PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER DEPARTMENT OF SURGERY General Surgery STANDARDS FOR PRIVILEGES In order to be eligible to request clinical privileges for both initial appointment and reappointment, a practitioner must the following minimum threshold criteria. EDUCATION: M.D. or D.O. Degree TRAINING: Privileges in General Surgery are granted in clinical cognitive areas and for specific procedures. Surgeons requesting General Surgery privileges are to be board certified by the American Board of Surgery or the American Osteopathic Board of Surgery, or have successfully completed a general surgery residency in a program accredited by the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA). REQUIRED CLINICAL EXPERIENCE: Recent clinical experience is required of all applicants for appointment and reappointment. Recent clinical experience for initial appointment and reappointment is defined as having performed at least 30 inpatient clinical services, procedures, or clinical consultations in a Joint Commission accredited hospital or hospital-based ambulatory setting in the last two years. The variety and type of clinical activities must be sufficient to cover the scope of practice and privileges requested. Applicants must certify at the time of initial appointment and reappointment, that there are no problems of health or mental status that will interfere with the exercise of clinical privileges requested. Requests for specific procedural privileges not present on this form should be made in writing to the Department Chair. This request must be accompanied by documentation of specific training, experience and current competence for the privilege(s) requested. Write-in privileges on this form are not accepted. SURGERY – ADDITIONAL CRITERIA FOR ADVANCED PRIVILEGES Privileges followed by an asterisk are identified in this table. Please submit required documentation at the time of request. The numbers indicated in this table represent minimal criteria for appointment and reappointment. Additional documentation of training, experience and/or current competence may be requested. Additional proctoring may be required at any time by the Department Chair, or the Medical Staff Executive Committee.
PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER DEPARTMENT OF SURGERY General Surgery Additional Criteria for Advanced Privileges PROCEDURE
CRITICAL CARE MANAGEMENT ANESTHESIA Procedural Sedation Adult and Pediatric CARDIOTHORACIC Install/Implant AICD* Pacemaker (temporary) Pacemaker (permanent) HEAD AND NECK Radical Neck Dissection
ENDOSCOPIC PROCEDURES Transoral Incisionless Fundoplication LAPAROSCOPIC PROCEDURES Appendectomy
Cholestectomy
Hernia Repair
Laparoscopic assisted Colon Resection Laparoscopic Fundoplication
Laparoscopic Spleenectomy
LASER KTP/YAG, C02
TRAINING NECESSARY
NUMBERS OF PROCEDURES FOR INITIAL APPOINTMENT
4
NUMBER OF PROCEDURES PROCTORED INITIALLY
NA
Successful completion of Conscious Sedation Test
Documentation of training and current competence
1 1 1
1 1 1
2
1
Completion of Hands On Course Successful completion of General Surgery Residency program Successful completion of General Surgery Residency program Successful completion of General Surgery Residency program Successful completion of General Surgery Residency program Successful completion of General Surgery Residency program Successful completion of General Surgery Residency program Documentation of training and current competence
Min. 2
2
1
2
1
2
1
2
1
2
1
2
1
2
3
NAME: ___________________________________
PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER DEPARTMENT OF SURGERY - General Surgery REQUEST FOR CLINICAL PRIVILEGES
SPECIALTY: BOARD CERTIFIED:
YES
Requested ()
NO
GENERAL PRIVILEGES
Approved ()
Not Approved ()
Admitting and Attending Privileges – First six (6) cases are to be proctored during the Provisional period (first two years) before a member is qualified for advancement. Assist in Surgery C-Arm with Fluoroscopy (Current Fluoroscopy Certificate Required) Consultation - First 10 cases are to be proctored during the Provisional period (first two years) before a member is qualified for advancement Critical Care Admission and Management*
BUNDLED PRIVILEGES ▪
These procedures are customarily performed by board certified or fully trained general surgeons, and;
▪
Documentation of specific training and current competence in bundled procedural privileges may be required, and;
▪
Bundled privileges have no asterisk.
ADVANCED PRIVILEGES ▪
These procedures may be performed by board certified or fully trained general surgeons, and;
▪
Advanced procedural privileges require documentation of training and current competence when requested by any surgeon, and;
▪
Advanced procedural privileges are denoted by one asterisk (*). Please review the above criteria sheet for current competence and proctoring requirements.
