DELINEATION OF CLINICAL PRIVILEGES SURGERY GENERAL

Transcription

1 Basic Education: MD or DO (Applicants must meet the following criteria) Be certified by or be currently qualified to take the board certification examination of a board recognized by the American Board of Medical Specialties; the Bureau of Osteopathic Specialists; the American Board of Podiatric Surgery; or a board or association with equivalent requirements approved by the Texas Medical Board in the specialty for which the practitioner will seek privileges and practice at the Hospital; or have completed an ACGME/AOA accredited residency training program in General Surgery and/or a fellowship approved by the ACGME that provided complete training in the specialty for which the practitioner will seek privileges and will practice at the Hospital. CORE PRIVILEGES Please place initials in the box next to the privilege you are requesting. Admit, examine, diagnose, consult, perform H&Ps, and provide pre-, intra-, and postoperative surgical care and procedures for patients of all ages (except where excluded) in all areas that constitute the principal components of general surgery. Abdominal wall surgery to include management of all forms of hernias, diaphragmatic, femoral, inguinal and orchiectomy in association with hernia repair Abdominoperineal resection Applicant Initials Approved Denied Abscesses and cysts, incision and drainage Alimentary tract surgery Amputations: -above/below knee -digits -toe -transmetatarsa Amputations: below knee -digits -toe -transmetatarsa Aneurysm repair Ano/fistulotomy, excision of fistula Anorectal region, inflammations/infections, excision of fistula or fistulotomy Aortic aneurysm Aortoiliac or aortofemoral bypass Appendectomy, open Arterial catheters, insertion and management of Arteriovenous graft Biliary enteric anastomosis Biliary tract resection/reconstruction Biopsies, to include but not limited to: -artery -breast -liver(intra-operative) -lymph node -nerve -scalene node Blood vessel repairs Breast abscess, incision and drainage Breast lesion, excision of Breast Ultrasound Bronchoscopy Bypass grafts, vein/artery Carotid body tumor, excision Carotid Endarterectomy Central venous catheters, insertion and management Chest tubes, insertion and management of Page 1 of 20

2 CORE PRIVILEGES Please place initials in the box next to the privilege you are requesting. Applicant Initials Approved Denied Chest wall tumor, excision Colectomy Cholecystectomy open, including IOC Choledochoscopy Choledochotomy Circumcisions (Pediatric Surgeons Only) Colonoscopy, including biopsy and polypectomy Colostomy Colotomy Distal common bile duct, investigations and manipulations of Duodenotomy for: -biopsy -exploration -foreign body removal Embolectomy, with or w/o catheter Emergency surgery, comprehensive management of Endocrine system, comprehensive management of Endorectal ultrasound Enteric fistulae management Enterolysis Enterostomy (feeding or decompression) Enterostomy of small intestine, incision, excision, resection Esophageal resection/reconstruction Esophagectomy, transhiatal Esophagogastrectomy Esophagogastroduodenscopy Extremity biopsy/i&d Fine-needle aspiration Flexible Sigmoidoscopy Fluid and electrolyte balance Foreign body removal Ganglion (palm or wrist/flexor sheath) removal of Gastric operations to include, but not limited to: -partial -radical -total gastrectomy Gastroduodenal surgery Gastrostomy (feeding or decompression) Gastrotomy Gynecomastia, surgery for Head and neck surgery, comprehensive management of Hematoma, incision/drainage Hemorrhoidectomy Page 2 of 20

