OPHTHALMOLOGY CLINICAL PRIVILEGES - Michigan Medicine

OPHTHALMOLOGY CLINICAL PRIVILEGES

Name:

Applicant: Check off 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.

Service Chief / Department Chair: Check the appropriate box for recommendation on the last page of this form. If recommended with conditions or not recommended, provide 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 OPHTHALMOLOGY Initial Applicants - To be eligible to apply for privileges in ophthalmology, the initial applicant must meet the following criteria:

Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited residency in ophthalmology.

AND

Current certification or board eligible (with achievement of certification within five years of completion of training) leading to certification in ophthalmology by the American Board of Ophthalmology or the American Osteopathic Board of Ophthalmology and Otolaryngology ? Head and Neck Surgery or UMHS approved international equivalent.

AND

Required Current Experience: Demonstrated current competence and experience with at least fifty (50) ophthalmologic procedures or elements of work, reflective of the scope of privileges requested, in the past 12 months or successful completion of an ACGME- or AOA-accredited residency or Association of University Professors of Ophthalmology (AUPO) approved or ACGME accredited clinical fellowship within the past 12 months.

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OPHTHALMOLOGY CLINICAL PRIVILEGES

Name: CORE PRIVILEGES ? OPHTHALMOLOGY

Applicant: Requested Initial Service Chief/Chair: Recommended

Requested Renewal Not Recommended

Evaluate, diagnose, treat, admit as needed and provide consultation, order diagnostic studies and procedures and perform surgical and non-surgical procedures on patients of all ages, with ocular and visual disorders, the eye and its component structures, the eyelids, the orbit, and the visual pathways. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.

Focused Professional Practice Evaluation (FPPE NEW HIRE/NEW PRIVILEGE) guidelines: New physicians will be monitored for their initial five (5) major operative procedures to include a representative mix of core ophthalmology privileges granted. Methods must include direct observation, and may include case review, proctoring, discussions with other medical professionals involved in the care of each patient, and review of patient feedback.

Reappointment (Renewal of Privilege) Requirements - To be eligible to renew privileges in ophthalmology, the re-applicant must meet the following criteria:

Board certification, board eligibility (with achievement of certification within five years of completion of training), or UMHS approved international equivalent.

AND

Demonstrated current competence and experience with at least one-hundred (100) ophthalmologic procedures, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes.

QUALIFICATIONS FOR OPHTHALMIC PLASTIC AND RECONSTRUCTIVE SURGERY

Initial Applicants - To be eligible to apply for privileges in ophthalmic plastic and reconstructive surgery, the initial applicant must meet the following criteria:

Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited residency in ophthalmology followed by an ACGME accredited or an American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) accredited fellowship in ophthalmic plastic and reconstructive surgery or the equivalent in training and experience.

AND

Current certification or board eligible (with achievement of certification within five years of completion of training) leading to certification in ophthalmology by the American Board of Ophthalmology or the American Osteopathic Board of Ophthalmology and Otolaryngology ? Head and Neck Surgery or UMHS approved international equivalent.

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OPHTHALMOLOGY CLINICAL PRIVILEGES

Name:

AND

Required Current Experience: Demonstrated current competence and experience with at least fifty (50) ophthalmic plastic and reconstructive procedures, reflective of the scope of privileges requested, in the past 12 months or successful completion of an ACGME- or AOA-accredited residency or ACGME, AUPOor AAO-accredited clinical fellowship within the past 12 months.

CORE PRIVILEGES ? OPHTHALMIC PLASTIC AND RECONSTRUCTIVE SURGERY

Applicant: Requested Initial

Requested Renewal

Service Chief/Chair: Recommended

Not Recommended

Admit, evaluate, diagnose, treat, and provide consultation to patients of all ages, presenting with conditions or disorders requiring reconstructive procedures within the head, face, neck and associated structures, including cutaneous head and neck oncology and reconstruction, management of maxillofacial trauma, soft tissue repair and neural surgery. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.

Focused Professional Practice Evaluation (FPPE NEW HIRE/NEW PRIVILEGE) guidelines: New physicians will be monitored for their initial five (5) major operative procedures to include a representative mix of core ophthalmic plastic and reconstructive surgery privileges granted. Methods must include direct observation, and may include case review, proctoring, discussions with other medical professionals involved in the care of each patient, and review of patient feedback.

Reappointment (Renewal of Privileges) Requirements - To be eligible to renew privileges in ophthalmic plastic and reconstructive surgery, the re-applicant must meet the following criteria:

Board certification, board eligibility (with achievement of certification within five years of completion of training), or UMHS approved international equivalent.

AND

Demonstrated current competence and experience with at least one-hundred (100) ophthalmic plastic and reconstructive procedures, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes.

