Biographical sketch, kathy matzka, cpmsm, cpcs



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HCPro Core Privileges Example


☐Initial appointment

☐Reappointment



All new applicants must meet the following requirements as approved by the governing body effective ____/____/______.

If any privileges are covered by an exclusive contract or an employment contract, practitioners who are not a party to the contract are not eligible to request the privilege(s), regardless of education, training, and experience. Exclusive or employment contracts are indicated by [EC].

Applicant: Check off the “Requested” box for each privilege requested. Applicants have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competence, current clinical activity, and other qualifications and for resolving any doubts related to qualifications for requested privileges.

[Department Chair/Chief]: Check the appropriate box for recommendation on the last page of this form. If recommended with conditions or not recommended, provide condition or explanation on the last page of this form.

Other Requirements

Note that privileges granted may only be exercised at the site(s) and setting(s) that have the appropriate equipment, license, beds, staff, and other support required to provide the services defined in this document. Site-specific services may be defined in hospital or department policy.

This document is focused on defining qualifications related to competency to exercise clinical privileges. The applicant must also adhere to any additional organizational, regulatory, or accreditation requirements that the organization is obligated to meet.

Qualifications for Family Medicine



  • To be eligible to apply for core privileges in family medicine, the initial applicant must meet the following criteria:

Successful completion of an Accreditation Council for Graduate Medical Education (ACGME)– or American Osteopathic Association (AOA)–accredited residency in family medicine.

AND/OR


Current certification or active participation in the examination process [with achievement of certification within [n] years] leading to certification in family medicine by the American Board of Family Medicine or the American Osteopathic Board of Family Physicians.

Required previous experience: Applicants for initial appointment must be able to demonstrate provision of care, reflective of the scope of privileges requested, for at least 24 inpatients as the attending physician during the past 12 months or demonstrate successful completion of an ACGME- or AOA-accredited residency, clinical fellowship, or research in a clinical setting within the past 12 months.

Reappointment requirements: To be eligible to renew core privileges in family medicine, the applicant must meet the following maintenance of privilege criteria:

Current demonstrated competence and an adequate volume of experience ([n] inpatients) with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current ability to perform privileges requested is required of all applicants for renewal of privileges.

Core Privileges

Family Medicine Core Privileges

Requested Admit, evaluate, diagnose, treat, and provide consultation to adolescent and adult patients with illnesses, diseases, and functional disorders of the circulatory, respiratory, endocrine, metabolic, musculoskeletal, hematopoietic, gastroenteric, and genitourinary systems. [May provide care to patients in the intensive care setting in conformance with unit policies.] Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.



refer and follow Privileges

Criteria: Education and training as for family medicine core privileges.

Requested Perform outpatient preadmission and history and physical, order noninvasive outpatient diagnostic tests and services, visit patient in hospital, review medical records, consult with attending physician, and observe diagnostic or surgical procedures with the approval of the attending physician or surgeon.



Pediatric Core Privileges

Criteria: As for family medicine core plus:
Required previous experience: Demonstrated current competence and evidence of the provision of care, reflective of the scope of privileges requested, to at least 10 pediatric inpatients in the past 12 months.
Maintenance of privilege: Demonstrated current competence and evidence of the provision of care to at least [n] pediatric inpatients in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

Requested Admit, evaluate, diagnose, and treat pediatric patients up to the age of 18 with common illnesses, injuries, or disorders. This includes the care of the normal newborn as well as the uncomplicated premature infant equal to or greater than 36 weeks gestation. Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.



Gynecology Core Privileges

Criteria: Must qualify for and be granted privileges in family medicine plus:
Required previous experience: Demonstrated current competence and evidence of provision of care, reflective of the scope of privileges requested, to at least 10 gynecologic inpatients in the past 12 months.
Maintenance of privilege: Demonstrated current competence and evidence of provision of care to at least [n] gynecologic inpatients in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

Requested Admit, evaluate, diagnose, treat, and provide consultation to postpubescent female patients with injuries and disorders of the female reproductive system and the genitourinary system. [May provide care to patients in the intensive care setting in conformance with unit policies.] Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.



Obstetrical Core Privileges

Criteria: Must qualify for and be granted privileges in family medicine. Plus, applicant must provide documentation of three to four months’ obstetrical rotation during family medicine residency with [n] patients delivered. Current NALS certification.

Required previous experience: Demonstrated current competence and evidence of the performance of at least 10 deliveries in the past 12 months.

Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least [n] deliveries in the past 24 months based on ongoing professional practice evaluation and outcomes.

Requested Admit, evaluate, and manage female patients with normal term pregnancy with an expectation of uncomplicated vaginal delivery, management of labor and delivery, and procedures related to normal delivery, including medical diseases that are complicating factors in pregnancy (with consultation). [May provide care to patients in the intensive care setting in conformance with unit policies.] Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.

