otolaryngology - CHRISTUS Santa Rosa Health System

To be completed by Credentialing Services
Initial Appointment
Reappointment
Effective from _____
_ to
______
OTOLARYNGOLOGY CLINICAL PRIVILEGES
Name:
Page 1
All new applicants must meet the following requirements as approved by the Board of Directors effective:
____/____/______.
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.
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 OTOLARYNGOLOGY
Initial Applicants: To be eligible to apply for privileges in otolaryngology, the initial applicant must meet
the following criteria:
Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) in otolaryngology or
American Osteopathic Association (AOA) accredited residency in otolaryngology/facial plastic surgery.
AND
Current certification in otolaryngology by the American Board of Otolaryngology or the American Osteopathic Board
of Ophthalmology and Otolaryngology – Head and Neck Surgery; OR Obtain certification within no longer than six
(6) years from the date of the completion of residency or sub-specialty training and be recertified as per the timing
required by the specific board. (The board certification requirement is applicable to Physicians applying for initial
appointment after October 31, 2003).
AND
Required Current Experience: Demonstrate current competence and evidence of at least 50 otolaryngology
surgery procedures, reflective of the scope of privileges requested, during the last 12 months, or successful
completion of an ACGME- or AOA-accredited residency or clinical fellowship within the past 12 months.
Reappointment (Renewal of Privilege) Requirements: To be eligible to renew privileges in otolaryngology,
the applicant must meet the following criteria:
Maintenance of Board Certification, where applicable, is required.
Current demonstrated competence and an adequate volume of experience 100 otolaryngology surgery procedures
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.
The Greeley Company © 2014
Revised: 5/14/2015 11:13:00 AM
Second Draft: 02/16/2015 (Dr. Biediger)
OTOLARYNGOLOGY CLINICAL PRIVILEGES
Name:
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CORE PRIVILEGES – OTOLARYNGOLOGY
Requested
CHSA
CSR - AH
CSR
MC
NB
WH
Admit, evaluate, diagnose, provide consultation and comprehensive medical
and surgical care to patients of all ages, presenting with diseases,
deformities, or disorders of the head and neck that affect the ears, nose,
throat, the respiratory and upper alimentary systems and related structures of
the head and neck. Head and neck oncology and facial plastic reconstructive
surgery and the treatment of disorders of hearing and voice are also
included. 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 listed below and such other procedures
that are extensions of the same techniques and skills.
CORE PROCEDURE LIST
This list is not intended to be an all-encompassing procedure list. It defines the types of
activities/procedures/privileges that the majority of practitioners in this specialty perform at this organization and
inherent activities/procedures/privileges requiring similar skill sets and techniques.
To the applicant: If you wish to exclude any procedures, please strike through those procedures which you do not
wish to request, initial, and date.
Otolaryngology
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Perform history and physical exam
Cryosurgery
Endoscopic biopsy
Endoscopy (direct laryngoscopy – fiberoptic and
rigid; nasopharyngoscopy; true vocal fold
injection/thyroplasty; laser/cold knife
microlaryngeal surgery/arytenoidectomy;
microdebrider endoscopy; esophagoscopy
(diagnostic, foreign body removal, dilation),
bronchoscopy (diagnostic, foreign body removal,
dilation, laser, fiberoptic)
Harvesting of skin, fat, or bone grafts of the head
and neck, hip, trunk, and extremities
Incision/excisional biopsy
Interpret otolaryngology radiographic images
Lip surgery including: lip shave wedge
excision/reconstruction; upper / lower lip
resection/reconstruction
Myocutaneous flap (pectorales, trapezius,
sternocleidomastoid)
Needle biopsy / punch biopsy
Plastic and reconstructive surgery, including
facial resurfacing, blepharoplasty, rhinoplasty,
rhytidectomy, otoplasty, mentoplasty, liposuction,
and implantation of autogenous, homologous,
and allograft, and repair of lacerations
The Greeley Company © 2014
12. Reconstructive procedure of the upper airway
13. Reduction of facial fractures
14. Repair of fistulas – oral-antral, oral-nasal, oralmaxillary, oral-cutaneous, pharyngocutaneous,
tracheo-cutaneous, esophagocutaneous
15. Surgery of the larynx, including external
approach (e.g. laryngofissure, laryngeal
framework surgery); internal/endoscopic
approach (fiberoptic flexible and direct
laryngoscopy, vocal fold surgery, laser surgery,
and microdebrider surgery); biopsy, partial or
total laryngectomy (AH – inpatient only), fracture
repair, balloon sinuplasty
16. Surgery of the nasal and paranasal sinuses
(frontal, maxillary, ethmoidal, sphenoidal), and
surgery of the nasal mucosa and turbinates
including: endoscopic e.g. nasal septoplasty,
inferior turbinoplasty, maxillary antrostomy
(Caldwell Luc), ethmoidectomy, sphenoidectomy,
frontal sinusotomy, repair of CSF fistula,
dacryocystorhinostomy, and non-endoscopic e.g.
