SPECIALTY OF FAMILY MEDICINE Delineation of Clinical Privileges Criteria for granting privileges: Current board certification in Family Medicine by the American Board of Family Medicine or the American Osteopathic Board of Family Physicians. Or Successful completion of an accredited ACGME or AOA accredited post-graduate training program in Family Medicine and board certification within 5 years of program completion. Applicants will be requested to provide documentation of practice and current clinical competence as defined on the attached competency grid. Applicants have the burden of producing information deemed adequate by the hospital for a proper evaluation of current clinical competence, and other qualifications and for resolving any doubts. If the applicant s documentation does not meet the age-specific requirements, the applicant may request to be proctored, and apply for privileges after successful completion of proctoring. At the discretion of the Department Chair, the Pediatric Medical Staff may supervise the management of any Family Medicine Pediatric admission. Current Clinical Competence - MLH In addition to the required education, experience and/or training specified on each DOP (Delineation of Privilege) form, documentation of current clinical competence is required. Current clinical competence is described as having performed the privilege recently and performed it well. Current clinical competence is assessed prior to granting privileges initially and is reassessed when renewing privileges at reappointment for maintenance of privileges. Current Clinical Competence (CCC) may be location specific (acute hospital care/surgery center (ASC) and/or age specific (adult, pediatric, neonatal). This should not be confused with Focused Professional Practice Evaluation (FPPE) FPPE: an evaluation of clinical competence of all new privileges as performed at the specific licensed MLH facility (MHMH, MHOBH) for which they have been initially granted. This applies to privileges for all new applicants as well as to new/additional privileges for current members. Both FPPE and current clinical competence assessments are privilege-specific. FPPE is conducted during the period after granting new/additional privileges. FPPE must occur at the MLH facility(ies) where privileges/membership are held. Current clinical competence may be evaluated from case logs provided by non-mlh facilities. Current Clinical Competence: Requirements for New Applicants If applying directly from training, or based on the training received in a formal training program, provider should submit case* logs from the program authenticated by the program director along with their recommendation attesting to the comparable training, experience and qualifications relative to the criteria for the clinical privileges requested. If applying more than 1 year after training completion, submit the following: Board approved: March, 2011, Revised 4/16/14, 2/18/15, 5/17/17, 11/15/17 1
o o o Aggregate data from acute care or surgery center facility for the previous 12 month time period, identifying the top 10 diagnosis codes and the number of patients per code. Any complications/poor outcomes should be delineated and accompanied by an explanation. Procedure list from acute care or surgery center facility for the previous 12 month time period, identifying the top 10 CPT/ICD codes and the number of procedures per code. Any complications/poor outcomes should be delineated and accompanied by an explanation. Case logs (see specifications below) for any special privileges requested that meet the criteria specific for the number of procedures defined for current clinical competence. Current Clinical Competence: Maintenance of Privileges for Current Members For active staff members: MLH source data will be aggregated to review cases and procedures performed. and/or special privileges, the practitioner will be required to submit additional case logs from other facilities. If this does not meet the minimum requirement for core For courtesy staff members with low activity and for certain active staff with activity that has diminished and is now low: Department chair recommendation should be obtained from their primary facility; and the practitioner should submit the following: o o o Aggregate data from acute care or surgery center facility for the previous 12 month time period, identifying the top 10 diagnosis codes and the number of patients per code. Any complications/poor outcomes should be delineated and accompanied by an explanation. Procedure list from acute care or surgery center facility for the previous 12 month time period, identifying the top 10 CPT/ICD codes and the number of procedures per code. Any complications/poor outcomes should be delineated and accompanied by an explanation. Case logs (see specifications below) for any special privileges requested that meet the specific number of procedures defined for current clinical competence. Case Logs All required case logs and/or procedure lists must contain the following information at a minimum: Date, patient identifier, CPT/ICD procedure code, diagnosis, complications, and disposition, and the facility name, name/title of the person authenticating the log, signature, date signed, and contact information. If the information requested is not available, please provide an explanation. *A case is defined as an episode of care either cognitive or procedural. For interpretive care, case is interpretation of one diagnostic study. Ongoing Professional Performance Evaluation (OPPE) OPPE is evaluated periodically (more frequently than annually) in the facility where membership/privileges are held. To assure OPPE requirements are satisfied, the practitioner must periodically exercise the privileges in the MLH facility(ies) where he/she has membership. OPPE must occur regularly on patient encounters in the MLH facility(ies) where privileges/membership are held. Board approved: March, 2011, Revised 4/16/14, 2/18/15, 5/17/17, 11/15/17 2
