Drafting Contemporary Clinical Privileges: You Can Do It! Session Code: TU12 Time: 2:30 p.m. 4:00 p.m. Total CE Credits: 1.5 Presenter: Catherine

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1 Drafting Contemporary Clinical Privileges: You Can Do It! Session Code: TU12 Time: 2:30 p.m. 4:00 p.m. Total CE Credits: 1.5 Presenter: Catherine Ballard, JD and Melinda Whitney, RN, BSN, BS, MS, CPHQ, CPMSM, FACHE

2 October 6, :30 4:00 p.m. Drafting Contemporary Clinical Privileges You Can Do It! Catherine M. Ballard, Esq. Bricker & Eckler, LLP 100 South Third Street Columbus, Ohio (614) v2 Melinda E. Whitney, RN, BSN, BS, MS, CPHQ, CPMSM, FACHE Senior Consultant, Quality/Medical Staff Services The Quality Management Consulting Group, Ltd. 100 South Third Street Columbus, Ohio (614) Definitions Credentialing: The ongoing process of assuring that only competent qualified practitioners are providing services. Privileging/Clinical Privileges: The identified scope of services that a practitioner is able to provide at a specific location. Medical Staff Appointment: The prerogatives and obligations that attach to the ability to exercise clinical privileges at a health care entity. Advanced Practice Professionals: Advanced practice nurses, physician assistants, licensed independent social workers, and all other health care providers to whom a health care entity grants clinical privileges. 2 Foundation for Privilege Set Creation Consistent with information contained within Medical Staff governing documents. Based upon CMS Medicare Hospital or Critical Access Hospital Conditions of Participation (CoPs). Based upon applicable Hospital or Critical Access Hospital accreditation standards. Based upon applicable State law. 3 1

3 CMS Hospital CoPs Hospital s governing body is responsible for conduct of hospital. Governing body delegates to Medical Staff accountability for quality of care provided to patients at hospital. [See 42 C.F.R (a)(5) and (b) and corresponding interpretive guidelines] 4 CMS Hospital CoPs Hospital must have a privileging process in place that complies with applicable CoPs, accreditation standards, and State law. The medical staff governing documents must describe the privileging process to be used in the hospital and the process must be approved by the hospital s governing body. The process must include criteria for determining the privileges that may be granted to individual practitioners and a procedure for applying the criteria to individual practitioners. [See 42 C.F.R (a)(6); (a)(2); (c)(4); (c)(6) and corresponding interpretive guidelines] 5 CMS Hospital CoPs The hospital s governing body must determine the types of practitioners who are eligible for medical staff appointment and who are eligible for privileges. Physicians (as defined by CMS): MD/DO; Dentists; Podiatrists, Optometrists, Chiropractors. Non-physician practitioners (as defined by CMS): physician assistant; advanced practice registered nurses (CNP, CNS, CRNA, CNM); clinical social worker; clinical psychologist; anesthesiologist s assistant; registered dietitian or nutrition professional. Other types of licensed healthcare professionals. [See 42 C.F.R (a)(1); (a) and corresponding interpretive guidelines] 6 2

4 State Scope of Practice Privileges granted to individual practitioners must be consistent with State scope of practice laws. Examples: Advanced Practice Registered Nurses Physician Assistants Podiatrists Etc. 7 CMS Hospital CoPs Medical staff governing documents must state the duties and scope of privileges each category of practitioner may be granted. Specific privileges for each category must clearly and completely list the specific privileges or limitations for that category of practitioner. Specific privileges must reflect the activities that the majority of practitioners in that category can do and that the hospital can support. [See 42 C.F.R (c)(2) and corresponding interpretive guidelines] 8 CMS Hospital CoPs The individual practitioner s ability to perform each privilege (task/activity) must be assessed and not assumed. If a practitioner is not competent to perform one or more privileges, the list of privileges must be modified for that practitioner. [See 42 C.F.R (a)(2); (c)(2) and corresponding interpretive guidelines.] 9 3

