Sutter Medical Center, Sacramento Department Of Diagnostic Imaging & Radiation Oncology - Delineation Of Privileges

Transcription

1 CRITERIA FOR DELINEATION OF PRIVILEGES Privileges in the Department of DIRO (Diagnostic Imaging and Radiation Oncology) will be applied for by individual physicians (who are members of the Medical Staff of Sutter Medical Center) using the attached form. The Administrative Committee of the Department (Chief, Immediate Past Chief, Vice Chief, Secretary and Chair of the Informal Sections of Diagnostic Radiology, Interventional Radiology, Nuclear Medicine and Radiation Oncology) will review the application and where indicated meet with the applicant personally to prepare recommendations for granting of privileges to the Credentials Committee of the Medical Staff. Physicians will submit documentation (when requested by the DIRO Administrative Committee) of their training, experience and evidence of Continuing Medical Education in those procedures for which they desire privileges. The basic criteria for department membership and delineation of privileges in Diagnostic Imaging and Radiation Oncology will be certification by the American Board of Radiology or the American Board of Nuclear Medicine, physicians who have completed an approved Radiology or Nuclear Medicine residency, or physicians with previous 10 years experience in a Joint Commission accredited hospital and have exercised similar privileges to those being requested. Within each general section, the procedures which are generally accepted as lying within the discipline will be included in the privileges. For example, General Diagnostic Radiology will include injection of contrast material, fluoroscopy, interpretation of radiographs, bronchography, CT and ultrasound under fluoroscopic control, etc. Radiation Oncology will include those procedures related to application of external irradiation, interstitial or intracavitary sealed radioactive sources, therapeutic use of radioactive isotopes, etc. Nuclear Medicine will include injections of radionuclides for diagnostic or therapeutic purposes, interpretation of physiologic and anatomic radionuclide studies, in-vitro tests using radionuclides, and use of monoclonal antibodies for diagnosis and/or treatment. Non-Invasive Vascular Imaging will also be part of Nuclear Medicine. The subspecialty practices of Angiography, Ultrasonography, Non-Invasive Vascular Imaging, Neuroradiology and Interventional Radiology will be considered for granting of privileges when these disciplines are included in the residency training and examination. Where these skills are acquired after residency training, consideration for delineation will be on an individual basis and take into account current and recent practice, post-graduate courses, preceptor training, or other forms of additional post-graduate training, and may require prior performance of an acceptable number of procedures. Privileges for General Diagnostic Imaging, Interventional Radiology, Neuroradiology and Interventional Neuroradiology require a Radiography Supervisor and Operator Permit. Consideration of granting of privileges to radiologists and non-radiologists must clearly reflect the major difference between specialists of various disciplines in view of the former s knowledge of all available imaging modalities. Training and background will be primary criteria for delineation of privileges for any physician. The quality of training, as well as its duration, will necessarily continue to be a primary prerequisite in the privileging process. Privileges are granted for Sutter Medical Center, Sacramento and exercise of privileges is based on the type of care, treatment and services provided at each facility. Privileges are granted for Sutter General Hospital, Sutter Memorial Hospital, Sutter Center for Psychiatry, Capital Pavilion Surgery Center, or Sutter Oaks Midtown and exercise of privileges is based on the type of care, treatment and services provided at each facility To request Privileges, please place an X in the request column. In box, indicate the number of identified procedures performed in previous 24 months from any facility. If the condition/privilege you desire is not included on this form, please submit a separate written request along with appropriate documentation of training and/or experience. Please be prepared to supply verification of volume performance if requested. [ ] Admitting Privilege NONE None None N/A [ ] H&P Privilege Page 1 of 17

