1215 Lee Street, McKim Hall, 1 st Floor, Room 1103, Charlottesville, VA

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1 1215 Lee Street, McKim Hall, 1 st Floor, Room 1103, Charlottesville, VA THORACI&';CARDIAC. AND VASCULAR SUR~ERY CLINICAL PRIVIL~GES Name: (S'u_o jj.k~{' a John.A; Kern, M.D.... ~j Page 1 Effective From / / To / /_ July 1,2013'-'June30, 2015 ~ o Initial Appointment (initial privileges) Reappointment (renewal of privileges) v:! All new applicants must meet the following requirements as approved by the governing body ';1 l effective: 12 Apr Applicant: Check off the "Requested" box for each privilege requested. Applicants have the burden of producing information deemed adequate by the Hospital for a proper evaluation of current competence, current clinical activity, and other qualifications and for resolving any doubts related to qualifications for requested privileges. [Department Chair/Chief]: Check the appropriate box for recommendation on the last page of this form and include your recommendation for Focused Professional Practice Evaluation (FPPE). If recommended with conditions or not recommended, provide condition or explanation on the last page of this form. Other Requirements Note that privileges granted may only be exercised at the site(s) and/or setting(s) that have sufficient space, equipment, staffing, and other resources r~uired to support the privilege. This document is focused on defining qualifications related to competency to exercise clinical privileges. The applicant must also adhere to any additional organizational, regulatory, or accreditation requirements that the organization is obligated to meet.. QUALIFICATIONS FOR THORACIC, CARDIAC AND VASCULAR SURGERY Initial Applicants: To be eligible to apply for privileges, the initial applicant must meet the following criteria: juccessful completion of an Accreditation Council for Graduate Medical Education (ACGIVIE) or American t)steopathic Association (AOA) accredited residency in thoracic, cardiothoracic, and/or vascular surgery, as appropriate for the privileges requested. AND Current certification or active participation in tbe examination process [with achievement of certification within [3] years] leading to certification in thoracic, cardiac, cardiothoracic, or vascular surgery by the American Board of Thoracic Surgery, or the American Osteopathic Board of Surgery. AND Required Current Experience: At least [25] surgical procedures, reflective of the scope of privileges requested, over the past 12 months or successful completion of an ACGME or AOA accredited residency or clinical fellowship within the past 12 months. Revised: 07108/11

2 Jot'ii'l A. K~rn, M;D'~ July :1,2013- June3C>, Lee Street, McKim Hall, 1st Floor, Room 1103, Charlottesville, VA THORACIC. CARDIAC, AND VASCULAR SURGERY CLINICAL PRIVILEGES Name: s:yu'n D f\.'6~''f\ Page 2 Effective From,, To,, Reappointment (Renewal of Privileges) Requirements: To be eligible to renew privileges in thoracic surgery, the reapplicant must meet the following criteria: Current demonstrated competence and an adequate volume of experience [50] surgical procedures) with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges. ~BS Board Certification, appropriate for the privileges requested: ABS Certificate ~(\erj Certificate No.: i...f-13~~ Date of expiration ~j I2 ) 1(p Other Certificates held: Name Number Date of Expiration <g \ \(J rz..ol (..O\}I 1~S '1\Za1~ CORE PRIVILEGES - Thoracic Surgery ~equested Admit, evaluate, diagnose, and provide operative, perioperative, and critical care to patients of all ages with pathological conditions within the chest. Includes [surgical care of coronary artery disease]; cancers of the lung, esophagus and chest wall; abnormalities of the trachea;[abnormalities of the great vessels and heart valves]; congenital anomalies of the chest, tumors of the mediastinum; and diseases of the diaphragm, Congenital and acquired vascular disorders of arteries and veins. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regardinq emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.. Revised: 07/08/11

