YALE-NEW HAVEN HOSPITAL CORE PRIVILEGES CARDIOLOGY Name: The clinical privileges and procedures identified below are the Core Privileges in General Internal Medicine and Cardiology. If you intend to use any type of laser at Yale-New Haven Hospital, please also complete the Use of Lasers Privilege Delineation. Qualifications: M.D. or D.O. Degree Successful completion of an ACGME or AOA-accredited fellowship program in Cardiology. Current certification or re-certification, or active participation in the examination process leading to certification or re-certification, in Cardiology by the American Board of Internal Medicine or the American Osteopathic Board of Internal Medicine. For Attending or Associate Medical Staff Members, satisfactory attainment of forty (40) points per year from the categories of activity as described on the Determination of Attending Status cover sheet. Privileges Core privileges in Cardiology may include the ability to admit, evaluate, diagnose, perform consultative service to the general medicine service and/or patients with cardiovascular disease. Please request ONE of the following three choices of privileges as appropriate based on your practice at Y-NHH by marking below: To be completed by Department Description Requested Approved Approved Not Approved with Proctoring 1. Admitting (includes the ability to admit patients to medical floors and critical care units* as well as to provide consultation and outpatient care) (Includes #2 and #3 below) 2. Consultation (includes the ability to perform consultation on inpatients, emergency department patients and outpatients only) (Includes #3 below) 3. Outpatient Care (includes the ability to care for patients in the emergency department and outpatient settings only) *Consultation may be required by the Unit Director or his/her designee for patients admitted to intensive care units. Consultation is required of all practitioners if patient management matters are beyond the scope of training or experience of the individual. Procedures The following procedures are included in the core privileges for Cardiology: elective cardioversion, insertion and management of central venous and pulmonary artery catheters, use of thrombolytic agents, official EKG interpretation, and temporary transvenous pacemaker placement.
The following procedures are considered core procedures for General Internal Medicine. Please select any that will be relevant to your hospital based practice at Y-NHH (evidence of current competence may be required): Diagnostic abdominal paracentesis Diagnostic lumbar puncture Diagnostic thoracentesis Diagnostic arthrocentesis Peripheral arterial puncture Special Procedure Privileges (not included in the Cardiology Core) To be eligible to apply for the special procedures listed in Categories A through D below, applicants must demonstrate successful completion of a fellowship in cardiology or other approved and recognized course or certification in cardiology and provide documentation of competence in performing or supervising that procedure consistent with the criteria as establish as indicated and acceptable outcomes. Criteria for Categories A and B are the criteria set forth by the Y-NHH Cardiac Catheterization Committee. NOTE: All INITIAL requests for privileges in Categories A and B must be submitted by the applicant directly to the Cardiac Catheterization Committee for approval. Cardiology Category A To be completed by Department Procedure Criteria Requested Approved Approved with proctoring Use of Fluoroscopy (without a radiologic technologist controlling the pedal) Initial Credentialing and Re- Credentialing: Requires completion of fluoroscopy training session via the Yale CME website: https://transact.med.yale.edu/cme/on line_courses/catalog.asp?ocoid=19 Please print and submit certificate to demonstrate completion of the training Not Approved Cardiology Category B: Advanced Heart Failure, Cardiac Transplant and Mechanical Circulatory Support Privileges in this category include the ability to manage the care of the following: patients being considered for, or who require, device-based heart failure management including temporary and permanent mechanical circulatory support devices pre and post heart transplant patients To be completed by Department Privilege Criteria Requested Approved Approved with proctoring Management of Advanced Heart Failure, mechanical circulatory support and cardiac transplant patients Initial appointment: Current certification in Cardiovascular Disease by the ABIM and eligible or certified in Advanced Heart Failure and Transplant Cardiology. Additionally, a commitment of four weeks/year on the inpatient advanced heart failure service. Re-appointment: A minimum of four weeks/year on inpatient advanced heart failure service and achievement of 12 CME s per year from AHF offerings. Not Approved
