DELINEATION OF PRIVILEGES - OTOLARYNGOLOGY

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1 KALEIDA HEALTH Name: Date: DELINEATION OF PRIVILEGES - OTOLARYNGOLOGY GENERAL STATEMENTS Adults and Pediatrics except as specified. Procedures are grouped by anatomic region. Procedures are also separated into levels of complexity (Level I, Level II, and Level III), which require increasing levels of education and experience. In general, procedures learned during residency are grouped in Level I and are granted upon evidence of successful completion of residency training. Level II procedures may require evidence of additional training or experience beyond residency. Documentation of additional training and/or experience is required for all Level III procedures. LASER privileges are listed separately in a final section and granted according to LASER safety committee standards. LEVEL I PRIVILEGES Procedures which are assumed to have been mastered following satisfactory completion of an approved Otolaryngology training program and can be performed by an Otolaryngologist whose documented training and experience qualify the applicant for the privilege. History and Physical for diagnosis and treatment. Admission and Follow-up Skull (excision, reconstruction, bone graft) Peripheral Nerve (excision, biopsy, graft, anastomosis) Thyroid/Parathyroid (aspiration, biopsy, resection) Thymus (excision) Eyelid (incision, excision, repair, reconstruction) Lacrimal System (biopsy, excision, probing, repair) Orbit (reconstruction, excision) Ear, External (diagnosis, repair biopsy, excision, reconstruction) Middle Ear (exploration, tympanoplasty, stapes, mastoid) Nasal (epistaxis, biopsy, septum, reconstruction, repair, excision) (aspiration, endoscopic, external) Oral cavity (biopsy, excision, repair, reconstruction) Tongue/FOM Salivary Gland (repair, excision) Oropharynx (tonsil) Pharynx Neck (congenital) Access to the Spine Cricopharyngeal Myotomy Larynx (excision, repair, reconstruction, trauma, TEF) Trachea (excision, tracheotomy, repair) Lung (bronchoscopy, biopsy) Vessels (incision, biopsy, excision, repair, ligation) Lymphatic (biopsy, excision, neck dissection) -- thoracic duct Esophagus (incision, biopsy, repair, endoscopy, repair, reconstruction, dilatation) Facial Bones (repair, biopsy, trauma, sequestrotomy) Mandible Integumentary (biopsy, excision, repair, skin graft, pedicle flaps, facial plastic surgery, scar revision, tissue expansion)

2 Otolaryngology Name: Page 2 PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow or line to make selections. We will return applications that ignore this directive. LEVEL II PRIVILEGES Requires certificate of added qualifications or approved fellowship in one of the following: Head & Neck Oncology, Pediatric Otolaryngology, Otology/Neuro-otology, Facial Plastic Surgery or documentation of surgical experience for three years preceding the request. Volume criteria may be applicable. Glossectomy Tracheal Resection Vessel Resection with Repair Percutaneous Tracheotomy Partial Laryngectomy Stapedectomy Liposuction Laryngo-tracheal separation Medialization Laryngoplasty Arytenoid Adduction Angiofibroma Arytenoidectomy < 8 yrs of age Arytenopexy < 8 yrs of age Endoscopic sinus surgery < 8 yrs of age Endoscopic CSF leak repair Lip-Tongue (Douglas procedure) NICU admission Vascular lesions, lymphangiomas, AVM, hemangiomas, < 8 yrs of age Thoracentesis Thoracostomy Cleft Lip repair Cleft Palate repair Browlift Otoplasty, Unilateral/bilateral Facelift Platysmoplasty Blepharoplasty Suction Lipectomy/lipolysis Chemical peel Tissue expanders (insertion, removal) Facial implants Treat facial paralysis Microtia reconstruction Endoscopic plastic surgery Facial reanimation Midfacelift Rib graft Bone graft *