3 John A. Kern,M.D... July 1, June 30; 21) Lee Street, McKim Hall, 1st Floor, Room 1103, Charlottesville, VA THORACIC. CARDIAC. AND VASCULAR SURGERY CLINICAL PRIVILEGES s:jbh{) ft \s-q."'d Effective From / / To / / Name: Page 3 This list is not intended to be an all encompassing procedure list. It defines the types of activities/procedures/privileges that the majority of practitioners in this specialty perform at this organization and inherent activities/procedures/privileges requiring similar skill sets and techniques. To the applicant: If you wish to exclude any procedures, please strike through those procedures which you do not wish to request, initial, and date. Thoracic Surgery 1. Perform history and physical exam 2. Cervical, thoracic or dorsal sympathectomy 3. Correction of diaphragmatic hernias, both congenital or acquired, and anti reflux procedures 4. Decortication or pleurectomy procedures 5. Diagnostic procedures to include cervical and mediastinal exploration, parasternal exploration, and mediastinoscopy 6. Endoscopic procedures including bronchoscopy, esophagoscopy, mediastinoscopy 7. Implantation of cardioverter defibrillator 8. Lymph node and superficial biopsy procedures 9. Management of chest and neck trauma,\. 10. Operations for achalasia and for promotion of esophageal drainage 11. Pericardiocentesis, pericardial drainage procedures, pericardiectomy 12. Procedures upon the chest wall, pleura, and lungs including wedge resections, segmentectomy, lobectomy, and pneumonectomy 13. Resection, reconstruction, or repair of the trachea and bronchi 14. Resection, reconstruction, repair, or biopsy of the lung and its parts 15. Surgery on the esophagus, mediastinum, and diaphragm including surgery for diverticulum, as well as perforation, resections" transhiatal esophagectomy, surgery for benign esophageal disease, surgery on mediastinum for removal of benign or malignant tumors.6. Thoracentesis 17. Thoracoscopy 18. Thoracotomy for trauma, hemorrhage, rib biopsy, drainage of empyema or removal of foreign body 19. Tracheostomy 20. Tube thoracostomy 21. Video-Assisted Thoracoscopic Surgery (VATS) CORE PRIVILEGES - Cardiac f1j Requested 1. Ablative surgery (RF energy, microwave, cryoablation, laser and high-intensity focused ultrasound, maze) 2. All procedures upon the heart for the management of acquired/congenital cardiac disease, including surgery upon the pericardium, coronary arteries, the valves, and other internal structures of the heart and for acquired septal defects and ventricular aneurysms 3. Correction or repair of air anomalies or injuries of great vessels and branches thereof, including aorta, pulmonary artery, pulmonary veins, and vena cava Revised: 07/08/11

4 1215 Lee Street, McKim Hall, 1st Floor, Room 1103, Charlottesville, VA THORACIC, CARDIAC, AND VASCULAR SURGERY CLINICAL PRIVILEGES Name: Gbhn ft kerd Page 4 Effective From,, To,, 4. Endarterectomy of pulmonary artery 5. Endomyocardial biopsy 6. Management of congenital septal and valvular defects 7. Minimally invasive direct coronary artery bypass (MIDCAS) 8. Off pump coronary artery bypass (OPCAS) 9. Operations for myocardial revascularization 10. Pacemaker and'or AICD implantation and management, transvenous and transthoracic 11. Palliative vascular procedures (not requiring cardiopulmonary bypass) for congenital cardiac disease 12. Pulmonary embolectomy 13. Surgery for implantation of artificial heart and mechanical devices to support or replace the heart partially or totally 14. Surgery of patent ductus arteriosus and coarctation of the aorta 15. Surgery of the aortic arch and branches; descending thoracic aorta for aneurysm'trauma 16. Surgery of the thoracoabdominal aorta for aneurysm 17. Surgery of tumors of the heart and pericardium 18. Vascular access procedures for use of life support systems, such as extra corporeal oxygenation and cardiac support 19. Vascular operations, e.g., caval interruption, emb.fljectomy, endarterectomy, repair of excision of aneurysm, vascular graft or prosthesis CORE PRIVILEGES - Vascular Surgery ttj,.req uested 1. Vascular access procedures for use of life support systems, such as extra corporeal oxygenation and cardiac support 2. Vascular operations, e.g., caval interruption, embolectomy, endarterectomy, repair of excision of aneurysm, vascular graft or prosthesis 3. Surgery of the thoracoabdominal aorta for aneurysm 4. Surgical treatment of other acquired or congenital disorders of arteries and veins. SPECIAL NON-CORE PRIVILEGES (SEE SPECIFIC CRITERIA) Non-Core Privileges are requested individually in addition to requesting the core. Each individual requesting Non-Core Privileges must meet the specific threshold criteria as applicable to the initial applicant or reapplicant. USEOF LASER [Criteria: Successful completion of an approved residency in a specialty or subspecialty which included training in laser principles or completion of an approved 8-10 hour minimum CME course which includes Revised: 07108/11

