CAPITAL MEDICAL CENTER Delineation of Surgical Privileges

Transcription

1 CAPITAL MEDICAL CENTER Delineation of Surgical Privileges Draft Surgical privileges shall be granted solely on the basis of training, documented competence, and experience. Requests for other than surgical privileges must be made on the appropriate privilege form. Please read attached criteria for laparoscopic, thorascopic and sterotactic procedures and attach appropriate documentation. IMPORTANT: Please check desired privileges in the REQ (Requested) or R/C (Requested with Consultation) column. "Request with Consultation" requires a surgeon with full privileges to perform the procedure to be physically present in the operating room during surgery. For Applicant Use For Committee Use REQ R/C APP DEN CORE SURGICAL PRIVILEGES ( ) ( ) ( ) ( ) Admission, H&P, Care & Discharge of surgical patients ( ) ( ) ( ) ( ) Digital Blocks ( ) ( ) ( ) ( ) Bier Blocks ( ) ( ) ( ) ( ) Suturing simple or complex lacerations not involving tendons or major nerves ( ) ( ) ( ) ( ) I & D abscess ( ) ( ) ( ) ( ) Simple skin biopsy or excision ( ) ( ) ( ) ( ) Removal of non-penetrating corneal foreign body ( ) ( ) ( ) ( ) Uncomplicated removal of foreign objects from bodily orifices ( ) ( ) ( ) ( ) Uncomplicated minor closed fractures not involving skeletal traction or major manipulation/reduction ( ) ( ) ( ) ( ) Uncomplicated dislocations of the upper and lower extremities excluding the hip and knee ( ) ( ) ( ) ( ) Preoperative care of the surgical patient ( ) ( ) ( ) ( ) Care of the uncomplicated burn patient ( ) ( ) ( ) ( ) Post-op care of the surgery patient at the surgeon's discretion ( ) ( ) ( ) ( ) Surgical assisting on other than own patients ( ) ( ) ( ) ( ) Assisting at surgery on the practitioner's own patient. ( ) ( ) ( ) ( ) IV Conscious Sedation REQ R/C APP DEN ABDOMINAL AND RECTAL SURGERY ( ) ( ) ( ) ( ) Abdominoperineal resection ( ) ( ) ( ) ( ) Gastroscopy ( ) ( ) ( ) ( ) Peritoneoscopy ( ) ( ) ( ) ( ) Large and small bowel resections ( ) ( ) ( ) ( ) Adnexal surgery ( ) ( ) ( ) ( ) Biliary tract ( ) ( ) ( ) ( ) Gall bladder ( ) ( ) ( ) ( ) Intestinal tract ( ) ( ) ( ) ( ) Pancreas ( ) ( ) ( ) ( ) Spleen ( ) ( ) ( ) ( ) Peritoneum and omentum ( ) ( ) ( ) ( ) Stomach and duodenum ( ) ( ) ( ) ( ) Paracentesis ( ) ( ) ( ) ( ) Appendectomy ( ) ( ) ( ) ( ) Diaphragmatic Hernia Repair ( ) ( ) ( ) ( ) Femoral Hernia Repair ( ) ( ) ( ) ( ) Incisional Hernia Repair ( ) ( ) ( ) ( ) Inguinal Hernia Repair ( ) ( ) ( ) ( ) Umbilical Hernia Repair ( ) ( ) ( ) ( ) Anal fissure ( ) ( ) ( ) ( ) Anal fistula ( ) ( ) ( ) ( ) Pilonidal cyst ( ) ( ) ( ) ( ) Hemorrhoidectomy ( ) ( ) ( ) ( ) TAH/BSO ( ) ( ) ( ) ( ) Open Gastric Bypass ( ) ( ) ( ) ( ) Abdominoplasty / Abdominopanniculectomy REQ R/C APP DEN VASCULAR SURGERY ( ) ( ) ( ) ( ) Anastomoses ( ) ( ) ( ) ( ) Aneurysms ( ) ( ) ( ) ( ) Aneurysmectomy ( ) ( ) ( ) ( ) Phlebectomy ( ) ( ) ( ) ( ) Thrombectomy Surgery Privs- Page 1

