general surgery privilege list.new format.12 medical center, sacramento department of surgery –...

SUTTER MEDICAL CENTER, SACRAMENTO Department of Surgery – General Surgery Section - Delineation of Privileges

NAME: INITIAL: [ ] RENEWED: [ ] DATE: ADDITIONAL: [ ] Privileges are granted for Sutter General Hospital, Sutter Memorial Hospital, Sutter Center for Psychiatry, Sutter Oaks Midtown or 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.

-A- INDICATES OUTPATIENT of 22

Request Privilege Appointment Requirements Proctoring Required Reappointment

Requirements Number

Performed

[ ] Admitting privileges None None None

[ ] History & Physical privileges - A None None None

General requirements for all applicants

Documentation of experience in the previous two years as a primary surgeon in at least six cases as well as 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 Services.

First six (6) cases must be proctored regardless

of the type of procedure

Six (6) cases as a primary surgeon and procedure specific

requirements

Request Abdomen Appointment Requirements Proctoring Required Reappointment Requirements

Number Performed

[ ] Abdominal perineal resection

[ ] Appendectomy

[ ] Hernia repair: • Diaphragmatic • Incisional- A • Inguinal- A • Umbilical- A • Incarcerated hernia

[ ] Koch pouch

[ ] Operation of biliary tract

[ ] Gallbladder

[ ] Intestinal tract

[ ] Pancreas


NAME:


Request Abdomen con’t. Appointment Requirements Proctoring Required Reappointment Requirements

Number Performed

[ ] Peritoneum, omentum

[ ] Spleen

[ ] Stomach

[ ] Roux-en Y gastric bypass (open)

[ ] Sympathectomy

[ ] All proximal stomach

[ ] Low colon anastomosis

[ ] Total colectomy

[ ] Liver resection: • segmental resection • lobectomy • tri-segmentectomy • insertion – hepatic catheter/hepatic artery pump

[ ] Adrenalectomy

[ ] Abdominal Hysterectomy

[ ] Salpingo-oophorectomy

[ ] Cystectomy

[ ] Anterior exposure of spine

[ ] Retroperitoneal tumors

[ ] Pelvic exenteration

[ ] Nephrectomy


NAME:


Request Abdomen con’t. Appointment Requirements Proctoring Required Reappointment

Requirements Number

Performed [ ] Intra-peritoneal Chemotherapy Perfusion (includes

writing orders for non-IV chemotherapy) Training and Documentation Requirements: 1. Graduation from a residency or fellowship program where

intra-peritoneal chemotherapy perfusion was part of the active training format. This training must have occurred within the previous two years. Verification in the form of a letter from the Director of the training program is required. If training occurred more than two years previous then request for privilege must also include documentation of prior experience in a Joint Commission accredited hospital in intra-peritoneal chemotherapy within the previous two years. Documentation must be by a letter from the Chief of Surgery or Chief of Staff. OR

2. Documentation of successful completion of a section approved course (which includes safety procedures). OR

3. Successful completion of an in-house learning and teaching program (which includes safety procedures.

First one (1) case None


NAME:


Request Laparoscopy Procedures. Appointment Requirements Proctoring Required Reappointment

Requirements Number

Performed [ ] Diagnostic Laparoscopy (e.g., lysis of adhesions,

biopsy) - A Pre-Requisite: The surgeon must have full privileges in the General Surgery Section including privileges for the respective open procedure. Training and Experience Requirements: 1. Documentation of residency training in the procedures

requested. OR 2. Attendance and certification of a special course

involving "hands on" training in laparoscopic cholecystectomy and/or advanced laparoscopic surgery as appropriate for the privileges requested. OR

3. Successful completion of an in-house learning and

teaching program at Sutter Medical Center, Sacramento Hospital.

Physicians meeting the advanced laparoscopic surgery privileging criteria shall be considered eligible for all laparoscopic abdominal procedures without the need for further credentialing.

