PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER DEPARTMENT OF SURGERY Bariatric Surgery

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1 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. In addition to these privileges, the surgeon must complete General Surgery Privilege Delineation. EDUCATION: M.D. or D.O. Degree TRAINING: Privileges in are granted for specific procedures. In addition to the requirements for granting of General Surgery privileges: Applicants can be divided into five categories: 1. Those with established credentials to perform open Bariatric surgery. 2. Those with established credentials to perform open and laparoscopic Bariatric surgery. 3. Those who can document at least 25 open and laparoscopic Bariatric surgical procedures during their general surgery residency (within the past three years). 4. Those trained in approved fellowships and as first assistants of an experienced Bariatric surgeon 5. Those who do not fall into any of the above categories. If an individual has credentials to perform Bariatric surgery at an accredited facility on the date of this document, but does not meet the conditions stated in Global Credentialing Requirements below, the surgeon will be given the opportunity to comply with the new requirements by the next reappointment date. Global Credentialing Requirements - To meet the Global credentialing Requirements in Bariatric surgery the applicant should: 1. Have credentials at an accredited facility to perform gastrointestinal and biliary surgery. 2. Document that he or she is working within an integrated program for the care of the morbidly obese patient that provides ancillary service such as specialized nursing care, dietary instruction, counseling, support groups, exercise training, and psychological assistance as needed. 3. Document that there is a program in place to prevent, monitor and manage short term and long term complications. 4. Document that there is a system in place to provide follow up for all patients, with the expectation that at least 50% of the patients who receive restrictive procedures and 75% of those with malabsorptive operations will be seen, on a regular basis, for at least five years. 5. Document that they have professional liability insurance coverage for privileges.

2 Provisional Privileges Provisional Bariatric surgery privileges are conferred to facilitate the pursuit of full bariatric surgical credentials. With this classification, it is appropriate for the surgeon to schedule Bariatric cases if the Global Credentialing Requirements and these additional conditions are met: 1. The successful completion of a bariatric training course of at least two days which includes both didactic and hands on laboratory work involving cadavers, AND 2. Documentation of three proctored cases in which the assistant is fully trained bariatric surgeon, OR 3. Completion of an approved preceptorship program. Open Privileges 1. To obtain open Bariatric surgery privileges, the surgeon must meet the Global Credentialing Requirements, AND 2. Document three proctored cases in which the assistant is a fully trained Bariatric surgeon, AND 3. Document the successful outcomes (with acceptable peri-operative complication rate) for 10 open bariatric surgical cases performed by the applicant. Laparoscopic Privileges 1. To obtain laparoscopic bariatric surgery privileges the surgeon must meet the Global Credentialing Requirements AND Have privileges at the given facility to perform advanced laparoscopic surgery. Document three proctored cases in which the assistant is a fully trained bariatric surgeon, AND Document the outcomes of 15 laparoscopic bariatric surgical cases performed as primary surgeon, demonstrating an acceptable peri-operative complication rate. 2. Laparoscopic Adjustable Gastric Band Placement. Training; Certificate by Lap Band Company in a MED weekend Course Proctor: Must be an industry sponsored, credentialed, insured practicing Lap Band Surgeon. The surgeon should continue to meet Global Credentialing Requirements for bariatric surgery at the time of reappointment. Continuing medical education and active participation in surgical societies related to this field is also strongly recommended.

3 Criteria for Bariatric Privileges BARIATRIC TRAINING NECESSARY NUMBERS OF FOR INITIAL APPOINTMENT NUMBER OF EVERY 2 YEARS NUMBER OF PROCTORED INITIALLY Open Bariatric Laparoscopic Bariatric Surgeon must meet global credentialing requirements and: Have privileges at the given facility to perform advanced laparoscopic surgery. Document three proctored cases in which the assistant is a fully trained bariatric surgeon, AND Document the outcomes of 15 laparoscopic bariatric surgical cases performed as primary surgeon, demonstrating an acceptable perioperative complication rate Laparoscopic Adjustable Gastric Band Placement Training: Certificate by Lap Band Co.in a MED weekend course; Proctor: Must be an industry sponsored, Credentialed, insured practicing Lap Band Surgeon for first time Lap Band Surgeon 1 for an experienced Lap Band Surgeon Vertical Sleeve Gastrectomy Gastric Bypass Privileges; Vertical Sleeve Gastrectomy Training Course (must have unrestricted Gastric Bypass Privileges) 2 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.

4 SPECIALTY: NAME: PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER REQUEST FOR CLINICAL PRIVILEGES BOARD CERTIFIED: YES NO Requested To document recent clinical experience, enter # and location performed in the last two years where indicated Approved Not Approved Number Location Bariatric Procedures (Advanced) Open Gastric Bypass Laparoscopic Gastric Bypass Revision of redundant skin on trunk and extremities following extreme weight loss. Laparoscopic Adjustable Gastric Band Placement Vertical Sleeve Gastrectomy 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

5 NAME: PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER REQUEST FOR CLINICAL PRIVILEGES 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 AS INDICATED. EXCEPTIONS/LIMITATIONS (Specify): Department Chair Date

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