2 Surgical Privileges Continued VASCULAR - Continued ( ) ( ) ( ) ( ) Embolectomy ( ) ( ) ( ) ( ) Vein ligation and strip ( ) ( ) ( ) ( ) Renovascular surgery ( ) ( ) ( ) ( ) Venous Access Port Placement ( ) ( ) ( ) ( ) Microsurgery ( ) ( ) ( ) ( ) Carotid Endarterectomy ( ) ( ) ( ) ( ) Placement of cardiac pacemakers ( ) ( ) ( ) ( ) Peripheral Angioplasty & Stenting** (Please request separate privilege delineation with privileging criteria) REQ R/C APP DEN BREAST SURGERY ( ) ( ) ( ) ( ) Breast biopsy ( ) ( ) ( ) ( ) Stereotactic breast biopsy** (see attached criteria) ( ) ( ) ( ) ( ) Sentinel node biopsy ( ) ( ) ( ) ( ) Excision of cyst or tumor ( ) ( ) ( ) ( ) Incision and drainage of abscess ( ) ( ) ( ) ( ) Mastectomy, simple ( ) ( ) ( ) ( ) Mastectomy, radical ( ) ( ) ( ) ( ) Reconstructive surgery ( ) ( ) ( ) ( ) Myocutaneous Flap REQ R/C APP DEN THORACIC SURGERY ( ) ( ) ( ) ( ) Resectional lung surgery ( ) ( ) ( ) ( ) Esophageal surgery ( ) ( ) ( ) ( ) Open drainage ( ) ( ) ( ) ( ) Closed drainage ( ) ( ) ( ) ( ) Rib resection & thoracoplasty ( ) ( ) ( ) ( ) Mediastinoscopy ( ) ( ) ( ) ( ) Mediastinotomy ( ) ( ) ( ) ( ) Thoraco-abdominal procedures ( ) ( ) ( ) ( ) Repair aortic or iliac aneurysms with endovascular technique (team approach only) ( ) ( ) ( ) ( ) Wedge Resection Pleurodesis REQ R/C APP DEN HEAD AND NECK SURGERY Ear, Nose, and Throat ( ) ( ) ( ) ( ) Tonsillectomy ( ) ( ) ( ) ( ) Adenoidectomy ( ) ( ) ( ) ( ) Tracheotomy ( ) ( ) ( ) ( ) Endoscopy, diagnostic ( ) ( ) ( ) ( ) Endoscopy, operative and foreign body ( ) ( ) ( ) ( ) Myringotomy ( ) ( ) ( ) ( ) Tympanoplasty (including stapedectomy and insertion of P.E. tubes) ( ) ( ) ( ) ( ) Mastoidectomy ( ) ( ) ( ) ( ) Labyrinthectomy ( ) ( ) ( ) ( ) Facial and nerve surgery ( ) ( ) ( ) ( ) Intranasal surgery and sinus surgery Head and Neck: ( ) ( ) ( ) ( ) Aesthetic facial surgery ( ) ( ) ( ) ( ) Excision lesions, limited (cysts, superficial skin lesions, etc.) ( ) ( ) ( ) ( ) Excision lesions, major ( ) ( ) ( ) ( ) Parotid surgery, including nerve dissection ( ) ( ) ( ) ( ) Radical neck dissections ( ) ( ) ( ) ( ) Thyroid/parathyroid surgery ( ) ( ) ( ) ( ) Oral tumors, including tongue ( ) ( ) ( ) ( ) Pharyngectomy ( ) ( ) ( ) ( ) Laryngectomy ( ) ( ) ( ) ( ) Laryngoscopy Surgery Privs- Page 2

3 Surgical Privileges Continued Maxillofacial ( ) ( ) ( ) ( ) Extractions ( ) ( ) ( ) ( ) Surgery of jaw and oral cavity, except malignancy ( ) ( ) ( ) ( ) Fracture of jaw ( ) ( ) ( ) ( ) Uncomplicated nasal fractures ( ) ( ) ( ) ( ) All facial fractures, open and closed REQ R/C APP DEN ENDOSCOPY ( ) ( ) ( ) ( ) Bronchoscopy ( ) ( ) ( ) ( ) Esophagoscopy ( ) ( ) ( ) ( ) Gastroscopy ( ) ( ) ( ) ( ) Mediastinoscopy ( ) ( ) ( ) ( ) Laparoscopy (see Laparascopic privileges below) ( ) ( ) ( ) ( ) Arthroscopy ( ) ( ) ( ) ( ) Endoscopic Carpal Tunnel Decompression ( ) ( ) ( ) ( ) GU Endoscopy ( ) ( ) ( ) ( ) Endoscopic Brow & Facial Surgery ( ) ( ) ( ) ( ) Colonoscopy ( ) ( ) ( ) ( ) Sigmoidoscopy REQ R/C APP DEN NEUROSURGERY ( ) ( ) ( ) ( ) Craniotomy ( ) ( ) ( ) ( ) Laminectomy for disc or tumor ( ) ( ) ( ) ( ) CSF shunting procedures ( ) ( ) ( ) ( ) Rhizotomy for