First three (3) diagnostic and/or basic laparoscopy cases and first three (3) advanced laparoscopy cases (dependent upon category or privileges requested)

None

[ ] Basic Laparoscopy (e.g., gallbladder, biliary tract, appendectomy) - A

[ ] Advanced Laparoscopy (e.g., suturing, anastamoses, solid organ resection, laparoscopic approach to spine surgery, lymph node dissection, hernia repair) - A


NAME:


Request Special Laparoscopy Privilegess Appointment Requirements Proctoring Required Reappointment

Requirements Number

Performed [ ] Laparoscopic Roux-enY Gastric Bypass Prerequisites for either procedure:

1. Documentation of experience in at least 50 cases in

advanced laparoscopic foregut surgery, including experience in esophageal and gastric surgery, suturing, endostapling, laparoscopic intestinal surgery (to construct the Roux-en-Y limb), positioning, etc. This experience can be either during training or from a Joint Commission accredited facility where these procedures have been performed subsequent to residency training.AND

2. Course Documentation:

a. Roux-en-Y - Documentation of training in the

principles of bariatric surgery, which would include training in residency and/or formal postgraduate training at a surgical bariatric center.

b. Laparoscopic Banded Gastroplasty – Documentation of successful completion of a didactic and hand-on course through the manufacturer of the band (as required by the FDA).

AND 3. Affiliation with bariatric internists and a

multidisciplinary bariatric team (behavorial therapists, physical therapists, psychologists, nutritionists).

First three (3) cases is required

None

[ ] Laparoscopic banded gastroscopy First three (3) cases is required


NAME:


Request Special Laparoscopy Privilegess con’t. Appointment Requirements Proctoring Required Reappointment

RequirementsNumber

Performed [ ] Robotic Assisted Abdominal Laparoscopy (in

accordance with approved FDA indications) *Note - This criteria is a shared with other surgical sections and the Department of Ob/Gyn

Pre-Requisite: 1. Must hold unrestricted privilege in the open procedure

2. Successful completion of an approved ACGME

residency program in General Surgery.

3. Initial applicants must also hold unrestricted privileges in advanced abdominal laparoscopy.

Training and Experience Requirements: 1. Must submit a certificate of successful completion of

approved “hands-on” training course in specialty specific robotic-assisted procedures relative to the privileges being requested (i.e., Intuitive Surgical Training, Certified Course) AND

2. Must have observed at least one (1) live case prior to being granted supervised privileges. AND

3. Must undergo at least five (5) hours of dry-time robotic lab experience. OR

4. Documentation of training and experience in residency or fellowship in robotic assisted procedures as the primary surgeon in a minimum of twelve (12) cases during the previous two years. OR

First three (3) robotic assisted laparoscopy cases and until such time as the proctor attests that the surgeon no longer needs to be observed. If competence is still under question after ten (10) proctored cases the Surgery QI/Administrative Committee with input from the Section must evaluate whether the physician under proctoring requires additional training.

To qualify for re-credentialing the applicant must have performed at least twelve (12) robotic assisted cases during the previous two years at any facility. If volume is not met the applicant must undergo another five (5) hours of dry-time robotic lab experience and have one (1) case proctored.


NAME:


Request Special Laparoscopy Privilegess con’t. Appointment Requirements Proctoring Required Reappointment

RequirementsNumber

Performed [ ] Robotic Assisted Abdominal Laparoscopy con’t.

(Once a surgeon has successfully performed at least 20 solo cases, he/she is eligible to proctor or train others.)

5. Currently credentialed and practicing unsupervised laparoscopic/ robotic-assisted privileges in his/her specialty at a Joint Commission accredited facilityand provide the following: • a letter from the reciprocal medical staff to verify

current privileges in the specific procedure(s) requested, AND

• documentation of at least twelve (12) cases as a primary surgeon in robotic assisted procedures during the previous two years.

Request Lymph Channels and Nodes Appointment Requirements Proctoring Required Reappointment Requirements

Number Performed

[ ] Biopsy - A

[ ] Excision - A

[ ] Incision and drainage - A

[ ] Node dissection- A

[ ] Minimally selective lymphadenectomy & sentinel node biopsy- A

Request Skin and Subcutaneous Tissue Appointment Requirements Proctoring Required Reappointment Requirements

Number Performed

[ ] Biopsy -A

[ ] Burns-A

[ ] Excision, lesion (cysts, polyps, lipomata) -A

[ ] Graft – pedicle-A

[ ] Tubular grafts-A

[ ] Incision & drainage (abscesses, paronychia, etc.) -A

[ ] Deep abscess (thyroglossal cyst, etc.)

