SPECIALTY OF PEDIATRICS Delineatin f Clinical Privileges Criteria fr granting privileges: Current bard certificatin in Pediatrics by the American Bard f Pediatrics r the American Ostepathic Bard f Pediatrics. Or Successful cmpletin f an accredited ACGME r AOA accredited pst-graduate training prgram in Pediatrics and bard certificatin within 5 years f prgram cmpletin. Applicants will be requested t prvide dcumentatin f practice and current clinical cmpetence as defined n the attached cmpetency grid. Applicants have the burden f prducing infrmatin deemed adequate by the hspital fr a prper evaluatin f current clinical cmpetence, and ther qualificatins and fr reslving any dubts. Current Clinical Cmpetence - MLH In additin t the required educatin, experience and/r training specified n each DOP (Delineatin f Privilege) frm, dcumentatin f current clinical cmpetence is required. TJC (The Jint Cmmissin) describes current clinical cmpetence as having perfrmed the privilege recently and perfrmed it well. Current clinical cmpetence is assessed prir t granting privileges initially and is reassessed when renewing privileges at reappintment fr maintenance f privileges. Current Clinical Cmpetence (CCC) may be lcatin specific (acute hspital care/surgery center (ASC) and/r age specific (adult, pediatric,nenatal). This shuld nt be cnfused with FPPE (Fcused Prfessinal Practice Evaluatin) FPPE: an evaluatin f clinical cmpetence f all new privileges as perfrmed at the specific licensed MLH facility (MHMH, MHOBH, Fayette, MECH) fr which they have been initially granted. This applies t privileges fr all new applicants as well as t new/additinal privileges fr current members. Bth FPPE and current clinical cmpetence assessments are privilege-specific. FPPE is cnducted during the perid after granting new/additinal privileges. FPPE must ccur at the MLH facility(ies) where privileges/membership are held. Current clinical cmpetence may be evaluated frm case lgs prvided by nn-mlh facilities. Current Clinical Cmpetence: Requirements fr New Applicants If applying directly frm training, r based n the training received in a frmal training prgram, prvider shuld submit case* lgs frm the prgram authenticated by the prgram directr alng with their recmmendatin attesting t the cmparable training, experience and qualificatins relative t the criteria fr the clinical privileges requested. If applying mre than 1 year after training cmpletin, submit the fllwing: Aggregate data frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 diagnsis cdes and the number f patients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. 1
Case lgs (see specificatins belw) fr any special privileges requested that meet the criteria specific fr the number f prcedures defined fr current clinical cmpetence. Current Clinical Cmpetence: Maintenance f Privileges fr Current Members Fr active staff members: MLH surce data will be aggregated t review cases and prcedures perfrmed. and/r special privileges, the practitiner will be required t submit additinal case lgs frm ther facilities. If this des nt meet the minimum requirement fr cre Fr curtesy staff members with lw activity and fr certain active staff with activity that has diminished and is nw lw: Department chair recmmendatin shuld be btained frm their primary facility; and the practitiner shuld submit the fllwing: Aggregate data frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 diagnsis cdes and the number f patients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm acute care r surgery center facility fr the previus 12 mnth time perid, identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Case lgs (see specificatins belw) fr any special privileges requested that meet the specific number f prcedures defined fr current clinical cmpetence. Case Lgs All required case lgs and/r prcedure lists must cntain the fllwing infrmatin at a minimum: Date, patient identifier, CPT/ICD prcedure cde, diagnsis, cmplicatins, and dispsitin, and the facility name, name/title f the persn authenticating the lg, signature, date signed, and cntact infrmatin. If the infrmatin requested is nt available, please prvide an explanatin. *A case is defined as an episde f care either cgnitive r prcedural. Fr interpretive care, case is interpretatin f ne diagnstic study. OPPE (Onging Prfessinal Perfrmance Evaluatin) The Jint Cmmissin (TJC) requires OPPE peridically (mre frequently than annually) in the facility where membership/privileges are held. T assure OPPE requirements are satisfied, the practitiner must peridically exercise the privileges in the MLH facility(ies) where he/she has membership. OPPE must ccur regularly n patient encunters in the MLH facility(ies) where privileges/membership are held. 2