pain, cranial or spinal nerves ( ) ( ) ( ) ( ) Excision cervical rib and/or anterior scalene muscles ( ) ( ) ( ) ( ) Implantation dorsal column or peripheral nerve stimulator ( ) ( ) ( ) ( ) Anterior cervical disc excision and fusion ( ) ( ) ( ) ( ) Peripheral nerve suture, exploration or neuroma excision ( ) ( ) ( ) ( ) Cordotomy, stereotactic or surgical ( ) ( ) ( ) ( ) Microsurgery of nerves ( ) ( ) ( ) ( ) Transphenoidal surgery ( ) ( ) ( ) ( ) Interstim Neural Sacral Stimulation REQ R/C APP DEN ORTHOPEDIC SURGERY ( ) ( ) ( ) ( ) Extensor tendon repair ( ) ( ) ( ) ( ) Major joint fusions, including spine fusion ( ) ( ) ( ) ( ) Spine and joint manipulation under anesthesia ( ) ( ) ( ) ( ) Closed reduction of simple fractures and dislocations ( ) ( ) ( ) ( ) Closed reduction of fractures and dislocations with or without internal fixation ( ) ( ) ( ) ( ) Open reduction of fractures and dislocations with or without internal fixation ( ) ( ) ( ) ( ) Bone Biopsy ( ) ( ) ( ) ( ) Reconstructive arthroplasty and joint replacement ( ) ( ) ( ) ( ) Spine Fusion with instrumentation ( ) ( ) ( ) ( ) Spine Fusion with pedicle screws ( ) ( ) ( ) ( ) Facet Surgery with fixation devices ( ) ( ) ( ) ( ) Vertebral Kyphoplasty with cement injection ( ) ( ) ( ) ( ) Lumbar Disc Replacement ( ) ( ) ( ) ( ) Cervical Disc Replacement (clinical trial) ( ) ( ) ( ) ( ) Insertion of Interspinous Spacer ( ) ( ) ( ) ( ) Resurfacing for THR ( ) ( ) ( ) ( ) Deuce TKR Amputations: ( ) ( ) ( ) ( ) Major ( ) ( ) ( ) ( ) Minor (i.e., fingers, toes) Hand Surgery: ( ) ( ) ( ) ( ) Major (trauma and reconstructive surgery) ( ) ( ) ( ) ( ) Minor Surgery Privs- Page 3

4 Surgical Privileges Continued REQ R/C APP DEN SKIN AND SUBCUTANEOUS TISSUE ( ) ( ) ( ) ( ) Biopsy ( ) ( ) ( ) ( ) Second and third degree burns ( ) ( ) ( ) ( ) Excision of lesion (cyst, lipomata, polyps) Skin Grafts: ( ) ( ) ( ) ( ) Free ( ) ( ) ( ) ( ) Pedicle ( ) ( ) ( ) ( ) Split Thickness ( ) ( ) ( ) ( ) Suture uncomplicated wounds ( ) ( ) ( ) ( ) Superficial excisions and biopsies REQ R/C APP DEN UROLOGIC SURGERY ( ) ( ) ( ) ( ) Open kidney procedures ( ) ( ) ( ) ( ) Open bladder procedures ( ) ( ) ( ) ( ) Open ureteral procedures ( ) ( ) ( ) ( ) Transurethral procedures ( ) ( ) ( ) ( ) Open urethral procedures ( ) ( ) ( ) ( ) Scrotal explorations ( ) ( ) ( ) ( ) Extracorporeal Shock Wave Lithotripsy (ESWL) (must provide documentation) ( ) ( ) ( ) ( ) Meatotomies ( ) ( ) ( ) ( ) Circumcisions ( ) ( ) ( ) ( ) Vasectomies ( ) ( ) ( ) ( ) Orchiectomies ( ) ( ) ( ) ( ) Anti-incontinence procedures ( ) ( ) ( ) ( ) GU Collagen Implantation ( ) ( ) ( ) ( ) Ureteroscopy ( ) ( ) ( ) ( ) Penile Prosthesis Implantation ( ) ( ) ( ) ( ) Cryotherapy- Kidney, Prostate ( ) ( ) ( ) ( ) Cryoablation- Prostate ( ) ( ) ( ) ( ) Penile Blocks ( ) ( ) ( ) ( ) Urinary Diversion REQ R/C APP DEN OPHTHALMIC SURGERY Orbit: ( ) ( ) ( ) ( ) Enucleation ( ) ( ) ( ) ( ) Exenteration ( ) ( ) ( ) ( ) Plastic repair ( ) ( ) ( ) ( ) Orbital tumors and explorations ( ) ( ) ( ) ( ) Lacrimal surgery Eyelids: ( ) ( ) ( ) ( ) Repair