New Privilege List - Family Medicine - Sutter Medical Center

SUTTER MEDICAL CENTER, SACRAMENTO
Department of Family Medicine Delineation of Privileges
NAME: INITIAL: [ ]
RENEWED: [ ]
DATE: ADDITIONAL: [ ]
Privileges are granted for Sutter General Hospital, Sutter Memorial Hospital, Sutter Center for Psychiatry, Capital Pavilion Surgery Center, or Sutter Oaks Midtown and exercise
of privileges is based on the type of care, treatment and services provided at each facility.
To request Privileges, please place an “X” in the request column. In “Number Performed” box, indicate the number of identified procedures performed in previous 24 months from any
facility. If the condition/privilege you desire is not included on this form, please submit a separate written request along with appropriate documentation of training and/or experience.
Request Privilege Appointment Requirements
[ ] Admit
[ ] History & Physical - A
Applicants for Core FM privileges must satisfy the following criteria:
1) Board certification in Family Medicine; or,
2) documentation of successful completion of an accredited residency
program in Family Medicine, and then Board Certification within
three years of completion of residency program – or –
3) for physicians non-certified within three years of completion of a
residency program must have documentation of ten years hospital
experience in a TJC accredited hospital.
Proctoring
Required
At least six (6) cases
must be proctored,
can include
newborn cases – see
below for newborn
proctoring
requirements.
Reappointment
Requirements
Board Certification
within three years of
completion of a
residency program or 10
years of practice in a
Joint Commission
accredited hospital and 2
cases
Number
Performed
Request Core Family Medicine Privileges Appointment Requirements
[ ] • Debridement of superficial wounds ‐ A
• Removal of foreign bodies from canals and superficial areas‐ A
• I & D superficial‐ A
• Endometrial biopsy ‐ A
• Biopsy of skin lesions‐ A
• Excision of cyst, lipoma and polyp of the skin ‐ A
• Anesthesia – local block‐ A
Applicants for Core FM privileges must satisfy the following criteria:
1) Board certification in Family Medicine; or,
2) documentation of successful completion of an accredited residency
program in Family Medicine, and then Board Certification within
three years of completion of residency program – or -
3) for physicians non-certified within three years of completion of a
residency program must have documentation of ten years hospital
experience in a TJC accredited hospital.
Request Core Obstetrical Privileges Appointment Requirements
[ ] • Management of low risk labor
• Vaginal delivery, uncomplicated low risk
• Mid-line episiotomy and repair
• Repair of perineal laceration, first, second and third degree
• Fetal heart rate monitoring: EFM & Fetal scalp electrode
• IUPC – placement and monitoring
• Amnio infusion
• Labor augmentation: AROM & Pitocin
• Induction of labor: AROM, Pitocin & Prostaglandin
• Undiagnosed antepartum bleeding, evaluation and initial management
• Management and delivery of stillbirth
• Anesthesia: local, pudendal block
• Vacuum-assisted outlet vaginal delivery
• Manual removal of placenta
(Continued on next page)
Initial appointment – documentation of obstetrical training in residency or
have performed at least (40) deliveries in previous three years in a TJC
accredited hospital;.
Granting of any obstetrical privilege is contingent on designation of a FM
call group with like obstetrical privileges to cover FM obstetrical cases
and, designation of a back up obstetrical call group to handle any needed
further obstetrical procedures that the FM physician does not hold
privileges for –see special FM/Obstetrics Plan policy.
Proctoring
Required
See admit
proctoring
requirements
Proctoring
Required
Reappointment
Requirements
Board Certification
within three years of
completion of a
residency program or 10
years of practice in a
Joint Commission
accredited hospital
Reappointment
Requirements
First six (6) cases. Document (10)
Number
Performed
Number
Performed
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SUTTER MEDICAL CENTER, SACRAMENTO
Department of Family Medicine Delineation of Privileges
NAME:
Request Core Obstetrical Privileges Appointment Requirements
• Diagnosis and management of premature labor and premature rupture
of membranes > 32 weeks
• tocolysis
• steroids
• Management of diet-controlled gestational diabetes
• Anesthesia – local, paracervical block
Request Tier One Obstetrical Privileges Appointment Requirements
Proctoring
Required
Proctoring
Required
[ ] Mediolateral episiotomy and repair Must also have been granted Core Obstetrical Privileges and have First (2) cases 1 case
[ ] Repair of fourth degree perineal laceration
completed an accredited Family Medicine OB fellowship program, or the
equivalent thereof (which must be approved by MEC), and provide
First (2) cases 1 case
[ ] Repair of deep vaginal cervix lacerations adequate documentation of all procedures and number performed. First (2) cases 1 case
[ ] Low forceps delivery First (2) cases 2 cases.