Cardiology Category C To be completed by Department Procedure Criteria Requested Approved Approved with proctoring Peripheral venous As appropriate based on training cutdown Stress 25 per year echocardiography Holter Monitoring 25 per year Treadmill Testing 25 per year (with or w/out radionuclide) Right heart As appropriate based on training diagnostic catheterization Right heart As appropriate based on training endomyocardial biopsy Transesophageal Echocardiography Initial Appointment: 100 Re-appointment: 50 per year Not Approved Cardiology Category D See Cardiac Catheterization Laboratory Privileging and Quality Assurance Standards (attached) for specific requirements for privileges for procedures as noted below. To be completed by Department Procedure Criteria Requested Approved Approved with proctoring Left heart diagnostic Privileging standards of Y-NHH Cardiac catheterization Cath Lab (attached) Coronary artery Privileging standards of Y-NHH Cardiac brachytherapy Cath Lab (attached) Percutaneous transluminal coronary angioplasty Coronary Stenting Intra-aortic balloon pump insertion Privileging standards of Y-NHH Cardiac Cath Lab (attached) Privileging standards of Y-NHH Cardiac Cath Lab (attached) Initial and Re-Credentialing: No additional requirements if requirements for cardiac catheterization and/or cardiac interventional procedures are met, otherwise must have documentation of experience and current competence at initial appointment and a minimum of five (5) per year for re-appointment Not Approved
Pericardiocentesis Peripheral vascular interventions Carotid angioplasty & stenting Conscious Sedation Initial and Re-Credentialing: No additional requirements if requirements for cardiac catheterization and/or cardiac interventional procedures are met, otherwise must have documentation of experience and current competence at initial appointment and a minimum of two (2) per year for re-appointment Per Y-NHH Criteria (attached) Per Y-NHH Criteria (attached) Standards of Y-NHH Sedation/Analgesia Protocol Cardiology Category E To be completed by Department Procedure Criteria Requested Approved Approved with proctoring Diagnostic electrophysiology studies Catheter ablation of arrhythmia AICD Insertion Permanent pacemaker insertion Re-appointment: at least 3 per year. If not performed at Y-NHH, a letter from Chief of Service at primary hospital must be provided. Re-appointment: combination of at least 50 ablations, AICDs and/or permanent pacemakers per year. Re-appointment: combination of at least 50 ablations, AICDs and/or permanent pacemakers per year. Re-appointment: combination of at least 50 ablations, AICDs and/or permanent pacemakers per year. Not Approved Cardiology Category F: Transcatheter Aortic Valve Replacement (TAVR) The intra-operative technical aspect of every TAVR procedure must be performed jointly with a cardiac surgeon who also has independent privileges to perform TAVR Criteria: Initial Credentialing: Evidence of the following: Evidence of completion of product specific training and Minimum of 100 career structural* heart disease procedures OR 30 left sided structural* procedures per year of which 60% are balloon aortic valvuloplasty, and Submission of all cases to the STS/ACC TVT Registry *Left sided procedures include EVAR, TEVAR, balloon aortic valvuloplasty, aortic valve and mitral valve prosthetic leak closures and ventral septal defect closures. Atrial septal defect and patent foramen ovale closure are not considered left sided procedures NOTE: Notwithstanding the above case number requirements, if the applicant has not performed at least five TAVR cases at Y-NHH, he/she will be eligible only for privileges with proctoring. The applicant then must serve as a primary cardiology operator for five (5)
cases at Y-NHH with a Y-NHH physician who has current independent privileges. Upon completion of these cases with an acceptable complication rate, the applicant may submit a request for independent privileges. Re-Credentialing: Evidence of having participated in a total of ten (10) cases per year and served as a cardiology primary operator in a minimum of five (5) with acceptable outcomes and Submission of all cases to the STS/ ACC TVT Registry To be Completed by Department Procedure Requested Approved Approved with proctoring Transcatheter Aortic Valve Replacement (TAVR) Not Approved PHYSICIAN ACKNOWLEDGEMENT I acknowledge that I have received, reviewed and am oriented to the Bylaws and Rules & Regulations of the Medical Staff as well as Yale-New Haven Hospital s policy regarding Standard Precautions and agree to be bound by the terms thereof. I agree to practice in accordance with my privileges as delineated and to obtain consultations as appropriate. In addition to the above, I understand that in an emergency, I am authorized to treat any medical