SUTTER MEDICAL CENTER, SACRAMENTO Department of Surgery Spine Section - Delineation of Privileges

Transcription

1 INITIAL: [ ] RENEWED: [ ] DATE: ADDITIONAL: [ ] Privileges are granted for Sutter General Hospital, Sutter Memorial Hospital, Sutter Center for Psychiatry, Sutter Oaks Midtown or Capitol Pavilion Surgery Center and exercise of privileges is based on the type of care, treatment and services provided at each facility. If you plan to use radiology equipment including the fluoroscope, you must provide a current operating permit that is issued by the Radiologic Health Branch of the California Department of Health Services. To request Privileges, please place an X in the request column. In box, indicate the number of identified procedures performed in previous 24 months from any facility. If the condition/privilege you desire is not included on this form, please submit a separate written request along with appropriate documentation of training and/or experience. Request Privilege Appointment ALL APPLICANTS TRAINING / DOCUMENTATION FOR ALL ADULT PRIVILEGES AND CATEGORY I CORE PRIVILEGES ADULT AND PEDIATRIC 1. Graduation from a residency or fellowship program where spine surgery (relative to the procedures being requested) was part of the active training format is acceptable. Verification in the form of a letter from the Director of the training program and case listing if applicant just recently completed training is outlining the applicant's experience in each category of privileges being requested. OR 2. Documentation of prior experience in a Joint Commission accredited hospital in spine surgery specific to the privileges being requested. This documentation must include a letter from the Chief of Surgery or Chief of Staff of that hospital AND include a case listing from the hospital from the previous two years. OR 3. If a requested procedure was not part of a residency or fellowship training, then documentation of successful completion of an acceptable course (approved by the Spine Section) is. OR - 4. Successful completion of an approved SMCS in-house learning program. *Note - Under the auspices of call coverage for an individual with pediatric spine privileges, a covering physician with Category I and Category II privileges can provide perioperative care for that physician s pediatric patients. of the applicants first six (6) cases and any procedure specific proctoring A minimum of six (6) cases as the primary surgeon and any procedure specific maintenance requirements -A- INDICATES OUTPATIENT Page 1 of 9

2 Request Privilege Appointment [ ] Admitting privileges [ ] History & Physical privileges - A Request Category I - Core Privileges Adult and Pediatric Appointment [ ] Laminectomy/discectomy cervical, thoracic, lumbar - A [ ] Anterior cervical discectomy/corpectomy/fusion with or without instrumentation - A [ ] Percutaneous procedures - Intradiscal injection/percutaneous discectomy/vertebral body biopsy [ ] Vertebroplasty/kyphoplasty See above requirements of the first one (1) case from this category of procedures is. [ ] Epidural tumor biopsy/resection [ ] Spinal cord stimulator [ ] Diagnostic procedures lumbar puncture, myelogram, diskogram, epidural steroid injections, facet joint injection [ ] Irrigation and debridement Request Category II Non-Instrumented Spine Adult Appointment [ ] Posterior fusion cervical, thoracic, lumbar spine without instrument [ ] Anterior lumbar interbody fusion (bone graft, interbody device) See above requirements and - If documentation of training is through a course certificate for any of the procedures then the course must have included cadaver experience. [ ] Anterior thoracic interbody fusion (bone graft, interbody device) -A- INDICATES OUTPATIENT Page 2 of 9

3 Request Category II Non-Instrumented Spine Adult Appointment [ ] Anterior exposure of the thoracic spine as the primary surgeon [ ] Anterior exposure of the lumbar spine as the primary surgeon See above requirements and - If documentation of training is through a course certificate for any of the Procedures then the course must have included cadaver experience. Request Category II - Instrumented Spine Adult Appointment [ ] Posterior cervical fusion with instrumentation (lateral mass screw fixation, pedicle screw fixation, cable fixation) [ ] Posterior thoracic fusion with pedicle screw fixation [ ] Posterior lumbar fusion with pedicle fixation [ ] Anterior thoracic discectomy/corpectomy/fusion with instrumentation [ ] Anterior lumbar discectomy/corpectomy/fusion with instrumentation [ ] Cervical disc arthroplasty [ ] Lumbar disc arthroplasty [ ] Vertebral column tumor resection and reconstruction cervical, thoracic and lumbar [ ] Thoracic/lumbar spinal deformity correction five or more levels [ ] Pedicle subtraction osteotomy [ ] Vertebral column resection and reconstruction cervical, thoracic and lumbar See above requirements and - If documentation of training is through a course certificate for any of the procedures then the course must have included cadaver experience. cases by a thoracic/ vascular surgeon is cases by a thoracic/ vascular surgeon is instrumentation Documentation of performance of at least four (4) procedures every two years -A- INDICATES OUTPATIENT Page 3 of 9

