SPECIALTY OF DERMATOLOGY Delineatin f Clinical Privileges Criteria fr granting privileges: Current bard certificatin in Dermatlgy by the American Bard f Dermatlgy r the American Ostepathic Bard f Dermatlgy. Successful cmpletin f an accredited ACGME r AOA accredited pst-graduate training prgram in Dermatlgy and bard certificatin within 5 years f prgram cmpletin. Current certificatin by the American Bard f Dermatlgy and subspecialty certificatin in pediatric dermatlgy. Successful cmpletin f an ACGME accredited pst-graduate training prgrams in dermatlgy and pediatric dermatlgy, and bard certificatin within 5 years f prgram cmpletin. 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. TJC (The Jint Cmmissin) describes current clinical cmpetence as having perfrmed the privilege recently and perfrmed it well. Current clinical cmpetence is assessed prir t granting privileges initially and reassessed when renewing privileges at reappintment. This shuld nt be cnfused with either FPPE (Fcused Prfessinal Practice Evaluatin) r OPPE (Onging Prfessinal Practice Evaluatin). FPPE: an evaluatin f clinical cmpetence f all new privileges (as perfrmed at Methdist Le Bnheur Healthcare) after they have been initially granted. This applies t all new applicants as well as t current members applying fr new/additinal privileges. OPPE: peridic (mre frequent than annually) evaluatin f prfessinal practice. Bth FPPE and the current clinical cmpetence assessment are privilege-specific. FPPE is cnducted during the perid after granting new/additinal privileges. 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: 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. OPPE (Onging Prfessinal Perfrmance Evaluatin) The Jint Cmmissin (TJC) requires OPPE 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. 2
Specialty/Prcedure Delineatin f Privilege Frm Dermatlgy Cre Educatin/Training Dcumentatin fr Initial Granting Current bard certificatin in Dermatlgy by the American Bard f Dermatlgy r the American Ostepathic Bard f Dermatlgy Successful cmpletin f an ACGME r AOA accredited pst-graduate training prgram in Dermatlgy and bard certificatin within 5 years f cmpletin. Initial Applicatin (Prf f current clinical cmpetence) 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. FPPE Validatin f cmpetence after appintment and/r granting f a new r additinal privilege (T be cmpleted within ne year) First 5 cases Maintenance Requirements 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. Dermatlgy Pediatric Cre Current bard certificatin in Dermatlgy by the American Bard f Dermatlgy and subspecialty certificatin in Pediatric Dermatlgy Successful cmpletin f an ACGME accredited pstgraduate training prgram in Dermatlgy and pediatric dermatlgy and bard certificatin within 5 years f cmpletin. 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. First 5 cnsults Department chair recmmendatin will be btained frm primary practice facility. 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 Department chair recmmendatin will be btained frm primary practice facility. First 5 cases Case lg dcumenting 5 prcedures within the previus 24 mnths Bard apprved: March, 2011, Revised 4/16/14
Specialty/Prcedure Delineatin f Privilege Frm MOHS Micrgraphic Surgery Educatin/Training Dcumentatin fr Initial Granting 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-n experience with lasers. Training in MMS during residency prgram in dermatlgy. If the residency prgram did nt include MMS training the applicant must have successfully cmpleted an apprved MMS fellwship training prgram r a frmal MMS training prgram that included preceptrship and prctred initial cases by an experienced MOHS surgen Lipsuctin Evidence f at least 30 cntinuing medical educatin hurs cvering the indicatins fr, technical aspects f, and pst-prcedure management f lipsuctin (if nt cvered by the applicant s residency training prgram) Initial Applicatin (Prf f current clinical cmpetence) Case lg dcumenting the perfrmance f at least 100 prcedures within the previus 12 mnths Case lg dcumenting the perfrmance f at least 50 prcedures within the previus 24 mnths FPPE Validatin f cmpetence after appintment and/r granting f a new r additinal privilege (T be cmpleted within ne year) Maintenance Requirements First 5 cases Case lg dcumenting the perfrmance f at least 100 prcedures within the previus 24 mnths First 5 cases Case lg dcumenting the perfrmance f at least 50 prcedures within the previus 24 mnths Bard apprved: March, 2011, Revised 4/16/14
Dermatlgy Cre Privilege: Admit, evaluate, diagnse, treat and prvide cnsultatin t patients f all ages except as specifically excluded frm practice, with benign and malignant disrders f the integumentary system (epidermis, dermis, subcutaneus tissue, hair, nails, muth, external genitalia and cutaneus glands) as well as sexually transmitted diseases. Access, stabilize and determine dispsitin f patients with emergency cnditins cnsistent with the Medical Staff plicy regarding e emergency r cnsultative services. Privileges include but are nt limited t: diagnsis and treatment f skin cancers, melanmas, mles, and ther tumrs f the skin, management f cntact dermatitis and ther allergic and nn-allergic skin disrders management f csmetic disrders f the skin such as hair lss and scars and the skin changes assciated with aging, including cnsultatin. The fllwing prcedures: simple excisin and repair skin and nail bipsy scalp surgery skin grafting sclertherapy electrsurgery cllagen injectins crysurgery dermabrasin Dermatlgy Pediatric Cre Privilege: Admit, evaluate, diagnse, cnsult and prvide care t infants and children under the age f 13 with diseases f the skin, e.g., infectius, immunlgic, and neplastic diseases. Access, stabilize and determine dispsitin f patients with emergency cnditins cnsistent with the Medical Staff plicy regarding e emergency r cnsultative services. Privileges include but are nt limited t: interpretatin f specially prepared tissue sectins cellular scrapings and smears f skin lesins by means f rutine and special (electrn and flurescent) micrscpes Diagnstic and therpeutic prcedures permitted include: skin bipsy Bard apprved: March, 2011, Revised 4/16/14
nail bipsy excisin and repair 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 4/16/14
Dermatlgy Clinical Privileges Check belw the particular privileges desired in Dermatlgy fr each facility: Privilege Descriptin Dermatlgy Cre Dermatlgy Pediatric Cre Special MOHS Micrgraphic Surgery Lipsuctin Please check () applicable age categries fr each privilege requested. Nenates (0-28 days) Methdist Healthcare Memphis Hspitals (MHMH) Germantwn, Le Bnheur Medical Center, Nrth, Suth & University, Outpatient Clinics & Diagnstic Facilities Infants (29 days 2 Years) Children & Adlescents (2-18 years) Adults & Adlescents (13 & Abve) Methdist Extended Care Hspital (MECH) Adults (18 & Abve) Methdist Healthcare Fayette Hspital (MHFH) 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 4/16/14