diseases, and to perform any medical or surgical procedure permitted by my license. I understand that this statement of conditions of clinical privileges will remain in effect for the duration of my service as a member of the Yale-New Haven Hospital Medical Staff unless amended. Physician s Signature Date ------------------------------------------------------------------------------------------------------------------------------------------------- DEPARTMENTAL REVIEW Except as indicated below, core privileges in General Internal Medicine and Cardiology are approved by the undersigned: Core Privileges and Procedures in General Internal Medicine and Cardiology Approved as indicated on previous pages Although I have not personally examined the applicant/reappointee or his/her medical records, I Do not Have Have (Please provide details) reason to believe that he/she suffers from a physical, emotional, or other health problem which impairs his/her ability to practice. Should I acquire information which changes this opinion, I will promptly notify the Chief Medical Officer. For Re-Appointments Only Additionally in consideration of this request for privileges, I have reviewed the reappointee s performance with respect to the ACGME six general competencies indicated below based upon direct knowledge or information available via peer reference. Areas of concern which I have addressed with the reappointee, if applicable, are noted below: (Please mark/ explain as applicable)
Patient Care Medical / Clinical Knowledge Practice Based Learning and Improvement Interpersonal & Communication Skills Professionalism Systems Based Practice No issues with any of the above. (Please mark as applicable) DEPARTMENTAL OR SUBSPECIALTY COMMENTS Approved privileges are commensurate with this applicant s current skill and competence. (Please mark if applicable) Approved: Gary V. Desir, M.D. Interim Chief, Internal Medicine Signature/Printed Name Date Michael C. Bennick, M.D. Associate Chief, Internal Medicine Date
YALE-NEW HAVEN HOSPITAL Criteria for Peripheral Vascular Interventions (Angioplasty & Stenting)* Initial Appointment 100 peripheral vascular diagnostic procedures with evidence in interpretation of diagnostic angiography, within a period of three years. 50 peripheral angioplasty/stenting/thrombolytic** procedures; primary operator in 25, within a period of three years Evidence in the interpretation of physiological pressure measurements and their application as well as non-invasive physiological testing in the non-invasive lab as part of the curriculum for new trainees or via CME accreditation for others Re-Credentialing 10 peripheral angioplasty/stenting/thrombolytic** procedures every two years 10 Category I CME credit hours related to peripheral vascular disease/interventions, every two years Participation in 75% of monthly multidisciplinary Peripheral Vascular M&M Conferences *Excludes neuro and cardiac **includes thrombolysis/mechanical thrombolytic procedures (psosis and angiojet) Approved April 2003 Revised June 2005 Revised September 2005
Yale-New Haven Hospital CARDIAC CATHETERIZATION LABORATORY PRIVILEGING AND QUALITY ASSURANCE STANDARDS Revised: Effective: 4-1-03 Supersedes: 6-1-96 I. Criteria for Privileges for Cardiac Catheterization A. Initial Privileges 1. Board certification in Internal Medicine and Cardiovascular Disease. If the Physician is a recent graduate from a fellowship training program, a two year period will be allowed for adequate time to take the boards. If board certification is not obtained by this time then the individual will no longer be eligible for cardiac catheterization privileges. 2. Documentation of satisfactory completion of fellowship in Cardiology, specific for cardiac catheterization. a. Performance of at least 300 left heart cardiac catheterizations during fellowship. Physicians in current practice must show evidence of performance of at least 300 left heart catheterizations. Procedurerelated complications may not exceed national guidelines. b. Fellowship must include a third year, and if required by American College of Cardiology (ACC) guidelines, a fourth year, of training with emphasis on cardiac catheterization for all fellowship graduates who complete fellowship after 1990. B. Maintaining Privileges 1. Catheterization operators must perform at least 75 diagnostic cardiac catheterizations per year in YNHH System or YNHH affiliated facilities. YNHH System Facilities include: Yale-New Haven Hospital (York and Saint Raphael Campuses), Bridgeport Hospital and Greenwich Hospital YNHH Affiliated Facilities include: West Haven Veterans Administration Hospital, Lawrence & Memorial Hospital and William Backus Hospital 2. For those cases performed at hospitals other than Y-NHH, adequate quality assurance documentation must be obtained and provided by the operator in an acceptable format to the Quality Assurance Committee semiannually in order to be eligible for continuation of privileges. 3. Complication rates must not exceed national standards without appropriate justification. 4. If a physician becomes temporarily disabled due to illness or is temporarily not practicing due to sabbatical leave, privileges will be continued even if the physician has not met volume requirements during the time period of disability or sabbatical up to a maximum time period of one year. If the time period of absence is greater than one year, the physician's privileges will lapse and reapplication for privileges will be required.
5. Attendance at least 50% of the Catheterization Lab morbidity and mortality conferences will be required for all physicians with cardiac catheterization privileges. Attendance at Catheterization Laboratory morbidity and mortality conferences that are held at YNHH System or Affiliated facilities (as defined previously) will be counted towards this requirement if verified by the Catheterization Lab director at the relevant facility. C. Cardiac Catheterization Laboratory Director 1. In addition to other qualifications which may be required, the Cardiac Catheterization Laboratory Director must have performed 200 left heart catheterizations per year for each of the preceding five years. 2. Complication rates must not exceed the national standards without appropriate justification. D. Reapplication for privileges after lapse or revocation 1. A physician whose privileges have lapsed or been removed for failure to meet eligibility requirements (e.g. volume, board certification, quality assurance data submission) may reapply for privileges once the physician can demonstrate that the applicable requirements have been fulfilled. An individual physician may reapply only once during any five year period. The five year period commences as of the date of reapplication. 2. In the reapplication process, and regardless of the reason for the lapse or loss of privileges, the physician must demonstrate a commitment to meeting all credentialing requirements in the future. II. Criteria for privileges for coronary angioplasty A. Initial privileges 1. Board Certification in Internal Medicine and Cardiovascular Disease is required with certification in Interventional Cardiology strongly recommended. A two year period will be allowed for adequate time to take and pass the boards. If board certification is not obtained within two years the physician will no longer be eligible for coronary angioplasty privileges. 2. Documentation of satisfactory completion of a fellowship in Cardiac Catheterization and Coronary Angioplasty must be provided in order to be eligible for coronary angioplasty privileges as a primary operator. The Fellowship must meet ACC guidelines and be ACGME accredited. The following is required: Performance of at least 150 coronary angioplasties as primary operator during fellowship; or, if the physician completed fellowship prior to 1990, then documentation of sufficient experience with coronary angiography and angioplasty (defined as IVUS, PCI, or FFR ) in practice must be provided. Specifically, an average of fifty (50) cases over the most recent two (2) year period with appropriate outcomes is necessary. B. Maintaining privileges 1. Coronary angioplasty operators must perform an average of fifty (50) coronary interventions (defined as IVUS, PCI, or FFR ) over a two (2) year period in YNHH System or YNHH Affiliated hospital as previously defined. Adequate quality assurance documentation of cases performed outside Y-NHH must be obtained and provided by the physician to the QA subcommittee semi-annually in order to be eligible for continuation of privileges. 2. Only one operator per angioplasty case will be permitted to count the case for quality assurance/volume and privileging purposes. 3. Complication rates must not exceed national standards without appropriate justification. 4. Coronary angioplasty/angiography morbidity and mortality conferences will be held on at least a bimonthly basis under the supervision of the director of the Catheterization Lab and PTCA Service. Attendance at at least 50% of these conferences over each calendar year is required by all physicians with coronary angioplasty
