Fairview Health Services CERTIFIED NURSE MIDWIFE Delineation of Privileges CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES

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1 PAGE 1 OF 4 Fairview Health Services CERTIFIED NURSE MIDWIFE Delineation of Privileges Applicant s Name (please print): CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES I Want to Work at the Following Fairview Entity Inpatient/hospital(s) Fairview Maple Grove Medical Center (Ambulatory Care Center) 1, 2 Fairview Maple Grove Ambulatory Surgery Center 1 Fairview Hospital-Based Clinic (such as UMMC Clinics, Fairview Ridges Specialty Clinic for Children, Fairview Southdale Oncology Clinic, Fairview Southdale Hospital Breast Center) 1, 3 Fairview Free-Standing Ambulatory Clinics 1 I need to the following Fairview Entity Box on Privilege Form Individual Fairview hospital(s) University of Minnesota Medical Center, Fairview (UMMC) Fairview Maple Grove Ambulatory Surgery Center (MGASC) Individual Fairview hospital where clinic is affiliated Fairview Group Practice Ambulatory Clinics (FV Clinics) 1 Ambulatory privileges to practice at Fairview hospital-based clinics and other non-hospital-based Fairview owned entities are only available to those practitioners authorized by Fairview to practice at those sites. Ambulatory privileges do not include performance of procedures which are not otherwise available or performed at the individual ambulatory sites as determined by the operational manager or other appropriate personnel. 2 Privileges granted by UMMC can also be exercised at these entities in Maple Grove in accordance with procedures available at the sites. 3 Privileges granted by the specific hospital entity can also be exercised at hospital-based clinics affiliated with that entity in accordance with procedures available at the clinic. z:\common\forms\cvo\privilege Forms\Certified Nurse Midwife.doc Approved: OB/GYN Committee: 10/19/93, Reviewed: 4/94 Approved: Credentials Committee: 10/93, Reviewed: 4/94 Approved: Executive Committee: 11/93, Reviewed: 5/94 Approved: Board of Directors: 11/18/93, Reviewed: 5/19/94 Revised: 5/05 (SCPC Subcomm); 3/08 new format only; 9/08; 6/09 (new format) revised 9/2010; 7/2011;9/12;12/13;1/14;2/14

2 PAGE 2 OF 4 Fairview Hospital Entity Codes UMMC - University of Minnesota Medical Center, Fairview FSH - Fairview Southdale Hospital FRH - Fairview Ridges Hospital FNH - Fairview Northland Medical Center FLH - Fairview Lakes Medical Center Fairview Ambulatory Entity Code FV Clinics = Fairview Free-standing Ambulatory Clinics MGASC = Fairview Maple Grove Ambulatory Surgery Center Definitions/Abbreviations Core Privileges - Privileges routinely taught in training programs Special Request Privileges - Privileges not routinely taught in training programs; new technology or procedure; high risk; or requires ongoing practice to maintain competency N/A - Indicates privilege not available at the specific Fairview entity AF - Indicates an additional form is required to request the privilege Threshold Criteria Core Privileges CERTIFIED NURSE MIDWIFE Must meet ALL of the following: 1) Completed RN education 2) Successfully completed a Nurse-Midwifery Educational Program accredited by the ACNM-ACME (American College of Nurse Midwives-Accreditation Commission for Midwifery Education). 3) Must hold current Minnesota RN license 4) Must be certified by the American Midwifery Certification Board or its designated certification board OR Must be within 6 months after completion of an advanced practice nursing course of study and in the process of meeting the requirements for certification. If you fail the certification examination, you must stop practicing as an advanced practice registered nurse (per MN Board of Nursing). 5) The applicant must provide documentation of collaborative agreements (attached) with OB/GYN physicians who have OB/GYN privileges and who are members in good standing on the medical staff of Fairview Southdale Hospital or UMMC. Collaborating physician must practice at the same hospital as the CNM. 6) Must document acting as primary attending during delivery of 24 patients during past 24 months. May count deliveries managed during training program if they meet 24 month time frame. Cross out privileges you do not perform Privileges include, but are not limited to, the independent management of women's health care, focusing particularly on pregnancy (including oligohydramnios), childbirth, the postpartum period, care of the newborn, and family planning and gynecological needs of women, such as preconception care, care of the child-bearing woman, health promotion and disease prevention, management of common health problems, and management of Competency Measures/ Required # Cases in Past 24 Months Check Entity(ies) Where Privileges Requested Hospital Entities Ambulatory 100 UMMC FSH FRH FNH FLH FV Clinics (Inpatient, ambulatory or consultative) N/A N/A N/A perimenopause and post-menopause. The certified nurse-midwife may participate in the management of care for the childbearing woman at risk in collaboration with a physician consultant. Nurse-midwifery practice includes admission to and discharge from the hospital and completion of a history and physical. The CNM may also provide consultation for well-woman gynecologic care to clients who are in the hospital receiving other medical services. The certified nursemidwife may write prescriptions appropriate to scope of practice. Privileges also allow for consultation, collaborative management, or referral as indicated by the health status of the client within the Fairview health care system. Practice is expected to be in accordance with the Standards for the Practice of Nurse-Midwifery, as defined by the American College of Nurse-Midwives. Core privileges do not include prescriptive authority privileges (see Prescriptive Core).

