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Name: _____________________________________________________

Effective from _______/_______/_______ to _______/_______/_______

□❏ Initial privileges (initial appointment) ❏□❏ Renewal of privileges (reappointment)

All new applicants must meet the following requirements as approved by the governing body, effective: ____/____/____.

If any privileges are covered by an exclusive contract or an employment contract, practitioners who are not a party to the contract are not eligible to request the privilege(s), regardless of education, training, and experience. Exclusive or employment contracts are indicated by [EC].

Applicant: Check the “Requested” box for each privilege requested. Applicants have the burden of producing information deemed adequate by the hospital for a proper evaluation of current competence, current clinical activity, and other qualifications and for resolving any doubts related to qualifications for requested privileges.

[Department chair/chief]: Check the appropriate box for recommendation on the last page of this form and include your recommendation for focused professional practice evaluation.[1] If recommended with conditions or not recommended, provide the condition or explanation on the last page of this form.

Other requirements

• Note that privileges granted may only be exercised at the site(s) and/or setting(s) that have sufficient space, equipment, staffing, and other resources required to support the privilege.

• This document is focused on defining qualifications related to competency to exercise clinical privileges. The applicant must also adhere to any additional organizational, regulatory, or accreditation requirements that the organization is obligated to meet.

Qualifications for General Pathology

Description: A General Pathologist is a specialist who is trained in diagnosis and in laboratory management, incorporating and integrating all aspects of laboratory methodology, playing a key role in quality assurance and the introduction of emerging technologies. This includes providing consultation to medical colleagues using morphologic techniques such as histopathology, cytology, autopsy, forensics and clinical laboratory methods, namely biochemistry, laboratory hematology, blood transfusion and microbiology. General Pathology is distinct because the training is divided between Anatomical Pathology and clinical laboratory medicine. General Pathologists are trained to practice in a variety of settings including large metropolitan, regional, and community hospitals, and may play a role in teaching or research. General Pathology can also be a route for sub-specialty or diploma training.

Initial privileges: To be eligible to apply for privileges in pathology (anatomic, clinical), the applicant must meet the following criteria:

Certification in General Pathology by the Royal College of Physicians and Surgeons of Canada or be recognized as a general pathologist by the College of Physicians and Surgeons of British Columbia by virtue of credentials earned in another jurisdiction that are acceptable to both the College and the organization.

AND

Required current experience: Full- or part-time pathology services, reflective of the scope of privileges requested, for the past 12 months or successful completion of an ACGME- or AOA-accredited residency or clinical fellowship within the past 12 months.

Renewal of privileges: To be eligible to renew privileges in pathology, the applicant must meet the following criteria:

Current demonstrated competence and an adequate volume of experience [full or part time] with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges.

Core privileges: General pathology - anatomic

❑ Requested Patient diagnosis, ordering, consultation, and laboratory medical direction in the following disciplines: surgical pathology (including intraoperative consultations), cytopathology, autopsy pathology, immunohistochemistry, and associated ancillary studies. Adherence to medical staff policy regarding emergency and consultative call services. The core privileges include the procedures listed on the attached privileges list and such other procedures that are extensions of the same techniques and skills.

Core privileges: General pathology - clinical

❑ Requested Patient diagnosis, ordering, consultation, and laboratory medical direction in the following clinical pathology disciplines: hematology and coagulation, blood bank and immunohematology, microbiology, serology, molecular pathology, clinical chemistry (including the subdivisions of special chemistry, automated chemistry, endocrinology, radioimmunoassay, toxicology, and electrophoresis), clinical microscopy, and other routine clinical pathology functions. Adherence to medical staff policy regarding emergency and consultative call services. The core privileges include the procedures listed on the attached privileges list and such other procedures that are extensions of the same techniques and skills.

To the applicant: If you wish to exclude any procedures, please strike through the procedures that you do not wish to request, and then initial and date.

