Fairview Health Services SURGICAL TECHNOLOGIST Professional Practitioner Scope of Practice CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES

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1 PAGE 1 OF 3 Fairview Health Services SURGICAL TECHNOLOGIST Professional Practitioner Scope of Practice Applicant s Name (please print): CROSSWALK FOR REQUESTING FAIRVIEW PRIVILEGES I Want to Work at the Following Fairview Entity Inpatient/hospital(s) Fairview Maple Grove Medical Center (Ambulatory Care Center) 1, 2 Fairview Maple Grove Ambulatory Surgery Center 1 Fairview Hospital-Based Clinic (such as UMMC Clinics, Fairview Ridges Specialty Clinic for Children, Fairview Southdale Oncology Clinic, Fairview Southdale Hospital Breast Center) 1, 3 Fairview Free-Standing Ambulatory Clinics 1 I need to the following Fairview Entity Box on Privilege Form Individual Fairview hospital(s) University of Minnesota Medical Center, Fairview (UMMC) Fairview Maple Grove Ambulatory Surgery Center (MGASC) Individual Fairview hospital where clinic is affiliated Fairview Group Practice Ambulatory Clinics (FV Clinics) 1 Ambulatory privileges to practice at Fairview hospital-based clinics and other non-hospital-based Fairview owned entities are only available to those practitioners authorized by Fairview to practice at those sites. Ambulatory privileges do not include performance of procedures which are not otherwise available or performed at the individual ambulatory sites as determined by the operational manager or other appropriate personnel. 2 Privileges granted by UMMC can also be exercised at these entities in Maple Grove in accordance with procedures available at the sites. 3 Privileges granted by the specific hospital entity can also be exercised at hospital-based clinics affiliated with that entity in accordance with procedures available at the clinic. Education: Certification: Sponsorship: THRESHOLD CRITERIA Graduate of an accredited program of surgical technology or documented equivalent experience. Certified by the American Association of Surgical Technologists preferred. The applicant must submit a Fairview Allied Health Professional Sponsorship Form completed by a physician in good standing on staff at the Fairview entity to which the applicant is applying. The Sponsorship Form is attached to this privilege form. z:\common\forms\cvo\privilege Forms\Surgical Technologist & Ophthalmic Surg Tech doc 11/14/95 Revised 5/96; 10/01; 1/06; 6/09 (new format); 7/13;8/13

2 PAGE 2 OF 3 Fairview Hospital Entity Codes UMMC - University of Minnesota Medical Center, Fairview FSH - Fairview Southdale Hospital FRH - Fairview Ridges Hospital FNH - Fairview Northland Medical Center FLH - Fairview Lakes Medical Center FRW - Fairview Red Wing Hospital Fairview Ambulatory Entity Code FV Clinics = Fairview Free-standing Ambulatory Clinics MGASC= Fairview Maple Grove Ambulatory Surgery Center Definitions/Abbreviations Core Privileges - Privileges routinely taught in residency/fellowship programs Special Request Privileges - Privileges not routinely taught in residency/fellowship programs; new technology or procedure; high risk; or requires ongoing practice to maintain competency N/A - Indicates privilege not available at the specific Fairview entity AF - Indicates an additional form is required to request the privilege Threshold Criteria Must meet Threshold Criteria listed on page 1 Scope of Practice SURGICAL TECHNOLOGIST Check Entity(ies) Where Privileges Requested Provide surgical patient care and related services in operating rooms by Hospital Entities Ambulatory performing tasks that help ensure a safe surgical environment, contribute UMMC FSH FRH FNH FLH FV Clinics MGASC to the operating team's efficiency and support the surgeon and others involved in operating procedures. The N/A technologist may set up the operating room, prepare surgical instruments, assist in their use, and prepare patients for surgery. The technologist has a knowledge of and experience with aseptic surgical techniques and is responsible for maintaining the sterile field during surgical procedures. Duties/Responsibilities: Prepare the operating room by selecting and opening sterile supplies. Assemble, adjust and check non-sterile equipment to ensure that it is in proper working order. Operate sterilizers, lights, suction machines, electrosurgical units and diagnostic equipment. Patient preparation may include providing physical and emotional support, checking charts and observing vital signs. May position patient on operating room table, assist in connecting and applying surgical equipment and/or monitoring devices, and prepare the incision site by cleaning the skin with an antiseptic solution. Maintain sterile field by making sure that all members of the team adhere to aseptic techniques. Pass instruments, sutures and sponges, assist the circulating nurse with the accounting of sponges, needles and instruments. Receive and prepare specimens for pathologic analysis. Prepare and apply sterile dressings following procedures. Special Request Privileges NOTE: You may also obtain referenced additional privilege form (AF) at Competency Measures/ Check Entity(ies) Where Privileges Requested Required # Hospital Entities Ambulatory Cases in Past 24 Months UMMC FSH FRH FNH FLH FV Clinics Robotic Surgery Instrument Placement through Trochars Initial Appointment or First Request: Documentation of completion of training course specific to the procedure completed within the past 24 months. If completion of the course was longer than 24 months ago documentation must also include documentation from sponsoring physician specifying competency in the procedure. Reappointment: Letter from sponsoring physician specifying competency in the procedure. See Criteria listed N/A N/A N/A