2 [ ] I. GENERAL DIAGNOSTIC IMAGING All aspects of patient management, exclusive of those listed below, which are within the generally recognized scope of Radiological practice. [ ] Stereotactic Breast Biopsy Stereotactic localization of breast lesions involves the use of dedicated radiographic equipment for targeting radiopaque breast lesions for subsequent biopsy. Stereotactic core needle type biopsy involves the use of the same radiographic equipment for localizing and subsequently performing percutaneous core needle type biopsy of breast lesions. Radiology Certificate Required Basic understanding of radiographic equipment and interpretation of mammographic abnormalities should be documented by certification of the American Board of Radiology and American College of Radiology, respectively. Physicians should meet the qualifications from the ACR standards for screening mammography and diagnostic mammography and problem solving breast evaluation and attest they meet Mammography Quality Standards Act (MQSA) standards. 1. Specific experience and/or training may be documented by either of the following means: a. satisfactory completion of an accredited residency program which includes a minimum of twenty-five (25) stereotactic breast biopsy procedures; OR b. post graduate applicant should demonstrate competency by: 1. Documentation of thirty (30) stereotactic localization and/or breast biopsy procedures with appropriate follow up documentation, OR 2. Documentation of involvement in twenty-five (25) stereotactic localization and/or breast biopsy procedures under the supervision of a qualified physician preceptor and three hours of Category I CME didactic instruction in stereotactic biopsy. First five (5) cases AND Evaluations at 3, 6 & 12 Months. NONE None Minimum of twenty-five (25) cases in a two year period. N/A (Continued on next page) At least one half of these cases must be performed at the equivalent level of the primary operator. Page 2 of 17

3 [ ] Stereotactic Breast Biopsy - Continued The five (5) cases should be performed within the previous one year at the time of application for privileges. A letter of verification from the applicants primary tutor who has performed at least five (5) cases with the applicant stating that the applicant is qualified to perform this procedure as a primary operator. [ ] Magnetic Resonance Imaging NONE NONE N/A [ ] Coronary CT Angiography Coronary CTA is a heart-imaging test using computed tomography (CT) to image the coronary arteries, cardiac chambers, valves, myocardium and pericardium and can help assess cardiac function (Continued on next page) Prerequisite: Must currently hold General Diagnostic First three (3) cases. Imaging privileges 1. Certification in radiology or diagnostic radiology by the American Board of Radiology, the American Osteopathic Board of Radiology, the Royal College of Physicians and Surgeons of Canada, or Le College des Medecins du Quebec and have completed 50 supervised interpretations of cardiac CT exams, excluding those performed exclusively for calcium scoring, in the past 36 months. Documentation of cases should be by case listing or a letter from the Chief of Staff or Medical Director of a Joint Commission accredited hospital where the cases were performed attesting to the number of cases. OR, 2. Competed an Accreditation Council for Graduate Medical Education (ACGME)-approved radiology residency program and have completed 50 supervised interpretations of cardiac CT exams, excluding those performed exclusively for calcium scoring, in the past 36 months. Documentation of cases should be by a letter from the director of the residency program attesting to the physician s competence to perform the procedure and volume of cases. AND, Minimum of Fifty (50) cases in a two year period. Page 3 of 17

4 Coronary CT Angiography Continued 3. Completed at least 40 hours of category I continuing medical education (CME) in cardiac imaging, including cardiac CT/coronary CTA anatomy, physiology, and/or pathology or documented equivalent supervised experience in a center actively performing coronary CTA. Documentation of CME can be by copies of certificates or listing of CME programs with date, title of program and number Category 1 CME credits granted. [ ] II. INTERVENTIONAL RADIOLOGY Radiography Certificate Required. First five (5) cases AND Evaluations at 3, 6 & 12 Months [ ] Central venous catheter placement with subcutaneous tunnel [ ] Central venous catheter placement without subcutaneous tunnel [ ] Transvenous repositioning a central venous catheter [ ] Transvenous extraction of central venous catheter fragment [ ] Central venous catheter placement with subcutaneous port [ ] Removal of central venous catheter either tunneled or with subcutaneous port [ ] Exchange of central venous catheter either tunneled or non-tunneled [ ] Transvenous stripping of central venous catheter [ ] Thrombolytic infusion for non-functioning central venous catheter [ ] Thrombolytic infusion for deep venous thrombosis [ ] Venous angioplasty [ ] Parathyroid and thyroid venous sampling [ ] Renal venous sampling [ ] Adrenal venous sampling [ ] Visceral venous sampling [ ] Wedge hepatic venogram [ ] Wedge hepatic venous pressure measurement [ ] Trans splenic portal venogram Page 4 of 17