General anatomic pathology

• Fine-needle aspiration and biopsy procedures (including ultrasound guided) and reporting of the specimens obtained

• Interpretation and reporting of papanicolaou-stained smears

• Interpretation and reporting of surgical pathology

• Autopsy, including forensic autopsy

• Interpretation and reporting of immunohistochemical investigations

General Clinical pathology

• Clinical consultation for conditions involving transfusion, coagulation, metabolic and molecular disease

• Interpret and report Gram stains

• Interpret and report blood and marrow specimens

• Interpret and report coagulation studies

Non-core privileges: Bone marrow biopsy

❑ Requested

Initial privileges: Successful completion of Royal College of Physicians and Surgeons of Canada (or equivalent) accredited postgraduate training in anatomic, general or hematological pathology that included training in bone marrow biopsy.

AND

Required current experience: Demonstrated current competence and evidence of the performance of [n] bone marrow biopsies in the past 12 months or completion of training in the past 12 months.

Renewal of privileges: Demonstrated current competence and evidence of the performance of [n] bone marrow biopsies in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

Other non-core privileges requiring proctoring and experience approved by department head

General Pathology

• Medical microbiology including identification of microorganisms, interpreting and reporting antibiotic susceptibility testing and management of an antibiotic stewardship program ❑ Requested

Qualifications for Anatomic Pathology

Description: Anatomical Pathology is that branch of laboratory medicine concerned with the study of the morphologic aspects of disease. It includes the subdomains of cytopathology, gynecological pathology, dermatopathology, gastrointestinal pathology, cardiovascular pathology, respiratory pathology, musculoskeletal pathology, renal pathology, genito-urinary pathology, endocrine pathology, ophthalmic pathology, head and neck pathology, neuropathology, pediatric pathology, forensic pathology, and certain laboratory methods such as immunohistochemistry, immunofluorescence, in-situ hybridization, flow cytometry, molecular pathology, electron microscopy.

Initial privileges: To be eligible to apply for privileges in cytopathology, the applicant must meet the following criteria:

Certification in Anatomic Pathology by the Royal College of Physicians and Surgeons of Canada or be recognized as a anatomic pathologist by the College of Physicians and Surgeons of British Columbia by virtue of credentials earned in another jurisdiction that are acceptable to both the College and the organization.

AND

Required current experience: Full- and/or part-time anatomic pathology services, reflective of the scope of privileges requested, for the past 12 months or successful completion of a Royal College of Physicians and Surgeons of Canada residency in anatomic pathology (or equivalent) or clinical fellowship within the past 12 months.

Renewal of privileges: To be eligible to renew privileges in anatomic pathology, the applicant must meet the following criteria:

Current demonstrated competence and an adequate volume of full- or part-time experience with acceptable results, reflective of the scope of the privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges.

Core privileges: Anatomic pathology

❑ Requested Patient diagnosis, ordering, consultation, and laboratory medical direction in the following disciplines: surgical pathology (including intraoperative consultations), cytopathology, autopsy pathology, immunohistochemistry, and associated ancillary studies. Adherence to medical staff policy regarding emergency and consultative call services. The core privileges include the procedures listed on the attached privileges list and such other procedures that are extensions of the same techniques and skills.

To the applicant: If you wish to exclude any procedures, please strike through the procedures that you do not wish to request, and then initial and date.

Anatomic pathology

• Fine-needle aspiration and biopsy procedures (including ultrasound guided) and reporting of the specimens obtained

• Interpretation and reporting of papanicolaou-stained smears

• Interpretation and reporting of surgical pathology

• Autopsy, including forensic autopsy

• Interpretation and reporting of immunohistochemical investigations

Non-core privileges: Bone marrow biopsy

❑ Requested

Initial privileges: Successful completion of an ACGME- or AOA-accredited postgraduate training in anatomic, general or hematological pathology that included training in bone marrow biopsy.

AND

Required current experience: Demonstrated current competence and evidence of the performance of [n] bone marrow biopsies in the past 12 months or completion of training in the past 12 months.