Specialty/Procedure Delineation of Privilege Form Family Medicine Core Education/Training Documentation for Initial Granting Current board certification in Family Medicine by the American Board of Family Medicine or the American Osteopathic Board of Family Medicine. Or Successful completion of an ACGME or AOA accredited post-graduate training program in Family Medicine and board certification within 5 years of completion. Initial Application (Proof of current clinical competence) Aggregate data from primary practice facility for the previous 12 month time period indentifying the top 10 diagnosis codes and the number of inpatients per code. Any complications/poor outcomes should be delineated and accompanied by an explanation. Procedure list from primary practice facility for the previous 12 month time period identifying the top 10 CPT/ICD codes and the number of procedures per code. Any complications/poor outcomes should be delineated and accompanied by an explanation. FPPE Validation of competence after appointment and/or granting of a new or additional privilege (To be completed within one year) Maintenance Requirements MLH Data will be obtained for active members when available, the applicant should supply additional case logs from other facilities HIM departments, if necessary, to meet the minimum requirement(s) to be considered for the privilege. Courtesy members should supply case logs from other facilities HIM departments to meet the minimum requirement(s) to be considered for the privilege. Aggregate data submitted should include the top 10 diagnosis codes, with the number of inpatients per code, and procedure lists indicating the top 10 CPT/ICD codes, with the number of procedures per code for the previous 12 months. Any complications/poor outcomes should be delineated and accompanied by an explanation. Family Medicine Pediatric Core Current board certification in Family Medicine by the American Board of Family Medicine or the American Osteopathic Board of Family Medicine. Or Successful completion of an ACGME or AOA accredited post-graduate training program in Family Medicine and board certification within 5 years of completion. Aggregate data from primary practice facility for the previous 12 month time period indentifying the top 10 diagnosis codes and the number of inpatients per code. Any complications/poor outcomes should be delineated and accompanied by an explanation. Procedure list from primary practice facility for the previous 12 month time period identifying the top 10 CPT/ICD codes and the number of procedures per code. Any complications/poor outcomes should be delineated and accompanied by an explanation. for evaluation and management: Gastroenteritis (1), Asthma/Bronchiolitis (2), FUO fever undetermined origin (2) Department chair recommendation will be obtained from primary practice facility. MLH Data will be obtained for active members when available, the applicant should supply additional case logs from other facilities HIM departments, if necessary, to meet the minimum requirement(s) to be considered for the privilege. Courtesy members should supply case logs from other facilities HIM departments to meet the minimum requirement(s) to be considered for the privilege. Aggregate data submitted should include the top 10 diagnosis codes, with the number of inpatients per code, and procedure lists indicating the top 10 CPT/ICD codes, with the number of procedures per code for the previous 12 months. Any complications/poor outcomes should be delineated and accompanied by an explanation. Department chair recommendation will be obtained from primary practice facility. Board approved: March, 2011, Revised 4/16/14, 2/18/15, 5/17/17, 11/15/17 3