5 [ ] Transhepatic portal venogram [ ] Venous angioplasty with stenting [ ] Uterine vein embolizations [ ] Gonadal vein embolizations [ ] Percutaneous occlusion of splenic artery for [ ] hypersplenism Bronchial artery embolization for hemostatis or tumor [ ] Venous embolization for venous malformation [ ] Venous ethanol injection for venous malformation [ ] Angioplasty and stenting transhepatic portosystemic shunt [ ] Embolization esophageal and gastric varices [ ] Percutaneous transhepatic cholangiogram [ ] Percutaneous biliary drainage [ ] Percutaneous transhepatic internal/external biliary drainage [ ] Percutaneous transhepatic biliary drainage with stent placement [ ] Percutaneous transhepatic extraction of biliary duct stones [ ] Percutaneous cholecystostomy [ ] Percutaneous dilatation of biliary stricture [ ] Percutaneous trans T-tube extraction of biliary stone [ ] Percutaneous nephrostomy [ ] Percutaneous nephrostomy for access prior to nephrolithotomy [ ] Nephrostomy tube change [ ] Antigrade ureteral stenting [ ] Whitaker exam renal collecting system with manometry [ ] Percutaneous Gastrostomy [ ] Percutaneous jejunostomy [ ] Percutaneous dilatation of enteric obstructions, plus/minus stenting [ ] Conversion of gastrostomy to gastrojejunostomy [ ] Fallopian tube dilatation Page 5 of 17

6 [ ] Ultrasound guided thoracentesis [ ] Ultrasound guided Paracentesis [ ] CT guided thoracentesis [ ] CT guided Paracentesis [ ] CT, ultrasound or fluoroscopic guided placement to thoracostomy tube [ ] Ultrasound, CT or fluoroscopic guided drainage of abscess (lung, pancreatic, subdiaphragmatic, retroperitoneal, renal, perirenal and pelvic) [ ] Ultrasound, CT or fluoroscopic guided drainage of hepatic, renal or pancreatic cyst [ ] Ultrasound, fluoroscopic of CT guided sclerosis of hepatic, pancreatic or renal cyst [ ] Percutaneous drainage of pancreatic pseudocyst [ ] Percutaneous creation of pancreatic-gastric cyst Gastrostomy [ ] Transrectal or transvaginal drainage of pelvic abscess [ ] CT, ultrasound or fluoroscopic guided biopsy (thyroid, lung, liver, pancreatic, retroperitoneal, intraperitoneal, muscle, bone, lymphoid, breast and prostate) [ ] Transjugular liver biopsy [ ] Percutaneous placement of inferior cava filter [ ] Percutaneous retrieval of intravascular foreign body [ ] Vascular embolization for bleeding [ ] Vascular embolization for arterial venous malformation [ ] Vascular embolization for tumor [ ] Chemo embolization for tumor [ ] Visceral arterial infusion for ischemia [ ] Percutaneous fluoroscopic declotting of thrombosed arterial venous grafts or shunts created for dialysis using either balloon fogarty or non-balloon (thrombolytic) technique [ ] Percutaneous ethanol ablation of tumors [ ] Transluminal occlusion of ureter [ ] Ureteral angioplasty for strictures Page 6 of 17

7 [ ] Percutaneous drainage of lymphocele [ ] Percutaneous celiac plexus blockade or ablation [ ] Percutaneous CT guided lumbar sympatholysis [ ] Percutaneous thrombectomy of pulmonary artery embolism [ ] Catheter directed intraarterial thrombolysis [ ] Catheter directed intravenous thrombolysis [ ] Peripheral Transluminal Angioplasty Peripheral angioplasty (PTA) is the percutaneous approach toarteriograph intervention by dilatation or atherectomy and may include stent placement. A diagnostic peripheral angiogram is any non-coronary or non-cerebral (intra/extra cranial) angiogram and is one that provides complete imaging of the entire vascular distribution and the runoff of the vessel(s) in question. (This privilege is shared with another department) (Continued on next page) Disciplines of Vascular Surgery, Radiology and Cardiology are eligible for credentialing. Basic understanding of cardiovascular disease should be documented by eligibility or certification by any one of the following: American Board of Radiology American Board of Internal Medicine with special certification in Cardiovascular Medicine fellowship American Board of Surgery with completion of a general vascular surgery one (1) year fellowship Physicians seeking to qualify by having completed a training program shall have documentation of having performed 100 peripheral angiograms, 50 peripheral interventional procedures (counted per lesion) within the past three years and shall have a letter from the Chief of his/her training program stating that the applicant is competent to perform peripheral vascular interventions as a primary operator. OR Documentation of having performed 100 peripheral angiograms, 50 peripheral angioplasties within the past three years at another Joint Commission accredited hospital and documentation of attendance at a dedicated symposium on PTA, which has live case demonstrations, shall be documented. OR Documentation of successful completion of an approved in-house learning program under the First Five (5) Interventional procedures Minimum of 50 therapeutic interventions (counted per patient) in a twoyear period Should an applicant not attain the suggested number of procedures proctoring may be initiated as determined by the Department Q.I./Administrative Committee. Page 7 of 17

