KALEIDA HEALTH Name: ___________________________________________

Date: ____________________

DELINEATION OF PRIVILEGES - OTOLARYNGOLOGY GENERAL STATEMENTS – Adults and Pediatrics except as specified. Procedures are grouped by anatomic region and may be identified by ICD-9 code. Procedures are also separated into levels of complexity (Level I, Level II, and Level III), which require increasing levels of education and experience. In general, procedures learned during residency are grouped in Level I and are granted upon evidence of successful completion of residency training. Level II procedures may require evidence of additional training or experience beyond residency. Documentation of additional training and/or experience is required for all Level III procedures. LASER privileges are listed separately in a final section and granted according to LASER safety committee standards.

LEVEL I PRIVILEGES Procedures which are assumed to have been mastered following satisfactory completion of an approved Otolaryngology training program and can be performed by an Otolaryngologist whose documented training and experience qualify the applicant for the privilege. History and Physical for diagnosis and treatment. Admission and Follow-up Skull (excision, reconstruction, bone graft) Peripheral Nerve (excision, biopsy, graft, anastomosis) Thyroid/Parathyroid (aspiration, biopsy, resection) Thymus (excision) Eyelid (incision, excision, repair, reconstruction) Lacrimal System (biopsy, excision, probing, repair) Orbit (reconstruction, excision) Ear, External (diagnosis, repair biopsy, excision, reconstruction) Middle Ear (exploration, tympanoplasty, stapes, mastoid) Nasal (epistaxis, biopsy, septum, reconstruction, repair, excision) (aspiration, endoscopic, external) Oral cavity (biopsy, excision, repair, reconstruction) Tongue/FOM Salivary Gland (repair, excision) Oropharynx (tonsil) Pharynx Neck (congenital) Access to the Spine Cricopharyngeal Myotomy Larynx (excision, repair, reconstruction, trauma, TEF) Trachea (excision, tracheotomy, repair) Lung (bronchoscopy, biopsy) Vessels (incision, biopsy, excision, repair, ligation) Lymphatic (biopsy, excision, neck dissection) -- thoracic duct Esophagus (incision, biopsy, repair, endoscopy, repair, reconstruction, dilatation) Facial Bones (repair, biopsy, trauma, sequestrotomy) Mandible Integumentary (biopsy, excision, repair, skin graft, pedicle flaps, facial plastic surgery, scar revision, tissue expansion)

Otolaryngology

Name:_________________________________________

Page 2

PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow or line to make selections. We will return applications that ignore this directive. LEVEL II PRIVILEGES Requires certificate of added qualifications or approved fellowship in one of the following: Head & Neck Oncology, Pediatric Otolaryngology, Otology/Neuro-otology, Facial Plastic Surgery or documentation of surgical experience for three years preceding the request. Volume criteria may be applicable. Glossectomy Tracheal Resection Vessel Resection with Repair Percutaneous Tracheotomy Partial Laryngectomy Stapedectomy Liposuction Laryngo-tracheal separation Medialization Laryngoplasty Arytenoid Adduction Angiofibroma Arytenoidectomy < 8 yrs of age Arytenopexy < 8 yrs of age Endoscopic sinus surgery < 8 yrs of age Endoscopic CSF leak repair Lip-Tongue (Douglas procedure) NICU admission Vascular lesions, lymphangiomas, AVM, hemangiomas, < 8 yrs of age Thoracentesis Thoracostomy Cleft Lip repair Cleft Palate repair Browlift Otoplasty, Unilateral/bilateral Facelift Platysmoplasty Blepharoplasty Suction Lipectomy/lipolysis Chemical peel Tissue expanders (insertion, removal) Facial implants Treat facial paralysis Microtia reconstruction Endoscopic plastic surgery Facial reanimation Midfacelift Rib graft Bone graft Conscious Sedation (Adult/Pediatric) 1. Initial Request: Must have completed a Kaleida Health approved training course (documentation required) or training during ACGME Accredited Residency (verification letter from program director required.) 2. Maintenance of privilege: The course needs to be taken again every 4 years. 3. The course can be found at: www.kaleidahealth.org/physicians/ModerateSedation/

PHYSICIAN REQUEST

Granted

Not Granted*

With Following Requirements** (Provide Details)

Otolaryngology

Name:_________________________________________

Page 3

LEVEL III PRIVILEGES Those procedures which categorically require documentation of additional training or experience, high risk procedures, new procedures or unlisted procedures will be included in this category. Volume criteria may be applicable. Otologic Procedures Acoustic neuroma Implantable Hearing Aids Cochlear Implants 8th Nerve section Temporal Bone Resection Plastic and Reconstructive Surgery TMJ procedures Micro vascular reconstruction (harvesting of flap, reconstruction) Craniofacial surgery Reconstruction congenital aural atresia, stenosis Sino Nasal Excision Pituitary tumor transphenoid Maxilla (osteoplasty) Mandible (osteoplasty, orthognathic) Excision Cribiform Plate Pediatric Practice Laryngeal Reconstruction < 8 yrs of age Cricoid decompression, Laryngoplasty, Tracheoplasty - < 8 yrs of age Tracheotomy < 2 yrs of age Endoscopy Endoscopy < 2 yrs of age (biopsy, dilation, excision, microscopy, foreign body removal, laser) laryngoscopy esophagoscopy bronchoscopy with f.b. removal < 2 yrs Other PEG Cricohyoidopexy

