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29 CHnical Privileges Update Form ORIGINAL _ OlNlVERS:: I 18qrVIH..GINIA David Lim Department of Pediatrics HF.JU.:n-ISYsTEM ~*... I have reviewed tile privileaes previously granted to me and request the following eilanges to include any new therapies, procedures, or additional training neeessary to perfonn new privileges requested. (Please include supporting documentation to verify competeney): New Privileges to be Added (please indicate category level and type ofexperience): Current Privileges not to be Renewed:" _ ,--., ~."...,...,_",",".~,.,~M'... ~'." ""... ". '... ~".. ~...,,'. '... '".,.. "~ ",..',,'... ". ~...,...",...," ""t."..,_ H"... ;'0...,...,,,... "', ~,._ _~,,,_~>'""_._'"''''..,..,_.... ',.. '~" '...-4-,... ~_... ~., "'... ~ 'r, ~,_~.~...,..". _.,"+,,," *Privlleps aot rcaewed are not reported u being yoluntarlly relinquished unlen tblt I. dode wblle YOI are UDder Inve.tlgatloa; or. ia return rar 80t eooduetlug an Inveldptloa or proeeedilll. Itprlyl1eaa are to be reported al voluntarily relluquillaed you will be notioed and reeelve a copy of tbe report to be Bled witb the National Practitioner Databa.k. ~--- "'" DATE,." CLINICIAN SIGNATlJRE ~7""'-'--.-- As the Division HeadIQI Liaison and Department Chair/Medleal DJrec:tor, we have reviewed the above.. named cllnlelan's level of experience, past performance and quality Indicators (if renewlnl privileges) BS related to requested pmu". and agree tbat the above named clinician's qualifications are appropriate. S1~c;e the date ortbe last appointment, we have reviewed applicable Information from the following sources of quailty and u tlon data: ollows: Acceptable review with recommendation of reappointment to the cllnlcalataff with clinical privileges as requested o Concerns noted on review with corrective action plan In place with recommendation of reappol '. to the clinical staff with privileges as requssted. but subject to a review In months. D Should have clinical privileges granted b/-tt'lcted as ~\'f7'f l( DATE ri I,. _~1nJ.JL_... DATE -W~~~~~\..Yi-..ll?~~~"'--1 DIVISION IlE,lU)lQI LIAISON TURE

31 Clinical Privileges Update Form David Lim Department of Pediatrics I have reviewed the privilegf!s previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type of experience): -_... _ Current Privileges not to be Renewed:* _-- - _ _ ~'"-,~ ~--.,-.-,----,-.~,,--.~,...,~.--.. "'",, , r "Privileges not renewed are not repol'ted as being voluntarily relinquished unless this is done while you are under Investigation; -... _ _._ lor. in return for not conducting an In-vestlgation or proceeding. Ifprlvlleges are to be reported as voluntarily relinquished you lwill be notifted and receive a copy of the report to be filed with the National Practitioner Databank. ~D'} ----_..- DATE --- As the Division HeadlQI Liaisim and Department ChairlMedical Director, we have reviewed the abovenamed clinician's level of experience, past performance and quality indicators (ifrenewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and ilization data: Acceptable review wittl recommendation of reappointment to the clinical staff with clinical privileges as requested Concerns noted on review with corrective action plan In place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in months. Should have clinical privileges granted b ~-120 I ~ ~~~~~~~~~~~~~~wj~ao DA~~~'---~ DIVIS ON HEAD/QI LIAISON SIGNATURE -~~TE.. --) u.,. () 1--- ~t<~ DEPARTMENT CHAIR SIGNATURE Revised 3/ t;;;.i 2 IJ04

