SPECIALTY OF CERTIFIED REGISTERED NURSE ANESTHETIST Delineatin f Clinical Privileges Criteria fr granting privileges: Current natinal bard certificatin Current unencumbered license t practice as a Registered Nurse and as a Certified Registered Nurse Anesthetist (CRNA) in the state f his/her practice. Cmpleted educatin frm a prgram f nurse anesthesia accredited by the Cuncil n Accreditatin f Nurse Anesthesia Educatinal Prgrams r its predecessr Or Current unencumbered license t practice as a Registered Nurse and as a Graduate Registered Nurse Anesthetist (GRNA) in the state f his/her practice. Cmpleted educatin frm a prgram f nurse anesthesia accredited by the Cuncil n Accreditatin f Nurse Anesthesia Educatinal Prgrams r its predecessr Natinal bard certificatin within six mnths f training cmpletin. Applicants will be requested t prvide dcumentatin f practice and current clinical cmpetence as defined n the attached cmpetency grid. Applicants have the burden f prducing infrmatin deemed adequate by the hspital fr a prper evaluatin f current clinical cmpetence, and ther qualificatins and fr reslving any dubts. Current Clinical Cmpetence - MLH In additin t the required educatin, experience and/r training specified n each DOP (Delineatin f Privilege) frm, dcumentatin f current clinical cmpetence is required. TJC (The Jint Cmmissin) describes current clinical cmpetence as having perfrmed the privilege recently and perfrmed it well. Current clinical cmpetence is assessed prir t granting privileges initially and is reassessed when renewing privileges at reappintment fr maintenance f privileges. Current Clinical Cmpetence (CCC) may be lcatin specific (acute hspital care/surgery center (ASC) and/r age specific (adult, pediatric,nenatal). This shuld nt be cnfused with FPPE (Fcused Prfessinal Practice Evaluatin) FPPE: an evaluatin f clinical cmpetence f all new privileges as perfrmed at the specific licensed MLH facility (MHMH, MHOBH, Fayette, MECH) fr which they have been initially granted. This applies t privileges fr all new applicants as well as t new/additinal privileges fr current members. Bth FPPE and current clinical cmpetence assessments are privilege-specific. FPPE is cnducted during the perid after granting new/additinal privileges. FPPE must ccur at the MLH facility(ies) where privileges/membership are held. Current clinical cmpetence may be evaluated frm case lgs prvided by nn-mlh facilities.
Current Clinical Cmpetence: Requirements fr New Applicants If applying directly frm training, r based n the training received in a frmal training prgram, prvider shuld submit case* lgs frm the prgram authenticated by the prgram directr alng with their recmmendatin attesting t the cmparable training, experience and qualificatins relative t the criteria fr the clinical privileges requested. If applying mre than 1 year after training cmpletin, submit the fllwing: Aggregate data frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 diagnsis cdes and the number f patients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Case lgs (see specificatins belw) fr any special privileges requested that meet the criteria specific fr the number f prcedures defined fr current clinical cmpetence. Current Clinical Cmpetence: Maintenance f Privileges fr Current Practitiners Practitiner shuld submit the fllwing: Aggregate data frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 diagnsis cdes and the number f patients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Case lgs (see specificatins belw) fr any special privileges requested that meet the specific number f prcedures defined fr current clinical cmpetence. Case Lgs All required case lgs and/r prcedure lists must cntain the fllwing infrmatin at a minimum: Date, patient identifier, CPT/ICD prcedure cde, diagnsis, cmplicatins, and dispsitin, and the facility name, name/title f the persn authenticating the lg, signature, date signed, and cntact infrmatin. If the infrmatin requested is nt available, please prvide an explanatin. *A case is defined as an episde f care either cgnitive r prcedural. Fr interpretive care, case is interpretatin f ne diagnstic study.
OPPE (Onging Prfessinal Perfrmance Evaluatin) The Jint Cmmissin (TJC) requires OPPE peridically (mre frequently than annually) in the facility where membership/privileges are held. T assure OPPE requirements are satisfied, the practitiner must peridically exercise the privileges in the MLH facility(ies) where he/she has membership. OPPE must ccur regularly n patient encunters in the MLH facility(ies) where privileges/membership are held.
