DEPARTMENT OF SURGERY OTOLARYNGOLOGY-HEAD AND NECK SURGERY CLINICAL PRIVILEGES REQUEST FORM Appointee: Date: NOTE: This request should be returned to: Medical Staff Affairs Office, Hershey Medical Center, Box 850, Hershey, PA 17033 and it will be forwarded to the Clinical Department for approval/disapproval. Initial Appointment: Indicate those privileges by virtue of training and current clinical practice for which you wish to be appointed. When requesting specialized privileges, those marked by an asterisk or those not listed below, please justify your qualifications (clinical experience or specialized training) in the Comments Section. Reappointment: Verify your privileges and add or delete according to your current clinical practice patterns. When requesting additional privileges, please justify your request by providing information demonstrating current clinical competence in the Comments Section. Board Certification/Eligibility Requirements: As per Medical Staff Bylaws, Rules & Regulations, Article III, Section 3.2.1 (c) - Basic Qualifications licensed physicians, dentists and Specified Professionals who are (in the case of physicians) certified and will maintain appropriate certification by a clinical specialty board, are eligible for such board certification or possess, by virtue of training and experience, comparable competence; shall be qualified for membership on the Professional Clinical Staff and approved by the Credentials Committee. SIGNATURE: I request specific clinical privileges as indicated by me on the following pages: Signature: Date:
Levels of Care: Indicate request for privileges by patient unit and age group. Location/Age Group Requested Recommended Not Recommended Emergency Department Outpatient Practice Site General Inpatient Care Unit Intermediate Care Unit Critical Care Unit with Consultant **Critical Care Unit without Consultant Care of Adults Care of Children **Qualifications: Must have all of the qualifications needed for specialty privileges in the specialty board and in addition, have: 1. Recent training or experience in the care of critically ill patients with multi-system disease, 2. Satisfactory to the Chairperson of the respective department and the Chief of the Medical Staff; and/or 3. Eligibility for or added certification in Critical Care Medicine if available in the specialty. 2
Appointee: Date: Initial Renewal DEPARTMENT OF SURGERY OTOLARYNGOLOGY-HEAD AND NECK SURGERY Last Name First Name M.I. Division: Check one: MD DO BOARD CERTIFICATION OR SPECIAL CERTIFICATE (1) EXPECTED DATE OF EXAMINATION DATE CERTIFIED (Yr) DATE RECERTIFIED (To be Recertified) (Yr) (2) (3) Initial Appointment Reappointment I request initial privileges I request my Present Privileges be continued without modification. (Please complete a new Privilege Form whether or not you wish changes in your privileges.) I request Increased Privileges as indicated on attached Privilege Form. (Documentation of training/experience must be included to support increase.) I request Decreased Privileges as indicated on attached Privilege Form. DEFINITION OF PRIVILEGE LEVELS: LEVEL I: Level I privileges are the core privileges which may be requested by a practitioner who meets the qualifications and criteria listed below. Place a check mark in the requested column next to the Level I privilege bundles you desire. LEVEL II: Level II privileges are Advanced Privileges, requiring documented special expertise and/or special training with certification, where appropriate. Place a check mark in the requested column next to the Level II bundles you desire. Refer to the enclosed list and also indicate the privileges in each bundle you do not want. Criteria are available from the Department Office.
PRIVILEGES LEVEL LEVEL I (CORE) QUALIFICATIONS AND CRITERIA 1. Successful completion of an accredited residency in the U.S. or Canada in Otolaryngology-Head and Neck Surgery or equivalent training. 2. Board Certification or active participation in the examination process or intent to enter the Board Examination process at the time of appointment. 3. Demonstration of ongoing technical competence in the past two years in your entire practice that includes activity in each bundle you are requesting privileges for. Exceptions must be submitted in writing to the Chair s office. 4. A Penn State Hershey faculty appointment. LEVEL II (ADVANCED) A. FORMAL RESIDENCY TRAINING IN OTOLARYNGOLOGY-HEAD AND NECK SURGERY Prerequisite training must include satisfactory completion of an accredited surgical training program, with subsequent certification by the American Board of Otolaryngology, or its equivalent, as required by the institution and active engagement in the MOC process. Board eligible surgeons may obtain privileges but must be Board certified within 5 years after completing their training. Surgeons trained outside of the United States must have equivalent training and qualifications as judged by the Chair of the Department and the Division Chief. B. FORMAL TRAINING IN THE SPECIALTY PERTINENT TO REQUESTED PRIVILEGES Must have successfully completed a residency and/or fellowship program that incorporated a structured experience in the specialty area being requested. Supply the appropriate documentation of training with subsequent certification by the American Board of Otolaryngology, Specialty Board or its equivalent and active engagement in the MOC process. Specialty Board eligible surgeons may obtain privileges but must be Board certified within 5 years after completing their training. C. PRACTICAL EXPERIENCE 1. Applicant s Experience Documented training experience that includes an appropriate volume of cases in the category of the surgical procedure for which privileges are being considered. Requests for acquisition of privileges must be in the area of the individuals clinical expertise and area of practice within the institution. The Chair of Surgery should determine the adequacy of this experience. D. FOLLOW-UP It is necessary to document that the surgeon has in place a process to monitor outcomes. 4