minor lacerations ( ) ( ) ( ) ( ) Major procedures requiring reconstructive techniques Extraocular: ( ) ( ) ( ) ( ) Corneal foreign body, superficial ( ) ( ) ( ) ( ) Corneal foreign body, central or deep, under slip lamp ( ) ( ) ( ) ( ) Eye muscle surgery ( ) ( ) ( ) ( ) Ptosis surgery Lens: ( ) ( ) ( ) ( ) Cataract removal ( ) ( ) ( ) ( ) Intraocular lens implantation ( ) ( ) ( ) ( ) Iris surgery (including glaucoma) ( ) ( ) ( ) ( ) Corneal surgery Retinal: ( ) ( ) ( ) ( ) Retinal detachments (scleral buckling, etc.) ( ) ( ) ( ) ( ) Photocoagulation ( ) ( ) ( ) ( ) Cryopexy Surgery Privs- Page 4

5 Surgical Privileges Continued REQ R/C APP DEN GYNECOLOGY SURGERY (also request OB-GYN Privilege sheet) ( ) ( ) ( ) ( ) Incidental GYN Procedures ( ) ( ) ( ) ( ) Pubovaginal Sling ( ) ( ) ( ) ( ) Monarch Bladder Hammock REQ R/C APP DEN PEDIATRIC SURGICAL PRIVILEGES (also request PEDS Privilege sheet) ( ) ( ) ( ) ( ) Orthopedic procedures ( ) ( ) ( ) ( ) Herniorrhaphy ( ) ( ) ( ) ( ) Pyloromyotomy ( ) ( ) ( ) ( ) Apendectomy ( ) ( ) ( ) ( ) Orthopedic Care ( ) ( ) ( ) ( ) Pylorotomy ( ) ( ) ( ) ( ) Chest Surgery ( ) ( ) ( ) ( ) Bowel Resection ( ) ( ) ( ) ( ) Circumcision ( ) ( ) ( ) ( ) Orchipexy ( ) ( ) ( ) ( ) Urology Procedures ( ) ( ) ( ) ( ) Exploratory Laparotomy ( ) ( ) ( ) ( ) Tumor Resection ( ) ( ) ( ) ( ) Ophthalmologic procedures ( ) ( ) ( ) ( ) Plastic Surgery procedures ( ) ( ) ( ) ( ) Congenital Chest Wall Deformity Repair ( ) ( ) ( ) ( ) Pectus Deformity Repair ( ) ( ) ( ) ( ) Fractures- open and closed reduction ( ) ( ) ( ) ( ) Spinal Surgery, including scoliosis REQ R/C APP DEN LAPAROSCOPIC SURGERY ** (see laparoscopic criteria below) ( ) ( ) ( ) ( ) Laparoscopic Cholecystectomy ( ) ( ) ( ) ( ) Laparoscopic Herniorrhaphy ( ) ( ) ( ) ( ) Laparoscopic Spine Surgery ( ) ( ) ( ) ( ) Laparoscopic Fundoplication ( ) ( ) ( ) ( ) Laparoscopic Colectomy ( ) ( ) ( ) ( ) Laparoscopic Splenectomy ( ) ( ) ( ) ( ) Laparoscopic Appendectomy ( ) ( ) ( ) ( ) Laparoscopic Adrenalectomy ( ) ( ) ( ) ( ) Laparoscopic Adjustable Gastric Band Surgery REQ R/C APP DEN THORASCOPIC SURGERY ** (see thorascopic criteria below) ( ) ( ) ( ) ( ) Thorascopic Spine Surgery ( ) ( ) ( ) ( ) Thorascopic Bleb/Wedge Resection, Stapling- with/without pleurodesis ( ) ( ) ( ) ( ) Thoracoscopy ( ) ( ) ( ) ( ) Video-Assisted Thorascopy for all open procedures I certify that I have the necessary training and experience to perform the privileges requested above. Name: Print Signature Date: Surgery Privs- Page 5

6 CAPITAL MEDICAL CENTER Criteria for Laparoscopic and Thorascopic Privileges Draft The following process has been established for privileging of laparoscopic and thorascopic privileges: A. Documented qualifications required as part of the application: 1. American Board of Surgery or Specialty Board certification or eligibility or at the discretion of the Committee. 