Renewal of privileges: Demonstrated current competence and evidence of the performance of [n] bone marrow biopsies in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

Other non-core privileges requiring proctoring and experience approved by department head

Anatomic Pathology

• Flow cytometry ❑ Requested

• Immunofluoresence ❑ Requested

• Molecular pathology ❑ Requested

• Electron microscopy ❑ Requested

• In situ hybridization ❑ Requested

Qualifications for Forensic Pathology

Description: Forensic Pathology is a subspecialty of Anatomical Pathology and General Pathology which applies basic pathologic principles and methodologies of these two specialties to support the medicolegal and judicial systems in determining causes and manners of death, supporting the investigation of circumstances surrounding deaths, and assisting in the interpretation of postmortem findings of medical legal significance.

Initial privileges: To be eligible to apply for privileges in cytopathology, the applicant must meet the following criteria:

Certification in General or Anatomic Pathology by the Royal College of Physicians and Surgeons of Canada or be recognized as a general or anatomic pathologist by the College of Physicians and Surgeons of British Columbia by virtue of credentials earned in another jurisdiction that are acceptable to both the College and the organization.

AND

Certification in Forensic Pathology by the Royal College of Physicians and Surgeons of Canada or be recognized as a forensic pathologist by the College of Physicians and Surgeons of British Columbia by virtue of credentials earned in another jurisdiction that are acceptable to both the College and the organization.

AND

Required current experience: Full- and/or part-time forensic pathology services, reflective of the scope of privileges requested, for the past 12 months or successful completion of a Royal College of Physicians and Surgeons of Canada residency in forensic pathology (or equivalent) or clinical fellowship within the past 12 months.

Renewal of privileges: To be eligible to renew privileges in anatomic pathology, the applicant must meet the following criteria:

Current demonstrated competence and an adequate volume of full- or part-time experience with acceptable results, reflective of the scope of the privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges.

Core privileges: Forensic pathology

❑ Requested Patient diagnosis, ordering, consultation, and laboratory medical direction in the following disciplines: surgical pathology (including intraoperative consultations), cytopathology, autopsy pathology, immunohistochemistry, and associated ancillary studies. Adherence to medical staff policy regarding emergency and consultative call services. The core privileges include the procedures listed on the attached privileges list and such other procedures that are extensions of the same techniques and skills.

To the applicant: If you wish to exclude any procedures, please strike through the procedures that you do not wish to request, and then initial and date.

Forensic Patbology

• Investigate and report causes and manners of death, supporting the investigation of circumstances surrounding deaths, and assisting in the interpretation of postmortem findings of medical legal significance, including suspicious infant death and the investigation of human skeletal remains.

Other non-core privileges requiring proctoring and experience approved by department head

Qualifications for neuropathology

Description: Neuropathology is the laboratory specialty concerned with the investigation and diagnosis of primary and secondary diseases of the central and peripheral nervous systems and skeletal muscle.

Initial privileges: Certification in Neuropathology by the Royal College of Physicians and Surgeons of Canada or be recognized as a neuropathologist by the College of Physicians and Surgeons of British Columbia by virtue of credentials earned in another jurisdiction that are acceptable to both the College and the organization.

AND

Required current experience: Full- and/or part-time neuropathology services, reflective of the scope of privileges requested, for the past 12 months or successful completion of a Royal College of Physicians and Surgeons of Canada residency in neuropathology (or equivalent) or clinical fellowship within the past 12 months.

Renewal of privileges: To be eligible to renew privileges in neuropathology, the applicant must meet the following criteria:

Current demonstrated competence and an adequate volume of full- or part-time experience with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges.

Core privileges: Neuropathology

❑ Requested Diagnose diseases of the nervous system and skeletal muscles, including the infirmities as they affect the nervous and neuromuscular systems, whether degenerative, infectious, metabolic, immunologic, neoplastic, vascular, or physical in nature by use of scientific studies of the tissues, cells, and body fluids. Apply technologies including immunohistochemistry, electron microscopy and immunofluorescence. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges include the procedures listed on the attached privileges list and such other procedures that are extensions of the same techniques and skills.

To the applicant: If you wish to exclude any procedures, please strike through the procedures that you do not wish to request, and then initial and date.

Neuropathology

• Autopsy examination related to the nervous and musculoskeletal systems

• Interpretation and reporting of immunohistochemical investigations

• Interpretation and reporting of electron microscopy studies

• Interpretation and reporting of investigations employing immunofluorescence

• Interpretation and reporting of diagnostic neurocytology cases

• Clinical consultation

Other non-core privileges requiring proctoring and experience approved by department head

Neuropathology

• Interpretation and reporting of molecular investigations including in-situ hybridization

❑ Requested

Qualifications for Medical Microbiology

Description: Medical Microbiology is a branch of laboratory and clinical medicine concerned primarily with the diagnosis, treatment and prevention of infectious diseases. The specialty of Medical Microbiology consists of four general spheres of activity:

1. Scientific development, and administrative and clinical direction of a microbiology laboratory.

2. Clinical consultations, in both in-patient and out-patient settings, on the investigation, diagnosis, treatment, and prevention of infectious diseases.

3. Infection Prevention and Control, and antibiotic stewardship.

4. The epidemiology of communicable diseases.

Initial privileges: Certification in Medical Microbiology by the Royal College of Physicians and Surgeons of Canada or be recognized as a medical microbiologist by the College of Physicians and Surgeons of British Columbia by virtue of credentials earned in another jurisdiction that are acceptable to both the College and the organization.

AND

Required current experience: Full- and/or part-time medical microbiology services, reflective of the scope of privileges requested, for the past 12 months or successful completion of a Royal College of Physicians and Surgeons of Canada residency in medical microbiology (or equivalent) or clinical fellowship within the past 12 months.

Renewal of privileges: To be eligible to renew privileges in medical microbiology, the applicant must meet the following criteria:

Current demonstrated competence and an adequate volume of full- or part-time experience with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges.

Core privileges: Medical Microbiology

❑ Requested Diagnose and monitor diseases caused by microorganisms, for patients of all ages. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges include the procedures listed on the attached privileges list and such other procedures that are extensions of the same techniques and skills.

To the applicant: If you wish to exclude any procedures, please strike through the procedures that you do not wish to request, and then initial and date.

Medical Microbiology

• Clinical consultation for diseases caused by microorganisms

• Interpretation and reporting of microscopy specimens including Gram stains

• Interpretation and reporting of antibiotic susceptibility testing

• Interpretation and reporting of microbial identification investigations

• Consultation for the following:

o Infection prevention and control

o Implementation and monitoring of new technologies related to the discipline

o Point of care testing devices

• Management of an antibiotic stewardship program

Other non-core privileges requiring proctoring and experience approved by department head

Medical Microbiology

• Investigation and reporting of virological disease ❑ Requested

Qualifications for Medical Biochemistry

Definition: Medical Biochemistry is a branch of medicine concerned with the biochemistry and metabolism in human health and disease. The Medical Biochemist is a specialist in laboratory medicine, is trained in the operation and management of clinical biochemistry laboratories, and acts as a consultant in all aspects of their use. The medical biochemist directs clinical laboratories, consults, diagnoses and treats patients with a variety of metabolic disorders and biochemical abnormalities.

Initial privileges: Certification in Medical Biochemistry by the Royal College of Physicians and Surgeons of Canada or be recognized as a medical biochemist by the College of Physicians and Surgeons of British Columbia by virtue of credentials earned in another jurisdiction that are acceptable to both the College and the organization.

AND

Required current experience: Full- and/or part-time medical biochemistry services, reflective of the scope of privileges requested, for the past 12 months or successful completion of a Royal College of Physicians and Surgeons of Canada residency in neuropathology (or equivalent) or clinical fellowship within the past 12 months.

Renewal of privileges: To be eligible to renew privileges in medical biochemistry, the applicant must meet the following criteria:

Current demonstrated competence and an adequate volume of full- or part-time experience with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges.

Core privileges: Medical Biochemistry

❑ Requested Apply laboratory techniques of medical biochemistry for diagnosis and management of disease for patients of all ages with congenital or acquired biochemical disease and assess the natural history of those disorders. Adhere to medical staff policy regarding emergency and consultative call services. The core privileges include the procedures listed on the attached privileges list and such other procedures that are extensions of the same techniques and skills.

To the applicant: If you wish to exclude any procedures, please strike through the procedures that you do not wish to request, and then initial and date.

Medical Biochemistry

• Clinical consultation for molecular and biochemical disease

• Interpretation and reporting of biochemical investigations

Other non-core privileges requiring proctoring and experience approved by department head

Qualifications for Haematogical Pathology

Description: Hematological Pathology is that domain of laboratory medical practice and science concerned with the study, investigation, diagnosis and therapeutic monitoring of disorders of blood, blood-forming elements, hemostasis and immune function in adults and children. The specialty also encompasses the direction and supervision of transfusion medicine services both at hospital and blood center level, ensuring safe and effective transfusion management for patients. The practice of Hematological Pathology requires an in depth knowledge of the basic sciences (immunology, biochemistry, molecular pathology, genetics) related to the specialty which are an essential foundation for the provision of expert knowledge in the morphology of blood and hematopoietic/ lymphoid organs, immunohematology, hemostasis and general hematology. The specialty also encompasses expertise in instrumentation, quality management systems, administrative and regulatory guidelines related to the directorship and management of diagnostic laboratory resources.

Initial privileges: Certification in Hematological Pathology by the Royal College of Physicians and Surgeons of Canada or be recognized as a hematological pathologist by the College of Physicians and Surgeons of British Columbia by virtue of credentials earned in another jurisdiction that are acceptable to both the College and the organization.

AND

Required current experience: Full- and/or part-time haematopathology services, reflective of the scope of privileges requested, for the past 12 months or successful completion of a Royal College of Physicians and Surgeons of Canada residency in haematopathology (or equivalent) or clinical fellowship within the past 12 months.

Renewal of privileges: To be eligible to renew privileges in haematopathology, the applicant must meet the following criteria:

Current demonstrated competence and an adequate volume of full- or part-time experience with acceptable results, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges.

Core Privileges – Hematological Pathology

❑ Requested Diagnose and monitor diseases of the haematopoetic system, for patients of all ages. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges include the procedures listed on the attached privileges list and such other procedures that are extensions of the same techniques and skills.

To the applicant: If you wish to exclude any procedures, please strike through the procedures that you do not wish to request, and then initial and date.

Hematological Pathology

• Clinical consultation for diseases of the haematopoetic system

• Management of a transfusion service

• Interpretation and reporting of autoimmune and immunohematology investigations

• Interpretation and reporting of blood and marrow morphology

• Interpretation and reporting of in-situ hybridization studies

• Interpretation and reporting of flow cytometry

• Interpretation and reporting of molecular tests related to the hematopoetic system

Non-core privileges: Bone marrow biopsy

❑ Requested

Initial privileges: Successful completion of an ACGME- or AOA-accredited postgraduate training in anatomic, general or hematological pathology that included training in bone marrow biopsy.

AND

Required current experience: Demonstrated current competence and evidence of the performance of [n] bone marrow biopsies in the past 12 months or completion of training in the past 12 months.

Renewal of privileges: Demonstrated current competence and evidence of the performance of [n] bone marrow biopsies in the past 24 months based on results of ongoing professional practice evaluation and outcomes.

Other non-core privileges requiring proctoring and experience approved by department head

Hematological Pathology

• Tissue banking ❑ Requested

• Immunogenetic techniques ❑ Requested

Acknowledgment of practitioner

I have requested only those privileges for which by education, training, current experience, and demonstrated performance I am qualified to perform and for which I wish to exercise at [hospital name], and I understand that:

a. In exercising any clinical privileges granted, I am constrained by hospital and medical staff policies and rules applicable generally and any applicable to the particular situation.

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 or related documents.

Signed ________________________________________ Date _____________________

[Department chair/chief]’s recommendation

I have reviewed the requested clinical privileges and supporting documentation for the above-named applicant and:

❑ Recommend all requested privileges

❑ Recommend privileges with the following conditions/modifications:

❑ Do not recommend the following requested privileges:

Privilege Condition/modification/explanation

Notes: ______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

[Department chair/chief] signature ________________________ Date _____________________

FOR MEDICAL STAFF USE ONLY

Credentials committee action Date _____________________

Medical executive committee action Date _____________________

Board of trustees action Date _____________________

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