3 CORE PRIVILEGES Please place initials in the box next to the privilege you are requesting. Applicant Initials Approved Denied Hepatic resection Herniorrhaphy, lap. and open Hidradenitis, excision of skin/subcutaneous tissue Hysterectomy and/or oophorectomy as part of general surgical procedure Intestinal obstruction, correction of Intra-abdominal abscess, drainage of Intraoral surgery, local excision Intravenous lines, insertion of Laparoscopic appendectomy Laparoscopy, basic Laparoscopic cholecystectomy and IOC Laryngoscopy, diagnostic and therapeutic Laparoscopic hernia repair Laparoscopic intestinal resection Laparoscopic Nissen Fundoplication Laparoscopic splenectomy Laparoscopic adrenalectomy Laparotomy for: diagnostic,-exploratory, intra-abdominal sepsis, management and trauma Laryngectomy, total/subtotal/partial Laryngotomy Lobectomy, pulmonary Lower extremity bypasses Lymph node dissections, radical, regional, excluding: -inguinal -pelvic -radical neck dissection -retroperitoneal Lymph node, excision/biopsy Mammary implant, removal Mammoplasty, augmentation with or w/o prosthetic implant Management of patients who may or may not require surgical intervention Mastectomy -complete with or without axillary lymph node dissection -modified radical -partial, with or without lymph node dissection -radical subcutaneous Mastopexy Maxillectomy Median Sternotomy Mediastinoscopy Nipple/areola reconstruction Oncologic disorders, including tumors of: -oral cavity -parathyroid -salivary glands - skin -thyroid Pancreatectomy Page 3 of 20

4 CORE PRIVILEGES Please place initials in the box next to the privilege you are requesting. Applicant Initials Approved Denied Pancreatic resection Pancreatic sphincteroplasty Pancreaticojejunostomy Pancreatitis, management of patients who may or may not require surgical intervention Paracentesis Parathyroidectomy Parotid tumor or gland excision Pelvic abscess, incision and drainage Percutaneous Endoscopic Gastrostomy (PEG) Pericardiocentesis, emergent Perirectal abscess, incision/drainage and debridement Peritoneal dialysis catheter, insertion and management Peritoneovenous drainage procedures for relief or ascites Pilonidal cyst, incision/excision of Pleurectomy Pneumonectomy Portal hypertension, management of patients who may or may not require surgical intervention Portal hypertension, shunt procedure Proctosigmoidoscopy Proctectomy, complete/partial Proctosigmoidoscopy, flexible/rigid Pulmonary wedge resection Reconstructive Breast Surgery Rectal lesion, excision of Retrosternal thyroid tumors, excision of Sengstaken-Blakemore Tube Insertion Sentinel lymph node biopsy for cancer Severe and complex illnesses, management Skin grafts (partial thickness, simple) Soft tissue tumors, management of Splenectomy - staging; - therapeutic; - trauma Splenorraphy Stereotactic breast biopsy Stereotactic Core-Cut Breast Biopsy (SCCB) Thoracentesis Thoracoabdominal exploration Page 4 of 20

5 CORE PRIVILEGES Please place initials in the box next to the privilege you are requesting. Thoracotomy, open (exploratory) Applicant Initials Approved Denied Thoracoscopy or Video-Assisted Thoracic Surgery (VATS) Thrombectomy Thromboendarterectomy Thyroglossal duct cyst, excision of Thyroidectomy Thyroidectomy and neck dissection Tonsillectomy Tracheoplasty Tracheostomy; open technique Tracheostomy; percutaneous technique Ureter Vagotomy, selective Vagotomy, transthoracic Valvuloplasty Varicosities, excision of Vascular system, comprehensive management of Vascular system, noninvasive diagnostic evaluation Visceral Artery Bypass/Reconstruction Viscus, repair of perforated: - gastric; - large intestine; - small intestine SPECIAL PRIVILEGES (Please place your initials in the box beside the privilege you are requesting.) Applicant must meet attached criteria for Trauma, Abdominal US for trauma, GES, ICU and Moderate Sedation privileges Abdominal Ultrasound for trauma Da Vinci Robotic Assisted Surgery (see attached criteria) Deep Brain Stimulation (see attached criteria) Gastric implantation (see attached criteria) Rib Matrix for Trauma Surgery Sacral nerve implant of neurostimulator (see criteria) Trauma privileges (see attached criteria) Therapeutic Hypothermia Criteria (see attached criteria) Moderate sedation (see attached criteria) Applicant Initials Approved Denied ICU Privileges SPECIAL PRIVILEGES Applicant must meet attached criteria for ICU privileges Definition Critical Care Units: those special care units, which are established for patients requiring extraordinary in patient care on a concentrated basis. At the University Medical Center of El Paso, these units include any medical or surgical Page 5 of 20

