New Privilege List - DI / Radiation Oncology - Sutter Medical Center

Sutter Medical Center, Sacramento 

Department Of Diagnostic Imaging & Radiation Oncology - Delineation Of Privileges 

NAME: 

CRITERIA FOR DELINEATION OF PRIVILEGES 

Privileges in the Department of DIRO (Diagnostic Imaging and Radiation Oncology) will be applied for by individual physicians (who are members of the Medical Staff of Sutter 

Medical Center) using the attached form. The Administrative Committee of the Department (Chief, Immediate Past Chief, Vice Chief, Secretary and Chair of the Informal Sections 

of Diagnostic Radiology, Interventional Radiology, Nuclear Medicine and Radiation Oncology) will review the application and where indicated meet with the applicant personally 

to prepare recommendations for granting of privileges to the Credentials Committee of the Medical Staff. 

Physicians will submit documentation (when requested by the DIRO Administrative Committee) of their training, experience and evidence of Continuing Medical Education in 

those procedures for which they desire privileges. The basic criteria for department membership and delineation of privileges in Diagnostic Imaging and Radiation Oncology will 

be certification by the American Board of Radiology or the American Board of Nuclear Medicine, physicians who have completed an approved Radiology or Nuclear Medicine 

residency, or physicians with previous 10 years experience in a Joint Commission accredited hospital and have exercised similar privileges to those being requested. 

Within each general section, the procedures which are generally accepted as lying within the discipline will be included in the privileges. For example, General Diagnostic 

Radiology will include injection of contrast material, fluoroscopy, interpretation of radiographs, bronchography, CT and ultrasound under fluoroscopic control, etc. Radiation 

Oncology will include those procedures related to application of external irradiation, interstitial or intracavitary sealed radioactive sources, therapeutic use of radioactive isotopes, 

etc. Nuclear Medicine will include injections of radionuclides for diagnostic or therapeutic purposes, interpretation of physiologic and anatomic radionuclide studies, in-vitro tests 

using radionuclides, and use of monoclonal antibodies for diagnosis and/or treatment. Non-Invasive Vascular Imaging will also be part of Nuclear Medicine. 

The subspecialty practices of Angiography, Ultrasonography, Non-Invasive Vascular Imaging, Neuroradiology and Interventional Radiology will be considered for granting of 

privileges when these disciplines are included in the residency training and examination. Where these skills are acquired after residency training, consideration for delineation will 

be on an individual basis and take into account current and recent practice, post-graduate courses, preceptor training, or other forms of additional post-graduate training, and may 

require prior performance of an acceptable number of procedures. Privileges for General Diagnostic Imaging, Interventional Radiology, Neuroradiology and Interventional 

Neuroradiology require a Radiography Supervisor and Operator Permit. 

Consideration of granting of privileges to radiologists and non-radiologists must clearly reflect the major difference between specialists of various disciplines in view of the 

former’s knowledge of all available imaging modalities. Training and background will be primary criteria for delineation of privileges for any physician. The quality of training, as 

well as its duration, will necessarily continue to be a primary prerequisite in the privileging process. 

Privileges are granted for Sutter Medical Center, Sacramento and exercise of privileges is based on the type of care, treatment and services provided at each facility. 

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. Please be prepared to supply verification of volume performance if requested. 

Request Privilege Appointment Requirements Proctoring Required 

Reappointment Number 

Requirements Performed 

[ ] Admitting Privilege NONE None None N/A 

[ ] H&P Privilege 

Page 1 of 17 

Note: Approval is subject to the terms of the hospital's exclusive contract for Radiology services, i.e., approval is for second opinion consultations only, it being understood that the 

hospital's contracting Radiologists are primarily responsible for these services.



NAME: 


[ ] I. GENERAL DIAGNOSTIC IMAGING 

All aspects of patient management, exclusive of those 

listed below, which are within the generally recognized 

scope of Radiological practice. 

[ ] Stereotactic Breast Biopsy 

Stereotactic localization of breast lesions involves the 

use of dedicated radiographic equipment for targeting 

radiopaque breast lesions for subsequent biopsy. 

