RENOWN REGIONAL MEDICAL CENTER DEPARTMENT OF ORTHOPAEDICS DELINEATION OF PRIVILEGES

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1 RENOWN REGIONAL MEDICAL CENTER DEPARTMENT OF THOPAEDICS DELINEATION OF PRIVILEGES BASIC EDUCATION: M.D. or D.O. MINIMAL FMAL TRAINING: ABMS Board certification or eligibility, or be able to document equivalent training and/or experience which is deemed acceptable on an individual basis by the Orthopedic Department (minimum equivalency, successful completion of a five-year post-graduate residency program in orthopedic surgery approved by the ACGME). 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. REQUIRED PREVIOUS EXPERIENCE: For individuals who have just completed an approved residency a letter from their program chairman supporting the granting of the privileges requested is necessary. For all others, the successful applicant must document performance of at least 100 orthopedic surgical procedures during the past 12 months. 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 Core privileges in Orthopedic Surgery include the ability to admit, evaluate, diagnose, treat and provide consultation to patients of all ages to correct or treat various conditions, illnesses and injuries of the extremities and associated structures by medical, surgical and physical means. H & P Core Privileges Amputation 81.20Arthrodesis Arthroplasty Drainage - bone Graft - bone Closed reduction, dislocation or fracture dislocation Closed reduction, fracture Repair tendons Primary S Secondary Tenotomy Wounds - major Peripheral nerve surgery Skin Grafting Open Reduction, Internal fixation of fractures and/or osteotomies Arthroscopy Implant Arthroscopy Arthrotomy, ligament repair and/or reconstruction of major joints Page 1 of 3

2 Orthopedic privileges encompass the skills required in the diagnosis, preoperative postoperative and rehabilitation management of the muscular-skeletal systems of the body SPECIAL REQUESTS: These procedures require additional documentation Laser Privileges (LS.CO, LS.YG) The CO2, Nd: YAG and Ho:Yag laser require specific application by all orthopedic surgeons who request the privilege in arthroscopies. All applications must be accompanied by supporting documentation of the applicant's training and experience, specifically a recent course in laser surgery with hands-on experience. Formal training in residency training and Proctoring for the first three cases. Midas Rex (high speed spine drill) (MR.00) Open reduction, internal fixation of fractures and/or osteotomies, AO/ASIF (.IF) Completed an Orthopaedic surgery residency subsequent to 1989, submit a letter from residency director documenting competence in AO/ASIF techniques, Completed a residency prior to 1989 and submit a. Certificate of completion of the AO/ASIF basic course. b. Document 50 cases of IF using AO/ASIF techniques. The assigned mentor, the Department, and the Department Chief all reserve the right to challenge an applicant's trauma competence, including AO/ASIF techniques, by oral examination prior to completion of the probationary period as well as prior to advancement to Active Staff. If in the course of mentoring it becomes apparent that the applicant's skill and judgment do not meet acceptable standards, the Department reserves the right to require the applicant to participate in an AO/ASIF fracture course, either for the first time or as repeated training. Arthroscopy (80.20) 2. Documentation of 50 arthroscopic cases. 3. Documentation of 5 cases of arthroscoping the specific joint which privileges are requested. Implant arthroplasty (81.96) 2. Documentation of 15 cases of replacement arthroplasty. 3. Documentation of five cases of the specific joint, which is to be replaced, possibly presenting x-rays as needed Spinal decompression, laminectomy, discectomy, fusion with or without instrumentation (81.00) 2. Documentation of 25 cases with the possibility of presenting x-rays in cases where in instrumentation was used. Page 2 of 5

3 Arthrotomy, ligament repair and/or reconstruction of major joints, (ankle, knee, hip, shoulder, elbow, wrist) (AR.TH) 1.. Proper training. 2. Documentation of 20 cases Spinal Arthroplasty Education: Completion of an ACGME-accredited or AOA approved Orthopaedic or neurosurgery residency program with inclusion of a significant focus on complex lumbar spine procedures. Have completed a spine fellowship. Completion of an ACGME-accredited or AOA approved Orthopaedic or neurosurgery residency program AND have significant clinical experience in spine surgery. Experience/Training: Experience with anterior spine interbody fusions, including at least 10 anterior spinal surgical approaches. Training: Training in the specific arthroplasty during residency and/or fellowship, with appropriate documentation. Certificate of completion and competency in the surgeon training course in the specific arthroplasty, which is being performed Total Ankle Arthroplasty Hands on training course or equivalent during residency/fellowship. 2. Significant Large Joint arthroplasty experience (shoulder, knee, hip), minimum documented cases 15 (fifteen) 3. 5 (five) cases mentored. Minimum of 25 CME credits on ankle arthritis/hind foot reconstruction in the past 3 (three) years, or 50% of practice related to hind foot related care or 6 month fellowship training in foot/ankle. Spine Call Spine Call * Qualifications/Criteria / Eligibility Orthopaedic surgeons with Active Staff privileges Orthopaedic surgeons applying for Associate Staff status directly out of Residency or Fellowship training Orthopaedic surgeons applying for Associate Staff status from JC credentialed institutions Training/Experience: 1. Orthopaedic physicians who have successfully completed an ACGME Spine fellowship training of 6 months or more will qualify for spine call privileges with mentoring for 6 months. 2. Orthopaedic physicians who have completed an ACGME accredited Residency which included management of 10 acute neurologically-compromised patients will qualify for spine call privileges with mentoring for 6 months Page 3 of 5

4 3. Orthopaedic surgeons with Active Staff status at RRMC will be required to document management of 10 neurologically compromised patients or undergo mentoring of the management of 10 neurologically compromised cases. Meeting one of the above requirements will qualify the physician for spine call privileges. 4. Orthopaedic surgeons applying for Associate Staff status from an outside JC accredited facility will be required to document management of 25 spine fracture patients or surgical management of the spine in order to qualify for mentoring for spine call. Reappointment: 1. Will be based upon documentation of ongoing management of 20 cases of spine injury/reconstruction/surgical management per 2 years. 2. Continued presence on spine call system with less than 6 months absence Spine Call Continued: Mentoring: Mentoring will be done by Active Staff Status Orthopaedic surgeons who have full Spine Call privileges. Mentor will be involved in the initial decision making and key operative component. Eligible physicians will be mentored until there is documentation of 10 acute neurologically compromised patients. Moderate Sedation Privileges 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. REAPPOINTMENT/CURRENT CLINICAL COMPETENCE: All members of the Department 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 will provide evidence of activity sufficient to demonstrate current clinical competence for the privileges requested. All members should have a minimum of 50 cases during the last reappointment period. Page 4 of 5

5 ELEVATION TO ACTIVE STAFF Must be mentored by an Active Staff Orthopaedic Department member who is not affiliated with the Associate Staff member. May be assigned to ER call while being mentored but cannot transfer call other than to another Active Staff Orthopaedic Department member. Can provide alternate coverage only by an Active Staff Orthopaedic Department member. Applicant Print Name Applicant Signature If Applicable - Section Chief Department Chief of Recommendation by the Credentials & Privileges Committee of Recommendation by the Executive Committee: of Approval by the Board of Governors: Page 5 of 5