5 CMS Hospital CoPs Privileges cannot be granted for: Tasks/procedures/activities that are not conducted within the hospital regardless of the individual practitioner s ability to perform them. [See 42 C.F.R (a)(1) and corresponding interpretive guidelines.] 10 CMS Hospital CoPs Any procedure/task/activity requested by a practitioner that goes beyond the specified list of privileges for that particular category of practitioner requires an appraisal by the medical staff and approval of the governing body. Appraisal must consider evidence of qualifications and competencies specific to the nature of the request. Must also consider whether activity/task/procedure is one that the hospital can support when it is conducted within the hospital. [See 42 C.F.R (a)(1) and corresponding interpretive guidelines.] 11 CMS Hospital CoPs Hospitals must assure that practitioners are competent to perform all granted privileges. Medical staff must periodically (defined as at least every 24 months in the absence of a State law that requires more frequent appraisals) conduct appraisals of individual current practitioners. [See 42 C.F.R (a)(1) and corresponding interpretive guidelines.] 12 4

6 CMS Hospital CoPs Medical staff appraisal procedures must evaluate each individual practitioner s qualifications and demonstrated competencies to perform each task or activity for which he/she has been granted privileges. [See 42 C.F.R (a)(1) and corresponding interpretive guidelines.] 13 CMS Hospital CoPs Components of practitioner qualifications and demonstrated competencies must include at least: current work practice, special training, quality of specific work, patient outcomes, education, maintenance of continuing education, adherence to medical staff rules, certifications, appropriate licensure, and currency of compliance with licensure requirements. [See 42 C.F.R (a)(1) and corresponding interpretive guidelines.] TJC and HFAP require that the hospital have an FPPE/OPPE process. 14 Building Privilege Sets Privilege sets are the work product of compliance with law and requirements regulating hospital care delivery. Privilege sets are built to reflect uniqueness of each hospital (i.e. physical plant, equipment, support staff capability, and care setting). Privilege sets must reflect eligibility requirements and a scope of practice that can be safely performed for a defined population in a specific setting. Build vs. purchase or borrow. 15 5

7 Building Privilege Sets Verify practitioner education, training, licensure and current clinical competence to exercise a defined set of privileges in a given setting. Patient health, safety, and wellness is the first concern in decision-making with respect to clinical privileges. 16 Building Privilege Sets Considerations for Privilege Set Scope Service line (e.g., Mother/Baby Medicine may reflect many disciplines within a service line OB/GYN, Anesthesia, Family Medicine, Midwifery, Pediatrics and NICU). Department (Surgery or Medicine e.g., Surgery may reflect General and Vascular, Colon and Rectal, and Thoracic and Cardiac). Division (e.g., Internal Medicine or Family Medicine as a Division within Department of Medicine). Specialty (Neurological Surgery, Otolaryngology or Neonatology - or other fellowship-based discipline). 17 Building Privilege Sets Elements of a Privilege Set Eligibility criteria (per the medical staff bylaws) to apply and to maintain privileges. Additional minimum threshold criteria (specialty or subspecialty training, etc.). Burden of proof statement (with respect to satisfaction of qualification requirements). Location/setting(s) and patient populations. Core privilege statement and procedure list (monitor core by aggregate patient volumes/outcomes). Special request privileges (additional training requirements; monitor each special privilege by per case volume/outcome). Performance volumes and quality monitoring (many initiatives). 18 6

