INITIAL: [ ] RENEWED: [ ] DATE: ADDITIONAL: [ ] Privileges are granted for Sutter General Hospital, Sutter Memorial Hospital, Capital Pavilion Surgery Center, and Sutter Center for Psychiatry or Sutter Oaks Midtown and exercise of privileges is based on the type of care, treatment and services provided at each facility. To request Privileges, please place an X in the request column. In Number Performed box, indicate the number of identified procedures performed in 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 Programs Appointment [ ] Admission and Treatment of Adults (18 years and over) at Sutter Center for Psychiatry (SCP) Competence demonstrated by documentation of Board certification by the American Board of Psychiatry and Neurology or successful completion of a minimum of 3 years residency training in Psychiatry. First six admissions as attending [ ] Admission and Treatment of Adolescents (Age 13 through the age of 17 years) at SCP Psychiatrists or psychologists who are members of the Medical Staff may request privileges to admit and treat s (those 13 through 17 years of age) to the or child units after demonstration of relevant training and/or experience in mental health. (Relevant Training - Applicant must submit a onepage summary of their training and/or experience in psychiatry. The Psychiatry Administrative Committee will determine whether training is relevant to approve the applicant s request for privileges.) Those Medical Staff members with adult privileges who apply for privileges will be proctored by a Medical Staff member with privileges on six admissions.
Request Programs Appointment [ ] Admission and Treatment of Children (through the age of 12 years) at SCP Training and Experience : Members of the Department of Psychiatry who wish privilege in Child Psychiatry will be either board eligible or board certified by the American Board of Psychiatry and Neurology in Child Psychiatry or psychologists who are members of the Medical Staff who demonstrate special training and experience in working with children. Six cases proctored by Member of the Child Psychiatry Staff holding full staff privileges (Three child and three ) unless applicant is also applying for Adult Psychiatry Privileges in which case the requirement drops to three cases. Request Privileges Appointment [ ] Formal Psychological Testing Must demonstrate practice experience and Formal Psychological Testing Certification Pre-requisite: 6 cases by a staff psychologist [ ] Informal Sub-Section of Interventional Psychiatry Members of the Department of Interventional Psychiatry who wish privileges in the Sub-Section of IP will hold ECT Privileges. Page 2 of 5
Request Privileges Appointment [ ] Electroconvulsive Therapy Training and Experience : Criteria for requesting privileges in Electroconvulsive Therapy (ECT) are the same as those for General Psychiatry. These privileges are outlined in the American Psychiatric Association 1990 Task Force Report (pp. 46-48) and form the basis of our credentialing procedure for ECT. In addition, the applicant should have completed a formal training module in an ACGME Psychiatric Residency or hold current ECT privileges at another. If the applicant is more than five years post-residency, he/she should complete a one-week post-graduate training module which includes both didactic and hands-on training. [ ] Vagus Nerve Stimulation (VNS) Training and Experience : 1. Prerequisite - Currently hold Electroconvulsive Therapy (ECT) procedure privileges at a Joint Commission 2. Evidence of completion of manufacturer training/certification to perform treatments with VNS.. Six (6) proctored cases of ECT during hospital stay (minimum of three treatments) in which three procedures on each case are observed by proctor. privileges. settings per patient) Six (6) ECT procedures on at least two patients within the last two years are required. Completion of twelve treatment. Page 3 of 5
Request Privileges Appointment [ ] Transcranial Magnetic Stimulation (TMS) Training and Experience : 1. Prerequisite - Currently hold Electroconvulsive Therapy (ECT) procedure privileges at a Joint Commission 2. Evidence of completion of manufacturer training/certification to perform treatments with the TMS device. privileges. treatments per case). Completion of 12 (12) treatment [ ] Ketamine Drip Treatment Prerequisite - Currently hold Electroconvulsive Therapy (ECT) procedure privileges at a Joint Commission Must Hold Privileges for Sedation and Analgesia Performed by Non-Anesthesiologists Physician must be familiar with literature regarding Ketamine Infusion Therapy as determined by interview with the Director of the ECT Program privilege. infusions per case). Completion of five (5) treatment. Page 4 of 5
Documentation of Volume Criteria for Special privileges # of procedures performed last 2 years # of procedures performed last 5 years Hospitals where performed Ketamine Infusion Therapy Transcranial Magnetic Stimulation (TMS) Vagus Nerve Stimulation (VNS) Please be prepared to supply verification of volume performance if requested. PHYSICIAN S SIGNATURE 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: Or Dept Chief (in lieu of mtg) Credentials Committee Date: Medical Executive Committee Date: Board of Directors Date: TEMPORARY PRIVILEGE APPROVAL Department Chief: Date: Document Approvals: Department of Psychiatry: 11/22/11 Credentials Committee: 12/13/11 Medical Executive Committee: 12/20/11 Board of Directors: 01/9/12. Page 5 of 5