[ ] Wounds-A

[ ] Split/full thickness grafts-A


NAME:


Request Head and Neck Appointment Requirements Proctoring Required Reappointment

RequirementsNumber

Performed [ ] Thyroidectomy

[ ] Parathyroidectomy

[ ] Oral cancer, excision – small-A

[ ] Oral cancer, excision – large

[ ] Radical neck

[ ] Parotidectomy

[ ] Tracheostomy

Request Vascular Privileges Appointment Requirements Proctoring Required Reappointment Requirements

Number Performed

CATEGORY I Requires no special documentation of experience and training for fully trained general surgeons. Physicians of other specialties would need to document training and experience.

None None

[ ] Embolectomy

[ ] Vein stripping/ligation-A

[ ] CATEGORY II - (includes not only the ability to perform any of the following procedures but handle complications that may arise from vascular interventions such as amputation, debridement, skin graft, tissue transfer, hernia repair, tracheostomy and placement of thoracostomy tube). • Intra-abdominal vascular procedures • Extremity vascular procedures • Extra-cranial cerebrovascular procedures –

(open carotid endarterectomy) • Non-cardiac thoracic vascular procedures

(including thoracic outlet syndrome) • Venous grafting or reconstruction • Vascular access surgery-A • Intraoperative angiography-A

Requires documentation of experience and training in these procedures during residency or fellowship or documentation from another Joint Commission accredited hospital where these procedures have been actively performed in the previous two years. In addition, vascular access surgery privileges require documentation that physician is certified or eligible for certification by the American Board of Surgery and has a minimum of one year’s training or experience in vascular surgery.

First six (6) cases None


NAME:


Request Special Vascular Privileges Appointment Requirements Proctoring Required Reappointment

RequirementsNumber

Performed [ ] Percutaneous Peripheral & Visceral Arteriography-A

• Pulmonary Angiography • Visceral and Bronchial Arterial Diagnostic

Angiography • Aortography • Renal Arteriography • Pelvic and Extremity Arteriography Note – privilege shared with another department

Training and Experience Requirements: 1. Evidence of training and competency by certification, or

admissible for certification by the American Board of Radiology, Cardiovascular Disease by the American Board of Internal Medicine or Vascular Surgery by the American Board of Surgery AND

2. Documentation from the training program that the training program included concentrated training and experience in angiography including at least 50 non-coronary arteriographic procedures performed proficiently and successfully. OR

3. In the absence of residency training in this procedure,

documentation of successful completion of 100 non-coronary angiographic procedures from a Joint Commission accredited hospital within the past three years is required. This documentation must also include a letter of reference from a physician who is familiar with the applicant’s experience in arteriography. OR

4. Successful completion of an approved In-house Learning

and Teaching Program in non-cerebral diagnostic peripheral angiography consisting of at least 50 procedures.

First five (5) non-cerebral peripheral angiography procedures.

20 non-coronary, non-cerebral peripheral and visceral arteriography patients during the previous two years.


NAME:


Request Special Vascular Privileges Appointment Requirements Proctoring Required Reappointment Requirements

Number Performed

[ ] Percutaneous Peripheral transluminal angioplasty and or stenting -A

Definitions: Peripheral angioplasty (PTA) is the percutaneous approach to transluminal intervention by dilatation or atherectomy and may include stent placement . A diagnostic peripheral angiogram is any non-coronary or non-cerebral (intra/extra cranial) angiogram and is one that provides complete imaging of the entire vascular distribution and the runoff of the vessel(s) in question.

Note – privilege shared with another department

Pre-requisite Must hold privileges is peripheral angiography Training and Documentation Requirements: 1. Disciplines of Vascular Surgery, Radiology and Cardiology

are eligible for credentialing.

2. Basic understanding of cardiovascular disease should be documented by eligibility or certification by any one of the following:

American Board of Radiology American Board of Internal Medicine with special certification in Cardiovascular Medicine fellowship American Board of Surgery with completion of a general vascular surgery one (1) year fellowship

Five first (5) interventional cases

A physician with privileges for peripheral vascular interventions shall perform at least 50 therapeutic interventions counted per patient) in a two-year period.

[ ] Percutaneous Peripheral transluminal angioplasty and or stenting con’t.