4 Request Special Procedures - Adult Appointment [ ] Thoracoscopic spine surgery discectomy/fusion/instrumentation A surgeon or co-surgeon with privileges in video assisted thoracoscopy and thoracotomy is [ ] Laparoscopic lumbar spine surgery discectomy/fusion/instrumentation A surgeon or co-surgeon with privileges in video assisted laparoscopy and open laparotomy is See above requirements and - If documentation of training is through a course certificate for any of the procedures then the course must have included cadaver experience. Documentation of performance of at least four (4) procedures every two years Request Lasers Appointment [ ] [ ] KTP laser YAG laser Surgeons requesting laser privileges must show that they have the appropriate training and/or experience in the safe use of laser equipment by meeting one of the following criteria: [ ] Argon laser l. Graduation from an approved training program in Surgery where laser application was part of the active training format. Verification shall be in the form of a letter from the Director of the training program or case listing. OR 2. Documentation of successful completion of a section approved post-graduate course with hands-on experience, designed to familiarize practicing physicians with laser technologies, safety and application. -A- INDICATES OUTPATIENT Page 4 of 9

5 Request Other Procedures - Adult Appointment [ ] Continuing care privileges in critical care units Continuing care privileges in the critical care units include the ability to see and care for the patient in the critical care setting. The privilege does not include ventilator management, elective intubation or insertion of invasive monitors. Requests for those privileges must be requested separately from continuing care privileges in critical care units. [ ] Post-Acute Care Privilege Continuing care of the patient in the Sutter Transitional Care Unit or Sutter Oaks Midtown -A- INDICATES OUTPATIENT Page 5 of 9

6 PEDIATRICS - All Applicants TRAINING/DOCUMENTATION FOR THE FOLLOWING PEDIATRIC SPINE PRIVILEGES (DEFINED AS THE PATIENT WHO IS UNDER 14 YEARS OF AGE) 1. Graduation from a residency or fellowship program where pediatric spine surgery was part of the active training format with a minimum of six months dedicated pediatric spinal surgery training being certified specific to the privileges requested is. Verification in the form of a letter from the Director of the training program and case listing if applicant just recently completed training is outlining the applicant's experience in each category of privileges being requested. OR - 2. Documentation of prior experience in a THE JOINT COMMISSION accredited hospital in pediatric spine surgery specific to the privileges being requested. This documentation must include a letter from the Chief of Surgery or Chief of Staff of that hospital AND include a case listing from the hospital from the previous two years. AND If the applicant is also applying for complex or special pediatric spine privileges the applicant must also include copies of operative reports of five (5) such procedures where the applicant was the surgeon of record in the procedures categorized as complex instrumented spine and operative reports of five such procedures where the applicant was the surgeon of record in the special procedures category of thoracoscopic and laparoscopic spine surgery. These reports must have been from the previous five years. OR 3. If a requested procedure was not part of a residency or fellowship training, then documentation of successful completion of an acceptable course (approved by the Spine Section) is. OR 4. Successful completion of an approved SMCS in-house learning program. requirements A minimum of six (6) cases as the primary surgeon in addition to any procedure specific maintenance requirements. Should a surgeon not meet the procedure specific maintenance requirements proctoring will be initiated. Surgeons are also to obtain at least ten (10) hours of category I pediatric spine continuing medical education credits -A- INDICATES OUTPATIENT Page 6 of 9