Specialty/Prcedure Delineatin f Privilege Frm CRNA Cre Educatin/Training Dcumentatin fr Initial Granting Current natinal bard certificatin Current, unencumbered license t practice as a Registered Nurse and as a Certified Registered Nurse Anesthetist (CRNA) in the state(s) f f his/her practice. Cmpleted educatin frm a prgram f nurse anesthesia accredited by the Cuncil n Accreditatin f Nurse Anesthesia Educatin Prgrams r its predecessr Initial Applicatin (Prf f current clinical cmpetence) Case lg frm primary practice facility dcumenting 350 hspital cases in previus 12 mnths FPPE Validatin f cmpetence after appintment and/r granting f a new r additinal privilege (T be cmpleted within ne year) First 5 cases Maintenance Requirements MLH Data will be btained fr practitiners when available, the applicant shuld supply additinal case lgs frm ther facilities HIM departments, if necessary, t meet the minimum requirement(s) t be cnsidered fr the privilege. If n activity is fund, applicant shuld supply case lgs frm ther facilities HIM departments t meet the minimum requirement(s) t be cnsidered fr the privilege. Aggregate data submitted shuld include the tp 10 diagnsis cdes, with the number f inpatients per cde, and prcedure lists indicating the tp 10 CPT/ICD cdes, with the number f prcedures per cde fr the previus 12 mnths. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. GRNA Cre Current, unencumbered license t practice as a Registered Nurse and as a Graduate Registered Nurse Anesthetist (GRNA) in the state(s) f his/her practice. Cmpleted educatin frm a prgram f nurse anesthesia accredited by the Cuncil n Accreditatin f Nurse Anesthesia Educatin Natinal bard certificatin within six mnths f cmpletin f training Case lg frm training prgram dcumenting 350 hspital cases in previus 12 mnths First 5 cases Department chair recmmendatin will be btained frm primary practice facility. MLH Data will be btained fr practitiners when available, the applicant shuld supply additinal case lgs frm ther facilities HIM departments, if necessary, t meet the minimum requirement(s) t be cnsidered fr the privilege. If n activity is fund, applicant shuld supply case lgs frm ther facilities HIM departments t meet the minimum requirement(s) t be cnsidered fr the privilege. Aggregate data submitted shuld include the tp 10 diagnsis cdes, with the number f inpatients per cde, and prcedure lists indicating the tp 10 CPT/ICD cdes, with the number f prcedures per cde fr the previus 12 mnths. Any cmplicatins/pr utcmes shuld be
Specialty/Prcedure Delineatin f Privilege Frm Educatin/Training Dcumentatin fr Initial Granting Initial Applicatin (Prf f current clinical cmpetence) FPPE Validatin f cmpetence after appintment and/r granting f a new r additinal privilege (T be cmpleted within ne year) Maintenance Requirements delineated and accmpanied by an explanatin. Cmmunity Pediatric Privileges Demnstrated cmpetence in prviding ASA 1 & 2 level pediatric anesthesia Case lg frm primary practice facility dcumenting 15 prcedures within the previus 12 mnths First 5 cases Department chair recmmendatin will be btained frm primary practice facility. Case lg dcumenting 15 prcedures within the previus 12 mnths
Scpe f Service and Respnsibility: Scpe f service is based upn educatin, clinical training, demnstrated skills and capacity t manage prcedurally related cmplicatins in the categries f preanesthetic preparatin and evaluatin, anesthesia inductin, maintenance, and emergence, pst-anesthesia care, peri-anesthetic and clinical supprt functins. The CRNA/GRNA shall be in cmpliance with all applicable state and hspital rules including, but nt limited t, supervisin and prtcls. Clinical Supervisin Requirements: The CRNA/GRNA will be supervised by an anesthesilgist wh is a member f the Medical Staff and apprpriately credentialed and privileged. CNRA/GRNA privileges shall be exercised in accrdance with their delineated privileges and shall nt exceed thse f the supervising anesthesilgist. The supervisin f the CRNA/GRNA will be cmpliant with all applicable state rules and regulatins. Cre CRNA/GRNA Cre Privileges: Management f patients f all ages rendered uncnscius r insensible t pain and emtinal stress during surgical, bstetrical and invasive medical prcedures under the supervisin f an anesthesilgist, with the exceptin f rgan transplant prcedures. Privileges include: 1. Administratin f specific types f anesthesia fr assigned cases under supervisin 