4. Physicians seeking to qualify by having completed a training program shall have documentation of having performed 100 peripheral angiograms, 50 peripheral interventional procedures (counted per lesion) within the past three years and shall have a letter from the Chief of his/her training program stating that the applicant is competent to perform peripheral vascular interventions as a primary operator. OR Documentation of having performed 100 peripheral angiograms, 50 peripheral angioplasties within the past three years at another Joint Commission accredited hospital and documentation of attendance at a dedicated symposium on PTA, which has live case demonstrations, shall be documented. OR Documentation of successful completion of an approved in-house learning program under the preceptorship of a senior qualified physician and the performance of at least 100 peripheral angiograms and 50 peripheral angioplasty procedures.


NAME:


Request Special Vascular Privileges con’t. Appointment Requirements Proctoring Required Reappointment

RequirementsNumber

Performed [ ] Endovascular Repair of AAA

Note – privilege shared with another department

Pre-requisite: 1. Privileges to perform traditional intraoperative repair of

abdominal aortic aneurysm. 2. Category II Vascular privileges 3. Intensive Care admitting privileges. 4. Fulfills the criteria for peripheral transluminal

angioplasty privileges unless assisted by another qualified surgeon, cardiologist or interventional radiologist who has stent placement experience.

Training and Documentation Requirements: 1. Completion of a vascular surgery fellowship program

where Endovascular AAA repair was an integral part of the training format. This 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 endovascular AAA repair. 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 ten (10) cases. OR

3. Documentation of successful completion of FDA approved course in Endovascular AAA Repair. The training must include a didactic course, hands-on deployment of the Endovascular devices using C-arm in a model, and live case demonstrations. OR

4. Successful completion of an approved in-house teaching program at Sutter Medical Center.

First two (2) cases None


NAME:


Request Breasts Appointment Requirements Proctoring

RequiredReappointment Requirements

Number Performed

[ ] Masectomy

[ ] Mastectomy – with lymphadenectomy

[ ] Breast biopsy-A

[ ] Intracavity Placement of Mammosite Device Training and Documentation Requirements: 1. Graduation from a residency or fellowship program where

intercavity placement of mammocite device was part of the active training format. This training must have occurred within the previous two years. Verification in the form of a letter from the Director of the training program is required. OR

2. Documentation of prior experience in a Joint Commission accredited hospital in inter-cavity placement of mammocite device within the previous two years. This experience must have occurred within the previous two years. Documentation must be by a letter from the Chief of Surgery or Chief of Staff. OR

3. Documentation of successful completion of a section approved “hand-on” training course in use of a device. Course must be been completed within the previous two years.

None None

Request Rectal Surgery Appointment Requirements Proctoring Required

Reappointment Requirements

Number Performed

[ ] Anal fissure/fistula/ hemorrhoidectomy-A

[ ] Pilonidal cyst-A

[ ] Trans-anal excision-A

[ ] Sphincteroplasty-A

[ ] Rectovaginal fistula repair

[ ] Prolapse procedures

Request Extremities Appointment Requirements Proctoring Required


Number Performed

[ ] Amputation – simple (Fingers, toes) -A

[ ] Amputation – major

[ ] Hemipelvectomy


NAME:


Request Extremities con’t. Appointment Requirements Proctoring Required


Number Performed

[ ] Radical soft part resection for sarcoma

[ ] Forequarter amputation

[ ] Isolation perfusion (hyperthermic/chemotherapy)

[ ] Suture of tendons and nerves-A

Request Thoracic Privileges Appointment Requirements Proctoring Required


Number Performed

General requirements for all applicants of thoracic surgery privileges

Requires documentation of experience and training in these procedures during residency or fellowship or documentation from another Joint Commission accredited hospital where these procedures have been actively performed within previous two years.

First six (6) cases

None

[ ] Pleurodesis

[ ] Pulmonary wedge resection

[ ] Lobectomy

[ ] Pneumonectomy

[ ] Thoracic vagotomy or sympathectomy

[ ] Pericardial window or resection

[ ] Open exposure for thoracic spine

[ ] Chest wall or sternal resection

[ ] Trans-thoracic esophageal resection, myotomy,fundoplication, or diverticulectomy

[ ] Repair of esophageal perforation

[ ] Trans-thoracic diaphragm resection or reconstruction

[ ] Esophageal replacement

[ ] Operation for thoracic outlet syndrome

[ ] Mediastinoscopy or mediastinotomy

[ ] Thoracoplasty, repair of chest wall deformity (i.e. pectus excavatum)

[ ] Tracheal resection or reconstruction

[ ] Blunt esophagectomy


NAME:


Request Special Thoracic Privileges Appointment Requirements Proctoring Required


Number Performed

[ ] Video Assisted Thoracic Procedures Training and Documentation Requirements: 1. The surgeon must have privileges for the open procedures

related to the video-assisted procedures for which the surgeon seeks privileges.