6 intensive care units, intermediate critical units, pediatric intensive care units and neonatal intensive care units. I. Fellowship track A. Successful completion of training in a General Surgery program approved by the Accreditation Council for Graduate Medical Education ACGME, or its predecessors, and board certification in Surgical Critical Care or eligibility to enter the board certification process. AND B. Positive recommendation of the Surgical Critical Care Director AND C. Positive recommendation of the Clinical Chief of Surgery AND D. Current provider status in Advanced Trauma Life Support and has had Pediatric Advanced Life Support within 1 year of beginning participation on the trauma call schedule OR II. Training and experience track A. Successful completion of training in a General Surgery program approved by the Accreditation Council for Graduate Medical Education ACGME, or its predecessors. Demonstrated special expertise in the care of surgical critical care patients for twelve months (including residency training) in the twenty-four (24) months preceding application for privileges. Documentation can be by letter signed by a responsible individual capable and competent to document such performance and must reference the location of pertinent medical records. This expertise may be gained through a preceptorship program as described in the Medical Staff Bylaws. AND B. Positive recommendation of the Surgical Critical Care Director AND C. Positive recommendation of the Department Chief of Surgery AND D. Current provider status in Advanced Trauma Life Support and has had Pediatric Advanced Life Support within 1 year of beginning participation on the trauma call schedule. Nothing in the foregoing precludes members of the University Medical Center of El Paso s Medical Staff who are not privileged in the critical care units from serving as consultants in these units, as appropriate. Participation of inpatient care in this manner is encouraged as a means to promote continuity of patient care and gain access to special expertise. ICU Privileges Applicant Approved Denied (Please place your initials in the box beside the privilege you are requesting.) Initials Admit, work up diagnose, perform H&Ps and provide treatment to patients in need of critical care Bronchoscopy Calibration and operation of hemodynamic recording systems Continuous arteriovenous hemofiltration and dialysis Diagnostic peritoneal lavage Flexible Fiberoptic bronchoscopy, including: - brushings, forceps biopsy, lavages, routine biopsy, transbronchial needle biopsy Gastroesophageal balloon tamponade Intubation Open or percutaneous tracheotomy/cricothyrotomy Placement of arterial, central venous, and pulmonary artery balloon flotation catheters Pericardiocentesis Page 6 of 20

7 Surgical intensive care unit privileges Therapeutic Hypothermia (see attached criteria) Transvenous Pacemaker Trans-esophageal echocardiography Tube thoracotomy Ventilator management Volume, pressure, or jet ventilators > 48 hours (COMPLEX) DELINEATION OF CLINICAL PRIVILEGES Note: Privileges granted may only be exercised at the site(s) and/or setting that have the appropriate equipment, license, beds, staff, and other support required to provide the services defined in this document. APPLICANT S SIGNATURE DATE APPLICANT S PRINTED NAME APPROVALS: MEDICAL DIRECTOR/TRAUMA SERVICES DATE CHIEF, SURGERY DEPARTMENT DATE Approved 1/06 Revised 2/09; 01/10,11/15 Page 7 of 20

8 Moderate Sedation Criteria I. Definition: As defined by the American Society of Anesthesiologists, Moderate Sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained. Continuum of Depth of Sedation and Definition of General Anesthesia and Levels of Sedation/Analgesia (Approved by ASA House of Delegates on October 13, 1999, and amended on October 27, 2004) Moderate Sedation should be distinguished from the following: Minimal Sedation: A drug-induced state during which patients respond normally to verbal commands. Deep Sedation: A drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. General Anesthesia: A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. *A licensed independent practitioner (LIP) must be present when moderate sedation is being administered. II. Eligibility: Physicians without general anesthesia privileges may obtain privileges to administer Moderate Sedation by providing evidence of: Successful training in administering Moderate Sedation either as part of an ACGME-approved residency training program or by virtue of the successful completion of the Hospital s Moderate Sedation training module consisting of moderate sedation guidelines and exam; AND Current certification in Advanced Cardiac Life Support (ACLS) or its equivalent (PALS, NRP, ATLS, FCCS) or current Board certification in Emergency Medicine or Critical Care Medicine. III. Renewal of privileges: Renewal of privileges will be dependant upon evidence that the physician competently performed Moderate Sedation during the past 24 months and current certification in ACLS or its equivalent (PALS, NRP, ATLS, FCCS) OR current Board certification in Emergency Medicine or Critical Care Medicine. Approved: BOM 6/09 Page 8 of 20

