KALEIDA HEALTH Name: Date: DELINEATION OF PRIVILEGES - OTOLARYNGOLOGY 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. GENERAL STATEMENTS Adults and Pediatrics except as specified. Procedures are grouped by anatomic region and may be identified by code. 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. Skull (excision, reconstruction, bone graft) 016, 020, 0204 Peripheral Nerve 041-0476, 0521 (excision, biopsy, graft, anastomosis) Thyroid/Parathyroid 0601-0699 (aspiration, biopsy, resection) Thymus (excision) 0780-0799 Eyelid 0801-0820 (incision, excision, repair, reconstruction) 0822-0825 0838 0844, 0851, 086-089 Lacrimal System 0911-0949 (biopsy, excision, probing, repair) 0953,0973-0981 Orbit (reconstruction, excision) 1601-1659 1691, 1692 Ear, External (diagnosis, repair biopsy, 1801-1879 excision, reconstruction) Middle Ear (exploration, tympanoplasty, 1900-1999 stapes, mastoid) 2000-2094 Nasal (epistaxis, biopsy, septum, reconstruction, repair, excision) (aspiration, endoscopic, external) Oral cavity (biopsy, excision, repair, reconstruction) Tongue/FOM 2100-2199 2200-2290 2501-252 2550-2559 2700-2753 2755-2761 2769-2799 LEVEL I PRIVILEGES (CON T) Salivary Gland (repair, excision) 2600-2699 Oropharynx (tonsil) 2800-2899 Pharynx 2900-2919 Neck (congenital) 2920-2999 Cricopharyngeal Myotomy 2931 Larynx (excision, repair, reconstruction, trauma, TEF) 3000-3100 3143-3169 Trachea (excision, tracheotomy, repair) Lung (bronchoscopy, biopsy) Vessels (incision, biopsy, excision, repair, ligation) 3110-3142 3170-3174 3179 3199 3200-3205 3321-3325 3802, 3821, 3832, 3862, 3869, 3882, 3931, 3932 4000-4050 4064-4069 4201 4239, 4241, 4270-4285,4292 7601-7630 7670-7700 Lymphatic (biopsy, excision, neck dissection) -- thoracic duct Esophagus (incision, biopsy, repair, endoscopy, repair, reconstruction, dilatation) Facial Bones (repair, biopsy, trauma, sequestrotomy) Mandible 7631-7646 Integumentary (biopsy, excision, repair, skin 8601-8684 graft, pedicle flaps, facial plastic surgery, 8693 scar revision, tissue expansion) 7667 7669
LEVEL I PRIVILEGES * LEVEL II PRIVILEGES Requires certificate of added qualifications or approved fellowship in one of the following: Head & Neck Oncology, PediatricOtolaryngology,Otology/Neurootology, Facial Plastic Surgery or documentation of surgical experience for three years preceding the request. Volume criteria may be applicable. Glossectomy 2531-2540 Tracheal Resection 3175 Vessel Resection with Repair 3842 Percutaneous Tracheotomy 3199 Partial Laryngectomy 3029-3010 Stapedectomy 19.1-19.29 Liposuction 86.83 Laryngo-tracheal separation 31.99 Medialization Laryngoplasty 31.69 Arytenoid Adduction 31.69 Angiofibroma 29.3 Arytenoidectomy < 8 yrs of age 30.29 Arytenopexy < 8 yrs of age 31.69 Endoscopic sinus surgery < 8 yrs of age 22.11-22.90 Endoscopic CSF leak repair Lip-Tongue (Douglas procedure) 22.59 NICU admission Vascular lesions, lymphangiomas, AVM, 38.6, 40.29 hemangiomas, < 8 yrs of age Thoracentesis 34.91 Thoracostomy 34.04 Cleft Lip repair 2754 Cleft Palate repair 2762, 2767 Browlift Otoplasty, Unilateral/bilateral 200137, 200139 Facelift Platysmoplasty 200288 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 *
Otolaryngology Name: Page 3 LEVEL II PRIVILEGES (CON T) * Conscious Sedation (Adult/Pediatric) 1. Initial Request: Must have completed a Kaleida Health approved training course (documentation required) or training during ACGME Accredited Residency (verification letter from program director required.) 2. Maintenance of privilege: The course needs to be taken again every 4 years. 3. The course can be found at: www.kaleidahealth.org/physicians/moderate Sedation/ 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 04.01 Implantable Hearing Aids 2095 Cochlear Implants 2096-2099 8th Nerve section 04.04 Temporal Bone Resection 77.9 Plastic and Reconstructive Surgery TMJ procedures 76.5, 76.93-76.97 Micro vascular reconstruction 86.63 (harvesting of flap, reconstruction) Craniofacial surgery Reconstruction congenital aural atresia, 18.6 stenosis Sino Nasal Excision Pituitary tumor transphenoid 0762, 07.62, 07.65 Maxilla (osteoplasty) 7665-7666 Mandible (osteoplasty, orthognathic) 7661-7664 Excision Cribiform Plate 01.2 Pediatric Practice Laryngeal Reconstruction < 8 yrs of age 478.74 Cricoid decompression, Laryngoplasty, 478.74, Tracheoplasty - < 8 yrs of age 31.79 Tracheotomy < 2 yrs of age 31.1 Endoscopy Endoscopy < 2 yrs of age (biopsy, dilation, excision, microscopy, foreign body removal, laser) laryngoscopy 31.42-31.99 esophagoscopy 42.41-42.70 bronchoscopy with f.b. removal < 2 yrs 33.21-33.25 Other PEG 43.11 Cricohyoidopexy 31.69 *
Otolaryngology Name: Page 4 ROBOTIC SURGERY If proctorship is a pre-requisite, contact the Medical Staff Office for instructions & to obtain the required forms. You must be approved with proctoring PRIOR to performing the procedure within Kaleida. 1. Applicant must have unrestricted privileges for open and/or endoscopic surgery procedures for which robot assisted surgeries/procedures will be performed AND must provide documentation of successful completion of an advanced didactic robotic course to include certification of completion of a robot-assisted animal laboratory course. Observation of a minimum of two (2) robotic cases and must complete five (5) *proctored cases with satisfactory outcomes; OR 2. Applicant must provide documentation of unrestricted robotic privileges at another hospital system, with satisfactory outcomes including a case log of the most recent 50 cases; OR 3. Applicant must provide documentation of successful completion of computer assisted surgical training in residency/fellowship including robotic surgery with a case log of 50 cases of all robotic surgery and must complete two (2) *proctored cases with satisfactory outcomes; AND 4. Applicant must have first ten (10) robotic cases retrospectively reviewed by the clinical service chief and/or designee regarding meeting the quality standards established by the clinical department. 5. Applicant must perform twenty five (25) robot-assisted surgeries each year with satisfactory results to maintain privilege. *To qualify to proctor robotic surgery, an applicant must also have completed a minimum of fifty (50) robotic surgery cases with satisfactory outcomes, and must agree to be present in the OR 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.
Otolaryngology Name: Page 5 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. *
Otolaryngology Name: Page 6 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. 11101 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 (OTO/mso-Reviewed and Revised 11/2013)