UNIVERSITY OF MICHIGAN HOSPITALS AND HEALTH CENTERS. Delineation of Privileges Department of Dermatology
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1 University of Michigan Hospitals and Health Centers UNIVERSITY OF MICHIGAN HOSPITALS AND HEALTH CENTERS Delineation of Privileges Department of Dermatology Name: Please Print or Type LEVEL I CORE PRIVILEGES Scope of Practice/Privileges Dermatology is a discipline of medicine that provides management (prevention, diagnosis, evaluation and treatment) of patients of all ages with benign and malignant disorders of the skin, mucous membranes, external genitalia, hair and nails, as well as sexually transmitted diseases. Diagnosis using cutaneous microbiology can be performed by the dermatologist. Treatment includes dermatologic surgery, phototherapy and photochemotherapy. Privileges also include the following representative list, but it is not intended to be allencompassing, but rather to reflect the categories/types of patient problems included in the description of privileges. Acne Allergy/immunodermatology Apply topical medications/dressings Clinical pathology Collagen injection Comprehensive examination, consultation, diagnosis, and treatment for patients of all ages with illnesses/injuries of the integumentary system (epidermis, dermis, subcutaneous tissue, hair, nails, and cutaneous glands) Contact dermatitis Cryotherapy Curettage Cutaneous infestations (e.g., lice, scabies) Cutaneous microbiology, including: - advanced; - routine; - STD's Cutaneous oncology Cutaneous infections, including but not limited to: - superficial and deep fungal; - leprosy; - viral; -bacterial Darkfield microscopy Dermatitis Dermatologic surgery, including: - biopsy techniques, skin and nail; - cryosurgery; - electrosurgery; - excisional surgery w/appropriate closures, including small flaps/grafts; - laser surgery; - nail surgery; - scalp surgery Dermatoses, common (e.g., psoriasis, lichen planus) Drug eruptions Electrolysis Epicutaneous testing Excisions, simple/uncomplicated Fungal infections, superficial CC090407ECCA
2 Gram stain Intradermal testing Lesions, removal of benign/malignant Microbe culture (e.g., fungi, bacterial, viruses) Parasitology Patch testing Pharmacotherapy, including: topical; systemic Photochemotherapy Phototesting Phototherapy Potassium hydroxide testing Psoralen ultraviolet therapy Pyodermas Scabies prep Scar revisions Sclerotherapy, including: - vein injection Shave removal Skin biopsy Skin cancer, uncomplicated Skin grafting Skin tumors, routine benign Subcutaneous injections Tzanck smear Ultraviolet A therapy Ultraviolet B therapy Wood's light examination Minimum Training and Experience All new faculty must provide proof of: 1. M.D., DO or equivalent international medical degree, and 2. Completion of an ACGME-approved dermatology residency program or equivalent foreign program if approved by the Chair of Dermatology. All new and current faculty must provide proof of: 1. Current American Board of Dermatology certification or equivalent from their home country or must retain eligibility for said certification. New faculty or those newly requesting privileges must provide: 1. Two letters of reference from colleagues aware of applicant s performance or 2. A letter of satisfactory completion from the Director of the Fellowship or Residency program if the request for privileges immediately follows a Fellowship or Residency. Current faculty must demonstrate: 1. Continued experience in the area as documented by Department-sanctioned clinical activity for a minimum of 20 hours in the previous year or 40 hours in the previous privileging period. CC090407ECCA
3 2. That at the time of reprivileging, the Chair of Dermatology, or designate, has reviewed all departmental quality assurance activities for the previous privileging period and determined that such peer evaluation of performance has been satisfactorily met for reprivileging. Unusual or unexpected incidents or volume will be reported to the Chair of Dermatology. Requested (Applicant) Recommended approval (Service Chief/Chair) LEVEL II MOHS MICROGRAPHIC SURGERY Scope of Practice/Privileges Mohs micrographic surgery including soft tissue reconstruction utilizing flaps and grafts. Minimum Training and Experience All new and current faculty must provide proof of: 1. Meeting level I minimal training and experience. New faculty or those newly requesting privileges must provide documentation of: 1. Completion of a Mohs Procedural Dermatology Fellowship approved by the ACGME; or completion of a fellowship in a program approved by the American College of Mohs Micrographic Surgery and Cutaneous Oncology if approved by the Head of the Cutaneous Surgery Unit; or an equivalent program if approved by the Chair of Dermatology, and 2. Evidence of receiving proctoring of three relevant cases, said proctoring to be performed by the Head of the Cutaneous Surgery Unit or other physician as designated by the Chair of Dermatology, or 3. Evidence of satisfactory participation in or completion of a fellowship in Mohs surgery at the University of Michigan Medical Center. Current faculty must demonstrate: 1. Continued experience documented by performance of a minimum of ten relevant cases in the previous privileging period. 2. That at the time of reprivileging, the Chair of Dermatology, or designate, has reviewed all departmental quality assurance activities for the previous privileging period and determined that such peer evaluation of performance has been satisfactorily met for reprivileging. Unusual or unexpected incidents or volume will be reported to the Chair of Dermatology. Requested (Applicant) Recommended approval (Service Chief/Chair) CC090407ECCA
