SUTTER MEDICAL CENTER, SACRAMENTO Department of Surgery Ophthalmology Section - Delineation of Privileges
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1 INITIAL: [ ] RENEWED: [ ] DATE: ADDITIONAL: [ ] Privileges are granted for Sutter General Hospital, Sutter Memorial Hospital, Sutter Center for Psychiatry, Sutter Oaks Midtown and 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 [ ] Admitting privileges None None None [ ] History & Physical privileges - A None None None Request CATEGORY I General Ophthalmology Appointment Six (6) cases as a primary surgeon and any procedure specific requirements General requirements for all applicants Documentation of experience in the previous two years as a primary surgeon in at least six cases as well as the procedures being requested. Documentation is from either a residency or fellowship case listing (if the applicant recently completed training) or a case listing from where the applicant has been practicing. Some procedure specific criteria may also require a letter from the Director or Chief of Services. First six (6) cases must be proctored regardless of the type of procedure [ ] Enucleation- A [ ] Evisceration- A [ ] Keratoplasty [ ] Irrigation of blood from anterior chamber- A [ ] Sclerotomy, posterior for foreign body [ ] Sclerectomy for glaucoma [ ] Iridectomy [ ] Cyclocryotherapy [ ] Discission lens or secondary membrane [ ] Aspiration of lens material [ ] Photocoagulation iris or retina [ ] Retinal detachment repair -A- INDICATES OUTPATIENT Page 1 of 5
2 Request CATEGORY I cont d Appointment [ ] Transconjunctival cryotherapy [ ] Eye muscle therapy- A [ ] Orbital repair or decompression- A [ ] Blepharoptosis or blepharoplasty- A [ ] Pterygium excision- A [ ] Conjunctivoplasty [ ] Dacryocystorhinostomy- A [ ] Probing and/or irrigation nasolacrimal system- A [ ] Intra-ocular lenses [ ] Cataract extraction [ ] Vitrectomy anterior [ ] Trabeculectomy Request CATEGORY II Complex Repair and Resection Appointment [ ] Vitreous iris prolapse Documentation if training or experience in another accredited [ ] Suture eye for wound- A facility in at least three (3) procedures during the previous two years. 2 cases 2 cases -A- INDICATES OUTPATIENT Page 2 of 5
3 Request Types of Lasers Appointment [ ] Argon Laser Training and experience requirements: None None 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: 1. 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 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. Request Laser Procedures Appointment [ ] Retinal laser photocoagulation None None None [ ] Acute neuroangle glaucoma [ ] Acute iridotomy Request Adult Appointment [ ] Continuing care privileges in critical care units Continuing care privileges in the critical care units includes 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.) -A- INDICATES OUTPATIENT Page 3 of 5
4 Request Pediatric 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 an appropriate member of the pediatric staff. [ ] Comprehensive pediatric surgical and medical continuing care privileges (including pediatric and neonatal ICU management) 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 required. Documentation must be in the form of a letter from the Director of the training program or from the Chief of Services of another Joint Commission accredited hospital. First three (3) cases by a surgeon who holds comprehensive pediatric continuing care privileges or by a Pediatric or Neonatal Critical Care Specialist. None Request Other Appointment [ ] Post-Acute Care Privilege Continuing care of the patient in the Sutter Transitional Care Unit or Sutter Oaks Midtown Please Note: The surgeon in charge is responsible for judging whether or not an assistant is required 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 TEMPORARY PRIVILEGE APPROVAL Surgery QI/Administrative Committee Date: Or Dept Chief (in lieu of mtg) Department Chief: Credentials Committee Date: Medical Executive Committee Date: Date: Board of Directors Date: FORM APPROVALS: Ophthalmology Surgery Section Date: 12/6/2010 Surgery Administrative Committee: Date: 2/3/2011 Credentials Committee: Date: 2/8/2011 Medical Executive Committee: Date: 2/22/2011 Medical Policy Committee: Date: 3/3/2011 -A- INDICATES OUTPATIENT Page 4 of 5
5 Board of Directors Date: 3/14/2011 -A- INDICATES OUTPATIENT Page 5 of 5
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