septoplasty,
17. Surgery of the oral cavity, including soft palate,
tongue, mandible, (e.g.
uvulopalatopharyngoplasty, tongue suspension
and volume reduction, genioglossus
Revised: 5/14/2015 11:13:00 AM
Second Draft: 02/16/2015 (Dr. Biediger)
OTOLARYNGOLOGY CLINICAL PRIVILEGES
Name:
advancement, sagittal split osteotomy
w/advancement, lipectomy, hyoid suspension,
partial/total glossectomy, floor of mouth
resection, mandibulotomy, resection – hard/soft
palate)
18. Surgery of the pharynx, trachea, parapharygneal
space, i.e. tracheotomy tracheal resection and
repair (AH - inpatient only), cervical
esophagectomy (AH – inpatient only), Zenker’s
diverticulum surgery (open and endoscopic),
mediastinal exploration/ dissection,
cricopharyngeal myotomy/myectomy, revision
stenotic tracheostoma, partial/total
pharyngectomy, pharyngeal reconstruction
19. Surgery of the salivary gland, including:
parotidectomy, ranula excision, plastic repair of
salivary complex
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20. Surgery of the thyroid / parathyroid: thyroid
lobectomy/subtotal/total thyroidectomy,
parathyroidectomy
21. Surgery on the ear, auditory canal, the tympanic
membrane, and the contents of the middle ear
(e.g. tympanoplasty, typanomastoidectomy,
labyrinthectomy, mastoidectomy, canaloplasty,
stapedectomy, auriculectomy/wedge
resection/reconstruction, temporal bone
resection)
22. Surgical removal of teeth in association with
radical resection
23. Tonsillectomy, adenoidectomy
24. Use of image guidance during procedures
QUALIFICATIONS FOR NEUROTOLOGY
Initial Applicants: To be eligible to apply for privileges in neurotology, the initial applicant must meet the
following criteria:
Successful completion of an Accreditation Council for Graduate Medical Education (ACGME) in otolaryngology or
American Osteopathic Association (AOA) accredited residency in otolaryngology/facial plastic surgery followed by
successful completion of an ACGME-accredited fellowship in neurotology.
AND
Current subspecialty certification in neurotology by the American Board of Otolaryngology; OR Obtain certification
within no longer than six (6) years from the date of the completion of residency or sub-specialty training and be
recertified as per the timing required by the specific board. (The board certification requirement is applicable to
Physicians applying for initial appointment after October 31, 2003).
AND
Required Current Experience: Demonstrate current competence and evidence of at least 50 neurotological
surgery procedures, reflective of the scope of privileges requested, in the last 12 months, or successful completion
of an ACGME-accredited residency or clinical fellowship within the past 12 months.
Reappointment (Renewal of Privilege) Requirements: To be eligible to renew privileges in neurotology, the
applicant must meet the following criteria:
Maintenance of Board Certification, where applicable, is required.
Current demonstrated competence and an adequate volume of experience 100 neurotological surgical procedures)
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.
The Greeley Company © 2014
Revised: 5/14/2015 11:13:00 AM
Second Draft: 02/16/2015 (Dr. Biediger)
OTOLARYNGOLOGY CLINICAL PRIVILEGES
Name:
Page 4
CORE PRIVILEGES – NEUROTOLOGY
Requested
CHSA
CSR - AH
CSR
MC
NB
WH
Admit, evaluate, diagnose, treat, and provide consultation to patients of all
ages, presenting with diseases of the ear and temporal bone, lateral skull
base and related structures including disorders of hearing and balance.