Requested
Anesthesia
Approved
Not
NAME: ___________________________________
PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER DEPARTMENT OF SURGERY - General Surgery REQUEST FOR CLINICAL PRIVILEGES
Completion of Written Exam Necessary
()
Procedural Sedation – Adult
Procedural Sedation - Child Anterior Approach for Spinal Procedures
Requested ()
Anterior Abdominal Approach
Anterior Thoracic Approach
Requested ()
Abdominal & Gastroenterological Bundle
Approved ()
Approved ()
Not Approved ()
Approved ()
Not Approved ()
Approved ()
Not Approved ()
Abdominoperineal Resection Anoplasty Appendectomy/Meckel’s Diverticulectomy Colon Resection Complex anorectal procedure Drainage of major abscess Enterolysis Exploratory laparotomy Internal Sphincterotomy Anoplasty Anal Fissurectomy Anal Fistulectomy Gastric Resection and reconstruction Gastric Ulcer Surgery Gastroenterostomy Gastrorrhaphy Gastrostomy Hemorrhoidectomy Hiatal hernia repair (open), anti-reflux procedures Ileal reservoir or conduit Paracentesis Peritoneal dialysis-catheter placement Pilonidal cyst excision Pyloromyotomy Pyloroplasty with vagotomy Retroperitoneal Exploration Small bowel resection Staging Laparotomy Transanal excision of neoplasm Hernia Repair Bundle
Requested ()
()
Epigastric Femoral Inguinal Umbilical Ventral
NAME: ___________________________________ Requested ()
Breast Bundle
Cardiac Bundle
Approved ()
Not Approved ()
Approved ()
Not Approved ()
Approved ()
Not Approved ()
Approved ()
Not Approved ()
Approved ()
Not Approved ()
Approved ()
Not Approved ()
Approved ()
Not Approved
Sentinel lymph node biopsy Axillary node dissection Breast Biopsy Mastectomy Reconstructive breast procedures
Requested ()
Requested ()
PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER DEPARTMENT OF SURGERY - General Surgery REQUEST FOR CLINICAL PRIVILEGES
Arterial Lines--Peripheral Central Venous Lines (Porta-Cath) Swan-Ganz catheterization
To document recent clinical experience, enter # and location performed in the last two years where indicated Number
Cardiothoracic – Nonbypass(Advanced)
Location
Install/implant Temporary Pacemaker* Install/implant Permanent Pacemaker* (Epicardial, Transvenous) Install/Implant AICD* Central Venous Bundle
Requested ()
Temporary & Permanent Esophagus Bundle
Requested ()
Repair Bundle
Requested ()
Requested ()
Esophageal anastomosis Esophageal dilation Esophageal-tracheal fistula repair Esophageal varices ligation, sclerosis Esophagomyotomy (Heller Procedure) Esophagotomy
Rectovagina fistula Surgical rent, bowel, or bladder Salpingectomy
Head & Neck Bundle
NAME: ___________________________________
PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER DEPARTMENT OF SURGERY - General Surgery REQUEST FOR CLINICAL PRIVILEGES ()
Requested ()
Branchial Cleft Cyst, Sinus Excision Excision submaxillary gland Eyelid Trauma Repair Parathyroidectomy Parotidectomy, superficial or deep with or without nerve dissection Thyroidectomy Thyroglossal duct cyst excision Tracheal repair ( trauma related, emergency) Tracheostomy
To document recent clinical experience, enter # and location performed in the last two years where indicated Number
Location
Approved ()
Not Approved ()
Approved ()
Not Approved ()
Approved ()
Not Approved ()
Approved ()
Not Approved ()
Approved ()
Not Approved
Head and Neck (Advanced) Radical neck dissection*
Requested ()
Liver, Billiary Tract, Pancreas Bundle
Lymphatic and Spleen Bundle
Requested ()
Excision Lymphadenectomy Splenectomy Splenic Repair Musculoskeletal- Extremity Bundle
Requested ()
Requested ()
Cholecystectomy, Operative Cholangiogram and CBD Exploration Choledocoenterostomy Cholecystostomy Hepatectomy (trauma related-emergency) Hepatic lobectomy Hepatic wedge resection Liver biopsy Pancreatectomy (partial or complete with reconstruction) Transduodenal sphincteroplasty
Excision Repair Amputations, minor and major (ray or distal, upper or lower body)
Skin and Subcutaneous Tissue Bundle
NAME: ___________________________________
PARKVIEW COMMUNITY HOSPITAL MEDICAL CENTER DEPARTMENT OF SURGERY - General Surgery REQUEST FOR CLINICAL PRIVILEGES ()
Biopsy Burn Treatment (