Specialty/Procedure Delineation of Privilege Form Education/Training Documentation for Initial Granting Initial Application (Proof of current clinical competence) Arthrocentesis Case logs documenting a minimum of 5 cases within the previous 12 months Chest Tube Case logs documenting a minimum of 5 Placement cases within the previous 12 months Flexible Case logs documenting a minimum of 25 Sigmoidoscopy cases ICU Care - Limit: Ages 16 If applying directly from Family Medicine & above and only at training or less than 1 year from Germantown, North and completion of training: South Hospitals Program Director s verification of a minimum of two months Critical Care rotation in which the service was total care of the ICU patient and verification of competency in caring for the ICU patient OR Training Director s letter verifying the applicant s competency in Critical Care AND the duration of Critical Care training If applying greater than 1 year from completion of Family Medicine training AND with evidence of continuous ICU experience/competency: Training Director s validation of ICU competency AND duration of Critical Care training. Case logs that validate longitudinal record of competency in ICU setting. Two peer references, one of which is a recommendation from the Chairman of the Critical Care Department or the Medical Director of ICU OR If applying greater than 1 year from completion of Family Medicine training AND with a gap in ICU current clinical competence of 1 year or less: Completion of Fundamentals of Critical Care Support course. Training Director s validation of ICU competency AND duration of Critical Care training. Case logs that validate longitudinal record of FPPE Validation of competence after appointment and/or granting of a new or additional privilege (To be completed within one year) with mandatory intensivist consult required. Maintenance Requirements Case logs documenting a minimum of 10 cases Case logs documenting a minimum of 10 cases Case logs documenting a minimum of 50 cases Maintain Active Staff category and case log documenting a minimum of 15 critical care cases annually with mandatory intensivist consult on each case. Board approved: March, 2011, Revised 4/16/14, 2/18/15, 5/17/17, 11/15/17 4
Specialty/Procedure Delineation of Privilege Form Education/Training Documentation for Initial Granting Initial Application (Proof of current clinical competence) competency in ICU setting. Two peer references, one of which is a recommendation from the Chairman of the Critical Care Department or the Medical Director of ICU FPPE Validation of competence after appointment and/or granting of a new or additional privilege (To be completed within one year) Maintenance Requirements Paracentesis Case logs documenting a minimum of 5 cases within the previous 12 months Surgical Assist Case logs documenting a minimum of 5 cases as assist within the previous 12 months Thoracentesis Case logs documenting a minimum of 5 cases within the previous 12 months Family Practice Documentation of a minimum of one Case logs from training program Obstetrical year training in a Family Medicine documenting a minimum of 50 c- obstetrical/gynecological training sections as primary operator C-section Core program Case log documenting the performance of deliveries and obstetrical procedures including at least 20 c-sections cases per year Case logs documenting a minimum of 10 cases Case logs documenting a minimum of 10 cases Case logs documenting a minimum of 10 cases Case log documenting the performance of at least 20 c-section cases per year as primary operator Obstetrical dilatation and Curettage in the 1 st trimester Postpartum sterilization mini- lap Must maintain Family Medicine Obstetrical/C-Section core privileges. Must maintain Family Medicine Obstetrical/C-Section core privileges. Procedure list identifying the top 10 CPT/ICD codes for your practice within the previous 12 months and the number of procedures performed from facility(ies) at which procedures were performed Case logs documenting a minimum of 20 cases as primary operator Case logs documenting a minimum of 20 cases as primary operator Case logs documenting a minimum of 20 cases as primary operator Case logs documenting a minimum of 20 cases as primary operator Board approved: March, 2011, Revised 4/16/14, 2/18/15, 5/17/17, 11/15/17 5
Family Medicine Core Privilege: Admit, evaluate, diagnose, and treat patients at or above the age of 13 for common illnesses and injuries including disorders common to old age. Access, stabilize and determine disposition of patients with emergency conditions consistent with the Medical Staff policy regarding emergency or consultative services. Privileges include but are not limited to: suture uncomplicated lacerations I&D abscess lumbar puncture perform simple skin biopsy or excision removal of non-penetrating corneal foreign body management uncomplicated minor closed fractures and dislocations gynecologic care for female patients (low-risk, non-operative) pre-operative and postoperative medical care for surgical patients Family Medicine Core privileges do not include attending on patients in the Methodist University Critical Care Units, Olive Branch Hospital ICU, or any OR,. Family Medicine Pediatric Core Privilege: Admit, evaluate, diagnose and treat pediatric patients up to the age of 18, without major complications or serious life-threatening diseases and conditions, i.e. those encompassed by the specialty of Family Medicine, which constitutes skills achieved during residency training. Access, stabilize and determine disposition of patients with emergency conditions consistent with the Medical Staff policy regarding emergency or consultative services. Consultation with appropriate pediatric specialist or sub-specialist should be obtained when complications develop during hospitalization and/ or when there is unexpected prolonged length of stay >5 days. Privileges include but are not limited to: suture of uncomplicated lacerations I&D abscess lumbar puncture simple skin biopsy or excision removal of non-penetrating corneal foreign body management of uncomplicated minor closed fractures and dislocations gynecologic care for female patients (low-risk, non-operative) venipuncture, newborn care, with appropriate consults for neonatal intensive care and newborn circumcision. Family Medicine Pediatric Core privileges do not include attending on patients in the Methodist University Critical Care Units, Le Bonheur Children s Critical Care Units, Olive Branch Hospital ICU, or any OR. Board approved: March, 2011, Revised 4/16/14, 2/18/15, 5/17/17, 11/15/17 6
