Northern california health care system (nchcs) Checklist of Clinical Privileges for Surgery Provider’s Name



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NORTHERN CALIFORNIA HEALTH CARE SYSTEM (NCHCS)

Checklist of Clinical Privileges for



Surgery
Provider’s Name: ______________________________________


Rev 8/13/2015

DELINEATION OF CLINICAL PRIVILEGES

Privileges with VA Northern California Health Care System (NCHCS) are granted for both clinical practice and specific procedures. Initial application by new members or requests by current staff members for additional privileges should be accompanied by documentation of training and experience. Any practitioner may request additional privileges at any time subsequent to completion of additional training. All practitioners requesting privileges with VANCHCS are subject to the same application process regardless of specialty.


In general, four categories (levels) of clinical privileges, (see below) may be granted for each clinical area. The category of privileges requested, if any, in each area must be specified. For SURGERY and SURGICAL SPECIALTIES, only the higher level categories apply (i.e. levels III and IV):
CATEGORY III: Practitioners with these privileges are expected to have training and/or experience and competence on a level commensurate with that provided by specialty training, such as in the broad field of surgery, although not necessarily at the level of the subspecialist. (Certification by the applicable Board) Such practitioners may act as consultants to others and may, in turn, be expected to request consultation when:
a. diagnosis and/or management remain in doubt over an unduly long period of time, especially in the presence of a life threatening illness;

b. unexpected complications arise which are outside this level of competence;

c. specialized treatment or procedures are contemplated with which they are not familiar.
CATEGORY IV: Practitioner with these privileges have the highest level of competence within a given field, on a par with that considered appropriate for a subspecialist. They are qualified to act as consultants and should, in turn, request consultation from within or from outside the facility staff whenever needed.
To facilitate volume tracking, and permit clarification if questions, many of the following privilege bundles include 5-digit numbers. These refer to “Current Procedural Terminology” (“CPT”) code numbers.

This form MUST be returned to VA Northern California Health Care System


CORE CRITERIA - Surgical Privileges and/or Anesthesia Privileges, VA Northern California Health Care System:

Basic Education Requirement: MD, DO or equivalent as recognized by the Educational Commission for Foreign Medical Graduates.

Post-graduate Training Requirement: Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) approved residency-training program in surgery, a specified surgical specialty, or anesthesiology. Certain privileges require successful completion of a fellowship program or equivalent-level training and experience.
Board Certification Requirement: Board eligibility or certification is required.

Background: Education should cover the general features of Surgery (see below), and, according to specialty, specific education and experience in the area of Otorhinolaryngology. The American Board of Surgery views "surgery" as a discipline encompassing not merely technical skills, but also core knowledge in areas such as anatomy, physiology, metabolism, immunology, nutrition, pathology, wound healing, shock and resuscitation, intensive care, and neoplasia. Additional areas such as microbiology, pharmacology, and statistics are certainly germane. The Surgical Service of the VA Northern California Health Care System, along with its component divisions (including anesthesiology), embraces this comprehensive view of surgery, anesthesiology, and the surgical disciplines.

Privilege(s) Requested


-----------

Place your initials below for each privilege you are requesting



Category Requested -----------

Select either Cat III, or IV (as defined on page 1 of this list) for each privilege you select




SURGERY
PRIVILEGE DESCRIPTION
Otorhinolaryngology
Criteria for privileges: See "Overview of Surgical Privileges, VA Northern California Health Care System."


Following each privilege you select below, please indicate by circling the appropriate location(s), at which of NCHCS's campuses you intend to practice your selected privilege(s).

Service Chief’s Approval





______



N/A

Prescribing Authority Requested:

rectangle 16 rectangle 15rectangle 13rectangle 14 All 2 3 4

rectangle 12rectangle 11rectangle 10rectangle 9 None 2N 3N 5

DEA Number: ________________ Expiration: ___________________





Cognitive privilege bundle (E&M CPT codes 99201 - 99499): (The applicant must be able to demonstrate that he/she has provided care for at least 20 patients during the past 24 months. Exceptions will be dealt with on a case by case basis.)

______

______

Cognitive bundle #1:

Evaluation and management of patients being considered for otorhinolaryngologic procedures (including reconstruction) and all phases of assessment, diagnosis, and recommendations for treatment. Consultation services for other medical/surgical practitioners. Assess and weigh intra-operative and postoperative risk, as well as the merits of procedures. Assess and weigh prognosis for certain surgical diseases, with and without surgical intervention. All holders of this privilege must have the ability to provide expert-level opinion to non-surgical practitioners.




C H I O T U E

L B N U E C D

C P P T L




______

______

Cognitive bundle #2:

Surgical critical care. Interpretation of information from invasive monitoring devices, nutrition management (including TPN), ventilator management, use of vaso-active medications, and complete management of critically ill and postoperative patients. Medical preparation of critically ill patients for surgery. Surgical critical care after surgery.



