DELINEATION OF PRIVILEGES - FAMILY MEDICINE

Transcription

1 KALEIDA HEALTH Name DELINEATION OF PRIVILEGES - FAMILY MEDICINE LEVEL I (CORE) PRIVILEGES Level 1 (core) privileges are those able to be performed after successful completion of an accredited residency program in that core specialty. The removal or restriction of these privileges would require further investigation as to the individual s overall ability to practice, but there is no need to delineate these privileges individually. LEVEL I (CORE) PRIVILEGES Applicants for Level I (core) privileges have successfully completed residency training in family practice and have broad experience in the management of acute and chronic illness in adults and children (individuals below the age of 19 years). They are able to diagnose and treat conditions which have typical presentations, recognized treatments, and expected outcomes. Consultation is expected when specialized skills are required or where complications arise which are beyond the usual scope of the physician s practice. History and Physical for diagnosis and treatment plan including Laceration repair breast, rectal and pelvic exam; diagnosis, treatment plan, consultations, hospital visits, patient counseling, pain management, and like skills included in any Family Practice training program curriculum. General Admitting Privileges - Physicians granted admitting privileges will be expected to have a broad range of knowledge, experience, training and competence to diagnose and treat most conditions that have common presentations, recognized treatments and expected outcomes. Department members with admitting privileges will be expected to request consultations in cases where specialized skills are required and in circumstances in which there is significant uncertainty in the optimum management of the patient. Examples where consultation would be expected include, but are not limited to, life-threatening complications, unanticipated deterioration in the patient's condition, or absence of expected response to standard therapy. Such consultations will be obtained promptly. Arthrocentesis - adult Nasogastric tube insertion Foley catheterization Cardiac monitoring Biopsy,excision and incision of skin growths, nails, and superficial soft tissues Simple non-displaced fractures - adult Incision and drainage Endometrial Biopsy IUD insertion and removal Assist at surgery under direct supervision of the surgeon. (Cannot act as attending on record) Newborn Circumcision

2 Family Medicine 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 Applicants for Level II privileges must meet criteria for Level I privileges and meet additional training or experience requirements listed, within last 5 yrs. Low Risk Vaginal Delivery, Episiotomy / Repair of 1,2,3 Lacerations (40 deliveries in last 3 yrs for initial privilege, 10 deliveries in last 2 yrs. for reappointment) Dilatation and Curettage (10 procedures) Elective Termination of Pregnancy to 12 weeks (10) Outlet Assisted (Forceps/Vacuum) Delivery (15) Colposcopy and Biopsy (10) Lumbar Puncture (adult 5/child 5) Newborn Lumbar Puncture CVP Insertion (5) Vasectomy (5) Thoracentesis- adult (5) Flexible Sigmoidoscopy with Biopsy adult (25) (ice: If a physician is credentialed to do Non-operative reduction of common closed fractures or dislocations-adult/child (10) Arthrocentesis child (10) Simple non-displaced fractures (10) (child) Screening Colonoscopy with biopsy (50) (ice: If a physician is credentialed to do Screening Ultrasonography (prenatal/aortic/carotid/thyroid/abdominal) (25 initial, 5 recredentialing) * With Following Requirements** (Provide Details)

3 Family Medicine Name: Page 3 Moderate/Conscious Sedation * With Following Requirements** (Provide Details) 1. Providers seeking privileges in moderate/conscious sedation must complete either the ASA sedation course cost $ ( or Medsimulation course cost $75.00 ( receiving a score of 85% or above. * e: Providers completing the on-line training course provided by Medsimulation from other institutions receiving a score of 85% or higher will be accepted as an equivalent measure of acceptable knowledge for sedation privileges. 2. Once the provider has successfully passed the course, he/she must send the certificate of course completion to the medical staff office via (medicalstaffoffice@kaleidahealth.org) or fax ( or ). 3. In addition to demonstrating medical knowledge through completion of this course, providers must also maintain airway management skills through current completed training and certification in ACLS, ATLS or PALS. (ACLS is offered through Kaleida Health Corporate Clinical Education. Please call for information. You can also take either course online if you prefer. The following are just a few suggestions. You may be able to obtain this training somewhere else: $179.00, $ or $ ) 4. After a four year period of privileging the provider must repeat either the ASA sedation course or Medsimulation course and receive a score of 85% or greater or a comparable course reviewed and accepted by the Chief of Anesthesiology. They must also maintain airway management skills through completed and current training and certification in ACLS, ATLS or PALS.

4 Family Medicine Name: Page 4 ADDITIONAL PRIVILEGES Privileges for diagnostic or therapeutic procedures that are outside of the usual scope of residency training require documentation of prior/training experience and of continued current competency prior to the granting/renewal of such privileges. This list is not all-inclusive and may be expanded or modified, as appropriate, based on education and demonstrated ability. EGD (30) Colonoscopy with Polypectomy (50) (ice: If a physician is credentialed to do Other (Please Specify): * Specialty/Chief of Service Initials IM/ IM/ KEY *NOT GRANTED DUE TO: Provide Details Below **WITH FOLLOWING REQUIREMENTS Provide Details Below 1) Lack of Documentation 1) With Consultation 2) Lack of Required Training/Experience 2) With Assistance 3) Lack of Current Competence (Databank Reportable) 3) With Proctoring 4) Other (Please Define) (i.e., Exclusive Contract) 4) 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 (42 U.S.C et seq.) / Signature of Applicant I recommend approval of the procedures requested by the applicant: a) as requested b) as amended / Signature of Chief of Service APPLICANT: RETAIN A COPY OF THIS SIGNED DELINEATION FOR YOUR RECORDS

5 Family Medicine Name: Page 5 As part of the application process in the Family Practice Clinical Service at Kaleida Health, note that the delineation of privileges includes the following procedures that are linked to a threshold number. If you are requesting any of these procedures listed on the delineation of privileges, please sign this attestation stating that you have maintained competence by properly performing the required number of each procedure requested over the past 2 years. New Residency graduates need to meet higher thresholds for some procedures for initial credentialing. Low Risk Vaginal Delivery, Episiotomy/Repair of 1,2,3 Lacerations (recent residency graduate = 40, established practitioner = 10) Dilation and Curettage (10) Elective Termination of Pregnancy to 12 weeks (10) Outlet Assisted (Forceps/Vacuum) Delivery (15) Colposcopy and Biopsy (10) CVP Insertion (5) Flexible Sigmoidoscopy with Biopsy (25) Non-operative reduction of common closed fractures (10) Thoracentesis (5) Vasectomy (5) Arthrocentesis (10) (children) Simple non-displaced fractures (10) (children) If, after reviewing your clinical activity, you meet these criteria, please check the box below, sign, and return with your privilege requests. I can support my request with clinical activity reports which I have attached. Signature