3 PAGE 3 OF 3 I attest that my professional liability insurance covers the responsibilities listed. Signature

4 PROFESSIONAL STAFF SPONSORSHIP FORM Professional Staff Practitioner s Name Sponsoring Physician s Name: (Sponsoring physician must be a member in good standing of the Medical Staff at the entity(ies) to which the applicant is applying) SPONSORING PHYSICIAN STATEMENT: I support the application of the above named individual for the services requested and agree to all of the terms, conditions and obligations associated with my supervising/sponsoring said individual as specified in the policies and rules of the Fairview entity(ies) to which applicant is applying. Sponsoring Physician Name PLEASE PRINT GROUP PRACTICE SUPERVISION In the event the above named individual for the services requested above will be supervised by several practitioners in a group practice, the group practice (name of group) shall support the application of the above named individual for the services requested and agree to all the terms, conditions and obligations associated with the supervision of said individual as specified in the policies and rules of the Fairview entity(ies) to which the applicant is applying relevant to the individual s practice at the hospital. The group practice promises that any practitioners providing the supervision shall be a member in good standing of the medical staff of the Fairview entity(ies) to which applicant is applying. Officer of Group c:\common\forms\cvo\credentialing Application Forms\Prof Staff Sponsorship-Eval Form.doc Revised 1/06; 10/10

5 PROFESSIONAL STAFF PERFORMANCE REVIEW FORM Professional Staff Practitioner s Name: Sponsoring Physician s Name: Instructions for Sponsoring Physician: The above-named practitioner has applied for Professional Staff appointment or reappointment at a Fairview entity(ies). Please complete this form to provide an evaluation of the practitioner s current clinical competence. Thank you. 1. Complete each of the criteria below based on demonstrated performance compared to that reasonably expected of a Professional Staff at his/her level of training, experience, and background. A = Acceptable, U = Unacceptable, N.O. = Not observed. CRITERIA A U N.O. COMMENTS Basic job knowledge, competence and skill Service orientation Ethical conduct/hipaa compliance Professional judgment Cooperativeness, ability to work with others Sense of responsibility (work timely, meet professional standards, completion of responsibilities, responsiveness to supervision) 2. The practitioner is capable of performing duties within the scope of his/her services as listed on the scope of practice. (If no, please comment below) 3. Is the overall quality of the patient care provided by the practitioner appropriate and acceptable? (If no, please comment below) Yes Yes No No Comments: RECOMMENDATION: Recommend Recommend with the following reservation(s) Do not recommend (please provide explanation in comment section) Sponsoring Physician Name PLEASE PRINT Return completed form to: c:\common\forms\cvo\credentialing Application Forms\Prof Staff Sponsorship-Eval Form.doc Revised 1/06 Fairview System Credentialing Office 2344 Energy Park Dr, Ste 127 St Paul, MN 55108