C H I O T U E

L B N U E C D

C P P T L





Privilege(s) Requested


-----------

Place your initials below for each privilege you are requesting



Category Requested -------------

Select either Cat III, or IV (as defined on page one of this privilege list) for each privilege you select




SURGERY
PRIVILEGE DESCRIPTION
Otorhinolaryngology

(Continued)





Following each privilege you select below, please indicate by circling the appropriate location(s), at which of NCHCS's campuses you intend to practice your selected privilege(s).

Service Chief’s Approval



Procedural privilege bundles

______

______

Procedural bundle #1: (The applicant must be able to demonstrate that he/she has provided care for at least 10 patients during the past 24 months. Exceptions will be dealt with on a case by case basis.)

All office based exams and procedures including laryngoscopy, nasopharyngoscopy and oral/oropharyngeal/nasopharyngeal biopsy. Includes topical/local anesthesia, and when indicated, use of sedation (see VANCHCS Policy Statement PS 11-25 Procedural Sedation and Analgesia By Non-Anesthesiologists).



C H I O T U E

L B N U E C D

C P P T L




______

______

Procedural bundle #2:

All procedures in bundle #1 plus all outpatient and inpatient excisional and incisional and reconstructive procedures encompassed in core of an otorhinolaryngology residency as defined by the Accreditation Council for Graduate Medical Education (ACGME) or the Royal College of Physicians and Surgeons Canada (RCPSC). Includes sinus, thyroid, parathyroid, salivary gland, and aerodigestive procedures. Includes surgical quadruple endoscopy (e.g. nasopharyngoscopy, direct larygoscopy, esophagoscopy, and bronchoscopy). Includes endotracheal intubation, tracheostomy, and placement of central venous access catheters. All graduates of comprehensive residency programs expected to qualify for this bundle.



C H I O T U E

L B N U E C D

C P P T L





Privilege(s) Requested


-----------

Place your initials below for each privilege you are requesting



Category Requested -------------

Select either Cat III, or IV (as defined on page one of this privilege list) for each privilege you select




SURGERY
PRIVILEGE DESCRIPTION
Otorhinolaryngology

(Continued)





Following each privilege you select below, please indicate by circling the appropriate location(s), at which of NCHCS's campuses you intend to practice your selected privilege(s).

Service Chief’s Approval



_____

____

Procedural bundle #3: (The applicant must be able to demonstrate that he/she has provided care for at least 4 patients during the past 24 months. Exceptions will be dealt with on a case by case basis.)

Fellowship-level training or experience in major head and neck surgery or head and neck oncology. Additional training and experience in major head and neck oncologic procedures. Includes experience with myocutaneous reconstructions and mandibular reconstructions. Familiar with skull base and major craniofacial procedures.



C H I O T U E

L B N U E C D

C P P T L




_____

____

Procedural bundle #4: (The applicant must be able to demonstrate that he/she has provided care for at least 4 patients during the past 24 months. Exceptions will be dealt with on a case by case basis.)

Includes major facial-plastic reconstructive procedures, including biopsy, excision, random flaps, superficial reconstructions, complicated reconstructions and myocutaneous flaps.




C H I O T U E

L B N U E C D

C P P T L




_____

_____


Procedural bundle #5: (The applicant must be able to demonstrate that he/she has provided care for at least 2 patients during the past 24 months. Exceptions will be dealt with on a case by case basis.)

Bundle #4 with microvascular free flaps.




C H I O T U E

L B N U E C D

C P P T L




_____

_____

Laser & Laser Ablation




C H I O T U E

L B N U E C D

C P P T L




_____

______


Other (Specify): __________________________
_________________________________________
_________________________________________
_________________________________________
_________________________________________


C H I O T U E

L B N U E C D

C P P T L






I, ____________________________________, hereby apply for practice privileges within the VA Northern California Health Care System. I have requested privileges only in areas in which I believe I meet applicable standards of education, training, demonstrated proficiency, and/or Board Certification. I understand that these privileges will be granted only after my application has been reviewed and approved by the Service Chief, Credentials/Professional Standards Board, Chief of Staff and the Director.


________________________________________ __________________



Applicant’s Signature Date

I have reviewed this provider’s data and information demonstrating current competence for the clinical privileges requested. After review of this information, I recommend that clinical privileges be granted as indicated with any exceptions or conditions as documented.

Check One:
________ Provider’s Focused Professional Practice Evaluation (FPPE) will be due six months from the time the provider is appointed. (New provider or renewing provider requiring more detailed monitoring).
________ Provider’s Ongoing Professional Practice Evaluation (OPPE) results support approving providers privileges. OPPE documentation has been forwarded to the Medical Staff Office for processing.
Privileges reviewed and recommended by

_________________________________________ __________________



Scott Hundahl, MD Date

Chief, Surgery Service





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