UNIVERSITY HOSPITAL



UNIVERSITY HOSPITAL

DEPARTMENT OF MEDICINE

SECTION OF GASTROENTEROLOGY

REQUEST FOR PRIVILEGES

To be eligible to request clinical privileges, the following threshold criteria must be met.

EDUCATION: MD or DO

TRAINING:

Successful completion of an approved residency training program in Internal Medicine. Successful completion

of an approved residency/fellowship in Gastroenterology. Applicant must meet the requirements for board

certification outlined in the Medical Staff Bylaws.

EXPERIENCE:

The initial applicant must be able to demonstrate training and/or experience on a level commensurate with

specialty training from an accredited internal medical residency program and residency/fellowship program in

gastroenterology or current competency in providing medical management and/or treatment to patients within the

scope of core privileges for Gastroenterology. Adequate documentation of this performance requires submission of

a case list and a reference letter. All initial applicants at completion of residency and/or fellowship must provide

an official case list and letter of recommendation assessing performance from the Residency and/or Fellowship

Program Director. All initial applicants beyond 12 months of residency/fellowship completion must provide a

case list from the hospital where the applicant has been actively practicing for the last year and a letter of

recommendation assessing performance from the hospital’s Chief of Staff or Department Chair.

Applicants must be able to demonstrate that they have successfully performed the following number of

procedures in the past 12 months:

|Procedure Name |Number Required |

|Diagnostic EGD |130 |

|Total colonoscopy |140 |

|Snare polypectomy |20 |

|Nonvariceal hemostasis |20 |

|(upper and lower, including 10 active bleeders) | |

|Variceal hemostatis (including 5 active bleeders) |15 |

|Esophageal dilation with guide wire |20 |

|Flexible sigmoidoscopy |30 |

|PEG |15 |

|ERCP (including 40 sphincterotomies and 10 stent placements) |200 |

|EUS: submucosal abnormalities |40 |

|Pancreaticobiliary |75 |

|EUS-guided FNA | |

|Nonpancreatic |25 |

|Pancreatic |25 |

|Tumor ablation |20 |

|Pneumatic dilation for achalasis |5 |

|Laparoscopy |25 |

|Esophageal stent placement |10 |

The reappointment applicant must demonstrate continuing competence and meet requirements for C.M.E.

according to the Medical Staff Bylaws. Reappointment is based upon unbiased, objective review of result

of care according to the hospital’s existing quality mechanisms.

SECTION OF GASTROENTEROLOGY

REQUEST FOR PRIVILEGES

PAGE 2

(This list is a sampling of privileges included in the core but is not intended to be an all-encompassing

list but rather reflective of the categories/types of privileges included in the core.)

CORE PRIVILEGES to include: REQUESTED GRANTED

|Admission of patients | | |

|Evaluation, diagnosis, and provision of non-surgical treatment including consultation for | | |

|patients admitted or in need of care to treat general medical problems | | |

|Consultation, evaluation, pre/post procedure care for patients presenting with illnesses, | | |

|injuries, and disorders of the stomach, intestines, and related structures such as the | | |

|esophagus, liver, gallbladder, and pancreas | | |

|Dilation, esophagus, bourginage or pneumatic | | |

|Endoscopy including with or without biopsy, fiberoptic esophagoscopy, fiberoptic | | |

|gastroscopy, fiberoptic duodenoscopy, proctosigmoidoscopy | | |

|Endoscopy including protosigmoidoscopy with or without polypectomy, and colonscopy | | |

|with or without biopsy and polypectomy | | |

|Gastric lavage | | |

|Esophageal manometry | | |

|Needle biopsy of Liver (Liver Biopsy) | | |

|Small bowel biopsy, peroral | | |

|Tamponade, balloon, esophagus | | |

|Flexible sigmoidoscopy | | |

|PEG | | |

|Paracentesis | | |

|Nonvariceal hemostasis | | |

|Variceal hemostatis | | |

Applicants requesting any other special privileges listed below must present documentation of training in

each privilege requested with a letter from the training director attesting to the applicant’s competence

and/or must meet any additional/other credentialing criteria which has been approved by the Medical Staff

and the Governing Board of University Hospital.

SPECIAL PRIVILEGES to include: REQUESTED GRANTED

|Therapeutic ERCP | | |

|Endoscopic gastrointestinal laser therapy | | |

|EUS-guided FNA: Nonpancreatic and Pancreatic | | |

|EUS: submucosal abnormalities | | |

|Esophageal stent placement | | |

|Laparoscopy | | |

|Hemorrhoidal banding | | |

|Tumor ablation | | |

|Pneumatic dilation for achalasis | | |

|Moderate Sedation | | |

|The applicant is required to submit a separate letter of | | |

|request for any privilege not included on this form. | | |

________________________________________ ___________________________

Applicant’s Signature Date 7/07

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