STANTON TERRITORIAL HEALTH AUTHORITY CREDENTIALS COMMITTEE REQUIREMENT CHECKLIST FOR HOSPITAL PRIVILEGES

Transcription

1 REQUIREMENT CHECKLIST FOR HOSPITAL PRIVILEGES Physician s Name: Address: Start Date: Home Phone: Work Phone: Fax: Place of work in NT 1. Application for Appointment to the Medical Staff 2. Privileges please see the attached lists of procedures you may request. 3. Curriculum Vitae 4. NWT License/Permit to Practice - Please contact the Professional Licensing Officer, Jeanne Gagnon, at jeanne_gagnon@gov.nt.ca or in order to apply. Your license will be faxed to our office once issued 5. CMPA Certificate Membership Update CMPA # Please ensure that the NWT is indicated as a territory of work. 6. Three (3) Letters of Reference (they may be the same three people that submit references to the Registrar of Professional Licensing but must be on the specific form attached the two departments do not share references) 7. Family Physicians requesting OB privileges must also provide the following: Documentation of having completed a recent ALARM, ALSO, or acceptably equivalent course. And a letter of reference or appropriate other assessment suggesting that the applicant has the skills, training, and proficiency to safely practice in a comparable environment to that of Stanton Hospital from either: a) an acceptable obstetrical or medical program director or colleague or b) a current member of Stanton s or Inuvik s Obstetrical Department. This letter of reference can be counted as one of the three letters of reference above in item 6. Please fax all documents listed above to: (867) Or mail to: Medical Affairs Department, Stanton Territorial Health Authority Box 10, (550 Byrne Road), Yellowknife, NT X1A 2N1 For more information call

2 PHYSICIAN APPLICATION FOR APPOINTMENT TO THE MEDICAL STAFF NAME: DATE OF BIRTH: (day/month/year) ADDRESS HOME PHONE WORK PHONE Please scan or mail a current photograph for identification purposes Please don t fax your photo ADDRESS AFFILIATED NWT CLINIC Family Physician Specialist please specify I am requesting appointment to the following category of medical staff: Active (Medical Practitioners who practice in the City of Yellowknife, appointed by the Board after having completed 6 months satisfactory services as an Associate) Associate (Medical Practitioners who practice in the City of Yellowknife; and are applying for initial appointment to the Medical Courtesy Staff) (The applicant does not reside within the City of Yellowknife; or the applicant s primary commitment is to another organization, or the applicant requests courtesy privileges; or where the Board deems it otherwise advisable and in the best interests of the Authority) Locums Tenens (Medical Practitioners who are working to meet specific clinical needs for a defined period of time, as a planned replacement for practitioners for a specific period of time; or to provide episodic or limited surgical) For office use only: The STHA Credentials Committee recommends that the physician be appointed to the following category of medical staff at the Stanton Territorial Health Authority. Active Associate Courtesy Locum Tenens I am requesting privileges for the following Health Authority(ies). (Check all that apply) DehCho (DHSSA) Fort Smith (FSHSSA) Hay River (HRHSSA) Beaufort Delta (BDHSSA) Sahtu (SHSSA) Tlicho (TCSA) Stanton Territorial (STHA) Yellowknife (YHSSA) 1. LIABILITY INSURANCE: CMPA Effective Date(s) Please attach copy of Update indicating the NT as a Territory of work or arrange to have one faxed directly to MEMBERSHIP ON OTHER HOSPITAL MEDICAL STAFF No Yes (complete section below) Hospital Category

3 3. CERTIFICATIONS: CERTIFICATION Advanced Cardiac Life Support (ACLS) Must be updated every 2 years. Required for Emergency Call and Anaesthesia Privileges Pediatric Advanced Life Support (PALS or APLS) Recommended Most recent date completed. DD/MM/YYYY Neonatal Resuscitation Course (NRP) (Mandatory) Advanced Trauma Life Support (ATLS) (optional) Advanced Life Support Obstetrics (ALSO) or ALARM or MORE OB Other: (please specify) 4. CONTINUING EDUCATION: Specialist Physicians are required to fulfill the Maintenance of Competency requirements for membership in the Royal College of Physicians and Surgeons, or equivalent. Family Physicians are required to fulfill CME requirements for membership in the College of Family Physicians of Canada or equivalent. summary attached listed below 5. Please indicate whether you have been a member of any hospital committee(s) requiring medical staff representation within the past year, and, if so, what type of committee and the time period when you were on the committee. Hospital Committee Time Period I,, hereby apply for Appointment to the Medical Staff of the Health Authorities indicated above, with privileges as requested (see attached list of privileges), if applicable, and for privileges to utilize laboratory and diagnostic imaging services of the Stanton Territorial Health Authority. I affirm that I will abide by the Bylaws, Policies, and Procedures of the health care facilities in which I am working, or in which I will utilize services provided by the facility. I also affirm I will abide by the Hospital & Health Facilities Standard Regulations of the NWT. I affirm that I will immediately notify the Chairperson of the STHA Credentials Committee should my license to practice be suspended, revoked or altered. I am aware that in addition to my credentials, privileges granted will depend upon the needs and resources of the individual Health Authorities, as well as the requirements of the medical programs (e.g. Family Practice, Obstetrics, Emergency Medicine) for which I am requesting privileges. Applicant s Signature Date Reviewed and Accepted by the STHA Credentials Committee Member of the STHA Credentials Committee Chairperson of the STHA Credentials Committee Date Date