2. Credentials to perform the laparoscopic procedure in the open setting. B. Applicants must comply with one of the following alternate training requirements: 1. Successful completion of a laparoscopic and/or thorascopic practicum providing for continuing medical education credit which includes: a. Didactic course work describing equipment used. b. Didactic training on indications, contraindications, and management of complications. c. An objective test of the participant's skills, including experience in performing procedures on animal models, and in use of the equipment on inanimate objects. 2. If laparoscopic and/or thorascopic practicum is NOT attended, the following criteria must be met: a. Observation of one procedure by an experienced physician. An experienced physician is defined as an individual who has performed a minimum of 12 procedures of the requested privilege. Observed physician will be asked to submit written documentation of the observing physicians participation. b. Performance of the procedure on animal models or documented experience on humans. Physician will be required to submit the date, time and place where this experience is obtained. 3. Residency training which includes all aspects outlined in subsection #1 of this section or have the privilege at another hospital and meet the minumum requirements under section B(1) and B(2). C. Applicants who have successfully complied with the above will be granted provisional privileges for the following: (#1 must be fulfilled, but #2 can be done concurrently.) 1. Participation as a co-surgeon or assistant surgeon on five procedures or have a physician who is credentialed in that specific procedure and has done at least 12 procedures proctor the first case. 2. Participation as a "responsible surgeon" on a minimum of five procedures. Applicant will be required to submit the necessary information to the departmental medical quality assessment committee for review of these cases before being granted full privileges to perform unsupervised. 3. Surgeons whose residency training included laparoscopic and/or thorascopic surgery programs must be fully reviewed by a credentialing committee to assure that the applicant surgeon fulfills the above requirements. In addition, the surgeon will be proctored on a minimum of two (2) cases, if direct questioning of his/her chairman indicates that proctoring would be beneficial. NOTE: Proctoring physician must be credentialed to do the proctored procedure at Capital Medical Center. The proctoring physician is responsible to the Medical Staff Credentials Committee for written documentation of physician's competency. This must be submitted on Capital Medical Center's proctoring form. Responsible surgeon means primary surgeon with backup from fully credentialed co-surgeon or assistant surgeon. D. The Medical Staff Credentials Committee will recommend to the Medical Executive Committee the granting of video endoscopic (laparoscopic) privileges for physicians who have successfully complied with all applicable aspects of the above procedure. ****************************************************************************** APPROVED BY: R. Dean Russell, M.D.; Chair, Department of Surgery; 12/14/95 David M. Deitz, M.D.; Chair, Credentials Committee; 12/14/95 Gregary M. Blackner, M.D.; Chair, Medical Executive Committee; 12/14/95 Surgery Privs- Page 6