Stereotactic core needle type biopsy involves the use of 

the same radiographic equipment for localizing and 

subsequently performing percutaneous core needle type 

biopsy of breast lesions. 

Radiology Certificate Required 

Basic understanding of radiographic equipment and 

interpretation of mammographic abnormalities should be 

documented by certification of the American Board of 

Radiology and American College of Radiology, 

respectively. Physicians should meet the qualifications 

from the ACR standards for screening mammography 

and diagnostic mammography and problem solving 

breast evaluation and attest they meet Mammography 

Quality Standards Act (MQSA) standards. 

1. Specific experience and/or training may be 

documented by either of the following means: 

a. satisfactory completion of an accredited 

residency program which includes a minimum 

of twenty-five (25) stereotactic breast biopsy 

procedures;– OR – 

b. post graduate applicant should demonstrate 

competency by: 

1. Documentation of thirty (30) stereotactic 

localization and/or breast biopsy 

procedures with appropriate follow up 

documentation, 

– OR – 

2. Documentation of involvement in twenty-five (25) 

stereotactic localization and/or breast biopsy 

procedures under the supervision of a qualified 

physician preceptor and three hours of Category I 

CME didactic instruction in stereotactic biopsy. 

First five (5) cases 

AND 

Evaluations at 3, 6 & 

12 Months. 

NONE 

Reappointment 

Requirements 

None 

Minimum of 

twenty-five (25) 

cases in a two year 

period. 

Number 

Performed 

N/A 

(Continued on next page) 

• At least one half of these cases must be 

performed at the equivalent level of the 

primary operator. 

Page 2 of 17 





NAME: 


[ ] Stereotactic Breast Biopsy - Continued • The five (5) cases should be performed within 

the previous one year at the time of application 

for privileges. 

• A letter of verification from the applicants 

primary tutor who has performed at least five 

(5) cases with the applicant stating that the 

applicant is qualified to perform this procedure 

as a primary operator. 

Reappointment 

Requirements 

Number 

Performed 

[ ] Magnetic Resonance Imaging NONE NONE N/A 

[ ] Coronary CT Angiography 

Coronary CTA is a heart-imaging test using computed 

tomography (CT) to image the coronary arteries, cardiac 

chambers, valves, myocardium and pericardium and can 

help assess cardiac function 


Prerequisite: Must currently hold General Diagnostic First three (3) cases. 

Imaging privileges 

1. Certification in radiology or diagnostic radiology by 

the American Board of Radiology, the American 

Osteopathic Board of Radiology, the Royal College 

of Physicians and Surgeons of Canada, or Le 

College des Medecins du Quebec and have 

completed 50 supervised interpretations of cardiac 

CT exams, excluding those performed exclusively 

for calcium scoring, in the past 36 months. 

Documentation of cases should be by case listing or 

a letter from the Chief of Staff or Medical Director 

of a Joint Commission accredited hospital where the 

cases were performed attesting to the number of 

cases. 

OR, 

2. Competed an Accreditation Council for Graduate 

Medical Education (ACGME)-approved radiology 

residency program and have completed 50 

supervised interpretations of cardiac CT exams, 

excluding those performed exclusively for calcium 

scoring, in the past 36 months. Documentation of 

cases should be by a letter from the director of the 

residency program attesting to the physician’s 

competence to perform the procedure and volume 

of cases. 

AND, 

Minimum of Fifty 

(50) cases in a two 

year period. 

Page 3 of 17 





NAME: 


Coronary CT Angiography – Continued 

3. Completed at least 40 hours of category I continuing 

medical education (CME) in cardiac imaging, 

including cardiac CT/coronary CTA anatomy, 

physiology, and/or pathology or documented 

equivalent supervised experience in a center actively 

performing coronary CTA. Documentation of 

CME can be by copies of certificates or listing of 

CME programs with date, title of program and 

number Category 1 CME credits granted. 