QUALIFICATIONS FOR NEURO-OPHTHALMOLOGY

Initial Applicants - To be eligible to apply for privileges in neuro-ophthalmology, the initial applicant must meet the following criteria:

Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) or American Osteopathic Association (AOA) accredited residency in neurology or ophthalmology followed by a fellowship in neuro-ophthalmology or the equivalent in training and experience.

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OPHTHALMOLOGY CLINICAL PRIVILEGES

Name:

AND

Current certification or board eligible (with achievement of certification within five years of completion of training) leading to certification in neurology by the American Board of Psychiatry and Neurology or the American Osteopathic Board of Neurology and Psychiatry or in ophthalmology by the American Board of Ophthalmology or the American Osteopathic Board of Ophthalmology and Otolaryngology ? Head and Neck Surgery or UMHS approved international equivalent.

AND

Required Current Experience: Demonstrated current competence and experience with at least fifty (50) neuro-ophthalmology patients, reflective of the scope of privileges requested, in the past 12 months or successful completion of an ACGME- or AOA-accredited residency or AUPO- or AAO-accredited clinical fellowship within the past 12 months.

CORE PRIVILEGES ? NEURO-OPHTHALMOLOGY

Applicant: Requested Initial

Requested Renewal

Service Chief/Chair: Recommended

Not Recommended

Admit, evaluate, diagnose, treat, and provide consultation, order diagnostic studies and procedures and perform surgical and non-surgical procedures on patients of all ages, with visual problems of the eye, brain, nerves, and muscles i.e., neurological conditions that affect the areas of the brain devoted to vision. May provide care to patients in the intensive care setting in conformance with unit policies. Assess, stabilize, and determine disposition of patients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. The core privileges in this specialty include the procedures on the attached procedure list and such other procedures that are extensions of the same techniques and skills.

Focused Professional Practice Evaluation (FPPE NEW HIRE/NEW PRIVILEGE) guidelines: New physicians will be monitored for their initial five (5) major operative procedures to include a representative mix of core neuro-ophthalmology privileges granted. Methods must include direct observation, and may include case review, proctoring, discussions with other medical professionals involved in the care of each patient, and review of patient feedback.

Reappointment (Renewal of Privileges) Requirements - To be eligible to renew privileges in neuroophthalmology, the re-applicant must meet the following criteria:

Board certification, board eligibility (with achievement of certification within five years of completion of training), or UMHS approved international equivalent.

AND

Demonstrated current competence and experience with at least one-hundred (100) neuro-ophthalmology procedures, reflective of the scope of privileges requested, for the past 24 months based on results of ongoing professional practice evaluation and outcomes.

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OPHTHALMOLOGY CLINICAL PRIVILEGES

Name:

NON-CORE PRIVILEGES (SEE SPECIFIC CRITERIA)

Non-Core Privileges are requested individually in addition to requesting the core. Each individual requesting Non-Core Privileges must meet the specific threshold criteria as applicable to the initial applicant or re-applicant.

CORNEAL TRANSPLANTS

Applicant: Requested Initial

Requested Renewal

Service Chief/Chair: Recommended

Not Recommended

Criteria: Successful completion of an ACGME- or AOA-accredited residency in ophthalmology that included corneal transplants. If residency training did not include performing corneal transplants, applicants must have completed a training program that included performing corneal transplants.

Required Current Experience: Demonstrated current competence and experience with the performance of at least ten (10) corneal transplant procedures in the past 12 months or completion of

training in the past 12 months.

FPPE NEW HIRE/NEW PRIVILEGE: All new applicants will be proctored for their first five (5) cases.

Renewal of Privilege: Demonstrated current competence and experience with the performance of at least twenty (20) corneal transplant procedures in the past 24 months based on results of ongoing

professional practice evaluation and outcomes.

REFRACTIVE SURGERY

Applicant: Requested Initial

Requested Renewal

Service Chief/Chair: Recommended

Not Recommended

? Photorefractive keratectomy ? Phakic intraocular lens implants ? Corneal ring implants ? LASIK

Criteria: Successful completion of an ACGME- or AOA-accredited residency program in ophthalmology followed by an AUPO- or AAO-accredited fellowship or experience in refractive or corneal surgery.

Required Current Experience: Demonstrated current competence and experience with the performance of at least ten (10) refractive surgery procedures, reflective of the scope of privileges

requested, in the past 12 months or completion of training in the past 12 months.

FPPE NEW HIRE/NEW PRIVILEGE: All new applicants will be proctored for their first five (5) cases.

Renewal of Privilege: Demonstrated current competence and experience with at least twenty (20) refractive surgery procedures, reflective of the scope of privileges requested, in the past 24 months based

on results of ongoing professional practice evaluation and outcomes.

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