7 Request Category III Non Instrumented Spine Procedures - Pediatric Appointment [ ] Anterior lumbar interbody fusion (bone graft, interbody device) [ ] Anterior thoracic interbody fusion (bone graft, interbody device) [ ] Posterior cervical/thoracic/lumbar fusion without instrumentation [ ] Anterior exposure of the thoracic spine as primary surgeon [ ] Anterior exposure of the lumber spine as primary surgeon See above requirements See above requirements cases by a thoracic/vascular surgeon is Request Category III - Instrumented Spine - Pediatric [ ] Posterior cervical fusion with instrumentation See above requirements [ ] Posterior thoracic fusion with pedicle screw fixation [ ] Posterior lumbar fusion with pedicle screw fixation 1-4 levels (including spondylolisthesis) [ ] Anterior thoracic discectomy/corpectomy/fusion with instrumentation [ ] Anterior lumbar discectomy/corpectomy/fusion with instrumentation Request Complex Instrumented Spine - Pediatric. Appointment [ ] Thoracic/lumbar spinal deformity correction five or more levels [ ] Vertebral body osteotomy (pedicle subtraction osteotomy, kyphectomy, etc.) [ ] Vertebral column tumor resection and reconstruction cervical, thoracic, lumbar See above requirements Documentation of performance of at least four (4) procedures every two years -A- INDICATES OUTPATIENT Page 7 of 9

8 Request Special Procedures - Pediatric. Appointment [ ] Thoracoscopic spine surgery discectomy/fusion/instrumentation A surgeon or co-surgeon with privileges in video assisted thoracoscopy and thoracotomy is [ ] Laparoscopic spine surgery A surgeon or co-surgeon with privileges in video assisted laparoscopy and open laparotomy is See above requirements See above requirements Four (4) procedures Request Other Pediatric Procedures Appointment [ ] Surgical and general pediatric continuing care privileges in pediatric Intensive care unit (PICU) where there are no other medical or child life issues involved. *If there are medical or child life issues the patient should be managed in tandem with a member of the pediatric staff. [ ] Comprehensive pediatric surgical and medical continuing care privileges (including pediatric and neonatal ICU management) TRAINING / DOCUMENTATION FOR COMPREHENSIVE CRITICAL CARE Documentation of training and experience (within the previous two years) in the comprehensive management of pediatric patients in the Neonatal or Pediatric Intensive Care Units is. Documentation must be in the form of a letter from the Director of the training program or from the Chief of Services of another THE JOINT COMMISSION accredited hospital. Continuing care privileges in the critical care units include the ability to see and care for the patient in the critical care setting. The privilege does not include ventilator management, elective intubation or insertion of invasive monitors. Requests for those privileges must be requested separately from continuing care privileges in critical care units.) of the first three (3) comprehensive critical care cases either by a surgeon with comprehensive pediatric continuing care privilege or by a Pediatric or Neonatal Critical Care Specialist is. -A- INDICATES OUTPATIENT Page 8 of 9

9 Please Note: The surgeon in charge is responsible for judging whether or not an assistant is for any procedure listed. Acknowledgment of Practitioner: I understand that (a) in exercising clinical privileges granted, I am constrained by Medical Staff Policies and Procedures, Rules and Regulations, and (b) any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my actions are governed by the applicable section of the Medical Staff Bylaws. I hereby attest to having performed the stipulated number of procedures as indicated above, thereby meeting the criteria for those privileges I have requested. ************************************************************************************************************************ COMMITTEE APPROVALS Surgery QI/Administrative Committee Date: TEMPORARY PRIVILEGE APPROVAL Or Dept Chief (in lieu of mtg) Credentials Committee Date: Department Chief: Medical Executive Committee Date: Board of Directors Date: Date: FORM APPROVAL Spine Surgery Section (by ballot) 05/13/11 Surgery QI/Administrative Committee 06/02/11 Credentials Committee 06/14/11 Medical Executive Committee 06/28/11 Medical Policy Committee 07/07/11 Board of Directors 07/07/11 Reviewed: 3/2000 Page 9 of 9 Revised: 2/95, 8/95, 8/96, 10/97, 3/99, 5/02, 4/08; 12/10 -A- INDICATES OUTPATIENT Page 9 of 9