33 Clinical Privili~ges Update Form David Lim Department of Pediatrics I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (Please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be Renewed:* *Privlleges not renewed are not rep0l1ed as being voluntarily relinquisbed unless this is done while you are under investigation; or, in return for not conducting an in"estigation or proceeding. Ifprivileges are to be reported as voluntarily relinquished you will be notified and receive a copy of::be report to be filed with the National Practitioner Databank. DATE ~~ CLINICIAN SIGNATURE As tbe Division HeadlQI Liaison and Department CbairlMedical Director, we have reviewed the abovenamed clinician's level of expe::-ience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We fi~as follows:. Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested IJ Concerns noted on re"iew with corrective action plan in place with recommendation of reappointment L to the clinical staff witfl privileges s quested, but subject to a review in months. o Should have clinical privileges gr nted (alv p [O--r. \---ja~c~~~~~;;.l- DA;1 /, t) -~-/-4Le------~------~---- DATE I r DEPARTMENT C _d

34 Clinical Privileges Update Form U~VERSITY.0VIRGINIA David Lim Department of Pediatrics HEALTH8YsTEM I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (Please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be Renewed:* *Privileges not renewed are not reported as being voluntarily relinquished unless this is done while )'OU are under investigation; or, in retul'll ror not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you will be notified and receive a copy or the report to be tiled with the National Practitioner Databank. CLINICI. As the Division Head/QI Liaison and Department ChairJl.\t[edical Dir'ector, we have reviewed the abovenamed clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualif1cations are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We fi~foilows: r --, Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in months. Should have clinical privileges granted bu(,jestricted as follows: Ljj JJ I ---Ii ~~'---_ DATE DIVISION HEADI AISON SIGNATURE l~i("o ~<-~ DATE DEPARTMENT CHAIR SIGNATURE

35 Clinical Privileges Update Form David Lim Department of Pediatrics I have reviewed the privileges previously granted to me and request the following changes: Ne7Jf;,g}to be Added (please ;ndicate c.t~ level and type of e,xperience): - ~~ '1k:Jt:;-.!- lt'} I--e. 1)r t: \r- G ( r~.; \r; j /)<1"',...d?JeJ {,., ~ ~ Current Privileges not to be Renewed:* i*privileges not renewed are not reported as being voluntarily relinquished unless this is done while you are under investigation; lor, In return for not conducting an investigation or proceeding. If privileges are to be reported as voluntarily relinquished you 'will be notified and receive a copy of the report to be filed with the National Practitioner Databank. ~~I to -' 1--, - v\." r ~. -D-A-T-E ~ ~ As the Division Head/QI Liaison and Department ChairIMedical Director, we have reviewed the libovenamed clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: 10 Number: Outpatient Clinical Practice Patient/Family Satisfaction Physician's Health & Mental Status Inpatient Attending Performance [::tv',.., Medical Records Reports Sentinel Events/Risk Management Reports, Infection Reports Drug Usage Reports Unscheduled Readmissions Morbidity/Mortality Reports We r~ ajj.ollows: lc?(v ~ Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested. D Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject t months. D Should have clinical privileges granted b ::;/L/C;'<"' DATE DIV EAD/QI LI~~rc::..U.!iIl'r < ~\C~- DATE DEPARTMENT CHAIR SIGNATURE Revl dioil7toi '\

36 Clinical Privileges Update Form David Lim Department of Pediatrics I have reviewed tbe privileges previously granted to me and request the following changes: New Privileges to be Added (please indicate category level and type of experience): Current Privileges not to be Renewed:* *Privileges not renewed are not reported as being voluntarily relinquisbed unless tbis is done wbile you are under investigation; or, In return for not conducting an Investigation or proceeding. Ifprivileges are to be reported as voluntarily relinquisbed you Iwill be notified and receive a copy oftbe report to be filed witb tbe National Practitioner Databank. As the Division Head/QI Liaison and Department ChairlMedical Director, we have reviewed the abovenamed clinician's level of experience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date of the last appointment, we have reviewed applicable information from the following sources of quality and utilization data: 10 Number: Outpatient Clinical Practice Patient/Family Satisfaction Physician's Health & Mental Status Inpatient Attending Performance Medical Records Reports Sentinel Events/Risk Management Reports Infection Reports Drug Usage Reports Unscheduled Readmissions Morbidity/Mortality Reports We find as follows: 14 Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested o Concerns noted on review with corrective action plan In place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in months. Should have clinical privileges granted bu DATE DATE

