VANDERBILT UNIVERSITY MEDICAL CENTER APPLICATION FOR SPECIAL PRIVILEGES ADVANCED PRACTICE PROVIDER PROFESSIONAL STAFF WITH PRIVILEGES (PSP)

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Joella Stevens
6 years ago
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1 FOR ADVANCED PROCEDURE S Advanced Procedure Privileges: Are those approved procedural privileges requiring additional education and training and may be granted only upon evidence of initial and ongoing competency. INSTRUCTIONS 1. Professional Staff Privileges providers requesting advanced procedure privileges must do so using the appropriate request form (Adult or Pediatric). Requests with supporting documentation are submitted to Provider Support Services and thereafter reviewed by the Joint Practice Committee. 2. Supporting Documentation: Requests for advanced procedure privileges at initial appointment, reappointment and additional privilege additions must be supported by the following: Procedure notes evidencing successful completion of required number of procedures performed; and/or Simulation/animal lab certificate of completion Colposcopy and Moderate Sedation privileges require a separate request form available through Provider Support Services. 3. Special procedures will only be approved if medically necessary as an integral part of the provider s scope of practice. Required forms must be signed by supervising physician. Competency threshold numbers are minimum baselines and may be increased at the discretion of the supervising physician. All providers privileged to perform advanced procedures are subject to the mandates of focused professional practice evaluation (FPPE) and ongoing professional practice evaluation (OPPE). 1

2 Practitioner Name: Department: Location: Primary Supervising Physician: The advanced practice provider with appropriate education, training, competency and board certification may request additional special procedural privileges as supported by the supervising physician. Procedures will only be approved if medically necessary as an integral part of the APP s scope of practice. The initial and continued competency requirements are subject to validation and attestation of competency and requirements may be increased based on national standards or at the supervising physician s discretion. b) Advanced Procedures Initial Adding Reappointment INITIAL (DOCUMENTED OVER A 12 MONTH (TO BE OBTAINED PERIOD AND Arterial line, insertion 5 4 Arterial puncture 4 3 Arterial sheath, removal 4 3 Arthrocentesis 4 3 Arteriotomy closures- femoral 5 4 Biopsies: Bone Marrow Aspiration 5 4 Endometrial biopsy 5 4 Cervical biopsy 5 4 Prostate biopsy 5 4 Skin punch biopsy 3 2 Skin biopsy 3 2 2

3 INITIAL (TO BE OBTAINED (DOCUMENTED OVER A 12 MONTH PERIOD AND Shave biopsy 3 2 Bone markers, insertion 4 3 Bone Marrow Harvest/Assist 4 2 Bronchoscopy for lavage 5 4 Cardiac Ventricular assist device optimization 4 3 Chemical or talc pleurodesis, bedside 4 3 Central line change over wire 4 3 Central line insertion 5 4 Chest tube, insertion (for fluid or air) 5 4 Chest tube, removal 4 3 Closed Reduction (casting/splinting/traction) 4 3 Complex laceration repair 4 3 Complex wound management 4 3 Cryosurgery benign skin lesions 3 2 Cystoscopy, stent removal, urethral dilation, 5 4 Emergency endotracheal intubation 10 5 Epicardial pacing wires, removal 4 3 Escharotomy 3 3 Facet and joint injections/aspiration 3 2 Femoral arterial sheath insertion 5 4 Filler injections dermatology 3 2 Gastrostomy tube, exchange and removal 4 3 Hemorrhoid banding 4 3 Image guided joint injections 5 4 Incision and drainage of minor abscess 5 4 (perirectal, breast, axillary, extremity, skin, etc.) Incision and drainage thrombosed hemorrhoids 5 4 Injection bulking agents; botox urology

4 INITIAL (TO BE OBTAINED (DOCUMENTED OVER A 12 MONTH PERIOD AND Instillation of antibiotics/tpa into EVD 5 4 Intraaortic balloon pump, removal 5 4 Intra-articular knee injections 3 2 Intracranial Pressure (ICP) Monitor Placement 5 4 Intrathecal baclofen trial 5 3 Intrathecal pump myleogram 5 3 Intrathecal pump myleogram refill 5 3 Intrathecal pump reprogram 5 3 Lap band adjustment 3 2 Laser hair removal 3 2 Laser removal benign lesions, 3 2 photo-damaged skin Laser treatment, leg veins 3 2 Lumbar puncture 5 3 Lumbar drain insertion 5 4 Nasopharyngeal endoscopy 5 4 Nasopharyngolaryngoscopy 5 4 Nerve block for dermal filler anesthesia 3 2 dermatology Neurostimulator analyze/program 10 5 Needle Localization 10 5 Occipital nerve block 3 3 Ommaya reservoir - access 3 2 Oropharyngeal soft tissue biopsies 5 4 Paracentesis 5 5 Percutaneous biopsy (superficial, thyroid, lymph 10 5 node) radiology Percutaneous tube and drain removal 4 3 4

5 INITIAL (TO BE OBTAINED (DOCUMENTED OVER A 12 MONTH PERIOD AND Photodynamic therapy-dermatology 3 2 Placement of LHRH agonists urology 3 2 Placement of negative pressure dressing 4 3 Pulmonary Artery Catheter, insertion 10 5 Screening Ultrasound: scrotal, prostate, renal 10 5 Shuntograms 3 2 Shunt reprogramming 3 2 Shunt Tap 3 2 Simple suturing 3 2 Small-vein sclerotherapy dermatology 3 2 Superficial percutaneous drain insertion 5 5 TCA peel dermatology 3 2 TCA application anal condyloma 3 2 Thoracentesis 5 4 Thrombin Injection for Pseudoaneursym 5 4 Tracheostomy, decannulation 4 3 Tracheostomy downsize/exchange 4 3 Trigger point injections 3 3 Trochanteric hip injections 3 2 Tunneled Catheter Insertion 5 4 Tunneled Catheter Removal/Repair 4 3 Tunneled Catheter with Reservoir Removal 4 3 Vasectomy 10 5 Video Urodynamics 5 2 OTHER Requires separate request Colposcopy see separate application Moderate Sedation see separate application 5

6 Requesting Practitioner Signature: Date: Initial Appointment Attestation: I have instructed, observed, or supervised throughout the required number of procedures for which is requesting advanced procedure privileges as delineated. I attest that he/she is competent to perform the requested procedures unsupervised, based on established practice protocols, unless otherwise noted. Reappointment Attestation: I have reviewed the procedural notes and technique for procedures which is requesting continued advanced procedure privileges as delineated. I attest that he/she is competent to perform the requested procedures unsupervised, based on established practice protocols, unless otherwise noted. Attestor: Date: Signature Approvals: Supervising Physician: Date: Department Chair/Chief of staff: Date: 6

VANDERBILT UNIVERSITY MEDICAL CENTER APPLICATION FOR ADVANCED PROCEDURE PRIVILEGES PROFESSIONAL STAFF WITH PRIVILEGES (PSP)

VANDERBILT UNIVERSITY MEDICAL CENTER APPLICATION FOR ADVANCED PROCEDURE PRIVILEGES PROFESSIONAL STAFF WITH PRIVILEGES (PSP) APPLICATION FOR ADVANCED PROCEDURE S PROFESSIONAL STAFF WITH S (PSP) Advanced Procedure Privileges: Are those approved procedural privileges requiring additional education and training and may be granted