sutter medical center, sacramento · pdf filedepartment of surgery – ophthalmology...

SUTTER MEDICAL CENTER, SACRAMENTO Department of Surgery – Ophthalmology Section - Delineation of Privileges

NAME: INITIAL: [ ] RENEWED: [ ] DATE: ADDITIONAL: [ ] Privileges are granted for Sutter General Hospital, Sutter Memorial Hospital, Sutter Center for Psychiatry, Sutter Oaks Midtown and Capitol Pavilion Surgery Center and exercise of privileges is based on the type of care, treatment and services provided at each facility. If you plan to use radiology equipment including the fluoroscope, you must provide a current operating permit that is issued by the Radiologic Health Branch of the California Department of Health Services. To request Privileges, please place an “X” in the request column. In “Number Performed” box, indicate the number of identified procedures performed in previous 24 months from any facility. If the condition/privilege you desire is not included on this form, please submit a separate written request along with appropriate documentation of training and/or experience.

-A- INDICATES OUTPATIENT of 5

Request Privilege Appointment Requirements Proctoring Required

Reappointment Requirements

Number Performed

[ ] Admitting privileges None None None

[ ] History & Physical privileges - A None None None

Request CATEGORY I General Ophthalmology Appointment Requirements Proctoring

RequiredReappointment Requirements

Number Performed

General requirements for all applicants Documentation of experience in the previous two years as a primary surgeon in at least six cases as well as the procedures being requested. Documentation is from either a residency or fellowship case listing (if the applicant recently completed training) or a case listing from where the applicant has been practicing. Some procedure specific criteria may also require a letter from the Director or Chief of Services.

First six (6) cases must be proctored regardless of the type of procedure

Six (6) cases as a primary surgeon and any procedure specific requirements

[ ] Enucleation- A

[ ] Evisceration- A

[ ] Keratoplasty

[ ] Irrigation of blood from anterior chamber- A

[ ] Sclerotomy, posterior for foreign body

[ ] Sclerectomy for glaucoma

[ ] Iridectomy

[ ] Cyclocryotherapy

[ ] Discission lens or secondary membrane

[ ] Aspiration of lens material

[ ] Photocoagulation – iris or retina

[ ] Retinal detachment repair


NAME:


Request CATEGORY I – cont’d Appointment Requirements Proctoring Required


Number Performed

[ ] Transconjunctival cryotherapy

[ ] Eye muscle therapy- A

[ ] Orbital repair or decompression- A

[ ] Blepharoptosis or blepharoplasty- A

[ ] Pterygium excision- A

[ ] Conjunctivoplasty

[ ] Dacryocystorhinostomy- A

[ ] Probing and/or irrigation nasolacrimal system- A

[ ] Intra-ocular lenses

[ ] Cataract extraction

[ ] Vitrectomy anterior

[ ] Trabeculectomy

Request CATEGORY II Complex Repair and Resection Appointment Requirements Proctoring

RequiredReappointment Requirements

Number Performed

[ ] Vitreous iris prolapse Documentation if training or experience in another accredited facility in at least three (3) procedures during the previous two years.

2 cases 2 cases

[ ] Suture eye for wound- A


NAME:


Request Types of Lasers Appointment Requirements Proctoring Required


Number Performed

[ ] Argon Laser Training and experience requirements: Surgeons requesting laser privileges must show that they have the appropriate training and/or experience in the safe use of laser equipment by meeting one of the following criteria:

1. Graduation from an approved training program in Surgery where laser application was part of the active training format. Verification shall be in the form of a letter from the Director of the training program. OR

2. Documentation of successful completion of a section approved post-graduate course with hands-on experience, designed to familiarize practicing physicians with laser technologies, safety and application.

None None

Request Laser Procedures Appointment Requirements Proctoring Required


Number Performed

[ ] Retinal laser photocoagulation None None None

[ ] Acute neuroangle glaucoma

[ ] Acute iridotomy

Request Adult Appointment Requirements Proctoring Required


Number Performed

[ ] Continuing care privileges in critical care units Continuing care privileges in the critical care units includes the ability to see and care for the patient in the critical care setting. The privilege does not include ventilator management, elective intubation or insertion of invasive monitors. Requests for those privileges must be requested separately from “continuing care privileges in critical care units”.)


NAME:


Request Pediatric Appointment Requirements Proctoring Required


Number Performed

[ ] Surgical and general pediatric continuing care privileges in pediatric intensive care unit (PICU) where there are no other medical or child life issues involved. *If there are medical or child life issues the patient should be managed in tandem with an appropriate member of the pediatric staff.

[ ] Comprehensive pediatric surgical and medical continuing care privileges (including pediatric and neonatal ICU management)

Documentation of training and experience (within the previous two years) in the comprehensive management of pediatric patients in the Neonatal or Pediatric Intensive Care Units is required. Documentation must be in the form of a letter from the Director of the training program or from the Chief of Services of another Joint Commission accredited hospital.

First three (3) cases by a surgeon who holds comprehensive pediatric continuing care privileges or by a Pediatric or Neonatal Critical Care Specialist.

None

Request Other Appointment Requirements Proctoring Required


Number Performed

[ ] Post-Acute Care Privilege – Continuing care of the patient in the Sutter Transitional Care Unit or Sutter Oaks Midtown

Please Note: The surgeon in charge is responsible for judging whether or not an assistant is required for any procedure listed. Acknowledgment of Practitioner: I understand that (a) in exercising clinical privileges granted, I am constrained by Medical Staff Policies and Procedures, Rules and Regulations, and (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. I hereby attest to having performed the stipulated number of procedures as indicated above, thereby meeting the criteria for those privileges I have requested. ************************************************************************************************************************ COMMITTEE APPROVALS Surgery QI/Administrative Committee Date: Or Dept Chief (in lieu of mtg) Credentials Committee Date: Medical Executive Committee Date: Board of Directors Date:

TEMPORARY PRIVILEGE APPROVAL Department Chief: Date:

FORM APPROVALS: Ophthalmology Surgery Section Date: 12/6/2010 Surgery Administrative Committee: Date: 2/3/2011 Credentials Committee: Date: 2/8/2011

Medical Executive Committee: Date: 2/22/2011 Medical Policy Committee: Date: 3/3/2011


NAME:


Board of Directors Date: 3/14/2011

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