8 Peripheral Transluminal Angioplasty - Continued [ ] Hepatic Artery Chemoembolization Sub-selective catheterization of the hepatic artery, or its branches, with subsequent infusion of chemotherapeutic agents and/or embolic agents (under fluoroscopic guidance) with immediate removal of the catheter after the procedure has been performed. [ ] Peripheral and Visceral Arteriography (noncoronary/non-cerebral diagnostic angiography) (This privilege is shared with another department) (Continued on next page) preceptorship of a senior qualified physician and the performance of at least 100 peripheral angiograms and 50 peripheral angioplasty procedures. Applicants will be required to provide such documentation from the Director of Fellowship training or by letter from primary hospital where he/she has been practicing for the previous two years: 1. Fellowship training in Interventional Radiology OR 2. Selective catheterization of the hepatic artery and performance of diagnostic Arteriography in at least ten (10) cases AND 3. Evidence of performance of Hepatic Artery Chemoembolization under supervision of a physician experienced in the procedure in at least five (5) cases. 1. Evidence of training and competency by certification, or admissible for certification by the American Board of Radiology, Cardiovascular Disease by the American Board of Internal Medicine or Vascular Surgery by the American Board of Surgery. AND 2 Documentation from the training program that the training program included concentrated training and experience in angiography including at least 50 noncoronary arteriographic procedures performed proficiently and successfully. -OR In the absence of residency training in this procedure, documentation of successful completion of 100 non-coronary angiographic procedures from a Joint Commission accredited hospital within the past three years is required. This documentation must also include a letter of reference from a physician who is familiar with the applicant s NONE Five (5) non-cerebral peripheral angiography procedures. Two (2) procedures within prior two year period Twenty (20) noncoronary, noncerebral peripheral and visceral arteriography procedures. Page 8 of 17

9 Peripheral and Visceral Arteriography - Continued experience in arteriography. -OR Successful completion of an approved In-house Learning and Teaching Program in noncerebral diagnostic peripheral angiography consisting of at least 50 procedures. [ ] Image Guided Tissue Ablation PRE-REQUISITE: It is understood that physicians who have been granted image-guided tissue ablation privileges may only utilize this therapy for the imageguided modality they hold privileges for (e.g., CT, ultrasound, MR, fluoroscopic). In order to perform image-guided tissue ablation, the physician must fulfill both criteria below: 1. Physician must have performed a minimum of fifty (50) image-guided biopsy procedures. AND NONE Minimum of 100 image-guided biopsies or ablations over a two-year period, of which ten (10) must be ablations. 2. Physician must provide written documentation of proof of training for each tissue ablation technique requested, i.e. cryo, radiofrequency- or microablation. Acceptable training can include: a. Manufacturer sponsored course; OR. Fellowship training with at least ten (10) procedures performed as primary operator for each specific technique for which credentials are requested; OR c. Direct supervision through an In House Learning and Teaching Program at a Joint Commission accredited hospital by an attending physician/preceptor who has had significant training using the specific ablation technique requested. Significant training of the preceptor is defined as at least five (5) ablation procedures performed in previous year. Page 9 of 17

10 [ ] Endovascular Repair of Aortic Aneurysms Prerequisite: 1. Must currently hold all Interventional Radiology privileges (to include peripheral arteriography, angioplasty, intravascular stenting, and intravascular embolization). 2. Participation with physicians who are privileged to perform open repair of aortic aneurysms. 3. Intensive care admitting privileges Training/Documentation Requirement: 1. Completion of an interventional radiology fellowship program where endovascular aortic aneurysm repair was an integral part of the training. This training must have occurred within the previous two years. Verification of this training in the form of a letter from the fellowship director is required. - OR - 2. Documentation of prior experience in a Joint Commission accredited hospital in endovascular aortic aneurysm repair. This experience must have occurred within the previous two years. Documentation must include a letter from the Chief of the Department or Chief of Staff documenting experience in at least ten (10) cases. - OR - 1. Successful completion of an approved in-house teaching program at Sutter Medical Center. -AND- Compliance with FDA guidelines for deployment of stent-graft devices in use. First two (2) cases. Minimum of ten (10) cases from a JC accredited hospital. ALSO Continuing education should be in accordance with the American College of Radiology Practice Guidelines for Continuing Medical Education (150 hours of CME every 3 years, 70% in specialtyspecific or related areas to include a minimum of 10 hours of category I CME specific to aortic pathology and endovascular repair). Page 10 of 17

