Hemodialysis Vascular Access Procedures

Transcription

1 The American Society of Diagnostic and Interventional Nephrology Application for Recertification Hemodialysis Vascular Access Procedures 3/19/2012

2 The American Society of Diagnostic and Interventional Nephrology Application for Recertification in Interventional Nephrology Hemodialysis Vascular Access Procedures This application packet is composed of several parts: Part 1 - HVA Recertification Criteria Part 2 - Application for HVA Recertification Form Part 3 Sample Forms a) Peer Reference Letter b) Case Index (Do not include patient names or identifiers) DO NOT RETYPE or REPRODUCE case notes c) Case Log Form Checklist (all items required) Completed Part 2 - Application for HVA Recertification Form Written Peer Letter Verification of Applicable Minimum Procedures in 24-month period Applicable Case/Procedure Notes with Case Log (example attached)-(remove any patient names or identifiers) CME Documentation Continuous Quality Improvement Documentation Recertification Fee ($200/ASDIN members or $450/non-members*) Case Index *Non-member fee includes ASDIN membership for remainder of membership year from date of recertification application. Submission Copies: Two copies of the application and all documentation should be submitted to the ASDIN office. Copies should include one of the following: a) two paper copies, OR b) one paper copy and one cd rom copy, OR c) one paper copy and one copy sent electronically to info@asdin.org. Recertification Fee: A fee of $200 for ASDIN members or $450 for non-members must accompany the application. This fee is nonrefundable. Checks should be made payable to The American Society of Diagnostic and Interventional Nephrology. This fee is to cover the expense of processing the application. Please mail application and fee to: ASDIN 134 Fairmont Street, Suite B Clinton, Mississippi SPECAIL NOTE: DO NOT SEND PATIENT IDENTIFIERS IN ANY OF THE PAGES SUBMITTED. PLEASE REVIEW CASE/PROCEDURE NOTES, CASE LOG AND CQI DOCUMENTATION TO ASSURE THAT PATIENT NAMES ARE REMOVED. YOUR APPLICATION WILL BE RETURNED TO YOU AND WILL NOT BE PROCESSED UNTIL AN APPLICATION WITHOUT PATIENT IDENTIFIERS IS SUBMITTED. 3/19/12 2

3 Part 1 - HVA Recertification Criteria 1. Applicants must be currently certified by ASDIN in HVA and actively doing interventional procedures. 2. Applicants must be currently Board certified in Surgery, Radiology, or Nephrology. 3. Recertification in HVA procedures will be granted for 5 years. 4. Applicants may apply for recertification in HVA procedures in either Broad Category or Hemodialysis Catheter Only Category. Each applicant must provide verification that the following minimum procedures have been performed by him/her in the past 24 months: I. Broad Category: A) 25 hemodialysis catheter placements (These may be tunneled or non-tunneled and they may be de novo placements and exchanges). A copy of the procedure note must be provided for review for 5 of these cases. B) 50 endovascular procedures (including 12 thrombectomy procedures on either a fistula or graft). A copy of the procedure note must be provided for review for 5 of these cases. II. Hemodialysis Catheters Only Category: A) 25 hemodialysis catheter placements (These may be tunneled or non-tunneled and they may be de novo placements and exchanges). A copy of the procedure note must be provided for review for 5 of these cases. 5. Applicants must provide documentation of 7 hours of Continuing Medical Education (CME) in vascular medicine, hemodialysis access, or interventional procedures obtained within the past 3 years. 6. Applicants must provide documentation of current CQI (Continuous Quality Improvement) in the past 24 months. A review of personal complication rates for interventional procedures or minutes of CQI meetings are examples of data that would satisfy this requirement. Suggestion: Complication rate can be tracked on the case log form. 3/19/12 3

4 The American Society of Diagnostic and Interventional Nephrology Part 2 - Application for HVA Recertification Form Recertification Category: (check one) Broad Category (hemodialysis catheters and endovascular procedures) Hemodialysis Catheter Placement Only Identifying Information: _ Last Name First Name Middle Name Date of Birth Citizenship Social Security Number Home Address City State Zip Code Practice Information: Practice Name Practice Address City State Zip Code Current Board of Certification Date of Certification Type of Practice: Private practice Academic medicine 3/19/12 4

5 Medical Facility Affiliations (List only current) 1) Name of Facility Staff Category 2) Name of Facility Staff Category 3) Name of Facility Staff Category Signature: I certify that the information contained herein is correct and complete to the best of my knowledge. Signature Date Telephone Number Facsimile Number Address 3/19/12 5

6 Part 3 Sample Forms Sample Case Index Summary: Number of hemodialysis catheter placements submitted Number of endovascular cases submitted List of Cases: Catheter cases: (please specify type of procedure below) Case 1 Case 2 Case 3 Case 4 Case 5 Endovascular cases: (please specify type of procedure below) Case 6 Case 7 Case 8 Case 9 Case 10 3/19/12 6

7 Part 3 Sample Forms The American Society of Diagnostic and Interventional Nephrology Letter of Peer Recommendation To Whom It May Concern: Date: I understand that has applied for certification in Diagnostic and interventional Nephrology. I have been asked to provide a letter of reference as part of the documentation required for this process. I have known the applicant for years. My relationship to the applicant during this time has been as. I have direct knowledge of the applicant s current medical practice activity as an Interventional Nephrologist, Interventional Radiologist, or Surgeon: Yes No I also have direct knowledge of the applicant s completion of the following procedures in the past 24 months: (direct knowledge may include a review of the case log form) (Please specify number for each must be at least the required number) DO NOT PUT CHECKMARKS THERE MUST BE A NUMBER ENTERED For Broad Category Applicants: # Hemodialysis catheter placements (25 required) # Endovascular procedures (50 required) For Hemodialysis Catheters Only Category Applicants: # Tunneled Catheter Case placements (25 required) My knowledge is best described as: Minimal Moderate Detailed My knowledge is based upon: Direct observation Shared patients Case Log Review I would describe the applicant as having a high expertise in Interventional Nephrology Yes No Comments: Sincerely, Name Address 3/19/12 7

8 Part 3 Sample Forms The American Society of Diagnostic and Interventional Nephrology Sample Case Log **Do not display patient names on submitted case log. Patient names must be blacked out. # Date (Within last 24 months) Patient Name** Type of Procedure Complications /19/12 8

9 # Date (Within last 24 months) Patient Name** Type of Procedure Complications /19/12 9