[ ] Complicated vacuum delivery First (2) cases 2 cases
[ ] Management of placental abruption and placenta previa First (1) case None
[ ] Management of PIH – mild or moderate First (1) case 1case
[ ] Induction of labor by mechanical means, i.e. balloon dilation or laminaria First (1) case 1 case
[ ] Management and delivery of VBAC (Must have C-Section privileges to
perform without consult) –
First (2) cases 1 case
[ ] C-Section First (2) cases 2 cases
[ ] Postpartum tubal ligation First (1) case 1 case
[ ] Retained placenta-complicated – manual removal First (1) case 1 case
[ ] Retained placenta-complicated – postpartum curettage First (1) case 1 per
[ ] Management of hematoma First (1) case None
Request Tier Two Obstetrical Privileges Appointment Requirements
Proctoring
Required
[ ] Management of PIH - severe and HELLP syndrome CONSULT REQUIRED Must also have been granted Core Obstetrical First (1) case 1 case
[ ] External version
Privileges and have completed an accredited Family Medicine OB
First (1) case
fellowship program, or the equivalent thereof (which must be approved by
1 case
[ ] Management of multiple gestation - includes antepartum care; vaginal MEC), and provide adequate documentation of all procedures and number First (2) cases 2 cases
delivery; surgical delivery; version and extraction of 2 nd twin.
performed.
[ ] Management of insulin-dependent diabetes of pregnancy, antepartum and
delivery
[ ] Management of pregnancies complicated by pre-existing medical
conditions, i.e. renal disease, cardiac disease, pulmonary disease,
neurologic disease, hematologic disease, etc.
First (2) cases 2 cases
First (2) cases 2 cases
[ ] Uterine packing First (1) case None
[ ] Cerclage placement for incompetent cervix First (2) cases 1 case
Reappointment
Requirements
Reappointment
Requirements
Reappointment
Requirements
Number
Performed
Number
Performed
Number
Performed
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SUTTER MEDICAL CENTER, SACRAMENTO
Department of Family Medicine Delineation of Privileges
NAME:
Request Tier Two Obstetrical Privileges Appointment Requirements
Proctoring
Required
[ ] Premature labor and premature rupture of membranes < 32 weeks gestation First (2) cases 2 cases
Request Core Gynecology Privileges Appointment Requirements
[ ] • Medical management of ectopic pregnancy
• Medical management of gestational trophoblastic disease
• Medical management of PID
Proctoring
Required
. Same as for core Family Medicine privileges See admit
proctoring
requirements
Request Special Gynecology Privileges: Appointment Requirements
Proctoring
Required
[ ] Mini-lap tubal ligation Documentation of experience or training in 10 cases. First (2) cases 2 cases
[ ] D&E Documentation of experience or training in 10 cases. First (2) cases 2 cases
[ ] D&C ‐ A Documentation of experience or training in 10 cases. First (2) cases 1 case
[ ] Culdocentesis Documentation of experience or training in 2 cases. First (2) cases 1 case
[ ] LEEP conization of cervix Documentation of experience or training in 10 cases. First (2) cases 1 case
Request Newborn / General Pediatric Privileges Appointment Requirements
[ ] Newborn Nursery Privileges – allows admission and care of the newborn
in the Newborn Nursery
Proctoring
Required
Same as for Core FM privileges First (2) cases *1 case
[ ] Circumcision Same as for Core FM privileges First (1) case *1 case
[ ] General Pediatric Care (non-newborn) Documentation of experience or training within the previous three years
in general pediatric – non-newborn care from either residency training or
a TJC accredited hospital.