8 Building Privilege Sets Format Election Build a master template for privilege set format first. Provide format template to teams working on privilege set creation/revision to ensure uniformity of format, font, header, etc. Prepopulate prompts for eligibility requirements, minimum performance volumes, special request privileges, etc. Review requirements for creation or amendment of privilege sets in medical staff bylaws to ensure process compliance. 19 Building Privilege Sets Clinical process that requires practitioner involvement. Utilize department chairs, credentials committee, or other suitable medical staff committees/leaders to assist, monitor, and review draft privilege sets. Tenured and newer practitioner mix of participants/perspectives is invaluable. Legal access needed for federal/state requirements and legal questions (e.g., supervision, turf issues, advanced practice professional scope, eligibility, etc.). 20 Building Privilege Sets Laundry list (alphabetical list of procedures/skills with or without privilege statement). Core (statements of scope of practice with or without procedures included). Combination (widely used as this format allows for election of a customized core and laundry list format to reflect individualized hospital parameters). Special Request privileges (additional special privileges that are not included in the core/laundry list/combo, e.g., moderate sedation privileges for non-anesthesiologists). 21 7

9 Building Privilege Sets Consider hospital capabilities and limitations to parameter the scope of privileges intended by the governing body. Do not project future growth of services. Build privileges to reflect current practice. Audit current patient populations/operative procedures to define the current scope of practice being exercised. Keep scope of practice within the privilege set to reflect basic practice of all practitioners, then use special request privileges for the few enhanced privilege elements. 22 Building Privilege Sets Each privilege set should reflect: Formal education (medical school, internships, residency, and fellowships). Training (aggregate competencies and acquired skills necessary for privilege eligibility). Current clinical competence (within last two years, volumes of successful performance of patient management, procedures, surgery scope, patient encounters, etc.). 23 Building Privilege Sets Initial professional references for competency verification of requested privileges. Focused Professional Practice Evaluation (FPPE) process. Ongoing Professional Practice evaluation (OPPE) process. Performance volumes regarding case management/ patient encounters for quality review purposes. Approved in accordance with requirements set forth in medical staff bylaws (i.e., department chair, credentials committee, medical executive committee, and board). 24 8

10 Clinical Skills and Setting Parameters Decision Tree 1. Patient needs in a defined care setting/one or more campuses or care locations. 2. Setting capabilities / facility designations. 3. Services to be offered (per governing body). 4. Current scope of management provided to target population in a specific setting. 25 Clinical Skills and Setting Parameters Example: An Orthopaedic Surgeon with Joint Replacement Training Community hospital vs. tertiary facility. Core general orthopaedic surgery privileges/no total joint replacement privileges at community hospital. May reflect preoperative total joint replacement patient evaluations and surgical planning privileges. Special request privileges (pain management injections, post-operative evaluations, etc.). Privilege parameters for setting (note that no joint replacement privileges are included in the community hospital setting). 26 Clinical Skills and Setting Parameters Specialists and Subspecialists What? Why? Where? Understand the intent of the practitioner in the specific setting. Determine the need to build a separate privilege set vs. adding special request privileges to an existing privilege set. Consider monitoring challenges for low volume, part-time practitioners (consider review of case volume options in and out of the specific hospital) - remember why they are needed in the setting/be creative on monitoring strategy. 27 9

11 Special Request Privileges Special request privileges may be applicable with: Non-core privilege/procedure that requires additional, specialized, or customized education and training (e.g., endovascular approach for seasoned surgeons, breast surgery specialty for general surgeons or plastic surgeons, focused minimally invasive surgery techniques, obstetrics for family medicine, etc.). Other unique privilege needs such as use of laser, (non-anesthesia provided) moderate sedation, child abuse evaluation/work-up, pediatric gynecology and (non-fellowship) specialties level of care/procedures/ management such as spinal specialty for orthopaedic surgeons, etc. 28 Sample Privilege Set Review See Handout Format election Surgical privileges should be reviewed and updated at least every two (2) years [See 42 C.F.R (a)(4)]. Eligibility (bylaws and additional requirements). Initial grant and regrant minimum patient encounter and/or procedural volumes for purposes of competency assessment. Core privilege statement and procedures list with minimum volumes for purposes of competency assessment. Special request privileges additional training with minimum volumes for purposes of competency assessment. 29 Additional Considerations CMS Designated Provider-Based Locations Provider-based means that CMS permits a hospital (main provider) to bill facilities or entities that are acquired or created as part of the hospital. The facilities or entities may be on the same campus or located off the campus of the hospital. All requirements of the provider-based rule must be met before the hospital can bill the facility or entity as part of the hospital. If a location is provider-based: The practitioner must have clinical privileges specific to that location If TJC/HFAP, must have a FPPE/OPPE process The practitioners must be part of the medical staff 30 10