9 Deep Brain Stimulation (DBS) Credentialing Criteria I. Definition: Deep brain stimulation (DBS) refers to high-frequency electrical stimulation of anatomic regions deep within the brain utilizing neurosurgically implanted electrodes. These DBS electrodes are stereotactically placed within targeted nuclei on one (unilateral) or both (bilateral) sides of the brain. There are currently three main targets for DBS -- the thalamic ventralis intermedius nucleus (VIM), subthalamic nucleus (STN) and globus pallidus interna (GPi), depending on the condition being treated in the patient. Two conditions that can be treated with DBS are essential tremor and Parkinson s disease. II. III. IV. Eligibility: Applicants must have completed an ACGME/AOA-accredited fellowship training program in functional and stereotactic neurosurgery. If the applicant did not complete fellowship training in functional and stereotactic neurosurgery, the applicant must provide documentation that he/she received training in the principals of stereotaxy in their neurosurgery residency and participated in, or observed, at least 4 DBS procedures performed by active DBS implanters, either in their residency, fellowship or in subsequent post-training experience. Renewal of privileges: Applicant should attend recurrent training (at least 2 procedures) if they have not performed a single DBS procedure over a period of 2 years. Neurosurgery Deep Brain Stimulation PI Indicators Complications: -Wound Infection - scalp infection -Bleeding/ Stroke -on the surface or within the deep brain from placing the electrode -Hardware -Fracture, Breakage or Migration of the Wire, and/or wire or cable (need to replace) -Battery-Failure Erosion -Plastic cable or device through the skin -Migration of the wire -Unable to find effective stimulation target -Death Approved by BOM: 1/2010 Page 9 of 20

10 Gastric Implantation for (Enterra Therapy System) Criteria The requirements for GES privileges in the Department of Surgery are as follows: 1. Privileged and credentialed within the parent department. 2. Completion of an ACGME/AOA accredited residency training program in General Surgery and/or a fellowship approved by the ACGME/AOA. 3. Successful completion of the Implantation and Operation of the Enterra Therapy System training by Medtronics. Page 10 of 20

11 Trauma Privileges Criteria The requirements for trauma privileges in the Department of Surgery are as follows: 1. Privileged and credentialed within the Surgery Department. 2. Board certified or Board eligible within 5 years of successful completion of an approved residency program. 3. Obtain 16 hours of trauma related CME annually of which 6 hours must be pediatric (over a 3 year period, at least half must be obtained outside Texas Tech/Thomason). 4. Successful completion of ATLS course within 1 year of beginning participation on the trauma call schedule, and maintain current ATLS provider status. 5. Successful completion of the PALS or equivalent course within 1 year of beginning participation on the trauma call schedule. 6. Participates in the care of approximately 35 or more trauma patients with immediate life threatening or urgent injuries (ISS greater than or equal to 15). 7. The trauma medical director must have 48 hours of external trauma related CME over a 3 year period. Revised 1/25/11 Page 11 of 20

