INITIAL: [ ] RENEWED: [ ] DATE: ADDITIONAL: [ ] Privileges are granted for Sutter General Hospital, Sutter Memorial Hospital, Sutter Center for Psychiatry, Sutter Oaks Midtown or Capitol Pavilion Surgery Center and exercise of privileges is based on the type of care, treatment and services provided at each facility. If you plan to use radiology equipment including the fluoroscope, you must provide a current operating permit that is issued by the Radiologic Health Branch of the California Department of Health Services. To request Privileges, please place an X in the request column. In box, indicate the number of identified procedures performed in previous 24 months from any facility. If the condition/privilege you desire is not included on this form, please submit a separate written request along with appropriate documentation of training and/or experience. Request Privilege Appointment [ ] Admitting Privileges None None None [ ] History & Physical Privileges - A None None None General requirements for all applicants Documentation of experience in the previous two years as a primary surgeon in at least six cases as well as the procedures being requested from either a residency or fellowship case listing (if the applicant recently completed training) or a case listing from where the applicant has been practicing. Some procedure specific criteria may also require a letter from the Director or Chief of Services. Request Head and Neck Appointment [ ] Parotidectomy - A [ ] Submandibular gland - A [ ] Maxillectomy [ ] Composite resection [ ] Radical neck [ ] Laryngectomy [ ] Thyroid surgery [ ] Tracheotomy [ ] Congenital cysts - A [ ] Head and neck malignancies - A [ ] Implantation of vagal nerve stimulator First six (6) cases must be proctored regardless of the type of procedure Six (6) cases as a primary surgeon and any procedure specific requirements -A- INDICATES OUTPATIENT Page 1 of 7
Request Otologic Appointment [ ] Myringotomy and tube - A [ ] Tympanoplasty - A [ ] Mastoidectomy - A [ ] Stapedectomy - A [ ] Facial nerve - A [ ] Acoustic neuroma [ ] Cochlear implant First two (2) cases None Request Endoscopic. Appointment [ ] Laryngoscopy - A [ ] Esophagoscopy - A [ ] Bronchoscopy A [ ] Endoscopic sinus surgery - A Request General Appointment [ ] Tonsillectomy & adenoidectomy A [ ] Septoplasty A [ ] Cardwell Luc A [ ] Ethmoidectomy A [ ] Frontal sinus surgery A [ ] Hypophysectomy, transnasal -A- INDICATES OUTPATIENT Page 2 of 7
LASERS General requirements for all applicants Appointment Surgeons requesting laser privileges must show that they have the appropriate training and/or experience in the safe use of laser equipment by meeting one of the following criteria: l. Graduation from an approved training program in Surgery where laser application was part of the active training format. Verification shall be in the form of a letter from the Director of the training program. OR None None 2. Documentation of successful completion of a section approved post-graduate course with hands-on experience, designed to familiarize practicing physicians with laser technologies, safety and application. Request Types of Lasers Appointment [ ] Argon/KTP Laser A [ ] Yag Laser A [ ] CO 2 Laser - A Request Laser Procedures Appointment [ ] Airway lesions A [ ] Otologic procedures - A [ ] Neurotologic procedures (i.e., acoustic neuroma) [ ] Skin lesions - A [ ] Nasal lesions - A -A- INDICATES OUTPATIENT Page 3 of 7
Request Plastic and Reconstructive Appointment [ ] Laceration and scar revision - A [ ] Rhinoplasty A [ ] Blepharoplasty - A [ ] Rhytidectomy A [ ] Otoplasty A [ ] Dermabrasion A [ ] Chemical Peel A [ ] Hair transplant A [ ] Nasal fracture A [ ] Non-mandibular facial fractures (i.e., zygomas, maxillary, nasal fractures) A [ ] T.M.J. surgery A [ ] Regional flaps/grafts A [ ] Cleft lip/palate A [ ] Facial implants - A [ ] Facial osteotomies/orthognathic surgery [ ] Microvascular surgery Request Plastic and Reconstructive Appointment [ ] Suction assisted lipectomy (head & neck) Training and Experience: None A surgeon performing this procedure must have a thorough knowledge of the specific physiologic effects of the cannula and the removal of tissue, the potential complications and ramifications of these complications. The surgeon must also be qualified to treat these potential complications and their consequences. Thorough knowledge of the deep surgical anatomy of the specific region of the body to be treated. Without this -A- INDICATES OUTPATIENT Page 4 of 7