11 III. DIAGNOSTIC NEURORADIOLOGY [ ] Core Diagnostic Neuroradiology Core Diagnostic Neuroradiology includes performance of diagnostic and image-guided diagnostic and therapeutic procedures related to the nervous system and head and neck. For example (not all inclusive): CT, MRI, myelography, spine injections, vertebroplasty, spine and maxillofacial biopsy. (Note: See separate multi-departmental privilege criteria for cerebral angiography.) [ ] Diagnostic Cerebral Angiography, Including WADA Test (This privilege is shared with another department) 1. Current certification by the American Board of Radiology; AND, 2. Completion of a neuroradiology fellowship and/or Certificate of Added Qualifications (CAQ) in Neuroradiology by the American Board of Radiology AND 3. Fifty (50) diagnostic neuroradiology cases in the previous two years as demonstrated by a letter from the Director of the training program or Department Chief. 1. Documentation of a formal training program in which diagnostic cerebral angiography was part of the training program. Documentation must be provided by the Director of the training program - OR- 2. Post Residency or Fellowship Training documentation of prior experience at another Joint Commission accredited hospital within the past three (3) years. Documentation must be provided by the Department Chief at the other hospital. - OR 3. Successful completion of an approved in-house learning and teaching program. Documentation must be provided by the Preceptor at the end of the in-house training program. AND (Meet one of the following) 1. Interventional Radiologists who hold Peripheral Transluminal Angioplasty privileges are required to provide evidence of training/experience in a minimum of 50 cerebral angiographies. 2. Neuroradiologists with fellowship training in Neuroradiology or admissible for subspecialty Certificate of Added Qualification in Neuroradiology by the ABR or evidence of continuous practice in the field in the previous two years. First six (6) cases. Current senior staff members who qualify under these criteria and have been performing these procedures will be grandfathered in and proctoring will not be required. The first Six (6) cerebral angiography procedures. Proctoring will be performed by another Senior Staff physician who holds cerebral angiography privileges. Twelve 12 different catheterizations in previous two years. Volume requirements can include cases the physician performed at other facilities and are not exclusive to SMCS patients. Twelve (12) cerebral angiography procedures. Should the applicant not attain the suggested number of procedures proctoring may be initiated as determined by the Department Q.I./Administrative Committee. Page 11 of 17

12 IV. INTERVENTIONAL NEURORADIOLOGY [ ] Core Neuro-Interventional Radiology Includes performance of image-guided therapeutic and diagnostic procedures which involve intracranial catheterization and/or instrumentation. For example (not all inclusive): aneurysm coiling; intracranial angioplasty and stenting; cerebral infusion treatment; embolizations intra and extra cranial; and, cord cyst puncture (This privilege criteria is shared with another department) [ ] Extra-Cranial Cerebral Revascularization Includes angioplasty and/or placement of stents in the extra-cranial circulation with proximal or distal protection devices. (This privilege is shared with another department) (Continued on next page) Pathway A: 1. Current certification by the American Board of Radiology; AND 2. Completion of a one or two-year Neuroradiology fellowship AND 3. Completion of an interventional Neuroradiology fellowship -OR- Pathway B: 1. Current certification by the American Board of Radiology; AND 2. Completion of a two-year Neuroradiology fellowship AND 3. Continuous practice in a Joint Commission accredited hospital since training in Neuroradiology with demonstration of interventional procedure experience in fellowship training. ALSO: Fifty (50) Neurointerventional Radiology cases in the previous two years as demonstrated by a letter from the Director of the training program or Department Chief. PREREQUISITES 1. Hold one of the following groups of privileges: a. Neuro-Interventional Radiology and Cerebral Angiography Privileges; or, b. Interventional Radiology Peripheral Transluminal Angioplasty and Cerebral Angiography Privileges. AND 2. Document prior experience in using distal protection devices in at least 20 cases in any vascular territory. First six (6) cases. Current senior staff members who qualify under these criteria and have been performing these procedures will be grandfathered in and proctoring will not be required. First six (6) extracranial revascularization procedures.. Proctoring will be performed by another Senior Staff physician who holds extra-cerebral revascularization privileges and who has also successfully completed proctoring. Twelve (12) interventional Neuroradiology cases in previous two years. can include cases that the physician performed at other facilities and are not exclusive to Sutter Medical Center, Sacramento patients. Physician should be prepared to supply verification of volume performance if requested. Six (6) intra-cranial cerebral revascularization (carotid stent) procedures with use of distal protection devices. Should an applicant not attain the suggested number Page 12 of 17

