DELINEATION OF PRIVILEGES - GENERAL SURGERY DIVISION …

KALEIDA HEALTH

Name: ___________________________________

Date: ____________________________

DELINEATION OF PRIVILEGES - GENERAL SURGERY DIVISION OF VASCULAR SURGERY

Adults and Pediatrics Unless Specified

GENERAL STATEMENTS

Privileges in Surgery are separated into the following divisions: General Surgery and Vascular Surgery. Applicants desiring procedure privileges in more than one division must complete separate forms for each division requested.

Procedures are also separated into levels of complexity (Level I, Level II, and Level III), which require increasing levels of education and experience. In general, procedures learned during residency are grouped in Level I and are granted upon evidence of successful completion of residency training. Level II procedures may or may not require evidence of additional training beyond residency. Documentation of additional training and/or experience is required for all Level III procedures.

LEVEL I (CORE) PRIVILEGES To be eligible to apply for core privileges in vascular surgery, the initial applicant must meet the following criteria:

Current subspecialty certification in vascular surgery by the American Board of Surgery or the American Osteopathic Board of Surgery

OR

Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) accredited residency in general surgery followed by successful completion of an ACGME accredited fellowship in vascular surgery, or successful completion of an accredited (ACGME) residency in vascular surgery, or completion of an accredited general surgery residency (AOA) and accredited vascular fellowship (ACGME), or (AOA) with review of case logs, and active participation in the examination process with achievement of certification within 5 years of completion of formal training leading to subspecialty certification in vascular surgery by the American Board of Surgery.

Required Previous Experience: Applicants for initial appointment must be able to demonstrate performance of a sufficient volume of vascular surgery procedures, reflective of the scope of privileges requested, within the past 24 months, or demonstrate successful completion of an ACGME accredited residency or clinical fellowship, in a clinical setting within the past 12 months.

Reappointment Requirements: To be eligible to renew core privileges in vascular surgery, the applicant must demonstrate current

competence and a sufficient volume of vascular surgery procedures, with acceptable results, reflective of the scope of privileges requested, for the past 24 months. Practitioners must also demonstrate participation in M & M/QI process of division/department by 50% or greater attendance.

LEVEL I (CORE) PRIVILEGES

The removal or restriction of these privileges would require further investigation as to the individual's overall ability to practice. There is

no need to delineate these privileges individually.

Admit, evaluate, diagnose, provide consultation and treat patients of all

History and Physical for diagnosis and treatment plan

ages with diseases/disorders of the arterial, venous, and lymphatic

circulatory systems, excluding the intracranial vessels or the heart.

Diagnostic Arteriography/Venography

Amputation of extremity or digit- upper or lower extremity

Procedures for varicose veins

Thoracic outlet surgery

Open Vascular Procedures:

Endovascular procedures including: angioplasty (all types), stent

Abdominal Aortic procedures- aneurysm, or occlusive disease

placement, atherectomy, thrombolysis, and stent-grafting of:

Peripheral revascularization- upper extremity, lower extremity, renal,

peripheral vessels

visceral

mesenteric or renal vessels

Extracranial cerebrovascular procedures

subclavian, innominate or proximal carotid vessels

AV access procedures

veins- including lower and upper extremity, and central veins

Embolectomy, thrombectomy

Embolization, therapeutic

Procedures for varicose veins

IVC filter placement and retrieval

Vein bypass or valvular reconstruction

PA Thrombolysis

Endovascular Procedures:

Percutaneous or by Direct Exposure:

EVAR, TEVAR

removal of intra-aortic counter pulsation balloon

Includes snorkel or embolization of associated vessels

Order respiratory services

Order rehab services

Assess, stabilize, and determine disposition of patients with emergent

Interpret noninvasive vascular lab studies

conditions consistent with medical staff policy regarding emergency and

Interpret angiographic studies

consultative call services.

Vascular Surgery 5/2017

Vascular Surgery Name: ___________________________________

Page 2

PLEASE NOTE: Please check the box for each privilege requested. Do not use an arrow or line to make selections. We will return applications that ignore this directive.

LEVEL II PRIVILEGES

Procedures listed below, including those not listed in Level I, may require documentation of additional experience or certification from a

Training Director regarding experience and demonstrated competence in the procedure requested.

PHYSICIAN Granted

Not

With Following

REQUEST

Granted* Requirements**

(Provide Details)

Endarterectomy or Bypass Graft or Aneurysm Reconstruction

Thoracic

Thoraco-abdominal

Direct Repair of Artery

Thoracic

Exploration Without Repair

Thoracic

LASER PROCEDURES

Requires completion of an approved training course and documentation of ten (10) cases per procedure requested for initial approval.

