BASIC QUALIFICATIONS

Transcription

1 DEPAMEN OF SUGEY GENEAL/VASCULA SUGEY PIVILEGES page 1 of 5 PACIIONE NAME LAS/FIS/MIDDLE INIIAL ELEPHONE BASIC QUALIFICAIONS Basic Education MD or DO Minimal Formal raining Completion of an ACGME-approved residency in the identified specialty Board Certified or Board Qualified Applicants must be board certified or meet the requirements for obtaining board certification with education, training and experience as required by the board in their respective specialties; or, have successfully completed an accredited residency in the specialty in which they are requesting clinical privileges. he boards recognized to satisfy the above requirements are those approved by the American Board of Medical Specialties. Category II Surgery Privileges: Documentation of training in surgical assisting in an ACGME-approved residency. Documentation of experience in surgical assisting of at least 25 procedures in the preceding two years. Current Unrestricted State of California Medical License Malpractice Liability Coverage in the Amount of 1,000,000/3,000,000 Documentation must be submitted that supports the number listed in the column below entitled Qualifying Number. For practitioners out of training less than two (2) years, a case log for the training period will be accepted. For practitioners out of training more than two (2) years, an activity report must be submitted from a hospital where you are currently most active documenting the type and number of procedures performed over the past two (2) calendar years. eappointment is based on unbiased objective results of care according to Medical Staff s quality management mechanisms. Applicants for reappointment must show that they have met identified thresholds for each privilege they request. - PACIIONE EQUESED SUGEY CAEGOY II PIVILEGES CIEIA PAS 2 YS Privileges in this category allow the practitioner to assist only on cases as indicated below. SEE BASIC QUALIFICAIONS 12/Y - PACIIONE EQUESED A - ONLY A GENEAL SUGEY CAEGOY I COE PIVILEGES PAS 2 YS Privileges to admit, evaluate, diagnose, consult, provide pre-, intra-, and postoperative surgical care, and perform surgical procedures to correct or treat various conditions, illnesses and injuries of the alimentary tract, abdomen and its contents, breast, skin and soft tissue, neck, thyroid and minor extremity surgery. Privileges include, but are not limited to prepare a History and Physical, insertion and management of arterial catheter; insertion and management of chest tubes, insertion and management of central venous catheters; lumbar puncture; tracheostomy; paracentesis, and management of complete care of critically ill patients with underlying surgical conditions 12/Y

2 DEPAMEN OF SUGEY GENEAL/VASCULA SUGEY PIVILEGES page 2 of 5 PACIIONE NAME LAS/FIS/MIDDLE INIIAL ELEPHONE in the emergency department and intensive care unit. he core privileges in this specialty include the procedures in the below list and such other procedures that are extensions of the same techniques and skills. A GENEAL SUGEY CAEGOY I SPECIAL PIVILEGES PAS 2 YS Percutaneous racheostomy : documentation of formal residency training with certification from the Chief of Service or has provided evidence of attendance at a didactic and hands-on course that is satisfactory to the Department of Surgery and currently holds unrestricted privileges to perform Percutaneous racheostomy at another acute care hospital where he/she holds Active Staff status in good standing. 2/Y Laparoscopic Surgery: equires documentation of training during residency, fellowship or certificate (didactic and hands-on, of any timeframe). he surgeon must have assisted on five laparoscopic cases and been proctored for five cases which he was the primary operator, before full privileges may be considered. Appendectomy Cholecystectomy Hernia/Hiatal Hernia Advanced Laparoscopy: equires documentation of training during residency, fellowship or certificate (didactic and hands-on, of any timeframe), with proof of 12 cases successfully performed within the past two years) and proctored on first 2 cases O certificate (didactic and hands-on, no older than 2 years prior to the date of the request). Surgeon must be proctored on first 4 3 cases. Nissen Fundoplication 6/yr Splenectomy Lymph Nodes Biopsy 6/yr Laparoscopic Colectomy A VASCULA SUGEY CAEGOY I COE PIVILEGES PAS 2 YS Privileges to admit, evaluate, diagnose, consult, provide pre-, intra-, and postoperative surgical care, and perform surgical procedures to correct or treat diseases and disorders of the arterial, venous, and lymphatic circulatory systems, excluding those of the heart and thoracic aorta and prepare a History and Physical. he core privileges in this specialty include the procedures in the attached list and such other procedures that are extensions of the same techniques and skills. 12/Y