2. Pre-anesthesia evaluatin and preparatin 3. Administratin f general anesthesia including adjunct drugs and reginal anesthesia/analgesia techniques 4. Administratin f emergency ancillary drugs and fluids t maintain physilgical hmestasis and prevent r treat emergencies during the peri-anesthetic perid 5. Airway management techniques 6. Peri-anesthetic invasive and nn-invasive mnitring 7. Tracheal intubatin/extubatin 8. Mechanical ventilatin/xygen therapy 9. Pst-anesthesia care/discharge Prcess Prtcl: The Certified Registered Nurse Anesthetist in cllabratin with the supervising physicians identifies the fllwing evidence-based resurces, texts, and reference dcuments that are applicable standards f care and prvide the applicable prcess prtcls fr care management:
Special Prcedures: The applicant must prvide dcumentatin f current clinical cmpetence in perfrming the prcedure cnsistent with the criteria set frth in medical staff plicies gverning the exercise f specific privileges and the appended cmpetency grid. Applicants have the burden f prducing infrmatin deemed adequate by the hspital fr a prper evaluatin f current clinical cmpetence, and ther qualificatins and fr reslving any dubts. Cmmunity Pediatric Privileges Evaluate, diagnse, cnsult, and prvide care management f pediatric (ages 2-13 years) patients rendered uncnscius r insensible t pain and emtinal stress utilizing varius pediatric sedatin, general r reginal anesthesia, place and use f invasive mnitrs (including arterial, central venus, and pulmnary artery catheters,) during surgical and certain ther medical prcedures, limited t ASA classificatins 1 and 2; including pre-, intra-, and pstperative evaluatin and treatment, supprt f life functins and vital rgans under the stress f anesthetic, surgical and ther medical prcedures, medical management and cnsultatin in pain management and critical care medicine, direct resuscitatin in the care f patients with cardiac r respiratry emergencies, including the need fr artificial ventilatin and pulmnary care.
Certified r Graduate Registered Nurse Anesthetist Clinical Privileges Check belw the particular privileges desired as Certified r Graduate Registered Nurse Anesthetist fr each facility: Privilege Descriptin Age Limitatins Certified Registered Nurse Anesthetist Cre Cmmunity Pediatric Cre Nenates (0-28 days) Please check ( ) applicable age categries fr each privilege requested. Methdist Methdist Healthcare Memphis Hspitals (MHMH) Extended Care Germantwn, Le Bnheur Medical Center, Hspital (MECH) Nrth, Suth & University, Outpatient Clinics & Diagnstic Facilities Infants (29 days 2 Years) Children 2-13 years) Adlescents (13-18 years) Adults & Adlescents (13 & Abve*) Adults (18 & Abve) Methdist Healthcare Fayette Hspital (MHFH) Adults & Adlescents (13 & Abve) Methdist Healthcare Olive Branch Hspital (MHOBH) Adults & Adlescents (13 & Abve*) Graduate Registered Nurse Anesthetist Cre Specialty Fcus: cnditin(s), disease(s) fr the patient ppulatin (e.g. pediatric Anesthesia neurlgy, adult cardilgy) Clinical privileges are granted nly t the extent privileges are available at each facility and t the extent the supervising physician is Limitatins granted privileges. *Nte: In the case f Obstetrical cases, privileges are extended regardless f the age f the patient. Darkly shaded areas represent privileges nt available t any practitiner due t the privilege nt being ffered by the facility. Acknwledgement f practitiner I have requested nly thse privileges fr which by educatin, training, current experience and demnstrated perfrmance I am qualified t perfrm and fr which I wish t exercise at the facilities indicated abve, t the extent services are available at each facility, and I understand that: (a) in exercising any clinical privileges granted, I am cnstrained by facility and medical staff plicies and rules applicable generally and any applicable t the particular situatin (b) any restrictin n the clinical privileges granted t me is waived in an emergency situatin and in such situatin my actins are gverned by the applicable sectin f the medical staff bylaws r related dcuments Practitiner's Signature Date Printed Name
Acknwledgement f spnsr I agree t abide by the clinical supervisin respnsibilities listed and the CRNA will abide by the privileges utlined abve and the apprpriate facility Medical Staff Rules and Regulatins. Date: Signature (N Stamps) Emplying r Supervising Physician Printed Name ID #