Family Medicine Obstetrical/C-Section Core Privilege: The practitioner may take care of routine ante-partum patients. Access, stabilize and determine disposition of patients with emergency conditions consistent with the Medical Staff policy regarding emergency or consultative services. The practitioner should be able to perform the following: Antepartum and postpartum care Normal vertex spontaneous vaginal delivery of the term (37-42 weeks) Manual rotation of the vertex from the transverse position Outlet forceps (vacuum extraction included) Repair of perineal, vaginal or cervical lacerations as well as episiotomies Use of oxytocin for augmentation of labor Placement of intrauterine scalp electrodes Intrauterine pressure catheters Amniotomy Local and pudendal anesthesia Circumcisions C-section with or without non-laparoscopic tubal ligation Consultation with an obstetrician is mandatory when a patient becomes no longer low risk. Some of the conditions that mandate an OB Consultation are listed below. The criteria listed do not represent a complete list. It is therefore recommended that obstetrical consultation be requested (physician to physician) and documented within the medical record when the status of either the mother or fetus is in doubt. Criteria/conditions identified are: known or suspected coagulopathy HELLP syndrome hypertension; both chronic pre-gestational and pregnancy induced insulin dependent diabetes; both pre-gestational and gestational labor disorders not responding to active management malpresentations breech, shoulder, face medical illness of pregnancy including (but not limited to) hyperthyroidism, adrenal disease, myasthenia gravis, cardiac disease, pulmonary disease, connective tissue disease, renal insufficiency, ulcerative colitis) morbid obesity multiple gestation oligohydramnios, polyhydramnios suspected placenta previa postpartum hemorrhage from suspected retained placenta/products pre-eclampsia, eclampsia pre-term labor and delivery (less than 34 weeks) premature rupture of membranes suspected sepsis, chorioamnionitis third trimester bleeding of undetermined etiology trophoblastic disease (molar pregnancy, choriocarcinoma, etc.) suspected uterine rupture Board approved: March, 2011, Revised 4/16/14, 2/18/15, 5/17/17, 11/15/17 7
Special: The physician requesting special privileges must meet the minimum criteria for the specialty core and demonstrate the appropriate post graduate training and/or demonstrate successful completion of an approved, recognized course when such exists, or other acceptable experience. Administration of moderate sedation: See Credentialing Policy for Sedation and Analgesia by Non-Anesthesiologists. Requires: Separate DOP, ACLS, NRP or PALS certification Board approved: March, 2011, Revised 4/16/14, 2/18/15, 5/17/17, 11/15/17 8
Family Medicine Clinical Privileges Check below the particular privileges desired in Family Medicine for each facility: Privilege Description Family Medicine Core Please check () applicable age categories for each privilege requested. Neonates (0-28 days) Methodist Healthcare Memphis Hospitals (MHMH) Germantown, Le Bonheur Medical Center, North, South & University, Outpatient Clinics & Diagnostic Facilities Infants (29 days 2 Years) Children & Adolescents (2-18 years) Adults & Adolescents (13 & Above) Family Medicine Pediatric Core Family Medicine OB/C-section Core Special Arthrocentesis Chest Tube Placement Flexible Sigmoidoscopy ICU Care - Limit: Ages 16 & above and only at Germantown, North and South Hospitals Paracentesis *Ages 16 & above Thoracentesis Dilatation and Curettage in the first trimester Must maintain Family Medicine OB/Csection Core privileges Post-partum sterilization mini-lap Must maintain Family Medicine OB/Csection Core privileges Surgical Assist Limitations Clinical privileges are granted only to the extent privileges are available at each facility. Darkly shaded areas represent privileges not available to any practitioner due to the privilege not being offered by the facility. Board approved: March, 2011, Revised 4/16/14, 2/18/15, 5/17/17, 11/15/17 9
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 for which I wish to exercise at the facilities indicated above, to the extent services are available at each facility, and I understand that: (a) in exercising any clinical privileges granted, I am constrained by facility 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 situation my actions are governed by the applicable section of the medical staff bylaws or related documents Physician's Signature Date Printed Name Board approved: March, 2011, Revised 4/16/14, 2/18/15, 5/17/17, 11/15/17 10