SUTTER MEDICAL CENTER, SACRAMENTO Department of Cardiovascular Disease – Cardiovascular Surgery - Delineation of Privileges NAME:

INITIAL: [ ] RENEWED: [ ] ADDITIONAL: [ ]

DATE:

Privileges are granted for Sutter General Hospital, Sutter Memorial Hospital, Sutter Center for Psychiatry, Sutter Oaks Midtown and the Capitol Pavilion Surgery Center and exercise of privileges is based on the type of care, treatment and services provided at each facility. If you plan to use radiology equipment including the fluoroscope, you must provide a current operating permit that is issued by the Radiologic Health Branch of the California Department of Health Services. To request Privileges, please place an “X” in the request column. In “Number Performed” box, indicate the number of identified procedures performed in previous 24 months 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

Privilege

Appointment Requirements

Proctoring Required

Reappointment Requirements

[ ]

Admitting Privileges

None

None

None

[ ]

History & Physical Privileges

None

None

None

[ ]

Consultation Privileges

None

None

None

General requirements for all new applicants

Request

Cardiac Surgery

[ ]

Adult open heart procedures*

[ ]

Adult closed heart procedures*

[ ]

Pediatric open heart procedures*

[ ]

Pediatric closed heart procedures*

Documentation of experience in the procedures being requested from either a residency or fellowship case listing (if the applicant recently completed training) or a case listing from where the applicant has been practicing. Some procedure specific criteria may also require a letter from the Director or Chief of Service. Appointment Requirements

Pre-Requisite: In order to exercise cardiac surgery privileges, a surgeon must be a member of a Cardiac Surgery Team meeting the requirements set forth in the Rules Applicable to Cardiac Surgery

Number Performed

First six (6) cases regardless of type of case or procedure Proctoring Required

Five (5) of each >aortocoronary bypass >valve Training: Board Certified or admissible for certification by replacement the American Board of Thoracic Surgery, with training and >open congenital experience in cardiovascular surgery heart >closed pediatric congenital heart

Reappointment Requirements

Participation in at last 100 pump assisted cases per year (200 in 2 years)

Number Performed

SUTTER MEDICAL CENTER, SACRAMENTO Department of Cardiovascular Disease – Cardiovascular Surgery - Delineation of Privileges NAME:

Request [ ]

Cardiac Surgery Cardiac transplantation**

Appointment Requirements

Proctoring Required

Reappointment Requirements

Number Performed

1. Board certification or admissibility in Thoracic Surgery. 2. Member of the Cardiovascular Disease Department of Sutter Medical Center Sacramento. 3. Member of a cardiac surgery program completing more than 150 open-heart cases per year. 4. Documentation of formal training in cardiac transplantation including: a.

Satisfactory completion of postgraduate training in cardiac transplantation in a thoracic surgery program approved by the American Board of Thoracic Surgery.

OR Operative experience as part of a heart transplant team as the operating surgeon or first assistant in five cases. b. Demonstrated experience with the immunosuppressive management of heart transplantation. 5. Must have full support of a full cardiac transplant team. 6. Formal affiliation with an established cardiac transplantation program to provide consultation when requested.

Note: If any privileges requested are covered by an exclusive contractual agreement, physicians who are not a party to the contract are not eligible to request the privilege(s) regardless of education, training and experience. Page 2 of 7

SUTTER MEDICAL CENTER, SACRAMENTO Department of Cardiovascular Disease – Cardiovascular Surgery - Delineation of Privileges NAME:

Request [ ]

Cardiac Surgery con’t. Laser transmyocardial revascularization*

Appointment Requirements 1.

Graduation from a residency or fellowship program where laser Transmyocardial revascularization was part of the active training format within the previous two years. Verification in the form of a letter from the Director of the training program is required.

2.

Documentation of prior experience in a Joint Commission accredited hospital in laser transmyocardial revascularization. This documentation must include a letter from the Chief of Surgery or Chief of Staff outlining how many procedures the applicant performed. The experience must have been within the previous two years.

