ JOINT ASPIRATION: If the applicant has completed a residency within the last five years, the applicant may obtain letter from Residency Director stating that physician applicant is adequately trained and capable of performing said procedure. If not - the applicant must provide documentation of 5 procedures within the last two years ARTERIAL CATHETER : If the applicant has completed a residency within the last five years, the applicant may obtain letter from Residency Director stating that physician applicant is adequately trained and capable of performing said procedure If not - the applicant must provide documentation of 10 procedures within the last two years angioplasty and intraoperative arteriogram will count towards arterial catheter Qualifications for adult airway maintenance and intubation privileges: To be eligible to apply for core privileges in airway maintenance and intubation, the initial applicant must meet at least one of the following criteria: 1) Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited postgraduate training program in the relevant medical specialty, and successful completion of an accredited ACGME or AOA fellowship in critical care medicine or pulmonary medicine. AND Current subspecialty certification or active participation in the examination process leading to subspecialty certification in critical care medicine or pulmonary medicine by the relevant American Board of Medical Specialties, or the American Osteopathic Board. 3) Successful completion of an ACGME or AOA accredited postgraduate residency training in general surgery or anesthesiology or emergency medicine. 4) Successful completion and documentation of training in airway maintenance and intubation, such as a dedicated course in difficult airway management. Reappointment Requirements: To be eligible to renew core privileges in airway maintenance and intubation, the applicant must meet the following maintenance of privilege criteria: Current demonstrated competence and an adequate volume of experience, including 12 patient contacts with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current ability to perform privileges requested is required of all applicants for renewal of privileges. If the applicant cannot provide evidence of 12 patient contacts at local hospitals, the physician will be asked to submit in writing, his or her reasons for wanting to retain the privilege. These reasons will be considered by the Credentialing Committee, and if sufficient, the applicant will be recommended for reappointment CLASS III PRIVILEGES Invasive procedures consistent with high level of expertise. Specific documentation of training in each technique required, individual case reports as required by appropriate subspecialty section. Current clinical competence reviewed by appropriate subspecialty section Peripheral Page 3 of 5

4 MODERATE SEDATION ANALGESIA A. Member Competence for Privileges Members other than Anesthesiologists, Trauma surgeons, Pulmonologists, Intensivist, Emergency Medicine, Pediatric Intensivist, Neonatologists, Otolaryngologists, Cardiologists and Gastroenterologists, seeking to direct moderate sedation for procedures performed at the Hospital must be privileged according to the following criteria: Moderate Sedation. Any active or Associate Member of the Medical Staff may apply for moderate sedation privileges as follows: a. Initial Privileges. The Member must submit a written request for moderate sedation privileges to the Medical Staff Services Office along with: (i) Completion of mandatory education materials and score of 80% on an examination that reviews the applicable pharmacology, adverse effects, administration, dosage and emergency interventions for the sedative(s) used at least once every two (2) years; and (ii) Maintenance of current ACLS certification. If the Member does not maintain current ACLS certification, then an individual certified in ACLS must be present every time the Member exercises his or her moderate sedation privileges. b. Reappointment Privileges. The Member must submit a Request for moderate sedation privileges to the Medical Staff Services Office along with: (i) Completion of mandatory education materials and 80% on an examination that reviews the applicable pharmacology, adverse effects, administration, dosage and emergency interventions for the sedative(s) used; (ii) Maintenance of current ACLS certification. If the Member does not maintain current ACLS certification, then an individual certified in ACLS must be present every time the Member exercises his or her moderate sedation privileges. ARTERIAL CATHETER ARTHROCENTESIS JOINT ASPIRATION 10 procedures within the last two years - angioplasty and intra operative arteriogram will count towards arterial catheter 5 procedures within the last two years CENTRAL VENOUS CANNULATION (CVC) 10 procedures within the last two years - Swan Ganz will count toward CVC. If a physician has completed postgraduate education in the field of Anesthesia, Internal Medicine, Emergency Medicine, Family Practice or Surgery, it will not be necessary to supply documentation for CVC. FLEXIBLE SIGMOIDOSCOPY 10 procedures within the last two years, needs a GI mentor; or demonstration completion of didactic training and be mentored for 10 cases by a GI mentor. LUMBAR PUNCTURE PARACENTESIS SWAN GANZ THORACENTESIS 5 procedures within the last two years 2 procedures within the last two years 5 procedures within the last two years (minimum of 3 for insertion; maximum 2 for monitoring); right heart catherization counts toward numerical documentation 2 procedures within the last two years - may utilize thoracostomy or pericardiocentesis procedures for documentation towards Thoracentesis Mentoring and Reappointment Ongoing proficiency is required to maintain privileges. Mentor reports for concurrently performed invasive procedures may be accepted to document initial proficiency. pharmacology and didactic review. Elevation to Active Staff and Mentoring: Members are eligible to request elevation to Active Staff, consistent with the Bylaws and Credentialing Policies of the Medical Staff. All physicians requesting elevation will have a minimum of ten charts reviewed by their mentor. Medical Records will pull these charts at the request of the mentor. Mentor Report Forms will be used to evaluate each chart. These forms are available in Medical Records and should be turned in to Medical Staff Services upon completion. Page 4 of 5

5 Privileges, Reappointment: All members of the Department of Medicine are reappointed every two years in accordance with the Bylaws and Credentialing Policies of the Medical Staff. Since reappointment is an affirmation of good clinical practice, each applicant for reappointment shall provide evidence of 10 patient contacts. If an applicant has not had 10 patient contacts at Renown Regional Medical Center, the applicant will be asked to provide evidence of 10 patient contacts at another local, Joint Commission accredited hospital. The facility will be queried to ascertain whether or not the physician is in good standing. If the applicant can not provide evidence of 10 patient contacts at a local hospital, the physician will be asked to submit in writing, his or her reasons for wanting to remain on the medical staff. The Department will consider these reasons, and if sufficient, the applicant will be recommended for reappointment. Applicant Print Name Applicant Signature Section Chief ( If applicable) Department Chief of Recommendation by the Credentials & Privileges Committee of Recommendation by the Executive Committee: of Approval by the Board of Governors: RENOWN SOUTH MEADOWS & OR RENOWN REHABILITATION HOSPITAL: Section Chief Department Chief of Recommendation by the Executive Committee: of Approval by the Board of Governors: Page 5 of 5