5 , John A. K~rn, M.D. July 1, 2013 ~June 30, Lee Street, McKim Hall, 1st Floor, Room 1103, Charlottesville, VA THORACIC. CARDIAC. AND VASCULAR SURGERY CLINICAL PRIVILEGES Name: GobI') -A-,\<~\'C\. Page 5 Effective From,, To,, training in laser principles. In addition, an applicant for privileges should spend time after the basic training course in a clinical setting with an experienced operator who has been granted laser privileges acting as a preceptor. Practitioner agrees to limit practice to only the specific laser types for which they have provided documentation of training and experience. The applicant must supply a certificate documenting that she'he attended a wavelength and specialty-specific laser course and also present " documentation as to the content of that course. Required Current Experience: Demonstrated current competence and evidence of the performance of at least [10] procedures in the past 12 months or completion of training in the past 12 months. Renewal of Privilege: Demonstrated current competence and evidence of the performance of at least [10 procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.] o Requested Vag o Requested C02 o Requested Other.\ 't< USE OF ROBOTIC ASSISTED SYSTEM FOR PROCEDURES (ESOPHAGEAL TUMORS, SOLID THORACIC TUMORS, THYMOMA AND RETROMEDIASTINAL TUMORS) [Criteria: Successful completion of an ACGME or AOA post graduate training program that included training in minimal access procedures and therapeutic robotic devices and their use or completion of an, approved structured training program that included didactic education on the specific technology and an educational program for the specialty specific approach to the organ systems. Training should include observation of live cases. Physician must have privileges to perform the procedures being requested for use with the robotic system, hold privileges in or demonstrate training and experience in minimal access irocedures. Practitioner agrees to limit practice to only the specific robotic system for which they have '):>rovided documentation of training and experience. Required Current Experience: Demonstrated current competence and evidence of at least [5] robotic assisted procedures in the past 12 months, or successful completion of training in the past 12 months, or the applicant's initial [5] cases will be proctored by a physician holding robotic privileges. Renewal of Privilege: Demonstrated current competence and evidence of at least [5] robotic assisted procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.] o Requested_Robotic-assisted procedures (esophageal tumors, solid thoracic tumors, thymoma and retromedias~inal tumors) SINGLE LUNG, DOUBLE LUNG, HEART/LUNG TRANSPLANTATION [Criteria: Successful compl~tion of an ASTS approved transplant fellowship training program or complete a one year formal transplant fellowship at a transplant program meeting UNOS membership criteria in lung transplantation or documented successful completion of [20] of organ transplant cases Revised: 07108/11

6 John.A. Kern, rvl'd., JuJY1;2013 ~ June 30, Lee Street, McKim Hall, 1st Floor, Room 1103, Charlottesville, VA THORACIC, CARDIAC. AND VASCULAR SURGERY CLINICAL PRIVILEGES.. Name: c:.y'ub 0 =A-. ~Q \' n. Page 6 Effective From,, To,, within the last five (5) years. Current certification by the American Board of Thoracic Surgery or its equivalent. If board certification in thoracic surgery is pending (as in the case of one just finished residency) conditional approval may be granted for a 24-month period, with the possibilityof its being renewed for an additional 24-month period to allow time for the completion of certification. Required Current Experience: Demonstrated current competence and evidence of 5 lung and'or heart/lung transplant procedures within the past 24 months. Renewal of Privilege: Demonstrated current competence based on the results of OPPE and outcomes. UNOS does not have a volume requirement for ongoing experience, requiring instead: The surgeon has maintained a current working knowledge of all aspects of lung transplantation. defined as a direct involvement in lung transplant patient care within the last 2 years. This includes performing the transplant operation, donor selection, the use of mechanical assist devices, recipient selection, postoperative hemodynamic care, postoperative immunosuppressive therapy, and outpatient follow-up. )( Requested HEART TRANSPLANTATION... \ [Criteria: Successful completion of an ASTS approved transplant fellowship training program or complete a one year formal transplant fellowship at a transplant program meeting UNOS membership criteria in heart transplantation or documented successful completion of [20] of organ transplant cases within the. last five (5) years. Current certification by the American Board of Thoracic Surgery or its equivalent. If board certification in thoracic surgery is pending (as in the case of one just finished residency) conditional approval may be granted for a 24-month period, with the possibility of its being renewed for an additional 24-month period to allow time for the completion of certification. Required Current Experience: j>emonstrated current competence and evidence of 5 heart transplant procedures within the past 24 months. Renewal of Privilege: Demonstrated current competence based on the results of OPPE and outcomes. UNOS does not have a volume requirement for ongoing experience, requiring instead: The surgeon has maintained a current working knowledge of all aspects of heart transplantation, defined as a direct involvement in heart transplant patient care within the last 2 years. This includes performing the transplant operation, donor selection, the use of mechanical assist devices, recipient selection, postoperative hemodynamic care, postoperative immunosuppressive therapy, and outpatient follow-up. {)(... Requested Revised: 07/08/11