LEVEL III - PERIPHERAL ENDOVASCULAR PRIVILEGES

For physicians applying for carotid/cerebral peripheral, visceral, percutaneous transluminal angioplasty, stents and other endovascular

interventions

a. Board eligible or board certified in Vascular Surgery without prior experience in the area of request; AND

b. Attendance at postgraduate courses for a total of 50 Category 1 CME Credits in diagnostic peripheral angiography and

percutaneous peripheral vascular interventional techniques; OR

c. Completion of a fellowship in percutaneous peripheral vascular intervention (a letter will be required listing the number of cases

performed and attesting to the competency in performing the procedures in which privileges are requested. A qualified physician

may gain case experience/volume by assisting another physician with full unrestricted privileges for that procedure.

PHYSICIAN Granted

Not

With Following

REQUEST

Granted* Requirements**

(Provide Details)

Carotid Angioplasty and Stenting

Applicant must have Vascular Boards or be Board eligible, submit evidence of at least 50 endovascular therapeutic procedures; 30

cerebral angiograms, ? as the primary surgeon; 25 proctored carotid angioplasties with stent placements, ? as the primary surgeon.

(must request approval before being proctored in Kaleida Health through the Medical Staff Office at 859-5502)

Carotid Angioplasty and Stenting

Endovascular Repair of Thoracic OR Abdominal Aorta-

complicated

Branched or fenestrated endografts

Applicant must have vascular board, or be board eligible, and

submit evidence of at least 6 Fenestrated or branched

endografts during training or with proctoring.

Vascular Surgery 5/2017

Vascular Surgery Name: ___________________________________

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MODERATE/CONSCIOUS SEDATION

1. Providers seeking privileges in moderate/conscious sedation must complete either the ASA sedation course ? cost $199.00 (education/online-learning/safe-sedationtraining-moderate) or Medsimulation course ? cost $75.00 () receiving a score of 85% or above. * Note: Providers completing the on-line training course provided by Medsimulation from other institutions receiving a score of 85% or higher will be accepted as an equivalent measure of acceptable knowledge for sedation privileges. 2. Once the provider has successfully passed the course, he/she must send the certificate of course completion to the medical staff office via e-mail (medicalstaffoffice@) or fax (859-5592 or 859-5593). 3. In addition to demonstrating medical knowledge through completion of this course, providers must also maintain airway management skills through current completed training and certification in ACLS, ATLS or PALS. (ACLS is offered through Kaleida Health Corporate Clinical Education. Please call 716-859-5515 for information. You can also take either course online if you prefer. The following are just a few suggestions. You may be able to obtain this training somewhere else: $179.00, aclsatubcampus.html $135.00 or courses/acls/ $175.00.)

4. After a four year period of privileging the provider must repeat either the ASA sedation course or Medsimulation course and receive a score of 85% or greater or a comparable course reviewed and accepted by the Chief of Anesthesiology. They must also maintain airway management skills through completed and current training and certification in ACLS, ATLS or PALS.

PHYSICIAN REQUEST

Granted

Not Granted*

With Following Requirements**

(Provide Details)

Vascular Surgery 5/2017

Vascular Surgery Name: ___________________________________

Page 4

KEY

*NOT GRANTED DUE TO: Provide Details Below

1) Lack of Documentation 2) Lack of Required Training/Experience 3) Lack of Current Competence (Databank Reportable) 4) Other (Please Define) (i.e., Exclusive Contract)

**WITH FOLLOWING REQUIREMENTS Provide Details Below

1) With Consultation 2) With Assistance 3) With Proctoring 4) Other (Please Define)

Details: _____________________________________________________________________________________________ _____________________________________________________________________________________________________

National Practitioner Databank Disclaimer Statement: - Kaleida Health must report to the National Practitioner Data Bank when any clinical privileges are not granted for reasons related to professional competence or conduct. (Pursuant to the Health Care Quality Improvement Act of 1986 (43 U.S.C. 11101 et seq.)

_____________________________________/_____________

Signature of Applicant

Date

_____ I recommend approval of the procedures requested by the applicant:____ a) as requested ____ b) as amended

__________________________________/______________

Signature of Chief of Service

Date

APPLICANT: PLEASE RETAIN A COPY OF THIS SIGNED FORM FOR YOUR RECORDS.

Vascular Surgery 5/2017

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