12 Therapeutic Hypothermia Criteria I. Definition: Temperature Hypothermia (TH) is the practice of transiently reducing body temperature to mitigate the effects of cerebral ischemia in selected patients. II. III. IV. Background: Cardiac arrest with resultant cerebral ischemia often leads to severe neurologic impairment. Studies of comatose survivors of out-of-hospital cardiac arrest have demonstrated favorable neurologic outcomes with initiation of therapeutic hypothermia. (1,2) The Advanced Life Support Task Force of the International Liaison Committee on Resuscitation has advised: Unconscious adult patients with return of spontaneous circulation (ROSC) after out-of-hospital arrest should be cooled to degrees Celsius for hours when the initial rhythm was ventricular fibrillation; such cooling may be beneficial for other rhythms or inhospital cardiac arrest. (3) Cooling methods typically include the combined use of refrigerated intravenous fluids, externally applied ice packs and cooling mats, and endovascular cooling catheters. i. Potential Complications: External cooling devices: skin breakdown Endovascular cooling catheter: bleeding, thrombosis, infection Hypothermia: electrolyte imbalance, shivering Eligibility: Applicants must be credentialed in Critical Care or Emergency Medicine. Use of the endovascular cooling catheter (InnerCool device) shall require the applicant to have completed basic education including both instructional video viewing and hands-on familiarization at an in-service. V. Performance Improvement: Data on all patients treated with TH modalities at UMC will be collected and reviewed yearly. Outcomes and complications will be examined by Performance Improvement personnel from appropriate departments and recommendations forwarded to the Credentials Committee. References 1. Bernard, S., Gray, T., Buise, M., Jones, B., Silvester, M. Gutteridge, M., et al. (2002). Treatment of Comatose Survivors of Out-Of-Hospital Arrest with Induced Hypothermia. New England Journal of Medicine, 346(8), The Hypothermia after Cardiac Arrest Study Group. (2002). Mild therapeutic hypothermia to Improve neurologic outcomes after cardiac arrest. New England Journal of Medicine, 346(8), Nolan, J., Morley, P., Hoek, V., Hickey, R., (Writing Group). (2003). Therapeutic Hypothermia after cardiac arrest. An advisory statement by the Advanced Life Support Task Force of the International Liaison Committee on Resuscitation. Circulation, 108, Page 12 of 20

13 SURGERY - GENERAL CRITERIA: The applicant must have fulfilled ONE of the following requirements: (1) Received minimum laser surgery training from a recognized CME-approved curriculum in the specialty in which the privileges are requested. Such course(s) shall be a minimum of 8 to 10 hours and shall be devoted to the teaching of laser principles and safety. (2) Received appropriate laser surgery training as part of residency/fellowship training program. (1) LASER COURSE COMPLETION: To be completed by Applicant Course Title: Date: Course Director: Hours: Laser Type: CO2 Argon Holmium Attach certificate of successful completion of course. (2) RESIDENCY/FELLOWSHIP TRAINING: To be completed by Program Director: Institution Name: Training Dates: I certify that has received appropriate training and has demonstrated competence for the following laser wavelengths while in our training program: Laser Type: CO2 Argon HOLMIUM Signature, Residency/Fellowship Director Date I hereby apply for the privileges as indicated and certify that I have adequate training and experience to carry out the procedures requested. Note: Privileges granted may only be exercised at the site(s) and/or setting that have the appropriate equipment, license, beds, staff, and other support required to provide the services defined in this document. APPLICANT S SIGNATURE DATE Applicant s Printed Name APPROVAL: Chief, IM/OB/GYN/Orthopedics or Surgery Department Date Page 13 of 20

14 REAPPOINTMENT OF LASER PRIVILEGES DELINEATION OF CLINICAL PRIVILEGES SURGERY - GENERAL To renew laser privileges complete the following: Laser Type Check if you wish to renew this privilege Number of times laser has been used in past 2 years CO2 Argon HOLMIUM Facility where laser was used I hereby apply for renewal of the privileges as indicated and certify that I have adequate training and experience to carry out the procedures requested. APPLICANT S SIGNATURE DATE Applicant s Printed Name APPROVED AS INDICATED: Approved Denied Reason Department Chief, (IM/OB/GYN/Orthopedics or Surgery) Date: Page 14 of 20

15 SURGERY - GENERAL CRDENTIALING CRITERIA ROBOTIC (DA VINCI SYSTEM) ASSISTED SURGERY PRIVILEGES To be eligible to request clinical privileges using the da Vinci System for robotic assisted surgery in the applicant s specialty, an applicant must meet the following minimum threshold criteria: GENERAL REQUIREMENTS Education: Minimal formal training: SPECIFIC REQUIREMENTS M.D. or D.O. Completion of approved residency or fellowship program in surgery or surgical subspecialty in an ACGME/AOA accredited training program. Certification or Board Eligible in the surgeon s specialty by a board recognized by the ABMS. Eligibility and active privileges to perform laparoscopic and open major procedures. AND ONE OF THE FOLLOWING TWO ALTERNATIVES Satisfactory completion of the Intuitive Surgical Clinical Pathway course, within 12 months prior to performing the first proctored case after being granted this privilege, in the da Vinci Surgical System from Intuitive Surgical, Inc. that included: a. 10 hours of computer-based training b. 2 hours of live case observation c. 4 hours of hands-on training with the robot using inanimate training aids d. 8 hours in a live porcine laboratory case The following criteria must be met: OR Previous practical experience via an accredited residency or fellowship program with documented clinical experience in a minimum of ten (10) procedures during training. The following is required: 1) letter from the surgeon s training program director must be submitted directly to UMC detailing the extent of training and that the applicant is proficient in robotic assisted surgery. Prior training during residency or fellowship or at a Joint Commission accredited institution meeting the minimal formal training parameters listed above. If this alternative is selected, evidence of current (within the preceding 2 years) competence must include a letter provided directly to UMC from the surgeon s training program director, for residency or fellowship, or from the Department or Robotic Committee Chairman with direct knowledge of the practitioner s clinical performance in using the da Vinci System, detailing the extent of training and level of proficiency. Page 15 of 20