2. Documentation of successful completion of section approved course which included hands-on training in video-assisted thoracic surgery (and laser for video-assisted thoracic surgery, if applicable) is required. OR

3. Documentation of experience and training during residency or fellowship as evidenced by a letter from the director of the training program.

First three (3) cases by a Senior staff member of Sutter Medical Center Sacramento Hospitals

None

[ ] Robotic Assisted Thoracic Procedures (in accordance with approved FDA indications) Note – this criteria is shared with other surgical sections and Department of Ob/Gyn

Pre-Requisite: 1. Must hold unrestricted privileges in the open procedure.

2. Successful completion of an approved fellowship program in

cardiothoracic surgery OR successful completion of a surgical oncology fellowship where thoracic surgery was part of the training program.

3. Initial applicants must also hold unrestricted privileges in thoracic surgery IN ADDITION TO video assisted thoracic privileges.

Training and Experience Requirements: 1. Must submit a certificate of successful completion of

approved “hands-on” training course in specialty specific robotic-assisted procedures in the privileges relative to the privileges being requested; i.e., Intuitive Surgical Training, Certified Course. AND

2. Must have observed at least one (1) live case prior to being granted supervised privileges. AND

3. Must undergo at least five (5) hours of dry-time robotic lab experience. OR

The surgeon must be proctored for a minimum of their first three (3) robotic assisted procedures and until such time as the proctor attests that the surgeon no longer requires observation. If there are questions of competence after the physician has completed 10 proctored cases, the Department Administrative Committee

To qualify for re-credentialing the applicant must have performed at least twelve (12) robotic assisted cases during the previous two years at any facility. If volume is not met the applicant must undergo another five (5) hours of dry-time robotic lab experience and have one (1) case proctored.


NAME:


Request Special Thoracic Privileges con’t. Appointment Requirements Proctoring


Number Performed

[ ] Robotic Assisted Thoracic Procedures con’t. (Note: Once a surgeon has successfully performed at least 20 solo cases, he/she is eligible to proctor or train others.)

4. Documentation of training and experience in residency or fellowship in robotic assisted procedures as the primary surgeon in a minimum of twelve (12) cases during the previous two years. OR

5. Currently credentialed and practicing unsupervised robotic-assisted thoracic privileges in his/her specialty at a Joint Commission accredited facility and provide the following: • a letter from the reciprocal medical staff to verify current

privileges in the specific procedure(s) requested, AND

• documentation of at least twelve (12) cases as the primary surgeon in robotic assisted procedures during the previous two years.

must evaluate whether the physician under proctoring requires additional training.

Request Endoscopy Procedures Appointment Requirements Proctoring Required


Number Performed

[ ] Upper intestinal endoscopy-A (Privileges in this category include the use of all flexible upper gastrointestinal endoscopes and includes mucosal forceps biopsy and various therapeutic procedures but does not include ERCP) Note – privilege shared with another department

Prerequsite Board admissible or certified in General Surgery Training and Documentation Requirements: 1. The applicant must present a letter from the Director of his/her training program or endoscopy instructor attesting to his/her experience and proficiency. The applicant shall also provide documentation of his/her experience including a minimum of 50 supervised examinations. OR 2. Physicians not Board admissible or certified nor any formal training in gastrointestinal endoscopy during residency or fellowship may seek privileges by documenting performance of at least the minimum number of supervised procedures while satisfactorily completing two years of practice in a Joint Commission Hospital.

First two (2) cases

20 procedures


NAME:


Request Endoscopy Procedures con’t. Appointment Requirements Proctoring Required


Number Performed

[ ] Colonoscopy-A (Privileges in this category include the use of all sigmoidoscopes and colonoscopes and includes electrocoagulation, thermocoagulation and polypectomy) Note – privilege shared with another department

Prerequsite Board admissible or certified in General Surgery or Colon and Rectal Surgery Training and Documentation Requirements: 1. The applicant must present a letter from the Director of his/her training program or endoscopy instructor attesting to his/her experience and proficiency. The applicant shall also provide documentation of his/her experience including a minimum of 50 supervised colonoscopies and 15 supervised polypectomies. OR 2. Physicians not Board admissible or certified nor any formal training in gastrointestinal endoscopy during residency or fellowship may seek privileges by documenting performance of at least the minimum number of supervised procedures while satisfactorily completing two years of practice in a Joint Commission Hospital.