12 Additional Considerations Hospital Systems When granting practitioners privileges to provide patient care, a hospital s governing body must specify those hospitals in the system where the privileges apply. TJC: Privileges must be site-specific. [See 42 C.F.R (b)(4) and corresponding interpretive guidelines] 31 Questions? (And our sincere thanks!) Catherine M. Ballard, Esq. Bricker & Eckler, LLP 100 South Third Street Columbus, Ohio (614) cballard@bricker.com Melinda E. Whitney, RN, BSN, BS, MS, CPHQ, CPMSM, FACHE Senior Consultant, Quality and Medical Staff Services The Quality Management Consulting Group, Ltd. 100 South Third Street Columbus, Ohio (614) mwhitney@qmcg.com 32 11

13 (This is an educational privilege set intended for discussion purposes only as part of NAMSS presentation not intended for use/incomplete document) HOSPITAL GENERAL SURGERY CLINICAL PRIVILEGES Applicant Name: Request Date: / / To be eligible to apply for privileges in general surgery at the Hospital, the applicant must meet the following criteria: And And And All minimum requirements set forth by the Medical Staff Bylaws Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited post-graduate training program in general surgery. Current certification or active participation in the examination process leading to certification in general surgery by the American Board of Surgery, or the American Osteopathic Board of Surgery Applicants for initial privileges must be able to demonstrate performance of at least xxx general surgical procedures during the past 12 months or demonstrate successful completion of a hospital-affiliated accredited residency, special clinical fellowship or research fellowship Applicants for initial privileges may be requested to provide documentation of the number and types of hospital cases during the past 24 months. Applicants have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current clinical competence and any other qualifications, and for resolving any doubts related to clinical privileging (and appointment as applicable). To be eligible to renew privileges in general surgery, the applicant must meet the following Maintenance of Privilege criteria: Current demonstrated clinical competence at the Hospital with an adequate volume of experience to equal or exceed (***number here***) surgical cases with acceptable results in the privileges granted for the past 24 months based on results of quality assessment/improvement activities and outcomes. Evidence of current ability to safely and competently perform privileges requested is required of all applicants for renewal of privileges Teaching Tool For Discussion Purposes Only v1

14 (This is an educational privilege set intended for discussion purposes only as part of NAMSS presentation not intended for use/incomplete document) (Consider reflecting one or more campuses and location in an X and Y axis grid format) GENERAL SURGERY CORE PRIVILEGES Requested Admit, evaluate, diagnose, consult, and provide pre, intra and post-operative care, and perform general surgical procedures, to pediatric (excluding newborn) and adult patients, except where specifically excluded from practice, to correct or treat various conditions, diseases, disorders and injuries of the alimentary tract, abdomen and its contents, extremities, breast, skin and soft tissue, head and neck, vascular and endocrine systems. Includes management of Level II trauma and care, stabilization and transfer out of critically ill patients with underlying surgical conditions from the emergency department, medicine, surgery and intensive care units. The privileges do not include complex or oncologic breast, vascular, or colorectal management, and does not include bariatric procedures, for patients of any age. In such cases, basic stabilization is expected with specialist consultation (as needed) and arrangements for transfer to a tertiary care center is anticipated. The core privileges in this surgical specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills. Note: the below list is a sampling of procedures that may be included in core privileges. This is not intended to be an all-encompassing list but rather reflective of the categories/types of procedures that are included in the core. Core Procedure List Sampling: Abdominoperineal resection Amputations, above the knee, below knee; toe, transmetatarsal, digits Appendectomy Biliary tract resection/reconstruction Breast: simple complete mastectomy with or without axillary lymph node dissection; excision of breast lesion, breast biopsy, incision and drainage of abscess, modified radical mastectomy, operation for gynecomastia, partial mastectomy with or without lymph node dissection, radical mastectomy, subcutaneous mastectomy Circumcision Colectomy (abdominal) Colon surgery for benign disease, including reanastomosis Colotomy, colostomy Correction of intestinal obstruction Drainage of intraabdominal, deep ischiorectal abscess Endoscopy (upper and lower) Emergency/urgent thoracostomy 2015 Teaching Tool For Discussion Purposes Only v1

