Initial privileges (initial appintment) Renewal f privileges (reappintment) Expansin f privileges (mdificatin) INSTRUCTIONS All new applicants must meet the fllwing requirements as apprved by the UNM SRMC Bard f Directrs effective: 03/21/2012 Applicant: Check ff the "Requested" bx fr each privilege requested Applicants have the burden f prducing infrmatin deemed adequate by the hspital fr a prper evaluatin f current cmpetence, current clinical activity, and ther qualificatins, and fr reslving any dubts related t qualificatins fr requested privileges Clinical Service Chief: Check the apprpriate bx fr recmmendatin n the last page f this frm If recmmended with cnditins r nt recmmended, prvide cnditin r explanatin n the last page f this frm Other requirements: Nte that privileges granted may be exercised nly at UNM SRMC and in setting(s) that have the apprpriate equipment, license, beds, staff, and ther supprt required t prvide the services defined in this dcument Site-specific services may be defined in hspital r department plicy This dcument is fcused n defining qualificatins related t cmpetency t exercise clinical privileges The applicant must als adhere t any additinal rganizatinal, regulatry, r accreditatin requirements that the rganizatin is bligated t meet QUALIFICATIONS FOR GASTROENTEROLOGY AND ENDOSCOPY CLINICAL PRIVILEGES T be eligible t apply fr cre privileges in Gastrenterlgy and Endscpy Clinical Privileges, the initial applicant must meet the fllwing criteria: Successful cmpletin f an Accreditatin Cuncil fr Graduate Medical Educatin (ACGME) r American Ostepathic Assciatin (AOA) accredited residency in internal medicine fllwed by successful cmpletin f an accredited fellwship in Gastrenterlgy and Endscpy Practice Area Cde: SRMC-Gastr Versin Cde: 03-2014a Page: 1
AND UNM SRMC Current subspecialty certificatin r active participatin in the examinatin prcess with achievement f certificatin within 3 years leading t subspecialty certificatin in Gastrenterlgy and Endscpy Clinical by the American Bard f Internal Medicine r achievement f a certificate f added qualificatins in Gastrenterlgy and Endscpy Clinical Privileges by the American Ostepathic Bard f Internal Medicine Nt withstanding the freging, applicants fr clinical privileges may seek an exceptin t this Bard Certificatin requirement under Sectin 2004 f the Bylaws f the Medical Staff f UNM Sandval Reginal Medical Center (the "Medical Staff Bylaws") and may be granted clinical privileges if such applicant is determined, in accrdance with Sectin 2004 f the Medical Staff Bylaws, t have qualified fr ne r mre f these exceptins Required previus experience: Applicants fr initial appintment must be able t demnstrate the prvisin f Gastrenterlgy and Endscpy treatment fr inpatient, utpatient, r cnsultative services, reflective f the scpe f privileges requested, r demnstrate successful cmpletin f an ACGME- r AOA-accredited residency, clinical fellwship, r research in a clinical setting within the past 12 mnths Reappintment requirements: T be eligible t renew cre privileges in Gastrenterlgy and Endscpy, the applicant must meet the fllwing maintenance f privilege criteria: Current demnstrated cmpetence and an adequate vlume f experience (inpatient, utpatient, r cnsultative services) with acceptable results, reflective f the scpe f privileges requested, fr the past 24 mnths based n the results f nging prfessinal practice evaluatin and utcmes Evidence f current ability t perfrm privileges requested is required f all applicants fr renewal f privileges Practice Area Cde: SRMC-Gastr Versin Cde: 03-2014a Page: 2
GASTROENTEROLOGY AND ENDOSCOPY CORE PRIVILEGES Privileges t admit, evaluate, diagnse, and prvide treatment r cnsultative services t patients with illnesses, injuries, and disrders f the stmach, intestines, and related structures, such as esphagus, liver, gallbladder and pancreas Requested CORE PROCEDURES LIST This list is a sampling f prcedures included in the cre It is nt intended t be an all-encmpassing list, but rather is reflective f the categries/types f prcedures included in the cre T the applicant: If yu wish t exclude any prcedures, please strike thrugh thse yu d nt wish t request, then initial and date CORE PROCEDURES FOR GASTROENTEROLOGY AND ENDOSCOPY 1 ERCP (diagnstic & therapeutic) 2 Diagnstic EGD 3 Ttal clnscpy with snare plypectmy 4 PEG 5 Liver Bipsy 6 Nnvariceal hemstasis 7 Variceal hemstasis 8 Flexible Sigmidscpy 9 Pneumatic dilatin fr achalasia 10 Esphageal stent placement Practice Area Cde: SRMC-Gastr Versin Cde: 03-2014a Page: 3
SPECIAL NON CORE PRIVILEGES(See Specific Criteria) If desired, nncre privileges are requested individually in additin t requesting the cre Each individual requesting nncre privileges must meet the specific threshld criteria gverning the exercise f the privilege requested including training, required previus experience, and fr maintenance f clinical cmpetence Internal Medicine Privilege Check here t request Internal Medicine privileges frm (Separate frm) Administratin f Sedatin and Analgesia privileges See hspital plicy fr sedatin and analgesia by nn-anesthesilgists Check here t request Mderate Sedatin privileges frm (Separate frm) Limited Ultrasund fr Guided Prcedure Check here t request Limited Ultrasund Guided Prcedure privileges frm (Separate frm) Practice Area Cde: SRMC-Gastr Versin Cde: 03-2014a Page: 4
Acknwledgment 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 UNM SRMC, and I understand that: a In exercising any clinical privileges granted, I am cnstrained by hspital 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 Signed Date Clinical Service Chief's Recmmendatin I have reviewed the requested clinical privileges and supprting dcumentatin fr the abve-named applicant and make the fllwing recmmendatin(s): Recmmend all requested privileges Recmmend privileges with the fllwing cnditins/mdificatins: D nt recmmend the fllwing requested privileges: PrivilegeCnditin/Mdificatin/Explanatin 1 2 3 4 Ntes: Print NameSignature Date Clinical Service Chief r Designee Signature Practice Area Cde: SRMC-Gastr Versin Cde: 03-2014a Page: 5