Request Plastic and Reconstructive Appointment knowledge, serious complications may be overlooked and patient safety jeopardized. Evidence of surgical anatomical competence exists when a surgeon has completed an American Board of Medical Specialties accredited residency in which a broad spectrum of surgical procedures were performed within the region of the body to undergo suction assisted lipectomy. A through knowledge of fluid and electrolyte management is fundamental to the safe performance of suction assisted lipectomy. Evidence of competence in the management of fluid and electrolyte abnormalities exists when a surgeon s residency training included a broad spectrum of critical care responsibilities. The surgeon performing the procedure must also be competent in and hold privileges for performing open dermo-lipectomy of the region of the body to be treated. Provide documentation of specific training of this technique within the given region of the body to be treated. Evidence of this training exists when it is contained within the curriculum of the surgeon s completed ABMS accredited residency or when the surgeon has successfully completed an approved symposium with the following criteria: In addition to audiovisual instruction, the symposium or course must include live presentation of cases and the open discussion of the following. The course must also provide an opportunity for supervised hands on experience in the use of the specific instrumentation to be utilized to perform the procedure: a. Basic science, surgical and physiologic concepts b. Surgical technique c. Preoperative evaluation d. Preoperative marking e. Postoperative treatment and recovery f. Recognition and treatment of complications -A- INDICATES OUTPATIENT Page 5 of 7
Request Plastic and Reconstructive Appointment SPECIFIC REQUIREMENTS FOR PRIVILEGES IN SUCTION ASSISTED LIPECTOMY BY REGION OF THE BODY: Head and Neck 1. Completion of an American Board of Medical Specialties accredited residency in Plastic and Reconstructive Surgery or Otolaryngology (Head and Neck surgery) 2. Documentation of specific training as described in section 6. Request Adult Appointment [ ] Continuing care privileges in critical care units Continuing care privileges in the critical care units includes the ability to see and care for the patient in the critical care setting. The privilege does not include ventilator management, elective intubation or insertion of invasive monitors. Requests for those privileges must be requested separately from continuing care privileges in critical care units. [ ] Post-Acute Care Privileges Continuing care of the patient in the Sutter Transitional Care Unit or Sutter Oaks Midtown. Request Pediatrics Appointment [ ] Surgical and general pediatric continue care privileges in the pediatric ICU where there are no other medical or child life issues involved or the child must be managed in tandem with an appropriate member of the pediatric staff. -A- INDICATES OUTPATIENT Page 6 of 7
Request Pediatrics con d Appointment First three (3) cases by a surgeon who holds comprehensive pediatric continuing care privileges or by a Pediatric or Neonatal Critical Care Specialist. [ ] Comprehensive pediatric surgical and medical continuing care privileges (including pediatric and neonatal management). Documentation of training and experience (within the previous two years) in the comprehensive management of pediatric patients in the Neonatal or Pediatric Intensive Care Units is required. Documentation must be in the form of a letter from the Director of the training program or from the Chief of Services of another JCAHO accredited hospital. None Please Note: The surgeon in charge is responsible for judging whether or not an assistant is required for any procedure listed. Acknowledgment of Practitioner: I understand that (a) in exercising clinical privileges granted, I am constrained by Medical Staff Policies and Procedures, Rules and Regulations, and (b) 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. I hereby attest to having performed the stipulated number of procedures as indicated above, thereby meeting the criteria for those privileges I have requested. ************************************************************************************************************************ COMMITTEE APPROVALS Surgery QI/Administrative Committee Date: TEMPORARY PRIVILEGE APPROVAL Or Dept Chief (in lieu of mtg) Credentials Committee Date: Department Chief: Medical Executive Committee Date: Board of Directors Date: Date: FORM APPROVAL Otolaryngology Surgery Section Date: 12/10/09 Surgery Administrative Committee Date: 4/1/10 Credentials Committee Date: 4/13/10 Medical Executive Committee Date: 4/27/10 Medical Policy Committee Date: 5/6/10 Board of Directors Date: 5/10/10 -A- INDICATES OUTPATIENT Page 7 of 7