4 Dr. Privileges Expire: GENERAL PRACTITIONER PROCEDURES PRIVILEGES FOR SURGICAL AND MEDICAL PROCEDURES General: Primary medical care of patients throughout their life span as per the scope of practice outlined by the Canadian College of Family Physicians, utilizing the biopsychosocial frame of reference, and including the performance of diagnostic and therapeutic procedures, the provision of therapeutic advice and prescription of pharmaceutical treatment, and patient counselling. General Surgery Incision & Drainage of: Superficial abscesses Pilonidal sinus abscesses Perianal abscess Thoracentesis Paracentesis Fine needle aspirate (FNA) biopsies Removal of nail, or wedge resection (not radical resection of nail bed) Suture of uncomplicated wounds (including external ear and face) Debridement and/or repair of wounds Local excision of skin lesions and lesions of oral mucosa (excluding skin of nose, external ear, and eyelid) Urinary catheterization Excision of superficial skin lesions Excision of subcutaneous lesions Vasectomy Circumcision Joint aspiration and injection Incision and drainage of abscesses Incision and evacuation of thrombosed hemorrhoids Sclerotherapy of varicose veins Sclerotherapy of spider nevi Excision of nails Cryotherapy Treatment of venereal warts Lumbar puncture Sedation for procedures Peripheral nerve blocks (ankle blocks, median nerve blocks) Bone marrow biopsy/aspiration Eye, Ear, Nose and Throat Surgery Nasal cautery and packing Removal of foreign body embedded in cornea Orthopedics Aspiration and injection of joints (knee, ankle, elbow, subacromial bursa) Closed reduction of common dislocations (fingers, toes, temporal mandibular joint, shoulder, elbow) Application and removal of casts Primary repair of extensor tendons of hand and foot Endoscopy Rigid sigmoidoscopy Anoscopy / Proctoscopy Medical Phlebotomy (peripheral vessel) Arterial blood gas Gynecological: Endometrial biopsy (number done in past 5 years ) IUD insertion (number done in past 5 years ) Artificial insemination Obstetrical: Antenatal care to 36 weeks gestation Antenatal care to term gestation Other: Acupuncture Applicant Signature: Date: Hospital Use Only Basic Privileges Approval Clinical Director of Family Practice Signature Date

5 Dr. Privileges Expire: OBSTETRICAL PROCEDURES ANTENATAL OBSTETRICAL PRIVILEGES: Note that Family Doctors need not apply for specific credentials to perform antenatal care in a hospital or hospital-based clinic. BASIC and INTERMEDIATE OBSTETRICAL PRIVILEGES: are site specific and will only be considered within facilities that provide intrapartum obstetrical services. Privileges are not required when a practitioner performs a medical procedure in an emergency situation when a more highly trained or experienced practitioner is not available. OBSTETRICS PRIVILEGES FOR: Inuvik *Yellowknife Successful applicants should have these additional requirements: Documentation of having completed a recent ALARM, ALSO, or acceptably equivalent course. A letter of reference or appropriate other assessment suggesting that the applicant has the skills, training, and proficiency to safely practice in a comparable environment to that of Stanton Hospital from either: a) an acceptable obstetrical or medical program director or colleague or b) a current member of Stanton s Obstetrical Department. BASIC OBSTETRICS PRIVILEGES Management of vaginal deliveries Vacuum extraction Repair of obstetrical lacerations (Grade 1 and 2) INTERMEDIATE OBSTETRICAL PRIVILEGES INTERMEDIATE OBSTETRICAL PRIVILEGES: should be supported by documentation from a preceptor or an institution indicating appropriate training and/or experience before privileges will be granted. There is no requirement for a minimum number of procedures to be performed before privileges will be granted, however the number performed in the past 5 years provides some measure of experience. Please indicate the procedures that you are applying for by checking off the appropriate box. Procedure Number done in past 5 Years Low forceps assisted deliveries Removal of retained placenta Repair of 3 rd degree lacerations Repair of 4 th degree lacerations Repair of cervical lacerations Umbilical vein catheterization Caesarean Sections Obstetrical Ultrasound 1 st trimester 2 nd and 3 rd trimester Biophysical profile/fluid/position Clinical Director of Obstetrics Signature Date