16 SURGERY - GENERAL CRDENTIALING CRITERIA ROBOTIC (DA VINCI SYSTEM) ASSISTED SURGERY PRIVILEGES Minimal Current Privileges: Fully credentialied in Advanced Laparoscopy in their specialty with supportive documentation. Full privileges to perform the equivalent open procedure without robotic assistance for which robotic privileges are sought, and/or Full privileges to perform the equivalent laparoscopic procedure without robotic assistance for which robotic privileges are sought. *Preceptor is defined as a surgeon who has met the above outlined qualification for credentialing and has had practical experience in the successful use of da Vinci surgical system. INITIAL PRIVILEGES: If the applicant is determined to have satisfied the training requirements and is initially granted privileges to utilize the DaVinci Surgical Platform, such privileges will be considered provisional and shall be subject to the following proctoring, review, and monitoring : Two (2) cases minimum, on two (2) different proctoring occasions (minimum 4 cases) no more than 2 weeks apart, proctored by a practitioner who is a Board Certified surgeon currently privileged to perform da Vinci System robotic surgery and who has performed a minimum of forty (40) successful robotic cases, must be successfully completed. To successfully complete the training, 10 robotic cases must be performed within the ensuing 90 days. If the surgeon is currently privileged at another Joint Commission accredited facility and has successfully performed a minimum of ten (10) robotic cases within the preceding twelve (12) months and satisfactory evidence of this experience is provided, UMC proctoring may be waived at the discretion of the Credentials Committee. After satisfactorily completing the foregoing four proctored cases or a waiver has been granted as provided in the preceding paragraph, the next five (5) cases must be reviewed by a Board Certified surgeon currently privileged to perform da Vinci System robotic surgery and who has performed a minimum of forty (40) successful robotic cases. If a proctoring waiver is granted, the five cases referenced in this paragraph must be performed with the assistance of a robotic trained and UMC privileged assistant. If one or more of these first five cases was not performed fully satisfactorily, including documentation, an additional five (5) cases, for a total of ten (10) will be required. The assessment provided by the reviewer must be documented on the form provided by the hospital and must be individual case specific as to the surgeon s judgment, knowledge and skill in using the system. An overall recommendation as to the granting of this privilege will also be required. Page 16 of 20

17 SURGERY - GENERAL CRDENTIALING CRITERIA ROBOTIC (DA VINCI SYSTEM) ASSISTED SURGERY PRIVILEGES For the purposes hereof, the terms proctored and proctoring shall mean the physical presence of, and direct observation by, the proctor of the surgeon's performance of the procedure. Interim Provisional privileges to be granted to the applicant for a period of no longer than 12 months under the supervision of a proctor/preceptor with the cases brought back to the Credentials Committee and Executive Committee upon completion in order to finalized privileges. Privilege Maintenance: This privilege is granted for a twenty four month period; however, in order to maintain full robotic privileges, the surgeon must perform (or assist with at least one hour console time in each counted case) a minimum of twenty four (24) robotic procedures each twelve (12) month period following initial granting and subsequent renewal of this privilege. Alternatively, up to five (5) of these twenty cases may be waived provided that five (5) hours of simulator training at 90% efficiency has been performed and satisfactory documentation provided. The surgeon must continuously meet the minimal current privileges requirement. If these conditions are not met, the privilege will be considered to have been voluntarily withdrawn by the surgeon, without right to fair hearing. Reinstatement of the privilege may be considerd upon satisfactorily completing the minimal formal training and current privilege requirements listed herein from the beginning. If a surgeon performs less than this, that surgeon will need to have one proctored case and five reviewed cases satisfactorily completed before being eligible to request the reestablishing of full robotic privileges. Tubal ligation, salpingectomies, and diagnostic laparoscopy will not be counted towards privilege maintenance requirement. The surgeon must actively participate in the UMC ongoing clinical performance improvement program associated with robotic surgery. At least 2 hours of CME related to the robotic approach is required annually. Page 17 of 20