privileges. Attendance at Catheterization Laboratory morbidity and mortality conferences that are held at YNHH System or Affiliated facilities (as defined previously) will be counted towards this requirement if verified by the Catheterization Lab director at the relevant facility. 5. Cardiac catheterization privileges must be maintained. 6. Coronary angioplasty cases will also be counted as diagnostic catheterizations. These cases are termed interventional catheterizations. III. Criteria for Privileges in Peripheral Transluminal Angioplasty A. Initial privileges 1. Board certification in Internal Medicine and Cardiovascular Disease. If the Physician is a recent graduate from a fellowship training program, a two (2) year period will be allowed for adequate time to take the Boards. If board certification is not obtained by this time, then the physician will no longer be eligible for privileges in perphiperal transluminal angioplasty. 2. Documentation of satisfactory completion of a fellowship in Cardiovascular Medicine. 3. Specific procedural qualifications and training these may be achieved by completing an appropriate postgraduate program, or may be demonstrated by documented diagnostic and therapeutic experience in training or in practice. a. Performance of at least 100 diagnostic peripheral angiograms with evidence of experience in interpretation of diagnostic angiography, within a period of three years; and b. Performance of 50 renal and/or peripheral percutaneous transluminal angioplasties/stentings with the applicant as primary operator in at least 25 of these cases within a period of three years; and c. Experience in the interpretation of physiological pressure measurements and their application as well as noninvasive physiological testing in the non-invasive lab as part of the curriculum for new trainees or via CME accreditation for others. d. Procedure-related complications will not exceed national guidelines without appropriate justification. Note: Concurrent cardiac catheterization privileges in the Cardiac Catheterization laboratory are not required to obtain or maintain privileges to perform peripheral transluminal angioplasty. B. Maintaining Privileges 1. Peripheral transluminal angioplasty operators must perform at least 10 angioplasty/stenting cases every two years at YNHH. These cases must consist of a combination of diagnostic and therapeutic (angioplasty/thrombolysis) procedures. Cases done at other institutions will not be included in the numerical criteria for privilege maintenance. 2. Performance of 50 peripheral vascular diagnostic procedures every two years. 3. Success and complication rates must meet appropriate national guidelines. 4. Cases, including complications and follow up, must be entered into the YNHH Vascular Registry. 5. Operator must demonstrate attendance at postgraduate courses related to peripheral vascular disease/interventions for a total of at least ten hours of Category 1 CME every two years. IV. Quality Assurance Monitoring A. Nurse to monitor operator cases and complications
1. A quality assurance supervisor reporting directly to the Director of the Cardiac Catheterization Lab will be responsible for collecting data on quality assurance issues including: a. Case numbers of cardiac catheterizations performed by primary operators at YNHH System and YNHH Affiliated hospitals as previously defined b. Complications resulting from cardiac catheterizations at Y-NHH. c. Case numbers of coronary angioplasties performed at Y-NHH d. Complications resulting from coronary angioplasty cases at Y-NHH. e. Case numbers of peripheral transluminal angioplasty cases at Y-NHH f. Complications resulting from peripheral transluminal angioplasty cases at Y-NHH. g. Attendance at angioplasty/angiography morbidity and mortality conferences. B. Cardiac Catheterization Lab Quality Assurance Subcommittee 1. A subcommittee will be convened to monitor quality assurance issues. 2. This subcommittee will be composed of: a. The Cardiac Catheterization Lab Director; b. The Associate Cardiac Catheterization Lab Director at the SRC campus c. The Director of Peripheral Vascular Interventions 3. The Quality Assurance Subcommittee will be responsible for: a. Semi-annual review of: 1) Case numbers of cardiac catheterizations performed by primary operators at YNHH System and Y-NHH Affiliate hospitals 2) Complications resulting from cardiac catheterization at Y-NHH. 3) Case numbers of coronary angioplasties performed at YNHH System, and Y-NHH Affiliate hospitals 4) Complications resulting from coronary angioplasty cases at Y-NHH 5) Case numbers of peripheral transluminal angioplasties performed at Y-NHH. 6) Complications resulting from transluminal angioplasties at Y-NHH 7) Attendance at coronary angioplasty/angiography morbidity and mortality conferences. If the Quality Assurance Sub-committee is to consider case data from sources outside of the Y-NHH York Street Campus, the physician must supply the required information by February 1 st and August 1 st each year in order to be eligible for continuation of privileges. The Committee will notify physicians as to the acceptable format in which the data must be supplied. If the physician fails to supply the required data after one reminder he/she will no longer be eligible for Cardiac Catheterization Laboratory privileges. Reinstatment may be permitted once required documentation is supplied.