Appointee: Date: Initial Renewal RE-PRIVILEGING IN PREVIOUSLY PRIVILEGED AREAS When a surgeon wants to be credentialed in an area he/she previously had privileges, the following process is to be followed. A. FORMAL TRAINING IN AN OTOLARYNGOLOGY-HEAD AND NECK SURGERY RESIDENCY PROGRAM Prerequisite training must include satisfactory completion of an accredited surgical residency program, with subsequent certification by the American Board of Otolaryngology or its equivalent as required by the institution and active engagement in the Maintenance of Certification process. B. FORMAL TRAINING IN THE SPECIALTY PERTINENT TO REQUESTED PRIVILEGES The surgeon must have received the appropriate training in the past. C. PRACTICAL EXPERIENCE 1. Applicant s Previous Experience Documentation of previous training experience that includes an appropriate volume of cases in the category of the surgical procedure for which privileges are being reconsidered. 2. Applicant must complete a formal course for the specific category of specialized procedure if appropriate and provide supporting documentation. 3. Experience with Preceptor and/or Proctor The surgeon requesting the re-privileging must be proctored by a surgeon to be determined by the Chair or his/her designee for a suitable number of procedures. The Chair will determine the specific role and qualifications of the proctor. E. FOLLOW-UP It is necessary to document that the surgeon has in place a process to document outcomes.
PRIVILEGING IN NEW AREAS When a surgeon wants to be privileged to perform new procedures, the following process is to be followed. A. FORMAL TRAINING IN AN OTOLARYNGOLOGY-HEAD AND NECK SURGERY RESIDENCY PROGRAM Prerequisite training must include satisfactory completion of an accredited surgical residency program, with subsequent certification by the American Board of Otolaryngology or its equivalent as required by the institution and active engagement in the Maintenance of Certification process. B. PRACTICAL EXPERIENCE 1. Applicant s Previous Experience Documentation of previous training experience that includes an appropriate volume of cases in the category of the surgical procedure for which privileges are being reconsidered. 2. Applicant must complete a formal course for the specific category of specialized procedure if appropriate and provide supporting documentation. 3. Experience with Preceptor and/or Proctor The surgeon requesting the privileging must be proctored by a surgeon to be determined by the Chair or his/her designee for a suitable number of procedures. The Chair will determine the specific role and qualifications of the proctor. C. FOLLOW-UP It is necessary to document that the surgeon has in place a process to monitor outcomes. 6
Appointee: Date: Initial Renewal LEVEL I CORE PRIVILEGES EVALUATION & CLINICAL CARE ENDOSCOPY FACIAL FRACTURES/CRANIOMAXILLOFACIAL GRAFTS / FLAPS LARYNX / TRACHEA NECK NOSE / MAXILLA / SINUS ORAL CAVITY / PALATE / NASOPHARYNX OTOLOGIC COSMETIC SKIN AND SOFT TISSUE (SST) LASER ADMINISTRATION OF SEDATION AND ANALGESIA OTHER: Recommended Not Recommended Recommended with the following modification(s) and reason(s):
LEVEL II ADVANCED PRIVILEGES MICROVASCULAR LARYNX / TRACHEA OTOLOGIC CRANIOMAXILLFACIAL ROBOTIC (contact Perioperative Services for Robotic Privileging) OTHER: Recommended Not Recommended Recommended with the following modification(s) and reason(s): 8
Appointee: Date: Initial Renewal Acknowledgement of Practitioner: I have requested only those privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform, and that I wish to exercise at the Penn State Milton S. Hershey Medical Center, and I understand that: (a) In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies and rules applicable generally and any applicable to the particular situation. (b) Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such a situation my actions are governed by the applicable section of the medical staff bylaws or related documents. Applicant Signature: Date: Conditions/Modifications: The requested clinical privileges have been approved by the appropriate Department Chief/Chair with the following conditions, modifications, and the explanation for same. Privilege Condition/Modification Explanation: Department Chair/Chief Recommendations: I have reviewed the requested clinical privileges and supportive documentation for the above named applicant and recommend action on the privileges as noted above. Division Chief: Date: Department Chair: Date: Dillon/Fedok