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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 general 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 RCPSC or equivalent accredited residency or clinical/research fellowship immediately following residency 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

❑ Requested Patient diagnosis, ordering investigations, consultation, and laboratory medical oversight in the following disciplines: anatomical pathology, including surgical pathology (including intraoperative consultations), cytopathology, autopsy pathology, immunohistochemistry, and associated ancillary studies; haematopathology, medical microbiology, and medical biochemistry. 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

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

• Interpretation and reporting of cytology specimens

• Interpretation and reporting of surgical pathology

• Autopsy, including forensic autopsy

• Interpretation and reporting of immunohistochemistry

• Medical oversight of an anatomical pathology laboratory

General Clinical pathology

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

• Medical microbiology including identification of microorganisms, interpreting and reporting antibiotic susceptibility

• Interpret and report blood and marrow specimens

• Interpret and report serum protein electrophoresis

• Bone marrow biopsy procedures

• Apply laboratory techniques of medical biochemistry for diagnosis and management of disease for patients of all ages with a variety of metabolic disorders and biochemical abnormalities

• Medical oversight of a clinical pathology lab

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

General Pathology

• Performance of fine needle aspiration ❑ Requested

• Examination of human skeletal remains ❑ Requested

• Examination for suspicious infant death ❑ 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. Medical oversight of an anatomical pathology laboratory

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

Certification in Anatomical 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 anatomical 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/research fellowship immediately following residency 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, (minimum of 24 weeks or 3000 L4Es for the past 36 months) based on results of ongoing professional practice evaluation and outcomes and the department head’s discretion. Evidence of current physical and mental ability to perform privileges requested is required of all applicants for renewal of privileges.

Core privileges: Anatomical 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. 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

• Interpretation and reporting of cytology specimens

• Interpretation and reporting of surgical pathology

• Autopsy, including forensic autopsy

• Interpretation and reporting of immunohistochemistry.

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

Anatomical Pathology

Oversight, interpretation and reporting of:

• Flow cytometry ❑ Requested

• Immunofluoresence ❑ Requested

• Molecular pathology ❑ Requested

• Electron microscopy ❑ Requested

• In situ hybridization ❑ Requested

• Examination skeletal remains ❑ Requested

• Suspicious infant death ❑ Requested

• Performance of fine needle aspiration ❑ 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 cause and manner of death, supporting the investigation of circumstances surrounding deaths, and assisting in the interpretation of postmortem findings of medicolegal significance.

Initial privileges: To be eligible to apply for privileges in forensic pathology, 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/research fellowship immediately following residency 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 (n) 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 autopsy pathology including associated ancillary studies. 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, interpret and report postmortem findings of medicolegal significance, including determination of cause of death, supporting the investigation of circumstances surrounding deaths. Autopsy subjects may include suspicious infant deaths and the investigation of human skeletal remains.

• Clinical consultation with respect to injuries or injury patterns in living patients.

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

Left blank deliberately

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/research fellowship immediately following residency 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 (n) 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 Diagnostic and consultative Neuropathology (as defined by the Royal College of Physicians and Surgeons of Canada); applied to neurosurgical and surgical specimens that have a direct impact on the nervous system, neurocytology and neuropathologic autopsy. Apply and oversee relevant diagnostic techniques that include: immunohistochemistry, electron microscopy and immunofluorescence. The core privileges include the procedures listed 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

• Interpretation and reporting of immunohistochemical investigations

• Interpretation and reporting of electron microscopy studies

• Interpretation and reporting of investigations employing immunofluorescence

• 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 based on quality management principles.

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 (including antibiotic stewardship)

4. The epidemiology of communicable diseases.

Within the latter three spheres, medical microbiologists are either the directors or the key members of the leadership committee. Details of each activity are provided in the Core Privileges section.

Initial privileges: Either:

• Certification in Medical Microbiology by the Royal College of Physicians and Surgeons of Canada; or

• 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: Either:

• Full- and/or part-time medical microbiology services, reflective of the scope of privileges requested, for average of 8 weeks per year over the prior 3 years; or

• Successful recent completion of a Royal College of Physicians and Surgeons of Canada residency in medical microbiology (or equivalent).

• Clinical/research fellowship immediately following residency 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 professional activity of an average of 8 weeks per year over the prior 3 years on a full- or part-time or part time basis. 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 Patient investigation, diagnosis, treatment, and prevention of diseases caused by microorganisms, for patients of all ages. Medical oversight/clinical direction of the medical microbiology laboratory, Infection prevention and control and Antibiotic Stewardship.

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.

• Clinical Consultation

o Clinical consultation including investigation, diagnosis, treatment and prevention of infectious diseases with or without direct patient care.

• Medical Laboratory

o Oversight/clinical direction/ of:

▪ All processes required for a comprehensive diagnostic medical microbiology practice

▪ Development and implementation of new or changing technologies

▪ Quality management systems

▪ Laboratory safety

• Infection Prevention and Control

o Medical oversight/ clinical direction of Infection Prevention and Control programs

o Clinical consultation for infection prevention and control

o Epidemiology and surveillance of communicable and health care associated infections

• Antimicrobial Stewardship

o Medical oversight/ clinical direction of Antibiotic Stewardship Program

o Clinical consultation for antibiotic stewardship

o Epidemiology and surveillance of antibiotic use and susceptibility patterns

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

• Oversight, interpretation and reporting of electron microscopy

• Oversight, interpretation and reporting of virus isolation

Qualifications for Medical Biochemistry

Definition: Medical Biochemistry is a branch of medicine based on principles of biochemistry and metabolismin human health and disease. The Medical Biochemist is a specialist in laboratory medicine, is trained in the operation and management of medical biochemistry laboratories, and is 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 Medical Biochemistry (or equivalent) or clinical/research 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 medical biochemistry for diagnosis and management of disease for patients of all ages with a variety of metabolic and biochemical disorders and assess the natural history of those disorders. Participate in the direction of method development. The core privileges include the procedures listed below 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

• Advise on biochemical basis of diagnosis and management of diseases including appropriate testing and interpretation of results for the following

a) Acute and chronic diseases in institutional, community and outpatient adult and pediatric medical biochemistry

b) adult and pediatric endocrine and metabolic testing

c) lipid diagnostic testing

d) protein chemistry

e) obstetric medical biochemistry

f) therapeutic drug monitoring (TDM) and toxicology

g) tumour markers, screening, monitoring and prognosis

h) critical care and trauma

i) neurology and degenerative diseases

• Population based prevention and health promotion

• Direction of Method development

• Direction of Quality Management (Arun to provide reference)

• Direction of Laboratory Medicine Point of Care testing

• Administrative direction and system management of Laboratory Medicine

• Medical consultation (direct patient care)

o Lipid disorders

o Bone disorders

o Diabetes mellitus

o Thyroid disorders

o Inborn errors of metabolism

o Nutrition and total parenteral nutrition (TPN)

o Other biochemically based metabolic disorders

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

Medical Biochemistry

Advise on appropriate testing, interpret and report results for:

|Non core privilege |Additional training required |Currency requirement |requested |

|Specialized pediatric medical |6 months mentoring |8 weeks / year | |

|biochemistry* | | | |

|Prenatal screening |2 months mentoring |8 weeks / year | |

|Neonatal screening |3 months mentoring |8 weeks / year | |

|Specialized toxicology |1 year mentoring |8 weeks / year | |

|(including forensic) | | | |

|Inborn errors of metabolism |1 year mentoring |8 weeks / year | |

|(biochemical genetics) | | | |

• *For Pediatricians who enter medical biochemistry, no further training required

Comment: How do we deal with on call coverage / cross coverage when the person covering doesn’t have credentially in that area?

Qualifications for Hematogical Pathology and Transfusion Medicine

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:

Applicants are expected to have a minimum of 40 days working experience (320 hours) per year averaged over three years including the following levels of activity:

o Bone marrow interpretation 40 cases per year averaged over three years

o Morphologic interpretations 80 samples per year averaged over three years (all tissues other than bone marrows)

o Transfusion medicine investigation report sign out 40 cases per year averaged over three years

o Sign off of new and reviewed policies and procedures

o Sign off of proficiency testing challenges, accreditation and other audits

o 8 hours of total CME specific to diagnostic hematopathology

o 8 hours of total CME specific to transfusion medicine

o Bone marrow aspiration and biopsy 10 cases per year averaged over three years

Renewal of privileges: To be eligible to renew privileges in hematopathology, 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 36 months based on results of ongoing professional practice evaluation and outcomes. Where the currency requirements are not met, there should be a conversation with the department head to determine the most appropriate course of action. 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 Medical laboratory oversight of testing, ordering of investigations, interpretive reporting and consultation for diseases of the hematopoetic system and transfusion medicine involving all patient populations. Assess, stabilize, and determine the disposition of patients with emergent conditions consistent with medical staff policy. 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 and advice for hematologic diseases and transfusion medicine with or with out patient contact

• Laboratory Medical oversight and direction of hematology and transfusion medicine laboratories with responsibility and authority for all medical and technical policies and procedures that affect laboratory personnel and test performance of all relevant tests inclusive of all applicable technologies and analytic modalities

o Quality management system

o Utilization management

o Budget prioritization

o Site test menu development and selection

o Test method and instrument selection and implementation

o Pre analytic collection and management of samples

o Post analytic result reporting and information management

o Education of laboratory staff and clinicians

o Technologist and other health care worker delegated medical activities

o Technologist and other health care worker consultation

• Management of a transfusion service with responsibility for or consultation in the development of all policies that relate to the care and safety of transfusion recipients (and donors as appropriate) (CSAZ109-10)

o Medical and nursing clinical practice oversight and management

o Product advice and utilization management

o Guideline and policy development and implementation

o Audit and quality improvement

o Transfusion reaction medical oversight of testing, ordering investigations, interpretive reporting and consultation management

o Allo immunized and autoimmune patient medical oversight of testing, ordering investigations, interpretive reporting and consultation

o Donor management and collection

• Medical oversight of tests, ordering investigations, interpretive reporting and consultation for autoimmune and immunohematology investigations

• Medical oversight of tests, ordering investigations, interpretive reporting and consultation for hematolymphoid and other tissue morphology for hematologic disorders

o Medical oversight of tests, ordering investigations, interpretive reporting and consultation of in-situ hybridization studies

o Medical oversight of tests, ordering investigations, interpretive reporting and consultation of flow cytometry

o Medical oversight of tests, ordering investigations, interpretive reporting and consultation of immunohistochemistry

o Medical oversight of tests, ordering investigations, interpretive reporting and consultation of molecular tests related to the hematopoietic system

o Medical oversight of tests, ordering investigations, interpretive reporting and consultation for morphologic interpretation of tissues involved by hematological disorders

▪ Peripheral blood

▪ Body fluids

▪ Bone marrow aspirate and biopsy

▪ Lymph nodes and other hematopoietic organs

▪ Other organs involved in hematopoietic disorders

• Medical oversight of tests, ordering investigations, interpretive reporting and consultation for hemostasis, thrombosis and platelet disorders

• Medical oversight of tests, ordering investigations, interpretive reporting and consultation for hemolytic and hemoglobinopathy disorders

• Medical oversight of tests, ordering investigations, interpretive reporting and consultation for biochemical and nutritional disorders affecting the hematopoietic system

• Performing a bone marrow aspiration and biopsy

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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