Proctoring Required

Reappointment Requirements

Number Performed

First one (1) procedure must be proctored if training obtained via criteria #1, #,2 or #3 First three (3) procedures must be proctored if training obtained via criteria #4

3. Successful completion of an approved in-house teaching program at Sutter Medical Center, Sacramento. This training must provide the applicant with experience in at least three (3) procedures either as the primary surgeon or first assistant. 4. Documentation of successful completion of a Department approved course on laser transmyocardial revascularization.

Note: If any privileges requested are covered by an exclusive contractual agreement, physicians who are not a party to the contract are not eligible to request the privilege(s) regardless of education, training and experience. Page 3 of 7

SUTTER MEDICAL CENTER, SACRAMENTO Department of Cardiovascular Disease – Cardiovascular Surgery - Delineation of Privileges NAME: Request [ ]

Cardiac Surgery con’t. Robotic assisted cardiac procedures (in accordance with approved FDA indications)*

Appointment Requirements

Pre-requisite: 1. Successful completion of an approved ACGME residency program in Cardiothoracic Surgery. 2. Initial applicants must also hold privileges in thoracoscopic surgery as well as cardiac surgery. Note: Once a surgeon has successfully performed at least 20 solo cases, he/she is eligible to proctor or train others. Training and Experience Requirements: 1. Must attach a certificate of successful completion of approved “hands-on” training in robotic-assisted procedures in the privileges requested; i.e., Intuitive Surgical Training, Certified Course. AND 2. Must have observed at least one (1) live case prior to being granted privileges. AND 3. Must undergo at least five (5) hours of dry-time robotic lab experience. AND 4. Must have successfully completed a 10-case in-house learning/ preceptorship program. OR 5. Currently credentialed and practicing unsupervised cardio/thoracic robotic-assisted privileges in his/her specialty at a Joint Commission accredited facility. Submission of the following: • a letter from the reciprocal medical staff to verify current privileges in the specific procedure(s) requested, AND • two (2) operative reports performed by the applicant as the primary surgeon in the specific procedures requested in the last 24 months.

Proctoring Required

Reappointment Requirements

Number Performed

Must have performed at least ten (10) robotic assisted cardiac procedures during the previous two years OR must undergo another five (5) hours of dry-time robotic If competence is experience. still under question after ten (10) proctored cases the Cardiovascular Administrative Committee must evaluate whether the physician under proctoring requires additional training. The surgeon must be proctored for a minimum of their first two (2) robotic assisted cardiothoracic procedures

Note: If any privileges requested are covered by an exclusive contractual agreement, physicians who are not a party to the contract are not eligible to request the privilege(s) regardless of education, training and experience. Page 4 of 7

SUTTER MEDICAL CENTER, SACRAMENTO Department of Cardiovascular Disease – Cardiovascular Surgery - Delineation of Privileges NAME:

Request

Other

[ ]

Placement of temporary pacemaker

[ ]

Placement of epicardial permanent pacemaker

[ ]

Placement and management of percutaneous ventricular assist device (VAD)

[ ]

Placement and management of surgical ventricular assist device (VAD)

Appointment Requirements

Proctoring Required

First (1) case Cardiovascular Surgeons must currently hold: 1. Open and/or Closed Heart Procedure privileges; AND, 2. Continuing care in critical care unit privileges.

Reappointment Requirements

Number Performed

Two (2) VAD cases within the previous 24 months.

Training and Documentation Requirements: 1. Completion of an interventional cardiology or surgical fellowship program where Percutaneous or Surgical VAD placement and management was an integral part of the training format. For those cardiologists requesting management of VAD only privileges, must have completed a cardiology residency where percutaneous or surgical VAD management was part of the training format. All training must have occurred within the previous two years. Verification of this training in the form of a letter from the fellowship Director is required. OR 2. Documentation of prior experience in a Joint Commission accredited hospital in Percutaneous or Surgical VAD Placement and Management. This experience must have occurred within the previous two years. Documentation must include a letter from the Chief of the Department or Chief of Staff documenting experience in at least two (2) cases. OR 3. Documentation of successful completion of FDA approved course in Percutaneous or Surgical VAD Placement and Management. OR 4. Successful completion of an approved in-house teaching program at Sutter Medical Center with a minimum of two (2) cases satisfactorily taught.