Reappointment 

Requirements 

Number 

Performed 

[ ] II. INTERVENTIONAL RADIOLOGY Radiography Certificate Required. First five (5) cases 

AND 

Evaluations at 3, 6 & 

12 Months 

[ ] Central venous catheter placement with 

subcutaneous tunnel 

[ ] Central venous catheter placement without 

subcutaneous tunnel 

[ ] Transvenous repositioning a central venous catheter 

[ ] Transvenous extraction of central venous catheter 

fragment 

[ ] Central venous catheter placement with 

subcutaneous port 

[ ] Removal of central venous catheter either tunneled 

or with subcutaneous port 

[ ] Exchange of central venous catheter either tunneled 

or non-tunneled 

[ ] Transvenous stripping of central venous catheter 

[ ] Thrombolytic infusion for non-functioning central 

venous catheter 

[ ] Thrombolytic infusion for deep venous thrombosis 

[ ] Venous angioplasty 

[ ] Parathyroid and thyroid venous sampling 

[ ] Renal venous sampling 

[ ] Adrenal venous sampling 

[ ] Visceral venous sampling 

[ ] Wedge hepatic venogram 

[ ] Wedge hepatic venous pressure measurement 

[ ] Trans splenic portal venogram 

Page 4 of 17 





NAME: 


[ ] Transhepatic portal venogram 

[ ] Venous angioplasty with stenting 

[ ] Uterine vein embolizations 

[ ] Gonadal vein embolizations 

[ ] Percutaneous occlusion of splenic artery for 

[ ] 

hypersplenism 

Bronchial artery embolization for hemostatis or 

tumor 

[ ] Venous embolization for venous malformation 

[ ] Venous ethanol injection for venous malformation 

[ ] Angioplasty and stenting transhepatic portosystemic 

shunt 

[ ] Embolization esophageal and gastric varices 

[ ] Percutaneous transhepatic cholangiogram 

[ ] Percutaneous biliary drainage 

[ ] Percutaneous transhepatic internal/external biliary 

drainage 

[ ] Percutaneous transhepatic biliary drainage with 

stent placement 

[ ] Percutaneous transhepatic extraction of biliary duct 

stones 

[ ] Percutaneous cholecystostomy 

[ ] Percutaneous dilatation of biliary stricture 

[ ] Percutaneous trans T-tube extraction of biliary stone 

[ ] Percutaneous nephrostomy 

[ ] Percutaneous nephrostomy for access prior to 

nephrolithotomy 

[ ] Nephrostomy tube change 

[ ] Antigrade ureteral stenting 

[ ] Whitaker exam renal collecting system with 

manometry 

[ ] Percutaneous Gastrostomy 

[ ] Percutaneous jejunostomy 

[ ] Percutaneous dilatation of enteric obstructions, 

plus/minus stenting 

[ ] Conversion of gastrostomy to gastrojejunostomy 

[ ] Fallopian tube dilatation 

Reappointment 

Requirements 

Number 

Performed 

Page 5 of 17 





NAME: 


[ ] Ultrasound guided thoracentesis 

[ ] Ultrasound guided Paracentesis 

[ ] CT guided thoracentesis 

[ ] CT guided Paracentesis 

[ ] CT, ultrasound or fluoroscopic guided placement to 

thoracostomy tube 

[ ] Ultrasound, CT or fluoroscopic guided drainage of 

abscess (lung, pancreatic, subdiaphragmatic, 

retroperitoneal, renal, perirenal and pelvic) 

[ ] Ultrasound, CT or fluoroscopic guided drainage of 

hepatic, renal or pancreatic cyst 

[ ] Ultrasound, fluoroscopic of CT guided sclerosis of 

hepatic, pancreatic or renal cyst 

[ ] Percutaneous drainage of pancreatic pseudocyst 

[ ] Percutaneous creation of pancreatic-gastric cyst 

Gastrostomy 

[ ] Transrectal or transvaginal drainage of pelvic 

abscess 

[ ] CT, ultrasound or fluoroscopic guided biopsy 

(thyroid, lung, liver, pancreatic, retroperitoneal, 

intraperitoneal, muscle, bone, lymphoid, breast and 

prostate) 