6 Dr. Privileges Expire: BASIC PRIVILEGES FOR EMERGENCY MEDICINE I, request delineation of privileges in emergency medicine as specified below. The privileges accorded include diagnosis, management and consultation. Note: In a code orange, mass casualty or multiple casualty trauma, any medical staff member who has general hospital privileges is permitted to provide any type of patient care necessary as a life-saving measure or to prevent serious harm regardless of his or her medical staff status or clinical privileges. Any practitioners with general privileges may also provide occasional coverage in the ER in order to help during physician illness or periods of high volume provided there is someone with active ER privileges supervising who could be on scene to assist them within 5 or 10 minutes. Experience & Education Criteria Approximate emergency clinical practice in the last 2 years: (average shifts per month) New CCFP (not EM) graduate 1-3 Less than one shift / month 4-6 More than 8 Check applicable emergency related education including any recent relevant CME CCFP-EM ATLS CCFP PALS / APLS FRCPC ACLS ACLS certification within the past 2 years (with a one year grace period) is required for all emergency coverage. Exceptions can be made for similar relevant education or experience. If you do not have up to date ACLS please document relevant experience / education you have in critical care and trauma. ATLS, APLS or PALS are strongly recommended An application for privileges in emergency medicine for new graduates (past 12 months) or clinicians with an average of less than one shift per month of emergency medicine experience in the past 2 years should be accompanied by documentation either in the form of references or from the clinical supervisor of the recent graduate's emergency medicine rotation, indicating that educational objectives have been met. Application for Basic Privileges (Community On-call and Hospital ER shifts): STANTON TERRITORIAL EMERGENCY COMMUNITY HOSPITAL EMERGENCY Application for basic emergency privileges is for performance of historical and physical examinations, including the ordering and interpretation of diagnostic studies including laboratory, diagnostic imaging and electrocardiographic examinations as shall normally be considered part of the practice of emergency medicine. As well these privileges include the administration of medications and the performance of other basic emergency treatments and procedures as shall normally be considered part of the practice of emergency medicine. The privileges also include the ability to request medevacs and urgent patient transport, consultations and technical procedures to be performed by other physicians and qualified consultants/technicians. Applicant Signature: Date: Hospital Use Only Basic Privileges Approval Clinical Director of Emergency Signature: Approval Date:

7 Dr. Privileges Expire: APPLICATION FOR EMERGENCY DEPARTMENT PHYSICIAN Application for Emergency Department Procedures: A. BASIC PROCEDURES Request for Emergency Medicine Basic Procedures includes the following procedures. Clinicians are to perform only those procedures on this list for which they have adequate training and skills. Requested ECG Interpretation Nasogastric and orogastric tube insertion Intubation with rapid sequence induction Cricothyrotomy Tube thoracostomy Pericardiocentesis Thoracentesis Paracentesis Diagnostic peritoneal aspiration Lumbar puncture Central line placement Arterial line placement Intraossesous line placement Venous cutdown Cervical immobilization Procedural sedation* Closed reduction of fractures and dislocations Joint/bursa aspiration and injection Primary repair of extensor tendons of hand and foot Casting and splinting Cardioversion / defibrillation Transcutaneous pacing Incision and drainage of abscesses Suture repair of wounds, incl. debridement if necessary Epistaxis control Slit lamp examination Removal of corneal foreign bodies Regional nerve blocks Suprapubic catheter insertion B. ADVANCED Requires review by Department Head and/or documentation of training competency, e.g. courses attended for skill acquirement. Requested Procedure Credentialing Criteria Documentation Transvenous pacemaker placement Total of 5 emergent or supervised procedures have been completed ED ultrasound Completed emergency medicine ultrasound course or equivalent * see Policy and Procedure Manual at your institution regarding specifics for performing sedation Applicant Signature: Date: Hospital Use Only Basic Privileges Approval Clinical Director of Emergency Signature: Date:

8 Reference letter for Health Care Professionals applying for Privileges in the Northwest Territories has applied for privileges in the Northwest Territories and your name was provided as a reference. Please answer the following questions regarding this applicant, and provide details for answers circled Yes. Please fax or mail this completed form directly to Medical Affairs at Stanton Territorial Hospital, P.O. Box 10, 550 Byrne Road, Yellowknife, NT, X1A 2N1. Fax: Note: the professional licensing authorities in the NWT, including the Medical Registration Committee, also require reference letters. The licensing bodies are entirely separate from the health authorities within the NWT, and separate from the Stanton Territorial Health Authority Credentials Committee. How long have you known the applicant, and in what capacity? Regarding this applicant, are you aware of any of the following: A physical or mental health problem that may interfere with this applicant s ability to provide an acceptable level of care to their patients/clients? A drug or alcohol problem (current or past)? Complaints regarding this applicant which have resulted in a formal investigation or disciplinary proceeding? Multiple complaints regarding this applicant s: o Interpersonal relationships with patients/clients, and/or with other health care professionals? o Adherence to departmental or hospital policies (including health records and on-call responsibilities)? o Clinical judgment regarding and/or medical/surgical management of patients/clients? Concerns regarding this applicant s ethical or professional behavior? Please provide details for any questions answered Yes, and please write any additional comments you feel are pertinent (may use separate sheet of paper). Name of Referee Signature Date Phone number and address