Note: If any privileges requested are covered by an exclusive contractual agreement, physicians who are not a party to the contract are not eligible to request the privilege(s) regardless of education, training and experience. Page 5 of 7

SUTTER MEDICAL CENTER, SACRAMENTO Department of Cardiovascular Disease – Cardiovascular Surgery - Delineation of Privileges NAME: Request

Other

[ ]

Transcutaneous Cardiac Valve Implantation and/or Repair

[ ]

Adult continuing care privileges in critical care units

Appointment Requirements

Proctoring Required

Training and experience requirements for initial applicants: Proctoring of the physician’s A. Board Certified or admissible for certification in first two (2) Interventional Cardiology or Cardiothoracic Surgery. cases by an – and – approved B. Participation in an FDA approved certification course. proctor is If directly out of training, documentation of adequate required. training in the procedure by letter from Director of training program. – and – C. Documentation of at least three (3) procedures as primary physician or first assistant. – andD. It is understood that procedural devices are approved under FDA and CMS mandated industry restrictions in regards to operator credentialing/inservice. Cath Lab Policy in regards to industry (vendor) credentialing/inservice and certification of operators per FDA/CMS mandates will be followed in the cath lab, hybrid suite and operating rooms.

Reappointment Requirements

Number Performed

Documentation of at least ten (10) transcutaneous cardiac valve implantation or repair procedures during the previous two years as the primary physician or first assistant.

The privilege does not include ventilator management or elective intubation. Those privileges must be requested separately from “continuing care privileges in critical care units.” [ ]

Pediatric surgical and general pediatric care privileges in the Pediatric and Neonatal ICU where there are no other medical of child life issues involved. If there are medical and child life issues involved then the child must be managed in tandem with an appropriate Pediatric Medical Staff member.

Note: If any privileges requested are covered by an exclusive contractual agreement, physicians who are not a party to the contract are not eligible to request the privilege(s) regardless of education, training and experience. Page 6 of 7

SUTTER MEDICAL CENTER, SACRAMENTO Department of Cardiovascular Disease – Cardiovascular Surgery - Delineation of Privileges NAME:

Request [ ]

Other

Appointment Requirements

Comprehensive surgical and medical Pediatric and Neonatal Training and Documentation Requirements: ICU continuing care privileges. Documentation of training and experience (within the previous two years) in the comprehensive management of pediatric patients in the Neonatal or Pediatric Intensive Care Units is required. Documentation must be in the form of a letter from the Director of the training program or from the Chief of Services of another Joint Commission accredited hospital.

Proctoring Required

Reappointment Requirements

Number Performed

First three (3) comprehensive critical care cases by a Surgeon with comprehensive pediatric continuing care privilege or by a Pediatric or Neonatal Critical Care Specialist is required.

The following procedures are germane to all surgeons: I&D, lumbar puncture, minor lacerations, tube thoracostomy, thoracentesis, venous cutdown, arterial cut down, hemodynamic line insertions * - Indicates the assistant is a physician or a physician’s assistant. The cardiac surgeon must have such assistance while the patient is on cardiopulmonary bypass. A cardiac surgeon must be available to assist in any emergency situation. ** - Indicates assistant by another cardiac surgeon is required. 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 Cardiovascular QI/Administrative Committee Or Dept Chief (in lieu of mtg) Credentials Committee Medical Executive Committee Board of Directors

TEMPORARY PRIVILEGE APPROVAL Date: Department Chief: Date: Date: Date:

Date:

Form approved by: Cardiovascular QI/Administrative Committee 11/10/11 Medical Policy Committee 2/2/12 Credentials Committee 1/10/12 Board of Directors 2/13/12 Medical Executive Committee 1/24/12 Note: If any privileges requested are covered by an exclusive contractual agreement, physicians who are not a party to the contract are not eligible to request the privilege(s) regardless of education, training and experience. Page 7 of 7