15 (This is an educational privilege set intended for discussion purposes only as part of NAMSS presentation not intended for use/incomplete document) Enteric fistulae, management Enterostomy (feeding or decompression) Excision of fistula in ano/fistulotomy, rectal lesion Excision of pilonidal cyst/marsupialization Excision of retrosternal thyroid tumors Excision of thyroglossal duct cyst Gastroduodenal surgery Gastrostomy (feeding or decompression) Genitourinary procedures not associated with malignancy or trauma Gynecological procedure incidental to abdominal exploration Hemorrhoidectomy Incision and drainage of abscesses and cysts Incision and drainage of pelvic abscess Incision, excision, resection and enterostomy of small intestine Incision/drainage and debridement, perirectal abscess Insertion and management of pulmonary artery catheters Intravenous access procedures, central venous catheter Laparoscopy, diagnostic, appendectomy, cholecystectomy, lysis of adhesions, mobilization and catheter positioning Laparotomy for diagnostic or exploratory purposes or for management of intraabdominal sepsis or trauma Liver biopsy (intra operative), simple liver resection Management of burns (excludes complex face, hands and feet) Management of hemorrhoids (internal and external) including hemorrhoidectomy Management of intraabdominal trauma, including injury, observation, paracentesis, lavage, drainage and open packing Management of stable trauma Management of soft-tissue tumors, inflammations and infection Operations on gallbladder, biliary tract, bile ducts, hepatic ducts (excludes biliary tract reconstruction Pancreatectomy (simple partial) Pancreatic sphincteroplasty Parathyroidectomy Peritoneal venous shunts, shunt procedure for stable portal hypertension Peritoneovenous drainage procedures for pressure relief or ascites Proctosigmoidoscopy, rigid or flexible with biopsy, with polypectomy/tumor excision Radical regional lymph node dissections (with applicable consultation) Removal of ganglion (palm or wrist; flexor sheath) Repair of perforated viscus (gastric, small intestine, large intestine) Scalene node biopsy Sclerotherapy Selective vagotomy 2015 Teaching Tool For Discussion Purposes Only v1

16 (This is an educational privilege set intended for discussion purposes only as part of NAMSS presentation not intended for use/incomplete document) Sigmoidoscopy, fiberoptic with or without biopsy, with polypectomy Skin grafts (partial thickness, simple) Small bowel surgery for benign disease Splenectomy (trauma, staging, therapeutic) Surgery of the abdominal wall, including management of all forms of hernias, including non-congenital diaphragmatic hernias, inguinal hernias, and orchiectomy in association with hernia repair Thoracentesis and chest tube insertion for drainage Thoracoabdominal exploration Thyroidectomy and neck dissection Tracheostomy Transhiatal esophagectomy Varicose vein surgery 2015 Teaching Tool For Discussion Purposes Only v1