Request Other Special Family Medicine Privileges Appointment Requirements
First (4) cases *1 case
Proctoring
Required
[ ] Nasal Pack, Anterior & Posterior. Documentation of experience in 4 cases in previous three years NONE 4 cases
[ ] Adult Continuing Care in Critical Care Units Completion of a Family Medicine residency program or documentation of
at least two months residency training or experience in the care of patients
in Critical Care Units in previous three year period; documentation must
be in the form of a letter from the Director of the training program or from
the Chief of Service of the TJC accredited hospital.
NONE 4 cases
Reappointment
Requirements
Reappointment
Requirements
Board Certification
within three years of
completion of a
residency program or 10
years of practice in a
Joint Commission
accredited hospital
Reappointment
Requirements
Reappointment
Requirements
Reappointment
Requirements
Number
Performed
Number
Performed
Number
Performed
Number
Performed
Number
Performed
Note: Includes ability to see and care for the patient in the critical care
setting. Exception: This privilege does not include ventilator
management, insertion of monitoring lines or elective intubation.
Requests for these privileges must be made separately through the
Medicine Department.
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SUTTER MEDICAL CENTER, SACRAMENTO
Department of Family Medicine Delineation of Privileges
NAME:
Request Other Special Family Medicine Privileges Appointment Requirements
[ ] EKG Interpretation (privilege allows physician to participate in an EKG
reading panel for official EKG interpretations)
Documentation of training and experience from TJC accredited hospital
or training program of at least 50 EKG interpretations in previous three
years.
[ ] Treadmill Interpretation Documentation of training and experience from a TJC accredited hospital
or training program of at least 10 Treadmill interpretations in previous
three years.
[ ] Post Acute Care Privilege – Continuing care of the patient in the Sutter
Sub- Acute Unit or Sutter Oaks Midtown
[ ] Vasectomy Documentation of training and experience from a TJC accredited hospital
or training program in 12 procedures during previous three years
[ ] Marsupialization or I&D’s of Bartholin Cyst Documentation of training and experience from a TJC accredited hospital
or training program in 2 procedures during previous three years
Proctoring
Required
First (6) cases NONE
First (2) cases NONE
6 cases only if not
requesting admit
privileges
Reappointment
Requirements
NONE
First (2) cases 2 cases
First (1) case 1 case
[ ] Venous Cutdown Documentation of training and experience from a TJC accredited hospital First (1) case 1 case
[ ] Puncture, jugular, external
or training program in 6 procedures during previous three years
First (2) cases 2 cases.
[ ] Lumbar Puncture Documentation of training and experience from a TJC accredited hospital
or training program in 2 procedures during previous three years
First (1) case 1 case
Number
Performed
[ ] Paracentesis Documentation of training and experience from a TJC accredited hospital
or training program in 2 procedures during previous three years
[ ] Thoracentesis Documentation of training and experience from a TJC accredited hospital
or training program in 2 procedures during previous three years
First (1) case; 1 case
First (1) case 2 cases
Please Note: Other special privileges, i.e. Assist in Surgery, Invasive Line Monitoring, Intubation, etc. should be requested through the Medical Staff Department that grants the individual
privilege. Please contact the Medical Staff Services Department (733-3097) if you have questions or need to request privilege lists for other departments.
Acknowledgment of Practitioner: I understand that (a) in exercising clinical privileges granted, I am constrained by Medical Staff Policies and Procedures, Rules and Regulations, and (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.
I hereby attest to having performed the stipulated number of procedures as indicated above, thereby meeting the criteria for those privileges I have requested.
************************************************************************************************************************
COMMITTEE APPROVALS
Family Medicine QI/Administrative Committee Date:
TEMPORARY PRIVILEGE APPROVAL
Or Dept Chief (in lieu of mtg)
Credentials Committee Date:
Department Chief:
Medical Executive Committee Date:
Board of Directors Date:
Date:
DOCUMENT APPROVALS: Dates:
Family Medicine Administrative Committee November 30, 2010
Credentials Committee January 25, 2011 (outside committee)
Medical Executive Committee January 25, 2011
Medical Policy Committee February 3, 2011
Board of Directors February 17, 2011
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