3 PAGE 3 OF 4 PRESCRIPTIVE CORE Threshold Criteria Core Privileges Must meet Threshold Criteria listed above for Certified Nurse Midwife core privileges Cross out privileges you do not perform Includes prescribing, administering and dispensing drugs and medical devices as delegated within practice as a nurse-midwife. Check Entity(ies) Where Privileges Requested Hospital Entities Ambulatory UMMC FSH FRH FNH FLH FV Clinics N/A N/A N/A Standard Documentation Requirements for Special Request Privileges: Each of the following privileges requires documentation of training and/or experience specific to the privilege requested. Unless otherwise noted, documentation must be within the last two years and in one of the following forms: 1) Letter from a training program verifying training specific to the procedure within the past 24 months; OR 2) Letter or certificate from an additional training course indicating training specific to the procedure has successfully been completed within the past 24 months; OR 3) Documentation of 5 cases specific to each procedure requested completed within the past 24 months (copies of operative reports, chart notes or a list of cases performed). Documentation must include date procedure was performed, type of procedure, and where performed (e.g. hospital/clinic). Please delete all patient identifiers such as medical record number, patient name from the documentation to protect confidentiality. Special Request Privileges Competency Check Entity(ies) Where Privileges Requested Measures/ Hospital Entities Ambulatory Required # Cases in Past 24 Months UMMC FSH FRH FNH FLH FV Clinics Repair of Third Degree Lacerations See Standard Documentation Requirements for Special Request Privileges above Repair of Fourth Degree Laceration See Standard Documentation Requirements for Special Request Privileges above 5 (or see above) N/A N/A N/A N/A 5 (or see above) N/A N/A N/A N/A Colposcopy Initial Appointment: Must provide documentation of ALL of the following: 1) Successful completion of an accredited comprehensive colposcopy course 2) Successful completion of the ASCCP Mentorship Program 3) Successful completion of the ASCCP Colposcopy Mentorship Program exam If above requirements were completed more than 24 months ago, must also provide documentation of 5 colposcopy cases* successfully performed in the past 24 months Reappointment: Documentation of 5 colposcopy cases* successfully performed in the past 24 months Hysterosalpingogram See Standard Documentation Requirements for Special Request Privileges above See criteria 5 (or see above) N/A N/A N/A N/A N/A N/A N/A * Submit case list - documentation must include date the procedure was performed, type of procedure and where performed, e.g., name of hospital or other facility. Please delete all patient identifiers such as name or medical record number from documentation to protect individual patient confidentiality.

4 PAGE 4 OF 4 For the high-risk patient, three levels of CNM/MD relationship exist: Consultation, Collaboration and Referral. The certified nurse-midwife must obtain consultation from a collaborating physician who has agreed in writing to provide such consultation for the following conditions except in potentially life-threatening circumstances in which appropriate consultation may be obtained from any qualified physician: a. Vaginal birth after caesarian (VBAC) (*collaboration at FSH) VBAC with pitocin or other complications (*collaboration at FSH and UMMC) b. History of shoulder dystocia (*collaboration at FSH and UMMC) c. Suspected fetal weight of <2500 gms or >4500 gms (*collaboration at FSH) d. Multiple gestation (*collaboration at FSH and UMMC) e. Pre-gestational or pre-existing insulin dependence (*collaboration at FSH and UMMC) f. Abnormal presentation (breech) (**referral at FSH *collaboration at UMMC) g. Intrauterine fetal death h. Labor <34 weeks or >42 weeks gestation (*collaboration at FSH) i. Abnormal vaginal bleeding persistent bleeding (*collaboration at FSH and UMMC) j. Mild pre-eclampsia severe pre-eclampsia (**referral at FSH, *collaboration at UMMC) k. Active genital herpes in labor (**referral at FSH) l. Maternal fever >100.4F m. Abnormal fetal heart rate pattern (*collaboration at FSH and UMMC) n. Arrest of cervical dilation o. Lack of progress in second stage (1 hour-multipara, 2 hour-primipara) (*collaboration at FSH and UMMC) p. Moderate or thick meconium * thick mec with abnormal FHR (*collaboration at FSH and UMMC) q. Prolapsed cord (**referral at FSH, *collaboration at UMMC) r. Uncontrolled post partum hemorrhage (**referral at FSH and *collaboration at UMMC) s. Retained placenta (**referral at FSH and *collaboration at UMMC) t. Third and fourth degree lacerations *Collaboration at FSH and UMMC if CNM is not privileged for this procedure u. Other medical or obstetrical abnormalities as determined by MD or CNM *= UMMC: MD collaborating and on campus for delivery (or postpartum event as indicated above) *= FSH: MD collaborating and on campus for the labor, delivery and/or significant event **= FSH: Requires immediate referral to the collaborating physician for management. Consultation: Consultation is the process whereby a certified nurse-midwife, who maintains primary management responsibility for the woman's care, seeks the advice or opinion of a physician. Collaboration: The process whereby a certified nurse-midwife and physician jointly manage the care of a woman or newborn who has become medically, gynecologically or obstetrically complicated. The scope of collaboration may encompass the physical care of the client, including delivery, by the certified nurse-midwife, according to a mutually agreed-upon plan of care. When the physician must assume a dominant role in the care of the client due to increased risk status, the certified nurse-midwife may continue to participate in physical care, counseling, guidance, teaching and support. Effective communication between the certified nursemidwife and physician is essential for ongoing collaborative management. Referral: Referral to medical management occurs at the discretion of either the CNM or the collaborating physician. I attest that I have written practice guidelines that are in accordance with the ACNM standards of practice and meet the UMMC guidelines for collaboration agreements between certified nurse-midwives and physicians which have been agreed upon by my collaborating physicians and which I agree to provide to UMMC at their request. I also attest that my professional liability insurance covers the privileges I have requested. Signature Date