13 Extra-Cranial Cerebral Revascularization - Continued TRAINING/EXPERIENCE REQUIREMENTS 1. Documentation of a formal training program where extra-cranial revascularization (carotid stenting) was part of the training program. Applicant must have performed at least 10 extracranial cerebral revascularization (carotid stent) procedures. Documentation must be provided by the Director of the training program. OR- 2. Post Residency or Fellowship Training a. Documentation of successful completion of a post-graduate course (approved by the department) - AND - b. Documentation of prior experience at another Joint Commission accredited hospital in at least 10 extra-cranial cerebral revascularization (carotid stent) procedures OR successful completion of an approved inhouse learning and teaching program in at least 10 extra-cranial cerebral revascularization (carotid stent) procedures. Documentation must be provided by the Chief of the Department of the other Joint Commission accredited hospital or by the Preceptor at the end of the in-house training program. of procedures proctoring may be initiated as determined by the Department Q.I./Administrative Committee. Page 13 of 17

14 V. NUCLEAR MEDICINE Evaluations at 3, 6 & 12 Months [ ] Diagnostic Nuclear Medicine 1. Completion of an approved Radiology or Nuclear Medicine residency within three years OR 2. Current certification by the American Board of Radiology or the American Board of Nuclear Medicine OR A mix of fifty (50) cases representative of the privileges requested. A written report of their evaluation should be submitted and include the case numbers. Maintain current California Radioactive Materials License [ ] Therapeutic Nuclear Medicine (Includes Radioactive Iodine Thyroid Therapy Privileges) 3. Documentation of previous 10 years experience in diagnostic nuclear medicine at a Joint Commission accredited institution AND Current California Radioactive Materials License 1. Completion of an approved Nuclear Medicine residency within three years OR 2. Certification or admissible to the Board of Nuclear Medicine OR A mix of fifty (50) cases representative of the privileges requested. A written report of their evaluation should be submitted and include the case numbers. Minimum of at least ten (10) therapeutic nuclear medicine procedures during the previous two years. 3. Documentation of previous 10 years experience in therapeutic nuclear medicine at a Joint Comission accredited institution with documentation of at least ten therapeutic nuclear medicine procedures performed at a Joint Commission accredited institution during the previous two years. Page 14 of 17

15 [ ] Non-invasive vascular testing 1. Currently granted Diagnostic or Therapeutic Nuclear Medicine privileges at Sutter Medical Center, Sacramento (SMCS) AND 2. Documentation of performance of at least 200 vascular studies of which 100 cases need to be carotid ultrasound during previous three years. Documentation can be from residency program or a letter from the department medical director or medical staff department chief at a Joint Commission accredited institution. [ ] Cardiac Treadmill and Pharmacologic Stress Testing 1. Currently granted Diagnostic Nuclear Medicine privileges at SMCS; AND (one of the following 1. Board certification or admissibility from the American Board of Radiology or American Board of Nuclear Medicine; or, 2. Documentation of at least fifty (50) procedures performed at a Joint Commission accredited A mix of fifty (50) cases representative of the privileges requested. A written report of their evaluation should be submitted and include the case numbers. Six (6) cases are to be proctored by a SMCS Senior Staff physician granted similar privilege. institution during the previous two years. VI. RADIATION ONCLOLOGY [ ] Core Radiation Oncology First five (5) cases [ ] Intra-operative Radiation Therapy 1. Must have full specialty privileges in the Diagnostic Imaging and Radiation Oncology Department. NONE NONE First two (2) cases NONE 2. Must either observe or assist in one case wit documentation submitted at the time of privilege request. Page 15 of 17

16 [ ] 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. Page 16 of 17

17 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