3 Otolaryngology Name: Page 3 MODERATE/CONSCIOUS SEDATION 1. Providers seeking privileges in moderate/conscious sedation must complete either the ASA sedation course cost $ ( or Medsimulation course cost $75.00 ( receiving a score of 85% or above. * e: Providers completing the on-line training course provided by Medsimulation from other institutions receiving a score of 85% or higher will be accepted as an equivalent measure of acceptable knowledge for sedation privileges. 2. Once the provider has successfully passed the course, he/she must send the certificate of course completion to the medical staff office via (medicalstaffoffice@kaleidahealth.org) or fax ( or ). 3. In addition to demonstrating medical knowledge through completion of this course, providers must also maintain airway management skills through current completed training and certification in ACLS, ATLS or PALS. (ACLS is offered through Kaleida Health Corporate Clinical Education. Please call for information. You can also take either course online if you prefer. The following are just a few suggestions. You may be able to obtain this training somewhere else: $179.00, $ or $ ) 4. After a four year period of privileging the provider must repeat either the ASA sedation course or Medsimulation course and receive a score of 85% or greater or a comparable course reviewed and accepted by the Chief of Anesthesiology. They must also maintain airway management skills through completed and current training and certification in ACLS, ATLS or PALS. *

4 Otolaryngology Name: Page 4 LEVEL III PRIVILEGES Those procedures which categorically require documentation of additional training or experience, high risk procedures, new procedures or unlisted procedures will be included in this category. Volume criteria may be applicable. Otologic Procedures Acoustic neuroma Implantable Hearing Aids Cochlear Implants 8th Nerve section Temporal Bone Resection Plastic and Reconstructive Surgery TMJ procedures Micro vascular reconstruction (harvesting of flap, reconstruction) Craniofacial surgery Reconstruction congenital aural atresia, stenosis Sino Nasal Excision Pituitary tumor transphenoid Maxilla (osteoplasty) Mandible (osteoplasty, orthognathic) Excision Cribiform Plate Pediatric Practice Laryngeal Reconstruction < 8 yrs of age Cricoid decompression, Laryngoplasty, Tracheoplasty - < 8 yrs of age Tracheotomy < 2 yrs of age Endoscopy Endoscopy < 2 yrs of age (biopsy, dilation, excision, microscopy, foreign body removal, laser) laryngoscopy esophagoscopy bronchoscopy with f.b. removal < 2 yrs Other PEG Cricohyoidopexy *

5 Otolaryngology Name: Page 5 ROBOTIC ASSISTED SURGERY 1. Applicant must have unrestricted privileges for open and/or laparoscopic surgery procedures for which robot assisted surgeries/procedures will be performed. 2. When 2 robotic cases are completed at a particular level (as per the DOP level I, II, III) the applicant is then qualified to perform any cases in that level. 3. Current medical staff members: Successful completion of Intuitive Surgical Inc. training course (or equivalent sanctioned course). AND 2 cases minimum proctored by a robotics experienced surgeon in the same specialty as the applicant. The proctor will then determine if applicant is competent to perform robotics independently. If the proctor does not sign off after 2 cases, the next course of action will be decided by the Chairman of that department along with the Director of Robotics. 4. Initial applicants to medical staff: A. If completing residency or fellowship - Documentation from the program director of the accredited training program in which robotics is a part of the experience obtained and verification of the individual s competency in the use of the robot for the procedures requested. This would include a case log and documentation as to the number of cases the applicant has been involved in. AND 2 cases proctored by a robotics experienced surgeon in the same specialty as the applicant (if the applicant is trained in a Kaleida Health residency program it is up to the discretion of the program director if trainee is required to have any proctored cases). B. If > 1 year since completion of residency or fellowship and held robotics privileges at another institution - Documentation from the Chair of that surgical specialty department of the previous institution stating a history of safe use of the requested robotics surgeries. AND 10 cases minimum, at least 2 of which were during the previous year, as the primary surgeon; documentation from hospital or physician case log. C. If no robotics privileges held at another institution - Successful completion of Intuitive Surgical Inc. training course (or equivalent sanctioned course). AND 2 cases minimum proctored by a robotics experienced surgeon in the same specialty as the applicant. 5. Re-privileging - To demonstrate current competence and maintain privileges, 12 cases must be performed at Kaleida Health during the 2-year reappointment cycle. 6. There will be periodic evaluations to monitor outcomes of all surgeons including patient safety, intra-op complications and O.R. time efficiency. 7. In the future if a Robot is placed at Children s Hospital these adult criteria may need to be revisited. 8. It is the responsibility of the surgeon applying for robotic privileges to arrange for the proctor. All efforts should be made by the applicant to secure a Kaleida Health surgeon to proctor. If this is not feasible then an outside proctor can be used. If the proctor does not have privileges at Kaleida Health and is going to assist in any way other than observation and discussion, the proctor must obtain temporary Kaleida Health privileges. 9. Proctor - To qualify to Proctor robotic surgery, in the Kaleida system an applicant must also have completed a minimum of (25) robotic surgery cases with satisfactory outcomes and must agree to be present in the O.R. during the entire surgical procedure being proctored. Transoral resections of benign and malignant lesions of the pharynx and larynx and oncologic resections of the supraglottis, tonsil and tongue base. *