7 CAPITAL MEDICAL CENTER CREDENTIALING CRITERIA LAPAROSCOPIC ADJUSTABLE GASTRIC BAND SURGERY SCOPE: Physicians wishing to perform laparoscopic adjustable gastric band surgery procedures at Capital Medical Center. Initial Appointment Requirements: Basic Education: M.D. or D.O. Completion and documentation of one of the following: A. Completion of a surgical residency and fellowship training in advanced laparoscopic and bariatric surgery which must be documented by the program director. Or A. Completion of an approved surgical residency and all of the following: 1. Documentation of successful completion of a didactic course in laparoscopic adjustable gastric banding including indications, contraindications and management of complications. And 2. Have a fully established bariatric program in place to include support for nutritional, physical and psychosocial needs of the patient. The applicant must submit a list of laparoscopic adjustable band procedures performed during the past two (2) years. The minimum threshold number for laparoscopic adjustable gastric band procedures is 25 within the past two (2) years. If the applicant has the privilege for laparoscopic adjustable gastric band procedures at another hospital, the hospital must provide a list of procedures performed by the applicant, including any identified quality variations. If the applicant is unable to meet the above minimum threshold number of cases, they will be required to perform five (5) laparoscopic adjustable gastric band procedures with a proctor credentialed for the procedure until clinical competence is established. The proctor will provide a written performance evaluation report to the Medical Staff Office. The first twenty (20) cases following approval of privileges will be reviewed by the Quality Improvement Council. Approved: David Deitz, MD 03/27/2008 Chairman, Credentials Committee Date Approved: Rajesh Sharangpani, MD 03/26/2008 Medical Executive Committee Date Approved: Wendy Holden, Chair 04/02/2008 Board of Trustees Date Surgery Privs- Page 7

8 CAPITAL MEDICAL CENTER Draft CREDENTIALING CRITERIA STEREOTACTIC BREAST BIOPSY 1. Initial training and qualifications: A. Have at least 3 hours of Category I CME in stereotactic breast biopsy which should include instruction in imaging triangulation for lesion location. B. Have performed at least 12 stereotactic breast biopsies or at least 3 hands-on stereotactic breast biopsy procedures under a physician who has performed at least 24 stereotactic breast biopsies. C. Be experienced in post-biopsy management of procedure complications. D. Initially obtain at least 15 hours of documented CME in breast imaging including pathophysiology of benign and malignant breast disease as well as clinical breast examinations. 2. Maintenance of Proficiency: A. Perform at least 12 stereotactic breast biopsies per year or re-qualify as specified in 1-A. Surgery Privs- Page 8