If available, comprehensive data provided by the Cardiac Catheterization Lab Director at a YNHH System Hospital or YNHH Affiliated Hospital (as previously defined) will satisfy this requirement. Physicians must complete the Hospital-required Quality Assurance Data forms appropriately. Cases in which this is not done will not be counted in the case numbers required for maintenance of privileges in the Laboratory. b. Ongoing assurance of high procedure quality of all physicians with catheterization and/or angioplasty privileges at Y-NHH. This Committee will have the authority to recommend maintenance of operator privileges at Y-NHH to the Credentials Committee. If case numbers and/or complication rates of Cath Lab physicians do not meet minimum quality assurance standards then the committee may: (1) recommend to the Credentials Committee that the relevant physician s privileges not be continued; (2) conduct a Focused Professional Practice Evaluation consistent with Medical Staff Policy to further evaluate the performance and outcomes of the individual physician; or (3) refer the matter to the Institutional Practice Quality and Peer Review Committee (IPQPQC). The Committee will be bound by the guidelines outlined in Section V below. c. Ongoing assurance of current definitions concerning case numbers and national accepted procedurerelated complication rates. Notification to the Physician The affected physician shall be notified in writing relative to any change or potential change in privileges having to do with failure to meet eligibility, quality assurance or other requirements for continuation of cardiac catheterization, coronary angioplasty, peripheral vascular angioplasty privileges including the initiation of a Focused Professional Practice Evaluation or referral to the Credentials Committee or IPQPRC. Notification to the Department of Physician Services All communication to physicians as described above shall be copied to the Department of Physician Services for retention in the physician s Medical Staff Peer Review file V. Loss of privileges A. Case numbers for privileged physicians will be monitored as follows: 1. Case numbers for diagnostic cardiac catheterizations If, after review of the preceding year by the Quality Assurance Sub-committee, it is determined that a physician has performed fewer than: 75 diagnostic procedures then the physician will no longer be eligible for diagnostic catheterization privileges. Reapplication will be necessary if the physician meets the requirements in the future. 2. Case numbers for coronary angioplasties If, after review of the preceding year by the Quality Assurance Sub-committee, it is determined that a physician has performed fewer than an average of fifty (50) interventional procedures over a two (2) year period as primary operator, then the physician will no longer be eligible for privileges. Reapplication will be necessary if the physician meets the requirements in the future. 3. Case numbers for peripheral angioplasties. If, after review of the preceding year by the Quality Assurance Sub-committee, it is determined that a physician has performed fewer than ten (10) peripheral transluminal angioplasties (a combination of
4. Exceptions diagnostic and therapeutic cases) over a two (2) year period, then the physician will no longer be eligible for privileges. Reapplication will be necessary if the physician meets the requirements in the future. a. No exception will be made to numerical requirements for total number of cardiac catheterizations, coronary angioplasties, or peripheral angioplasties to be performed at a YNH Health System or Y-NHH Affiliate hospital. b. If at the end of the relevant year, a physician has performed within 10% of the relevant number of cases required at Y-NHH, and complication rates are considered acceptable, privileges may be continued for the subsequent year, during which time numerical criteria must be met. This exception will not be granted more than once in any five year period. Notification to the Physician The affected physician shall be notified in writing of failure to meet case volume eligibility requirements for continuation of privileges and what he/she must do in order to be considered for