18 SURGERY - GENERAL CRDENTIALING CRITERIA ROBOTIC (DA VINCI SYSTEM) ASSISTED SURGERY PRIVILEGES Specialty Specific Additional Requirements: The applicant must be fully credentialed in open and laparoscopic procedures that correspond to the da Vinci robotic approach as listed below: The cases listed below are defined as either Basic or Advanced robotic procedures. 1. A new robotic surgeon will be expected to perform at least thirty (30) cases from the Basic Group before being eligible to request privileges for advanced robotic surgery. Recommendations of such privileges will be made by the Robotic Section. 2. Gynecologic Oncologists will be eligible to proceed to Tier II cases after satisfactorily completing their first four (4) proctored and five (5) reviewed cases and upon recommendation by the Robotic Section. 3. If the Surgeon has completed advanced fellowship training or can submit a laparoscopic case list, the surgeon may be eligible to request privileges for advanced robotic surgery upon recommendation by the Robotic Section. GENERAL SURGERY ROBOTICS CREDENTIALLING Applicant must be fully credentialed in open and laparoscopic procedures that correspond to the da Vinci robotic approach. Robotic Privileging Recommendations for General Surgery 1. A new robotic surgeon will be expected to perform at least twenty (20) cases from the Basic Group before being eligible to request privileges for advanced robotic surgery. Recommendations of such privileges will be made by the Robotic Section. 2. If the surgeon has completed advanced fellowship training or can submit a laparoscopic case list, the surgeon may be eligible to request privileges for advanced robotic surgery upon recommendation by the Robotic Section. 3. The following recommendations are made for case progression. The goal of all new robotic surgeons is to perform basic (easy) cases initially before being eligible to request to be proctored/assisted on more difficult and complex cases. This process will vary somewhat based on the sub-specialty: TIER I- GENERAL SURGERY ROBOTIC CASES: 1. Cholecystectomy 2. Gastric banding 3. Appendectomy 4. Simple hernia repairs 5. Right colectomy 6. Repair bowel lacerations 7. Basic trauma repairs 8. Splenectomy Page 18 of 20

19 SURGERY - GENERAL CRDENTIALING CRITERIA ROBOTIC (DA VINCI SYSTEM) ASSISTED SURGERY PRIVILEGES TIER II GENERAL SURGERY ROBOTIC CASES: 1. Nissen Fundoplication 2. Rectal surgery (Low anterior resection) 3. Whipple procedure 4. Pancreatectomy 5. Advanced trauma repairs This list is not all inclusive. In general, a Basic Procedure is done on an essentially healthy normal weight (BMI < 35) patient that can be concluded in less than two (2) hours. Surgeries that require advanced skills with fourth arm manipulation, sewing and complex anatomy should be postponed until the surgeon has mastered basic cases first. In our institution, this is defined as thirty (30) cases. As with all other specialties, the first two (2) cases will require proctoring; the first five (5) cases will require a focused review. Approved: 09/10/2013 Page 19 of 20

20 SURGERY - GENERAL Credentialing Criteria Sacral Nerve Stimulation Implantation (Neurostimulation) The requirements for Sacral Nerve Stimulation implantation privileges in the Department of Surgery are as follows: 1. Privileged and credentialed within the parent department. 2. Completion of an ACGME/AOA accredited residency training program in General Surgery and/or a fellowship approved by the ACGME/AOA. 3. Successful completion of the Sacral Neuromodulation for Bowel Control E-learning training by Medtronics. BOM Approved: 05/2016 Page 20 of 20