PHYSICIAN REQUEST

Granted

Not Granted*

With Following Requirements** (Provide Details)

Otolaryngology

Name:_________________________________________

Page 4

ROBOTIC SURGERY If proctorship is a pre-requisite, contact the Medical Staff Office for instructions & to obtain the required forms. You must be “approved with proctoring” PRIOR to performing the procedure within Kaleida. 1. Applicant must have unrestricted privileges for open and/or endoscopic surgery procedures for which robot assisted surgeries/procedures will be performed AND must provide documentation of successful completion of an advanced didactic robotic course to include certification of completion of a robot-assisted animal laboratory course. Observation of a minimum of two (2) robotic cases and must complete five (5) *proctored cases with satisfactory outcomes; OR 2. Applicant must provide documentation of unrestricted robotic privileges at another hospital system, with satisfactory outcomes including a case log of the most recent 50 cases; OR 3. Applicant must provide documentation of successful completion of computer assisted surgical training in residency/fellowship including robotic surgery with a case log of 50 cases of all robotic surgery and must complete two (2) *proctored cases with satisfactory outcomes; AND 4. Applicant must have first ten (10) robotic cases retrospectively reviewed by the clinical service chief and/or designee regarding meeting the quality standards established by the clinical department. 5. Applicant must perform twenty five (25) robot-assisted surgeries each year with satisfactory results to maintain privilege. *To qualify to proctor robotic surgery, an applicant must also have completed a minimum of fifty (50) robotic surgery cases with satisfactory outcomes, and must agree to be present in the OR during the entire surgical procedure being proctored.

PHYSICIAN REQUEST

Granted

Not Granted*

With Following Requirements** (Provide Details)

Transoral resections of benign and malignant lesions of the pharynx and larynx and oncologic resections of the supraglottis, tonsil and tongue base.

Otolaryngology

Name:_________________________________________

Page 5

APPLICATION FOR LASER & STERIOTACTIC SURGERY PRIVILEGES 1.

Have you completed laser surgery training in an accredited residency program?

YES_____ NO_____

State date and name of institution where you completed your training: Institution___________________________________________________________ Date_________________ 2.

In lieu of number (1) above, have you completed an approved laser surgery training program within eighteen (18) months of making application that included “hands on” training for each privilege requested? YES_____ NO_____ PLEASE ATTACH DOCUMENTATION TO SUPPORT YOUR APPLICATION

3.

I am a member in good standing of my Department.

4.

I understand that the need for supervision of an applicant performing new laser surgery procedures will be determined by the Credentials Committee upon the recommendation of the Department Chair.

5.

I understand that a Pathology specimen must be obtained prior to laser ablation procedure where clinically appropriate as defined by the Department (see delineation of privilege form attached).

6.

I understand that Laser Ablation Surgery may only be performed using the laser machine indicated, e.g., YAG, Krypton, Argon, CO2, etc. (see delineation of privilege form attached).

Type of LASER to be used

Documentation/supervision and/or course attendance

CO2 Argon KTP Nd-Yag Pulse Dye Feather Silk Touch CO2 Alexandrite Ruby Diode Ebrium Yag

Stereotactic system use for Otolaryngology applications Fluoroscopic Balloon Sinuplasty

Other

Documentation of taking Acclarent Sinuplasty Catheter training course or other training required. Must be mentored by a physician who is already trained in this procedure during first case.

PHYSICIAN REQUEST

Granted

Not Granted*

With Following Requirements** (Provide Details)

Otolaryngology

Name:_________________________________________

KEY

**WITH FOLLOWING REQUIREMENTS

*NOT GRANTED DUE TO:

Provide Details Below

Provide Details Below

1) Lack of Documentation 2) Lack of Required Training/Experience 3) Lack of Current Competence (Databank Reportable) 4) Other (Please Define) (i.e., Exclusive Contract)

Page 6

1) 2) 3) 4)

With Consultation With Assistance With Proctoring Other (Please Define)

DETAILS:_________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

National Practitioner Databank Disclaimer Statement: Kaleida Health must report to the National Practitioner Data Bank when any clinical privileges are not granted for reasons related to professional competence or conduct. (Pursuant to the Health Care Quality Improvement Act of 1986 (43 U.S.C. 11101 et seq.)

___________________________________________________/__________________

Signature of Applicant

Date

(1) I approve of the procedures requested by the applicant ____ as requested or ____ as amended.

(2) ________ I have consulted with Pediatric ENT Site Director on _____/_____/_____ who agrees to recommend approval of the requested Level II/III privileges for Pediatric care in Otolaryngology.

___________________________________________________/___________________

Signature of Chief of Service

Date

APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED DELINEATION FOR YOUR RECORDS (Otolaryngology 12/2015)