First two (2) cases (one must be a polypectomy)

20 procedures

[ ] Rigid Bronchoscopy-A

[ ] Flexible Bronchoscopy-A

Request Endoscopy Procedures con’t. Appointment Requirements Proctoring Required


Number Performed

[ ] Proctoscopy-A

[ ] Sigmoidoscopy-A (Includes use of biopsy forceps but does not include therapeutic electrocoagulation or polypectomy) Note – privilege shared with another department

Experience and Training 1. Applicant must present evidence of his/her experience, including completion of a minimum of 20 flexible sigmoidoscopies (unless physician holds colonoscopy privileges)

First three (3) cases

None

[ ] Culdoscopy-A


NAME:


Request Types of Lasers Appointment Requirements Proctoring


Number Performed

[ ] CO2 Laser-A Surgeons requesting laser privileges must show that they have the appropriate training and/or experience in the safe use of laser equipment by meeting one of the following criteria:

l. Graduation from an approved training program in Surgery where laser application was part of the active training format. Verification shall be in the form of a letter from the Director of the training program. OR

2. Documentation of successful completion of a section approved post-graduate course with hands-on experience, designed to familiarize practicing physicians with laser technologies, safety and application.

None None

Request Lasers Procedures Appointment Requirements Proctoring Required


Number Performed

[ ] Fulguration of condyloma-A

Request Pediatric Surgery Appointment Requirements Proctoring Required


Number Performed

[ ] Category I (Age 2 and under) Open to all qualified general surgeons with full privileges in General Surgery.

First three (3) cases by a Senior surgeon who holds Category I or Category II Pediatric Surgical privileges.

None

[ ] Minor pediatric surgical procedures (i.e., skin and subcutaneous pathology) -A

[ ] Pediatric hernia repair-A

[ ] Category II (Age 2 and under) Documentation of a pediatric surgical fellowship or its equivalent. First six (6) cases by a Senior surgeon member who holds Category II Pediatric Surgical privileges.

None

[ ] Pediatric appendectomy

[ ] Correction of all pediatric congenital malformations


NAME:


Request Other Appointment Requirements Proctoring Required


Number Performed

[ ] Renal transplantation Pre-Requisite: Renal transplant is a team-oriented activity dependent upon hospital-wide resources for successful implementation. Training and experience are essential in the development of competent transplant surgeons. Surgeons requesting renal transplant privileges at Sutter Medical Center, Sacramento Hospitals must show that they are certified by either the American Board of Surgery or American Board of Urology and have appropriate training and experience by meeting one or more of the following criteria: Training and Experience Requirements: 1. Successful completion of a two year fellowship within the past

five years in a renal transplant program which is approved by the American Society of Transplant Surgery including documentation that applicant participated as the first assistant or primary surgeon in at least 15 cases per year – OR

2. Successful completion of a one year fellowship within the past five years in a renal transplant program which is approved by the American Society of Transplant Surgery and documentation as a first assistant in 15 renal transplant cases at Sutter Medical Center, Sacramento Hospitals before requesting primary renal transplant privileges OR

3. Documentation of training and experience and current

unrestricted renal transplant privileges at another facility which operates a renal transplant program approved by the American Society of Transplant Surgery. Documentation must also be provided that applicant has been the primary or first assistant on at least 15 renal transplant cases per year OR

4. Successful completion of an approved in-house teaching

program at Sutter Medical Center, Sacramento Hospitals. This training must provide the applicant with experience in at least 20 renal transplants; 10 as the first assistant and 10 as the primary surgeon.

