ADVANCED WOUND CARE Delineatin f Clinical Privileges Criteria fr granting privileges: Maintain clinical privileges in a primary specialty Maintain current Advanced Cardiac Life Supprt (ACLS) certificatin Prvide dcumentatin f residency training in Hyperbaric Medicine and satisfactry evidence frm the prgram directr f satisfactry cmpletin Bard Certificatin in Hyperbaric Medicine Prvide dcumentatin f training in the past year in an accredited Hyperbaric Medicine prgram. Prvide certificatin f satisfactry attendance at a curse in Hyperbaric Medicine and Wund Care as apprved by the American Cllege f Hyperbaric Medicine and/r the Undersea and Hyperbaric Medical Sciety cnsisting f at least 40 hurs CME credits. 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 (acute hspital care, surgery center) 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. Bard apprved: March, 2011 1
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. 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 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 Advanced Wund Cre Debridement-Subcutaneus & Muscle Debridement-Subcutaneus & Muscle/Bne Prvide dcumentatin f residency training in Hyperbaric Medicine and satisfactry evidence frm the prgram directr f satisfactry cmpletin Bard Certificatin in Hyperbaric Medicine Dcumentatin f training in the past year in an accredited Hyperbaric Medicine prgram Prvide certificatin f satisfactry attendance at a curse in Hyperbaric Medicine and Wund Care as apprved by the American Cllege f Hyperbaric Medicine and/r the Undersea and Hyperbaric Medical Sciety cnsisting f at least 40 hurs CME credits successful cases Maintain current ACLS certificatin. Case lg dcumenting 6 Case lg dcumenting 6 I & D, Abscess, Cmplex Case lg dcumenting 6 Cauterizatin Case lg dcumenting 6 Bipsy, Bne Case lg dcumenting 6 Preparatin & applicatin f skin substitutes (bilaminate & dermal) Case lg dcumenting 6 Department chair recmmendatin will be btained frm primary practice facility. Maintain current ACLS certificatin. Data btained frm MHMH surces dcumenting 6 previus 24 mnths. If the numbers btained d nt meet the minimum requirements, the practitiner will be required t submit additinal case lgs frm ther facilities. 6 hurs CME credits frm the previus tw years applicable t privileges in wund care. Case lg dcumenting 6 Case lg dcumenting 6 Case lg dcumenting 6 Case lg dcumenting 6 Case lg dcumenting 6 Case lg dcumenting 6 Bard apprved: March, 2011 3
Advanced Wund Care Cre Privileges: Debridements: Skin - Partial Thickness Skin - Full Thickness Skin and Subcutaneus Tissue Hyperbaric Therapy Physician Supervisin-HBO 2 Tx Other Prcedures I & D, Abscess, simple Bipsy Skin TcpO 2 interpretatin - Multi Level Dppler Study Interpretatin Vacuum Assisted Clsure Applicatin Special privileges fr Wund Care t be determined by demnstratin f cmpetencies thrugh prvisin f case lgs r fcused prfessinal practice evaluatins, r apprved nging cre privileges with MHMH surgical r surgical specialty department as apprpriate. 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 4
Advanced Wund Care Clinical Privileges Check belw the particular privileges desired in Advanced Wund Care fr each facility: Privilege Descriptin Age Limitatins Advanced Wund Care Cre Special Privileges Debridements subcutaneus muscle Debridements subcutaneus muscle/bne I & D, Abscess, Cmplex Cauterizatin Bipsy, Bne 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 Infants Nenates Children & Adlescents (29 days (0-28 days) (2-18 years) 2 Years) Adults & Adlescents (13-& Abve) Preparatin and applicatin f skin substitutes (bilaminate & dermal) Limitatins Clinical privileges are granted nly t the extent privileges are available at each facility. Lightly shaded areas represent privileges granted nly t thse practitiners hlding a valid cntract t prvide thse services. 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 5