5 Fairview Health Services COLLABORATING PHYSICIAN ATTESTATION FORM FOR CERTIFIED NURSE MIDWIFE Certified Nurse Midwives are associate professional staff at University of Minnesota Medical Center and/or Fairview Southdale Hospital are credentialed for certain activities as outlined within the CNM privilege form (attached). Each CNM is required to have a collaborative agreement with an OB/GYN physician who is a member, in good standing, of the Medical Staff at the Fairview Hospital at which the CNM is practicing. The collaborative agreement must meet the "UMMC Guidelines for Collaborative Agreements Between Certified Nurse Midwives and Physicians" as attached. As a collaborating physician, I have reviewed the privilege form and "Guidelines for Collaborative Agreements Between Certified Nurse Midwives and Physicians" with, CNM and attest that I do have a written agreement with the CNM identified above which meets these guidelines. Physician Name (please print) Physician Signature Date

6 PAGE 1 OF 2 GUIDELINES FOR COLLABORATIVE AGREEMENTS BETWEEN CERTIFIED NURSE MIDWIVES PHYSICIANS Purpose: The purpose of these guidelines is to identify issues which must be addressed in collaboration agreements between certified nurse-midwives (CNM) and physicians (MD) for certified nurse-midwives to be considered for professional staff privileges at University of Minnesota Medical Center (UMMC) and or Fairview Southdale Hospital. Collaboration agreements may address additional issues and these guidelines are not intended as an exhaustive framework for all of the considerations which may be included in such an agreement. Development: The development of a collaboration agreement is a complex task. The collaboration agreement reflects mutual trust and effort between the CNMs and MDs. Collaboration agreements should be developed jointly by the certified nursemidwives and collaborating physicians. Each CNM is required to have a signed collaboration agreement with at least one MD who is a member in good standing of the medical staff at UMMC or FSH (depending on facility used by the physician and CNM). More than one CNM or more than one MD may be the party to a collaboration agreement, provided that each of the midwives and physicians are individually bound to the responsibilities and obligations set forth in the agreement. Collaboration agreements should be reviewed and renewed at least every two years prior to the time of the CNM's application for reappointment and may be reviewed and modified more frequently if the circumstances warrant changes. Requirements: 1. Background: A Collaboration Agreement must include the following background information: Name, practice address, and telephone numbers of the CNM or CNMs; and Name, address and telephone numbers of collaborating MD or MDs. 2. Call Consulting Coverage: The collaboration agreement must include a statement identifying the arrangements between the CMNs and MDs for call coverage and consultation for patients at UMMC consistent with the policies of UMMC and good patient care for availability and timeliness. 3. Written Practice Guidelines: The collaboration agreement will provide for written practice guidelines which are agreed upon with the collaborating MD. The practice guidelines may be a part of the collaboration agreement or an attachment which is addressed in the collaboration agreement. The practice guidelines shall contain a description of the scope of the CNM's practice and relationship with the collaborating MD. In addition, the practice guidelines must specifically address guidelines for consultation with the physician for the following conditions: a. Vaginal birth after caesarian (VBAC) (*collaboration at FSH) VBAC with pitocin or other complications (*collaboration at FSH and UMMC) b. History of shoulder dystocia (*collaboration at FSH and UMMC) c. Suspected fetal weight of < 2500gms. or >4500gms (*collaboration at FSH) d. Multiple gestation (*collaboration at FSH and UMMC) e. Gestational or pre-existing insulin dependence (*collaboration at FSH and UMMC) f. Abnormal presentation (breech) (** referral at FSH, *collaboration at UMMC) g. Intrauterine fetal death h. Labor <34 weeks or >42 weeks gestation (*collaboration at FSH)