[ ] Transjugular liver biopsy 

[ ] Percutaneous placement of inferior cava filter 

[ ] Percutaneous retrieval of intravascular foreign body 

[ ] Vascular embolization for bleeding 

[ ] Vascular embolization for arterial venous 

malformation 

[ ] Vascular embolization for tumor 

[ ] Chemo embolization for tumor 

[ ] Visceral arterial infusion for ischemia 

[ ] Percutaneous fluoroscopic declotting of thrombosed 

arterial venous grafts or shunts created for dialysis 

using either balloon fogarty or non-balloon 

(thrombolytic) technique 

[ ] Percutaneous ethanol ablation of tumors 

[ ] Transluminal occlusion of ureter 

[ ] Ureteral angioplasty for strictures 

Reappointment 

Requirements 

Page 6 of 17 


hospital's contracting Radiologists are primarily responsible for these services. 

Number 

Performed



NAME: 


[ ] Percutaneous drainage of lymphocele 

[ ] Percutaneous celiac plexus blockade or ablation 

[ ] Percutaneous CT guided lumbar sympatholysis 

[ ] Percutaneous thrombectomy of pulmonary artery 

embolism 

[ ] Catheter directed intraarterial thrombolysis 

[ ] Catheter directed intravenous thrombolysis 

[ ] Peripheral Transluminal Angioplasty 

Peripheral angioplasty (PTA) is the percutaneous 

approach toArteriograph intervention by dilatation or 

atherectomy and may include stent placement. A 

diagnostic peripheral angiogram is any non-coronary 

or non-cerebral (intra/extra cranial) angiogram and is 

one that provides complete imaging of the entire 

vascular distribution and the runoff of the vessel(s) in 

question. 

(This privilege is shared with another department) 


Disciplines of Vascular Surgery, Radiology and 

Cardiology are eligible for credentialing. 

• Basic understanding of cardiovascular disease 

should be documented by eligibility or certification 

by any one of the following: 

• American Board of Radiology 

• American Board of Internal Medicine with special 

certification in Cardiovascular Medicine fellowship 

• American Board of Surgery with completion of a 

general vascular surgery one (1) year fellowship 

• Physicians seeking to qualify by having completed 

a training program shall have documentation of 

having performed 100 peripheral angiograms, 50 

peripheral interventional procedures (counted per 

lesion) within the past three years and shall have a 

letter from the Chief of his/her training program 

stating that the applicant is competent to perform 

peripheral vascular interventions as a primary 

operator. 

– OR – 

Documentation of having performed 100 peripheral 

angiograms, 50 peripheral angioplasties within the 

past three years at another Joint Commission 

accredited hospital and documentation of attendance 

at a dedicated symposium on PTA, which has live 

case demonstrations, shall be documented. 

– OR – 

Documentation of successful completion of an 

approved in-house learning program under the 

First Five (5) 

Interventional 

procedures 

Reappointment 

Requirements 

Minimum of 50 

therapeutic 

interventions 

(counted per 

patient) in a twoyear 

period Should 

an applicant not 

attain the suggested 

number of 

procedures 

proctoring may be 

initiated as 

determined by the 

Department 

Q.I./Administrative 

Committee. 

Page 7 of 17 


hospital's contracting Radiologists are primarily responsible for these services. 

Number 

Performed



NAME: 


Peripheral Transluminal Angioplasty - Continued 

[ ] Hepatic Artery Chemoembolization 

Sub-selective catheterization of the hepatic artery, or 

its branches, with subsequent infusion of 

chemotherapeutic agents and/or embolic agents (under 

fluoroscopic guidance) with immediate removal of the 

catheter after the procedure has been performed. 

[ ] Peripheral and Visceral Arteriography (noncoronary/non-cerebral 

diagnostic angiography) 



preceptorship of a senior qualified physician and 

the performance of at least 100 peripheral 

angiograms and 50 peripheral angioplasty 

procedures. 

Applicants will be required to provide such 

documentation from the Director of Fellowship 

training or by letter from primary hospital where 

he/she has been practicing for the previous two years: 

1. Fellowship training in Interventional Radiology 

OR 

2. Selective catheterization of the hepatic artery and 

performance of diagnostic Arteriography in at 

least ten (10) cases 

AND 

3. Evidence of performance of Hepatic Artery 

Chemoembolization under supervision of a 

physician experienced in the procedure in at least 

five (5) cases. 

1. Evidence of training and competency by 

certification, or admissible for certification by the 

American Board of Radiology, Cardiovascular 

Disease by the American Board of Internal Medicine 

or Vascular Surgery by the American Board of 

Surgery. 

– AND – 

2 Documentation from the training program that the 

training program included concentrated training and 

experience in angiography including at least 50 noncoronary 

arteriographic procedures performed 

proficiently and successfully. 

-OR – In the absence of residency training in 

this procedure, documentation of successful 

completion of 100 non-coronary angiographic 

procedures from a Joint Commission accredited 

hospital within the past three years is required. This 

documentation must also include a letter of reference 

from a physician who is familiar with the applicant’s 

NONE 

Five (5) non-cerebral 

peripheral angiography 

procedures. 

Reappointment 

Requirements 

Two (2) procedures 

within prior two 

year period 

Twenty (20) noncoronary, 

noncerebral 

peripheral 

and visceral 

arteriography 

procedures. 

Number 

Performed 

Page 8 of 17 





NAME: 


Peripheral and Visceral Arteriography - Continued experience in arteriography. 

-OR – Successful completion of an approved 

In-house Learning and Teaching Program in noncerebral 

diagnostic peripheral angiography consisting 

of at least 50 procedures. 

[ ] Image Guided Tissue Ablation PRE-REQUISITE: It is understood that physicians 

who have been granted image-guided tissue ablation 

privileges may only utilize this therapy for the imageguided 

modality they hold privileges for (e.g., CT, 

ultrasound, MR, fluoroscopic). 

In order to perform image-guided tissue ablation, the 

physician must fulfill both criteria below: 

1. Physician must have performed a minimum of 

fifty (50) image-guided biopsy procedures. 

AND 

Reappointment 

Requirements 

NONE Minimum of 100 

image-guided 

biopsies or 

ablations over a 

two-year period, of 

which ten (10) 

must be ablations. 

Number 

Performed 

2. Physician must provide written documentation of 

proof of training for each tissue ablation technique 

requested, i.e. cryo, radiofrequency- or microablation. 

Acceptable training can include: 

a. Manufacturer sponsored course; OR 

. Fellowship training with at least ten (10) 

procedures performed as primary operator for 

each specific technique for which credentials 

are requested; OR 

c. Direct supervision through an In House 

Learning and Teaching Program at a Joint 

Commission accredited hospital by an 

attending physician/preceptor who has had 

significant training using the specific ablation 

technique requested. Significant training of 

the preceptor is defined as at least five (5) 

ablation procedures performed in previous 

year. 

Page 9 of 17 





NAME: 


[ ] Endovascular Repair of Aortic Aneurysms Prerequisite: 

1. Must currently hold all Interventional 

Radiology privileges (to include peripheral 

arteriography, angioplasty, intravascular 

stenting, and intravascular embolization). 

2. Participation with physicians who are 

privileged to perform open repair of aortic 

aneurysms. 

3. Intensive care admitting privileges 

Training/Documentation Requirement: 

1. Completion of an interventional radiology 

fellowship program where endovascular aortic 

aneurysm repair was an integral part of the training. 

This training must have occurred within the previous 

two years. Verification of this training in the form of 

a letter from the fellowship director is required. 

- OR - 

2. Documentation of prior experience in a Joint 

Commission accredited hospital in endovascular aortic 

aneurysm repair. This experience must have occurred 

within the previous two years. Documentation must 

include a letter from the Chief of the Department or 

Chief of Staff documenting experience in at least ten 

(10) cases. 

- OR - 

1. Successful completion of an approved in-house 

teaching program at Sutter Medical Center. 

-AND- 

Compliance with FDA guidelines for deployment of 

stent-graft devices in use. 

First two (2) cases. 

Reappointment 

Requirements 

Minimum of ten 

(10) cases from a 

JC accredited 

hospital. 

ALSO 

Continuing 

education should 

be in accordance 

with the American 

College of 

Radiology Practice 

Guidelines for 

Continuing 

Medical Education 

(150 hours of CME 

every 3 years, 70% 

in specialtyspecific 

or related 

areas to include a 

minimum of 10 

hours of category I 

CME specific to 

aortic pathology 

and endovascular 

repair). 

Number 

Performed 

Page 10 of 17 





NAME: 


III. DIAGNOSTIC NEURORADIOLOGY 

[ ] Core Diagnostic Neuroradiology 

Core Diagnostic Neuroradiology includes 

performance of diagnostic and image-guided 

diagnostic and therapeutic procedures related to the 

nervous system and head and neck. For example 

(not all inclusive): CT, MRI, myelography, spine 

injections, vertebroplasty, spine and maxillofacial 

biopsy. (Note: See separate multi-departmental 

privilege criteria for cerebral angiography.) 

[ ] Diagnostic Cerebral Angiography, Including 

WADA Test 


1. Current certification by the American Board of 

Radiology; AND, 

2. Completion of a neuroradiology fellowship and/or 

Certificate of Added Qualifications (CAQ) in 

Neuroradiology by the American Board of 

Radiology 

AND 

3. Fifty (50) diagnostic neuroradiology cases in the 

previous two years as demonstrated by a letter 

from the Director of the training program or 

Department Chief. 

1. Documentation of a formal training program in 

which diagnostic cerebral angiography was part of 

the training program. Documentation must be 

provided by the Director of the training program 

- OR- 

2. Post Residency or Fellowship Training 

documentation of prior experience at another Joint 

Commission accredited hospital within the past 

three (3) years. Documentation must be provided 

by the Department Chief at the other hospital. 

- OR – 

3. Successful completion of an approved in-house 

learning and teaching program. Documentation 

must be provided by the Preceptor at the end of 

the in-house training program. 

AND (Meet one of the following) 

1. Interventional Radiologists who hold Peripheral 

Transluminal Angioplasty privileges are required 

to provide evidence of training/experience in a 

minimum of 50 cerebral angiographies. 

2. Neuroradiologists with fellowship training in 

Neuroradiology or admissible for subspecialty 

Certificate of Added Qualification in 

Neuroradiology by the ABR or evidence of 

continuous practice in the field in the previous two 

years. 

First six (6) cases. 

Current senior staff 

members who qualify 

under these criteria and 

have been performing 

these procedures will be 

grandfathered in and 

proctoring will not be 

required. 

The first Six (6) 

cerebral angiography 

procedures. 

Proctoring will be 

performed by another 

Senior Staff physician 

who holds cerebral 

angiography privileges. 

Reappointment 

Requirements 

Twelve 12 different 

catheterizations in 

previous two years. 

Volume requirements 

can include 

cases the physician 

performed at other 

facilities and are 

not exclusive to 

SMCS patients. 

Twelve (12) 

cerebral 

angiography 

procedures. 

Should the 

applicant not attain 

the suggested 

number of 

procedures 


initiated as 


Department 


Committee. 

Number 

Performed 

Page 11 of 17 





NAME: 


IV. INTERVENTIONAL NEURORADIOLOGY 

[ ] Core Neuro-Interventional Radiology 

Includes performance of image-guided therapeutic and 

diagnostic procedures which involve intracranial 

catheterization and/or instrumentation. For example 

(not all inclusive): aneurysm coiling; intracranial 

angioplasty and stenting; cerebral infusion treatment; 

embolizations intra and extra cranial; and, cord cyst 

puncture 

(This privilege criteria is shared with another 

department) 

[ ] Extra-Cranial Cerebral Revascularization 

Includes angioplasty and/or placement of stents in the 

extra-cranial circulation with proximal or distal 

protection devices. 



Pathway A: 


Radiology; AND 

2. Completion of a one or two-year Neuroradiology 

fellowship AND 

3. Completion of an interventional Neuroradiology 

fellowship 

-OR- 

Pathway B: 


Radiology; AND 

2. Completion of a two-year Neuroradiology 

fellowship 

AND 

3. Continuous practice in a Joint Commission 

accredited hospital since training in 

Neuroradiology with demonstration of 

interventional procedure experience in fellowship 

training. 

ALSO: 

Fifty (50) Neurointerventional Radiology cases in the 

previous two years as demonstrated by a letter from 

the Director of the training program or Department 

Chief. 

PREREQUISITES 

1. Hold one of the following groups of privileges: 

a. Neuro-Interventional Radiology and Cerebral 

Angiography Privileges; or, 

b. Interventional Radiology Peripheral 

Transluminal Angioplasty and Cerebral 

Angiography Privileges. 

– AND – 

2. Document prior experience in using distal 

protection devices in at least 20 cases in any 

vascular territory. 

First six (6) cases . 

Current senior staff 

members who qualify 

under these criteria and 

have been performing 

these procedures will be 

grandfathered in and 

proctoring will not be 

required. 

First six (6) extracranial 

revascularization 

procedures.. Proctoring 

will be performed by 

another Senior Staff 

physician who holds 

extra-cerebral 


privileges and who has 

also successfully 

completed proctoring. 

Reappointment 

Requirements 

Twelve (12) 

interventional 

Neuroradiology 

cases in previous 

two years. 

Requirements can 

include cases that 

the physician 

performed at other 

facilities and are 

not exclusive to 

Sutter Medical 

Center, Sacramento 

patients. 

Physician should 

be prepared to 

supply verification 

of volume 

performance if 

requested. 

Six (6) intra-cranial 

cerebral 


(carotid stent) 

procedures with 

use of distal 

protection devices. 

Should an applicant 

not attain the 

suggested number 

Number 

Performed 

Page 12 of 17 





NAME: 


Extra-Cranial Cerebral Revascularization - 

Continued 

TRAINING/EXPERIENCE REQUIREMENTS 

1. Documentation of a formal training program 

where extra-cranial revascularization (carotid 

stenting) was part of the training program. 

Applicant must have performed at least 10 extracranial 

cerebral revascularization (carotid stent) 

procedures. Documentation must be provided by 

the Director of the training program. 

OR- 

2. Post Residency or Fellowship Training 

a. Documentation of successful completion of a 

post-graduate course (approved by the 

department) - AND - 

b. Documentation of prior experience at another 

Joint Commission accredited hospital in at 

least 10 extra-cranial cerebral 

revascularization (carotid stent) procedures 

OR successful completion of an approved inhouse 

learning and teaching program in at 

least 10 extra-cranial cerebral 

revascularization (carotid stent) procedures. 

Documentation must be provided by the 

Chief of the Department of the other Joint 

Commission accredited hospital or by the 

Preceptor at the end of the in-house training 

program. 

Reappointment 

Requirements 

of procedures 


initiated as 


Department 


Committee. 

Number 

Performed 

Page 13 of 17 





NAME: 


V. NUCLEAR MEDICINE Evaluations at 3, 6 & 

12 Months 

[ ] Diagnostic Nuclear Medicine 1. Completion of an approved Radiology or Nuclear 

Medicine residency within three years 

OR 


Radiology or the American Board of Nuclear 

Medicine 

OR 

A mix of fifty (50) 

cases representative of 

the privileges requested. 

A written report of their 

evaluation should be 

submitted and include 

the case numbers. 

Reappointment 

Requirements 

Maintain current 

California 

Radioactive 

Materials License 

Number 

Performed 

[ ] Therapeutic Nuclear Medicine 

(Includes Radioactive Iodine Thyroid Therapy 

Privileges) 

3. Documentation of previous 10 years experience in 

diagnostic nuclear medicine at a Joint 

Commission accredited institution 

AND 

Current California Radioactive Materials 

License 

1. Completion of an approved Nuclear Medicine 

residency within three years 

OR 

2. Certification or admissible to the Board of Nuclear 

Medicine 

OR 








Minimum of at 

least ten (10) 

therapeutic nuclear 

medicine 

procedures during 

the previous two 

years. 

3. Documentation of previous 10 years experience in 

therapeutic nuclear medicine at a Joint Comission 

accredited institution with documentation of at 

least ten therapeutic nuclear medicine procedures 

performed at a Joint Commission accredited 

institution during the previous two years. 

Page 14 of 17 





NAME: 


[ ] Non-invasive vascular testing 1. Currently granted Diagnostic or Therapeutic 

Nuclear Medicine privileges at Sutter Medical 

Center, Sacramento (SMCS) 

AND 

2. Documentation of performance of at least 200 

vascular studies of which 100 cases need to be 

carotid ultrasound during previous three years. 

Documentation can be from residency program or a 

letter from the department medical director or 

medical staff department chief at a Joint 

Commission accredited institution. 

[ ] Cardiac Treadmill and Pharmacologic Stress Testing 1. Currently granted Diagnostic Nuclear Medicine 

privileges at SMCS; 

AND (one of the following☺ 

1. Board certification or admissibility from the 

American Board of Radiology or American Board 

of Nuclear Medicine; or, 

2. Documentation of at least fifty (50) procedures 

performed at a Joint Commission accredited 








Six (6) cases are to be 

proctored by a SMCS 

Senior Staff physician 

granted similar 

privilege. 

institution during the previous two years. 

VI. RADIATION ONCLOLOGY 

[ ] Core Radiation Oncology First five (5) cases 

[ ] Intra-operative Radiation Therapy 1. Must have full specialty privileges in the 

Diagnostic Imaging and Radiation Oncology 

Department. 

Reappointment 

Requirements 

NONE 

NONE 

First two (2) cases NONE 

Number 

Performed 

2. Must either observe or assist in one case wit 

documentation submitted at the time of privilege 

request. 

Page 15 of 17 





NAME: 


Reappointment 

Requirements 

[ ] Gamma Knife 1. Must have full specialty privileges in the 

NONE Minimum of 10 

Diagnostic Imaging & Radiation Oncology 

(10) cases in a two 

Department at Sutter Medical Center, 

year period. 

Sacramento. 

Also, must 

participate in 

2. Must be board certified or board eligible by 

emergency 

the American Board of Radiology. 

response 

procedures every 

3. Must have successfully completed 

month and must 

specialized training in gamma knife 

attend and 

stereotactic radiosurgery at an approved 

actively 

Elekta sponsored gamma knife radiosurgery 

participate in 

user training course. 

30% of all 

scheduled gamma 

4. Must have documentation of involvement in 

knife patient 

five (5) gamma knife procedures under the 

selection and 

supervision of a qualified physician preceptor 

follow up 

involving the application of ionizing 

conferences within 

radiation for the treatment of neurological 

a 24-month 

lesions using stereotactic techniques, 

period. 

including target localization, treatment 

planning, treatment procedures, radiation 

safety and emergency response procedures 

applicable to stereotactic radiosurgery 

techniques. 

Note: Critical Care Unit Privileges are obtained through the Department of Medicine 

5. Must participate in emergency response 

procedures every twelve months and must 

attend and actively participate in 30% of all 

scheduled gamma knife patient selection and 

follow up conferences within a 24-month 

period. This requirement is necessary to 

obtain and maintain privileges. 

Number 

Performed 

Page 16 of 17 





NAME: 

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. 

By completing and submitting this privilege delineation form, you are attesting that you have performed the stipulated number of procedures as indicated above. 

********************************************************************************************************************************* 

COMMITTEE APPROVALS 

Department QI/Administrative Committee Date: 

Or Dept Chief (in lieu of mtg) 

Credentials Committee Date: 

Medical Executive Committee Date: 

Board of Directors Date: 

TEMPORARY PRIVILEGE APPROVAL 

Department Chief: 

Date: 

DOCUMENT APPROVAL Dates: 

Dept of DIRO Administrative Committee October 12, 2011 

Credentials Committee November 8, 2011 

Medical Executive Committee December 20, 2011 

Medical Policy Committee January 5, 2012 

Board of Directors February 13, 2012 

Page 17 of 17

New Privilege List - DI / Radiation Oncology - Sutter Medical Center

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