SPECIALTY OF TRANSPLANT SURGERY Delineatin f Clinical Privileges Criteria fr granting privileges: Maintain current General Surgery clinical privileges at the facility Current certificatin by the American Bard f Surgery Successful cmpletin f an ACGME, accredited pst-graduate training prgram in General Surgery and bard certificatin within 5 years f prgram cmpletin. And One year frmal transplant fellwship training and ne year f experience t cmplete a tw year frmal transplant fellwship at a transplant prgram meeting UNOS membership criteria. 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. Current clinical cmpetence is described 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 and/r age specific (adult, pediatric, nenatal). This shuld nt be cnfused with Fcused Prfessinal Practice Evaluatin (FPPE) FPPE: an evaluatin f clinical cmpetence f all new privileges as perfrmed at the specific licensed MLH facility (MHMH, MHOBH) 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: Bard apprved: March, 2011, Revised: 5/20/13, 1/15/14, 4/16/14, 8/17/16 1
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 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. Onging Prfessinal Perfrmance Evaluatin (OPPE) OPPE is evaluated 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. Bard apprved: March, 2011, Revised: 5/20/13, 1/15/14, 4/16/14, 8/17/16 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 Transplant Surgery Cre Maintain current General Surgery clinical privileges Current certificatin by the American Bard f Surgery. Successful cmpletin f an ACGME accredited pst-graduate training prgram in general surgery and bard certificatin within 5 years f cmpletin And One year frmal transplant fellwship training and ne year f experience t cmplete a tw year frmal transplant fellwship at a transplant prgram meeting UNOS membership criteria. 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. 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. Use f Laser Cmpletin f an apprved eight hur minimum CME curse which includes training in laser principles and safety, basic laser physics, laser tissue interactin, discussins f the clinical specialty field and hands-n experience with lasers. A letter utlining the cntent and successful cmpletin f curse must be submitted, r dcumentatin f successful cmpletin f an apprved residency in a specialty r subspecialty which included training in laser principles and safety, basic laser physics, laser tissue interactin, discussins f the clinical specialty field and a minimum f six hurs bservatin and hands- Department chair recmmendatin will be btained frm primary practice facility. Case lg dcumenting at least 5 prcedures within the previus 24 mnths. Bard apprved: March, 2011, Revised: 5/20/13, 1/15/14, 4/16/14, 8/17/16 3
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 Renal/Pancreas Transplant Liver Transplant Laparscpic Prcedures n experience with lasers. One year frmal transplant fellwship training and ne year f experience t cmplete a tw year frmal transplant fellwship at a transplant prgram meeting UNOS membership criteria. One year frmal transplant fellwship training and ne year f experience t cmplete a tw year frmal transplant fellwship at a transplant prgram meeting UNOS membership criteria. If applying directly frm r within five (5) years f training, dcumentatin frm training directr regarding qualificatins and experience. Case lg dcumenting the perfrmance f at least 20 prcedures within the previus 24 mnths Case lg dcumenting the perfrmance f at least 20 prcedures within the previus 24 mnths, as either primary r 1 st assist Case lg dcumenting the perfrmance f at least 5 prcedures within the previus 12 mnths Case lg dcumenting the perfrmance f at least 15 prcedures within the previus 24 mnths Case lg dcumenting the perfrmance f at least 20 prcedures within the previus 24 mnths, as either primary r 1 st assist Case lg dcumenting the perfrmance f at least 5 prcedures within the previus 24 mnths If nt applying directly frm training, dcumentatin f hands n curse r training under a preceptr r accredited fellwship (may be mdified by the department chair upn evidence f prir experience), And Recmmendatin f the medical directr r department chair f the facility. Bard apprved: March, 2011, Revised: 5/20/13, 1/15/14, 4/16/14, 8/17/16 4
Transplant Surgery Cre Privileges: Includes privileges t admit, evaluate, diagnse and treat slid rgan transplant patients and perfrm rutine prcedures including thse listed belw: gan prcurement frm deceased r living dnrs Selectin f recipient Selectin f dnr (living r deceased) Knwledge and interpretatin f histcmpatibility and tissue typing Immediate pstperative care Pstperative transplant care Management f immunsuppressive drugs Management f allgraft dysfunctin Interpretatin f ancillary tests fr allgraft dysfunctin Perfrming allgraft bipsy Interpretatin f allgraft bipsy Management f cmplicatins f allgraft Lng term patient care Renal Transplant: Pancreas Transplant: Liver Transplant: Admit, evaluate, diagnse, cnsult and manage patients f all ages except as specifically excluded frm practice with renal dysfunctin r end stage renal disease requiring kidney transplantatin Admit, evaluate, diagnse, cnsult and prvide surgical care t patients f all ages except as specifically excluded frm practice with end stage pancreatic disease requiring pancreas transplantatin Admit, evaluate, diagnse, cnsult and manage patients f all ages except as specifically excluded frm practice with liver dysfunctin r end stage liver disease requiring liver transplantatin 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. Administratin f mderate sedatin: See Credentialing Plicy fr Sedatin and Analgesia by Nn-Anesthesilgists. Requires: Separate DOP, ACLS, NRP r PALS certificatin Bard apprved: March, 2011, Revised: 5/20/13, 1/15/14, 4/16/14, 8/17/16 5
Transplant Surgery Clinical Privileges Check belw the particular privileges desired in Transplant Surgery fr each facility: Privilege Descriptin Age Limitatins Transplant Surgery Cre Renal Transplant Pancreas Transplant Liver Transplant Special Laparscpic Prcedures 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 Infants Children & Adlescents (0-28 days) (29 days 2 Years) (2-18 years) Adults & Adlescents (13 & Abve) 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: 5/20/13, 1/15/14, 4/16/14, 8/17/16 6