Qualifications for Geriatric Medicine (Applicable when a family medicine physician treats geriatric patients only, has completed a fellowship and/or holds subspecialty certification.)


  • To be eligible to apply for core privileges in geriatric medicine, the initial applicant must meet the following criteria:

Successful completion of an Accreditation Council for Graduate Medical Education (ACGME)– or American Osteopathic Association (AOA)–accredited residency in either family medicine or internal medicine followed by an ACGME- or AOA-accredited fellowship in geriatric medicine.

AND/OR


Current subspecialty certification or active participation in the examination process [with achievement of certification within [n] years] leading to subspecialty certification in geriatric medicine by the American Board of Internal Medicine, or the American Board of Family Medicine, or a Certificate of Added Qualifications in Geriatric Medicine by the American Osteopathic Board of Family Physicians.

Required previous experience: Applicants for initial appointment must be able to demonstrate provision of inpatient care, reflective of the scope of privileges requested, for at least 24 patients as the attending practitioner during the past 12 months or demonstrate successful completion of an ACGME- or AOA-accredited residency, clinical fellowship, or research in a clinical setting within the past 12 months.

Reappointment requirements: To be eligible to renew core privileges in geriatric medicine, the applicant must meet the following maintenance of privilege criteria:

Current demonstrated competence and an adequate volume of experience ([n] inpatients) with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current ability to perform privileges requested is required of all applicants for renewal of privileges.

Core Privileges

Geriatric Medicine Core Privileges

Requested Admit, evaluate, diagnose, treat, and provide consultation to older adult patients with illnesses and disorders that are especially prominent in the elderly or have different characteristics in the elderly, including neoplastic, cardiovascular, neurologic, musculoskeletal, metabolic, and infectious disorders. [May provide care to patients in the intensive care setting in conformance with unit policies.] Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.


Special Noncore Privileges (See Specific Criteria)

If desired, noncore privileges are requested individually in addition to requesting the core. Each individual requesting noncore privileges must meet the specific threshold criteria governing the exercise of the privilege requested including training, required previous experience, and maintenance of clinical competence.

CESAREAN Section

Criteria: Must qualify for and receive family medicine obstetrics privileges.

Required previous experience: Demonstrated current competence and the successful completion of an accredited one- to two-year family medicine obstetric fellowship in the past 12 months or [n] cesarean births as primary operator during the past 12 months.

Maintenance of privilege: Demonstrated current competence and evidence of [n] cesarean births as the primary operator in the past 24 months.

Requested



Attendance at delivery to assume care of normal newborns

Criteria: Successful completion of an accredited residency which included training in this procedure, or the applicant must have completed hands-on training in this procedure under the supervision of a qualified physician preceptor. Current NALS certification.

Required previous experience: Demonstrated current competence and evidence of attendance at [n] deliveries in the past 12 months.

Maintenance of privilege: Demonstrated current competence and evidence of attendance at [n] deliveries in the past 24 months based on results of quality assessment/improvement activities and outcomes.

Requested



Circumcision

Criteria: Successful completion of formal training in this procedure or the applicant must have completed hands-on training in this procedure under the supervision of a qualified physician preceptor. Evidence of having performed [n] proctored procedures during training.
Required previous experience: Demonstrated current competence and evidence of the performance of at least [n] procedures in the past 12 months.

Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least [n] procedures in the past 24 months based on results of quality assessment/improvement activities and outcomes.

Requested



Flexible Sigmoidoscopy

Criteria: Successful completion of an ACGME- or AOA-accredited residency in family medicine that included training in flexible sigmoidoscopy or evidence of prior training and experience.

Required previous experience: Demonstrated current competence and evidence of at least 30 procedures in the past 12 months.

Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least [n] procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

Requested



Lumbar Puncture

Criteria: Successful completion of an ACGME- or AOA-accredited residency in family medicine that included training in lumbar puncture, or evidence of active clinical practice in the procedure.

Required previous experience: Demonstrated current competence and evidence of the performance of at least [n] lumbar punctures in the past 12 months.