37 REQUEST FOR CLINICAL PRIVILEGES Department of Pediatrics University of Virginia Health System Name :vq...j~.,l S'uUZ. L,... Division P<;u'...J.-.'c (~c:r.''.)l'-1 Medical School ~o ~ Skp~ Year ofgraduation \ 9 '11... Residency/Fellowship Training: Institution Specialty Year 1. ujvl~ ~ v 2. 1l\f\.'''/~7:J, '& Board/Sub Board Certification: Specialty Year Certified 3. iv Admitting Privileges? fiyes DNa PLEASE MARK AS REQUESTED ONLY THOSE AREAS WHERE YOU ARE REGULARLY ASSIGNED TO PRACTICE; EMERGENCY PRIVILEGES SHOULD BE MARKED WHERE YOU ARE THE DESIGNATED PERSON TO COVER AN AREA IN WHICH YOU DO NOT REGULARLY PRACTICE. AREAS IN WHICH YOU DO NOT REGULARLY PRACTICE SHOULD BE LEFT BLANK. I. MEDICAL General Pediatric Privileges. The minimal requirement is campletian af a Pediatric Residency in an accredited t/ Pediatric residency program and certificatian by the American Baard af Pediatrics ar equivalent. Subs~ecialty Privileges (all reguire General Pediatric Privileges). The minimal requirement is completian af an accredited subspecialty residency (ar v- equivalent as apj!f"aved by Divisian Head and Department Chair). within 2 years for Pediatric Cardialagy --~Pediatric diagnastic cardiac catheterizatian Includes right and left heart catheterizatian, angiacardiography,.and ballaan atrial septastamy, and myocardial biapsy. Requires pediatric cardiolagy certification and perfarmance of > 30 cases/year..~ Interventianal pediatric catheterizatian Includes ballan valvulaplasty, baltan angiaplasty, intracardiac and intravascular stent placement, and therapeutic vessel ar defect occlusian. Requires pediatric cardiolagy certification, diagnostic cardiac catherizatian 1

38 r ~ "" privileges, evidence of formal instruction, performance of at least 10 cases "' -with supervision, and annual performance of > 20 cases/year. Neonatology (required for Neonatal Intensive Care Unit Attending) ECMO (requires ECMO training and approval by ECMO Medical Director) Pediatric Endocrinology Pediatric Hematology/Oncology Bone marrow aspiration, biopsy, and harvest; hematopoietic stem cell reconstitution: Requires performance of 7 procedures under supervision of physician with these privileges. Pediatric Allergy Pediatric Critical Care (required for Pediatric Intensive Care Attending) Pediatric Nephrology Pediatric Rheumatology and Immunology Pediatric Infectious Disease Pediatric Gastroenterology Pediatric endoscopy, liver biopsy Pediatric Pulmonology Pediatric bronchoscopy Pediatric Genetics Developmental/Behavioral Pediatrics Additional Privileges ----.!...:::COnscious sedation ~ Swan-Ganz catheter placement DATE Clinician Signature Print Name: Division Head Approval New Appointment I have reviewed this request for clinical privile es and approve it based on the applicant's training and Prin Re-appointment I have reviewed this request for clinical privileges and approve it based on my personal observation of the applicant's clinical performance and the following Division-based quality data: 2

39 .-- PCAJ I Jb~? 7 -/6~I Print Name Signature Date Department Credentials Committee The Pediatric Credentials Com,mittee has reviewed this application and quality data supplied by University of Virginia Health System and approves the requested privileges. Print Name Signature Date Department Chair/Medical Director I have reviewed this application for clinical privileges and recommend appointment/reappointment to the Clinical Staff with the above describe rivileges. Date clin_pri.ped 3

Clinical Privileges Update Form

Clinical Privileges Update Form Mark Mendelsohn epartment of Pediatrics I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures,