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

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Sutter Medical Center, Sacramento Department Of Diagnostic Imaging & Radiation Oncology - Delineation Of Privileges NAME: Request Privilege Appointment Requirements Proctoring Required 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 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.
Sutter Medical Center, Sacramento Department Of Diagnostic Imaging & Radiation Oncology - Delineation Of Privileges 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 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.
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New Privilege List - DI / Radiation Oncology - Sutter Medical Center

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