17 (This is an educational privilege set intended for discussion purposes only as part of NAMSS presentation not intended for use/incomplete document) SPECIAL REQUEST (NON-CORE/ADDITIONAL PRIVILEGES (See Additional Qualifications and/or Specific Eligibility Criteria*) To be eligible to apply for the special request (non-core) privileges listed below, the applicant must demonstrate successful completion of an approved, recognized course (when such exists), or acceptable supervised training in residency, fellowship or other acceptable experience, and provide documentation of current clinical competence in performing the requested procedure consistent with criteria set forth in medical staff policies governing the exercise of specific privileges and as required below. (SPECIALIZE EQUIPMENT/TECHNIQUE) USE OF LASER Requested Criteria: Completion of an approved 8 hour minimum CME course which includes training in laser principles and safety, basic laser physics, laser tissue interaction, discussions of the clinical specialty field and hands-on experience with lasers. A letter outlining the content and successful completion of course must be submitted, or documentation of successful completion of an approved residency in a specialty or subspecialty which included training in laser principles and safety, basic laser physics, laser tissue interaction, discussions of the clinical specialty field and a minimum of 6 hours observation and hands-on experience with lasers. (INVASIVE PROCEDURE) INSERTION AND MANAGEMENT OF PULMONARY ARTERY CATHETERS (PAC) Requested Criteria: successful completion of an accredited residency or fellowship in internal medicine, general/vascular surgery, cardiology, anesthesiology, pulmonary medicine, critical care, or family practice; and performance of at least XX PACs during this formal training, as primary operator, or; successful completion of an accredited residency in another field; and participation in a significant Category 1 accredited continuing medical education training program in pulmonary artery catheter insertion and management; and successful insertion and subsequent management of pulmonary artery catheters in at least XXX patients during the past 36 month, Required Previous Experience: Active hospital practice in the chosen respective field; clinical privileges to treat complex cardiac cases; and performance (as the primary operator) of at least XXX PACs during the past 24 months. Maintenance of Privilege: Performance of at least XX PACs per year as the primary operator (INVASIVE PROCEDURE) STEREOTACTIC BREAST BIOPSY Requested [Criteria: successful completion of training in the stereotactic and ultrasound guided technique of breast biopsy during residency or in an accredited course or institution; and possession of privileges for breast imaging interpretation. Required Previous Experience: Successful completion of at least 15 hours of Category 1 continuing medical education in stereotactic breast biopsy; or performance of at least XX stereotactic breast biopsies in the past three years, 2015 Teaching Tool For Discussion Purposes Only v1

18 (This is an educational privilege set intended for discussion purposes only as part of NAMSS presentation not intended for use/incomplete document) and; successful evaluation of at least XXX mammograms per year in the last two years in consultation with a physician who is qualified to interpret mammography under the MQSA; and successful completion of at least 4 hours of Category 1 continuing medical education in medical radiation physics, and; performance of either of the following: at least XX stereotactic breast biopsies; or at least three hands-on procedures with a physician who is qualified to interpret mammography under the MQSA and has performed at least XX procedures. Maintenance of Privilege: Performance of at least XX stereotactic breast biopsies in the past 12 months; or requalification of those requirements specified under Required Previous Experience. ADMINISTRATION OF SEDATION AND ANALGESIA Requested Sedation and Analgesia See hospital policy for specific requirements and competency validation for the provision of Sedation and Analgesia by Non-Anesthesiologists. VASCULAR SURGERY PROCEDURES Requested Arterial or Venous Reconstruction Criteria: successful completion of vascular surgery fellowship training and current board certification (or active participation in the examination process leading to certification in vascular surgery) as a vascular surgeon. Required Previous Experience: Successful completion of at least XX hours of Category 1 continuing medical education in vascular surgery; or performance of at least XX vessel reconstructions in the past three years. Maintenance of Privilege: Performance of at least XX vessel reconstructions in the past 12 months; or requalification of those requirements specified under Requirements and Required Previous Experience. Requested Urgent or Emergent Abdominal Aortic Aneurysm (AAA) repair, grafting, stenting Criteria: successful completion of vascular surgery fellowship training and current board certification (or active participation in the examination process leading to certification in vascular surgery) as a vascular surgeon. Required Previous Experience: Successful completion of at least XX hours of Category 1 continuing medical education in vascular surgery; or performance of at least XX AAA repairs in the past three years; or requalification of those requirements specified under Requirements and Required Previous Experience. Maintenance of Privilege: Performance of at least XX vessel reconstructions in the past 12 months; or requalification of those requirements specified under Requirements and Required Previous Experience. Requested Insertion of Inferior Vena Cava Filter (IVF) Criteria: successful completion of vascular surgery fellowship training and current board certification (or active participation in the examination process leading to certification in vascular surgery) as a vascular surgeon. Required Previous Experience: Successful completion of 2015 Teaching Tool For Discussion Purposes Only v1

