MIDLAND MEMORIAL HOSPITAL Delineatin f Privileges ORTHOPEDIC SURGERY Physician Name: Yur hme fr healthcare Orthpedic Surgery Cre Privileges Qualificatins Minimum threshld criteria fr requesting privileges in rthpedic surgery: Basic educatin: MD r DO Successful cmpletin f an ACGME- r AOA accredited residency in rthpedic surgery AND Current certificatin r active participatin in the examinatin prcess (with achievement f certificatin within 5 years) leading t certificatin in rthpedic surgery by the ABOS. (*Members f the Staff prir t the adptin f Bylaws 10/2007 are cnsidered grandfathered in and are encuraged but nt required t achieve bard certificatin). Required current experience fr Initial Applicatin: At least 100 general rthpedic prcedures, including prcedures fr trauma and fractures f the hips and knees, f the shulders and elbws, f the feet and ankles, f the spine, f the hand, and musculskeletal nclgy prcedures, reflective f the scpe f privileges requested, during the past 12 mnths, r the demnstrated successful cmpletin f an ACGME r AOA accredited residency r clinical fellwship within the past 12 mnths. References fr New Applicants If the applicant is recently trained, a letter f reference shuld cme frm the directr f the applicant s training prgram. Alternatively, a letter f reference may cme frm the applicable department chair and/r clinical service chief at the facility where the applicant mst recently practiced. Reappintment Reappintment shuld be based n unbiased, bjective results f care accrding t the rganizatin s existing quality imprvement measures. T be eligible t renew cre privileges in rthpedic surgery, applicants must demnstrate cmpetence and an adequate vlume f 50 rthpedic prcedures, including prcedures fr trauma and fractures f the hips and knees, f the shulders and elbws, f the feet and ankles, f the spine, f the hand, and musculskeletal nclgy prcedures) with acceptable results, reflective f the scpe f privileges requested, fr the past 24 mnths based n results f nging prfessinal practice evaluatin and utcmes. Evidence f current physical and mental ability t perfrm privileges requested it required f all applicants fr renewal f privileges. Please check requested privileges. Requested Apprved Nt Apprved Cre privileges include but are nt limited t: Perfrmance f histry and physical Cre Privileges: Cre privileges fr rthpedic surgery Hips and knees: include the ability t admit, evaluate, diagnse, treat, and prvide cnsultatin t patients f all ages t crrect r treat varius cnditins, illnesses, and injuries f the extremities, Amputatin surgery, including immediate prsthetic fitting in the perating rm; Arthrcentesis, diagnstic; Arthrdesis, stetmy, and ligament recnstructin f spine, and assciated structures by medical, surgical, and the majr peripheral jints (excluding ttal replacement f jints); Arthrgraphy; Arthrscpy; Bne grafts and physical means, including but nt limited t cngenital allgrafts; Clsed reductin f fractures and dislcatins; defrmities, trauma, infectins, tumrs, metablic disturbances Debridement f sft tissue; Excisin f sft tissue/bny f the musculskeletal system, defrmities, injuries, and masses; Fasitmy and fasciectmy; Fracture fixatin; degenerative diseases f the spine, hands, feet, knees, hips, Jint replacement, including minimally invasive techniques shulders, and elbws, including primary and secndary muscular prblems and the effects f central r peripheral nervus system lesins f the musculskeletal system. (excludes hip resurfacing); Ligament recnstructin; Management f infectins and inflammatins f bnes, jints, and tendn sheaths; Muscle and tendn repair; Plicy Tech Ref #: 5077 1 Apprved: 12/21/2016
Physicians may prvide care t patients in the intensive care setting in cnfrmity with unit plicies. Cre privileges als include the ability t assess, stabilize, and determine the dispsitin f patients with emergent cnditins cnsistent with medical staff plicy regarding emergency and cnsultative call services. Shulders and elbws Ft and ankle Hand Skin grafts Spine Open reductin and internal/ external fixatin f fractures and dislcatins f the skeletn; Recnstructin f nnspinal cngenital musculskeletal anmalies; Treatment f cartilage injuries (e.g., autlgus chndrcyte implantatin [ACI] and stearticular transfer system [OATS]); Treatment f trauma Amputatin surgery, including immediate prsthetic fitting in the perating rm; Arthrcentesis, diagnstic bne graft; Arthrscpy; Jint replacement ([includes] minimally invasive techniques); Clsed reductin f fractures and dislcatins; Muscle and tendn repair; Open reductin and internal/external fixatin f fractures and dislcatins; Debridement f sft tissue; Excisin f sft tissue/bny masses; Fascitmy and fasciectmy, and dislcatins Amputatin surgery, including immediate prsthetic fitting in the perating rm; Arthrscpy; Treatment f trauma; Jint replacement ([includes minimally invasive techniques); Clsed reductin f fractures and dislcatins; Muscle and tendn repair; Open reductin and internal/external fixatin f fractures and dislcatins; Debridement f sft tissue; Excisin f sft tissue/bny masses; Fascitmy and fasciectmy; Treatment f cartilage injuries (e.g., ACI and OATS) Arthrplasty f large and small jints, wrist, r hand; Amputatin surgery, including immediate prsthetic fitting in the perating rm; Arthrcentesis; Diagnstic bne graphing and Allgraphs; Nerve decmpressin; Fascitmy and Fasciectmy; Fracture fixatin with cmpressin plates r wires; Neurrrhaphy; Clsed reductins f fractures and dislcatins; Remval f sft tissue mass, ganglin n the palm r wrist, flexr sheath, etc.; Repair f laceratins; Repair f rheumatid arthritis defrmity Assessment f the neurlgic functin f the spinal crd and nerve rts; Interpretatin f imaging studies f the spine; Management f traumatic, cngenital, develpmental, infectius, metablic, degenerative, and rheumatlgic disrders f the spine; Treatment f extensive trauma; Open reductin and internal/external fixatin f fractures and dislcatins f the skeletn; Clsed reductin f fractures and dislcatins Musculskeletal nclgy Use f laser Detectin f tumrs thrugh varius imaging techniques, including x-ray, MRI, and bne scan prcedures; Tumr resectin with lcal treatment; Tumr resectin with majr limb recnstructin r amputatin; Bipsy and excisin f tumrs invlving bne and adjacent sft tissues Grwth disturbances such as injuries invlving plates with a high percentage f grwth arrest, grwth inequality, epiphysidesis, stapling, r bne shrtening r lengthening prcedures Plicy Tech Ref #: 5077 2 Apprved: 12/21/2016
Requested Apprved Nt Apprved Criteria Refer-and-fllw privileges Privileges include perfrming utpatient preadmissin histry and physical, rdering nninvasive utpatient diagnstic tests and services, visiting patients in the hspital, reviewing medical recrds, cnsulting with the attending physician, and bserving diagnstic r surgical prcedures with the apprval f the attending physician r surgen. Requested Apprved Nt Apprved Prcedure Hand Clinical Fellwship 6 mnth fellwship and/r CAQ Training Implants Nerve graft Wrist arthrscpy Endscpic carpal tunnel release Micr-vascular surgery Replants Free flaps Cmplex RA surgery Tendn recnstructin (free graft, staged) Tendn transfers Requested Apprved Nt Apprved Prcedure Criteria Nn-Cre Privileges Fr each special request, threshld criteria (i.e., additinal training r cmpletin f a recgnized curse and required experience) must be established. Special requests in rthpedic surgery include. Hip resurfacing Percutaneus lumbar discectmy New Applicant: Applicants must have cmpleted an ACGME-/AOA-accredited training prgram in rthpedic surgery fllwed by cmpletin f specialized training in hip resurfacing. It is recmmended that a surgen experienced in the hip resurfacing prcedure prctr an applicant s initial cases. Applicants must be able t demnstrate that they have perfrmed at least 10 hip resurfacing prcedures in the past 12 mnths. A letter f reference shuld cme frm the directr f the applicant s hip resurfacing training prgram. Alternatively, a letter f reference regarding cmpetence shuld cme frm the chief f rthpedic surgery at the institutin at which the applicant mst recently practiced. Reappintment: Applicants must be able t demnstrate that they have maintained cmpetence by shwing evidence that they have perfrmed at least 10 hip resurfacing prcedures annually ver the reappintment cycle. New Applicant: Applicants must have cmpleted an ACGME/American Ostepathic Assciatin (AOA) accredited residency r fellwship-training prgram in rthpedic surgery, neurlgical surgery, neurlgy, physical medicine and rehabilitatin, anesthesilgy, interventinal radilgy, r pain medicine. Applicants must prvide evidence that the training prgram included flurscpy and discgraphy. In additin, applicants shuld have cmpleted a training curse in the PLD methd fr which privileges are requested. Applicants must be able t demnstrate that they have perfrmed in the past 12 mnths at least five prcedures in the PLD methd fr which privileges are requested. A letter f reference frm the directr f the applicant s training prgram that included discgraphy and/r frm the directr f the applicant s PLD training prgram. Alternatively, a letter f Plicy Tech Ref #: 5077 3 Apprved: 12/21/2016
Percutaneus vertebrplasty Balln kyphplasty Lumbar disc arthrplasty reference regarding cmpetence shuld cme frm a physician experienced in discgraphy at the institutin where the applicant mst recently practiced. Reappintment: Applicants must be able t demnstrate that they have maintained cmpetence by shwing evidence that they have perfrmed at least 5 prcedures in the PLD methd fr which privileges are requested annually ver the reappintment cycle New Applicant: Successful cmpletin f an ACGME- r AOAaccredited residency prgram in rthpedic surgery, neurradilgy, interventinal radilgy, neursurgery, r pain medicine that included training in percutaneus vertebrplasty r cmpletin f an apprved training curse in percutaneus vertebrplasty that included prctring. Applicants must be able t demnstrate that they have perfrmed at least five percutaneus vertebrplasty prcedures in the past 12 mnths If the applicant is recently trained, a letter f reference shuld cme frm the directr f the applicant s training prgram. Alternatively, a letter f reference may cme frm the directr f