Maintenance of privilege: Demonstrated current competence and evidence of the performance of at least [n] lumbar punctures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

Requested



Ventilator Management

Criteria: For ventilator cases not categorized as complex (up to 36 hours), successful completion of an ACGME- or AOA-accredited postgraduate training program that provided the necessary cognitive and technical skills for ventilator management not categorized as complex.
For complex ventilation cases, the applicant must demonstrate successful completion of an accredited fellowship that provided the necessary cognitive and technical skills for complex ventilator management.
Required previous experience: Demonstrated current competence and evidence of the management of at least [n] mechanical ventilator cases in the past 12 months.
Maintenance of privilege: Demonstrated current competence and evidence of the management of at least [n] mechanical ventilator cases in the past 24 months based on results of ongoing professional practice evaluation and outcomes.
Source: California Thoracic Society Position Paper—Clinical Privileges for Mechanical Ventilator Management 05/25/06

Requested Ventilator Management (not complex including CPAP—up to 36 hours)

Requested Complex, including BiPAP. *More than 36–48 hours, or for patients defined as those having any of the following ongoing characteristics or any other of similar complexity: PEEP requirement  10 cm of water; FI02 requirement  0.6; static plateau pressure  30 cm of water; presence of significant preexisting pulmonary disease; multisystem organ failure; chronic ventilator dependence; patient not meeting previous criteria, but clinical condition deteriorating.

Administration of Sedation and Analgesia

Requested See Hospital Policy for Sedation and Analgesia by Non-Anesthesiologists



Core Procedure List

This list is a sampling of procedures included in the core. This is not intended to be an all-encompassing list but rather reflective of the categories/types of procedures included in the core.

To the applicant: If you wish to exclude any procedures, please strike through those procedures that you do not wish to request, initial, and date.

General

  1. Arthrocentesis and joint injection

  2. Burns, superficial and partial thickness

  3. Chronic ventilator management

  4. I & D abscess

  5. Local anesthetic techniques

  6. Manage uncomplicated minor closed fractures and uncomplicated dislocations

  7. Perform history and physical exam

  8. Perform simple skin biopsy or excision

  9. Peripheral nerve blocks

  10. Placement of anterior and posterior nasal hemostatic packing

  11. Remove nonpenetrating foreign body from the eye, nose, or ear

  12. Suture uncomplicated lacerations

Pediatrics

  1. I & D abscess

  2. Manage uncomplicated minor closed fractures and uncomplicated dislocations

  3. Perform history and physical exam

  4. Perform simple skin biopsy or excision

  5. Remove nonpenetrating corneal foreign body

  6. Suture uncomplicated lacerations

Gynecology

  1. Biopsy of cervix, endometrium

  2. Colposcopy

  3. Cryosurgery/cautery for benign disease

  4. Diagnostic cervical dilation and uterine curettage

  5. Excision/biopsy of vulvar lesions

  6. Incision and drainage of Bartholin duct cyst or marsupialization

  7. Insertion of intrauterine devices

  8. Perform history and physical exam

  9. Removal of foreign body from vagina

  10. Suturing of uncomplicated lacerations

  11. Uterine curettage following incomplete abortion

Obstetrics

  1. Amniotomy

  2. Augmentation of labor

  3. D&C including suction and postpartum

  4. Excision of vulvar lesions at delivery

  5. External and internal fetal monitoring

  6. Induction of labor with consultation and pitocin management

  7. Initial management of post partum hemorrhage (PPH)

  8. Investigative OB ultrasound for presentation only

  9. Management of prenatal and postpartum care

  10. Management of uncomplicated labor including normal spontaneous vaginal delivery or a term vertex presentation

  11. Manual removal of placenta, post delivery

  12. Normal spontaneous vaginal delivery

  13. Oxytocin challenge test

  14. Perform history and physical exam

  15. Post partum endometritis

  16. Pudendal anesthesia

  17. Repair of episiotomy—first, second, and third degree

  18. Repair of vaginal lacerations

  19. Vacuum assisted delivery


Geriatric Medicine

  1. Apply the general principles of geriatric rehabilitation, including those applicable to patients with orthopedic, rheumatologic, cardiac, and neurologic impairments

  2. Assess patient to includes medical, affective, cognitive, functional status, social support, economic, and environmental aspects related to health

  3. Manage areas of special concern such as falls and incontinence

  4. Manage aspects of preventive medicine, including nutrition, oral health, exercise, screening, immunization, and chemoprophylaxis against disease

  5. Manage the appropriate interdisciplinary coordination of the actions of multiple health professionals, including physicians, nurses, social workers, dieticians, and rehabilitation experts, in the assessment and implementation of treatment

  6. Perform history and physical exam

  7. Recognize and evaluate cognitive impairment

  8. Treat and prevent iatrogenic disorders


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 that I wish to exercise at Hospital, and I understand that:

a. In exercising any clinical privileges granted, I am constrained by Hospital 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.



Signature: Date:

[Department Chair/Chief]'s Recommendation

I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and make the following recommendation(s):

Recommend all requested privileges.

Recommend privileges with the following conditions/modifications:

Do not recommend the following requested privileges:

Privilege Condition/Modification/Explanation

1.

2.

3.

4.

Notes







[Department Chair/Chief] Signature: Date:

FOR MEDICAL STAFF OFFICE USE ONLY

Credentials Committee action Date:

Medical Executive Committee action Date:

Board of Trustee action Date:

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