Includes medical and surgical management skills for the care of diseases
and disorders of the petrous apex, infratemporal fossa, internal auditory
canals, cranial nerves and lateral skull base, in conjunction with neurological
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 listed below and such other procedures
that are extensions of the same techniques and skills.
CORE PROCEDURE LIST
This list is not intended to be an all-encompassing procedure list. It defines the types of
activities/procedures/privileges that the majority of practitioners in this specialty perform at this organization and
inherent activities/procedures/privileges requiring similar skill sets and techniques.
To the applicant: If you wish to exclude any procedures, please strike through those procedures which you do not
wish to request, initial, and date.
Neurotology
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Perform history and physical exam
Acoustic neuroma surgery
Cochlear implantation
Facial nerve decompression
Decompression membranous labyrinth
cochleosaculotomy, encolymphatic sac operation
Electrophysiologic monitoring of cranial nerves
VII, VIII, X, XI, and XII
Excision of glomus tumor
Excision of skull base tumor
Interpret imaging techniques of the temporal
bones and lateral skull base
Labyrinthectomy
11. Mastoid tympanoplasty
12. Middle/post fossa skull base surgery
13. Osseo integrated implants, for auricular
prosthesis, for bone anchored hearing aid
14. Petrous apiectomy plus radical mastoid
15. Reconstruction congenital aural atresia
16. Repair fistula (OW, RW)
17. Resection CP angle tumor
18. Stapedectomy
19. Temporal bone resection
20. VII nerve repair/substitution
21. VIII nerve section
SPECIAL NON-CORE PRIVILEGES (SEE SPECIFIC CRITERIA)
Non-Core Privileges are requested individually in addition to requesting the core. Each individual requesting NonCore Privileges must meet the specific threshold criteria as applicable to the initial applicant or re-applicant.
ADMINISTRATION OF SEDATION AND ANALGESIA
Criteria: Successful completion of an approved airway management module or ACLS and documentation of
training in Procedural Sedation by achieving completion of the “Sedation and Anesthesia Care” self-study module
with a score of 80% or higher. Required Current Experience: Demonstrated current competence and evidence
of the performance of at least ten (10) cases of procedural sedation in the past 12 months or completion of training
in the past 12 months with documentation of procedural sedation cases during training. Renewal of Privilege:
Demonstrated current competence and evidence of the performance of at least ten (10) cases of procedural
The Greeley Company © 2014
Revised: 5/14/2015 11:13:00 AM
Second Draft: 02/16/2015 (Dr. Biediger)
OTOLARYNGOLOGY CLINICAL PRIVILEGES
Name:
Page 5
sedation in the past 24 months based on results of ongoing professional practice evaluation and outcomes. See
Hospital Policy for Sedation and Analgesia by Non-Anesthesiologists
Requested
CHSA
CSR - AH
CSR
MC
NB
WH
USE OF LASER – KTP, NDYAG, CO2
Criteria: Successful completion of an approved residency in a specialty or subspecialty which included training in
laser principles or completion of an approved 8 -10 hour minimum CME course which includes training in laser
principles. In addition, an applicant for privileges should spend time after the basic training course in a clinical
setting with an experienced operator who has been granted laser privileges acting as a preceptor. Practitioner
agrees to limit practice to only the specific laser types for which they have provided documentation of training and
experience. The applicant must supply a certificate documenting that she/he attended a wavelength and specialtyspecific laser course and also present documentation as to the content of that course. Required Current
Experience: Demonstrated current competence and evidence of the performance of at least five (5) procedures in
the past 24 months or completion of training in the past 12 months. Renewal of Privilege: Demonstrated current
competence and evidence of the performance of at least ten (10) procedures in the past 24 months based on
results of ongoing professional practice evaluation and outcomes. Source: American Society for Laser Medicine
and Surgery
Requested
CHSA
CSR - AH
CSR
MC
NB
WH
ACKNOWLEDGEMENT 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 CHRISTUS Santa Rosa, 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
The Greeley Company © 2014
Date
Revised: 5/14/2015 11:13:00 AM
Second Draft: 02/16/2015 (Dr. Biediger)