7 PAGE 2 OF 2 i. Abnormal vaginal bleeding persistent bleeding (*collaboration at FSH and UMMC) j. Mild pre-eclampsia severe pre-eclampsia (**referral at FSH, *collaboration at UMMC) k. Active genital herpes in labor (**referral at FSH) l. Maternal fever >100.4F m. Abnormal fetal heart rate pattern (*collaboration at FSH and UMMC) n. Arrest of cervical dilation o. Lack of progress in second stage (1 hour-multipara, 2 hour-primipara) (*collaboration at FSH and UMMC) p. Moderate or thick meconium * thick mec with abnormal FHR (*collaboration at FSH and UMMC) q. Prolapsed cord (*referral at FSH *collaboration at UMMC) r. Uncontrolled post partum hemorrhage (*referral at FSH and *collaboration at UMMC) s. Retained placenta (*referral at FSH and *collaboration at UMMC) t. Third and fourth degree lacerations *Collaboration at FSH and UMMC if CNM is not privileged for this procedure u. Other medical or obstetrical abnormalities as determined by MD or CNM *= UMMC: MD collaborating and on campus for delivery (or postpartum event as indicated above) *= FSH: MD collaborating and on campus for the labor, delivery and/or significant event **= FSH: Requires immediate referral to the collaborating physician for management. Practice guidelines for the listed conditions should include specific statements regarding call coverage and timeliness for consultations and should identify under what conditions the consulting physician must be present at UMMC for the consultation. Minimal expectation is that the MD will be on campus for labor and delivery (at FSH) or delivery (at UMMC) in which collaboration occurs (including all asterisk deliveries). 4. Practice and Consultation Review: The collaboration agreement shall describe the process through which the CNM and MD will review patient care to identify any areas which require changes in the practice guidelines or changes in the scope of the CNM's practice or the consulting relationship with the MD. A general review and discussion of the practice should be held not less frequently than once a year, and more often as circumstances or the understandings between the parties may require. 5. Description of Scope of Certified Nurse Midwife's Prescriptive Practice: The collaboration agreement shall include a description of the general scope of the CNM's prescribing practice and should identify the drugs and devices which the CNM may prescribe, with any limitations, without review by the consulting MD. The consulting MD and the CNM shall regularly review the prescriptive practices consistent with the community standards for care. The nature and frequency of such review may be based upon the nature of the practice, the patient acuity and the experience of the providers. The collaboration agreement should describe a schedule and general method for review of the prescriptive practices. 6. Signatures of Parties: The collaboration agreement must be signed by each of the CNMs and MD who agree to collaborate on patient care in the manner described in the agreement. It is not adequate to have the agreement signed on behalf of the practice group, corporation or other entity. An entity may be an additional party to a collaboration agreement, but it must be signed by the individuals who will be collaborating.

8 VERIFICATION OF PATIENT MANAGEMENT & PARTICIPATION FOR CERTIFIED NURSE MIDWIFE CORE PRIVILEGES This Section to be Completed by Certified Nurse Midwife Applying for Privileges Practitioner Name Initial Appointment Reappointment I am requesting the following core(s) privileges. I attest that I have managed and participated in or completed the minimum number of patients/procedures listed for each of the requested core(s) within the past 24 months. Certified Nurse Midwife patients This Section to be Completed by CLINIC MANAGER OR PEER* Verifying Practitioner s Patient Management & Participation *Must have current knowledge of practitioner s practice The above-referenced practitioner is applying for core privileges at a Fairview hospital or clinic. Please complete the following questions to verify the practitioner has met the current clinical competency criteria for the core privileges being requested. Thank you for your assistance. 1. Within the past 24 months, has the above-referenced practitioner managed and participated in or completed the above-noted required number of patients/procedures in the core(s) being requested (either inpatient, ambulatory or consultative)? Yes No* *If no, please explain below in the Additional Comments area. 2. Do you have any concerns about this physician performing the requested privileges? Yes* No *If yes, please explain below in the Additional Comments area. Additional Comments: Name (please print) Title Phone Number Signature Date Clinic Name and Address CLINIC MANAGER OR PEER - RETURN FORM WITHIN 1 WEEK DIRECTLY TO: Fairview System Credentialing Initial Appointments - Fax (612) Reappointments - Fax (612) If you have questions, please contact the Fairview System Credentialing Office at (612)

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