reinstatement of privileges. Notification to the Department of Physician Services All communication to physicians as described above shall be copied to the Department of Physician Services for retention in the physician s Medical Staff file. B. Complication Rates 1. If, after review of the preceding year the Quality Assurance Sub-committee finds that procedure-related complication rates exceed the national average as defined by the NCDR registry, the committee may recommend one of two courses of action: a. a relevant period of in person proctoring including review of case appropriateness which will be implemented under the direct supervision and authority of the Quality Assurance Sub-committee and the Catheterization Lab Director b. that the physician agree voluntarily not to exercise the relevant privileges pending further review of the concerns identified In the event that the physician has been asked to voluntarily not exercise certain privileges and refuses to do so, the Chief Medical Officer and Chair of the Medical Board s Institutional Practice Quality & Peer Review Committee (IPQPRC) will be immediately notified by the Catheterization Lab Director. If the Catheterization Lab Director believes that the practice of the physician poses a threat of imminent harm to patients and the Chief Medical Officer or Chair of IPQPRC is not immediately available, he/she may immediately suspend relevant privileges with notification to the Chief Medical Officer. The physician is notified in writing of the requirements and expectations of any of the above and copies of all such communication are provided to the Department of Physician Services for retention in the physician s Medical Staff Peer Review file. 2. Guidelines for coronary and peripheral transluminal angioplasty complication rates will be obtained from current widely accepted registries such as the ACC and NCDR. 3. Physicians who perform diagnostic catheterizations that show no or minimal (less than 50%) evidence of cardiovascular disease in greater than national averages of catheterized patients (excludes cardiomyopathy and cardiac transplant patients) will be subject to a period of proctoring to ensure appropriate case selection. If during the one year proctoring period the proctor determines that no improvement has been made the matter will be referred to the IPQPRC.
C. Other Requirements 1. Attendance at coronary angioplasty/angiography morbidity and mortality conferences. If after review of the preceding year, the quality assurance committee finds that a given physician with coronary and/or peripheral transluminal angioplasty privileges has not attended 50% or more of scheduled angioplasty/angiography morbidity and mortality conferences consistent with the requirements set forth in previous sections of this policy, the physician will be notified that he/she has one (1) year to demonstrate compliance with attendance requirements. If the physician does not attend the required number of conferences in that year, he/she shall no longer be eligible for continuation of privileges. The physician and the Department of Physician Services will be notified in writing. 2. Physicians will be expected to practice in a manner that is consistent with the Centers for Medicare and Medicaid Services (CMS) appropriate use criteria and standards. 3. Compliance with Medical Staff rules concerning completion of medical records and requirements for preprocedural history and physical examinations and other documentation is required. VI. Mechanisms for Revising Quality Assurance Standards All aspects of the quality assurance standards will be reviewed by the Catheterization Lab Committee as needed. Changes to the requirements of this policy may be recommended by agreement of at least two thirds of the Catheterization Lab Committee and are referred to the Credentials Committee, Medical Board and Patient Safety & Clinical Quality Committee of the Board of Trustees for approval. The exception to this is when there are requirements prescribed by law or Hospital agreement with regulatory authorities. Approvals: Credentials Committee: June 2, 2015 Medical Board: June 3, 2015 Patient Safety & Clinical Quality Committee of the Board of Trustees: June 17, 2015