19 (This is an educational privilege set intended for discussion purposes only as part of NAMSS presentation not intended for use/incomplete document) at least XX hours of Category 1 continuing medical education in vascular surgery; or performance of at least XX IVC Filter insertions in the past three years; or requalification of those requirements specified under Requirements and Required Previous Experience. Maintenance of Privilege: Performance of at least XX vessel reconstructions in the past 12 months; or requalification of those requirements specified under Requirements and Required Previous Experience Teaching Tool For Discussion Purposes Only v1

20 (This is an educational privilege set intended for discussion purposes only as part of NAMSS presentation not intended for use/incomplete document) Acknowledgement of Practitioner Applicant: I have requested only those privileges for which by education, training, current experience and demonstrated successful performance I am qualified to perform and for which I wish to exercise at the Hospital, and I understand that: (a) (b) In exercising any clinical privilege granted, I am constrained by Hospital and Medical Staff policies and rules/regulations applicable generally and any applicable to the particular situation. 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 or related documents. Signed: Date: Department Chair/Division Chief Recommendation(s) I have reviewed the requested clinical privileges and supporting documentation for the abovenamed applicant and make the following recommendation(s): Recommend all requested privileges Recommend privileges with the following conditions/modifications: Do not recommend the following requested privileges (Requires notation in the Note section below): Privilege Condition/Modification/Explanation Notes: Division Chief Signature: Department Chair Signature: Date: Date: **********For Medical Staff Office Use Only ********** 2015 Teaching Tool For Discussion Purposes Only v1

21 (This is an educational privilege set intended for discussion purposes only as part of NAMSS presentation not intended for use/incomplete document) Credentials Committee Recommendation: Date: Medical Executive Committee Recommendation: Date: Governing Body Action: Date: Effective Dates : / / to / / Correspondence/Notes: TAKE AWAYS FROM EDUCATIONAL SURGERY PRIVILEGE SET REVIEW REVIEW AND DISCUSS NEED FOR ORTHO, VASCULAR, GYN, BREAST AND ANY OTHER INCIDENTAL KINDS OF SURGICAL MANAGEMENT AND PROCEDURES THAT A GENERAL SURGEON MAY PERFORM AT THE HOSPITAL REVIEW AND DISCUSS MINIMUM REQUIREMENTS OF ELIGIBILITY TO REQUEST PRIVILEGES AND VOLUME FOR MAINTENANCE OF PRIVILEGES (NEGOTIATED) HAVE LEGAL REVIEW, APPROVE, BUILD SPECIFICS AS APPLICABLE (STATE STATUTE, APPLICANT ATTESTATIONS, FORMAL APPLICATIONS, OTHER LEGAL LANGUAGE) THINK MAJORITY OF PRACTITONERS FOR CORE PRIVILEGE CONTENT DISCUSS NEED FOR SPECIAL REQUEST PRIVILEGES VS. NEW PRIIVLEGE SET CREDENTIALS COMMITTEE MAY SERVE THE TEAM AS GO TO FOR PRIVILEGE SET DISCUSSION AND FIRST APPROVAL IF YOU HAVE SEEN ONE PRIVILEGE SET, YOU HAVE SEEN ONE PRIVILEGE SET PRIVILEGE SETS ARE ESSENTIAL DOCUMENTS THAT REQUIRE TIME, EFFORT, CONSIDERATION AND PATIENCE TO CORRECTLY BUILD 2015 Teaching Tool For Discussion Purposes Only v1