4 Scope of Practice/Privileges SKIN RESURFACING (If performed by laser, also complete Laser Surgery Privileging as a separate Application.) Minimum Training and Experience All new and current faculty must provide proof of: 1. Meeting level I minimal training and experience. New faculty or those newly requesting privileges must provide documentation of: 1. Postgraduate coursework or experience in skin resurfacing as approved by the Chair of Dermatology. Current faculty must demonstrate: 1. Continued experience documented by performance of a minimum of ten relevant cases in the previous privileging period. 2. That at the time of reprivileging, the Chair of Dermatology, or designate, has reviewed all departmental quality assurance activities for the previous privileging period and determined that such peer evaluation of performance has been satisfactorily met for reprivileging. Unusual or unexpected incidents or volume will be reported to the Chair of Dermatology. Requested (Applicant) Recommended approval (Service Chief/Chair) SPECIAL PRIVILEGES A separate application is required to APPLY or REAPPLY for the following Special Privileges: FLUOROSCOPY LASER ROBOTIC SURGICAL PLATFORM SEDATION PRIVILEGES FOR A NON-ANESTHESIOLOGIST PLEASE go to URL: for instructions, or contact your Clinical Department Representative. CC090407ECCA
5 University of Michigan Department of Dermatology Faculty Privileging Form Continued Privileges in General Dermatology (Level I) Faculty Name: I certify that the above named faculty member has continued experience in general dermatology as documented by department-sanctioned clinical activity in general dermatology or a subspecialty thereof for a minimum of 20 hours in the previous privileging period. I have reviewed all departmental quality assurance activities for the above named physician for the previous privileging period and I have determined that peer evaluation of performance has been satisfactorily met for reprivileging. Unless listed below, there was no unusual or unexpected incidents nor was there any unexpected incidence of unexpected results. Approved by: Department Administrator Chair, Department of Dermatology CC090407ECCA
6 University of Michigan Department of Dermatology Faculty Privileging Form Mohs Surgery Proctoring Faculty Name: Faculty was proctored and approved based on the following Mohs surgery cases including preoperative evaluation and postoperative follow-up. Case (Provide date and description of the procedure performed.) Proctor Name Proctor s Dr. # Approved (Indicate by proctor s initials) ************************************************************************************ Approved by: Director, Cutaneous Surgery Unit Chair, Department of Dermatology CC090407ECCA
7 University of Michigan Department of Dermatology Faculty Privileging Form Continued Privileges in Special Dermatologic Surgery Faculty Name: I certify that the above named faculty member has continued experience as documented by department-sanctioned clinical activity for a minimum of 10 relevant cases in the previous privileging period. I have reviewed all departmental quality assurance activities for the above named physician for the previous privleigng period and I have determined that peer evaluation of performance has been satisfactorily met for reprivileging. Unless listed below, there was no unusual or unexpected incidents nor was there any unexpected incidence of unexpected results. Above approval and qualification for: Mohs Surgery Sclerotherapy Laser Therapy Skin Resurfacing ************************************************************************************ Approved by: Department Administrator Chair, Department of Dermatology CC090407ECCA
8 TO BE COMPLETED BY APPLICANT: I meet the previously stated minimum criteria and request that my application be considered for the privileges as outlined above. I authorize and release from liability, any hospital, licensing board, certification board, individual or institution who in good faith and without malice, provides necessary information for the verification of my professional credentials for membership to the Medical Staff of The University of Michigan Health System. Applicant Signature: : DEPARTMENT ACTION: Approval: As Requested As Modified (please explain) I have reviewed and/or discussed the privileges requested and find them to be commensurate with his/her training and experience, and recommend that his/her application proceed. Justification for approval is based on careful review of the applicant s education, postgraduate clinical training, demonstrated clinical proficiency and Board Certification or qualifications to sit for the Boards. Department Chair: : Service Chief: : CREDENTIALS COMMITTEE ACTION: Approval as Requested Not Approved (please explain) Credentials Committee Member: : EXECUTIVE COMMITTEE ON CLINICAL AFFAIRS ACTION: Approval as Requested Not Approved (please explain) Executive Committee On Clinical Affairs - Member: : CC090407ECCA
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