3 DEPAMEN OF SUGEY GENEAL/VASCULA SUGEY PIVILEGES page 3 of 5 PACIIONE NAME LAS/FIS/MIDDLE INIIAL ELEPHONE A VASCULA SUGEY CAEGOY I SPECIAL PIVILEGES PAS 2 YS Peripheral Angiography: Must have privileges in peripheral angiography. Documentation required of training in residency/fellowship in performance of peripheral angiography procedures and competence in percutaneous use of catheters and wires. A minimum of 10 cases as primary operator. O Documentation of approved Certified Course(s) that are anatomically specific to the vascular anatomy to be approved. Evidence of satisfactory performance of 10 procedures specific to the privileges being requested. Proctoring: 3 cases minimum in each area of anatomy requested. Documentation of Fluoroscopy Certificate required. Peripheral Angiography enal Angiography 5/yr Carotid Angiography ENDOVASCULA INEVENIONS: Must have privileges in peripheral angiography. Documentation required of training in residency/fellowship in performance of peripheral angiography procedures and competence in percutaneous use of catheters and wires. A minimum of 10 cases as primary operator. O Documentation of approved Certified Course(s) that are anatomically specific to the vascular anatomy to be approved. Evidence of satisfactory performance of 10 procedures specific to the privileges being requested. Proctoring: 3 cases minimum in each area of anatomy requested. Documentation of Fluoroscopy Certificate required. Peripheral Vascular: (includes upper and lower extremities, venous, renal and dialysis access) 5/yr Abdominal Aorta and horacic Aorta Carotid Arteries GENEAL SUGEY COE PIVILEGE LIS VASCULA SUGEY COE PIVILEGE LIS ABDOMEN (Excludes laparoscopic procedures) Abdominal perineal resection Adrenal Gland Appendectomy Amputations: Upper Extremity* (requires mandatory orthopedic consultation PIO to) Lower Extremity Operations in the biliary tract Operations on the gall bladder Operations on the intestinal tract Operations on the pancreas HYOID e-opening of wound for hemorrhage hroidectomy LYMPH CHANNELS AND NODES Biopsy Incision and Drainage Excision ECAL SUGEY Anal Fissure Anal Fistula Anoscopy, protoscopy, sigmoidoscopy Excision of lesion (local) Excision of lesion (malignant) Aortic aneurysm Arterial bypass grafts Carotid Endarterectomy Embolectomy Phlebectomy hrombectomy Vein ligation, stripping, excision of varicose veins

4 DEPAMEN OF SUGEY GENEAL/VASCULA SUGEY PIVILEGES page 4 of 5 PACIIONE NAME LAS/FIS/MIDDLE INIIAL ELEPHONE Operations on the peritoneum/omentum Operations on the spleen Operations on the stomach Paracentesis epair of diaphragmatic hernia epair of femoral hernia epair of inguinal hernia epair of umbilical hernia epair of other hernia BEASS Excision of cyst or tumor Incision and drainage of abscess Mastectomy (simple) Mastectomy (radical) HEAD AND NECK Excision of local lesions hyroglossal ducts racheostomy racheotomy Excision of lesion (external) Excision of lesion (internal) Hemorrhoidectomy (external) Hemorrhoidectomy (internal) Incision and drainage Pilonidal cyst and/or sinus SKIN AND SUBCUANEOUS ISSUE Biopsy Burns: 1 st, 2 nd, 3 rd degree Excision of lesions (cysts, lipomata, polyps, etc) Skin Graft Incision and drainage of abscesses, paronychia, etc. Incision and drainage of deep abscesses, thyroglossal cyst, etc. Suture of uncomplicated wounds Colonoscopy Colonoscopy with Biopsy Flexible Sigmoidoscopy - PACIIONE EQUESED POCEDUAL SEDAION GAN GAN Procedural Sedation Applicant must complete review of all Procedural Sedation Study Guide materials, including completing an examination with a minimum score of eighty percent (80%) - PACIIONE EQUESED A - ONLY FLUOOSCOPY PIVILEGES GAN Applicant must have a current X-ay Operator s license

5 DEPAMEN OF SUGEY GENEAL/VASCULA SUGEY PIVILEGES page 5 of 5 PACIIONE NAME LAS/FIS/MIDDLE INIIAL ELEPHONE ACKNOWLEDGEMEN OF APPLICAN I HAVE EQUESED ONLY HOSE CLINICAL PIVILEGES FO WHICH MY EDUCAION, AINING, CUEN EXPEIENCE AND DOCUMENED PEFOMANCE SUPPOS HA I AM QUALIFIED O PEFOM A S. VINCEN MEDICAL CENE; AND, I UNDESAND HA IN EXECISING ANY CLINICAL PIVILEGE, I AM CONSAINED BY GENEALLY APPLICABLE HOSPIAL AND MEDICAL SAFF POLICIES AND ULES AND ANY OHES APPLICABLE O HE PAICULA SIUAION; AND, ANY ESICION ON HOSE CLINICAL PIVILEGES ME IS WAIVED IN AN EMEGENCY SIUAION AND IN ANY SUCH SIUAION WHEE MY ACIONS AE GOVENED BY HE APPLICABLE SECION OF HE MEDICAL SAFF BYLAWS, ULES O ELAED DOCUMENS. PACIIONE SIGNAUE DAE APPOVALS HE ESOUCES NECESSAY O SUPPO HE ABOVE EQUESED PIVILEGES E DEEMINED O BE CUENLY AVAILABLE. DAE DEPAMEN OF SUGEY O SECION CHAI SIGNAUE MEDICAL EXECUIVE COMMIEE APPOVAL SVMC BOAD OF DIECOS APPOVAL