First three (3) renal allograft cases by a Senior Sutter Medical Center, Sacramento surgeon

None


NAME:


Request Other con’t Appointment Requirements Proctoring


Number Performed

[ ] Pancreas transplantation Pre-Requisite: Surgeons requesting pancreas transplant privileges at Sutter Medical Center, Sacramento Hospitals must show that they have appropriate and necessary training and experience by meeting the following criteria in order to be eligible for such privileges: Training and Experience Requirements: 1. Eligibility for unrestricted privileges in renal transplantation at

Sutter Medical Center, Sacramento Hospitals - AND ONE OF THE FOLLOWING:

2. Successful completion of a fellowship in transplantation in which pancreas transplants were performed OR

3. Active participation in a UNOS/OPTN transplant program with experience of four pancreas transplants (as primary surgeon in 2 of 4 cases) and four pancreas retrievals (as primary surgeon in 2 of 4 cases) over a consecutive two year period within the past five years. Active participation in a UNOS/OPTN transplant program with experience of four pancreas transplants (as primary surgeon in 2 of 4 cases) and four pancreas retrievals (as primary surgeon in 2 of 4 cases) over a consecutive two year period within the past five years. OR

4. Successful completion of an approved in-house teaching program at Sutter Medical Center, Sacramento Hospitals. This training must provide the applicant with experience in at least 4 pancreas retrievals (2 as assistant and 2 as the primary surgeon) and four pancreas transplants (2 as the assistant and 2 as the primary surgeon).

First two (2) cases by a Senior Sutter Medical Center, Sacramento surgeon

None


NAME:


Request Other con’t Appointment Requirements Proctoring


Number Performed

[ ] High-resolution image guided thermal therapy Pre-Requisite:

It is understood that physicians who have been granted image guided thermal therapy privileges may only utilize this therapy for the open surgical privileges they have been granted. In order to be granted privileges for high-resolution, image guided thermal therapy, the following criteria must be met: Training and Documentation Requirements: 1. Graduation from a residency or fellowship program where the

Image Guided Thermal Therapy (cryo, heat, radiofrequency) was part of the active training format. Documentation in the form of a letter from the Director of the Training program is required. OR

2. Documentation of prior experience at another Joint Commission accredited Hospital. This experience must have occurred within the previous two years. Documentation must include a letter from the Chief of Surgery or Chief of Staff outlining how many procedures the applicant performed. OR

3. Documentation of successful completion of a section approved

hands-on training course or participation in an animal lab training course must be submitted.

First three (3) cases by a Senior Sutter surgeon

None


NAME:


Request Other con’t Appointment Requirements Proctoring Required


Number Performed

[ ] Intra-operative radiation therapy Training and Experience Requirements: 1. The surgeon must have full surgical privileges in the

Department of Surgery. 2. Qualified surgeons who wish to request intra-operative

radiation therapy privileges are required to either observe one case or act as an assistant surgeon in one case prior to beinggranted this privilege.

It is to be emphasized that it is not the complexity of the procedure that initially restricts the physician involvement but the desire to develop a smooth working medical and non-medical team to keep complications and problems at a minimum.

3. Other surgeons may assist on these cases per their usual

practice.

First One (1) intra-operative radiation therapy case by a Senior Sutter Medical Center, Sacramento Hospitals surgeon

None

Request Adult Appointment Requirements Proctoring Required


Number Performed

[ ] Continuing care privileges in critical care Continuing care privileges in the critical care units for physicians trained in general surgery includes the ability to see and care for the patient in the critical care setting as well as the following: • Intubation • Ventilator management • Arterial line placement • CVP line placement • Swan Ganz placement

[ ] Post Acute Care Privileges – Continuing Care of the Patient in Sutter Transitional Care Unit or Sutter Oaks Midtown


NAME:


Request Pediatric Appointment Requirements Proctoring


Number Performed

[ ] Surgical and general pediatric continuing care privileges in the pediatric intensive care unit (PICU) where there are no medical or child life issues involved. *If there are medical or child life issues the patient should be managed in tandem with a member of the pediatric staff.

[ ] Comprehensive pediatric surgical and medical continuing care privileges (including pediatric and neonatal ICU management)

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.

First three (3) cases by a surgeon who holds comprehensive pediatric continuing care privileges or by a Pediatric or Neonatal Critical Care Specialist.

None

Please Note: The surgeon in charge is responsible for judging whether or not an assistant is required for any procedure listed. 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:

FORM APPROVALS: General Surgery Section Date: 12/9/2010 Surgery Administrative Committee: Date: 2/3/2011 Credentials Committee: Date: 2/8/2011 Medical Executive Committee: Date: 2/22/2011 Medical Policy Committee: Date: 3/3/2011 Board of Directors Date: 3/14/2011

general surgery privilege list.new format.12 medical center, sacramento department of surgery –...

Documents