7 Joh" A.Kern,' M.D. July 1, 2013 June,30, Lee Street, McKim Hall, 1st Floor, Room 1103, Charlottesville, VA THORACIC. CARDIAC. AND VASCULAR SURGERY CLINICAL PRIVILEGES Name: C51)~n. k.\2., \f\ PaQe 7 Effective From / / To / / ENDOVASCULAR REPAIR OF THORACIC (TAA) AND ABDOMINAL AORTIC ANEURYSMS (AAA) [Criteria: Successful completion of an ACGIVIE or AOA accredited post graduate training program in thoracic and/or vascular surgery 1. Successful completion of a STS, AA TS, or SVS sponsored endovascular training course. Applicant agrees to limit procedure to use of endovascular graft device for which they have demonstrated training and experience. Qualifications should include experience with at least 10 open thoracic surgical procedures; a minimum of 25 wire/catheter placements; participation in 10 abdominal or 5 thoracic aortic endovascular stent grafting procedures; experience with large bore femoral sheath cannulation; and experience with retroperitoneal exposure of, and procedure on, the iliac arteries. Required Current Experience: Demonstrated current competence and longitudinal experience with patients with thoracic aortic diseases (20 patients in the past 2 years) documentation of experience in at least [5] endovascular repairs of TAA and/or AAA procedures in the past 12 months or completion of training in the past 12 months. In addition, supervision by a physician experienced in performing endovascular repair of TAAs is recommended for an applicant's initial [5] cases. Renewal of Privilege: Demonstrated current competence and evidence of the performance of at least [10] endovascular repair of TAA and/or AM procedures in the past 24 months based on results of ongoing professional practice evaluation and outcomes.] ~ReqUested ADMINISTRATION OF SEDATION AND ANALGESIA ~ Requested See Hospital Policy for Sedation and Analgesia by Non-Anesthesiologists 1 Other specialties involved i~clude cardiovascular medicine, cardiac surgery, vascular surgery, and vascular and interventional radiology Revised: 07/08/11

8 '] John A. Kern, M~D: i;~ July 1, June 30, Lee Street, McKim Hall, 1 st Floor, Room 1103, Charlottesville, VA Name: THORACIC. CARDIAC. AND VASCULAR SURGERY CLINICAL PRIVILEGES G)bQtl bqro. Effective From,, To,, PageS ACKNOWLEDGEMENT OF PRACTITIONER I have requested only those privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform and for which I wish to exercise at University of Virginia Medical Center, and I understand that:. a. In exercising any clinical privileges granted, I am constrained by the Clinical Staff Bylaws and Medical Center policies applicable generally and any applicable to the particular situation. b. Any restriction on the clinical privileges granted to me is waived in an emergency situation and in such situation my acti s re governed by the applicable section of the Clinical Staff Bylaws or related docume s I I Signed Date t{~z2 fl1 [DEPARTMENT CHAI I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and make the following recommendation(s): n Recommend all requested privileges., 'd Recommend privileges with the following conditio'n\'modifications: o Do not recommend the following requested privileges: Privilege "otes Condition/Modification/Explanation Department Division Chief Division Ch~ ~re Date ~ 2.. It (J [Department Chair/Chief] Signature~/'~ Date~~-+==10~iJ~1~=--_ Credentials Committee Action Clinical Staff Executive Committee Action Medical Center Operating Board Action FOR CLINICAL STAFF OFFICE USE ONL Y Date Date Date Revised: 07108/11

9 .. ' Clinical Privileges Update Form John Kern Department of Surgery I have reviewed the privileges previously granted to me and request the following changes to include any new therapies, procedures, or additional training necessary to perform new privileges requested. (please include supporting documentation to verify competency): New Privileges to be Added (please indicate category level and type of experience): a1r.... C I, C, I f/t"")r, - rtd) 'I' ~/F/~-o. i"t'rivilp"". not renewed are not reported as being voluntarily relinquished unless is done while you are investigation; in return for not conducting an investigation or proceeding. Ifprivileges are to be reported as voluntarily relinquished you be notified and receive a copy of the report to be filed with the National Practitioner Databank. a1l-...- CLi~NATURE... As the Division Head/QI Liaison and Department ChairlMedical Director, we have reviewed the abovenamed clinician's level ofexperience, past performance and quality indicators (if renewing privileges) as related to requested privileges and agree that the above named clinician's qualifications are appropriate. Since the date ofthe last appointment, we have reviewed applicable information from the following sources of quality and utilization data: We find as follows: 00 Acceptable review with recommendation of reappointment to the clinical staff with clinical privileges as requested DATE Concerns noted on review with corrective action plan in place with recommendation of reappointment to the clinical staff with privileges as requested, but subject to a review in months. Should have clinical privileges granted but restricted as follows: ~ ~ /I~~~--=---- _~f Ull-~----~-~----~----- DATE DIVISION HEAD/QI LIAISON SIGNATURE DEPARTMENT CHAIR SIGNATURE Revised J/lllOO6

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