6 Otolaryngology Name: Page 6 APPLICATION FOR LASER & STERIOTACTIC SURGERY PRIVILEGES 1. Have you completed laser surgery training in an accredited residency program? YES NO State date and name of institution where you completed your training: Institution Date 2. In lieu of number (1) above, have you completed an approved laser surgery training program within eighteen (18) months of making application that included hands on training for each privilege requested? YES NO PLEASE ATTACH DOCUMENTATION TO SUPPORT YOUR APPLICATION 3. I am a member in good standing of my Department. 4. I understand that the need for supervision of an applicant performing new laser surgery procedures will be determined by the Credentials Committee upon the recommendation of the Department Chair. 5. I understand that a Pathology specimen must be obtained prior to laser ablation procedure where clinically appropriate as defined by the Department (see delineation of privilege form attached). 6. I understand that Laser Ablation Surgery may only be performed using the laser machine indicated, e.g., YAG, Krypton, Argon, CO2, etc. (see delineation of privilege form attached). Type of LASER to be used CO2 Argon KTP Nd-Yag Pulse Dye Feather Silk Touch CO2 Alexandrite Ruby Diode Ebrium Yag Stereotactic system use for Otolaryngology applications Fluoroscopic Balloon Sinuplasty Other Documentation/supervision and/or course attendance Documentation of taking Acclarent Sinuplasty Catheter training course or other training required. Must be mentored by a physician who is already trained in this procedure during first case. *

7 Otolaryngology Name: Page 7 KEY *NOT GRANTED DUE TO: Provide Details Below **WITH FOLLOWING REQUIREMENTS Provide Details Below 1) Lack of Documentation 1) With Consultation 2) Lack of Required Training/Experience 2) With Assistance 3) Lack of Current Competence (Databank Reportable) 3) With Proctoring 4) Other (Please Define) (i.e., Exclusive Contract) 4) Other (Please Define) DETAILS: National Practitioner Databank Disclaimer Statement: Kaleida Health must report to the National Practitioner Data Bank when any clinical privileges are not granted for reasons related to professional competence or conduct. (Pursuant to the Health Care Quality Improvement Act of 1986 (43 U.S.C et seq.) / Signature of Applicant Date (1) I approve of the procedures requested by the applicant as requested or as amended. (2) I have consulted with Pediatric ENT Site Director on / / who agrees to recommend approval of the requested Level II/III privileges for Pediatric care in Otolaryngology. / Signature of Chief of Service Date APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED DELINEATION FOR YOUR RECORDS

8 Otolaryngology Name: Page 8 (Otolaryngology 12/2015)

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