Specialty/Prcedure Delineatin f Privilege Frm Educatin/Training Dcumentatin fr Initial Granting Initial Applicatin (Prf f current clinical cmpetence) FPPE Validatin f cmpetence after appintment and/r granting f a new r additinal privilege (T be cmpleted within ne year) Maintenance Requirements Pediatric Cre Current bard certificatin in Pediatrics by the American Bard f Pediatrics r the American Ostepathic Bard f Pediatrics. OR Successful cmpletin f an ACGME r AOA accredited pst-graduate training prgram in Pediatrics and bard certificatin within 5 years f cmpletin. Aggregate data frm primary practice facility fr the previus 12 mnth time perid indentifying the tp 10 diagnsis cdes and the number f inpatients per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Prcedure list frm primary practice facility fr the previus 12 mnth time perid identifying the tp 10 CPT/ICD cdes and the number f prcedures per cde. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. 5 cases including Gastrenteritis (1 case); Asthma/Brnchilitic (2 cases); FUO, fever undetermined rigin (2 cases) and/r 5 evaluatin and management f newbrn MLH Data will be btained fr active members when available, the applicant shuld supply additinal case lgs frm ther facilities HIM departments, if necessary, t meet the minimum requirement(s) t be cnsidered fr the privilege. Curtesy members shuld supply case lgs frm ther facilities HIM departments t meet the minimum requirement(s) t be cnsidered fr the privilege. Aggregate data submitted shuld include the tp 10 diagnsis cdes, with the number f inpatients per cde, and prcedure lists indicating the tp 10 CPT/ICD cdes, with the number f prcedures per cde fr the previus 12 mnths. Any cmplicatins/pr utcmes shuld be delineated and accmpanied by an explanatin. Department chair recmmendatin will be btained frm primary practice facility. Bard apprved: March, 2011, Revised 6/17/13
Pediatric Cre Privilege: Admit, evaluate, diagnse, treat and prvide cnsultatin t patients 0-18 admitted with bth cmmn illnesses and injuries including disrders cmmn t general pediatric diseases and cnditins. Access, stabilize and determine dispsitin f patients with emergency cnditins cnsistent with the Medical Staff plicy regarding emergency r cnsultative services. Privileges include but are nt limited t: Bne marrw aspiratin Burns, superficial and partial thickness I&D f superficial abscess Lcal anesthetic techniques Lumbar puncture Management uncmplicated minr clsed fractures and dislcatins Perfrm simple skin bipsy r excisin Peripheral arterial puncture Digital peripheral nerve blcks Placement f anterir and psterir nasal hemstatic packing Pre-perative and pstperative medical care fr surgical patients Remval f freign bdy by speculum, frceps, r superficial incisin Remval f nn-penetrating crneal freign bdy Suprapubic bladder aspiratin Suture uncmplicated laceratins Venipuncture Special: The physician requesting special privileges must meet the minimum criteria fr the specialty cre and demnstrate the apprpriate pst graduate training and/r demnstrate successful cmpletin f an apprved, recgnized curse when such exists, r ther acceptable experience. N special prcedures/techniques have been apprved fr Pediatric Cre. Bard apprved: March, 2011, Revised 6/17/13
Pediatric Clinical Privileges Check belw the particular privileges desired in Pediatrics fr each facility: Privilege Descriptin Pediatric Cre Please check () applicable age categries fr each privilege requested. Methdist Healthcare Memphis Hspitals (MHMH) Germantwn, Le Bnheur Medical Center, Nrth, Suth & University, Outpatient Clinics & Diagnstic Facilities Nenates (0-28 days) Infants (29 days 2 Years) Children & Adlescents (2-18 years) Methdist Healthcare Fayette Hspital (MHFH) All Peds (0-18) Methdist Healthcare Olive Branch Hspital (MHOBH) Nenates (0-28 days) Limitatins Clinical privileges are granted nly t the extent privileges are available at each facility. Darkly shaded areas represent privileges nt available t any practitiner due t the privilege nt being ffered by the facility. Acknwledgement f practitiner I have requested nly thse privileges fr which by educatin, training, current experience and demnstrated perfrmance I am qualified t perfrm and fr which I wish t exercise at the facilities indicated abve, t the extent services are available at each facility, and I understand that: (a) in exercising any clinical privileges granted, I am cnstrained by facility and medical staff plicies and rules applicable generally and any applicable t the particular situatin (b) any restrictin n the clinical privileges granted t me is waived in an emergency situatin and in such situatin my actins are gverned by the applicable sectin f the medical staff bylaws r related dcuments Physician's Signature Date Printed Name Bard apprved: March, 2011, Revised 6/17/13