spine surgery at the facility where the applicant mst recently practiced Reappintment: Applicants must demnstrate that they have maintained cmpetence by shwing evidence that they have successfully perfrmed 10 percutaneus vertebrplasty prcedures in the past 24 mnths. New Applicant: Applicants must have cmpleted an ACGME/AOA-accredited residency prgram in rthpedic surgery, neurradilgy, interventinal radilgy, neursurgery, r pain medicine that included training in balln kyphplasty, r cmpleted an apprved training curse in balln kyphplasty that included prctring. Applicants must als have cmpleted a device manufacturer s training curse n the use f kyphplasty devices. Applicants must be able t demnstrate that they have perfrmed at least 5 balln kyphplasty prcedures in the past 12 mnths. If the applicant is recently trained, a letter f reference shuld cme frm the directr f the applicant s training prgram. Alternatively, a letter f reference may cme frm the directr f spine surgery at the facility where the applicant mst recently practiced. Reappintment: Applicants must demnstrate that they have maintained cmpetence by shwing evidence that they have successfully perfrmed 10 balln kyphplasty prcedures in the past 24 mnths. New Applicant: Successful cmpletin f an ACGME- r AOA-accredited spine fellwship r cmpletin f an ACGME- r AOA-accredited residency training prgram in rthpedic surgery that included extensive experience in disc arthplasty and a series f mentred peratins with anther surgen accmplished in disc arthrplasty and Plicy Tech Ref #: 5077 4 Apprved: 12/21/2016
Cervical disc arthrplasty Mderate Sedatin cmpletin f a lumbar disc arthplasty curse by the ffering technlgy cmpany. In additin prficiency with flurscpy is required. Applicants must demnstrate cmpetence and evidence f anterir lumbar interbdy fusin experience (the perfrmance, n average, f ne r tw such prcedures in each f the preceding 12 mnths) and evidence f the perfrmance f at least 2 lumbar disc arthplasty prcedures in the past 12 mnths r cmpletin f training in the past 12 mnths. Reappintment: The applicant must demnstrate current cmpetence and evidence f the perfrmance f at least 4 lumbar disc arthplasty prcedures in the past 24 mnths based n results f nging prfessinal practice evaluatin and utcmes. In additin prficiency with flurscpy is required. New Applicant: Successful cmpletin f an ACGME- r AOA-accredited fellwship r cmpletin f an ACGME-r AOA-accredited residency training prgram in rthpedic surgery that included extensive experience in disc arthrplasty, a series f mentred peratins with anther surgen accmplished in disc arthrplasty, and cmpletin f a cervical disc arthrplasty curse by the ffering technlgy cmpany. Applicants must demnstrate current cmpetence and evidence f at least 10 cervical disc arthrplasty prcedures in the past 12 mnths r cmpletin f training in the past 12 mnths. Reappintment: Demnstrated current cmpetence and evidence f the perfrmance f at least 10 cervical disc arthrplasty prcedures in the past 24 mnths based n results f nging prfessinal practice evaluatin and utcmes. Meet the criteria set frth by the Rules and Regulatins fr Anesthesia Services and cmplete Requirements fr Mderate Sedatin Privileges frm. Requested Apprved Nt Apprved Privilege/Criteria Current Privileges: List any current privileges nt listed abve in cre r nn-cre. These privileges will remain in effect until the end f the current appintment perid and then will be mved up t the apprpriate cre/nn-cre sectin. Please prvide criteria and supprting dcumentatin t medical staff ffice fr any nn-cre privileges listed. Cre Nn-Cre Plicy Tech Ref #: 5077 5 Apprved: 12/21/2016
T the applicant: If yu wish t exclude any privileges, please strike thrugh the privileges that yu d nt wish t request and then initial. I understand that by making this request, I am bund by the applicable bylaws r plicies f the hspital, and hereby stipulate that I meet the minimum threshld criteria fr this request. I have requested nly thse privileges fr which by educatin, training, current experience and demnstrated perfrmance I am qualified t perfrm and fr which I wish t exercise at Midland Memrial Hspital. I als acknwledge that my prfessinal malpractice insurance extends t all privileges I have requested and I understand that: (a) In exercising any clinical privileges granted, I am cnstrained by Hspital and Medical Staff plicies and rules applicable generally and any applicable t the particular situatin. (b) Applicants have the burden f prducing infrmatin deemed adequate by Midland Memrial Hspital fr a prper evaluatin f current cmpetence, ther qualificatins and fr reslving any dubts. (c) I will request cnsultatin if a patient needs service beynd my expertise. Physician s Signature/Printed Name Date I have reviewed the requested clinical privileges and supprting dcumentatin fr the abve-named applicant and: Recmmend all requested privileges Recmmend privileges with the fllwing cnditins/mdificatins: D nt recmmend the fllwing requested privileges: Privilege Cnditin/mdificatin/explanatin Ntes: Department Chair/Chief Signature Date Plicy Tech Ref #: 5077 6 Apprved: 12/21/2016